The Tenuous Line of Sanity by Frank Siegrist - HTML preview

On another day they were in Jack's office reviewing patient-files. This was highly irregular, of course. Jack had no right whatsoever to show the patient-files to his brother. They had crossed a line here. The idea of swapping places with each other was still hypothetical, but it was somehow becoming something a bit more than just a mind-game. Imperceptibly, it had developed from an innocent badinage into something they were considering seriously, sort of.
Joe read through one of them, growing more and more wary by the minute, trying to piece together the meaning of the obscure terminology, trying to imagine himself writing a file like this one day...
He was reading aloud:
“Odd beliefs or magical thinking, influencing behaviour and inconsistent with subcultural norms. What on Earth does that mean?”
“Oh,” said Jack with a wave of the hand, “that just means he's superstitious.”
“But what about the stuff about the subcultural norms?” asked Joe.
“Well, since everybody is superstitious anyway, it just means that this patient is superstitious in his own way rather than following his subculture.” explained Jack.
“Wait, I want to get this right!” said Joe, “does this mean it's okay to be superstitious as long as it's a superstition shared with your subculture and not your very own?”
“Exactly,” said Jack, “that's exactly what it means. If you drink wine in church saying that it's the blood of Jesus, that's okay, because it's part of your subculture. If you drink a coke saying that it's the blood of an extraterrestrial who crash-landed in your garden, then it means you have a personality disorder.”
“Nobody really believes that wine could literally be the blood of Jesus, though, do they?” asked Joe.
“Sure they do,” said Jack, “but it's okay because it's part of their subculture.”
“Why did you write that stuff about the subculture anyway? Why didn't you just write that he has unusual superstitions? Why didn't you write down what those superstitions are specifically, so that it would really be about the patient, rather than writing this bullshit about subcultural norms?” asked Joe.
“Read on,” said Jack, “I'll explain later.”
“What about this?” asked Joe, reading aloud: “Obsessive ruminations without inner resistance, often with dysmorphophobic, sexual or aggressive contents. What's that?”
“This just means,” said Jack, “that the patient is obsessed with his body and its perceived imperfections, with sex and with wanting to attack someone he hates.”
“And what does this <<dysmorphophobic>> mean?” asked Joe.
“I just explained it,” answered Jack a bit impatiently, “it just means he's preoccupied with some perceived imperfections of his body.”
“But aren't we all?” asked Joe. “We all have something we would change about our physical appearance if we could, haven't we?”
“Sure,” said Jack, “we're just not all obsessed by it.”
Joe read on: “Unusual perceptual experiences including somatosensory illusions, depersonalization and derealization. What kind of bullshit is that?”
“So, you're already calling it bullshit now, are you?” asked Jack.
“Well, seeing how you're explaining this stuff, it must be bullshit, mustn't it?” said Joe moodily.
“Yeah, you're right,” said Jack, “depersonalization just means that you feel as though you were watching yourself and your actions without controlling them, and derealization means that everything feels unreal, like you're seeing it through a window-pane or on TV or something, without being really involved in it. Depersonalization and derealization usually go hand in hand.”
“But why don't you write something real about the patient in those files? Why don't you write what he really believes instead of saying that he suffers from <<magical thinking unrelated to the subcultural norm>> or some other bullshit like that? Why write all this bullshit with all those wise words? Where do you get all those wise words from anyway? Is that what you learned during your years and years of training as a psychiatrist?”
“Yeah, it is, I guess,” said Jack simply.
“Well,” said Joe, “if you needed years and years of training to be able to write such bullshit, how do you expect me to write similar bullshit without any training at all? How do you expect me to play you without anyone noticing?”
“It's easy!” exclaimed Jack. “Just look at the final diagnosis!”
“Where is it?” asked Joe.
“There, at the top of the page!” said Jack.
“Schizotypal personality disorder” read Joe. “And what does that mean?”
“It means,” said Jack patiently, “that you suffer from magical thinking inconsistent with subcultural norms, from depersonalization and derealization, etc., etc.”
“But where do you get all those fancy words from?” asked Joe in desperation. “How can I ever take over from you if I don't know how you do it?”
“It's easy,” said Jack once again. He shoved the notebook-computer over to Joe and said: “Just google <<schizotypal personality disorder>>!”
Joe did, paying attention to spell it right, laboriously copying it from the top page of the file. He found a Wikipedia-page straight away.
“Bloody hell!” he exclaimed. “You just copied all the bullshit from here!”
“No, I didn't,” answered Jack, “I got it from the DSM, the diagnostic and statistical manual of mental disorders. It's the bible of us psychiatrists. But okay, you can get it all from Wikipedia as well. Do you feel more confident now about writing patient-files, now that you know that you can just copy everything from a manual, or even from Wikipedia, for that matter?”
“Well no!” said Joe. “You still didn't explain how you got to the diagnosis! How did you decide that this patient had schizo-thingummy personality disorder?”
“Oh, that's easy!” said Jack. “He wasn't crazy enough to have full-blown schizophrenia, but he was still pretty crazy, so I gave him this diagnosis!”
“Well,” said Joe, “even if he wasn't crazy enough for schizophrenia, he might have been crazy enough for something completely different! After all, as you just told me, there's a whole diagnostic and statistical and whatnot manual of diagnoses to choose from!”
“Yeah, there's a whole manual to choose from, but really crazy people always have schizophrenia, so there you are!” said Jack.
“And what about those who have something else?” asked Joe.
“Well, those ones, they're not really all that crazy, or in any case not in the usual sense. But those who are just plain crazy, they have schizophrenia and that's it!”
“So what do I do about those who are not crazy in the usual sense?” asked Joe.
“If they’re depressed, you give them antidepressants,” answered Jack.
“And if they’re not depressed either?” asked Joe.
“Then they're just plain crazy, so they have schizophrenia!” answered Jack.
“But what if they're neither depressed, nor really crazy, but have something else?” asked Joe.
“Well, then you'll come and see me and we'll talk about it!” said Jack. “But I don't think you'll have many patients like that. Most are either depressed or just plain crazy, in other words schizophrenic. You won't see much else, so stop worrying!”
“Okay, okay, I get it,” said Joe. “The schizophrenics get antipsychotics and the depressed get antidepressants, which are the two big classes of drugs we were talking about earlier, and that's it, right?”
“Exactly!” said Jack. “So, are you less scared of taking over now?”
“Yes, indeed...,” said Joe. He was really less scared. Jack was undoubtedly oversimplifying everything, but Joe was beginning to feel he would be able to fill in the blanks himself.
On the other hand, Joe was beginning to wonder if he still really wanted to take over from Jack. The more he listened to Jack, the more the whole prestige of the profession seemed to melt away...
The house with the breath-taking view of the lake and the mountains, the cozy Mercedes..., were they really enough to compensate for being locked up in this office day in and day out, writing such bullshit as he had just been reading right now rather than having long walks in the forest with Daisy?
But then he remembered Blanca and how it would feel to press her naked body against his own at last, and this made up his mind for him.

 

Later they still came back to the topic of the « other » patients. Joe just wouldn’t believe that every patient coming to see a psychiatrist was either « plain crazy » (i.e., schizophrenic) or depressed. There had to be others.

Jack admitted it in the end. But he said those « others » in most cases couldn’t really be treated with medication. Okay, the anxious ones could still be given anxiolytics, he admitted.

« Aha! » said Joe. « So there aren’t just the two classes you told me about! I knew it! »

« Yes, okay, you’re right, anxiolytics are in a third class. They enhance GABA-signalling in the brain… »

« You see! » said Joe. « I knew there was more than just serotonin and dopamine! »

« Oh, » said Jack, « I never claimed that the brain mostly works with serotonin and dopamine! Quite the opposite! The main neurotransmitter is glutamate. But if you act on glutamate-signalling, you’re acting on the whole brain at once. While if you act on serotonin-signalling, you only act on the serotonin pathways and downhill from there, and if you act on dopamine-signalling, you only act on the dopamine pathways and downhill from there. They’re sort of the two pathways on which you can act separately because they have their own neurotransmitters. »

« Yes, yes, I understood that! » said Joe impatiently. « So what about this GABA? »

« Well, » said Jack, « GABA is an inhibitory neurotransmitter. This means that when a cell squirts out GABA at another cell, it calms the other cell down rather than activating it! »

« Why does the brain need that? » asked Joe.

« Well, » said Jack, « the cells squirting out GABA are mostly used in feedback loops. When A activates B, B has to somehow tell A that it got the message so that A can calm down again. And that’s what the GABA-cells do. Cell B tells a GABA-cell to go and calm down cell A. »

« Yeah, I know about feedback loops, » said Joe. « Doesn’t the anti-baby pill work through a feedback loop too? »

« Actually yes, you’re right! » said Jack. « At first sight it might seem a bit paradoxical that you would take a pregnancy-hormone to avoid pregnancy. But that’s because it works through a feedback loop. The brain sends a signal to the ovary to prepare an ovule, and the ovary prepares the ovule as well as sending hormones out into the body to prepare it for pregnancy. Once pregnancy is achieved, this is mainly progesterone. So a lot of progesterone circulates throughout the body, sustaining pregnancy and also telling the brain (and that’s the feedback part) that there is no need to send new signals for a new ovule to be prepared, since pregnancy is already achieved. When you take progesterone-pills, that’s what you want - you want the brain to stop ordering new ovules from the ovary! »

« There’s just one thing I don’t understand, » said Joe. « If progesterone-pills make the body believe that it’s already pregnant, then why don’t you take them for nine months straight? Why do you stop taking them for a while every month? »

« That’s a very good question! » said Jack. « And actually, as far as I know, there is no medical reason for that. You could easily take the anti-baby pill continuously. The interruption every month is just to allow women to have a monthly bleeding… »

« As if they had their periods? » asked Joe.

« Yes, I believe that’s the only reason - just to let them feel less ‘unnatural’ by allowing them to bleed every month as if they were having their periods… »

« That’s stupid! » said Joe.

« Women who are themselves doctors think so too and take the pill continuously, I believe… » said Jack.

« And women who are too stupid to understand this, they just bleed every month just so that they can feel more ‘natural’? » asked Joe.

« A lot of medicine is like that, » said Jack. « People don’t understand and are quite happy not to understand. They are scared of genetically modified foods, for example, but they happily take medication produced by all kinds of genetically modified organisms, never wondering how it was made or how it works. »

« Because a ‘God in white’ gave it to them! » said Joe. « Perhaps they think it’s a kind of magic that you couldn’t understand anyway, even if you wanted to. »

« But let’s not be harsh, » said Jack. « Coming back to the contraceptive pill, perhaps there is more to the monthly cycle than just ignorance and stupidity. Perhaps you get less breakthrough bleeding if you have a scheduled withdrawal bleeding every month… »

« When they start taking a new pill, women get plenty of breakthrough bleeding anyway! It goes away after a time… » said Joe.

« Well, you’re the expert on this, with all the adventures you’re having with so many different women! » said Jack.

Joe let this pass. Then he said: « Maybe it’s not so much the women themselves who want to bleed. Maybe this cycle-thing for the pill was invented to get the pill accepted by the Church and their crazy ideas that women MUST bleed because of original sin and all that. »

« Yes, perhaps… » said Jack. « But as far as I know, the Catholic Church doesn’t accept the contraceptive pill anyway, bleeding or no bleeding. »

« But the women taking it might still feel less bad about taking it since those monthly bleedings make it seem less ‘unnatural’… » insisted Joe.

« Yeah, maybe… » admitted Jack.

« Okay, let’s get back to the GABA! » said Joe, feeling he had made his point.

« Okay, » said Jack in return, getting back on track. « And you were right, by the way, now that I think of it, drugs that influence GABA-signalling in the brain really are in a whole class of their own! So you’re right - there isn’t just serotonin and dopamine that you can influence! »

« But if those GABA-cells are all over the brain, isn’t enhancing GABA-communication a bit like what inhibiting glutamate-communication would be like? In the sense that it will just calm down the whole brain at once? »

« In some sense, yes, » said Jack. « Most anxiolytics sort of sedate the brain as a whole, and that’s how they work. Anti-convulsants given to epileptics do the same, sedating the brain somewhat, and that’s how they prevent convulsions… »

« Yes, but as a psychiatrist, » asked Joe, « who would I give such GABA-communication-enhancing drugs to? »

« Well, you would give them to treat anxiety, of course. And you can also give valproate - that’s another one of them - to someone with bipolar disorder… »

« You see? » said Joe. « The more I talk to you, the more complicated things become! Earlier you said there were just the plain crazy patients and the depressed patients. Now we’ve added the anxious ones, and now comes ‘bipolar disorder’! So what exactly is ‘bipolar disorder’ and why do you treat it with valproate? »

Jack shrugged his shoulders, then he said: « Okay, okay… So, people with bipolar disorder have manic and depressed phases. In their manic phase, they suddenly think they have the solution to all the world’s problems, they write to the president of the United States, and so on. When the president doesn’t answer and the world isn’t saved and all that, they fall into a depressed phase which lasts for a while until the next manic phase starts. »

« Oh, I think I know some people like that! » said Joe.

« Sure, » said Jack. « We’re probably all a bit like that. But people with bipolar disorder are TOO much like that and they need to be treated. »

« So you enhance the GABA-communication in their brain and that calms them down? » asked Joe.

« Exactly, you do that with valproate which calms down their brain. Valproate is given to epileptics too, by the way, to prevent convulsions… »

« Why don’t you just give those bipolar patients antipsychotics? » asked Joe. « After all, if dopamine is the ‘move-your-ass-and-be-bloody-motivated’ neurotransmitter, cutting back on dopamine communication would seem like a good idea, wouldn’t it? That should calm them down when they’re in a manic phase! »

« Yes, you can do that, » answered Jack. « And really, during a manic phase, that’s even better than valproate. But for long-term use, lithium is an even better choice… »

« Lithium? » asked Joe. « Really Jack, you’re driving me crazy! First there was just serotonin and dopamine, and you said that was all there was, but then came GABA, and now lithium! »

« Lithium is not a neurotransmitter, » said Jack. « Actually no one truly knows how it works. There certainly aren’t any lithium-receptors in the brain (or I would be very surprised if there were). But even if there are no specific receptors for it, it can still have an effect… »

« You mean in the same way sand can fuck-up cog-wheels even though cog-wheels definitely don’t have specific receptors for sand? » asked Joe.

« Exactly! » said Jack. « That’s exactly it! Lithium probably ‘fucks up’ some mechanisms somewhere, but in some cases this ‘fucking-up’ can be beneficial, at least sort of… »

« Like lead, » said Joe. « That fucks up lots of things in the body and brain! »

« Well, » said Jack, « a chemist would surely be horrified that you compare lithium to lead, lithium being the lightest metal and lead one of the heaviest ones… »

He shrugged, then he continued: « But yes, you’re right, lead binds to enzymes and fucks them up. It stops new synapses from forming and so on, and people with too much lead in their bodies actually literally become dumber! But lithium isn’t that bad. For a start it doesn’t accumulate in the body like lead does. The kidneys dump it into the urine and that’s how the body gets rid of it. But it can damage the kidneys in the process… »

« But what does lithium do specifically? » asked Joe.

« I don’t know exactly, » said Jack. « One of the hypotheses about bipolar disorder is that people with this disorder are too sensitive to dopamine (the move-your-ass-and-be-bloody-motivated neurotransmitter, as you said). They react too strongly to it and that’s how they enter the manic phase. The over-stimulated cells at the receiving end of dopamine end up setting up less receptors for dopamine to avoid being continuously over-stimulated. This is called ‘down-regulation’. But too much down-regulation means the patients have no motivation for anything anymore and they enter a depressed phase… »

« So they up-regulate again and the next manic phase starts! » Joe completed Jack’s sentence.

« Exactly, » said Jack. « But the whole problem probably starts with being too sensitive to dopamine. Now, when dopamine activates a receptor, the activated receptor activates some kind of coupling-protein which activates an enzyme which produces cyclic AMP… »

« You’ve lost me… » said Joe.

« Okay, okay! » said Jack. « Forget all that! Anyway, activated receptors (if there’s enough of them) lead to an activated cell which then finally squirts out a neurotransmitter to the next cell in the circuit. Something like that. And somewhere in this process lithium probably fucks up something to some degree so that the reaction would be less strong, and that solves the problem, okay? »

« Okay, » said Joe. « So no more down-regulation followed by up-regulation and so on. So no more manic and depressed phases! »

« Exactly, » said Jack. « For all I know, that’s how lithium works. »

« But wouldn’t some equilibrium be reached eventually anyway? » asked Joe.

« With too much sensitivity to dopamine, » said Jack, « it’s like you were trying to make a pencil stand on its sharp end - it always tips over to one side or the other! The only way to make it stand on its tip is to make the tip blunter… »

« So lithium blunts the reaction to dopamine, and that solves the problem? » asked Joe.

« I think so, » said Jack. « A patient given lithium must have lots of check-ups, though, so that the lithium-concentration in his blood would always be just right. Lithium is not as toxic as lead, but if you have too much of it (because the kidneys don’t get rid of it as fast as you thought or whatever) that will still have lots of bad effects. So you have to be careful! »

« And you expect me to do that without any training? » asked Joe.

« No, don’t worry! » said Jack. « That will be done by the pharmacist, not you! You just write the prescription and send the patients on their way! »

« Ah, good! » said Joe, relieved.

 

A bit later Joe asked: « So what do you do with patients you can’t treat with medication? »

« Well, » said Jack, « there’s cognitive behavioural therapy where a patient gradually learns to face situations he or she is afraid of. This works quite well in some cases, but you can’t always do it in a psychiatrist’s practice. Someone afraid of heights should be gradually exposed to higher and higher heights so as to discover that nothing bad happens up there, for example. But you’re not going to climb ladders with your patients in your office, are you? The idea is to encourage them to do such things on their own… It’s like you give them homework.»

« And what else? » asked Joe.

« There’s interpersonal psychotherapy where the patients learn about relationships (in part through their relationship with you) and how these relationships impact mood and vice versa… » said Jack.

« And do you practice any of that? » asked Joe.

« Well, » said Jack. « I mostly practice what I simply call ‘talking therapy’ when I can. I just let the patients talk. Often that in itself already helps them! »

« And then you give them advice or what? »

« No, no, no advice. I just let them talk, occasionally pointing out a contradiction in what they’re saying, but often even that isn’t necessary, because the patients realize it themselves when they’re contradicting themselves. When they’re forced to put their problems in words (so that they can tell you about them) that forces them to look at them in a new way. And often being forced to take this new perspective is what helps them. »

« So you just let them talk and talk, like they’re having a monologue, and you silently sit there listening? Or not even listening? And that’s what helps them? » asked Joe.

« Oh, I do listen! » said Jack. « And when their explanations become too messed up, I tell them they’re too messed up, forcing them to try harder to put them into words that make sense! »

« Can’t you give me an example how this works in practice? » asked Joe.

« Well, this is a bit caricatural, » said Jack, « but imagine the following situation: you ask your patient why he drinks, and he tells you it’s because his wife is always sad. Then you ask him why his wife is always sad, and he says it’s because he drinks… »

« And then you point out to him that this is turning around in circles? » asked Joe.

« Often you don’t even need to point it out, » said Jack. « The patient realizes it himself when he says it. So then he starts wondering if there wasn’t perhaps something else originally that made him start drinking or that made his wife sad… Maybe a child that was hoped for but that was never born. Or something else they never managed to talk about with each other and that is just eating them up from inside… »

« But why the hell do they need a psychiatrist for that? » asked Joe. « Couldn’t they just discuss that with some friends? »

« Friends might be part of the problem, » said Jack. « A befriended couple might be smug because they DO have children, so you wouldn’t want to talk about that with them. They might start looking down on you, and that would be unbearable. It’s much easier to talk about these things with someone you don’t meet socially in any other context. Someone you only meet in a strictly limited setting like a therapy session. An imposing practice, with marble lions at the entrance, helps even more. You feel that the secrets you tell in there will be well-protected by those marble lions… »

« Aha, » said Joe, « I thought marble lions were just to show how rich you are, meaning you have a lot of clients, meaning you must be bloody good if so many clients chose you, meaning you are the best choice for me as well and that I should choose you above all other psychiatrists… »

« Aha, you thought it was just a status symbol? Well, now you know there’s more to it than that! » said Jack.

« Yeah, I see… » said Joe, pretending to be awed by this revelation (which, coming from Jack, was of course only half-serious, as Joe very well knew).

After a moment of silence Joe asked: « And did you help many patients this way? »

« With talking therapy? » asked Jack. « Yes, I think so. That’s the way I help them most. Distributing medication just makes patients more manageable without really healing them. But when patients feel they can freely talk about their problems, sometimes it really opens up a flood-gate, and that can lead to cathartic healing! »

« But I guess you just need the marble lions for that, » said Joe. « the psychiatrist’s diploma is actually fucking useless! »

« Yes, that’s somewhat true… » mused Jack. « You need human experience, of course, but the medicine studies have practically nothing to do with it. That’s why I’m confident you could do it just as well as I can. »

« And won’t you be sad that you can’t do it anymore? » asked Joe.

« Somewhat… somewhat… » said Jack. « But you know, I’m sick of always having to justify the need for talking therapy so that the health insurances would pay for it! The health insurances are always much happier to pay for pills! And often the patients themselves don’t have time to delve into their problems either. They need to go back to work as fast as possible, so they just want an antidepressant. They themselves aren’t even interested in talking therapy. »

« What about schizophrenics? » asked Joe.

« Oh, you can’t help schizophrenics with talking therapy! » said Jack. « When I was a young and idealistic psychiatrist I thought maybe you could, and that maybe you could even wean them off their medication. But I gave up on such ideas long ago! Schizophrenics have just really lost their marbles! If you let them talk, you just cultivate their paranoid or otherwise crazy confabulations! They can’t be reached through logics or common sense or anything! They just need their medication. »

« That sounds bleak, » said Joe. « So that’s why you’re sick of being a psychiatrist? »

« Yes, that’s why, » admitted Jack. « But don’t let all this discourage you! You will be new to the job, you’ll have fresh ideas! And since you didn’t study psychiatry, your mind isn’t as cluttered with bullshit as mine! You will bring a fresh wind to the practice of psychiatry! »

Well, most of all I’ll live in a beautiful house, I’ll have a cool-looking wife, and I’ll drive a softly purring luxury car, Joe thought to himself…

 

Later Joe asked: « You keep telling me that schizophrenics are just plain crazy. But to me it would seem there are lots of ways to be crazy, and schizophrenia with its hallucinations and voices in the head would be just one of them…? »

Jack answered: « Probably there are a lot of ways to GO crazy, but once you’re crazy, it’s pretty much always the same, it’s schizophrenia. You see, among other things the brain is a machine for receiving signals from the outside world, or rather from the sense organs, interpreting those signals and then initiating an appropriate response. When this goes wrong, it interprets the signals wrong (that’s what you call a hallucination) and it initiates inappropriate actions as a consequence. And that’s schizophrenia. »

« But what about the voices in the head? » asked Joe. « To me that still seems like something very specific that not every crazy person needs to have! »

« Well, » said Jack, « we humans are talking beings, we spend an enormous part of our social lives talking. And our social lives are an enormous part of our lives in general, since we are social beings! Someone once said that a single chimpanzee is no chimpanzee at all! You won’t at all see what a chimpanzee is about if you only have one of them (in a zoo, for example). Well, the same goes for human beings, and even more so. A single human being isn’t even a human being at all. We only become human through our interactions with each other! And a huge part of those interactions consist of TALKING (rather than looking for fleas in each other’s fur as chimps do). So a lot of brain activity is involved in receiving and understanding and producing speech. And when this goes wrong, you hear voices that aren’t really there. So whenever a human brain is fucked-up, in whatever way it’s fucked up, you can almost be sure that one of the symptoms will be hearing voices that aren’t really there… »

« I think I got it, » said Joe. « You mean that since the human brain is in a very big part all about sensing speech, when it goes wrong there’s a good chance something will not be working correctly in this very process of sensing speech. Just like a car that is for driving, and if it goes wrong, then it probably doesn’t drive properly anymore… »

« Yes, » said Jack. « Our brains are continuously picking up sounds from our ears, analyzing them and deciding whether it’s someone saying something or rather just leaves rustling in the wind. When the brain fucks up, this very important thing it is constantly doing is probably fucked up too. And so it hears voices that aren’t really there… »

« I still can’t too much imagine how this works in practice… » said Joe. « I can’t imagine how someone could be continuously hearing voices that aren’t really there. And how their brain could be continuously inventing all the stuff these voices would be saying. That must be exhausting! »

« I guess it IS exhausting, » said Jack. « That’s one of the reasons schizophrenics can’t bear additional stimulation, like a TV running or something like that. They already have a TV running in their head! And it’s not just running (else they might conceivably learn to ignore it) - they’re forced to make up the programme themselves on the spot, continuously! »

« But what are those voices saying all day long? I think my brain wouldn’t be able to produce imaginary voices all day long! - it would just run out of ideas! »

« Mostly they don’t say anything all that creative… » answered Jack. « Some of them just describe everything you’re doing in third person: now he’s lifting his glass, now he’s taking a gulp, now he’s putting the glass down again… Sometimes they’re nasty and insult you all day long, telling you over and over again what a loser you are… »

« But, as a psychiatrist, wouldn’t it be interesting to know what the voices are saying? » asked Joe.

« That’s what I thought when I was young and idealistic! » answered Jack. « But now I know this leads nowhere. If you encourage patients to describe what their voices are saying, they just go crazier and crazier! »

« But surely those voices have something to do with who they are, what problems they have and how those problems could be solved? » insisted Joe.

« Well, » said Jack, « religious people of course believe it’s an angel or Jesus or God talking to them! So you can imagine where that might lead if you start discussing what the voices are saying! The patients will end up telling you that they are the chosen one, the next prophet, or that they are ‘the way, the truth and the life’ or who knows what! »

« Hm… » said Joe.

« There’s really no other option than to shut those voices down, » said Jack. « And once the patients are on antipsychotics, even if they should still hear the voices, they at least won’t be motivated to act on them anymore. »

« What about giving them a GABA-communication-enhancing drug instead of an antipsychotic? » asked Joe.

« Well, this has been tried, » said Jack. « And yes, it calmed them down. But it didn’t stop their psychotic thinking. To stop that, at this point there just really isn’t anything even coming close to antipsychotics, however nasty they may be otherwise! »

« But antipsychotics are just dopamine-communication-inhibiting pills, aren’t they? » asked Joe.

« Yes, » answered Jack.

« But why dopamine? » asked Joe. « You said dopamine was the move-your-ass-and-be-bloody-motivated neurotransmitter. What has that got to do with hearing voices in your head? Why wouldn’t something calming the brain more generally (like a GABA-communication-enhancing pill) work just as well or even better to stop those voices? »

« Well, » said Jack, « wanting to move your ass and being bloody motivated means wanting to participate in everything happening around you, or at least in the thing that motivates you so much. And that’s what dopamine does - it makes you bloody alert! You pay attention because you don’t want to miss anything because you want to take part! »

« And that’s how Ritalin works, I bet, » said Joe. « It makes you more alert. »

« Exactly, » said Jack.

« And when you’re TOO alert and paying TOO much attention, you end up hearing and seeing things that aren’t really there, is that it? » asked Joe.

« Yes, you could say that… » said Jack. « The brain is very good at completing incomplete information. When you listen to someone talking in a crowded room where everybody else is talking at the same time, you can usually still understand that person, because your brain just fills in whatever your ears didn’t manage to pick up in the surrounding noise. But if you do too much of this ‘filling-in’ - if your brain goes in overdrive with completing incomplete information - even the rustling of leaves in the wind will end up sounding like spoken words to you! In the end, even no sound at all will sound like spoken words to you! »

« You mean there’s a fine line between filling in missing information and outright inventing? » asked Joe.

« Well, when it’s unconscious, you don’t call it ‘inventing’ - you call it ‘hallucinating’. » said Jack. « And as to the ‘fine line’, I wouldn’t say there’s any line at all - we’re all hallucinating! »

« You mean there is no objective reality? » asked Joe.

« Well, » said Jack, « that could be the subject of a whole philosophical discussion of its own… Every perception is also an interpretation. Who decides which interpretations are wrong, which perceptions are just hallucinations? » asked Jack rhetorically.

« Yes, » said Joe, « who decides that? Who decides that schizophrenics and their hallucinations are sick and that we are the healthy ones? »

« I think it’s all about suffering, » said Jack. « If you manage to live fine with your way of seeing and hearing the world, who am I to criticize it? But if you suffer, then you have a problem… »

« Well, » said Joe, « there’s still a line, then. Somewhere a line has to be drawn - if there’s too much information missing for something to be a spoken word, you have to decide, at some point, that it isn’t a spoken word at all, but just some leaves rustling in the wind… »

« Yes, okay, » said Jack, « you’re right. And if you’re pumped full with dopamine and over-motivated to see meaning in everything, you might come up with the strangest things! And occasionally it might lead you to a great insight that everyone else missed, but most of the time it just makes your life impossible! »

« So overdosing on Ritalin, for example, could make you hallucinate? Because it enhances dopamine signalling, I mean… » asked Joe.

« Sure, » said Jack. « With cocaine the risk is even bigger! »

« And with antipsychotics you get the opposite effect, right? » asked Joe.

« Yes, that’s right. Patients describe the effect of antipsychotics as feeling wrapped up in cotton-wool - every sound seems to reach you from far, far, far away… »

« Because it takes a long, long time to decide that a spoken word is really a spoken word rather than leaves rustling in the wind? » asked Joe.

« I guess so… » said Jack.

« Okay, » said Joe, « so antipsychotics stop the voices and cocaine may start them. But schizophrenics don’t have these voices in their heads because of cocaine, do they? Do they have those voices in their heads because they have too much dopamine for other reasons? »

« I guess not, » answered Jack. « I don’t think schizophrenics have too much dopamine - if they really did, antipsychotics probably wouldn’t have so many undesirable effects. They have those voices in their heads for other reasons. You can block those voices with antipsychotics, because producing them is dependent on an intact dopamine-system, but that doesn’t mean the root-cause is there… »

« So where is the root-cause? » asked Joe.

« There are various theories, » said Jack. « One of them is about your internal clocks being out of sync. »

« We have internal clocks? » asked Joe.

« Sure, » said Jack. « We estimate durations all the time, whether they’re split seconds or weeks, months, years or even decades… And most of all we need to know about any two things which one came first and which one came second, because that’s how we can hypothesize about which one might have caused the other… »

« I don’t too much see what that has got to do with voices in your head, » said Joe.

« Let’s say you have a thought, » said Jack. « Your brain automatically puts a time-stamp on that thought, so that if you recall it later, you have some idea WHEN you had it. »

« Okay, » said Joe.

« Now let’s say this thought gets put into words by the language centre of your brain… » said Jack.

« Some people would argue thoughts are made of words anyway! » said Joe.

« Well, » said Jack, « if thoughts were necessarily made of words, your dog couldn’t think, could she? »

« Can you think, Daisy? » Joe asked his dog.

Daisy looked up from the floor where she had been snoring a moment earlier and started wagging her tail expectantly.

« I know what she’s thinking, » said Joe. « She’s wondering whether I’ll pronounce the magical word ‘wa.…’! I don’t want to say it now, because she would feel cheated if we didn’t really go for one! But anyway, doesn’t that mean that even dogs think in words? »

« Oh, » said Jack dismissively, « this one maybe does! Maybe other dogs do too, since they spend their whole lives listening to their masters! But their ancestors the wolves certainly don’t! »

« And what about me? » asked Joe. « Whenever I have a thought, I just can’t stop it from taking the form of words, it seems… »

« That’s just an illusion, » said Jack. « Whenever you concentrate on not thinking in words, this causes a deluge of words to fill your mind! It’s the same when I tell you NOT to think of a pink bear. Of course the image of a pink bear straight away fills your mind, while otherwise I’m sure you never think of pink bears! »

« Yeah, maybe… » said Joe.

« Or let’s try this, » said Jack. « Picture yourself in a bright red sports car with a top-model girl in a short skirt sitting beside you… »

Jack paused dramatically, then he asked : « So, did you see that in front of your inner eye? Was it all just words or was it a visual impression? »

« Okay, you’re right, » said Joe. « I got a visual impression. I could try to describe it now, of course, but it was definitely just a visual impression to start with! I even saw the highlights in the girl’s hair, and it took me a moment, right now, to find the right word for it, namely ‘highlight’! »

« You see? » said Jack.

« Yes, okay, so we definitely think in images as well, not just in words. That’s probably because we are very visual creatures. We don’t have a sense of smell as impressive as a dog’s! Do dogs think in smells? »

« I guess so, » said Jack. « But so can we! If I tell you to imagine the smell of fresh rain on hot asphalt or something like that, I’m sure you get an impression of it! »

« Well, yeah, » said Joe. « But I’m not sure that really counts as a ‘thought’. Like you said, it’s just an impression… »

« Okay, okay, » said Jack. « We’re not going to fight over that! In any case, if I ask you to describe to me how you walked home yesterday evening, you will remember the impressions of the light drizzle on your face, the smell of fresh rain on the still hot asphalt, the reflection of the street lamps on the wet road, and so on and so on. You will replay the impressions in your mind and then put them into words for me. »

« Okay, I agree, » said Joe. « But some would argue that it only becomes a structured ‘thought’ once you’ve put it into words. »

« It doesn’t really matter what you call it, » said Jack. « What counts is that the brain KNOWS that remembering the impressions came first, and putting them into words came second. »

« You mean the brain puts a kind of time-stamp on the replaying of the impressions, and another time-stamp on the process of putting that into words? » asked Joe.

« Exactly, » said Jack. « That’s exactly it! And if the clocks in your brain are out of sync, the time-stamps might be wrong, making you believe you first had the words in your mind and only then remembered the impressions of the drizzle on your face, the smell of the wet asphalt, the glittering reflections of the street-lamps… »

« Oh, I get it! » said Joe. « If you believe the words came first, before replaying the impressions in your mind, you will wonder where those words came from! »

« That’s right, » said Jack. « You’ll believe the impressions were caused by the words describing them, but then where did the words come from? »

« Yeah, I get it! » said Joe. « You’ll mix up cause and consequence because of the wrong time-stamps! »

« Yes, » said Jack, « and if the words weren’t caused by the impressions but rather the other way around, then what caused the words? The only answer the brain can come up with is that someone spoke them to you! »