Method In Madness

Case Studies In Cognitive Neuropsychiatry

Peter W. Halligan, John C. Marshall

• Publisher: Psychology Press
• Year: 2013
• ISBN:
  9781317775126
• Edition: 1
• Topic: Psicología
• Subtopic: Historia y teoría en psicología

In clinical neuropsychiatry, case studies provide invaluable demonstrations of the range and types of unusual psychological states that can occur after brain damage. In the pursuit of objectivity and scientific respectability, however, many academic reports of neuropsychiatric disorders appear cold, contrived and impersonal. The essence and character of the patient's experience and behaviour is easily obscured or even lost - a fact that cannot help researchers, therapists and other practitioners to relate their conceptual knowledge to the flesh-and-blood people they meet in their professional lives. In practice, much of the actual discourse of such patients has been ignored as unworthy of scientific interest. This book describes real patients in a clear and jargon-free way. These cases should serve to reduce the discrepancy between the formal representations of psychiatric illness in the mainstream literature and the reality of people struggling to make sense of their own predicament in everyday life.

Section C

WHO AM I?

The concept of a unitary, stable, and enduring self is usually accepted without much question in modern societies (at least by the mythical “person-in-the-street”). None the less, there have been philosophies, psychologies, and religions in which it was argued that the person and the individual mind were not what they seemed. For David Hume, the mind “is nothing but a heap or collection of different perceptions”; B.F. Skinner admits “the uniqueness of the individual”, but only as a particular assembly of changeable habits; and, for the Buddha, “this bundle of elements is void of Self”. Scholars who, on the contrary, do believe in selves have disagreed about how many such entities can be associated with a single body. From Arthur Wigan to Joseph Bogen, the notion that each cerebral hemisphere might contain its own independent mind has appeared plausible to at least some members of the neuroscience community.

Although the views of such advanced, not to say enlightened, thinkers should certainly give one pause, most of us manage quite nicely with the view that “I” is somewhat more than the first person singular of a linguistic system. The thoughts and actions of this ego should “make sense” to others and, paradoxically, to itself (thereby denying the initial premise that the self is unitary). But what if someone’s behaviour seems quite inexplicable in terms of the usual beliefs, purposes, and goals that guide our lives?

The “strangeness” of dementia praecox (now known as schizophrenia) is shown purportedly by our inability to empathise (as opposed to sympathise) with what the patient is experiencing, thinking, or feeling; on meeting a schizophrenic patient, people often report a “praecox feeling” of an unbridgeable gulf and this feeling has often been regarded as almost a defining characteristic of the condition. And yet there is a well-known countertradition within personality theory that regards schizotypy (or “psychoticism”) as a continuum, where the difference between the sane and the mad is quantitative rather than qualitative.

Irrespective of that particular controversy, the chapters by McKay, McKenna, and Laws, and by David, Kemp, Smith, and Fahy, provide pointers towards how we might eventually come to understand patients who show different forms of severe fragmentation of the self: in “classical” schizophrenia where a previously cohesive personality seems to have dissolved into a condition where there is “no private self”; and in multiple personality disorder where there seems to be fractionation of the personality into “many public selves”.

However uncanny these conditions are, it must be even more alien to “normal” rationality to believe that one is dead—the Cotard delusion described in the chapter by Young and Leafhead. If we accept Descartes’ argument that “I think, therefore I am” (“cogito ergo sum”), what must a patient experience in order to infer that he or she is not?

A Cartesian might also argue, “I will, therefore I do”. But in this case our philosopher would be puzzled by the “neurological” condition of alien hand, described in Parkin’s chapter. If “my” hand engages in apparently purposive action, but not under the control of “my” will, we see yet another form of fragmentation of the self, a form that must surely perplex the patient as much as it does the examiner.

6	Severe Schizophrenia: What Is It Like?

A. Paula McKay, Peter J. McKenna, and Keith Laws

Fulbourn Hospital, Cambridge, and Department of Experimental Psychology, University of Cambridge, Cambridge, UK

When psychologists, or other clinicians who are not closely involved with psychiatry, think about schizophrenia, what thoughts go through their minds? Almost certainly, they will know that the disorder is not in any sense a split or dual personality, but that it was originally so named to denote a fragmentation of mental functioning which was believed to be the common denominator of its many and varied symptoms. They will probably also be aware that schizophrenia is a serious—perhaps the most serious—psychiatric disorder, in which the prospects for recovery are not good. This will likely lead on to a recollection that the cause or causes of schizophrenia are not well understood, and that there has been a longstanding dispute about whether the disorder i essentially the result of some kind of disturbance of brain function, or whether it is better understood psychodynamically, as a pattern of maladaptive behaviour arising from intolerable inner conflicts or disordered family relationships. From their reading of journals, they cannot have failed to notice that currently the biological school of thought is dominant, and that a substantial literature on the structural and/or functional cerebral basis of the disorder is building up. Finally, like most people, they will be aware that medication is the mainstay of treatment for schizophrenia and that in most cases this is less than satisfactory. There may be some hazy awareness of recent claims for advances in drug therapy, although like everything else in schizophrenia research, there is some dispute about this.

The psychiatric literature is full of descriptions of schizophrenia, but these convey little of the everyday clinical realities of the disorder. By means of an account of a particularly severe and intractable case, this chapter will try to give an impression of what schizophrenia is like for the clinicians who have to deal with it, and also, taking advantage of the fact that the patient ultimately became able to recount her experiences quite rationally, to some extent what it is like for the patient. The case description will be followed by a brief resumé of current thinking on the nature of schizophrenia, what underlies its symptoms, and the state of the art in the treatment of the disorder.

LAURA: A PATIENT WITH SEVERE, CHRONIC, AND TREATMENT-RESISTANT SCHIZOPHRENIA

Laura is a 28-year-old woman. She was born and grew up in North America, the elder of two daughters of a cardiologist father and a librarian mother. There is no history of mental illness in Laura’s family, except that her maternal grandmother stopped eating and became rambling in speech in the few months before her death (in all probability this reflected senile dementia). However, her father is alleged by her mother to have been an alcoholic who may also have abused drugs and certainly led a dissolute life, being absent from the home for long periods, ostensibly at conferences, before eventually deserting his family altogether.

Laura was a healthy child, with normal developmental milestones. The family moved a number of times with her father’s work, and her parents separated when she was 13 years old; after this she and her sister remained with their mother but saw their father regularly. At school, Laura was considered to be of above average ability in some classes, and of average ability or below in others, but without showing particular learning difficulties. Throughout her childhood and early teenage years she made friends easily and was described as “quite extrovert”. According to her mother, however, she was affected by the stressful relationship between her parents. Apart from a period of having nightmares at around six years of age, which settled over a few months, she showed no obvious behavioural or psychiatric problems during childhood. In her teens, though, she truanted from school. There is no history of alcohol or drug misuse (the latter is extremely common in urban Americans of her age group).

Laura first became psychiatrically ill at the age of 16. At this time, her family and friends noticed that her behaviour was gradually becoming more and more strange. She would spend hours pacing back and forth, had a distracted air, and sometimes could be caught talking to herself. Later she started tearing up her clothes, and on one occasion she had to be prevented from jumping out of an upper storey window. She was admitted to a psychiatric hospital for several months, and received treatment with drugs and psychotherapy. On discharge from hospital, she was described as being “more or less normal”.

After a few months, Laura’s condition deteriorated. She started failing to turn up to school and running away when she did attend. This and a return of her other symptoms led to a further admission, following which she also made a good recovery. Over the next 12 years, she spent several long spells in hospital; typically these lasted 12–18 months, and the longest period of time between admissions was nine months. When ill, her mother and sister described Laura’s behaviour as varying from extreme overactivity to near stupor. She would be rambling and incoherent in her speech, and at times slept all day and was awake all night. She also indulged in bizarre behaviours such as locking herself in the bathroom and cutting holes in her mother’s and sister’s clothes. Even at her best, between bouts of illness, she was described as being given to making biting personal comments and having an unpredictable “Jekyll and Hyde” tendency. A lot of the time she was obsessed with cleanliness. She also exhibited minor peculiarities of movement and speech, for example making animal noises or holding her fingers to her mouth and blowing on them. She did not mix much outside her family and was shy in the company of strangers. She would go shopping with her sister or mother, and did simple tasks in the home, but would get rather mixed up if she attempted more complex procedures such as cooking a full meal.

Prior to her most recent admission to hospital Laura was living with her mother and sister in Belgium. During this period her interest in her usual activities waned and she began spending much of her time smoking and sitting in front of the television, seemingly without caring what programme was on. She also made no attempt to learn to speak French. Gradually, her behaviour again became increasingly strange, with the re-emergence of some of the peculiarities she had shown before, such as talking to herself, both in her normal voice and in other affected voices. She would spend hours cleaning in the house, but in an abnormal way, for example cleaning one carpet tile over and over but leaving the rest of the carpet. At times she seemed distressed and tearful but seemed unable to say what was troubling her—when she did try to explain what she said made little sense.

Eventually, Laura was admitted to hospital in Belgium. By this time she was very psychotic. Against a background of being generally withdrawn and uncommunicative, she had virtually daily bouts of behavioural disturbance, ranging from a restless agitation to singing, screaming, sexual disinhibition, and occasionally violence. She often required physical restraint; this may have included a straitjacket (these are still in use in America and many other countries, although not in Britain).

During this time she was subjected to a regime of drug treatment which was aimed both at controlling her disturbed behaviour and also treating her underlying illness. The mainstay of this was neuroleptic drugs (antipsychotics, major tranquillisers). These have a definite therapeutic effect on the symptoms of schizophrenia, but the effect is often limited and the dose has to be progressively increased according to clinical judgement—there are no laboratory tests to tell when the optimum dosage has been reached. Neuroleptic drugs are also sedative; this is particularly so when they are first given and this aspect of their effect tends to wear off with continued treatment. Other sedative drugs, notably benzodiazepines and barbiturates, are therefore often also needed to control disturbed behaviour. An idea of Laura’s lack of progress and the difficulties in management that she presented during this admission can be gained from Table 6.1.

After nine months her family moved to Britain (a move which was at least partly in order to gain further and hopefully more successful treatment). Laura travelled with her mother and sister and was admitted to hospital immediately after she arrived in the country. At this time, she was thin, but general physical and neurological examination was normal. Her behaviour was severely disturbed. She seemed distressed and frightened, and would run about the ward in a chaotic fashion. At other times she would adopt bizarre postures for long periods, for example kneeling with her arms crossed, or repeating a sequence of movements many times. Sometimes these ritual sequences would involve the inappropriate repetition of a normal action—on one occasion she was noted to spend hours wiping the top of a bedside locker. She often made grimac...

Table of contents

• Cover
• Title Page
• Copyright Page
• Table of Contents
• Preface
• List of Contributors
• Section A INTRODUCTION
• Section B WHO ARE YOU?
• Section C WHO AM I?
• Section D WHERE WAS I?
• Section E WHAT DO I BELIEVE?
• Author Index
• Subject Index