Projections, page 11
These results—turning social behavior up or down by shifting the balance of excitatory and inhibitory cells—also had illustrated the broader worth of a particular kind of scientific process, beyond the intrinsic value of the scientific finding. Here psychiatry had helped guide fundamental neuroscience experiments, which in turn had helped illuminate processes that could be going on within unusual human minds in the psychiatry clinic—coming full circle in casting light upon clinical moments as emotionally complex and intellectually profound as Aynur’s immersive storytelling.
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“I know we’ve gone an hour over our time,” Aynur said, filling a pause that I just realized had existed, in the moment of its ending. “I’m sorry if you missed your lunchtime. Thank you for listening—I just wanted to explain. The French doctors wanted me to follow up here, but I’m not suicidal now. I had a time of weakness, that’s all.
“I don’t mean to be too dramatic about any of this, but just to say: I could become weak like that again. Now I know I need my family, and I cannot live without them. These bonds that created the human way of life, that maybe allowed us to survive, also might have left a vulnerability. I don’t mean to say all of us would react the same way, but I know I never felt the weakness so strongly as in those three months, I was so nearly destroyed by something not related to food, or shelter, or even reproduction. I almost died, even though I could easily have found ways to stay in the West, with new friends, and new partners.
“I still could. There were men that looked at me. There was one man that I looked at too.
“We met and talked one night in a café by the stadium. Things seemed about to explode. How to describe it to you? Eruptive, I want to say, but I don’t know if that’s a word. Brimful? So many possibilities. I wasn’t thinking in English then—that was more than six months ago—but it doesn’t matter, none of the languages I know have the right words.
“Nothing happened, anyway. We just drank coffee from clunky purple cups. And I realized as I walked away, after, that our social bonds only reinforce a strength we already have built in.
“I knew something the man I had coffee with didn’t know, that social structure came only after the venomous sting. Evolutionary biologists think that having such a sting was crucial for allowing evolution of social behavior in the wasp lineage, by providing a remarkable level of defense for what had been such a small and fragile animal. And I agree—you can only be social with strong weapons to defend your nest and young. That strength can free you from harming others. The need to connect with others is strength—not weakness.”
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Extroverts like Aynur, and natural politicians with near inexhaustible sociability, draw energy from conversations and avoid being alone—an inversion of the value system of those on the autism spectrum. And like Aynur and Charles, many people favoring one extreme of social intensity can find a coerced exposure to the other extreme unpleasant, like nocturnal mammals forced out into the midday sun.
Evolution has helped the nocturnal mammal to find daylight aversive, because this negative feeling makes the right behavior happen—which is to retreat from the light and await conditions that are more suited to the animal’s design and hence less dangerous, and more rewarding. It is similarly possible that social or nonsocial brain states could be harmful if present under the wrong environmental conditions, which might help the mismatched condition (over the long timescales of evolution) become associated with aversive or negative feelings.
Just as different survival strategies are suited for nocturnal versus diurnal life, there may also be fundamentally distinct brain modes for different rates of information processing—each mode of value, but not mutually compatible (at least, not at the same time). The mode of dealing with a dynamic, unpredictable system (exemplified by social interaction) may be incompatible, or at least dwell in tension, with another mode that we need at other times. This second state would be one that allows us to quietly evaluate an unchanging system—a simple tool, a page of code, an algorithm, a calendar, a timetable, a proof—anything static and predictable, for which the best strategy toward understanding is to take the time to look at the system from different angles, with confidence that it will remain unchanged between one inspection and another. Brain states differentially suited for these two distinct situations might need to be switched on or off from moment to moment (with relative state preference tuned across millennia of evolution, and with variation from individual to individual in the strength and stability of each state).
Our optogenetic excitation/inhibition results were later replicated in independent mouse lines, but a key question remained: was there a link between this cellular imbalance shown to be causal for social deficits in mice and the informational crisis as experienced by Charles (and perhaps others on the autism spectrum)? Optogenetics helped unearth an idea for how this linkage might work; in our initial excitation/inhibition paper in 2011, we also had reported that causing high excitability of prefrontal excitatory cells (an intervention that elicited social deficits) actually did reduce the information-carrying capacity of the cells themselves, in a way that we could measure precisely, in bits per second. Thus, the very same kind of altered excitation/inhibition balance that disrupted social interaction was also making it harder for brain cells to transmit data at high information rates—corroborating what Charles had described for us in his account that the information coming in through eye contact overloads the rest.
Another remaining question was the origin of the aversive quality of information overload—so powerfully experienced as unpleasant by Charles and others on the spectrum. Being unable to keep up with social information feels bad in these individuals, but it is not obvious why. The information overload need not have any emotional valence at all, or perhaps even could have been positive—a sense of freedom upon realizing that one cannot keep up, with solace and a kind of peace in the resulting isolation. Here, though, I did understand, in part through listening to my patients, how difficult it could be to make your way through life with others constantly expecting higher social insight than you could routinely provide. And so the aversion might have been socially conditioned, learned through a lifetime of mildly stressful interactions, devastating misunderstandings, and everything in between.
But instead of this aversion needing to be learned, could information excess be innately aversive in itself, when above a person’s carrying capacity? Certainly everyone, from the typically social to the simply introverted to the autism-spectrum individuals, can experience aversion after prolonged social interaction, when social circuitry becomes exhausted to some extent. It might make sense evolutionarily, in a long-social species like our own, to have developed a built-in aversion mechanism, providing motivation to withdraw from important social interactions when the system is fatigued, and likely to begin causing errors of understanding or trust.
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“One more thing,” said Aynur, as we stood up together—I thought I had initiated the action, finally needing to prepare for my one o’clock, but she had responded so quickly and closely that we were moving in perfect synchrony and then I wasn’t even sure who had started it. “I know they just wanted me to have a onetime evaluation with you, and so we probably won’t see each other again—but you had asked earlier, when we were talking about my family, how we made the silk to get those colors, and I didn’t get back to that.
“This part is really interesting. I remember when I was little, I most loved the light-pink form of the tamarisk silks. It made me feel like seeing the flowering tree in person; the color seems so delicate but the silk is strong, all just like the tree. I don’t know if you’ve ever seen one. The tamarisk is such a wonderful bit of life. A desert fir, evergreen but also colorful.
“By the way, there are wasps that lay eggs in the tamarisk tree. Then a new kind of wood forms around the egg—a growth, a gall: a twisting ball of nut and root. It’s like a teratoma, but it doesn’t hurt the tamarisk. There is no need for the tree to fight it.
“I was reading the other day, the tamarisk is now an invasive species here. You call it a salt cedar—I like that name. People say it was first brought over here from Asia just for decoration, and now it’s taking over parts of the American West. The tree thrives in salt, and makes the soil salty too, which gives it an advantage over the willows and cottonwoods.
“In some areas around here, hikers are apparently being asked to pull up the salt cedar shoots wherever they are seen, to protect the native plants and animals. Birds are losing the trees they used to live in—but it seems doves are okay with nesting in the tamarisk—hummingbirds too. In other places people have given up fighting, and now just let it go. So there’s a flood of salt cedar color in parts of the western desert. I saw a picture—you really need to see it. I wish I could show you.
“Anyway, what we do for silk—I can only tell you about the traditional way my mother taught me, how we do it slowly, by hand. I don’t know how it’s done when mass-produced. We sort the cocoons first, and for the stained and odd-shaped ones we have to boil them; they all change to the same shade in water.
“Then we stir with a stick, separate the threads, and twist the threads into strands; we need a few dozen threads to make a strong strand. To color, we dip each bundled strand into different pigments, dyeing one strand at a time. I remember this all as very slow, especially for those fine pinks and purples, the pale and light colors of the tamarisk tree.”
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An ever-growing share of all human interaction appears to lack the full vivid color of natural social information. By suppressing rich social multidimensionality, we relieve ourselves of its mental burden (though we may come to miss, or even crave, this burden once discarded). We suppress the visual stream of information on the phone, or simplify the entire social data stream using emails and posts and texts; each of these methods for reducing data-per-interaction confers a kind of insulation and enables a higher rate of individual social events, if desired (though allowing more frequent misunderstandings).
The trend toward increased social partners and contacts, with fewer bits of data transmitted at each contact, may have already reached a practical limit, approaching a mode of one bit per interaction (liked or not). That remaining bit can still be imbued with immense intensity, arrogating attention, driving passion and intrigue—because the bit is charged with social context and our imagination: that is, with premade models in our cortex, ready to run. Human connection in some form is now possible through only a few words or characters, even a binary flip of a switch—obviating some of the pressures of social complexity and unpredictability.
We could perhaps now relax categorizations of sociability (as a little outdated) that define what is healthy or optimal based on only the typical high-information-rate in-person social interaction. People with autism (at least on the high end of the spectrum) can seem more socially adept if the interaction is moved out of real time—to low bit rates, as with text. Though any interaction style still risks errors and misunderstandings, communication can seem improved if given the grace of time.
The bits to be transferred can be prepared at leisure, and then discharged when ready with a tap; no reply is needed immediately. These bits may then be placed in the broader context by the recipient—over minutes, hours, or days—to be evaluated from different angles. Possible replies may be considered, and scenarios run forward like a chess match for two or twenty moves, off the clock—until a reply may come, a tap or two when ready: Morse for the late-modern human.
The autism spectrum, then, need not be seen entirely as a “theory of mind” challenge—which has been a popular and helpful idea, holding that in autism there is a fundamental problem with even conceptualizing the minds of others. Instead, the bit-rate-limitation idea (which optogenetics has helped reveal) would perhaps fit more fully with the experiences of many patients, who are capable enough but require time to run their models, to fit their own carrying capacities.
Psychiatry and medicine broadly—though still constructed around interpersonal communication—can survive and operate well with much less social information than the traditional face-to-face interview provides. I came to this understanding first as a resident at the local Veterans Administration hospital, where (under the relentless pressure of overnight call shifts) I found that the unique human connection needed in psychiatry can form first through a thin audio channel, the low-dimensional projection that is a phone call, if extended in time.
I then rediscovered this for myself, also in a time of necessity, as an attending during the global coronavirus pandemic of 2020. Emergency psychiatry, I saw again and again, though it somehow surprised me each time, can be carried out with precision even over the phone, through that lonely single line.
The Veterans Administration hospital rises like a mirage out of grassy foothills near the university. An oasis of contradictions, this VA system inspired Ken Kesey’s One Flew Over the Cuckoo’s Nest, but is now largely staffed with university-affiliated academic physicians at the leading edge of the field—and so to this day, the VA still evokes simultaneously both psychiatry’s prescientific troubled distant past and the neuroscience-driven promise of its near future.
The on-call psychiatrist at the VA is dubbed the NPOD (neuro-psychiatrist on duty). The main duties of the NPOD (one resident for the whole hospital, all night) are wrangling emergency room admissions, responding to consults from inpatient services, and caring for the psychiatry inpatients on the locked units. A major side job, however, is fielding calls coming in from the outpatient community, throughout the immense catchment area of this flagship hospital encompassing all the military veterans who might be phoning in from home—especially those suffering from PTSD (a common and deadly disease that is often resistant to treatment by medication).
Page the NPOD: an invocation when all else has failed. In the midst of other emergencies, the NPOD receives a call forwarded from a veteran beyond the walls of the hospital: a reaching-in from a human being who is jangled and guilty and helpless, needing only to talk with someone, anyone, who might understand. I found these calls could require an hour or more to work through. Less time would be taken in person, but a different mode was needed for these purely auditory conversations that were still sensitive and vital, with the gray specter of suicide looming.
When the call would come, seemingly always near three o’clock in the morning—perhaps in the middle of a chaotic scramble from the inpatient ward to the emergency room, or sometimes just as I was going to try for a few minutes of sleep in the barren housestaff call room—early in my training it was hard to suppress feelings of anger, especially since there was no concrete goal for the call, at least that a combat veteran could typically describe. The patient just needed to talk—and so I learned to transform myself from efficient physician to purely empathic partner. Both veteran-as-patient and myself-as-NPOD, I came to realize, were fighting a new battle in different ways, each trying not to bring feelings from prior personal trauma into the present, to not transfer presumptions and imputations from one context into another.
I would often field these pages in the call room, curled up for hours on the impossibly hard and narrow plastic mattress—still in scrubs and ready for any urgent summons to the locked unit for patients with chest pain or needing restraints—but under a thin hospital blanket to ward off that bone-chilling pre-morning despair, phone braced uncomfortably between cheek and shoulder. Not a propitious arrangement for deep connection, yet somehow by the end of each call, the patient and I could usually both move on—to the next interaction, the next challenge, or perhaps even to a shallow snippet of sleep—with a kind of peace, a gift of warmth from another human being, after a true social interaction drawn out across the line.
The coronavirus sweeping over the planet, years after my VA service, coerced a retelling of this story in a new way. As populations from city center to countryside became fragmented, by design, to manage the contagion, many human interactions either were forced to play out at a distance or were simply sacrificed. The culture of traditional psychiatry thus seemed initially vulnerable. Video and phone appointments (desperately needed as a replacement for clinic visits during the crisis) were for the first time widely approved and scheduled; this normalization of virtual psychiatry interactions had long been possible but resisted by the established clinical structures for an undeniable flaw: lacking the full information rate of in-person communication.
Younger patients were immediately at ease with video appointments via the Internet, considering this interaction to be as natural as any other (and even preferable), but some of my older patients were uncomfortable with the idea and preferred the telephone. During one of these audio-only visits—with Mr. Stevens, a man in his mideighties I had known for years—I was startled by the immediate reactivation within me of that intensity of focus and feeling, all centered on the spoken word: that purely auditory information stream, that thin squiggle of time-varying sound, which by necessity had guided so much of my psychiatric caregiving during call shifts in residency.
Mr. Stevens had relapsed into depression four weeks prior (before the COVID-19 pandemic took hold in California), at which time I had bumped up the dose of one of his medications. Now as I exchanged pleasantries at the start of the phone call (taking time even before discussing his disease symptoms, while knowing that if suicide were a risk, I would never see him face-to-face in time), I noticed that I had adopted that familiar life-or-death focus on his timbre and tone and pauses and rhythms that I had learned with the veterans at the VA—and that I already knew all I needed to know about his mental status. By the time we got around to his actual description of symptoms and feelings, I found we were only confirming what had already become clear to me, quantitatively and with certainty: that his depression had lifted by about 20 percent.
