Psychopath (4 page)

Jonah took her hand.  It was soft and delicate, with long, graceful fingers — a hand to rival his own. He noticed she wore a four-or five-carat diamond engagement ring on her middle finger.  She probably hadn’t had time to have the ring sized since her engagement.  Or maybe she wasn’t engaged at all, and the ring was an heirloom given her by her adoring grandmother.  "Savior may be going a bit far," Jonah said.

"You aren’t the one who’s been taking call every other night for seven months," she said, tilting her head in a feminine and wonderful way.  She let go of his hand.  "Every third is going to feel like heaven." She looked at Ellison.  "You’ve worn me out."

"Never know it, looking at you," Ellison said, with a slight bow.

"Time you get your lenses checked," Jenkins said.  She glanced over Ellison’s shoulder.  "Paul’s here."

Jonah turned and saw a man in a dark blue blazer and wrinkled khakis heading over.

"Paul Plotnik," Ellison said.  "The third musketeer."

Plotnik, a wiry man of about fifty-five, with sparse, unruly hair and narrow, sloped shoulders, joined the group.  The sleeves of his blue blazer were a bit short.  His khakis were stained above his left knee.  "Got a tough one for you today," he said to Ellison, with a slight lisp.  His eyes darted to Jonah, then to Jenkins, then back to Ellison.  "Ten years old, nearly mute.  He hardly moves.  Hearing voices, I’d guess.  Maybe seeing visions."

"Tell it to Dr. Jonah Wrens, from Medflex," Ellison said, nodding toward Jonah.  "I’ve asked him to sit in for me today."

"Wonderful," Ellison said.  He shook Jonah’s hand — too hard.  "I’ve heard a lot about you.  When did you arrive?"

"Just today," Jonah said.  "That’s quite a handshake."  He noticed that the left side of Plotnik’s face drooped slightly.  He’d had a minor stroke.  That explained his lisp.

"Been told that.  Been told that," Plotnik said, finally letting go.

"Dr. Ellison’s putting you right to work," Jenkins said to Jonah.  "Trial by fire."

"I don’t mind," Jonah told her.  He held her gaze.  Or was she holding his?  "Rescue me if you see me going down in flames."  He listened to his own words as he spoke them, heard how they married nurturance, sexual passion, and danger. 
Rescue me.  Going down.  Flames
.  He hadn’t planned to deliver such a potent message.

"I will," Jenkins said, a whisper of seduction in her voice.

Ellison raised an eyebrow.

"Well, then, why don’t we get started?" Plotnik said, smiling a nervous smile.  "See what twenty grand a month buys these days."

Jonah laughed.

"Paul, that’s inappropriate," Ellison said.

"A joke," Plotnik said, holding both his hands in the air.  "A joke.  Nothing more."

"No offense taken," Jonah said.

"Dr. Ellison didn’t spill the beans," Plotnik said to Jonah.  "He’s as tight-lipped as they come.  I once looked into working for Medflex.  I’ve kept my eye on what they pay."

"You decided to sit tight," Jonah said.

"Craig offered me twenty-two a month," Plotnik said, erupting into laughter.

"When hell freezes over," Jenkins said.

"Why don’t we get started," Ellison said.

"Seriously though," Plotnik said to Jonah.  "No one’s expecting you to crack this case wide open.  He’s already been on the unit almost three weeks.  Get him to string two words together, and you’re a hero."  He turned on his heels and marched toward the lectern at the front of the room.

t h r e e

The auditorium was filled nearly to capacity.  Ellison explained to Jonah that Canaan Memorial was one of the few places in Vermont where mental health professionals could earn the continuing education credits they needed to keep their licenses.  Social workers, psychologists, and psychiatrists from all over the state attended the weekly case conference.

Jonah listened from a seat in the front row as Paul Plotnik began to present the psychiatric history of nine-year-old Benjamin Herlihey.  After the presentation, Herlihey would be brought in to be interviewed.

"Benjamin Herlihey is a nine-year-old white male admitted to the locked psychiatric unit on January third of this year," Plotnik read from prepared notes.  "He is the only child born to his father, who works at a local lumber yard, and his mother, who works as a day care provider in the couple’s home.  According to his parents, Benjamin showed worsening symptoms of major depression for nearly three months prior to admission, including lack of appetite with a seventeen-pound weight loss, decreased sleep with early morning awakening, loss of interest in all activities that once brought him pleasure, decreased energy, and intermittent tearfulness."  Plotnik paused, but continued to stare at his notes.  He pushed the tip of his pointer finger into his ear and twirled the fingertip, as if removing ear wax.

Ellison leaned toward Jonah.  "A nervous habit," he whispered.

Very nervous, Jonah thought to himself.

"Benjamin was treated by an outpatient psychiatrist who prescribed him Zoloft at fifty milligrams, without any improvement in symptoms," Plotnik went on.  "The dosage was slowly increased to one hundred milligrams, then to two hundred.  No beneficial results were obtained.  The patient’s symptoms continued to worsen.  Desipramine was added at fifty milligrams each morning.  But despite the combination of medicines, the patient’s energy continued to decline, and his weight continued to fall.  He stopped attending school and became more and more reclusive at home.  By mid-December, Benjamin had become nearly mute, answering yes or no to questions, but offering nothing more.  He began to avoid eye contact.  His outpatient psychiatrist then reasoned, wisely by my estimation, that Benjamin, rather than suffering a major depression, was experiencing a first psychotic break, heralding the onset — in childhood — of paranoid schizophrenia."

Whispers in the audience spoke to the poor prognosis of early onset schizophrenia.  Major depression, while no cakewalk, was far more treatable.

Plotnik drove his fingertip inside his ear again, twirled it around, then used it to flip to the next page of his presentation.  "Since his admission to Seven West on January third, the patient has maintained almost complete silence.  He seems, at times, to be distracted, presumably by hallucinations.  He looks up toward the ceiling, as if hearing a voice or seeing a vision.

"Benjamin has not maintained a normal diet since falling ill, and his anorexic behavior has only worsened on the unit and now places him in metabolic jeopardy.  We are delivering him nutrients by IV, but will need to place a feeding tube within days to ensure his survival.  His parents have already consented to the surgery.  We plan to initiate electroconvulsive treatment immediately thereafter, in hopes of impacting Benjamin’s psychosis.

"Psychodynamically, it seems relevant that Benjamin’s father deserted the family with no notice three years ago, almost to the day, that his son’s symptoms began.  Mr. Herlihey stayed away four months, refusing all contact with his family, then reuniting with them just as suddenly.  He did not then — nor has he since — communicated the reason for his abrupt departure or return.

"One would wonder whether Benjamin is replicating his father’s silence, starving himself physically as a concrete symbol of the starvation he experienced emotionally."  Plotnik looked up from his notes for the first time.  "As I feared he would, Benjamin’s father dismissed my theory out of hand.  He remains unwilling to fill in the gap as to what he was doing — and what his motivations for doing it might have been — during his absence."

Plotnik nodded at Jonah.  "We have as our case consultant today the newest member of the psychiatry staff at Canaan Memorial, Dr. Jonah Wrens."  Shifting his gaze to a young man standing just inside the door to the auditorium, he said, "Please bring Benjamin in."

Plotnik left the podium and headed for the seat next to Jonah’s.  Jonah stood.  He started toward the wingback chairs behind the oak table, but stopped as the door to the auditorium opened and Benjamin Herlihey, slumped to the left side of a wheelchair, each of his arms hooked up to an IV, was pushed into the room.

Even under a white hospital blanket, Herlihey looked like something out of a World War II concentration camp.  His sunken eyes had bluish circles beneath them.  His red hair was fine and thinning, his scalp showing through in places.  The bones of his legs and arms barely tented the woven white fabric covering them.  He seemed ageless to Jonah, nine or ninety, close to birth and close to death.

Jonah walked the rest of the way to the front of the auditorium.  He moved one of the armchairs away from the oak table, making room for Benjamin’s wheelchair.  He took the other armchair.  Then the two of them — doctor and patient — sat opposite one another in silence, with Benjamin’s head flopped to the side, his vacant eyes peering up at Jonah.

"My name is Dr. Wrens.  Jonah Wrens."

Benjamin did not speak or show any emotion.

"Dr. Plotnik asked me to talk with you, to see if I can help."

Benjamin’s eyes rolled up and to the left, staring several seconds at the ceiling, then slowly returning to center.

Jonah looked up at the spot where Benjamin’s eyes seemed to have traveled.  There was nothing there.  He looked back at the boy.  "Dr. Plotnik told me about the trouble you’ve been having.  I want to understand it."

Benjamin didn’t respond.

Jonah was about to ask another question, to prod the boy into uttering a word or two.  But he stopped himself, settled back in his chair, and simply sat with him.  A minute passed.  Then two.  Occasionally, Benjamin’s eyes would roll up to the ceiling, and when they did, Jonah rolled his own eyes in precisely the same arc.

Two minutes of quiet is more than most people can stand.  People in the audience shifted nervously in their seats.  Out of the corner of his eye, Jonah could see some leaning to whisper to their colleagues.  He could imagine what they were saying. 
Who is this guy, anyway?  Is he going to do anything?  Why doesn’t he say something, for Christ’s sake?

Jonah dismissed them all from his mind.  Never breaking eye contact with Benjamin, he slowly began moving his own head, neck, chest, arms, hips, thighs, knees, feet into the same positions as the boy’s, becoming his mirror image, judging the exact center of Benjamin’s equilibrium by the pressure he felt on his skin in some places and not in others, the tenseness in some of his muscles and the lack of it in others.

Another two minutes passed in this state of suspended animation, with the audience getting more and more jittery, and Jonah slumping further in his chair, looking more and more like a clone of the broken boy across from him.

Then, of a sudden, Jonah straightened up in his chair.  He stood up.  He stepped over to Benjamin, crouched in front of him and looked into his eyes.  "I’m going to touch you now," he said, his voice barely audible.  "Don’t be afraid."  He held his hands out where Benjamin could see them.

The room fell completely silent.  Psychiatrists do not touch.  They maintain rigid boundaries.  They heal from across the room.

"What the heck?" Jonah heard Paul Plotnik mutter.

Jonah glanced at Craig Ellison and saw a dubious look on his face.  But he also glimpsed Michelle Jenkins leaning forward in her seat, transfixed.

He focused on Benjamin again.  "Don’t be afraid," he said.  He kept looking into his eyes for several seconds, then turned his attention to the boy’s left arm, lying motionless on his thigh.  He lifted it about eight inches, let go and watched it fall like a dead weight.  Then he lifted his right arm and dropped it.  It slowly drifted back down.

Like a man working the extremities of a life-size Gumby, Jonah pushed and pulled Benjamin’s arms and legs this way and that.  He ran the tip of his thumb along the bottoms of Benjamin’s feet, watching the way his toes curled in response to the peculiar pressure.  He leaned even closer, bringing his face within a few inches of Benjamin’s.  He looked left and right, up and down, noting when Benjamin’s eyes tracked along with his, as ocular reflexes would dictate, and when they did not.

He sat back on his heels.  "Thank you," he said to Benjamin.  "I think I see the problem."  He stood up and motioned for the man who had wheeled Benjamin into the room.  "All set," he said.

He walked to the lectern and waited for Benjamin to be wheeled away.  He looked out over the audience and let out a long breath.  "This is an unusual case," he said.

"It’s an unusual case conference," Paul Plotnik said in a stage whisper.

Nervous laughter filled the room.

Jonah looked at Plotnik, who had broken into a wide grin.  "Glioblastoma brain tumors in this age group are exceedingly rare," he said.  "In this case," he went on, addressing the whole audience, "the tumor mimics mental illness perfectly, because of its location.  Its point of origin lies just lateral to the limbic system, on the right side of the brain, so that the malignant cells invaded the amygdala first, causing mood alterations and changes in muscle function.  They then moved into the caudate nucleus, slowing invading upward, into the medial sulcus of the cortex, which is, of course, the primary speech center."  He paused and looked at Paul Plotnik again.  "Dr. Plotnik," he said.  "Did you get a CAT scan?"

"Of course," Plotnik said defensively.

"I knew you would have, because of how thorough your presentation was," Jonah said.  He wanted to save Plotnik from looking foolish and save himself from making an enemy.  He looked out over the audience again.  "The trouble is that eight percent of glioblastoma lesions show up only on MRI.  And we don’t generally order MRIs on patients whose symptoms seem to be explained by depression — or schizophrenia."  He paused.  "Benjamin doesn’t need electroconvulsive therapy.  He needs surgery — and right away.  Glioblastomas are aggressive, but treatable if caught early."

"What about the psychosis?" Michelle Jenkins asked.  "How do we explain that?"

"I don’t think Benjamin is seeing visions," Jonah said.  "His eyes drift upward and toward the left because the nerves to the ocular muscles which center the eye are weak.  The tumor is destroying them."