Projections, page 18
Instead, all the threads together manifested health or disease: only in unity did they form the full tapestry. It seemed to Winnie that mental illnesses—schizophrenia but others too, like depression, autism, and eating disorders—even though heavily genetically determined, were mostly not handed down across generations like a watch or a ring, nor like the single genes controlling sickle cell or cystic fibrosis. Instead, in psychiatry it was as if the risk were projected forward as a set of many vulnerabilities from both parents. Each person’s mind was created by thousands of crossing threads, intersecting orthogonally and forming patterns diagonally, to create the twill of the individual. There were genes for proteins creating electrical currents in cells, genes for molecules at the synapses controlling information flow between cells, genes for guiding the structure of DNA in neurons that would direct production of all the electrical and chemical proteins, and genes for guiding the long-range threads within the brain itself, the axons that connected one part of the organ to another, on an inner loom of interwoven wiring controlling everything, directing all aspects of the mind, setting traits and dispositions like tolerance for the unlikely and the weird.
In some people, Winnie realized, when the warp and weft intertwine just so, a new way of being is allowed—a pattern coalesces with just the right or wrong set of threads. Hints of what might come can be found on both sides, forming the family tartan, in those predisposed. Looking back, partial motifs can be discerned among the vertical or horizontal threads—human traits as proto-patterns. In both lineages, there may be found uncles or grandmothers who were just odd enough, who could let their minds relax the vise of illusion, who could loosen the grip of an old paradigm, to close, firm, around a new one.
And the stronger the old paradigm—with more societal inertia—the more certain these outlier human beings had to be of their new outlook. Their convictions had to be fixed—once shifted, never letting go—committed for no good reason, since there was none. For who can defend the new and unproven against the old and established? Only the unjustly certain—who believe to a level never provable, who already must dwell a bit apart and aside, who already can access now and then the fixity of delusion.
But when two highly vulnerable lineages converge, a person might emerge who is too disengaged, allowing too much through, having lost control of thought—or rather lost the reassuring illusion, the perception of thought’s order and flow. A shaken human being is formed who cannot decide which paradigms to abandon, or which to never let go—who cannot even pretend to decide anything, any longer, amid the stirred-up turbulence, the swarms of bubbles effusing and bursting forth unchecked from the champagne. Then all the bubbles become spent, and the human being ends with the negative symptoms Dr. D. had described—avolitional and flat.
As Winnie read more about severe schizophrenia, she found it harder to preserve that idea she had as an inpatient, that there could be some benefit to the disease—for those suffering, or for their loved ones. It seemed that the most insidious symptom Dr. D. had described, the thought disorder, inexorably progresses if untreated, until utter disintegration. Thinking becomes more and more distorted, until the mind cannot keep track of obligations and connections, and loses emotional range, both highs and lows. Gone is any urge to work, to clean, to connect with friends and family. The mind becomes awash in chaos and terror, the body frozen and catatonic. If left untreated, the patient’s life ends in confused and bizarre isolation, with the duration of any planned thought shrunk down to a few seconds or less before its annihilation.
Winnie remembered vividly something the doctor had said in the hallway, in their final conversation, when she had been repeating that error need not mean disease. “A group in which some people tolerate unlikeliness this way may do well over time,” he had said, “but don’t forget—some will suffer terribly.” Now in her apartment she wanted to respond, but it was too late. She wanted to tell him that she understood now, and that this was not just true, and important, but should be taught to the community—to advance understanding, to elicit gratitude even—so that all could truly see the people who were ill, to understand their burden borne for us.
He would probably agree, but what he would not like was another thing she wanted to say, of which she was just as certain—that we all need delusion as individuals now and then. She wanted to tell him that within each person there should be a breakdown in reality at times. We should recognize this need, in ourselves and each other, and move with it like music, and sweep each other along, leading or following as life suggests, since there is not one reality that works for every decision in each phase of life, for every pair or group or nation. We have brains and hands; we might make our delusions real.
And she imagined his rejoinder already, since like any good lawyer she could play his side just as well: that this was fine and romantic to imagine, but one cannot make anything real, create any complexity, without controlled thinking, the ability to plan many steps—and schizophrenia shuts all that down. Evolution has not worked out how to consistently protect everyone from thought disorder—leaving human minds with a vulnerability especially destructive in the modern world. Simple and small primate groups may not have needed thoughts to flow in sequence for long periods of time—but the stability of our community structure requires people to live and work together over long timescales, and allows multistep planning to matter.
Winnie knew this perspective had to be at least a little bit right; she had found plenty of data to support the idea that civilization contributes to the problems caused by schizophrenia—including evidence that disease symptoms are more common and strong in city dwellers. People with only mild genetic predispositions could still, it seems, be pushed over the edge into psychosis by other risks and stressors of modern life. Winnie also found many accounts of perfectly healthy people who became psychotic only after their first cannabis exposure—and of others with seemingly pure mood disorders like depression, who experienced delusions only because of the mood disorder, not schizophrenia. She thought these human beings probably all had at least the proto-pattern, half-woven. With a tweak from the environment, a toxic chemical, a stress from city living or social disruption, an infection—whatever it might be, Winnie thought, a second hit on top of genetics can complete the pattern, and change reality.
Two hits: this was a concept she was familiar with from cancer. Winnie remembered asking her oncologist as a teenager, why her? Why not Nelson or AJ? Why not her best friend Doris, who smoked secretly every chance she got? Maybe the two-hits hypothesis could explain this, her doctor said; maybe Winnie had some vulnerability from genetics, but mammals have two copies of every gene, and other kinds of backup systems too, so some second hit was needed to allow the cancer to happen, through another change in her DNA. It could have been a cosmic ray, a long-range particle traveling from the sun, or a gamma ray from another galaxy even, traveling through space for billions of years, and hitting one chemical bond in one gene in one cell of one young girl in Wisconsin. This was happening all the time to everyone, but in Winnie’s cell there was already another problem, an altered gene from birth. A disruption came atop another; it was a double tap, too much, and the system tipped over into the uncontrolled growth of cancer.
Nobody knew if the two-hits idea was right for mental illness, but Winnie thought it could be. The science was not there yet in psychiatry, that much was clear as she spent nights reading the papers and reviews. The biological knowledge was limiting in this field, though there were a few insights. There was altered communication across the brain in schizophrenia, shown with methods for imaging brain activity in people. Parts of the brain were not keeping the other parts updated. There even had been observed, during hallucinations, an altered synchrony of activity across the organ, like one hand not knowing what the other hand was doing.
Winnie had so many questions, so much to say, and nobody to listen. She remembered he might have said a patient’s break with reality had brought him to psychiatry in the first place. Not that it mattered, but it mattered, and she wanted him to know that it did. We take our shared reality for granted, and our reaction to that illusion, and if she could ask him to do something, it would be to let the world know a simple Truth: our shared reality is not real; it is only shared.
* * *
•
In her second week home a goal emerged, a god took form, a mango ramjet. She would write to him, in a detailed letter, by hand, in unerasable black marker, in all caps so nothing would be missed, with everything she never had time to say, that she hadn’t known how to say clearly.
She would tell him more thoughts, mote thoughts. There was a dispersed element, moonlit underdrumming, a nocturne. Java Pajama Princess was her new name, that was something to tell him. He might not understand, he was unbearded, an unjesus. He would write back with his full name, not what the nurses called him on the floor, that false note, popish. No, his full name, and she would tell him so, she said she was not of Dravidian ancestry and did not appreciate the implication—misogamy—her voice cracking, turning to a weak whisper even as her helpless anger grew—what was he implying. Not one kilogauss of influence upon her, she was pure and free, not some ropedancestepdancing firebrat. Was she eating too much? Lickerish. She was double-tapped. The influence was coming, the outlet was not easy or east but westnorthwestwardly. She paused, took a breath, and apologized. A torsade. It was none of her business what he was trying to imply.
Her phone went off; something clenched her deep. Fillet the firstborn, the fistborn. It was him. Winnie reached out to the phone, but hesitated. The other side of the screen. She let him buzz through to voicemail. An hour later she played the message on speakerphone, after she felt the phone’s capacitors had fully discharged. The cytology report had come back, from the spinal tap, that last formality: “Rare highly atypical lymphoid cells, consistent with prior material, involvement by a T-cell lymphoma.”
Her engine of a brain revealed at last its dark secret. Covered over but always there, her frailty had been lying in wait, like AJ’s AVM. And then came the second hit: for him, the pressure surge; for Winnie, it was cancer cells, stirring up the champagne bubbles, swimming in her vulnerable sweet sea.
She settled to the floor, reaching out again to AJ’s last day. It was not hard; the air loom projected across time as well as space. And she knew the threads that mattered; some of them were hers. When he saw the bank clock, AJ knew he would have to jog the rest of the way. As he ran he looked down at himself and his shirt. There was some dough baked on there and he tried to brush it with his hand—most of it came off but there was still some white stuff that he couldn’t wipe away, and his hand was sweating, and it all made things a little worse. He should have brought another shirt. He kept up a steady pace, trying not to exert himself too much as he neared the bank, and jogged across the South Main intersection and into the plaza, skirted the fountain, and ran through the glass doors just behind a guy on crutches. He saw the elevator but no time, up five floors two steps at a time; he walked quickly down the hallway, checked behind him to make sure he wasn’t leaving flour footprints, and stopped just outside the office waiting to catch his breath. Wiping his forehead he looked around at the walls and the ceiling; the hallway was very clean and brown. He thought about the frozen yogurt girl next to the bakery and her hair, curving up like a cinnamon roll, firm and brown. He thought about how her eyes had circled around his face, like a nervous blue jay, when he had asked for her number. After a minute he reached for the door with a shaky feeling inside, watching the dim and shadowy reflection of his face in the glass panel of the door, feeling he was at the crest of a hill, carrying over the summit a large piece of cardboard in his sweaty hands, to slide it down the summer slope like he did with Winnie and Nelson when they were kids. He was going to see how things looked, on the other half of the world, after a long climb getting ready to coast down. The cries of triumph and pain of the other climbers were fading into nothing for a moment…as if in respect for this instant. The door was locked; it took AJ a bit to realize the door was locked. It was strange—the knob turned but the door wouldn’t open. AJ trembled and tried again. He stepped back then, trying to think what it meant. His eyes looked for some message or note or clue, but there was nothing. Wrong office maybe. He reached for the appointment card in his pocket, but it was the wrong card, it was the mechanic’s. He’d brought no number, going to miss the appointment it had taken him months to get. His head twinged. AJ pressed his hands to his temples as he walked back down the hall. He took the stairs slowly, knees buckling, feeling a strange and surging flood. The lobby was lost in a black fog. Scared, he walked as steadily as he could through the lobby and out the door. The sun was hot, but dim. His legs and arms were shaking but he made his way slowly to the plaza fountain. He walked around the spray, unsteady, and waited to cross South Main, watching the faces in the cars as they passed him by. He went to his knees. He remembered a bird he had seen collide with a glass bus stop once. It had beat the dusty pavement with its wings for a while, unable to lift off, and then just looked and watched the other birds fly by, intent on their own lives, haloed by the sun, to mate and feed and build and sing. Twilight seemed to be deepening over everything. He thought that he might see the frozen yogurt girl if he could just get back to the bakery. I would like to stay there with her, he thought. It was a slight slope downward; if he could get up all he had to do was swing each foot forward, one after the other, and he could just almost coast. All the faces in the cars going home…The door would not open. The door was locked. The pain in his head rose and spread. So clean and shiny the glass was everywhere, it looked as though it wasn’t even there, the bird hit and the glass was everywhere. The hallway was long and dim, firm and brown. It was not easy to see seeing again. Sort of a dove, the bird had reminded him of Winnie, he had been so worried for her. As he bent over, the bird looked straight up at him, just like Winnie would, steady and the only one who would. Waiting for it to pass, he clenched his eyes shut, waiting for it too. From his knees he fell down flat, and then she was there with him, smoothing his forehead in a gentling of wings.
CHAPTER 6
CONSUMMATION
Farewel happy Fields
Where Joy for ever dwells: Hail horrours, hail
Infernal world, and thou profoundest Hell
Receive thy new Possessor: One who brings
A mind not to be chang’d by Place or Time.
The mind is its own place, and in it self
Can make a Heav’n of Hell, a Hell of Heav’n.
What matter where, if I be still the same,
And what I should be, all but less then he
Whom Thunder hath made greater? Here at least
We shall be free; th’ Almighty hath not built
Here for his envy, will not drive us hence:
Here we may reign secure, and in my choyce
To reign is worth ambition though in Hell:
Better to reign in Hell, then serve in Heav’n.
—From John Milton, Paradise Lost
The medical student and I began to take our leave. Our first ninety minutes with Emily had brought no understanding and revealed no useful role for hospitalization. She had been directly admitted to our open unit by the inpatient psychiatry director, leaving me out of the loop in determining if admission was a good idea.
Emily was eighteen years old, legally an adult but much younger than our other inpatients, and would have been sent to child psychiatry if she had shown up just a few weeks earlier. The initial chief complaint—unable to sit through class—was actually her parents’ complaint, and to me this situation seemed better suited for the children’s hospital than for our acute adult inpatient service.
Over the course of the intake examination, we discovered that Emily had been a star student, but the full fifty minutes of a class period had become too much; at the beginning of the school year she had somehow developed the need to get up and leave class halfway through, and then over a month or so, this had progressed to the point that she couldn’t go to class at all. Nobody knew why, and she would not say. We did learn from her that she was well versed in poetry and literature, and had won trophies as a softball pitcher and competitive equestrian.
During our interview, the orthopedic surgery ward clerk had paged me several times about a patient of ours who needed transfer orders to come back to psychiatry after hip surgery. At this point working with orthopedics, as peevish as they were, seemed more productive than continuing with Emily, since they wanted something I could provide. We began navigating around the chairs toward the door of Emily’s room—trying not to seem too hurried, promising to return.
“One more thing,” said Emily, and I turned back from the door. From her cross-legged perch on the tightly made bed, she was stretching her arms above her head, arching against the sunlight streaming from the window. “I really don’t think I should be alone right now.”
Oh. Well, here we go. Now the reveal; the inner storm would finally break. I waited, not asking.
Emily’s blue-gray side-eye contact with me was accompanied by a quarter smile. She said nothing more. The silence stretched and filled space too. The pressure built, but no cloudburst came.
I looked around the room for insight. There was oddness: her still-packed suitcase, and her laptop and phone neatly stacked on the bedside table—personal possessions that were not a typical sight even on the open unit. But this I understood—the whole sequence of our usually choreographed intake process was off, due to the unusual nature of the admission. She had just arrived and hadn’t even been met by the charge nurse yet.
