Obsessed (4 page)

It worked. Emily glanced down and then shrank back. “I didn't realize—” she started.

“Any patient is going to notice. Someone like Mr. Black, with body dysmorphia, is going to be riveted. He's already made a remark about your body. It's like having a clanging bell in the room providing a constant source of interference.”

“Of course, you're right.” Emily looked up at me. “How inconsiderate of me. Do you think that's the reason I haven't been getting anywhere with him? I keep trying to get him to examine other aspects of his life, his personality, when this first arose—and he always comes back to ‘I need to cut off my arm.'”

“That's classic resistance,” I said. “You poke around where he's sensitive and he becomes intractable. He redirects the dialogue.”

“Every time.
I need to cut off my arm
. It's like a mantra that he keeps chanting at me.” Emily gave an anxious glance at her front. The suit jacket had stayed in place.

“I'm sure there's more to his resistance than what you're wearing,” I said. What a therapist wore was easily fixed, once he or she was aware. “I had an obsessive patient who drove me nuts. He'd go on and on about how miserable his life was. Nothing I could do could make him shift perspective. With people who are obsessed like that, it takes on such intensity that no matter how logically you argue, you lose.”

“That's Mr. Black all right,” Emily said. “Remember, we talked about whether the roots of his obsession might be organic?”

It was an interesting idea which Emily had begun to investigate. At first I'd dismissed the notion that something in Mr. Black's brain was telling him that he shouldn't have an arm. Then I reconsidered. Why not? People with phantom limb syndrome continue to feel sensations in an arm or leg long after that limb has been amputated. We'd speculated about what a functional MRI might show. Maybe arm movement on one side elicited qualitatively different responses in the brain. One of the pleasures of working with a bright young psychologist, new to the field, was wrestling with fresh ideas.

“I was able to convince Dr. Shands to give me an hour on the new system.”

“
New
system?” I asked. In recent years, magnetic resonance imaging technology had taken huge strides. Scanners had become smaller and less intimidating, and at the same time more powerful. And unlike PET and CT systems, huge magnets didn't give off radiation.

“It's a four-point-five tesla machine.”

I whistled. That made it nine times as strong as the one we had at the Pearce. Must have cost a fortune. But then, the medical schools would be flocking to it with their research grants. It would pay for itself long before it became outdated. In the meantime Shands had his own his own high-tech playground—a researcher's dream.

“I've never seen a system that powerful. I'll be very interested to see what you find out.”

“You want to observe? It's tomorrow night,” Emily said, her color rising. “There's usually a no-observers policy, but I'm sure he'll make an exception for you. You can sit in the control room with me. You'll actually see the images as they come in. The computer synthesizes them to three-D. It's like watching a movie of the brain in action.”

I glanced up at my crayon drawing of the brain, at the plastic model of the brain I kept on my shelf. I remembered the excitement I'd felt when I dissected my first brain. I couldn't turn down a ringside seat, watching a brain in operation.

Tomorrow night? Shit. That was when I had a date with Annie. I heard myself saying “What time?” Immediately I felt a rush of guilt. I'd just stood Annie up and now I was about to do it again.

“Eight.” She turned to a new page in her notebook and wrote, tore off the sheet, and handed it to me. The note said “University Medical Imaging Center” with a Sidney Street address in Cambridge.

Surely the test wouldn't take more than an hour. I'd call Annie and see if we could get together after. As I tucked the paper into my pocket I wondered what the hell was wrong with me anyway. Most men had the problem of letting the little head control their actions. I seemed to be letting my big one run amok.

“Thanks for the feedback.” Emily stood, reaching out to shake. I got up and grasped her hand. “I was also wondering what you thought about my questioning. Did I overstep?” she asked. Her hand was warm in mine. I felt a moment of discomfort as she held on, her eyes rapt.

“Not for the most part,” I said, jerking my hand away and reaching to straighten my bow tie. Okay, she's pretty and you're flattered by the attention, I told myself. You're her supervisor. Where's your clinical distance? “The only place I thought you skated the line was when you reminded him that he wouldn't be able to change his mind. It wasn't so much
what
you said as
how
you said it. It felt somewhat confrontational.” My voice sounded stiff and formal.

“I guess I don't want him to make a terrible mistake.”

It was the kind of thing you typically heard from an inexperienced therapist. “Remember, you never know what's best for your patient.” I opened the door for her.

“But what if he makes the wrong decision? I mean, amputation? It's barbaric.”

“It's his decision to make. His life to live. You can't help him unless you truly believe that.”

She was halfway out the door when she stopped and turned back. “How do you think he knows I drive a Miata?”

I'd wondered the same thing. “You think it could be him?”

“I wouldn't have thought so,” she said.

I agreed—Mr. Black seemed far too self-absorbed to have formed an obsessive attachment to Emily. On the other hand, I'd evaluated enough murderers to know that villains took surprising shapes. Ralston Bridges had fooled a jury.

“I wouldn't rule anybody out unless you know for sure,” I said. “Please be careful.”

“I'
M SURE
you'll be dazzled by it,” Annie said dryly after I told her I had an opportunity to see a functional MRI on this new machine, and could we postpone our date. “Actually, I was going to call you. Something has come up—”

“I could be there by nine-thirty. Ten, the latest,” I tried.

“No, really, it's okay. I'm probably going to be tied up.”

“Another family emergency?”

“Something like that.”

“Is there anything I can do to help?”

“Maybe.” I heard some papers rustle on her end. “I'll let you know.”

I hoped “family emergency” wasn't just a convenient excuse. I was coming up with one bad scenario after another. I'd been crowding her and she needed some space. An old boyfriend was in town. She was doing round-the-clock surveillance on a particularly dangerous case and didn't want to worry me.

“You could try calling me when you're done,” Annie said. “I may be finished.”

“Sounds great. I can pick us up some takeout from Mary Chung's, maybe a pint of French vanilla from Toscanini's?” I get that from my mother, a belief in the power of good food.

“Mmm,” she said, but it sounded as if her mind was already somewhere else.

Her good-bye was distinctly distant and our conversation felt unfinished. It was still gnawing at me the next evening when I drove to the imaging center. My stomach rumbled, reminding me that I hadn't eaten anything since a bowl of tepid minestrone soup and a packet of saltines at lunch. Some dun dun noodles from Mary Chung's sure would hit the spot. I hoped Annie would be home when I was done.

I turned down Sidney Street. This area had been transformed over the last five years. Once the home of the Simplex Wire and Cable Company, the area was now the poster child for urban renewal, Cambridge style—a mixture of residential buildings, office space targeting before-the-bust dot-coms and biotech startups, with a hotel and giant supermarket thrown in for good measure. A historic brick-and-beam factory building, where myth has it they baked the first Fig Newton, was now artist lofts.

I drove past the modern glass-and-granite office building. The entrance to the basement parking garage was around the corner. I had to go two levels down to find a spot. Then I rode the elevator up to the main floor.

The lobby had a high ceiling with an old-fashioned crystal chandelier that would have felt right at home at the Met. The interior, with its warm wood and brass fittings, was designed for tenants who could afford to pay plenty of overhead.

A uniformed security guard behind a circular mahogany counter asked me to sign in. He pointed me to the two-story archway that led to the University Medical Imaging Center. A pair of potted trees, taller than I, flanked the double glass doorway.

In the waiting area, the large window in the wall was slid open. A young woman at a desk on the other side had her jacket on and was shutting down her computer. She was tall and blond, like she was fresh off Malibu Beach. I told her who I was and why I was there. She disappeared into the back.

While I waited I looked around the empty carpeted waiting room. Rows of straight-backed chairs were punctuated by low tables loaded with magazines. The photos on the wall were blow-ups of historic Boston. I was admiring a picture of the Old Howard—a burlesque house in Scollay Square, that mythic part of Boston long ago torn down to make way for a soulless Government Center—when the door to the inner area flew open. A tall, handsome man with a chiseled profile and a mane of silver curls came toward me, his hand outstretched. He wore wire-rimmed glasses and his teeth glowed.

“Dr. Zak?” he said. “Dr. Ryan has told me all about you. I'm Jim Shands.”

He had the firm handshake of a seasoned politician. He ushered me into an antiseptic-smelling area where harsh fluorescent lighting bounced off a white vinyl floor.

“Please, call me Peter. I've read your papers on Lewy body dementia. Very interesting.”

“And I've read yours on memory,” he said. “Impressive.”

His gaze fell to a FedEx box on the floor. “What the…?” he started. Labels on it read
WET ICE
and
STORE AT
4
C
. “How the hell long has this been here? They know I've been waiting for this.” He looked around and, seeing no one, raised his voice. “Why in God's name didn't someone tell me this was here?”

He picked up the box like someone might pick up a newborn baby and cradled it in his arms. “Amanda,” he barked. “Where is that girl?”

“I think she went home,” I said.

“Incompetence.” He muttered some more about how he'd told her a million times. Then to me, “Sorry. I need to take care of this. This won't take a minute.”

He disappeared down the corridor. When he returned a short time later he seemed fully recovered.

“I appreciate your allowing me to observe,” I said. “I don't know nearly as much as I'd like to about MRI technology.”

“If you're going to see it, this is the place. We've got the strongest whole-body magnet used for clinical imaging in the country.”

We started down the corridor.

“I understand you do some forensic work?” he said.

“I evaluate people who are accused of crimes.” I didn't mention that I always work for the defense. I'd learned not to the hard way, having sat through more than my share of lectures that began with raised eyebrows and a knowing look, followed by
Oh, so you're one of those hired guns
.

“Have you read about the recent Johns Hopkins work, examining brain scans of convicted criminals?” Shands asked. “They found abnormalities in the prefrontal cortex.”

I'd read the study. Their findings confirmed what had been hypothesized for years—that the prefrontal cortex plays a role in controlling emotions and behavior. It invited the question: Could we “fix” a criminal's frontal lobes so he'd stop committing crimes? This kind of speculation had encouraged a flurry of work exploring drug therapies and brain surgery. Cingulotomies—operations to excise a portion of the brain's limbic system—were in vogue. The operation seemed to help certain patients, especially extreme obsessives. Still, the thought of it made me shudder. I hoped we weren't headed back to the good old days of frontal lobotomies àla
One Flew Over the Cuckoo's Nest.

We approached a pair of double doors. There was a sign on one of them, a bright yellow triangle with a picture of a horseshoe magnet on it with zaps of lightning coming from the ends. Below it were the words
STRONG MAGNETIC FIELD
, and below that
NO METALLIC IMPLANTS
.

Shands pointed to the sign and gave me a questioning look.

“No implants,” I said. “At least none that I know of.”

I'd heard that the magnetic pull of an MRI system could be powerful enough to stop pacemakers. The magnet could dislodge an aneurysm clip in the brain, tearing the artery it had been used to repair.

Shands pushed one door open; I pushed the other. On the other side was what felt like the hub of the lab. There was a large, semi-circular counter in the center with rolling desk chairs and low file cabinets arrayed around it. Everything was white except for dark red chair cushions. Corridors radiated off in three directions.

“The magnet is always on, even if the power to the unit is shut down,” Shands said. “So even though the scan room is shielded, you have to be careful what you take any closer.” He gave me a plastic container. “Something as innocuous as a paperclip has a terminal velocity of over a hundred miles an hour when pulled into the magnet. Not to mention the magnetic field erases all your credit cards.”

Emily Ryan came in as I was taking off my watch and emptying my pockets, dropping my credit cards, spare change, cell phone, and car keys into the container. She had on a white lab coat over her dark suit, and her ponytail swung from side to side as she walked toward us.

“Dr. Zak,” she said, her face lighting up. She hoisted herself up onto the countertop and swung her legs. She was obviously comfortable here. “I'm just about finished getting Mr. Black set up. Should be another ten, fifteen minutes.”

“Why don't I take Peter back with me, then?” Shands said. “I can tell him about the work we've been doing.”

Shands's office was spacious and bright with a view overlooking an atrium courtyard. Green and pink spotlights illuminated a jungle of tropical plants. A few tall trees reached up toward the light. Unlike the vegetation we had adorning the neuropsychiatric unit, I was willing to bet that not one of these was plastic.

“So Dr. Ryan is working for you, too?” He raised his eyebrows, as if “working for” were code for something else.

“She's doing a post-doc on the neuropsychiatric unit.”

“She's very eager,” he said. “A hard worker.” I wondered if he always sounded so condescending talking about the people with whom he worked. “She tells me you rescued her the other night. Did you see anything?”

“What kind of anything?”

“Oh, like the person who she says is following her. It's got her so spooked she's afraid of her own shadow.”

“I may have seen something,” I said. It was a lie, but I didn't want to undercut Emily's credibility and make her look like a kook. Her terror had seemed so real. “And?”

I shrugged. “I didn't get a good look at whoever it was.”

“I'm glad you made sure she got home safely,” he said, as some of the tension lines in his forehead erased themselves.

I felt a pang of guilt. I probably should have. “Actually, I offered to, but—” I adjusted my tie. Why was I doing this? I didn't owe him an explanation. “Nice office,” I said, looking around.

There were the usual diplomas and awards hanging behind the massive mahogany desk. Less usual was a bank of light boxes. One had a film of a brain scan clipped to it. It was a slice looking from the top down with areas highlighted in color. In the neighboring light box was a transparency of what looked like a tissue sample. I leaned in to get a closer look at the red cells with white halos around them, floating on a mottled reddish background.

“That was our breakthrough,” Shands said. “The first patient we diagnosed with Lewy body dementia from a functional MRI and later confirmed. Those are cortical Lewy bodies.” Shands pointed to the deformed brain cells with their white borders. “They're actually cytoplasmic inclusions that seem to kill brain cells, resulting in Lewy body dementia and Parkinson's disease. What we've discovered is that by altering cell membrane permeability, we can stop the formation of Lewy bodies and prevent the death of brain cells.”

Among the dementias, Lewy body was once thought to be extremely rare. We'd come to realize it was actually much more common. But it could only be diagnosed definitively by examining brain cells.

“Autopsy?” I asked.

He nodded.

That was the frustrating thing. You could look at behavior, test results, brain scans, blood work, and X rays until you were blue in the face. Still, a diagnosis on a living patient was usually at least part guesswork. Too bad patients had to die to satisfy scientific curiosity.

“Must have been very exciting,” I said.

“Probably the most satisfying moment of my career.” He pointed to an area of the MRI scan. “Here's the marker. We could actually see the change in the diffusion of water molecules. See here, and here. The cells are less permeable.” He was pointing to the basal ganglia. I nodded, though I didn't know what I was supposed to be seeing.

“That would account for the movement disorders,” I said.

“Of course, this was only the first case. We've had lots more since. We'll need hundreds to convince the medical community.”

Hundreds of brain scans. Then hundreds of autopsies to confirm the diagnosis. At least patients with Lewy body dementia died fairly quickly—within a year or two. It would only take a few decades for Shands to make his case.

My mother had refused to authorize an autopsy after my father died. Didn't matter to her one way or another whether it was Alzheimer's or something else that had taken my father's soul long before his heart stopped beating. She wanted no more indignities inflicted on him. I'd been the one who wanted to know, but it was her decision to make.

“Now we can give a definitive diagnosis early,” Shands continued. “Before there are even symptoms. We're looking at extremely early intervention. Medication that increases the permeability of brain cells. We're administering Cimvicor.”

Cimvicor had been approved by the FDA for the treatment of high cholesterol. It had long been known that many drugs that reduced cholesterol also increased cell permeability.

Shands went on. “Within just a few weeks we're seeing changes in the brain in response to the drug. That's a whole lot faster than the months it takes for us to see definitive cognitive improvement.”