Mr W, a first-break schizophrenic in his twenties, had looked just terrible on initial presentation. Flat, near-mute, meeting all efforts to initiate discussion with "No comment," or just a hostile wall of blankness. Gradually the medications began to work their magic and he became more able to relate to others; but he'd continued to refuse to discuss his symptoms. He kept it all inside until he'd been on the inpatient unit for over a month. Then one day, very carefully, judiciously, circumspectly, he allowed: "Well, I was hearing people talk and relating it all back to me."
The team psychologist ventured softly, Did you ever hear the TV talking to you?
Mr W burst out in surprised laughter, and it all came tumbling out. He'd kept it to himself for at least a year. Said it felt like being underwater, where he would be convinced the people on TV were talking about him; then by dint of effort he would pull himself briefly above the waterline - no that's not true that's crazy - and then be swallowed once again.
He'd gone traveling through Asia for six months, thinking he could leave behind the stress and deconditioning that, he reasoned, must have been the cause of this - this oddness. But he found that people on the streets, speaking in languages he did not know, were talking about him. He was utterly certain of this, though he could not understand their speech. He had several brief relationships with other travelers, women; but they all ended because, well, "Things got weird."
He recalled talking with the interviewer when he'd first come in, when he would only say "No comment." He remembered her eyes looked enormous and he was afraid, certain that if he spoke he would come to some vague and terrible harm.
Delusions - fixed false beliefs, characteristic of psychotic states - call up a whole slew of questions related to knowledge. We know that we know; but how do we know? (For an interesting discussion of this question, check out Robert Burton's website and his recent book.)
Mr W was madly curious, he wanted to know everything - and what's a neurotransmitter? and are there other ones besides dopamine? and what part of the brain? and how does it all work?
All good questions, and ones for which the answers are far from clear. He was fascinated, scared, but also relieved to know this had a name, that others had suffered from it, that he was not alone in this bizarreness.
It is an incredible treat to speak with schizophrenic patients who have such clear insight into their disease. Many of the patients we see are old and broken from long years in and out of hospitals and many trials of different drugs, both prescribed and recreational. Even at the best of times, when they are not frankly paranoid or delusional or hallucinating, they typically cannot or will not describe their experience in any kind of meaningful way. I was fascinated by Mr W, I could have sat and talked with him for hours about his experiences. I had a similar feeling when I read Elyn Saks' excellent book, The Center Cannot Hold. It offers a rare and precious chance to hear an eloquent and clear-minded individual recall the alternate reality of psychosis.
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Comments
You pretty much lose your relative. The person they were is gone; they've becomes someone else, and you're stuck with the fallout.
It's harder when the patient is intractable. Some people (like the guy in this essay) respond really well to the first medication they get. It's almost miraculous to see someone climb out of the pit of psychosis, and it's this sense of wonder I was trying to get across in this essay. Don't know how well I succeeded.
On the other hand, there are lots of people who don't respond well to the first med, or sometimes to the second... or the third. It's totally understandable to have frustrated and angry families in this situation. But antipsychotic medications, though far from foolproof, are the best tools we have against severe mental illness of this type.
Well, the care we offer is typically a combo of medications, talk therapy, and social support (help arranging living situations, etc.).
Of what would "real care" consist, in your view?
I agree with Stellaa regarding how much of a treat it is for families of those with severe mental illness (and for those suffering from mental illness). This sentence betrays a lack of "clear insight" on your part, I hate to say.
I also would say that the curiosity you seem to have is the very thing that is lacking in a clinical environment. You've said yourself that medications are tools, but some people who share your profession seem to think a hammer is as good as an awl, and will just keep banging away without too much thought for the outcome.
That's certainly true, and I don't consider myself an apologist for the profession of psychiatry as a whole. There are a lot of things I would change (that's a whole blog post, maybe for another day).
On the other hand I would like to point out that, well, unfortunately it is a fact of life that there are always some lemons in the bunch. There are always going to be good shrinks and bad shrinks, just as with any other profession. (The key for the patients is how to figure out when they've got the latter so they can switch to the former before too much harm is done.)
Chris says: "I agree with Stellaa regarding how much of a treat it is for families of those with severe mental illness (and for those suffering from mental illness). This sentence betrays a lack of "clear insight" on your part, I hate to say. "
I don't agree with you that an interest in psychiatric disease as an entity precludes compassion for those who suffer from it. I would suggest that any doctor who does *not* also have an intellectual interest in the diseases he treats is probably not one of the better doctors.
It was the use of the term "treat" that bothered me. To me, there really is nothing about mental illness that's a treat, no matter what side you're on. The word just seems to have a trivializing effect (and makes me think of Rice Crispies Treats).
"It was the use of the term "treat" that bothered me. "
Well if this is just about word choice, then I'm happy to take editorial suggestions. Impression noted.
On the other hand, it sounded to me as if both you and Stellaa were offended by the fact that I find mental illness interesting, in addition to wanting to help the people who suffer from it.
Did I misread you?
The few who have reacted negatively to the above sentence seem to me to be displaying a lack of empathy. What they either miss or mischaracterize is that you are speaking from the point of view of a therapist, which is, of course, quite different from that of a loved one or caregiver.
Thank you for telling it. It is a fascinating story.
Secondly, I don't know if you've ever heard of "Second Life" (an online environment, is the best way I know to describe it). Inside Second Life, I believe it was some docs at USC, put together an experience where "normal" people can have an experience like schizophrenia via video, sound, and 3-D modeling. It is one of the most disturbing experiences I've ever had.
Medications are such a catch-22 for so many of us, but I think it's clear that for many people they work.