demon rum

I'm on an outpatient neurology month, mostly a pretty calm scene compared to the inpatient psychiatric wards - until Ms Q arrives on the scene.  Forty-five minutes late for her appointment, she stumbles in on the arm of the fellow, mascara streaking down her cheeks.  "She's intoxicated," the fellow murmurs gently in his refined hint-of-British, hint-of-Indian accent as he steers her to a chair.  

"I hate it, I hate it," she sobs incoherently.  An overpowering odor of alcohol wafts about her.  She has been swigging from a bottle in the car all the way from home, over an hour away.  I shudder at the thought of the unsuspecting commuters who shared her road.

I am assigned to calm her down; my few months' worth of psychiatric education have won me this one.  I murmur soothingly, knowing there is little useful diagnostic information to be obtained from her right now.  She is a blond beach girl, far from home; and it shows in her long yellow hair, bright pink lids and lips, pink toenails in metal-ringed sandals.  "I hate you," she rages.  "I know you're trying to be empathetic, but you don't understand.  Look at you - you're young, you're pretty, you have cute shoes..." She dissolves into a bathtub of drunken tears.  Cute shoes... emblematic of the good life.  I sigh and pat her on the back.  Miss Sunshine, in need of some perspective at the least.

But she is right, of course.  I don't know what it's like to be an alcoholic.  I have worked in recovery programs, and noticed that the addiction specialists with drug histories often seemed more effective than those without.  Regardless of training and other forms of institutionalized expertise, in the addict's own head it is important that his therapist "understand where he's coming from."  All that training is for naught if you can't even get the addict to listen to you.  For people with their own drug histories, that door is already wide open.

One wouldn't expect one's cardiologist to have his own history of heart attacks; nor ask one's internist if he's tried the antibiotic or diuretic he suggests for you.  Yet psychiatry is somehow different, removed from the clearly delineated ethics and protocols that apply in other areas of medicine.  

insight into madness

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 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.

boundary transgressions

I found out for myself, again, the hard way, why 'professional boundaries' are so important.  Cardinal sin - I hugged a patient.  Should have thought twice, then twice again.  He was a thin wreck of a heroin junkie with wise sad gentle eyes behind scholarly horn-rims, sunken cheeks fuzzed with gray stubble, yellow horse-teeth in an occasional bitter laugh.

Strange how some patients leave me utterly cold, without a fig's worth of worry for whether they end up in the gutter or not.  Others take odd hold of me.  I remembered this man from a previous admission, after he'd driven his car into a tree - for the third time.  What was going on behind those sad gentle eyes that could make anyone wish to die so violently?  He spoke from between clenched yellow teeth, a mountain man trapped in a prison made of poppy stems.  Somehow he struck me.  

He was oddly, unexpectedly open in the interview.  He described unbidden his fear, loneliness, abandonment - until his eyes began to well and I quickly reassured him that he needn't speak of anything that would upset him so.  He drew back, but later returned to trying to explain. Finally he offered, "You ever just need a hug?"  He was staring frankly, a challenge perhaps?

Of course, I think that's pretty normal.

He described standing in the same room with his mother and brother and how desperately he'd wanted a hug, but had been completely unable to ask.  

Why not?

The expected cant about manliness, etc.  My heart rushed out to him.

You want a hug?

"Yeah, I do want a hug."  Testing me?  Wanting to see if I would be as good as my word?  Or, instead, if I would have the strength to resist?  I wasn't sure which option was the failing one.

I'll give you a hug.  No turning back now.  But you have to ask for it.  A psychiatrist's trick, or a weak attempt to give myself - or him - an out?  Regardless, he met my eyes.

"Could I have a hug?"

I hugged him, in my office, with the door closed, this man I'd just met; a long hard hug, rubbing his back as I would that of a sister or dear friend who was sobbing on my shoulder.  He smelled of cigarettes and pine bark.

Afterward I asked something inane, like How was that? or Was that helpful?

The former, I think.  He said he felt unsettled, almost nauseated.  I asked if he needed to throw up; he said no.  He said he hadn't had a hug in ten years.  Then he amended it: "Well, a hug from one of your buddies, that's something different.  But a nurturing hug..." He trailed off.  Then, "I haven't touched a woman in ten years."

Uh-oh.  Sirens, alarm bells.  How could I think such an act could stand independently of gender?  Fooling myself utterly.  But not innocently either - would I have done that for a patient I hadn't felt so drawn to?  Honestly, probably not.  Or, just - not.  Then how far could I fool myself to pretend I thought he would take it as such?

Let's get back to the interview.  I sought escape in a return to officialdom - pathetic and weak, as I'd abandoned that bulwark voluntarily already, showing it to be nothing but a sheet of tissue.  But he cooperated, bless him, returning also to the thin fiction of protocol.  

And later, of course, he avoided me entirely while others laughed and waved; as if we'd shared an intimacy far beyond what we had in deed.  That was when I realized the magnitude of my error.

Later I crafted fictions to forgive myself.  I wanted him to see that he could ask a small favor and have it granted.  I wanted to show him the possibilities that remained for human touch.  He needed it.  But all those were rationalizations.  True in ways perhaps, but at bottom I wanted to do it, wanted to pull close this scrawny middle-aged heroin junkie, this wasted scrap of human potential and make him feel warmed, supported, loved.  Why him and not others, I don't know.  Probably just because he had once been handsome, and because he spoke with such measured dignity and cocked his head so attentively to one's words.  Difficult to explain, of course.  Of course.

the dogs of war

What a vast wreckage of human potential this senseless, endless war has brought.  These boys must have been so sturdy and shining, all big grins and lanky muscles; elan and eagerness; brawn and bravado; going somewhere  Now they recount their grisly everydays in beaten voices, giving no special emphasis to the horrors that became as nauseatingly familiar to them as weak tepid OJ in the glaring Mideast morning.

Were I their mothers, how insatiable would be my fury.  To think these bland smirking suits had taken all the life in one's beaming child and ground it down to this.  And that the thought should cross any mother's mind how very lucky he was to be back at all, not to be the subject of someone else's horror story; how unspeakable that for this one should have to feel grateful.

These boys, I am nothing to them; and yet I would like to hold them to my chest and let their warm hot tears flow over us both, let them crawl back into a time when horror movies were just a bit of fun and the thought of war exciting, nothing more.

it could happen to you

Mr G, a gentleman in his sixties with an engaging manner and a professional degree, had never set foot in a psychiatric unit until today.  Bald and avuncular, with a rich white beard and a mischievous wink, he had a bit of a drinking problem and some deep-buried scars from his time in Vietnam.  But nothing else really, none of the 'meat' of inpatient psychiatry (schizophrenia, schizoaffective, bipolar disorder) that we spend our time handling.

Someone somewhere thought two antidepressants and some Antabuse would be good for him.  In a week or two he had changed his personality entirely, wandered into moving traffic, threatened the police who came to the scene, and attempted to seduce the psychiatry resident who admitted him - nothing anyone who knew him could have believed.  Indeed his family members called daily, frantic for understanding, unable to comprehend how their loved one had been replaced by a stranger.  In short, he had had a manic and psychotic episode.

But what is 'psychotic,' other than a term used loosely by the ignorant to describe the behavior of those who irritate them?  Psychosis is a mental state characterized by the impairment of reality testing.  Any society typically has a consensus about what is 'real' and what isn't.  (Judgements about this may differ between societies, but that's a different treatise.)  People suffering from psychosis have fallen off this bandwagon and have very different ideas about what is 'real' from the man on the street.  But there's a method to the madness: psychosis typically involves several specific, bizarre modes of thought. Auditory hallucinations (usually voices), delusions (fixed false beliefs), and paranoia (the pervasive and unshakable feeling that unknowable dangers lurk) are hallmarks of the syndrome.  Though each patient is unique, themes quickly emerge, and anyone who has spent more than a week or two on an inpatient psychiatric unit will begin to recognize the patterns.

Psychosis, clearly, is not a torture reserved for the unlucky few born to its ravages, like cystic fibrosis or a Thalidomide deformity.  I suspect it may be an alternative mode of function that lies buried in each of us, more deeply for some than for others.  It can be precipitated in otherwise mentally healthy people by pregnancy, medical illness, or - as in Mr G's case - merely the wrong combination of medications.  An unlucky few have the problem of chronic or recurrent psychosis.  This is the disease schizophrenia, a disorder with its peak onset in the normally promising and productive years of early adulthood.

Some are doubtless more susceptible than others; as with every human trait, psychotic tendencies lie along a continuum.  Mr G had always been a bit up-and-down in his moods, and while another person might have been able to tolerate the double-antidepressant regimen, for Mr G it magnified his normal highs and lows into an off-the-charts manic spike that came, as extreme mood disorders sometimes can, with the booster benefit of psychotic symptoms.

But what is this psychosis then, what is it for?  Why does its potential lie buried somewhere in so many of us?  What purpose does it serve?  Some have argued that it is a byproduct of the development of social complexity in the human brain  (see for example, Burns JK).

Unfortunately, this particular argument (and related ones) suffer from a lack of specificity and a paucity of evidence.  They certainly sound reasonable; but the logic boils down to this: Schizophrenia is a complex behavioral disorder - social and creative endeavors require complex processing and behavior - schizophrenics have difficulty with social functioning - ergo, these modules are related.

I don't doubt that schizophrenia (and psychosis more generally) are related to social functioning, given how important social functioning is to humans - almost everything we think or do is related to social functioning, broadly defined.  But that makes the hypothesis that 'schizophrenia is related to social functioning' so broad as to be useless. 

Another line of reasoning jumps off the intriguing finding that artistic inclinations and schizophrenia are often found in the same families (see Horrobin DF), and posits that schizophrenia is merely the other face of the coin of creativity.   This one is slightly more specific (creativity being less of a blanket term than 'social function') and can claim at least some circumstantial evidence to its credit.  

Dr Horrobin also does a nice job of suggesting a biochemical basis, though I am in general skeptical of papers that claim to pinpoint individual biochemical factors or pathways as causative of psychiatric diseases.  Psychiatric illnesses are complex states of the person as a whole, and doubtless they affect and are affected by many, many biochemical pathways (most of which, as we are discovering, interact with each other anyway).  Generally I'd say that trying to pinpoint a single gene, factor, or pathway in the pathogenesis of psychiatric disease is sort of like blaming global warming on a carbon dioxide spike in Juneau in the summer of 1998.  Sure, they're related; but there are a bunch of other factors involved, and who knows which way the causal arrow goes anyway.

In any case, those optimistic scientists who have persisted in trying to pinpoint single specific causes of psychiatric diseases are indeed finding out that the problem is significantly larger than one might have guessed back in the flushed and heady days of the one-disease-one-gene school of thought (Iwamoto and Kato).

I don't doubt that we'll make some interesting progress on this problem once as we develop better tools to manage and investigate complexity in biology.  The ever-growing computational power that's available to us makes it feasible to look at complex interactions in a way that was impossible twenty years ago.  It's going to be an interesting next couple of decades.

truth to power

The unspoken derives its power from its very mystery.  To make explicit is to deprive of power. The psychotic patient knows this, perhaps better than we.  Psychotic patients often seem in touch with a deeper, animal reason.

Mr. B. behaved like nothing so much as a cornered animal in the locked psychiatric unit.  Behind closed doors, he admitted his demons to his worried mother, who relayed them to us; but to the doctors he was close-lipped and angry, hiding with insults his fear at what had happened to him.

His threatening, hostile stare fairly made the air vibrate in the room... yet the moment the attending asked of him, frankly and without guile, "Why are you staring at me?" the spell collapsed, deprived of all its power.

"I'm not staring at you," was his only, weak recourse.

But it was nothing so simple as her bare words that disarmed him.  I pictured the same patient on a gritty street corner, leveling his rapier gaze at a fellow thug.  The same phrase spoken in an equally hostile tone by a burly, puff-jacketed swaggart would have but escalated the situation.  It is the opt-out, the calm inquiry, the untroubled curiosity, that undercuts the threat.

Good therapists wield this tool with skill and precision.  They refuse to play the game, choosing rather to analyze it.  All of us, as humans, have some understanding of this complex social game.  We approach and retreat, feint and parry, dance an endless dance of human relations - all without a word, a world of interactions parallel to but separate from our explicit verbal exchanges.

People who play the game well become leaders, extracting what they wish from others while retaining their loyalty and affection.  People who have a shallow or incomplete understanding of it become recluses, frustrated at every turn by interactions that go awry.

But whether they play it well or poorly, in the normal course of human behavior the game is never made explicit.  To make it explicit is to undermine it entirely.  The therapist does this in a controlled manner, slicing the game out of its skin and dissecting it apart, displaying its innards openly to his patient's wonder and, perhaps, dismay.