From there they went through a series of investigations over the course of quite a long period of time. Timothy, after all, had to continue to go to school, and even though Dr. Putnam was true to his word about fighting balking insurers successfully, such fights sometimes took a fair amount of time.
One of the first things Dr. Putnam considered was that perhaps episodes of low blood sugar were what triggered Timothy’s outbursts. Timothy read up on this himself a bit, once he was told about it, and he thought it made some sense, at least as a possibility. After all, very low blood sugar—so he learned—tended to trigger the body to release large amounts of the various stress hormones, activating the fight-or-flight system, and this, combined with the low blood sugar making the brain function poorly, could lead to hostile and irrational behavior, even violence. Dr. Putnam even told Timothy about a tribe—he inserted the caveat that this story might be entirely fictional, as far as he knew—that somehow had a tendency toward low blood sugar, and who had developed the practice of, upon meeting one another, getting into semi-ritualistic fights, so their hormone responses would raise the glucose level back up and make them feel better.
Dr. Putnam also told Timothy that, paradoxically, some people who were at risk for developing diabetes showed up initially with episodes of low blood sugar, as their pancreas overcompensated for insulin resistance. Timothy tried to recall whether, on the many occasions when his temper had taken control of him, he’d had enough to eat, or if there had been any other pattern to his diet one way or the other. He could, unfortunately, recall nothing specific about what or when he’d eaten on any of those occasions.
Dr. Putnam said that he already knew, based on standard blood tests, that Timothy’s fasting blood sugar was normal, but that the fact didn’t mean Timothy couldn’t still be insulin resistant. So, after first doing an irritating test called a glucose tolerance test—involving fasting, a blood draw, drinking a sugary drink and then having three more blood draws—that showed nothing, Timothy was put through an even more irritating test called an insulin tolerance test. This involved fasting for twelve hours, getting his blood drawn, and then being given insulin, which dropped his blood sugar down even from his fasting level.
This test made Timothy feel as awful, as nauseated, as vague, as physically tired, as stupid, and just generally as barely alive as he could remember feeling, but it did not make him feel angry—not even at Dr. Putnam nor at the people who administered the test. When he was allowed to eat finally, after more blood tests measuring glucose, and growth hormone, and other blood hormone levels, the cheap hospital food they gave him tasted more wonderful than anything he’d ever had before in his life.
All of this turned out to be for naught, since the hormone and chemistry levels revealed by those tests were, per Dr. Putnam, all completely within normal range. He jokingly told Timothy that the only abnormal thing about his tests so far was how normal they all were. Timothy could see the humor in this, and he could also recognize the man’s point when he commented that at least Timothy knew, better than most young men his age, that his health was excellent. However, it was frustrating. It didn’t make him angry—his sense of rage-inducing injustice never included a reaction to simple facts of inanimate reality. Reality, as far as he could see, promised nothing and owed nothing, so if brute facts turned out not to be the way he wished them to be, well…that was just tough.
Another possibility Dr. Putnam entertained, but which he apparently considered somewhat less likely, was that Timothy’s outbursts were a form of seizure. Once he learned a little more about what seizures were, Timothy found this potential explanation much more intriguing. It felt more right to him than some of the things that had been discussed before—except the brain tumor notion—because when Timothy’s rages occurred, they really felt as though they were coming from some separate and irresistible part of him that was beyond his control, as though there was another being inside his head, a being that expressed itself—indeed, that existed—only in extreme rage. If this was caused by some atypical, irregular firing from a microscopic lesion somewhere in a specific part of his brain, then that would match nicely with Timothy’s experience.
He found the process of getting an EEG interesting, in some ways more so than the MRI had been, and certainly it was far preferable to the ordeals of the two “tolerance tests” he’d endured. It felt almost like science fiction to be having wires attached that sensed the electrical activity in his brain, weirdly even more so than the MRI had felt. Unfortunately, that interest was unrequited, for Dr. Putnam informed him that his brain’s electrical activity—like its physical structure, like his blood, like his hormones, like everything else so far—was entirely within normal limits.
Timothy amused himself at one point with the notion that he was so angry because he was perfectly designed and everything and everyone else was so imperfect that they couldn’t be tolerated. Of course, this was just an ironic mental joke, one he never spoke out loud, for he was the last person to think of himself as perfect.
The thoroughly non-pathological results of all the tests so far would have been far less irksome if Timothy’s problems had been diminishing. Unfortunately, they had not. His deliberate self-isolation protected him from many personal arguments and conflicts that could have escalated, but it left him with a bit less emotional armor against some other frustrations. Thankfully, he had no new altercations before his hand was reasonably healed and his brace unnecessary, because it was doubtful that unhealed fractures would have deterred him.
Not too long after, though, on his way to school, a passing student whom he’d seen but with whom he’d never interacted, mistakenly prodded the sleeping dragon in Timothy’s head. Timothy had some mild trouble with seasonal allergies, and during the springtime, especially in the morning, his tended to breathe through his mouth due to congestion. Something about his expression, with his mouth hanging open as he walked to school, must have seemed amusing, because this other boy, who was mildly overweight and didn’t seem like a mental marvel himself, walked adjacent to Timothy for several steps and said, “Look at the retard!”
Since there was no one else close enough to be the target of the remark, Timothy was obviously its victim. He didn’t have time, at the moment, to think about the stupidity of the boy’s remark, how poorly it reflected on him rather than on Timothy, how utterly unlike the truth it was, since Timothy was one of the better students in the school. He just felt instantaneous ignition in response to the mean-spirited, hurtful snipe, and in response to the sneer on the other boy’s slightly chubby face.
Without thought or warning, Timothy exploded, swinging his left fist across his body and into the left side of the boy’s face. There was no thought behind this, and there was likewise no notice of any feedback to Timothy of the pain in his own fist caused by striking the cheekbone of the boy, padded though it was. His senses were suddenly and acutely narrowed. The targeted boy, who had clearly not even seen the blow coming, recoiled, and he fell over to his side more because of the surprise and the tangling of his feet than in response to the force of the blow.
“What the fuck…” the boy said as he stumbled, catching himself with his right arm, so he didn’t completely become prostrate on the ground. This was just as well for him, because Timothy did not hesitate, but instead followed up with a kick that landed on the boy’s upper rear thigh. The swinging of this kick was accompanied by a growl of rage from Timothy, in whom coherent, human thought was temporarily suspended.
The boy yelped when the kick landed, and he quickly rolled himself away from Timothy. Looking back up, his eyes wide with surprise more than pain, he seemed about to shout something at Timothy. That shout never reached the air, though, for Timothy continued to stride forward, swinging his other leg toward the boy’s face.
Though plump, the boy had good reflexes, and he blocked and dodged at the same time, taking only a glancing blow on his forearm. Timothy growled more loudly, his noise mingling with the other boy’s own inarticulate cries of surprise and growing fear.
The boys had been walking on a sidewalk next to a side-street, along the normal path to Timothy’s school. In rolling and scrambling away, the targeted boy fell into the street. A car was, at that moment, passing by on the other side of the road, and the driver honked, though the vehicle was half-a-road-width away from the boy. This startled the boy, but not Timothy, who had no eyes for anything but the target of his ire. This time, for no clear reason, he switched back to his arm, and with it and a flexing of his upper body, he swung down at the boy.
Again, the boy’s good reflexes served him well, and he was able to take the blow on his own raised arm. This was a more solid connection than the kick had been, and it probably hurt, but the boy was able to ignore it. He rolled, scrambled, and forced his way farther out into the street, finally regaining his feet as he scrambled toward the other side of the road.
If the road had been very busy, either or both of the two boys might have been hit by a car, but to their good fortune there was a relative lag in the traffic. The targeted boy, realizing intuitively that he was facing someone on whom words would not work—though they had triggered the attack—just did his best to get to his feet and run. Despite what might have seemed to be a sedentary frame, he seemed to have good underlying physical health, because he was able to rise and begin sprinting in nearly one motion, taking off at an impressive pace, across the street and onto the opposite sidewalk, heading more or less toward the school. Some part of his brain probably told him that, if he were to reach the school, or even to get close to it, the presence of adults might deter his growling pursuer. He was almost certainly wrong in this, since Timothy was not more likely to be inhibited by the presence of authority figures than he was by the presence of potentially lethal automobiles. Instead, it was luck, and Timothy’s blind rage, that prevented any further damage.
Timothy sprinted across the street after the boy, his rage giving him terrific speed, and his own lighter frame easier to get into motion than the other boy. However, his riveted focus on his target meant that he didn’t pay much attention to where he was going, so when he went up onto the other side of the road, his foot caught on the edge of the curb. His forward progress was levered into a downward trajectory, and though there was a grassy berm on that side, Timothy was tall enough that his face came into contact with the sidewalk.
He didn’t feel the pain of the contact, but the blow jarred him enough to send his perceptions bouncing and jangling around in his head, with flashes of whiteness exploding from within the redness of his furious vision. This barely stunned him for even a second, but that was enough time for the other boy to gain a significant lead, and to go around a nearby corner. Timothy began to scramble to his own feet, but his trailing shoe still dangled over the curb, and he stumbled again. Thwarted now in his targeted rage, he howled aloud in fury—not noticing that the several other students within earshot turned and looked at him with fear and puzzlement.
Not thinking still, he slammed his left fist down in a hammer blow against the sidewalk pavement. He would probably have repeated this several times, but he caught sight of a good-sized rock nearby, one larger than his two fists put together—probably a remnant of some past construction job—and he seized this, raising it and then slamming it down onto the sidewalk. The sound of its impact rang out like a muffed gunshot, and this noise pleased the anger that possessed Timothy. He raised the stone again, still almost fully prone, and smacked it down onto the sidewalk.
Even the most enraged young teenager couldn’t develop enough force to do any serious damage to a concrete sidewalk, but the stone, evidently made of more flawed material, cracked after the fifth such impact. Timothy, who had punctuated each blow with an incoherent shout that was almost a roar, first hit the pavement with each of the two new, smaller rocks, then flung them randomly away from him.
By now, no longer in the presence of its target, and apparently accepting that it would be unsatisfied, his anger began to fade. Timothy struck the sidewalk with the sides of both fists once, and now he was able to feel the soreness in the bones of his right hand as he did this, as well as the stinging in his left hand from the previous, more severe, blow. He lowered his face into the border of the grass and the pavement, giving a final shout that contained self-directed anger in almost as great a proportion as that which was directed outward, and he clenched his eyes shut.
Slowly, he regained a semblance of calm. When a passing student, a girl, asked him if he was all right, he was able to reply, “I’m fine,” with reasonable, if limited, courtesy, not looking up, before finally getting to his own feet and continuing toward school. His whole body shook with the residua of anger, but his self-loathing was the greater force. He averted his eyes from any other gaze the rest of the way to the school, so he didn’t know if anyone was looking at him, nor did he listen for any comments on his mad behavior.
The incident was never reported to any school officials, apparently, whether because the other boy was afraid or felt that he’d started the “fight”, or because he just thought it would be more trouble than it was worth. So, this was one of the rare incidents whose only consequences were painful scrapes and bruises on Timothy’s forehead and hands, and a renewed aching in the recently healed bones of his right fist. The other boy never approached him again, and indeed, Timothy never saw him except from a distance. He supposed, if that other boy had been part of some gang, there might have been more dire consequences. That could have been bad indeed, for Timothy didn’t think that he’d be deterred by a gang of boys any more than he would be by a single one, or by a car, or by a teacher. This would not, though, make him immune to any weapons—sticks, knives, and even guns were not outside the realm of possibility—that a youth gang might bring against someone who had wronged one of their members.
There were occasions, through the months and years, when Timothy regretted that there had been no such reprisal. There were many times when he more than half-envied his father’s destruction at the hands of an armed bar patron.
As the months and even years ticked by, Timothy’s tests ordered by Dr. Putnam continued to come back negative. Though many others would have been pleased by such results, in Timothy’s mind, they lived up to their designation. He saw only detrimental facts about reality in his discovery that he had—so far—no obvious, organic cause within him that provided a clear source for his episodes of uncontrollable rage. As more and more tests failed to give him the moral reassurance that his temper was not simply a character flaw, his mood and sense of self became more and more despondent. To his credit, he continued to work hard in school, to study, to practice, to work toward a future in which he could be a productive member of society. This felt like an impossible dream at times, though he knew it was painfully prosaic.
He continued to get into “fights” as time went by, their frequency never seeming to diminish. As before, he was often saved from far more severe outcomes, such as possibly causing permanent damage or even killing someone, by apparent good luck more than anything else. He was suspended from school on more than one occasion, and by rights—given the whole tendency toward zero-tolerance policies that were becoming more and more common—he probably should have been expelled. Thankfully, though, nearly all the faculty and staff of the school knew him to be a dedicated student, a hard worker, as well as a lonely young man. They also couldn’t help but notice the pattern that Timothy’s rage was always in response to something that someone else had done. It was usually out of proportion, but there was always a trigger in someone else’s behavior. This led to the speculation that Timothy was being bullied, or abused, either by other students, by some family member, or even by some other, unrelated adult.
It was also to Timothy’s great fortune that, in his rages, he never tended to reach for any kind of weapon. This seemed to be either a function of the primitive urgency of his fury, which precluded the use of anything but fists and feet, or to some tiny degree of subconscious control exerted by the rational part of Timothy’s brain. It was not merely good luck, for there were many occasions on which a nearby rock, or stick, or chair, or some other object could easily have been wielded, producing potentially lethal results. Yet, as with the boy on the way to school, Timothy only ever used such makeshift weapons against inanimate objects or against himself.
Timothy’s mother became increasingly impatient with him as she was called to the school on multiple occasions, often the subject of thinly veiled suspicion that she was a less-than-fit mother. She was frustrated with the occasional trips to the emergency room, but this was helped by Dr. Putnam, who told them that, for minor injuries that might require no worse than stitches, they could simply bring Timothy to his office, and he would be worked in. This saved on embarrassment sometimes, and it saved on fighting insurance companies to reimburse for ER visits and ambulance rides. Timothy suspected as well that Dr. Putnam frequently chose not to bill them for such visits.
As the more glaring physical causes of Timothy’s rage were ruled out, Dr. Putnam was forced to move to other possible diagnoses, though he never wavered in his belief that these rages were caused by some dysfunction in Timothy other than a mere problematic personality. Timothy’s recollections of the various events to the doctor seemed only to reinforce that sense.
Dr. Putnam came to wonder, as he said in some of his discussions, whether Timothy’s rages might be the presentation of some form of endogenous depression, as he had mentioned in one of their earliest meetings. This, Timothy suspected, was at least partly due to reports from the school, where Mrs. Gibson, and some of the teachers, noted that Timothy had become more isolated and withdrawn from social interaction with other students, though there were acquaintances with whom he interacted, and even people he helped with homework and the like.
In one of his office visits, during the early part of his junior year of high school, Dr. Putnam asked Timothy about depression, leading finally to the question, “Timothy, do you ever think about hurting or killing yourself?”
Timothy gave a mordant laugh and replied, “Well, I hurt myself a lot, but I guess you know that. But that’s usually just…well, not accidental, but you know, it’s not really something I think through. I mean, I’ve heard about people doing things like cutting themselves and burning themselves and all that. I’ve even wondered sometimes about what it felt like, and everything, and I’ve certainly gotten pissed at myself enough to think about doing it like a punishment. But I really don’t think it’d make me less angry, or whatever. And I’m worried it might even make me worse, because it’d be something I’d feel nervous about and all that. And it’d hurt, too, and that…doesn’t tend to make me less angry.”
Dr. Putnam watched Timothy with a tilted head, as he often did, waiting through several seconds of silence before saying, “You didn’t answer the other part of my question.”
Timothy sighed, having been quite aware of his own omission. He took a moment to compose his thoughts before saying, “Okay, well…if you mean, do I think about, like, ending it all because I feel miserable and want to get away…you know, want to escape from pain or something like that, or just because I hate myself, then, no. I mean, for one thing, I don’t think I could ever do that to Mom. Not for something like that. I’d rather try anything I could—everything I could—before I’d even think of doing anything like that.
“But…ever since you told me about that Texas Tower guy…and when I think about those kids in Columbine, and the other stories you hear in the news about people killing their families, or their girlfriends, or whatever, and then killing themselves…well, from a long way back, I decided that, if I ever thought that I was getting to the point where I was going to do something like kill innocent people, or especially kill my Mom, or people at school, or anything like that…well, I figured, if I was at that point, then, yeah. I’d make sure to kill myself first. I mean, I have the right to kill myself, right? But I don’t have the right to kill anyone else.”
It was hard to read Dr. Putnam’s face as he said, “I see.”
“Is that crazy?” Timothy asked, honestly curious but not worried about the doctor thinking so.
“No,” Dr. Putnam said, shaking his head quickly. “It’s not crazy. I’d go so far as to say that it’s unusually sane. At least in a certain sense. But I do need to know how seriously you’ve considered this, so I want to know…if you don’t mind, have you ever thought about…how you might do something like that, if the time came?”
“Well, yeah,” Timothy admitted, now feeling slightly embarrassed. “I mean, I wouldn’t want to do anything that’d cause anybody too much trouble, right? I sure wouldn’t want to kill myself at home, so that Mom would have to be the one to find my body or something. That’d be terrible. And I don’t think I’d want to cause other people too much trouble, either. I mean, I thought about jumping off a building or something, but that’d be dangerous if I did it when anyone else was around. So, if I did that, it’d have to be at night, or someplace kind of deserted. I thought about maybe even going to the ocean somewhere and just trying to…I don’t know, swim out as far as I could, until I couldn’t swim anymore. But that’d take some serious willpower, you know? I’m not sure I could pull it off. But it would be pretty clean, at least.
“Or I guess I could try to…find someone around school or the neighborhood who sells drugs and try to take an overdose of something. Stuff like that.”
After another long pause, Dr. Putnam said, “It sounds like you’ve thought about this a lot.”
“I don’t know if I’d say that,” Timothy said, eager to wipe the worried frown off his doctor’s face. “I mean, I’ve thought about it…carefully, I guess you might say. But it’s not like I think about it regularly or anything. I don’t. Almost never. But I figured, once I’d decided that, if I had to, I was gonna do it, I might as well think it through, you know? Doing something like that just…off the cuff is just gonna make things messy and bad, you know? But it’s probably been months since the last time I thought about it.”
There was another long pause, Dr. Putnam regarding Timothy with what now seemed to be a look of real compassion and concern. Timothy wasn’t sure, but he thought, behind his glasses, that Dr. Putnam’s eyes seemed to be glistening slightly, as if he were fighting tears. But then, he thought, surely that wasn’t the case. After all, Dr. Putnam had to have seen an awful lot of people suffering, and even dying. He couldn’t be moved near to tears by some stupid teenager who couldn’t control his temper. If he was that touchy-feely, he surely would have had a nervous breakdown by now.
With a sigh, Dr. Putnam finally spoke, saying, “Well…I wouldn’t say that you have typical symptoms of depression, but well, it can present in lots of unusual ways, especially in young people. And it can present with irritability, certainly, that’s a known fact. So, maybe it really is the cause of your difficulties. But that leads to a bit of a problem.”
“What’s that?” Timothy asked.
“Well…the treatments for depression are…well, many and varied is probably an understatement. There’s therapy, of course. Cognitive behavioral therapy is probably the most consistently effective of these, and it works very well in a lot of people. And it has the advantage of not producing side-effects…unless you count a greater self-awareness as a side-effect. But the thing is, it works on people’s negative thoughts, helps them reorient and correct problematic patterns of thinking. And I don’t see that as the root or nature of your difficulties.”
“Okay,” Timothy said, not completely sure that he was keeping up, but agreeing with the doctor in that he didn’t think he had patterns of thought that led to his anger. If anything, he tried to be positive, he was disciplined, he worked hard. And he didn’t dislike other people, either. In fact, his troubles might have been fewer if he did. After all, if he hated other people and the world, he wouldn’t care much about occasionally losing control and brutalizing them.
“So, if you’re suffering from depression, then it truly is an endogenous type, some trouble with a set-point in your brain somewhere, in the mood circuitry. And the treatments for that are pretty much anti-depressants or, in extreme cases, ECT.”
“What’s that?” Timothy asked.
Looking embarrassed, Dr. Putnam replied, “It’s ‘electro-convulsive therapy.’ Sometimes people call it electro-shock therapy, but that’s a little misleading. But I don’t see myself being able to get you treated with ECT, even if you wanted to be, even if I thought it was the right choice, without serious lying through my teeth. And having you lie through your teeth. And I don’t get the impression that you’re a very good liar.”
Timothy thought about that comment, not ever really having considered the notion before. After only a moment’s thought, he said, “Yeah, I don’t really think I am. Sorry about that.”
“No need to apologize,” Dr. Putnam said. “It’s not something to be ashamed of. A lot of people may find lying useful in the short term, but I think it’s one of the attributes of humanity that’s caused us the most trouble throughout history. I like the fact that you’re not a good liar.
“But the trouble with the chemical anti-depressants, which are our other options, is that, for one, they’re just fraught with unpredictable side-effects. More importantly, though, there’s good evidence that when they’re given to children and adolescents, they don’t act in quite the same way they do in adults. There’s even some data to indicate that they increase the rate of suicide in such individuals.”
“Whoa,” Timothy said. “That doesn’t sound like a good thing.”
“No, it doesn’t,” Dr. Putnam said, smiling a little in apparent amusement at Timothy’s understatement. “Not to say that every young person who takes them has a bad outcome. I’m sure they’re useful in many cases. But…they’re so hard to predict. It’s impossible to know, for instance, which particular med, or even class of med, is going to work on any given patient. It all comes pretty much down to trial and error. Which is not the ideal way to practice medicine.”
“Yeah, I guess not,” Timothy said, surprising himself by feeling disappointed. The notion that his rages might be caused by some underlying depression, some misaligned set-point in his brain, was at least consistent with the fact that it never seemed to come from a conscious process, and indeed seemed more to be a force that overwhelmed him than the product of some errant train of thought.
Dr. Putnam paused for another interval. Timothy idly wondered whether there were other patients waiting to be seen, and the thought made him feel slightly guilty.
Before he could mention anything about that, though, Dr. Putnam said, “Timothy, I know we’ve spoken briefly of it before…but I was wondering, did you ever…well, have you ever tried marijuana?”
“What?” Timothy said, then caught up with his thoughts. “Oh. Yeah, I remembered you talking about that once, and…well, there were these guys from school who were going off somewhere to smoke some once, after school, and I kind of…well, I went up to them. They looked a little nervous at first—I mean, I’m not someone who hangs out with guys like that much, and I’m like a ‘good student’ type, except for the fighting, so maybe they thought I was gonna tell on them or something. But I just kind of…asked if it’d be all right if I tried a little, like a puff of it or something. I even offered to pay for it.”
“Of course, you did,” Dr. Putnam said with a smile.
“Yeah,” Timothy went on. “Well, anyway, they were, like…well, they were like really cool about it, actually. I was kind of surprised. I mean, I’d always kind of thought that people who used drugs were like, seedy and suspicious and kind of…I don’t know, bad kids and that. But they were really cool.”
“Well, there are drugs and there are drugs,” Dr. Putnam interjected. “Marijuana is quite different, in lots of ways, from most other illicit drugs.”
“I guess so,” Timothy said, not sure he understood the point. “But anyway, these guys were all, like…really welcoming, you know. It was almost like how I’d imagine people’d be if you asked if you could join a church service on Sunday or something. They were all smiles and congratulations, you know?”
Dr. Putnam smiled more widely, and he said, “Huh. I’d never thought about it quite that way, but…well, it makes sense. Marijuana can be almost like a religion to some people, and it certainly can be a sacrament. I’m not too surprised they welcomed you.”
“Yeah, they did,” Timothy said. “And not even in a funny kind of way, like a ‘ha-ha, isn’t this hilarious, this good student coming and asking to take a hit off our joint,’ kinda thing. They really seemed like they liked the idea of me trying it, like they thought it might be good for me. I kinda liked them.”
“I see,” Dr. Putnam said. “So, what happened?”
“Well…I took a puff, and tried to hold it in, like they said I should. Man, I couldn’t do that for long. I was coughing and stuff, and they kinda laughed and everything, but I was laughing, too, so it wasn’t like they were being mean. And they said I probably shouldn’t do more than that my first time, or I might feel sick.”
“Interesting,” Dr. Putnam said. “Sounds like a good and a careful bunch of pot-heads.”
Timothy cocked an eyebrow. He realized that Dr. Putnam was speaking tongue-in-cheek, but he still felt mildly irritated by what seemed like a condescending attitude. The look on the doctor’s face, though, alleviated his irritation, for the expression of pleased affection was impossible to miss. At least, it was impossible for Timothy to miss, who had come to know his doctor better than he knew pretty much any of the kids at school.
Forcing a smile, himself, Timothy said, “Yeah, I guess so.”
“So, what was it like?” Dr. Putnam asked.
“Well, it was…interesting, that’s for sure,” Timothy said. “I mean…everything felt a little different, and all that, with some things getting sharper and some things more…I don’t know, not blurry really, but unimportant or not worth noticing, something like that. And I felt a little floaty. And time got a little weird, too. I mean, when I walked home after that, I felt like I was moving in slow motion, and that everything didn’t seem quite real, you know. And I felt like it must’ve taken hours for me to get home, but when I looked at the clock it was the same time as usual.”
“So, did you like it? Did it help?” Dr. Putnam asked. Timothy thought he sounded as though he were struggling between unreasonable optimism and fatalistic pessimism. But, of course, he had to know something about the outcome, since Timothy was here now. His problem hadn’t disappeared.
“Well…not really,” Timothy said. “I mean, those guys told me I should come back any time I wanted, which was really nice of them, but…I never felt like I wanted to do that again. It was too weird, I felt too out of control…though that’s not quite right, I mean, I didn’t do anything weird.
“But also…it didn’t help my temper. In fact, it might’ve made it worse, or at least different. You see, I got into my closet a little bit after getting home, and maybe I was more clumsy than usual, but…well, I had a bunch of board games and other stuff from when I was little up on the shelf, and I guess I bumped them and a lot of them fell down. And an old Etch-a-Sketch hit me on the head. And I just…flipped out.”
“What do you mean?” Dr. Putnam asked.
“Well, I…I mean, well, I don’t usually get mad at…at things, you know. But I sure did this time. I mean, I ripped a lot of those games to shreds, and I threw them around the room, and I smashed the Etch-a-Sketch against my bed post, and my desk, and threw it against the wall…I can remember it happening, but it was like I wasn’t doing it myself, quite…though, I guess that’s not quite right, because it was definitely me that was so mad. I mean, I hated that stuff that had fallen on me, I hated the fact that that junk was up there, even though I hadn’t used it in I don’t know how long. I hated myself for being so stupid as to want to keep it all, just because it was from when I was younger, and it was stuff I had fun with back then. And I wanted to just…just wreck it so bad that you couldn’t even tell what it used to be.”
“Wow,” Dr. Putnam said quietly. He looked as though his heart had just been broken.
“Yeah,” Timothy said. “I mean, by the time I calmed down, the room was…well, it looked like a bomb had gone off in it. The stuff from inside the Etch-a-Sketch was all over, and paper and cardboard and game pieces were everywhere…and puzzle pieces, and old pieces of plastic models, too. I really did a job on it.
“I mean, it’s good that Mom doesn’t come home early. I had time to clean everything up and throw it in the dumpster down the way before she got there, and to vacuum up the Etch-a-Sketch stuff…that stuff’s a pain, I can tell you. I couldn’t fix everything…I mean, there’s dings in the paint in a couple spots on the walls of my room, and the edge of my desk has a bunch of marks where I hit it with stuff, and so does the end of my bed. But…well, when Mom came in later, all she said was she was impressed that I’d cleaned my room on my own, and when I told her I’d decided to get rid of a bunch of the old stuff I had in my closet, I’m pretty sure she knew it wasn’t that simple. But she just said ‘good’ and thanked me again and all that. I only realized later that she could probably smell weed on my clothes and stuff…I hadn’t even thought about it. I don’t know what she might’ve thought about that. Maybe she thought I’d had a stash that I was trying to clean up or something.”
“Somehow I doubt that,” Dr. Putnam said quietly.
“Yeah, I was really just kidding about that,” Timothy said. “I think she kind of guessed what must’ve happened but decided not to make anything of it. I mean…I had cleaned up after myself, after all.”
“So you had,” Dr. Putnam said. He was not smiling.
“Yeah,” Timothy said. He thought that Dr. Putnam must be thinking that his words sounded like those that might have been spoken by someone who had committed some quite severe crime…perhaps even a murderer. Or maybe he just thought Dr. Putnam was thinking that because it was how he felt, himself.
After a silent pause, something with which the two had become at least fairly comfortable in each other’s presence, Dr. Putnam said, “Well…I think that’s put the kibosh on that hope, at least. And obviously, I’m not going to recommend any other kinds of illicit drugs. They’re all much more likely to do harm than to do good in your circumstances. I don’t think even MDMA would be a good idea, however much some people find that it makes them feel…what would you call it, unconditional love? But it lasts far too long in the body, anyway, so if you had a bad reaction…well, I don’t even like to imagine that.”
“Yeah, seriously,” Timothy commented, though at that point in his life, he had no idea what MDMA was.
“Similar problems—maybe even worse ones—apply to LSD or Psilocybin,” Dr. Putnam went on. “Although there has been some recently renewed research into their therapeutic benefits, I don’t think we know enough yet, and again…their effects last far too long.”
“Right,” Timothy said. He at least recognized the acronym LSD, though he didn’t know much about it, and he guessed that the other word, which he could not recall having ever heard before, might refer to something similar.
“But…well, the whole point of most antidepressants is that they have long effects, as well,” Dr. Putnam said. Then, with a wrinkling of his brow, he added, “Well, no, I guess that’s not the whole point. But still, a medication of that sort is usually best if the patient can take it once or, at most, twice a day. Most medicine that’s used for any kind of chronic purposes is made that way. And the antidepressants are just such animals. And I don’t know the latest data on it, but they’re probably second only to blood pressure meds among the most prescribed pharmaceuticals in the word, or at least in America. And of course, we don’t know in great detail how any one of them works in any given person to combat depression…not that we have a very much better idea of the causes and responses to hypertension, if it comes down to that. And this is all despite the millions and millions of people who have used these medicines.”
Timothy wasn’t sure what to say. He felt very much that Dr. Putnam was now talking to himself.
“But I don’t like the idea of sitting and doing nothing while counting on luck to keep you from getting involved in some situation that causes you much more trouble than you’ve had so far,” Dr. Putnam went on, now focused more on Timothy. “After all, you have been lucky in some ways, and you can’t count on that forever. I don’t remember where I read it, but some law enforcement expert once said that if you keep on getting into gun fights, sooner or later, you’re going to be killed in one, no matter how good you are. And I don’t want anything parallel happening to you.”
“Okay,” Timothy said, moved by the doctor’s obvious concern, but far from clear about what the plan was.
Dr. Putnam looked down at the surface of the desk, on which Timothy’s medical record lay open. Timothy didn’t think he was really reading it, but was just staring randomly, while the wheels in his head turned and he tried to think of the best course of action. Finally, the doctor looked up and said, “Okay. Well, here’s what I think we should do. I’m going to write you a prescription of the lowest dose of the antidepressant, Paxil. It’s what’s called a selective serotonin reuptake inhibitor. That’s a fancy way of saying that it works by making the neurotransmitter serotonin stay in a synapse longer, and serotonin is at least one of the neurotransmitters associated with positive mood and equanimity. Now, for that class of meds, Paxil is sometimes decried because it has a relatively short half-life, but in your case, I think that makes it our number one choice. So…I’ll have you start by taking half a pill in the morning, even of the smallest dose, and seeing how it goes for at least a week before going to the full pill.”
He pulled out a prescription pad and started writing on it. Timothy, a bit troubled, said, “So…I mean, what do people…what does someone feel like when they take this medicine? I mean, it’s a medicine for depression, so it’s gonna make you feel different, right?”
Dr. Putnam looked up from his pad, tilted his head, and replied, “Well, to some degree, I suppose. Though the antidepressants famously aren’t really supposed to make you feel in any noticeable way different other than to very gradually improve the symptoms of depression. If they do that, because, by the way, like I said, it’s often difficult to find the right medicine for any given person. But with Paxil, at least, people don’t’ tend to feel sedated, or groggy, or anything like that. A few people I’ve prescribed it have reported that it made them much more garrulous than usual.”
“Garrulous?” Timothy asked. He’d heard the word, but he couldn’t recall its meaning.
“Talkative, chatty…gabby, I guess you might say,” Dr. Putnam explained.
Timothy couldn’t help but chuckle. “That’d be a really…interesting change for me,” he said.
Dr. Putnam chuckled as well, and he said, “Yes, you do tend to be a bit laconic, don’t you?”
“Yeah, I guess I do,” Timothy replied, privately telling himself that he needed to look up the meaning of ‘laconic’ when he got home, because he felt too embarrassed to ask Dr. Putnam to elaborate about two words in a row. He guessed it must be somehow opposite to ‘garrulous,’ but he didn’t want to make a mistake, especially about a word that seemed to apply to him.
“Anyway,” Dr. Putnam said, “it’s relatively low in side-effects, and since you’re taking a very small dose, it should be particularly good that way. A few people get a little bit of nausea when they start taking it, but that tends to pass quickly. It’s not supposed to cause dry mouth or anything along those lines, though of course some patients will still claim that it does for them, and I’m in no position to gainsay them.
“Now…this is a very important point,” Dr. Putnam’s tone suddenly became much less casual as he finished writing out his prescription. Looking directly into Timothy’s eyes, he said, “I told you already that, in younger people, there is some indication that SSRIs and other antidepressants can sometimes increase the risk of things like suicide. And even in adults, in the early stages of treating depression, as the mental inertia starts to fade, but before depression symptoms are all gone, there can be a brief bump in the risk of attempted suicide. Now, obviously, I think this is a small risk in your case…very small, because I wouldn’t be taking even a chance of it if I thought it was…I don’t know, even a one in a hundred chance. But it’s serious business, no matter how unlikely. If you find that you’re thinking…differently than you usually do, especially in a bad way, especially about things like hurting yourself or killing yourself…I want you not to take a single other dose of this, and I want you to call me at your next full pause. Understand?”
Timothy felt a bit nervous—which he supposed was Dr. Putnam’s intent—and he wasn’t at all sure he liked the idea of taking something that required such warnings. Still, he was more than happy to agree to these particular terms. “Yeah,” he said. “I understand.”
“Good,” Dr. Putnam responded, smiling in clear relief that Timothy was taking his warning seriously. He tore off the paper on which he had been writing and handed it to Timothy.
Timothy looked down at the paper which he now held. Dr. Putnam’s handwriting wasn’t quite as bad as cliché made out such writing to be in physicians, but still Timothy had to squint to make out what looked like it might be the word “pavaxetine” or “panoxatine” or something along those lines, followed by “10ng,” perhaps, then below this a clear “1/2 tab” followed by what looked for all the world like “qam,” which was not a word Timothy could be sure how to pronounce. Would it “kam” or “quam”? He would have suspected the word “gam,” which he knew from reading was an old slang term for legs, if not for the very prominent rearward tail on the “q”. In any case, that would make little more sense than the unpronounceable thing he thought was correct.
All this was followed by a peculiar line that read, “increase to” then a weird symbol like a small “i” with a horizontal line between the dot and the main body of the letter, then the word “qam” again, and a clear bit of English, “as directed.”
At the bottom of the open space, above Dr. Putnam’s signature and various license numbers was the line, “Disp # 30.” This, at least, seemed clearly to mean that 30 pills would be given through this prescription. That made sense, he supposed; a month was about thirty days. So, he was expected to need to take this medicine for at least a month, it seemed.
Then, he noticed, on a pre-printed space that read “Refills____”, Dr. Putnam had entered the number “5”.
Jesus. Did that mean he was expected to need to take this medicine for 6 months? This was a new thought to him. The longest course of medicine he’d ever taken before had been a two-week course of Amoxicillin when he’d had a particularly bad sinus infection a few years before. He knew that many adults had to take daily medications, of course, but he hadn’t expected to need to do so at his age. Even his mother took no prescription medications, and rare over-the-counter meds.
Looking up at Dr. Putnam with some trepidation, he asked a question that was only tangential to his real concerns. “Is this gonna be expensive? I mean, is insurance gonna cover it?”
Dr. Putnam gave what amounted to a combined shrug and nod, and he said, “It ought to. I’ve written it for the lowest dose, and for the generic version of the drug. Of course, if your mother has any questions or wants to talk to me about anything regarding the medication before your start it, she’s more than welcome to call the office, and they’ll have me call her back. She knows, of course, that I was thinking of trying antidepressants, and she already gave her permission, but I want her to be as comfortable as possible.”
“Right,” Timothy said. He knew very well that Dr. Putnam and his mother had discussed the possibility of medication for his problem. His mother’s big caveats had been that she didn’t want him on one of those “tranquilizer” meds like Valium or Xanax, and that she sure as hell didn’t want him on “that Ritalin shit.” Dr. Putnam had laughed pleasantly in response to this last comment, assuring her that he was not even close to considering “that Ritalin shit.” He had sounded more contemptuous of the stuff than Timothy’s mother had, and this had seemed to reassure her.
Now Dr. Putnam leaned forward, looking at Timothy with even more directness and seriousness. He said, “Now, listen, Timothy. I want you to try these, and to try them seriously. I’m hoping that they may be able to help, and if they don’t, that another, related medicine might. But I want you to be very…careful, I guess is the word. I’m quite serious about you telling me if something is changing about the way you think, especially if you start thinking about hurting yourself, okay?”
Timothy thought he understood the doctor’s concern, and he was more than a little nervous because of it, so he was quite honestly able to reply, “Don’t worry. I’ll tell you.”
He left after a quick exchange of pleasantries and made an appointment for a two-week follow-up on the way out. As it turned out, though, it was not hurting himself that was the issue with this new therapeutic approach, and it was fortunate for him—and for others as well, no doubt—that his first really troubling encounter after starting the paroxetine was with invertebrates rather than with a fellow human.