THE DOCTOR, THE BOY AND THE SHAMAN

A medical mystery involving a Hmong child caused a doctor to challenge what he knew and attend a ritual to drive out the evil spirits

Herbert Schreier - Sunday, December 24, 2006

In my quarter-century as a child psychiatrist, I thought I had seen it all. Children mangled by pit bulls, a boy suffering from flashbacks after a grenade exploded in his hand in Iraq, a 3-year-old who had watched her mother being stabbed.

But then I was called to the hospital to see a 9-year-old Laotian boy who had stopped eating and communicated mainly through terrified looks. He would whisper almost unintelligibly about pain in his throat and tell his mother that his heart was sick.

He had been born in California to immigrant parents who escaped from the hills of northern Laos and settled in Oakland. His mother said that one day she had been called to his school -- a frequent occurrence, because he had again been in a fight -- and told he was suspended for three days.

That night at dinner he was "shamed" in front of his older brother and stepfather. The following weekend, when the parents returned from tending their strawberry patch in a distant valley, they were upset to find that the boy's 19-year-old brother, a college student, had decided to further punish him by having him wash all the walls in the two-bedroom apartment. The next day they found the boy sitting in a corner of his room drooling, staring blankly ahead with a frightened look on his face, and otherwise betraying no sense of recognition.

This was the child I found three days after he was admitted to the hospital. Doctors are taught an old saw in medical school: "When you hear hoofbeats, expect a horse to appear and not a zebra." But in this case, there was apparently no horse. The medical team had ruled out neurological and infectious disorders and then asked for a psychiatric consultation.

I was first curious about the distinct rhythmic movements he made with his arms and hands. Most psychological disorders with physical symptoms such as paralysis or so-called "hysterical blindness" rarely have specific signs that allow us to draw a definitive conclusion about their origins, so the diagnosis often has to be made by excluding all other possible medical causes first. Once the neurologist assured me that these movements were not the worm-like limb motions seen in neurological diseases, I could throw myself into the kind of detective work I love and try to come up with a diagnosis and treatment.

The nurse reported that the patient's only activity was to get up suddenly, his face more contorted in fear than usual, and search frantically underneath his bed. And it was here that my patient's fears engendered my own.

My thoughts turned to a nightmarish and unsolved medical mystery that afflicted young Southeast Asian survivors of the wars in their home countries. In 1981, the Centers for Disease Control and Prevention in Atlanta reported on 25 Hmong and eight other Southeast Asian refugees -- all healthy men, all but one in their 20s -- who had died inexplicably and suddenly in their sleep or soon after waking from a frightening dream. No physical causes could be found.

I had been acquainted with the medical and anthropological literature describing other examples of "psychological deaths" such as voodoo (death by suggestion), and their presumed origin. One of my graduate psychology students had reported on several deaths of siblings of children who had died of serious medical illnesses, close to the date of the death anniversary, which incorporated symptoms of the dead child's disease.

There is also a syndrome known in the Philippines, described in the cultural conditions section of the Diagnostic Manuel of the American Psychiatric Association, called Bangungut (the Tagalog word for "nightmare"). Survivors of Bangungut report nightmares that include an animal or spirit sitting on their chest and taking their breath away.

My patient was complaining of sharp pain in his throat and chest, which he described as his "heart breaking," and repeatedly whispered that he could not breathe.

I questioned the mother about any history of family psychiatric disorders, but she could not think of any. The patient's condition worsened. He refused contact with anyone, including his mother, and stopped even whispering. He wouldn't eat and took only small amounts of liquids.

On the ninth hospital day, the stepfather announced that at great expense he had hired a shaman who was well-known for his ability to communicate with the spirits that troubled a patient. In the Hmong culture, and many others, depression is believed to be caused by the spirits of family members who have not been appropriately mourned.

Successful prevention of "nightmare deaths" by shamans has been described in the medical literature. In one case, a former Cambodian soldier fleeing Pol Pot's onslaught with this wife and child had watched in horror the murder of many relatives trying to escape with them. When he resettled in Chicago with the help of a benefactor, he began waking from nightmares in which he saw his benefactor sitting on his chest and "stealing his breath." His shaman spent several hours chanting in the family's apartment and was successful in halting the nightmares.

The Hmong boy's stepfather invited the medical team to attend the ceremony with the shaman. I arrived, as the lone hospital representative, to find the ceremony under way.

It was an all-day function that took place in a tent erected in the backyard of the four-unit apartment building in east Oakland. There was a small, three-brick-high makeshift fireplace in the middle of the tent, into which symbolic paper cutout resemblances of the dead-to-be-appeased were fed, along with money.

The shaman, wearing a long, colorful vest, chanted while friends and relatives of the family talked and played cards on folding bridge tables, in the usual manner of these ceremonies. In the next yard, a few feet away, neighborhood kids were shooting hoops and glancing over at us curiously.

During the ceremony, I was startled by a sudden ringing and feared the interruption could ruin the child's recovery. As I reached down to silence my ubiquitous link to the hospital, I was surprised to see it wasn't my beeper. A man handed the shaman a cell phone. Later, a relative explained that this shaman was constantly in demand because of his skills appeasing the dead.

While the chanting continued, I was beckoned to the family's apartment one flight up to partake in a ceremonial meal. There was a whole butcher-slaughtered pig laid out on a coffee table and another being cooked. Fortunately, the pork served to me with a bowl of rice was very well cooked. But when the patient's mother -- clearly pleased with my participation -- placed a bowl of greens in front of me, I was told the raised thin red lines running through it were drizzles of raw pig's blood. So, I begged off because of a "religious prohibition against eating raw animal food." Out of politeness, I think, this explanation was accepted.

When I asked, the mother told me the boy did not know about the ceremony. I think I was searching for a Western explanation (the placebo, or suggestion, effect) should the intervention work and my patient get better.

The next day, the boy did begin to take small amounts of fluids and then some food. Because he no longer needed intravenous feeding, a transfer to a psychiatric hospital for children was arranged.

He was still quite frightened, so we gave him small amounts of lorazepam, a drug in the class of benzodiazepines (in the Valium family). When I called the hospital the next day, I found out he had perked up, was communicative with his family and had already been discharged to his home.

A few days later when I saw him in my office, he was quite reserved and refused to talk, but his mother reported that he was quite animated at home. I could only think that my original diagnosis had been correct, and that he had been cured by the shaman's taking care of the spirits that tormented him. But to appease my Western-medicine mind, I believed that his mother really had told him about the ceremony.

But he wasn't cured. Two months later, I was beeped to the emergency room where the Hmong boy had been readmitted with all of the same symptoms as before. About a week before, his mother said, he had stopped taking his medications, a plan the family and I had agreed to.

Visiting his room, I found him sitting up in bed, drooling a bit and non-communicative. His mother told me of a bizarre gesture that he had made the day before at home. He suddenly jumped up and started running across the floor toward the door, but just as suddenly stopped, frozen in midstep in a statue-like position, until he was led back to a chair.

Now it finally dawned on me that what we were dealing with was not the nightmare death syndrome of Laotian refugees, but a syndrome of catatonia. I approached the patient in bed, held his hand up, away from his body, and then let go. He held his arm in that position for more than 20 minutes without moving. This is called "waxy flexibility," another sign of catatonia. It was now clear that the initial hand movements I had insisted the neurologist rule out were really another sign of this disorder. His shutting down and not eating were clear hallmarks of catatonia.

The description of catatonia was first made in Innsbruck, Austria, in 1869 by Ludwig Karl Kahlbaum. He compiled a list of the almost 40 signs involving unusual movements.

Despite Kahlbaum's statements to the contrary, for decades catatonia was thought to be a type of schizophrenia. It does occur more frequently in people with other disorders, especially depression and post-traumatic stress disorder. There are two types: the stuporous one that afflicted my patient, who was frozen in a state of out-of-contact withdrawal, and an excited type of catatonia in which the patient is wildly active but not eating. The latter can result in a total collapse, with the patient at grave risk of dying.

Even my patient's peculiar response to lorazepam, a relatively mild anti-anxiety drug that seemed to work quite well, fits with the clinical experience found in catatonia.

Another useful treatment is the much-maligned electroconvulsive therapy. There is a case in the literature of an 11-year-old girl with excited catatonia who had not responded to medication and was near death. She was cured by a series of electroconvulsive treatments, although no improvement was seen until the 11th session. After her 19th, there was complete recovery. Fortunately, my patient did not require this treatment.

Now certain of my diagnosis of the Hmong boy's condition, I could tell the resident in the emergency room to try to bend his leg, knowing the likelihood that there would be resistance. This sign is known by the German word for resistance, "gegenhalten."

I wish I could report the same smooth outcome as experienced by the 11-year-old girl who, three years after her course of electroconvulsive treatment, was functioning perfectly normally. While the Hmong boy has not had another episode of catatonia, his underlying bipolar disorder was more difficult to treat, and he ended up being hospitalized twice more.

For a while, he lived in a group home, where he was well-liked. He is now home and going to school, and looking forward to no longer having to take medications someday.

Recently, I was asked to consult on a 17-year-old girl in an intensive care unit who, six months after being assaulted, had taken to bed and refused most contacts. She then completely shut down, did not recognize others, did not talk or eat, and was admitted to the hospital because she was becoming dehydrated.

This time, when I went to the bedside, I was quicker to look for waxy flexibility. I raised her arm and she kept it in the air without support for many minutes. I had to persuade the girl's grandmother to let me order a small dose of lorazepam, but eventually she gave us permission to begin the intravenous infusion. I told her if it worked, we would know the diagnosis very shortly.

Forty minutes later, I received a phone call telling me that the girl was sitting up and talking animatedly. Two months later, as with my Hmong patient, the girl had another episode during a psychotherapy session. She became totally frozen and had to be carried, almost like a mannequin, to the ambulance to be taken to a psychiatric facility.

Research is rapidly closing in on the genetics and biology of many of psychiatry's mysteries: schizophrenia, depression, autism, and the psychosis and dementia associated with Huntington's disease -- and their interaction with the patient's everyday life. But we are no better at understanding catatonia than Kahlbaum was, and our success in treating catatonia is no better understood than the shaman's ability to prevent nightmare deaths.

So much in psychiatric diagnosis still depends on context. Despite the old saw, sometimes it's hard to tell whether the animal making the hoofbeats really is a horse and not a zebra. I likely would have come to my first diagnosis of catatonia somewhat more quickly had my patient not been Hmong. But because of my experience with the Hmong boy, no matter what the ethnic background of the second patient, I would have lifted her arm to see if it would hang in the air.

Herbert Schreier is a psychiatrist with Children's Hospital & Research Center at Oakland.