Projections, page 16
In the midst of the doctor’s questions, though, his pager went off; he apologized and went away. She spent an hour alone, looking at the wall in front of her, and then he came back, rejoining without preamble, acting as if it had only been a minute. Winnie asked what was going on. “It was just an emergency on the floor, sorry. I’m almost done here, but I can tell you what’s happening,” he said, sitting back down. “We’re waiting for a couple tests to come back, but the bottom line is nobody can find anything wrong in your body—every test and scan looks normal. So that means we think what is going on is psychiatric. And the good news about that outcome is that there are treatments that can help you.”
Winnie was not surprised. It had looked increasingly like the ER staff thought things were headed that way, though it didn’t really matter—at this point she didn’t care what they said, all she wanted was to go home. The ER docs had informed her she was “on a legal hold” and could not leave until psychiatry had seen her, but now she had seen everyone. Nothing had been resolved at home or work, and so she had things to do; in fact it was possible her work situation might have deteriorated a bit. She asked him if she could follow up in his clinic; it would be easy to call to make the appointment when she got home.
“Okay, let’s talk about that,” he said. “Would you be willing to stay in the hospital while we figure this out? And if not, what would you do when discharged, if we could make that happen?”
Winnie didn’t have to think about it—that was easy, she wouldn’t cause trouble at work anymore, that had clearly been a mistake. She would go home, resume her vacation, finish taking down the east-facing wall, and start ripping out the ceiling too—she was on the top floor, so it was safe, no risk to anyone. “I’m not staying here,” she told him, “there is too much to do. I’ll just go home and finish my Faraday cage.”
He nodded at that phrase, and Winnie asked him if he knew the principle of Faraday cages, that they were conductive enclosures to cancel out electromagnetic fields. He nodded again. “Yes, I use them in the lab all the time,” he said. “We put basically mesh cubes around our rigs. The rig is what we build to measure electrical signals in neurons. It’s a Faraday cage just like you are building. It blocks noise from other electrical sources that might be in the room, or behind the wall”—he gestured where her gurney had been before she moved it, at the edge of the tiny room—“so we can detect currents, even from single brain cells, even in living animals.”
Though still wary, Winnie couldn’t help but get a little excited at this connection. She wondered if he knew of the experimental discovery of this shielding principle by Benjamin Franklin, and then the beautiful theorem that had emerged from the physics of electromagnetism, that external fields cannot access the area within a conducting enclosure. That the field creates a compensatory distribution of charges on the conductor, one that exactly cancels out the field itself. A field by its own nature creating its own annihilation. A thesis truly creating its antithesis. “Information suicide,” she said.
He seemed to become restless at that, shifting his position in the chair. “So there are some things we’re worried about,” he said. “You’ve told me, and everyone, you don’t want to hurt yourself—or anyone else actually—and I believe you. But you’re destroying your home, and your plan is to keep doing it, because of the worry about your neighbor, that he’s downloading your thoughts through his satellite dish. So you’re actively tearing your house apart…”
Winnie could tell what was coming: they were going to trap her here. She searched his lips as he spoke, looking for signs he was under their control too. Actively destroying her home? This was not true, not at all. She was doing the only thing possible to save it.
“I have some paperwork for you—here, this indicates you’re going to be admitted, brought in to the hospital tonight, on what we call a legal hold, which we can do, which we have to do, for grave disability,” he said. “We need to do this because you have a psychiatric symptom that’s causing real problems for you, that we call psychosis, which means a break with reality. You’re hearing a voice in your head, and you have fears that are not physically realistic, that are causing you to damage your home, and put your own safety at risk.”
She felt the world narrowing, going gray except for a narrow tunnel of distorted light around his face.
“It’s now our duty to try to figure out what is causing this,” he said. “There are lots of different possible causes—and hopefully we can try a medication that could help you.” Words came to her mind unbidden, and she tried to match them to his lip movements. Soapsuds, waitressless, matilda.
The doctor kept talking for a while longer, then stood up, and she focused back on the meaning of his sounds. He said he would see her tomorrow since he was also working in the locked unit during the day that week, and he left her with a sheet of paper with many words and numbers. Grave disability, she saw, and 5150. There was that code from the ambulance. Grave. They had her now. She kept her face still as a fossil, staring straight ahead at the scuffed yellow wall, not daring to picture what lay beyond.
* * *
•
The staff administered to her a new medicine that first night, and gave her an information sheet with it, which she kept to study; it was called an atypical antipsychotic, and they asked her to sign something about it. Whatever else it did, or didn’t do, the tiny white pill certainly knocked her out, and she slept for fourteen hours.
When she awoke, Winnie found herself upstairs, in what they called the locked unit, among a group of fellow travelers, each a refugee from a different sort of storm, washed up onto the same shore. Winnie just listened that morning, not speaking but able to learn from them; it helped that her own storm had made a kind of landfall itself and expended some of its energy already, even by the first morning. She could still hear the disconnect voice, but it was less intrusive, no longer a shout—and she was able to focus on people more stably, and follow conversations.
She learned how to slash her arms with a toothpaste tube—she didn’t do it, she didn’t want to, but she learned it anyway. Two patients were talking in the breakfast area who had done this before—for different reasons—and were comparing strategies like recipes. One, a young woman named Norah, seemed to just want to cut herself a little bit, just to feel pain and see blood, to leave a mark and have it known. The other, Claudia, a large woman who could have been the mother of the young-adult brood, was focused on actual suicide—cutting arteries, letting all the blood out. Claudia was about to start electroconvulsive therapy treatment for severe depression—the doctors thought it would help, but Claudia had a different plan. She was utterly invested in ending her life. All her feelings and thoughts led there, currents joining into one flow that could not be slowed or diverted by wall or lock.
But the unit staff were a step ahead, it seemed—not even a toothpaste tube was available. The nurses were mostly miraculous—with only words and gestures, they managed to maintain peace among twenty altered and demonstrative men and women. The unit was like nothing else Winnie had experienced—a contradictory place, both hard and soft, desperate and secure. And the other patients—she could spend an eternity contemplating their individually damaged worlds. The unit was a maelstrom of fascinating and frightening alternate realities.
Winnie thought about the toothpaste, how the bottom of the tube worked for this job. Its stiffness sufficed; it had the right material properties for sharpenability. She pictured Norah and Claudia each as they had been in other inpatient settings, on less restricted units in the hospital, surreptitiously grinding the end of their tubes on any gritty surface, getting in a few or a few hundred strokes here or there when they could isolate themselves from staff. Winnie thought about how compelling repetitive action could be—with needle or knife—repeating the same action again and again, hundreds, thousands of times. She had an odd idea—that rewarding the act of repetition was the first achievement of the human brain. With relentless rhythm, to make a hard thing sharp: a stick, or a flint, or a bone. Striking again and again, grinding against rock, all through the winter—but with a different goal: to survive back then, not to die.
Winnie picked up psychiatry knowledge too—not from the other patients, but from brief conversations with the psychiatrist who had admitted her—about what they called psychosis. He saw her twice a day, once around eight in the morning in the room she shared with Norah, and then sometime in the afternoon, usually in the hallway when they happened to cross paths. Winnie noticed he seemed as sleepy during the day as he had at midnight. She liked that he liked Faraday cages, and she called him Dr. D. As her storm cleared more and more each day, she began to ask questions.
“Psychosis, what exactly is that?” she asked. “I mean, I think I know, but it’s strange to hear you say it—it’s an old-sounding word.”
“Just a break with reality,” Dr. D. said. “It can be used for hallucinations like that disconnect voice you hear. It also applies to having delusions—that’s the word we use for beliefs that are false, but fixed.”
She considered that. “What do you mean, fixed?”
“This fixity part is important,” he said. “Delusions can’t be reasoned away. Evidence does not help. I used to try, for my patients, when I was still learning. Maybe every psychiatrist has tried—but not for long. The delusion can’t be budged. Some patients have these extremely unlikely ideas in impenetrable armor, so they can’t be touched.”
This idea of the fixed belief clicked with Winnie’s engineering expertise. It was like the Kalman filter, an algorithm for modeling complex unknown systems—in which every guess at the value of a system property comes tagged with an estimate of the guesser’s level of confidence. And more weight is given, when modeling the system, to guesses with higher certainty. It made sense to Winnie that the brain should work that way too, that knowledge should exist only with certainty tags, and that some types of knowledge of the world—not just the delusional ones—should be trusted all the way to the point of fixity, and placed in the brain within a special bucket called Truth, not subject to hedging or discounting. The category of Truth would allow fast and simple determination of action without clock cycles wasted on statistical computation, and allow the brain to build complex edifices of logic on top of these unquestioned facts. But she didn’t say all that to him.
“I think it’s not just psychosis that gets fixed like that,” she said hesitantly, feeling pressure to get everything from her mind out before he walked away, “but also maybe other ideas.” She tugged her Raiders hat down tight—force of habit, really, she was feeling lately that she did not need to wear it all the time. “Like trusting your family, and marriage, and religion, and some kinds of social and political beliefs. It’s normal. Every bit of knowledge should have a confidence number attached to it, and some ideas should have a perfect score.”
“I guess so,” he said. “I think you’re right, we do need those…rankings, I guess. Confidence estimates.” There was an awkward silence. He look down at his patient list, which she knew meant he would soon move on to the undergraduate student, the next room down—blond and smiling and manic and so many words—and never get back to her.
But then he continued. “I think, though, for most ideas about how the world works, a perfect score would not be helpful. And some possible explanations for things are so unrealistic— they should never get close to becoming such trusted facts.” He paused again. They were standing in the hallway near the nurses’ station, an odd pair, she could see that. She in her hospital gown and Raiders cap, he in his daytime getup of button-down shirt and slacks—one prisoner, one free, and patients meandering around them. And yet a connection was there; they were passing information back and forth, untouched through the noise, on their own local area network. “These unlikely ideas,” he said, “should never even get access to our minds in the first place, should never be let loose to rise up into our working active consciousness at all. Do you think you had any ideas like that right before you came to the hospital? Distractions—really unlikely, that should have been just filtered out—before ever rising to the surface.”
He was talking about filters, but not quite correctly. In the quieting of her storm, Winnie thought he might be referring to something she had told him in the ER—her story of the screw in the parking lot. She saw now that the idea she had at the time—that the screw had been placed there by Erin to torment her—was quite improbable.
But so what? she thought. Fixity was seen in delusions, but probably was also essential for healthy committed behavior—and similarly, allowing consideration of unlikely ideas seemed to Winnie to be normal and necessary as well. “You know, allowing awareness of something that’s unlikely is not a disease,” she said. “If you’re talking about a filter, you should understand how they work. Optimal filters will still block a few things that you actually wanted to go through—and also will still allow some things that you wanted blocked to instead go through. That’s for an optimal filter.”
And for ten minutes she described for him Chebyshev and Butterworth electronic filters, and explained how Chebyshev type I filters do successfully block from going through what is not wanted, but unfortunately also block a bit of what is wanted, what should have been passed through. Fine for some electronics, or maybe some nervous systems, but not for the human brain. A species like ours, with survival so clearly based on intelligence and information, should not run the risk of blocking and throwing away potentially valuable ideas.
Other designs, like Butterworth filters, have the opposite weakness: these discard nothing of potential value, but allow too much to slip through. “I think the Butterworth design makes more sense for a human brain,” said Winnie, “or, for all the brains of our species considered together. Unlikely beliefs held by some are a sign the species overall is working well.” She said she would send him “On the Theory of Filter Amplifiers,” Butterworth’s 1930 paper. Winnie felt it was actually quite important for him to know that every system operates with an error rate that it accepts, to balance against some other consideration.
“Same with our electrophysiological signals in neuroscience,” he said, seeming to agree. “We record tiny currents, and so we have to filter out noise to see the currents, and even the best-designed filters will still block or distort some useful things and allow through some useless things.” Winnie had more to say, but at least with that she could let him move on. Now he seemed to know that distortion does not mean disease.
* * *
•
The inner voice grew still more quiet over the next day. She also felt decently stable without the Raiders hat and stopped wearing it. Winnie could sense something was getting better, though she felt a bit wary about revealing this to the doctor. He might assign credit to the pill, and conclude that this illness model he had for her was correct.
Dr. D. dropped the 5150 before it expired; Winnie had agreed to stay voluntarily on the locked unit until discharge, since the voluntary unit, the open floor, was full. But she was happy to work with the current clinical team, while the tests continued. She was on vacation anyway, she was learning a lot, and home still didn’t feel quite safe.
“There are different reasons people can experience psychosis,” Dr. D. said in the hallway, later in the afternoon after dropping the 5150, “and not all have been ruled out yet for you.”
“But I thought you agreed,” Winnie said, “that there might not even be a problem, it might just be my design. Our design.”
“Yes, well,” he said, “as you pointed out, people could be designed with different filters, just like everyone has different settings on their sound system. But there’s a problem with that idea….This experience has never happened to you before. As far as I can tell, you’ve always been logical and systematic, with a selective filter—it’s maybe one of your greatest strengths, actually. So this whole thing is not really your design.”
“What could make things change then, if they did?” Winnie pressed.
“Drugs could do it, but there were no traces of drugs in your system that we found,” he said. “Infection or autoimmune disease also, but we found no hint of those in your blood work either. Severe depression or mania could do it as well, but you have no symptoms of these. Schizophrenia, though, has not been ruled out.”
Winnie had some sense of what schizophrenia was, and it didn’t fit with what she was experiencing. “Doesn’t that start in teenagers?” she asked. “I would have had symptoms long before now.”
“That’s true for men, but twenty-nine is not atypical for first break in women,” he said. “First break—that’s what we say when schizophrenia declares itself, with visible symptoms like delusions and hallucinations. And sometimes one’s own actions can seem foreign, controlled from outside the body—”
“Are there theories for what causes hallucinations?” she asked. “What could be the biology of something like that?”
“Scientifically, nobody really knows,” he said. “Some people think that inner voices—like that one you hear—might be caused by one part of your brain not knowing what another part is doing, the brain not recognizing its own inner thoughts as itself. And so your own internal narrative, like the word disconnect, gets heard, and interpreted, as the voice of someone else.
“Similarly, you could feel that your actions are not your own, but reflect control from outside. It could just be that in schizophrenia, one part of your brain has no idea what another part wants or is trying to implement, and so an action of the body gets interpreted as a sign of meddling from the outside. The brain—casting around for explanations, which it always does—finds only unlikely ideas, like control by radio transmissions or satellites.”
