Friday, May 30, 2008

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.

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