The Collected Schizophrenias

Diagnosis

• Craziness scares us because we are creatures who long for structure and sense; we divide the interminable days into years, months, and weeks.
• A diagnosis is comforting because it provides a framework - a community, a lineage - and, if luck is afoot, a treatment or cure. A diagnosis says that I am crazy, but in a particular way.
• Schizophrenia in the Diagnostic and Statistical Manual (DSM-5):
  • A: Two or more of the following for a significant portion of time during a 1-month period:
    • Delusions
    • Hallucinations
    • Disorganized speech
    • Grossly disorganized or catatonic behavior (which can include excessive motor activity)
    • Negative symptoms (ie diminished emotional expression or avolition)
  • B: Markedly reduced function in one or more major areas, like work, interpersonal relations, or self care.
  • C: Continuous signs of disturbance for at least 6 months.
  • D: Ruled out schizoaffective disorder and depressive or bipolar disorder with psychotic features.
  • E: Not due to drugs, medication, or another medical condition.
  • F: If there is autism spectrum disorder or a childhood onset communication disorder, then prominent delusions or hallucinations.
• Medicine is an inexact science, but psychiatry is particularly so.
• Schizoaffective Disorder, Bipolar type, involves schizophrenic symptom in addition to a major depressive or manic mood episode
• Emil Kraepelin is credited with pinpointing the disorder he called "dementia praecox" in 1893, but the Swiss psychiatrist Eugen Bleuler coined the word "schizophrenia" ("split mind", to address the loosening of associations that are common in the disorder) in 1908.
• People diagnosed with schizophrenia are more likely to be born in the winter than in the summer; perhaps due to maternal infection during pregnancy. Difficult births, obstetrical complications, and stressful events suffered by the mother, such as assault and war, are also correlated.
• Certain categories, as crude as they are, are still useful in capturing a group of individuals that probably have more in common in terms of etiology or basic mechanism than they are different. And certain disorders are better than others in that regard. So autism has proven to be a pretty useful thing. bipolar disorder has proven to be, I think, more useful then schizophrenia. Obsessive-compulsive disorder is probably one of the more specific ones. Major depression is problematic. Generalized anxiety disorder is very problematic.
• Schizophrenia's subtypes - paranoid, disorganized, catatonic, and undifferentiated - no longer exist in DSM-5, which means, among other things, that pop culture has lost "paranoid schizophrenia" as a diagnosis upon which to hang criminal acts
• One potential explanation suggests that the evolutionary development of speech, language, and creativity, while bestowing significant gifts, has "dragged" along less desirable genetic tendencies with it; from this perspective, schizophrenia is simply the price humanity pays for the ability to write hearrending operas and earthshaking speeches.

Toward a Pathology of the Possessed

• Humans might all be ciphers to one another, but people with mental illness are particularly opaque because of their broken brains. We cannot be trusted about anything, including our own experiences.

High-Functioning

• Schizophrenia and its ilk are not seen by society as conditions that coexist with the potential for being high-functioning, and are therefore terrifying. No one wants to be crazy, least of all truly crazy - as in psychotic. Schizophrenics are seen as some of the most dysfunctional members of society: we are homeless, we are inscrutable, and we are murderers.
• Among psychiatric researchers, having a job is considered one of the major characteristics of being a high-functioning person... as having a job is the most reliable sign that you can pass in the world as normal.

Yale Will Not Save You

• There might be something comforting about the notion that there is, deep down, an impeccable self without disorder, and that if I try hard enough, I can reach that unblemished self. But there may be no impeccable self to reach, and if I continue to struggle toward one, I might go mad in the pursuit.

The Choice of Children

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On the Ward

• A primary feature of the experience of staying in a psychiatric hospital is that you will not be believed about anything. A corollary to this feature: things will be believed about you that are not at all true.
• I was overwhelmed with a sense of free-floating terror that spread like blood and congealed around vulnerable targets such as my face, the patterns in the carpet and on the bedspread, the view of dry and dusty Reno from our window.
• Though nearly all the statements a psychiatric patient can make are not believed, proclamations of insanity are the exception to the rule. "I want to kill myself" generally holds water, and a therapist who hears those words is legally required to disclose them to prevent client self-harm.
• A person who is hospitalized with schizophrenia will inevitably be put on some type of second-generation antipsychotic. Zyprexa, for example, is known to put the brakes on manic activity. Hospitalization is generally reserved for times of psychiatric crisis, and so Zyprexa, or a drug like it, may shut down the most violent behaviors.
• But medication is only one part of the ideal treatment plan. According to the American Psychiatric Association's Practice Guideline for the Treatment of Patients with Schizophrenia, 2nd ed, that plan has three major components:
  • To reduce or eliminate symptoms.
  • To maximize quality of life and adaptive functioning.
  • To promote and maintain recovery from the debilitating effects of illness to the maximum extent possible
• All of this should be done swiftly: according to a 2012 study, the average stay in a psychiatric hospital is 10 days. The contemporary psychiatric hospital is intended to stabilize its patients, and then to set them up for recovery in the outside world.
• According to the Department of Justice, nearly 1.3m people with mental illness are incarcerated in state and federal jails and prisons.

The Slender Man, the Nothing, and Me

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Reality, On-Screen

• I'd taken the emergency dose because I felt myself slipping, and sensed myself hurtling into the reality of the film (Lucy), leaving my own behind. I could fell my brain twitching with the belief that I, too, was gaining access to more of my brain than that of ordinary mortals, and that if I tried, I could destroy objects with its power.
• The more I consider the world, the more I realize that it's supposed to have a cohesion that no longer exists, or that it is swiftly losing - either because it is pulling itself apart, because it has never been cohesive, or, most likely, some jumbled combination of the above. I can understand only one piece or the other, even though the sky is supposed to belong to the same world as the curtains, and the dog that enters the room draws my attention as an entirely new object to contend with.
• The moment of shifting from one phase to the other is usually sharp and clear; I turn my head and in a single moment realize that my coworkers have been replaced by robots, or glance at my sewing table as the thought settles over me, fine and gray as soot, that I am dead. In this way I have become, and have remained, delusional for months at a time, which feels like breaking through a thin barrier to another world that sways and bucks and won't throw me back through again, no matter how many pills I swallow or how much I struggle to return.

John Doe, Psychosis

• EMDR or Eye Movement Desensitization and Reprocessing: thinking about other things while moving your eyes in a prescribed way rewires the brain.
• A fictional narrative is considered nuanced when it includes contradictions, but a narrative of trauma is ill-advised to do the same.

Perdition Days

• I write this while experiencing a strain of psychosis know as Cotard's delusion, in which the patient believes that they are dead.
• I looked at the antique sewing table in my office, seeing red wood without totally seeing it, and felt the old anxiety of unreality.
• In past psychotic episodes, my response has been to desperately assemble rituals or structures that will somehow ward off the anxiety of psychotic fracture, or Eugen Bleuler's "loosening of associations." To assemble the parts of my mind, which has begun to fall apart - to become "scatterbrained" - into cohesion.
• Debruyne and his colleague's suggest that Cotard's delusion is related to Capgras delusion, which I have also frequently experienced. Both delusions are rare, and both affect the fusiform face area and the amygdala, which processes emotions. The normal emotion that I would feel looking at a loved one's face is absent. The person afflicted with Cotard's is unable to feel emotions about familiar faces. It is thought that with Capgras this lack leads to a conclusion that the person's loved ones have been replaced by doubles, and with Cotard's that the person experiencing the delusion is herself dead.
• Delusions are harder to medicate away than hallucinations. My form of schizoaffective disorder was, Dr M. said, medication-resistant. Both agreed that the best course of action was for me to learn coping mechanisms and practice acceptance.
• If I am psychotic 98% of the time, who am I? If I believe that I don't exist, or that I am dead, does that not impact who I am? Who is this alleged "person" who is a "person living with psychosis", once the psychosis has set in to the point that there is nothing on the table save acceptance.
• When the self has been swallowed by illness, isn't it cruel to insist on a self that is not illness? Is this why so many people insist on believing in a soul?
• Psychosis causes my reality to become a hodgepodge; the addition of fictional elements is more unnecessary fodder for the mix, and the content can make me more scrambled and agitated than I already am.

L'Appel du Vide

• Susan Sontag: "The painter constructs, the photographer discloses."
• Jackson Pollock: "I am interested in expressing, not illustrating my emotions." But I look at those pictures and see anything but expression. Instead, there is an approximation, or an illustration, of what I believe an emotion should be.

Chimayo

• According to the growing field of autoimmune neurology, the immune system can wage a misguided attack on a person's central or peripheral nervous system. My previously suspected diagnosis of anti-NMDA receptor encephalitis is one such example - the disorder occurs when the immune system attacks the brain's NMDA receptors, resulting in a chaotic array of symptoms such as speech dysfunction, hallucinations, delusions, and cognitive and behavioral disturbances - symptoms, in other words, that look like schizophrenia. In a Danish study, researchers concluded that "a history of any autoimmune disease was associated with a 45% increase in risk for schizophrenia.

Beyond the Hedge

• Picasso: "Everything you can imagine is real."
• People who are thin-skinned have perceptions that are wide-open; they perceive what is happening in the other realm. Thin-skinned, or skinless, individuals will start to think they're crazy because they see, sense, and feel things outside of the regular scope of experience.
• Bernstein posits the idea of "borderland personalities" - people whose sensitivities and unusual perceptions are "nothing short of sacred".
• The line between insanity and mysticism is thin; the line between reality and unreality is thin. Liminality as a spiritual concept is all about the porousness of boundaries.
• Dreams are the most common expression of liminality - more common than, say, seeing or feeling the presence of saints, angels, or God, which are all liminal experiences. To work with the liminal is to probe the notion of what is real vs imaginary, or even psychotic.
• The divine is nonrational and indicates the limits of symbolic understanding; insanity is irrational and indicates a structural failure of reality.
• I don't want o go into the liminal realms. I want to know how to control myself when frightening things happen to me, and if there's a chance that a ribbon around my ankle will keep me tethered to this world or safer, somehow, when I do tumble out of it.
• When a certain kind of psychic detachment occurs, I retrieve my ribbon; I tie it around my ankle. I tell myself that should delusion come to call, or hallucinations crowd my senses again, I might be able to wrangle sense out of the senseless. I tell myself that if I must live with a slippery mind, I want to know how to tether it too.