The particular incident I want to tell about took place in the first month of my psychiatric residency, a very long time ago. But in order to make my reaction understandable, I have to go back even further, to the time when I was in college.
I developed a panic disorder when I was a sophomore in college. The attacks I had were not called panic attacks in those days. They were called anxiety reactions; but they were no different from what is understood now as panic disorder, usually appearing in association with agoraphobia. A typical panic attack has two elements: the physiological responses of sudden fear—shortness of breath, and/or dry mouth, so dry it makes swallowing difficult, and/or palpitations, and/or trembling hands, and/or a wobbly, “dizzy” feeling, which is more a sense of unsteadiness than a true vertigo, that is, spinning. The second, more prominent, element of a panic attack is psychological: a feeling of imminent loss of control. The panicky person feels trapped and in danger of doing something that is either embarrassing or dangerous. Someone driving feels an impulse to drive into a crowd or off a bridge. Others are troubled by an intrusive thought of jumping out of an open window, or off a subway platform. The embarrassing thing a panicky person fears is falling to the ground, or vomiting, or experiencing a heart attack, or screaming or some other such exaggerated or outlandish behavior.
My particular variation on this theme was a sudden sense of losing control of myself in a classroom and yelling out some obscenity. Other quiet places made me uncomfortable. The library at Princeton University was particularly threatening. Picture a very big room with twenty or thirty parallel tables, each one occupied by twenty or so students, all of whom were COMPLETELY SILENT! I used to stand at the entrance and imagine myself suddenly screaming out something awful. In my mind’s eye I could see every eye turning towards me.
In time, relying on methods which have now become standard for the treatment of panic disorder, I recovered. I may still have had a rare panic attack, but I was no longer afraid of losing control. Until one day at the beginning of my residency.
I was late that day arriving to a conference in which the featured speaker was a psychiatrist from Africa. The room was very crowded. There were about forty to fifty people squeezed into a space which looked to me as if it usually held about fifteen. Looking more closely, I spotted a seat way up in front just to the side of the speaker, who was still being introduced. I made my way with difficulty through the packed room and finally settled into a folding chair. I looked out into the audience which was made up by the whole department, and which was looking right back at me, it seemed, since I was seated directly next to the lecturer.
The speaker was a psychoanalyst, according to our department chief, who was making the introduction, the only psychoanalyst in Africa. That struck me as funny, for some reason. I imagined him sitting with a notebook in hand at the very center of the African continent with couches arranged in concentric circles all about him, in larger and larger circles, as if he were psychoanalyzing all of them, millions of them, all at the same time. But then I thought, how would he ever get any psychoanalytic patents at all without any other psychoanalysts to refer to him? I did not have a very sophisticated idea of life in Africa. I imagined a Watusi stretching out on an analytic couch, his feet sticking out, coming every day for a few years to talk about his life growing up with other Watusis. That was my state of mind, probably a result of the nervousness of starting a job that was very important to me and trying to make a good first impression. I was a little giddy.
The guest lecturer began to speak. I listened to him and watched the faces of the audience, who seemed rapt. This residency was considered one of the best in the country and one of the hardest to get into; and these particular people looked very bright. And serious. At least as far as you can judge such things by watching someone watch and listen to someone else.
I only remember two remarks by this psychoanalyst. After all, it was a long time ago. But I’m pretty sure I would not have remembered, even the following week, anything but those two remarks. But I have never forgotten those two remarks.
He mentioned in passing that there was no schizophrenia in a particular tribe. It was a large tribe, about 200,000 people. This struck me as interesting. I thought I had read that the incidence of schizophrenia was about one to two per cent of every population that had ever been studied; and this tribe would constitute an exception. But I wasn’t sure. When you are a first year resident—or a first year anything—you are not sure of anything that you think you know. Then the lecturer said that the reason why he knew there was no schizophrenia in this tribe was that he knew all of them.
Wait a second, I thought. That was a lot of people. Say it took this experienced clinician ten minutes to determine whether or not someone was schizophrenic. That would mean he could rule out six people every hour—sixty during a ten hour day, four hundred and twenty every week, assuming they filed by him at a regular speed, and he did not take out time to eat or go to the bathroom. That would be about twenty thousand people every year—if he did nothing else. Then it would take him ten years to be introduced to and to diagnose the entire tribe! This guy was talking bullshit! He was making this silly stuff up. I started to laugh, and stopped abruptly when the audience turned to me. No one else was laughing! No one was smirking or smiling and whispering to a neighbor. Why weren’t they laughing?
Whatever the reason, I was not about to call attention to myself. And suddenly, I began to feel like I used to when I had panic attacks. I felt like something was irrupting inside of me; and I was going to make a spectacle of myself. Was I really sure I could control myself, like I always thought I could?
I began to fidget. I would have left the room if I had been sitting anywhere near the door; but I knew it would take me a few minutes to wind my way between all the other people. They would stare at me the whole time. So, I contained myself. I started to take notes to distract myself. But the notes I wrote were more figures. Suppose it took him twenty minutes to diagnose a schizophrenic—or the absence of schizophrenia. That would mean he would have spent twenty years getting to know all these African guys. I began to feel worse. I tried concentrating on other things. And that began to work. I was able to sit there silently, trying to look like a rock. Until the next memorable remark.
Somehow, the lecturer had got on the subject of masturbation. He was against masturbation because the penis was like everything else in the body: if you rub it too much it loses sensitivity. WHAT? And if you rub it too hard, you grow hair on your palm. Right? You ninny!! The penis is supposed to be rubbed, one way or the other. I looked around. This guy was giving this lecture to a roomful of psychiatrists. Was he crazy? They were all going to laugh at him. BUT THEY WEREN’T LAUGHING. Why weren’t they laughing? Suddenly, I felt the overwhelming urge to laugh. This was awful. My God, suppose I became hysterical in front of everyone when someone started talking about masturbation? I would never live it down. I gritted my teeth and held on to the seat of my chair, as if it was going to rise up under its own power and sail about the room. I forgot all those mental things I used to do to distract myself when I was panicky. It was me or The Laugh.
And why wasn’t anyone else laughing?
That was the thought that troubled me from time to time over the next few years: why wasn’t anybody else laughing?
Oh, and by the way, it turns out that when the stakes are high enough, you can control yourself even when you are panicky. I did not laugh. I sat there stony- faced and tried not to listen. I doodled. I scratched myself. But I did not laugh. (c) Fredric Neuman