Think Like a Doctor: Running in Circles

Think Like a Doctor

Solve a medical mystery with Dr. Lisa Sanders.

The Challenge: Can you solve the mystery of a 23-year-old man with uncontrollable episodes of aggressive, manic behavior?

Every month, the Diagnosis column of The New York Times Magazine asks Well readers to sift through a difficult case and solve a diagnostic riddle. Usually I provide all kinds of detailed lab reports and images from the patient's medical chart. But not this time.

Today, I'm presenting a case in which the diagnosis was made based on the patient's history alone. I'll share everything that the doctor involved had to work with, but I warn you, it's a tough one. As usual, the first reader to figure out this puzzle gets a signed copy of my book "Every Patient Tells a Story."

Let's get started.

The Patient's Story:

"Don't come near me!" the young man on the gurney shouted at the doctor who had just entered the small patient room in the emergency department of Alta Hollywood Hospitals (now called Southern California Hospital) in Culver City, Calif., near Los Angeles.

Dr. Jory Goodman, the psychiatrist on duty that day, calmly surveyed the agitated 23-year-old. The man was sunburned and unshaven. He had the distinct aroma of someone who hasn't showered in many days. His rumpled T-shirt and sweat pants were covered with stains and dark with sweat. A middle-aged man and woman introduced themselves as his parents. They appeared tired and anxious.

Their son had a history of manic depression that had never been well controlled, the mother explained. For the past six years, since his diagnosis, he'd been to many doctors and tried a dozen psychiatric medications. None of them worked. Some even seemed to make him worse. A few months ago he'd been on five drugs — the most he'd ever taken at one time — and still he had these wild episodes of erratic and aggressive behavior.

Descending Into Chaos

As the mother talked, she looked close to tears. Her face was drawn with fatigue; her eyes were bloodshot and swollen. The father sat quietly as his wife spoke. Their current psychiatrist had been tapering off the young man's medications, she continued, and for the past few weeks he'd been off nearly all of them. The plan was to start a new regimen once the drugs had been cleared from his system.

Then, a week ago, he'd gone completely wild. He stopped sleeping; he stopped eating. He ran around the yard half-dressed. His bedroom looked like the epicenter of an earthquake, with everything thrown randomly into the middle of the room – books, computer, CD's, furniture, pictures. He'd moved to the garage where he did the same thing, except that this time he built himself a tiny, carpeted cave amid the piled detritus.

Time in the Psych Ward

The parents finally called 911 one afternoon when their son began to run through the house and wouldn't stop. For hours, he ran in through the front door then out through the back, through the yard and back in the front door. Again and again and again he hurled himself through the house, bumping and sliding against doorways, walls, furniture, apparently unheeding of his encounters with the hard, cold reality of solid objects.

He had experienced episodes of these repetitive behaviors before, but never with such wild indifference to his own well-being. His mother tried to stop him – she grabbed his arm, his sleeve, his hand to slow him down, to try to get him to calm down. But each time he shook her off roughly and kept going. Terrified for his safety, she called the sheriff.

The arrival of the authorities quieted the young man almost immediately, but after assessing the devastated household, the sheriff took him to a psychiatric holding area for observation. There he was so out of control that at times it took six or seven people to restrain him. The next morning he was taken to a local hospital and admitted to the psychiatric ward.

The hospital discharged him after three days; he was too disruptive to keep, his parents were told. None of the drugs that doctors administered to calm him seemed to work; he remained agitated and uncontrollable. The psychiatrist didn't think he was a danger to himself or to others – the only reason the hospital would be required to keep him – and so he was released to his parents' care.

Desperate, they called their son's doctor. He instructed them to take the young man some two hours away to the Alta Hollywood Hospitals, where Dr. Goodman was on duty. He was an excellent psychiatrist, and an old friend. He would know how to treat their son. And so, she concluded, looking at Dr. Goodman, here they were.

A Doctor's Observations:

In his 30-year career, Dr. Goodman had made something of a name for himself as a doctor who could figure out the puzzling patients who ended up in the psychiatric ward. Dr. Goodman watched the young man closely as his parents told their story. He had already been given powerful sedatives to quiet him, and at times it seemed as if he were about to fall asleep. But just as his eyes began to close, he would erupt with expletives and strike out at those around him, then sink again into an uneasy quiet.

"Does he have any medical problems?" Dr. Goodman asked. Not really, the parents explained. Their son smoked a lot, both tobacco and marijuana. He drank, too. His back sometimes bothered him. Otherwise, he had no real medical problems.

Even so, over the past couple of years, he had episodes of abdominal pain severe enough to send him to the local emergency room. They never found anything. He'd had a bunch of tests – CT scans, colonoscopies, scores of tests of his blood and stools. He'd been checked for Crohn's disease and for ulcers. He'd been tested for everything anybody could think of.

When the tests all came back normal, time after time, doctors decided that he had irritable bowel syndrome, a disturbance in bowel function. His newest gastroenterologist didn't agree with that diagnosis. She thought he had some kind of intermittent muscle spasm in his abdominal wall. She gave him lidocaine patches, and that seemed to help. But mostly he was healthy, except for his outbursts.

Bipolar disorder ran in her family, the mother continued. Her uncle and several other members of her family had it.

Dr. Goodman looked at the young man on the stretcher: plump, disheveled and sunburned, angrily struggling against the powerful sedating medications. Then he turned back to parents. "I don't think your son has bipolar disorder," he said.

Solving the Mystery:

Can you figure out what this young man has? Dr. Goodman did.

Make your guesses in the comments box. I'll post the answer on Friday.

Updated, April 4 3:43 p.m. | Thanks for all your responses. Read about the correct diagnosis at "Think Like a Doctor: Running in Circles Solved!"

Rules and Regulations: Post your questions and diagnosis in the comments section. The correct answer will appear Friday on Well. The winner will be contacted. Reader comments may also appear in a coming issue of The New York Times Magazine.

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