Ranim Hussain looked at the red-haired, red-eyed woman in front of her, wondering quite what to say. The patient wasn’t yet near the diagnostic threshold where a referral for schizophrenia made sense, and Camden Community Mental Health Resources were stretched enough already. Yet the young woman, who had only just registered with Primrose Hill Surgery, having so recently moved to the area, was obviously in distress, and exhibiting some peculiar symptoms.
‘Miss Ferguson, can we go over it again?’
‘You can, you know, call me Jo. If you’re going to be my GP? I don’t need formality.’
Ranim smiled warmly. ‘If that makes you happier, of course.’ She turned to her PC, tapped a couple of keys, checked her notes. ‘Were you on first-name terms with your last GP? Up in in North Finchley?’
‘Well, no.’ The young woman managed an anaemic laugh. ‘That’s the point! I hardly ever saw him, because I was barely ever ill. I was happy and healthy, one year to the next. Loved my job. Loved life. I don’t smoke, I eat right, exercise all the time, as much as I can—’
‘Drink?’
Jo Ferguson paused. She looked at her nails. Ranim noted that a couple of them were bitten.
‘Yes, I drink. Probably too much. But not waaaaay too much.’
Ranim tapped a few keys.
‘How many units would you say, a week? Given that one small glass of wine is a unit.’
Jo closed her eyes, doing the maths; then opened her eyes and said,
‘Ten units in a sober week? Fifteen in a boozy week? That’s a bad week though.’
Ranim nodded, and mentally doubled each number. She’d learned from long experience that almost everyone – other than the completely abstinent, or Muslims like her own family, and even then not all – her beery Uncle Danesh! – lied about alcohol intake. Double or triple the estimate and you were invariably closer.
And yet, even if this woman was drinking thirty units a week, a bottle of wine every other day, plus a couple of cocktails at weekends, that was nowhere near enough to explain these odd hallucinations. Voices from machines? Something was awry. But what?
‘So, please, just one more time to get it straight?’
Jo smiled, meekly, and earnestly. ‘If you think it’ll help.’
The smile wasn’t convincing. Ranim could see fear in the young woman’s eyes, a tiny tremor in the mouth.
‘You say the machines started talking to you a couple of weeks ago, and then your phone and your laptop have joined in, sending you messages, Skyping you.’
Jo carefully folded the scarf in her lap. ‘Yes. About that long: about two weeks ago.’
‘And what is so unnerving about the things they say, Jo?’
A long, awkward pause. They both listened to the cars slishing through the melted snow on Regent’s Park Road.
‘Stuff about my, uh, life. The past.’
That pause, again. It was significant. A tell. Jo Ferguson, Ranim reckoned, was concealing something, even as she elaborated.
‘They say things about my student days, my marriage, and also when I was a kid. They seem to know lots of stuff about me. At first I thought that was because the tech was hacked, my ex-husband is a tech geek, like I said, he installed these Assistants, he has a reason for revenge, and his wife dislikes me, and he’s, like, the only person who knows so much about my past, so it has to be him and her? It seems logical. But then—’ The feebly confident voice faltered, came closer to tears. ‘Then the phone thing, the Skype thing, the poetry, all that, that feels like actual madness, it sounds like I am mad, doesn’t it? And I need to know. So I came to you.’
‘Has anyone else witnessed these phenomena?’
Jo dropped the scarf to her side, lifted her anxious, pretty face to the doctor, blushing. Trying to answer. Struggling.
She shook her head. ‘No. A neighbour saw the lights flickering, but that might have been my fault, misusing the app.’
‘So no one at all has, say, heard the Assistants talking to you, singing to you, strangely and bizarrely? Apart from you?’
Jo shook her head, pushed coppery red hair back from her green eyes.
‘No. No one at all. And that’s one of the reasons I am here. All the creepy messages I get disappear, so I am left with nothing. I’ve tried to screengrab them, anything, record stuff, but it all gets magically erased.’ A second sigh. ‘Perhaps I imagine them, too?’
With the hair pushed away, Ranim realized that with a week of good sleep and less worry behind her, Jo Ferguson would be a notably attractive young woman. She was also articulate, educated, and quite lucid.
Jo leaned closer, her face full of misery. ‘Does that mean it’s all in my head? That means I am mad, right? It’s me hearing all this. I’m like my dad, like I told you, late-onset schizophrenia. The first symptom he had was the TV talking to him. With me its Home Assistants and computers. What’s the difference? I’m still cracking up, like Dad, still a schizo, a nutter, and I’m going to end up like him. He gassed himself, like Sylvia Plath, down there.’ Jo Ferguson pointed out of the window, towards Chalcot Square, Fitzroy Road, where the poetess had, indeed, gassed herself. Everyone who lived or worked in Primrose Hill, for long enough, knew that story.
Jo went on, ‘In fact, you wanna know something? Something really mad? For a while I thought I’d seen her ghost, Plath’s ghost, walking her kids, in the snow.’
‘Sorry?’
Jo seized on the doctor’s response, the obvious surprise.
‘Exactly. It’s got that bad. I am considering the idea of ghosts. The ghost of some poet, and her poor kids. It doesn’t get madder than that.’
Her patient trailed off into silence. Ranim typed a few extra sentences into her PC, then returned her concentration to her subject. Jo sat there quietly, her jeans still damp from her wintry walk along Primrose Hill, from the splashes of melted snow from passing cars.
‘Look, Jo. I’ll be clear. You’ve probably heard all this from Dr Google anyway, but I’ll tell it to you anyway. For me to make even a tentative diagnosis of possible schizophrenia, for me to refer you to a specialist, at UCH, say, or the Royal Free, you have to fulfil one of several criteria, for more than a month at least.’
‘And they are?’
‘Severe hallucinations, delusions, hearing voices, incoherent speech, and we need to see what’s called a flattening of emotions. Flat affect.’
Jo’s eyes sparkled unhappily.
‘But I have at least three of those: delusions, hallucinations, hearing voices!’
‘Not nearly bad enough or long enough.’ Ranim raised a calming hand as the winter afternoon turned the dead streetlights pink. ‘And there’s no flatness of affect. Consequently it’s too soon to talk about major illnesses. Also, we need to see that these symptoms have been seriously impacting your work. You’re a journalist, right? Have you noticed any impact?’
Jo slowly, even reluctantly, shook her head.
‘No, a bit, but no – I’m still writing. I’ve stopped pitching so much, the money is drying up, but that’s because I am distracted.’
‘But you can still write?’
‘Yes, I can still write, when I sit down and do it, in fact it helps. I lose myself.’
Ranim smiled as reassuringly as possible. ‘There you are then. As I said, there’s a fair way to go before we begin to think of such a dramatic diagnosis as schizophrenia—’
‘But what is it then?’ Jo lifted her hands, almost imploring. ‘Why am I hearing things, seeing things? How am I doing things that I can’t remember? Like, I had this dating profile, OKCupid, whatever, and it disappeared. Yet I don’t recall deleting it. Yet it must have been me! What is happening to me?’
Ranim raised a hand. ‘Wait, wait. Slow down.’
Jo waited. Sad eyes wide, and expectant, as the doctor continued:
‘Lots of this could easily be emotional stress. You quite recently divorced, you have money worries, then there’s loneliness: you work from home, where you are largely alone, or so you tell me. Perhaps you also have a guilty conscience about something. That could be a factor. And everybody is capable of seeing things when they are stressed. It’s normal, a reflex, the voice in the dark, the ghost on the street – it’s not hallucination, it is the mind trying to be careful of danger.’ Ranim waited for a reaction in Jo’s face. There it was, that tremor in the lips. She went on. ‘In addition, the Skype call happened in the middle of the night – it could have been a lucid dream. And the texts that disappeared – perhaps you imagined them. As I say, the stressed and anxious mind can play all kinds of tricks – without being insane.’
‘Hmm.’ Jo looked down at her black boots, then across at the coat-rack. Then at her watch.
‘I’ve got another question, Jo.’
‘Yes?’
‘Do you ever misuse drugs?’
‘Sorry?’
‘You know. Cocaine? Ecstasy? Ketamine? Even a bit of marijuana? You can tell me in complete confidence.’
Jo’s denial, as she stood and put on her coat, was firm and heartfelt.
‘No! Nothing like that.’
‘They could explain many of your symptoms.’
‘But I don’t do any of them. And I haven’t done so for—’ Jo blinked, quickly, repeatedly, guiltily. ‘Not for ages, since I was a student.’
Ranim shrugged. ‘Not even tranquillizers, or sleeping pills?’
Jo was blushing. She couldn’t answer.
And Ranim thought, Ah. She smiled, reassuringly. ‘OK, I suspect you’re taking sleeping pills, yes? If you are, you must have bought them elsewhere.’ Ranim turned to her computer screen. ‘Because, as far as I can see, you have never been officially prescribed anything like that. No anxiolytics, no tranquillizers, no anti-depressants, nothing.’
Jo admitted, with a slightly shameful voice, ‘I take Xanax. And sometimes Valium.’
Ranim sat up straight. ‘What?’
Her new patient was staring, guiltily, at the floor, as she explained. ‘After my divorce, I went on a long holiday, across Asia, Laos to Cambodia, Thailand, Malaysia. It was brilliant. But there was lots of jet lag and massive bus journeys and someone said you can buy this stuff over the counter – Xanax. Valium. So I did. I bought a whole lot. And it worked, helped me sleep on trains and planes, smoothed my moods. Xanax is so helpful.’
‘And you’re still taking them?’
‘Yes. On and off. But they’re OK, aren’t they?’ Outside, the lights were on, the street a wintry black and white. ‘I mean, you know, they’re only sleepers, you can buy them in chemists out there. You don’t even need a prescription.’
Ranim stood up, crossed the carpeted floor and put a warm hand on Jo Ferguson’s shoulder. ‘Jo, those are very powerful drugs. Diazepam – which is another name for Valium – should only be used for a couple of weeks. And as for Xanax, or Alprazolam,’ she exhaled, vehemently, ‘that’s actually dangerous. You do know it’s basically illegal in the UK? Almost no one is allowed to prescribe Xanax. Because it is deeply addictive, and can have many unpleasant side effects. And the withdrawal can be hugely serious; it is one of the few drugs where sudden or involuntary cessation, if mishandled, can actually kill you. And you’re stopping and starting Xanax just like that? How many do you have left?’
Jo shrugged, furtively, but with a faintly hopeful smile. Apparently relieved at this diagnosis, yet also unnerved, and embarrassed. ‘I don’t know. A few hundred? I brought tons home because they helped me think, my anxiety went away, I slept better, but – but you truly think they could be causing all this?’
‘Yes!’ Ranim spoke loudly, trying to bring this gravity home to her new patient. ‘Goodness. Xanax! If you’re taking it on and off, you could be withdrawing, some days, without realizing, and that can cause confusion, hostility, dissociation, derealization – everything. We need to deal with this, get you weaned off properly. Come and see me in a couple of weeks, when you’ve calmed down. And in those weeks I want you to take your regular dose of Xanax daily, and monitor that intake. Afterwards we can discuss a regime to very slowly and safely taper you off. OK?’ The doctor shook her head, ‘And whatever you do, don’t increase the dose!’
Jo tightened the scarf around her neck, and buttoned her raincoat. Her smile seemed slightly happier.
‘OK, thanks. Thank you. Maybe that’s all it is: some silly pills I bought in Phnom Penh? I was popping them, on and off, almost like sweets. Idiotic. That was so idiotic.’
‘Yes, well, at least we got there in the end. Goodbye, Jo, and please make an appointment in two weeks’ time.’
‘I will, and … thank you.’
Ranim watched as her patient left the office. She tapped a few initial notes into her PC, and into Jo Ferguson’s file. Then she got up and looked out of the window.
Jo Ferguson was out there. In the cold. Trudging home. Fresh snow was falling. The street was deserted. The little cafes and trendy pet shops, the Vietnamese pho restaurant. All silent. The moonlit snow looked pretty: falling thick and fast. Emptying the streets, turning cars into anonymous humps of snow.
Amidst this melancholy prettiness, the hunched, solitary figure of Jo Ferguson looked quite distinct: like some polar explorer, scarved and hatted and muffled. Heading for something distant. Determined to go somewhere pointless, yet dangerous.
Ranim felt, for a moment, a deep, surging pity for this very solitary young woman, so definitively lonely. Yet what could she do?
Briskly, she went back to her desk, leaned over, and buzzed Reception.
‘Fiona, can you send up the next appointment?’
After that, she sat down at her computer, and concluded her notes about Jo. Some evidence of bipolarity, or depression. Too early to diagnose. Investigate once Xanax has been tapered. Assess for alcohol intake, as well. Ranim’s fingers paused, then she added,
Also some underlying symptoms of schizophrenic behaviour. Possibly genetic.