R E P O R T

WHICH WAY
MADNESS LIES
Can psychosis be prevented?
By Rachel Aviv

A nna did not simply decide one

day that people were made of paper.
three years ago, schoolwork had be-
come daunting for the first time. She
overwhelmed by the task of physically
forming the sounds of words that she
She came to the conclusion slowly had studied Russian, German, and lost the ability to speak. She knew
and reluctantly, several what she wanted to say,
months after she first no- but she couldn’t will her-
ticed that the consistency self to make such odd
of everything around her little noises.
had subtly changed. I met Anna last year
Books and chairs and at her Illinois home, a
buildings were no longer small, brightly painted
solid but composed of town-house apartment,
tiny, buzzing particles. and she tried to pinpoint
She thought if she blew when she had stopped
on a lamppost it should believing in the reality
disperse into air. On her she’d contentedly inhab-
way to school every ited all her life. A petite
morning, she was per- twenty-eight-year-old
plexed by the implausibil- wit h clea nly pa r ted
ity of the process: that she blond hair, she spoke in
could walk along the side- a thin, strained voice
walk, her boots pressed and avoided looking at
against the concrete, me. My lips, she said, ap-
without falling through. peared as if they were
Anna had always been moving at a different
the kind of student who pace than my voice, and
would do anything to she had to bat away the
please her teachers, and thought that she was
from a young age she had watching a dubbed film.
single-mindedly pursued A n na’s mot her i s
a career as a scholar.1 But schizophrenic, and Anna
by her first semester of graduate school French, yet she found herself forget- had always found her mother’s world-
1
To protect patients’ privacy, all names and ting words she’d known for years. Even view—derived in part from messages
a few identifying details have been changed. English no longer felt like a native she deciphered in processed-food
language. She sometimes examined packaging—distasteful and impossible
the appearance of words, the align- to comprehend. She assumed that
Rachel Aviv is a recipient of the 2010 Rona
Jaffe Foundation Writers’ Award. Her arti- ment of angles and curves on the page, when her mother had a schizophrenic
cle “Like I Was Jesus” appeared in the Au- until she lost sight of their meaning. break, the delusions had taken her by
gust 2009 issue of Harper’s Magazine. Once, with her friends, she became so force, engulfing her. But an alternate

Quem, by Sebastiaan Bremer. Courtesy the artist REPORT 35

Aviv Final2cx2.indd 35 10/25/10 6:42 PM

 reality did not come to Anna fully agnosed with certainty. Yet in the mas. Many psychiatrists worry that
formed. Throughout her first year of past decade, doctors have begun to young patients will become fatalistic
graduate school, she kept monitoring trace the illness back to its earliest about their future and define them-
her own perceptions, wondering signs. The place where Anna re- selves in relation to a chronic disease
whether they didn’t have some “tinge ceives therapy, the First Episode they may never develop. Yet once
of unreality.” She searched for a nar- Psychosis Clinic at the University of people have a full-blown psychotic
rative that would explain why the Illinois Medical Center (she began episodes—the schizophrenia diagno-
world was being transformed. One day, treatment in April 2008, shortly af- sis requires a month of psychotic
wandering the halls of an academic ter she noticed the particles sur- behavior—there may be irreversible
department, she became fascinated by rounding her), is one of about sixty changes in the brain. Studies have
the physical details of the building: clinics in the United States that shown that the longer someone is
tiny cracks in the wall, a light switch, work to help people experiencing unhinged from reality before getting
a rubber doorstop that looked lumi- early psychotic symptoms maintain treatment for the first time, the
nous and functionless. A bust of Plato, a grasp on reality. About a third of worse their long-term prognosis.
which she had never noticed before, these programs focus exclusively on Based in part on the findings of
seemed to be calling out to her. As she patients who appear to be in what is the Prodrome Longitudinal Study, a
gazed at Plato’s mournful expression, known as the prodrome, the aura new diagnosis, the psychosis risk syn-
she imagined that he had singled her that precedes a psychotic break by drome, was proposed last year for the
out to unburden himself and shed up to two or three years. During this fifth edition of the Diagnostic and
light on the “overwhelming strange- phase, people often have mild Statistical Manual of Mental Disorders
ness of the world.” hallucinations —they might spot a (forthcoming in 2013), psychiatry’s
But after she left campus and re- nonexistent cat out of the corner of central reference text. Symptoms
turned to her apartment that day, their eye or hear their name in the would include
the electricity of her mood passed, sound of the wind—yet they doubt
and she wanted nothing to do with that these sensations are real. They feeling perplexed, confused, or strange,
Plato’s secrets. She blamed herself for still have “insight”—a pivotal word thinking that the self, the world, and
attending too avidly to the stream of in psychiatric literature, indicating time has changed (often in ways that
cannot be described), having ideas of
her own consciousness. “It wasn’t as that a patient can recognize an al- reference that are not perceived as di-
if this bust suddenly started talking tered worldview as a sign of illness, rectly threatening to the individual,
to me out of thin air,” she told me. “I not a revelation. unusual ideas (about the body, guilt,
wanted him to, and then I sort of By working with people when nihilism), overvalued beliefs (about
convinced myself that he did. It they are still skeptical of their own philosophy, religion, magic) . . .
didn’t feel like I was passively being delusions, doctors hope to stop the
subjected to another reality. It felt disease before it has really begun. Once patients believe in their delu-
like I somehow actively Three years ago, the results of a sions with full conviction, they are

P
engaged in creating it.” study of nearly 300 patients who said to have crossed the threshold to
sought treatment because of “recur- psychosis—a process com-

A
sychiatry has many names for ring unusual thoughts,” “unusual monly called “conversion.”
the symptoms of florid psychoses but sensory experiences,” or “increased
almost no language that describes suspiciousness” were published by lthough the DSM is written by
the anomalous experiences that the North American Prodrome Lon- the country’s leading psychiatrists,
gradually lead up to this state. The gitudinal Study, a collaboration of the neurological mechanisms behind
psychoanalyst Harry Stack Sullivan, eight prodromal outpatient clinics. mental disorders are too poorly under-
who worked with hundreds of peo- The researchers found that 35 per- stood to have much bearing on the
ple with schizophrenia, proclaimed cent of patients had a psychotic way the manual separates health from
as early as 1927, “I feel certain that break within two and a half years of pathology. Instead, the fifty-eight-
many incipient cases might be ar- enrolling at a clinic.2 (If symptoms year-old book guides psychiatrists to-
rested before the efficient contact continue, the patients will eventual- ward diagnoses with checklists of be-
with reality is completely suspend- ly be diagnosed with schizophrenia havioral signs that require a “minimal
ed.” But doctors had no means of or another psychotic disorder.) This amount of inference on the part of
finding and recruiting patients who line of research may promise the the observer” (according to the 1987
were, for all intents and purposes, closest thing there has ever been to edition). The outer limits of normality
still healthy. a “cure” for psychosis, but because of are decided by committee, with defi-
It is impossible to predict the pre- the high false-positive rate, the work nitions of illness deferring to consen-
cise moment when a person has em- has been tempered by ethical dilem- sus opinion. A “delusion,” one of the
barked on a path toward madness, five key symptoms listed for schizo-
since there is no quantifiable point
2
The others found that their symptoms phrenia, is a “false belief . . . firmly sus-
passed or plateaued. For patients who
at which healthy thoughts become used cannabis, amphetamines, opiates, or tained despite what almost everyone
insane. It is only in retrospect that hallucinogens, the risk of psychosis rose to else believes.” A “bizarre delusion,” a
the prelude to psychosis can be di- 43 percent. more severe symptom, has gone

36 HARPER’S MAGAZINE / DECEMBER 2010

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 through numerous revisions. In
one edition of the manual, it
had to have “patently absurd”
content with “no possible basis
in fact”; in the next, it involved
“a phenomenon that the per-
son’s culture would regard as to-
tally implausible.” After the re-
vision, 10 percent of patients
who were previously deemed
schizophrenic were given a new
diagnosis, the majority of them
because their delusions were no
longer bizarre.3
The DSM is designed to
avoid the slippery spaces be-
tween disorders, the complaints
not easily named or seen. Per-
haps more than any other dis-
order, the psychosis risk syn-
drome puts pressure on the
logic of the entire enterprise, as
it forces doctors to break down
the process of losing one’s
mind. They have to identify
delusions before the patient re-
ally believes in them. When
does a strong idea take on a
pathological flavor? How does
a metaphysical crisis morph
into a medical one? At what
point does our interpretation of
the world become so fixed that
it no longer matters “what al-
most everyone else believes”? tient at the Psychosis Clinic, after had vigorously argued that the fan-
Even William James admitted that he finding it online. She was still get- tastical stories her mother told were
struggled to distinguish a schizophren- ting A’s in school, and there was no logically impossible: there was no
ic break from a mystical experience. one symptom that bothered her global con spiracy, t he phones
For Anna, early symptoms were most—it was only the sum total of weren’t tapped, there was no need
nearly impossible to describe, and these nameless experiences. to put all their belongings on the
the only way to communicate them Anna’s psychologist, Cherise sidewalk. Anna was terrified of be-
was by making up new phrases: she Rosen, would not speak to me di- coming schizophrenic herself—more
wrote in her journal that she was rectly about Anna’s treatment, but than 10 percent of people with a
struggling with “migrating electrical Anna said that she was initially schizophrenic parent develop the
sensations” and the sense that told that her symptoms were mild disease, compared with about 1 per-
“words were alive.” The first thera- and her prognosis good. Although cent in the rest of the population—
pist Anna went to see didn’t know she never received an official diag- but by the time she reached her ear-
what to make of her disparate symp- nosis, Anna tentatively concluded, ly twenties, she was so socially and
toms and, after a few sessions, told after scouring psychiatric literature intellectually at ease that she as-
Anna she didn’t know how to help on psychosis and recognizing her- sumed the window of risk had
her. Anna left without a referral. self in the descriptions, that she passed. “I defined myself in opposi-
Two months later, she became a pa- was in the prodrome to schizophre- tion to that backdrop of illogicality,”
nia. (The clinic accepts some pro- she said.
3
Michel Cermolacce, Louis Sass, and Josef
Parnas, writing in Schizophrenia Bulletin, dromal patients but primarily works Yet in the course of a few months,
offer a detailed account of the evolution and with people soon after a fi rst psy- she had become too suggestible: she
uses of this descriptor. Non-bizarre delusions chotic break.) would come up with sweeping theo-
are easier to pin down: according to the Anna and I spoke several times ries about the structure of reality—
DSM-IV they include “situations that occur
in real life, such as being followed, poisoned, over the past year, and she always that time no longer existed, that the
infected, loved at a distance, deceived by approached her symptoms with crit- world was made entirely of gasses—
spouse or lover, or having a disease.” ical distance. As an adolescent, she and then, moments later, scold her-

A Walk in the Park, by Sebastiaan Bremer.

Courtesy the artist and BravinLee, New York City REPORT 37

Aviv Final2cx2.indd 37 10/25/10 6:42 PM

 self for allowing the experience schizophrenia is so deeply entrenched ume in certain parts of their brains,
when there was “not a shred of sci- in psychiatric practice that when pa- particularly the hippocampus, which
entific evidence.” She kept waiting tients recover, they’re occasionally is crucial for learning and memory.
for the particles to vanish on their told that they must have had a differ- (These findings are too rough to
own. When they didn’t, she worried ent disorder all along. People with serve as a diagnostic tool.) In one
she was “addicted to an idea.” She schizophrenia take up 25 percent of study, McGlashan and other re-
felt that by wondering about the the nation’s hospital beds, and 10 searchers had patients listen to re-
properties of matter—by blowing on percent of them eventually commit cordings of several people speaking
books to see whether they would suicide. Over the past century, doc- simultaneously so that their words
disintegrate—she had taken some tors have tended to grasp at anything were indecipherable. Those patients
irrevocable step toward illness. resembling a cure, allowing little who could detect meaning—they
Anna’s doctors urged her to take time to elapse between a new theory heard the words “the children,”
antipsychotic medication, but Anna and its practical application. They “bombing,” “the administration,”
did so only sporadically, rarely at a injected patients with blood drawn “seem to have trouble,” “practice
therapeutic dose, primarily because from epileptics; put them into insu- dancing”—were more likely to be-
the drugs made her feel too tired lin-induced comas so that they might come psychotic within one year.
and mentally cloudy. During her wake up renewed and transformed; McGlashan and his team at Yale
weekly sessions, the psychiatrist at and carved out parts of their prefron- are among those who have pushed
the clinic would check up on her tal cortices—where unhealthy fixa- for the psychosis risk syndrome (or,
with a stream of standard queries: tions were thought to reside—with more recently, the “attenuated psy-
Do you think your thoughts are not ice picks. chotic symptoms syndrome”) to be
your own? Do you ever hear voices? Then, for decades, the prevailing included in the DSM, so that psychi-
For months, Anna said no, but she treatment model called for no physi- atrists won’t turn away patients sim-
became increasingly uncertain. The cal contact. Patients reclined on ply because they haven’t fulfilled di-
boundar y between fantasy and leather couches while psychiatrists agnostic criteria. McGlashan has
lived reality had become too po- plumbed their childhoods for hints compared the historical importance
rous. When she focused closely of abuse or neglect, for mothers who of prodromal research to Freud’s dis-
enough on her thoughts, she could had been too frigid or overprotec- covery that dreams reveal the un-
make herself hear a soft voice be- tive or needy. “We were just build- conscious. But many of his colleagues
hind them. More and more, her ing castles, sand castles,” Thomas object to adding the diagnosis, since
thoughts began to feel like “things,” McGlashan, the first American doc- even the best clinics predict psycho-
she said. They had their own loca- tor to open a prodromal clinic, told sis with less than 40 percent accura-
tion and sentience: she could feel me. He spent fifteen years as an an- cy and there is no clearly established
t hem ci rcli ng a rou nd alyst at Chestnut Lodge, a famous method for preventing conversion.

F
her brain. psychiatric asylum in Maryland, un- It’s impossible to know whether early
til he was overwhelmed by the sense intervention has prevented a psy-
or the past two centuries, that the disease had eluded him and chotic break or whether the patient
schizophrenia has been defined in his colleagues. “We can’t just sit was never going to have one in the
part by its incomprehensibility. The there and guess why someone has first place.
psychiatrist Karl Jaspers wrote that gone mad,” he said. “We have to A few prodromal clinics prescribe
schizophrenic symptoms embody watch it happen.” antipsychotics to the majority of pa-
“something inaccessible and foreign McGlashan was inspired by the tients but most, including Mc-
which, for this very reason, language work of the New Zealand psychiatrist Glashan’s, treat patients for the
defines as deranged.” In the 1940s, Ian Falloon, who, in the late 1980s, symptoms they have, not the ones
doctors turned their own sense of had attempted to treat all the people they may eventually develop.4 Thera-
alienation into a diagnostic marker. in two towns north of London who py, psychosocial education, and anti-
If they could not feel empathy for showed possible signs of impending anxiety and antidepressant medica-
their patients, they would get a cold, psychosis. After giving these patients tions are used. But if the diagnosis is
vertiginous sensation known as the low doses of antipsychotics and administered by clinicians not spe-
“praecox feeling” (schizophrenia used home-based therapy for four years, cially trained in the field, the possi-
to be known as dementia praecox). Falloon reported that the two towns bility of overmedication is much
Sigmund Freud apparently got this had one tenth as many new cases of greater—a potential “public health
feeling and gave up on talk therapy psychosis as the rest of the country. 4
In one early experiment, McGlashan ex-
with schizophrenics. “Ultimately I More recent studies have shown that amined the efficacy of the antipsychotic drug
had to confess to myself,” he wrote to in the years before people have a psy- olanzapine, but the study produced mixed
a colleague, “that I do not care for chotic break, they struggle to identify results. It also prompted an investigation by
these patients, that they annoy me, tastes and smells—a banana no lon- the federal Office for Human Research Pro-
tections, in part because McGlashan had
and that I find them alien to me and ger tastes like a banana, or fresh wa- not adequately informed his patients that the
to everything human.” ter begins to carry the odor of drug has side effects: participants gained an
T he pes simi sm su r rou ndi ng mold—and they lose gray-matter vol- average of twenty pounds.

38 HARPER’S MAGAZINE / DECEMBER 2010

Aviv Final2cx2.indd 38 10/25/10 6:43 PM

 " #!
!#!
!!#"##"" "## ### #

HANDCRAFTED STORIES FROM THE

catastrophe,” in the words of Allen Jorge, a peppy high school junior
Frances, chair of the DSM-IV Task who was referred to the program two
HARPER’S MAGAZINE ARCHIVES
Force. In a letter to the board of the years ago after walking across the
American Psychiatric Association George Washington Bridge with a
last year, he and Robert Spitzer, the four-foot samurai sword wrapped in a
architect of DSM-III, warned that if blanket. He had become obsessed
the psychosis risk syndrome were in- with black magic, spending hours a
cluded in the manual, the associa- day on a website for occult research-
tion would run the risk of “medical- ers. At the time, he felt like he was
izing normality, and of trivializing on the brink of tapping into his own
the whole concept of psy- mystical powers. “I need to control

O
chiatric diagnosis.” myself when I study something,” he
told me, swiveling around in an of- For 160 years, Harper’s Magazine
ver the course of several fice chair. “It sticks on me too hard. I has published fiction and non-
months last winter, I visited the Cen- get so dragged into the subject that I fiction by some of the world’s
ter of Prevention & Evaluation become it.” most renowned authors. The
(COPE), a prodromal outpatient Like nearly all American prodro- Balvenie is pleased to bring to
clinic on the fourth floor of the New mal clinics, COPE admits patients
you a selection of these pieces
York State Psychiatric Institute in based on their responses to the
Manhattan’s Washington Heights Structured Interview for Psychosis- from writers who have helped
neighborhood. The clinic’s director, Risk Syndromes, a two-hour exam define world literature since
Cheryl Corcoran, a compassionate, developed by McGlashan—modeled 1850, including:
soft-spoken psychiatrist who has on a similar test authored by psychia-
studied schizophrenia for her entire trists in Melbourne—that evaluates Horatio Alger
career, does not think the “risk” di- genetic risk, cognitive deterioration, Hans Christian Andersen
agnosis is ready for unrestricted use, social withdrawal, and the earliest Lewis Carroll
because of the difficulty of reliably flickers of psychosis. Winston Churchill
identifying inchoate psychotic symp- Joseph Conrad
Do you daydream a lot or find yourself
toms. Some patients can still hold preoccupied with stories, fantasies, Stephen A. Douglas
down jobs, excel at school, or lead or ideas? A. Conan Doyle
full social lives, yet they complain of Do you think others ever say that
transformations in their moods or George Eliot
your interests are unusual or that
perceptions. They often come to the you are eccentric? Thomas Hardy
six-year-old clinic (by referral or In- Do familiar people or surroundings William Dean Howells
ternet search) because other doctors ever seem strange? Confusing? Un- Henry James
aren’t sure how to classify what they real? Not a part of the living world? Rudyard Kipling
are going through. In a paper in Psy- Alien? Inhuman? Sinclair Lewis
chiatric Quarterly, Corcoran pub- Have you ever felt that you might not
actually exist? Do you ever think Henry Cabot Lodge
lished excerpts of interviews with pa- that the world might not exist? Jack London
tients’ parents, many of whom relied Henry Wadsworth Longfellow
on non-medical explanations to ar- Another part of the exam assesses Herman Melville
ticulate what had changed: “I didn’t people’s capacity for abstract thought.
Theodore Roosevelt
know if he was possessed by the dev- They are asked to interpret proverbs,
il, because he was himself one day such as “Don’t count your chickens Arthur Symons
and then dramatically different and before they hatch,” and to describe Mark Twain
not coming back.” “She is like a ves- the similarities between an apple and
sel that is never full.” “It’s hard be- a banana. The correct response— Please visit
cause I don’t even know this person.” “Both are fruit”—eludes some of the www.harpers.org/sponsor/
“It’s not good to go against God— sicker patients, who instead home in thebalvenie/
you can lose your soul.” on concrete characteristics. The psy-
I met with six patients individually chologist who administers the exam
in a small therapist’s office overlook- told me that one of the most common
ing the Hudson River and with pho- wrong answers is “Both have skin.”
tographs of serene scenery on the At the clinic, health is measured
walls: Central Park in autumn, a by degrees of conviction. Corcoran
dock overlooking the sea. They rare- routinely checks up on her patients
ly used the word “schizophrenia,” but to see how compelling (on a scale of
they all spoke of the fear of losing 1 to 10) they find their unusual be-
their minds. “This whole thing has liefs. How do you think people are
turned me into a philosopher,” said reading your mind? she asks gently.

Handcrafted to be enjoyed responsibly

REPORT 39

$YLY)LQDOF[LQGG 30
 Are they reading it right now? Do gaging with questions of cause and black peacoat buttoned up to her
you ever think it could be your imag- effect.) Studies have shown that peo- chin for the length of our conversa-
ination? As they flesh out their sto- ple’s chances of developing the disor- tion. Each time she described a par-
ries, people sometimes dismiss their der increase after demoralizing ticularly troublesome symptom, she
fears as “crazy” or “goofy” or “absurd.” events—sexual or physical abuse, would laugh at herself, a soft, low,
Treatment becomes a process of rein- emotional neglect, witnessing a infectious giggle. “I think too much
terpreting and naming experiences bombing or shooting, a mother’s about every action I take. Like, ‘I’m
that once felt too private and ineffa- death. Other factors include poverty, moving my hand right now! That’s
ble to share. “The man on the sub- growing up with more than three so magical!’ ” She wiggled her fi n-
way may know what I’m thinking” is siblings, living in an urban area, and gers in the air.
translated as “I’m feeling paranoid.” immigration. When people move to Chloe described her father as the
“When people are not entirely con- a neighborhood where they are the “town nut” and then quickly apolo-
vinced, you can work with that in- ethnic minority, their chances of be- gized for saying it. As a child, she had
sight,” Corcoran said. “The experi- coming schizophrenic increase. As struggled to understand that the sto-
ence doesn’t have to impose a change the anthropologist T. M. Luhrmann ries he told about ghosts from the
on their identity.” put it, “If your skin is dark, your risk Civil War were no more real than the
Although people with schizophre- for schizophrenia rises as your neigh- fairy tales she read before bed. When
nia are born with a biological vul- borhood whitens.” she went home to visit her family re-
nerability that predisposes them to About a third of the patients at cently, she sat in the back yard with
the disease, the theory that psychosis COPE immigrated to the United her father, who had refused treatment
arises from psychological turmoil is States. Chloe, a glamorous, well- his whole life, and played house with
not as anachronistic as many have dressed twenty-four-year-old Japa- figures he had made out of sticks. “I
been led to believe. (As if to com- nese American who worked as a never want to be one of those people,”
pensate for the psychoanalytic era, writer’s assistant, told me that many she said softly.
when a generation of parents were of her symptoms stemmed from “this At times, she imagined that the
made to feel responsible for their constant questioning of what my act of having a bad thought—and
children’s suffering, psychiatrists true self is— even though that then thinking about that act—would
have become squeamish about en- sounds really cheesy.” She kept her cause blood to leak from her brain.

40 HARPER’S MAGAZINE / DECEMBER 2010 Mirror, by Sebastiaan Bremer. Courtesy the artist

Aviv Final2.indd 40 10/22/10 9:33 AM

 The fear was new to her and, like then let’s look for it,’ ” and they go ed to check herself into the hospi-
Anna, she struggled to hold on to on the Web together. (When pa- tal, but the first cab she flagged
the experience. “Sometimes I’ll just tients can’t find the site, Pollard down had an advertisement for the
sit there and be like, ‘Is there really says, they are usually able to accept Broadway play Wicked on its roof.
anything wrong with me? What if I that it doesn’t exist.) Whether “I knew it might be crazy, but
am making these things up because about all-knowing blogs or guiding there was a part of me that felt
I’m so attention-starved?’ ” She man- angels, there’s a uniformity to many that if I got into a cab that says
aged a polite smile. “Or what if it’s delusions. They offer an explana- ‘Wicked,’ it would take me to Hell.
the fact that I’m making these things tion for an unfamiliar feeling: the Because I’m wicked!”
up that makes me mentally ill?” experience of losing control over Eventually she got into another
When I asked which experiences she one’s mind. cab. This one had an advertisement
may have invented, she put her The terror of this loss was de- for Absolut Vodka. “I thought, ‘Oh,
chin in her palms and shook her scribed most vividly to me by one of Mormonism says you can’t drink al-
head. “There are no words. It’s like the oldest patients at COPE, a slim cohol! But that’s lesser. A smaller
trying to explain what a bark sounds twenty-eight-year-old named Mela- sin. All right, I’ll get in the cab.’ ” As
like to someone who’s nev- nie, who wore khakis, penny loafers, she drove to the hospital, she had a

A
er heard of a dog.” and a turtleneck to our meeting. She kind of double awareness: she felt
seemed to have come closer to psy- crazed and terrified, and yet she also
lthough the psychiatric liter- chosis than any other patient I inter- saw herself as crazed and terrified—a
ature describes a premorbid person- viewed there, but she used a few person she couldn’t quite relate to. “I
ality common to those who later de- shreds of logic to tether herself to re- have a science background,” she told
velop schizophrenia—withdrawn, ality. Her symptoms began in Janu- me. “I was thinking, Why are you
self-conscious, alienated—few of the ary 2009, shortly after US Airways having these religious feelings? You
patients I spoke with at COPE or at Flight 1549 hit a flock of geese and are an atheist now. Richard Dawkins!
the Aware Program in Bangor, landed in the Hudson River. As she The God Delusion! You’re misinter-
Maine, another prodromal clinic watched the footage of passengers preting! There’s something wrong
where I interviewed patients, fit that huddling on the wings of the floating with your brain!”
description. The only commonali- aircraft, she recalled a status update If Melanie had waited longer be-
ties were that nearly all of them had she’d recently posted online that re- fore she went to the hospital, if her
moved through childhood and ado- ferred to the saying “A bird in the symptoms had persisted for another
lescence feeling more thoughtful, hand is worth two in the bush.” “I few weeks (the religious thoughts
intelligent, or probing than their felt a huge jolt,” she told me, speak- lasted for about two days), she
family and peers and that there had ing rapidly. Her pale face flushed. might have been diagnosed with
been an existential tinge to their “I’ve never been one to say I predict- schizophrenia. But she began tak-
preoccupations years before their ed anything, but—for one thing, ing a low dose of antipsychotics
symptoms emerged. Aaron, a patient birds. Birds had taken down the and almost immediately stopped
at Aware who had been the presi- plane. And then bush—President worrying about Hell. A few days
dent of his high school class, said Bush. I thought, ‘Oh my God, this is later, she went back to work and
that he and the others in his thera- another 9/11, and I predicted the recently received a promotion.
py group had “all gotten caught whole thing.’ ” She’s not sure whether the medica-
up on the deep, f undamental Although raised Mormon, Mela- tion and therapy cures psychosis or
que stion s — religion, mor a lit y, nie had been an atheist since col- just delays it forever, or whether
ethics—and sucked in by them.” lege, and in the days after the the distinction even matters. In
The raw material of delusions crash she was dismayed to find the the past year, she has occasionally
tends to evolve with the times, and God of her childhood reentering wondered whet her people a re
over the past century, literature her life. Every encounter seemed tracking her, but she’s usually able
about psychosis reflects a steady the- to have been orchestrated by Him. to ignore the fear. “I can catch it
matic progression: delusions about “When I heard a car honk out in right at the beginning—before it
communing with prophets and t he st reet, I remembered t hat becomes so intense that the only
kings gave way to fears of being ma- there are supposed to be two trum- thought that matches up with
nipulated by the secret powers of pets announcing the Second Com- those brain signals is: It’s the Apoc-
factories, UFOs, radio DJs, fax ma- ing,” she said, sitting upright at alypse, your soul is suffering.”
chines, Al Qaeda, the Internet. Jes- the edge of her chair. “The first Melanie said that her grandfather,
sica Pollard, the director of the trumpet calls for the good people, a former aerospace engineer, had a
Aware Program, said that a few of and the second trumpet is for ev- schizophrenic break while he was
her patients have become consumed eryone else. There was a part of testing missiles for the government.
by the fear that their private me that wondered”—she lowered When he began to have delusions
thoughts are being chronicled on- her voice to a whisper—“ ‘Is that that his coworkers were spying on
line. “I’ll say, ‘Okay, you really think one of the trumpets?’ ” She felt like him, the fantasy was close enough
there’s a website about you? Well, an “alien on this earth” and decid- to his everyday life that it did not

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 strike him as obviously implausible. showed it to the interviewer and planations have been replaced by a
Melanie, on the other hand, was translated the title to the interviewer new narrative. When I asked pa-
at a point in her life where the con- as “The Book of Ideas.” tients at COPE and the Aware Pro-
cept of a religious awa kening Interpretation: Preoccupation with gram about the “cause” of their
was clearly out of context. “I was unusually valued ideas symptoms, many responded by refer-
like, Ha!” she said. “My Case: Larry reported that he was not ring to neurobiological processes:

T
atheism saved me.” his usual self, as if part of him was “The hippocampus is firing too
missing. He reported feeling discon- much and telling me to be afraid.”
he course of psychosis is nected from everything but found “It’s the adrenaline, the epineph-
much more va r iable t ha n t he people’s concern for him strange. rine, and the norepinephrine; and
DSM’s definitions allow, and one Interpretation: Missing self the amygdala can either heighten
of the dangers of including the risk What it means to have a self— the anxiety or diminish it, depend-
syndrome in the manual is that and then to lose it—is central to ing on which direction I take with
this subtle state of mind is not eas- any attempt to understand psycho- my thoughts.”
ily expressed as a list of behavioral sis, but the DSM (and the reams of Anna, too, found herself scruti-
signs. Thomas McGlashan says p s yc h i a t r i c l it e r a t u r e it h a s nizing the degree of agency she had
psychiatric diagnosis is “just as spawned) do not encourage doctors over the inner workings of her
completely primitive as it’s always to probe their patients’ subjective brain. She enrolled in a neurobiolo-
been,” yet if he wants prodromal experiences. The manual is so con- gy elective in school and tried to
intervention to be widely practiced cerned with statistical reliability determine which pathological neu-
he will have no choice but to ad- (the book was meant to show “psy- ral process was making her thoughts
here to diagnostic standards. The chiatry becoming more of a sci- take on their own timbre. “It’s the
Psychosis-Risk Syndrome, his new ence,” as one editor put it) that the whole efference copy system,” she
guidebook for clinicians, features a brain is portrayed as a kind of black told me. “I’m double-hearing, I
series of tables with a list of his pa- box: only behavioral output is chart- think, and my thoughts are coming
tients’ symptoms and a correspond- ed. For a person who feels that her back to me as external.” But the
ing interpretation, but with no thoughts are implanted by the gods, knowledge did little to ease the phe-
speculation as to what gave rise to or broadcast on the radio, or stolen nomenon, and sometimes, in the
a particular behavior or belief, the by her own cat, the standard medi- midst of writing a paper, she would
analysis is circular. The symptom cal model—which treats symptoms become alarmed that she had ever
is essentially the interpretation as something external and discrete, imagined she could come up with
and the disorder itself. A critique independent of the self—fails to an idea and wonder whether her
in Schizophrenia Bulletin describes capture the core of the illness. thoughts were outside of her brain,
such methods as “akin to predict- Psychiatrists hope that soon a neu- floating. “The more I focus on my
ing extreme heat by an increase in rological explanation will make terms thoughts, the more it feels like they
temperature, without identifying like “self” and “reality” irrelevant for don’t actually belong to me,” she
the fire.” diagnosis, but in the absence of a cure, said. “It physically feels like my head
even the most nuanced neuroscientific is just completely hollow.”
Case: Trinity presented at the inter- theory can go only so far in explaining For Anna, there was no single mo-
view in a lovely spring dress, wearing someone’s altered sense of the world. ment of “conversion,” no sudden
a straw hat that was completely lined Aaron, at Aware, struggled with the break from one state of mind to the
with aluminum foil. She had plastic delusion that he was attracted to young next. If there is a boundary between
wrap around her hands and her shoes
and large wads of cotton protruding
children and would be persecuted for health and insanity, Anna felt her-
from her ears. his desires. He said he was assured that self creeping across it with pained
Interpretation: Grossly strange ap- these beliefs were “chemical” and self-awareness. She remembered as a
pearance “brain-based.” “What happens if there’s teenager feeling dismayed by her
some truth to your delusion? What if it mother’s inability to communicate:
Case: Mike reported that he thinks is tied to reality?” he said. “They don’t her thoughts no longer conformed to
people think negatively about him
and are plotting to make him con-
want you to come up with mythical the “laws that literally allow us to
fess everything that he has ever explanations. So they keep telling you make sense.” Now Anna worried
done wrong. over and over again: it’s just that she, too, had somehow been un-

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Interpretation: Concern about plots your brain.” moored from the rhythms of every-
day life. Occasionally she could read
Case: Dexter stated that he spends hirty years ago, people with dense academic texts, but other times
an increasing amount of time think-
ing about different ideas and is be-
psychotic symptoms might have ex- she couldn’t follow more than a few
coming preoccupied with these plained their problems by talking lines. She stopped going to class.
ideas. . . . He feels that it is important about the mixed messages they had Time no longer felt as if it passed:
to write these ideas down and to en- received at home. “It’s the way I was each moment had become discon-
code them in a private codebook. He raised,” or, “It’s because my mother nected from the next. She would lie
carried the codebook with him, always rejected me.” But these ex- in bed for hours, with the lights off,

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 watching the play of shadows on a not abnormal. But her current con- had become less compelling. Ordi-
wall that she wasn’t sure existed. dition now shades everything that nary activities, like lounging on a
An elegant and scrupulous writer, came before. Since psychiatric diag- bed and trusting that it wouldn’t
Anna was often dismayed to look noses are based almost entirely on sink through the floorboards, no
back at earlier pages of her journal the patient’s self-report—and Anna longer felt alien and unnatural. She
and see notes about futuristic mind always felt that her descriptions said that her psychologist and psy-
experiments involving implanted were inadequate and distorting— chiatrist strongly believed the
memories and telepathy, or the phys- she was left with the feeling that change came from her taking a new
ics of a new sphere of reality. In col- she’d somehow constructed the ill- antipsychotic drug, asenapine, for
lege, she had romanticized madness, ness herself. By naming these expe- the past t wo months, but she
but this was insanity as cliché. It of- riences, she worried she had brought couldn’t convince herself of this ex-
fered no revelation. Knowing that them into being. planation and was thinking of stop-
these thoughts were just “symp- Anna said she would have been a ping the medication. It wasn’t as if
toms”—a word that struck her as “lost soul” had she not found Dr. her perceptions had become normal
overburdened with consonants— Rosen, who was the only person with again, she argued. Hard surfaces still
didn’t diminish their force. She whom she could openly share these felt airy and insubstantial, but now
struggled to create some theory that experiences, but at times she strug- she made conscious decisions every
would explain why people seemed so gled to maintain belief in the reality day to rely on them just as she had
phony and lifeless and small, as if of her appointments. “Dr. Rosen will before. It was a matter of ignoring
they could be manipulated in her try to convince me, through Socratic swaths of her own perceptual expe-
fingers. She considered many possi- reasoning, that the appointment is rience, of relearning how to con-
bilities: they were marionettes, ro- actually happening,” Anna told me struct the world in her mind.
bots, drawings, automatons, agents of in March. She kept her thick, cord- Along with a renewed interest in
an omniscient godhead. Eventually, like hair tucked behind her ears and the mundane chores of living—
she settled on paper figurines. It was wore a small, fitted V-neck sweater eating, reading, exercising, clean-
never a conclusion with which she that narrowed her body. “She’ll say, ing dishes—she felt overcome by
was content, just the one that ‘Anna, you are sitting on a chair, why academic ambition for the first time
seemed to border on reasonable. She aren’t you falling through the chair?’ in a year. She was preparing to ap-
would walk down the streets talking And I’ll have to admit, ‘Yes, I am sit- ply to a new school, where she
to herself and didn’t care that people ting on a chair, and I know the chair could start fresh, away from the
were staring at her, because they is solid because I am sitting on it.’ people who had seen her at her
were only made of paper. She’ll say, ‘Well, are you talking to most unhinged. She seemed both
A year after beginning treatment, me right now?’ And I’ll say, ‘Yes, I’m calmer and more energetic, and I
she was briefly hospitalized after she talking to you right now.’ ” She dug wondered whether she felt as good
came to the clinic incapable of utter- her fingers into her hair, cupping the as she had before her earliest symp-
ing a word. She assumed that the hos- back of her head with both hands. toms emerged, before she ever be-
pital billed her insurance for treating “But the thing is, it goes nowhere. gan doubting the solidity of ob-
schizophrenia, but she has never seen She can reason with me like that, jects. That was impossible, she told
her formal diagnosis. “Schizophrenia” and it doesn’t in any way change my me. The illness was about not just
is a term that Dr. Rosen tends to avoid, mind. I’m perfectly aware that I can the active symptoms but also a
since it implies (because of its history, navigate space and move in time, more fundamental shift that made
and the way the DSM constructs the and at the same time, none of it feels them plausible. “The symptom that
illness) a bleakly fixed outcome, which like it’s happening. It just doesn’t bothers me the most is the one I
is often not the case.5 make a difference.” can’t even begin to describe,” she
Anna went back and forth be- It wasn’t as if she had surrendered said, leaning back on her white
tween feeling as if there was some- to the world of particles; she found it couch, the sun pouring into her
thing inevitable about the cascade dismaying and unbelievable, and yet living room.
of symptoms and wondering wheth- she couldn’t dismiss it as false. After months spent struggling to
er the illness might not have pro- “There’s a sense in which the law of ar ticulate what she wa s going
gressed if she had gotten help even contradiction—that something can’t through, she felt her memories of
earlier, when the only trouble was a be X and not X at the same time— the experience slipping away. “I
low yet constant hum of anxiety—a has ceased to matter,” she said slowly. can resort to bizarre metaphors, but
state of mind that, for most of us, is “What I know and what I believe no I can’t even in the grossest, rough-
5
Some psychiatrists now argue that the longer coincide, and I est way communicate that state of

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term “schizophrenia” shouldn’t be used at can’t make them.” mind.” She paused, looking away.
all because it describes not a coherent entity “The substance of my experience is
but a collection of symptoms with widely he last time I spoke with thrown into doubt. I am left with
varying outcomes. In Japan, the syndrome
was renamed “integration disorder” in Anna, in June, more than two years this incredibly deep sense that
2002; this led to twice as many patients be- after she fi rst became a patient at none of these things ever happened
ing informed of their diagnosis. the clinic, she said her delusions to me.” Q

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