The Expansion

Cast

DR. HAROLD WHITCOMB, 74

Chairman. Has chaired the committee since before it had a name.

DR. BOB KESSLER, 69

Divorced twice, once from Janice.

DR. GERALD FENN, 71

Carries a pipe he is no longer allowed to light.

DR. MORTIMER ASH, 94

Asleep for most of the meeting. Votes yes anyway.

DR. DANIEL REYES, 29

Chief resident, first in his class. His prize is a seat at this table and a commemorative pen.

Setting

A wood-paneled room at a private club. Portraits of older men line the walls. Brandy is served at 10 a.m. A banner reads: ANNUAL MEETING OF THE COMMITTEE ON NEW DISORDERS.

Scene 1: The boys who won’t sit still

WHITCOMB Gentlemen. And, young man. Welcome to the Annual Meeting. Dr. Reyes graduated first in his class, and as his reward, he gets to watch medicine being made.

REYES It’s an honor, sir. I’ve read everything you’ve published.

WHITCOMB Then you’ve read the same paragraph forty times. Gerald, the schools report.

FENN (opening a folder) As you know, we now have children sitting at desks seven hours a day. In rows. Facing a chalkboard. Learning about the War of 1812.

KESSLER Tremendous progress.

FENN And we’ve made a troubling discovery. Some of the boys won’t sit still. They fidget. They stare out the window. One of them carved a horse into his desk. A fully rendered horse.

WHITCOMB Good horse?

FENN Excellent horse. Which is how we knew something was wrong.

KESSLER We believe they’re born with it. A defect. Some kind of hyperactivity, with a terrible deficit of attention.

WHITCOMB Something in the wiring.

REYES (carefully) Is it possible they’re just… bored?

A pause. The men look at each other. Then FENN laughs, warmly.

FENN Of course they’re bored! Boredom is part of the disorder!

KESSLER Classic presentation.

WHITCOMB (writing) “Patient finds seven hours of the War of 1812 boring.” That’s going in the criteria.

REYES But wouldn’t anyone…

WHITCOMB Anyone who has the disorder. Yes.

Scene 2: The janitor

KESSLER And it isn’t only children. We’re starting to see it in adults.

FENN Tell him about the janitor.

KESSLER There was a janitor in our building. Lovely man, Ernesto. We’d tell him things. “Ernesto, the third-floor bathroom.” “Ernesto, my office smells like fish.” And he would just forget.

WHITCOMB Profound inattention.

FENN And he always had an excuse. Said he worked two jobs and slept four hours a night.

REYES That… sounds like it might actually be the reason.

KESSLER That’s what we thought at first. And then it hit us. The sleep problems are also part of the disorder.

WHITCOMB Comorbid.

FENN It explains the second job, too. Restlessness. Can’t commit to one employer.

REYES Or… rent?

WHITCOMB (not hearing him) We put him on a stimulant and he got much better at both jobs.

KESSLER Proof.

ASH (asleep, murmuring) …aye.

WHITCOMB Mortimer votes yes.

Scene 3: How it all started

REYES Can I ask something? How did you all get into… disorders? Why not just call them symptoms? Like fatigue. You can have fatigue from a hundred different things. Anemia. Thyroid. Not sleeping. Couldn’t not being able to focus be like that?

Silence. The men look at each other.

FENN (slowly) Fatigue… disorder.

KESSLER We had not thought of that!

WHITCOMB writes it down. Then he sets down his brandy and leans back.

WHITCOMB Well, son. Listen. It all started with Bob.

KESSLER (solemn) It started with Janice.

WHITCOMB Bob realized his ex-wife Janice had a disorder. Borderline personality.

KESSLER She said I never listened to her. She said it for eleven years. Unstable.

WHITCOMB And I thought, well, that’s just Janice. But then I went on a date with a woman. Patricia. Sharp woman. Didn’t work out. And I realized it wasn’t just that bitch Janice. Patricia couldn’t sustain a stable relationship either.

FENN How many dates?

WHITCOMB One. Which proves it.

FENN She was crazy, that Patricia. Kept making up these stories about how her father raped her or something.

KESSLER Dramatic.

FENN She just wanted attention. Which is…

WHITCOMB, KESSLER, FENN …part of the disorder.

REYES opens his mouth. Closes it. Writes something in his notebook. Crosses it out.

Scene 4: The women

WHITCOMB Anyway. Back to the other disorders. ADHD and autism.

FENN Women have started coming in saying they also lack attention.

KESSLER Women?

FENN I know.

WHITCOMB Well, they certainly weren’t fidgeting at their desks in 1950.

REYES Weren’t most of them told to sit still and be quiet?

WHITCOMB Exactly. And it worked, so they didn’t have it. Now they have it.

KESSLER Some sort of contagion.

FENN The trouble was, they sat perfectly still.

KESSLER A hyperactivity disorder with no hyperactivity.

WHITCOMB So we made a subtype.

FENN Inattentive type.

REYES So a woman sitting quietly, not paying attention to you…

WHITCOMB Fully diagnosable now.

KESSLER We used to call that marriage.

FENN And we’ve discovered something fascinating. ADHD is about dopamine.

KESSLER And estrogen helps regulate dopamine.

FENN So a woman’s ADHD is worst when her estrogen drops. The week before her period.

WHITCOMB And menopause. That’s when it’s most pronounced.

REYES So that’s when you give them estrogen?

Silence.

WHITCOMB No, no, no.

KESSLER We don’t prescribe hormones.

FENN We prescribe psychiatric medications.

REYES So what do you do?

KESSLER Raise the stimulant the week before her period.

WHITCOMB And at menopause, we add an antidepressant.

FENN Hormones are for gynecologists.

WHITCOMB (dismissively) Plumbing.

KESSLER We treat the mind.

WHITCOMB The most complex organ in the body.

REYES You mean the brain?

WHITCOMB The mind, son. We don’t study the brain.

KESSLER (darkly) My ex-wife’s borderline was worse before her period, too.

WHITCOMB Comorbid.

FENN We had a woman come in recently. Loved her job.

KESSLER She got so excited about a project, she forgot to eat lunch.

FENN Sometimes stayed up past her bedtime working on it.

REYES (smiling) She sounds great.

WHITCOMB But when her manager asked her to do a male coworker’s work for him…

KESSLER She struggled to focus.

REYES Well, sure. Who wouldn’t?

A beat.

WHITCOMB (writing) Hyperfocus.

FENN Part of the attention disorder.

REYES She paid too much attention.

KESSLER To the wrong things.

REYES Doesn’t everyone…

WHITCOMB Anyone who has the disorder.

Scene 5: The deficits

WHITCOMB Now. The poor.

FENN The prevalence of these disorders people are born with goes up dramatically when they’re poor.

WHITCOMB Fascinating.

REYES Oh. Right. Like the janitor. Ernesto probably doesn’t have that much money.

WHITCOMB Exactly!

KESSLER (delighted) See? You’re catching on, son.

WHITCOMB Smartest one we’ve ever had in this room.

FENN The smartest.

REYES sits up a little straighter.

FENN And when they’re dyslexic.

REYES But don’t you think dyslexia might just make it harder to read? And if you can’t read the board, maybe that makes it harder to focus on the board?

A pause.

FENN Huh. We hadn’t thought about that.

WHITCOMB But no. Because when we give them amphetamines, they’re fixed.

KESSLER Suddenly they focus very well.

WHITCOMB Which proves they were born with a disorder.

REYES Wouldn’t amphetamines help anyone focus?

WHITCOMB Gerald, how long have you been taking them?

FENN Since ’71.

WHITCOMB And do you have the disorder?

FENN (lighting the pipe he isn’t allowed to light) I do now.

KESSLER You know, I once met a very, very intelligent dyslexic.

WHITCOMB Really.

KESSLER If you can believe it. He struggled with digit span. Couldn’t remember a string of numbers and repeat it back to you backwards.

FENN Tragic.

KESSLER But he did well on the other sections. I think if it weren’t for these impairments of his, he could have been exceptionally intelligent.

WHITCOMB Oh, I know the one. Won the Nobel Prize in Physics.

KESSLER That’s him.

WHITCOMB Based on our testing of intelligence, we believe he could have been truly superior, if it weren’t for these deficits.

REYES He… won the Nobel Prize.

FENN Imagine what he could have done with a working memory.

REYES Actually, I saw some lab work in mice suggesting working memory isn’t just digits. It seems to involve multiple parts of the brain, the prefrontal cortex, the hippocampus…

WHITCOMB (raising a hand) Stop.

FENN We do not…

KESSLER We do not.

WHITCOMB We absolutely do not value data that comes from rodents.

FENN We don’t believe we need any of that.

WHITCOMB We simply talk to people. We ask them about numbers. We show them pictures. That is all we need.

KESSLER We tried to understand the brain once. It produced worse results.

FENN We found it quite hard to focus on the material.

WHITCOMB We believe our inability to focus was related to the material.

KESSLER It was inaccurate.

FENN Potentially specific to mice.

WHITCOMB Or simply impossible to understand.

KESSLER Not a disorder, you understand. A perfectly reasonable response to bad material.

A pause.

REYES So you…

WHITCOMB Don’t.

Scene 6: The spectrum

WHITCOMB Now. Autism.

FENN We used to work with very, very disabled adults. They struggled to make eye contact.

KESSLER Very troubling to work with.

FENN And they often had low intelligence. Based on our tests.

REYES The tests where you ask about numbers and show them pictures.

WHITCOMB The very same. (to the others) He’s listening.

KESSLER We’ve had wonderful successes with them. Especially the severe cases.

FENN The ones who couldn’t speak.

KESSLER They couldn’t sleep, either. Up all night, keeping the whole ward awake.

WHITCOMB So we started them on clonidine. Harmless. It’s just a blood pressure medication.

FENN Now they sleep like babies.

REYES But doesn’t clonidine cut REM sleep? I thought one study said by three-quarters.

FENN (pulling a booklet from his jacket) Son. I wrote the dosing guide for children.

He reads, savoring every word.

FENN Start at 0.05 milligrams at bedtime. Increase every three to seven days, as needed. Up to 0.4 milligrams a night. Most children respond to 0.2 or less.

KESSLER Very precise.

FENN It’s now the most prescribed sleep medication for children in the country. Eighty-six percent of us who treat children use it.

REYES What’s the guide based on?

FENN (proudly) Six children.

WHITCOMB And not one of them has ever said a peep about it.

KESSLER And then one day we were in the faculty lounge with Michael.

FENN Ugh. Michael.

WHITCOMB Nobody liked Michael. He corrected your citations. He didn’t laugh at Bob’s jokes. And it occurred to us that Michael reminded us of those struggling adults.

KESSLER And we thought, perhaps there are more people we could help. More people we could give medication to, if we just included them.

FENN Perhaps it’s a spectrum.

REYES So it started with… someone you didn’t like.

WHITCOMB They all start with someone we didn’t like, son. Janice. Patricia. Michael. That’s how you know it’s real.

REYES (hesitant) Actually… there’s a guy in my residency cohort. Dennis.

WHITCOMB Go on.

REYES He never looks up from his notes. He interrupts. He’s always right, and he makes sure you know it.

KESSLER Does he laugh at your jokes?

REYES …No.

FENN (writing) Spectrum.

WHITCOMB (to the others, delighted) He’s a natural.

Scene 7: The conferences

KESSLER And we’ve had great results with medication.

FENN We used to give people lithium.

WHITCOMB Worked beautifully. Cheap, too.

KESSLER But then we went to many, many conferences, hosted by various pharmaceutical companies. And we learned there were so many more options.

WHITCOMB We realized that prescribing one working solution was too simple.

FENN Way too simple.

KESSLER I remember it particularly at the conference in Cabo.

WHITCOMB Cabo.

FENN (fondly) Cabo.

KESSLER We came to understand that lithium had a lot of side effects. And these other medications had brief trials with very promising results. Presented on a sunset dinner cruise.

WHITCOMB Six weeks long. Very promising.

FENN Fewer side effects, we believed. So we started including them.

KESSLER And at the next conference, we learned something wonderful.

FENN We found out we could treat the side effects of one medication with another medication.

WHITCOMB Weight gain? There’s a pill.

KESSLER Can’t sleep on that pill? There’s a pill.

FENN Groggy from the sleeping pill?

KESSLER That’s the ADHD.

FENN They just hadn’t been diagnosed with it yet.

REYES And the side effects of those?

WHITCOMB (spreading his hands) That’s what the conferences are for.

REYES Who ran the trials?

WHITCOMB holds up his pen. REYES looks down at his own commemorative pen. It says VELORAX.

REYES turns the pen over in his fingers. Then he clicks it and slides it into his breast pocket.

REYES How does lithium compare to the new ones?

WHITCOMB Well. I’m not aware of any comparisons being done.

KESSLER But perhaps they’ll teach us about it at the upcoming conference.

FENN In Aspen.

WHITCOMB Aspen.

KESSLER (fondly) Aspen.

REYES I read the very promising results for antidepressants. I noticed even primary care doctors can prescribe them.

KESSLER We don’t think they’re qualified.

FENN But we can’t stop them.

WHITCOMB We’ve tried. Their conferences are in Ohio.

REYES But I’ve been reading about receptors, how they adapt over time. Maybe the early studies were too short. Because people don’t seem less depressed, despite all the medication.

WHITCOMB This is a great question. Before, people were depressed and they weren’t coming to us.

KESSLER So of course depression stays high. Now we know about it.

FENN Before, everyone was depressed and we did not know. Now everyone is being treated.

REYES But a national study compared people on antidepressants with people who weren’t. After two years, you couldn’t tell them apart.

WHITCOMB And do you know how we can prove they work?

REYES How?

KESSLER When we take them off, they go back to being extremely depressed.

FENN Sometimes even worse than before we put them on it!

WHITCOMB (triumphant) Proof.

REYES Couldn’t that be withdrawal?

KESSLER Relapse.

REYES But they’re worse than before they ever started.

FENN A very aggressive relapse.

WHITCOMB Which is why no one should ever stop.

REYES Have you read the Yale papers on ketamine? It worked for people nothing else had helped.

WHITCOMB Ketamine.

KESSLER No.

ASH (waking briefly) I went to Yale. In 1950.

ASH goes back to sleep.

FENN At first it was anesthesiologists running those clinics.

WHITCOMB Drug dealers.

KESSLER Hooking people up to a drip and sending them home.

REYES Isn’t that what the studies did?

WHITCOMB No therapy. No intention. No integration.

FENN shakes an amphetamine out of a bottle and swallows it.

FENN Drug dealers.

KESSLER So Howard opened a proper one.

WHITCOMB Lovely space. Candles. Howard says they do most of the work.

FENN He modeled it on an ayahuasca ceremony. A sound bath. A drum circle. A plant medicine shaman.

REYES But ketamine isn’t a plant. A drug company made it in a lab.

WHITCOMB At a pharmaceutical plant.

KESSLER Plant medicine.

REYES The depression research came out of Yale and the NIH. It’s an IV drip.

FENN Howard plays rainforest sounds over the drip.

KESSLER And every infusion comes with a pre-intention session.

FENN And a post-integration session.

WHITCOMB And an integration-of-the-integration session.

KESSLER Billed separately.

FENN Infusions once a week.

REYES I thought the studies did them twice a week for a few weeks. Spaced out further, the effects don’t consolidate.

KESSLER Howard says consolidation sounds like an ending.

FENN And ketamine is a new beginning.

WHITCOMB Every Tuesday.

Scene 8: Bipolar and trauma

KESSLER And then we found people who were very, very depressed, but had moments of being less depressed.

FENN So similar to the bipolar patients.

WHITCOMB Practically identical.

KESSLER And we thought, maybe we’re missing a large group of people we could be medicating.

WHITCOMB Bipolar Two.

KESSLER Take one of our Bipolar Two patients. When she wasn’t depressed, she was exceptionally productive.

FENN Doing many, many things.

KESSLER Ran the school board. Started a business. Finished a novel.

WHITCOMB We knew right away it was mild mania.

REYES How?

WHITCOMB We had never seen a woman so productive before.

FENN So we medicated her, so that it wouldn’t happen again.

REYES Did that fix her depression?

KESSLER No. Bipolar depression is almost impossible to treat.

FENN We really focus on the productive periods.

REYES So now she’s just…

KESSLER Stable.

FENN There’ll be a Three.

WHITCOMB And then there’s trauma.

FENN Son, did you know that thirty percent of people who experienced atrocities were born with a disorder?

REYES Born with… what?

KESSLER Post-traumatic stress disorder.

REYES Isn’t that… caused by the atrocity?

WHITCOMB Then why didn’t the other seventy percent get it?

FENN Same atrocity. Perfectly fine.

REYES How do you know they’re fine?

KESSLER They never came to see us.

A long beat. REYES takes out the VELORAX pen and writes that down.

REYES …Right.

He hesitates.

REYES (quietly) Do you think Patricia had PTSD? From what her father did?

WHITCOMB No, no, no.

KESSLER PTSD is for atrocities that happened in war.

FENN To men.

WHITCOMB Patricia’s was borderline.

REYES And her father?

WHITCOMB What about him?

REYES Did he have a disorder? What about murderers? Rapists?

WHITCOMB Oh, no.

KESSLER We looked into it.

FENN We noticed it’s universal across many other mammals.

KESSLER Lions. Dolphins. Chimpanzees.

WHITCOMB Perfectly natural.

REYES But you said you don’t value data from rodents.

WHITCOMB Note that we did not try to understand the brain.

FENN We simply observed the animals.

KESSLER Like we observe the humans.

WHITCOMB Rigor, son.

REYES So she has a disorder, and he…

WHITCOMB Don’t.

Scene 9: What medicine is

REYES Has anyone tried fixing what happened to them? Smaller classes. Safe homes. Paying parents enough to sleep?

A long pause.

WHITCOMB Son, that’s not medicine. That’s politics.

KESSLER Though we have become much more accepted by liberals and progressives.

FENN They used to be such a pain. Back when homosexuality was a disorder.

WHITCOMB But we eventually voted that out.

ASH (asleep) …aye.

KESSLER And now we stick to diagnosing war veterans. Child abuse survivors. Sexual assault victims.

FENN The differently abled. The unhoused.

WHITCOMB People of lower socioeconomic opportunity.

KESSLER Persons experiencing poverty.

WHITCOMB (to REYES) I’m trying my best to be politically correct. I believe these are the latest terms.

REYES I think “differently abled” is out now.

WHITCOMB (writing it down) Thank you, son. (to the others) Smartest one we’ve ever had.

FENN We’re cutting edge.

WHITCOMB Let me show you what medicine is. Let me tell you how to talk to a patient. Gerald, be the patient.

FENN (instantly, flat) I was in the war. I remember the war zone. I hear the guns. I can’t focus. I feel very sad.

WHITCOMB (leaning in, hand over heart) Yes. You do feel those things. I believe you.

FENN (dropping character) This is where they start to trust you.

WHITCOMB And then you explain. Because I believe you, I am going to prove to everyone else that you have been telling the truth. That you really do experience these things.

KESSLER And how do you prove it?

WHITCOMB By assigning you a disorder that fits your set of experiences.

FENN (back in character, moved) Thank you, doctor.

KESSLER They leave so relieved. Finally, someone acknowledges their disorder.

REYES But you’ve just… written down what they told you.

WHITCOMB With a code number, son. That’s what makes it true.

KESSLER And it comes from a doctor.

FENN A medical doctor. Highly respected for our scientific rigor.

REYES Respected by other doctors?

A pause.

WHITCOMB Other doctors, no.

FENN But people who aren’t doctors can’t tell the difference.

KESSLER Although they often feel it isn’t fully acknowledged until we prescribe several medications.

FENN So we always do that.

WHITCOMB Otherwise they feel inadequate. Like it’s not truly that bad.

REYES Unless they take the medication.

WHITCOMB (proudly) And we believe it.

KESSLER And the families are essential. Concerned friends. Worried mothers.

FENN They hear it’s a real disorder, and they say, then why aren’t you taking anything?

KESSLER If you’re not taking the medication, you’re not treating it.

WHITCOMB And if you’re not treating it, it can’t be that bad.

FENN So the family makes sure she takes it.

REYES So the medication is how everyone knows you’re really sick.

WHITCOMB (beaming) It’s how we prove you’ve been telling the truth.

REYES says nothing.

WHITCOMB (warmly) But these are excellent questions, Daniel. Truly. You question everything. You resist authority. You won’t accept what you’re told by your betters, even in a room full of them.

REYES Thank you, sir.

WHITCOMB (to the others) Gentlemen. I think we have our next one.

KESSLER Oppositional.

FENN Defiant.

WHITCOMB Disorder.

A pause. Everyone looks at REYES. He considers it.

REYES You know… I couldn’t sit still as a boy, either.

WHITCOMB (gently) Born with it.

REYES Is there a medication?

KESSLER Not yet.

FENN There’s a conference in March.

WHITCOMB, KESSLER, FENN Cabo.

REYES takes out his VELORAX pen, clicks it, and writes it down. KESSLER pours him a brandy. WHITCOMB slides a nameplate across the table: DR. DANIEL REYES, COMMITTEE MEMBER. ASH wakes, briefly.

ASH Aye.

FADE OUT.