Over the last week I have read almost all of Robert Sapolsky's book Determined. When I finish it, which should be today, I intend to start writing a reply to his argument and post it here. The reason I slowed down towards the end is because Sapolsky includes a section about 'schizophrenia' which I almost entirely disagreed with and it has been difficult for me to pick the book up again. I wrote an email to him concerning this section but received an automated response. The automated response does not say that he never reads emails but it seems likely that he will not read mine. So I have decided to publish the letter here.
Hi Dr Sapolsky,I recently bought and have read most of Determined, Life Without Free Will. Although I have not yet quite finished it, I read with interest your discussion of schizophrenia. I am writing to you with some thoughts and criticisms concerning this part of the book.
You say that John Nash “struggled his entire adult life with schizophrenia”. I admit that this is the impression one gathers from watching the film A Beautiful Mind. However, although I have not read the biography the film is very loosely based on, I do know Nash said at some point in later life that he believed that medication "impeded the process of recovery". This strongly suggests that after he was permitted to go off medication, Nash indeed recovered. This though is not the message of the film, nor what you say in the book.
Interestingly I believe Virginia Woolf was schizophrenic. This may seem absurd – she was an accomplished writer who penned a number of literary masterpieces. However, if we recognise that if schizophrenia is anything at all it is an episodic condition, it seems less ridiculous. Just before she drowned herself, she wrote a letter to her husband saying, “The voices have come back and you and I can’t go through another one of those terrible times.” My feeling that Woof would have been diagnosed schizophrenic today is based not only on biographical information about her that I have picked up but on a reasonably close reading of the novel Mrs Dalloway.
You discuss research that suggests that the brains of schizophrenics shrink and quite rightly raise the question of whether it is the ‘condition’ or the medication that causes the brain shrinkage. You cite research that suggests the brains of schizophrenics have started shrinking even before the first psychotic episode, before the sufferer is put on ‘antipsychotics’. However I have read articles in psychiatric journals that suggest that it is indeed the drugs that cause the shrinkage. Olanzapine and Haloperidol were given to rats and monkeys (I think capuchin monkeys) and the experiments showed quite conclusively that it was indeed the drugs that caused the brain shrinkage. Research in areas like this is very heterogenous and is not conclusive. I wonder if you are cherry picking studies that support your argument.
I turn now to the most important issue. You describe ‘schizophrenia’ as “a disease of disordered thoughts”. You say that it is possible to pick that someone is schizophrenic from a thirty second encounter, from the “meandering incoherence” of their speech. I would like to suggest that you are quite wrong.
I first experienced a psychotic episode in 2007 at the age of twenty-seven. I believe that I had a vulnerability to psychosis caused by my parents’ divorce when I was seven and that the proximate cause of this first episode was acute stress occasioned by a stint working at a popular student radio station here in Auckland, New Zealand. I was removed from my flat and shortly after started seeing a psychiatrist who put me on the ‘antipsychotic’ Risperidone. At one of these early appointments, this psychiatrist leant towards me and said that his sister was schizophrenic, leading me to believe that I had been diagnosed schizophrenic myself. I experienced psychosis for the rest of the year, was reasonably well in 2008, and then became psychotic again in very early 2009. For the first time I began hearing voices. I was taking medication at the time. In August, after I threatened to kill myself, I was allowed to go off the Risperidone. Shortly after, I was put on Olanzapine. I was totally well from early 2010 until early 2013 at which time I became psychotic again and, having not been a patient of the Mental Health Service for a year, voluntarily reentered the Mental Health Service. My hope was to receive competent psychological therapy rather than pharmacological treatment. In early 2014, I was put under a Compulsory Treatment Order which I am still under today. This has involved me coming into the clinic monthly, and for a period of several years fortnightly, to receive a long lasting injection of Olanzapine.
In 2013, I asked my then psychiatrist what my diagnosis was. She said, “Schizophrenia”. Subsequently in medical reports I had to take to Social Welfare service centres, as they are called in New Zealand, my condition was described sometimes as “schizophrenia” and sometimes as “symptoms of schizophrenia”. I do not know if I am still supposedly diagnosed “schizophrenic” today but suspect that I still am.
I do not believe I have ever exhibited thought disorder. Even when I heard voices these voices didn’t cause me to say anything incoherent. My experience of voice-hearing was that in 2009 and early 2010, I would enter into what I believed were telepathic conversations with people like Jon Stewart and later Barack Obama; even then though I do not think I ever displayed disordered speech when talking with real people in the real world. There is only one instance that I can think of that comes close to disordered speech. In 2007 and 2009 I thought all the apparent right-wingers in New Zealand were really left-wingers pretending to be right-wingers and vice versa. Sometimes during this period my lovely mother and I would visit my godmother who lives in the small city of Whanganui. At this time, the mayor of Whanganui was a horrible reactionary called Michael Laws. I thought my godmother and her friends were pretending to dislike Laws but secretly liked him. I made a comment to my godmother on one occasion ostensibly critical of Laws but, by means of vocal inflection, tried to communicate to her that I was being ironic; I was trying to play the ‘game’ that everyone else seemed to be playing. A look of confusion crossed her face. As a result of this I reevaluated my beliefs and recognised that Michael Laws is genuinely a shit.
You might say that I wasn’t in a position to know if I was exhibiting thought disorder during these periods of psychosis. But I can approach this question in another way. In 2010 and 2011 I attended a weekly Coffee Group, an opportunity to socialise with other patients, where I met and conversed with a rotating cast of young people who were supposedly ‘mentally ill'; I occasionally attended this coffee group in 2012 and 2013. During this time, at least until 2013, I was completely well. I never noticed any thought disorder in any of the other patients, never had any trouble understanding them.
You talk about thought disorder in terms of people being “pulled by the sounds of words, their homonyms, vaguely discernible leaps of connnectiveness.” I never noticed this in others or myself. If your claim were true then, by this logic, poets should all be classed as schizophrenics. In very late 2009 I met a girl at a Hearing Voices group, another supposed schizophrenic, who I fell for immediately. I sensed straightaway that she was very clever indeed. This girl loved palindromes and shared a couple with me very soon after we met. She had also memorised pi to a thousand places and would sometimes recite it as a party trick. This girl has gone on to win a number of prizes in poetry and has twice come second in the Sunday Star Times short story contest, the most important short story contest in New Zealand. Her most recent volume of poetry contains mostly extraordinarily difficult poetry – but this is not indicative of thought disorder but rather the obscurity of modern poetry that began with Modernists like Ezra Pound and has flowed through into Postmodernism. Her poetry reminds me of a very famous American poet, John Ashbery. This problematises any idea that we can ascribe thought disorder to people like this girl.
I return to the idea in your book that it is possible to pick whether someone is schizophrenic or not based on a thirty second encounter. In 2012, when I was on a very low dosage and was in the care of my GP rather than a psychiatrist, I undertook a Masters in Creative Writing through an Auckland university. Partway through the year I decided to write a screenplay about schizophrenia based on the girl I just mentioned and partly inspired by my own experiences. Not a single person in the class realised that I was drawing from my own life. In the screenplay the girl, who I called Jess, decides that she is responsible for the February 2011 Christchurch earthquake, something the real girl did. When I told my lecturer about this, he said, “They do that, don’t they.” Incredibly, by chance, there was a retired psychiatrist in the class. (She initially wanted to write a novel about a sane man who accidentally finds himself in a lunatic asylum, taking her inspiration presumably from One Flew Over the Cuckoo’s Nest.) She had no idea I was drawing from life experience. The class read a portion of the screenplay in which Jess starts overhearing the thoughts of others in a supermarket. The retired psychiatrist said to me that schizophrenics don’t hear voices in the way I described in the screenplay. I felt like saying, “I actually know more about this than you do.”
This raises the very serious issue of confirmation bias. If I had been a patient in this woman's consultation room when she was still practicing, she might well have deliberately looked for thought disorder and so found it, by which I mean falsely imputed it to me. Because I was a fellow student in a creative writing class, she was simply not looking for evidence of thought disorder in my speech and so never considered the possibility that I might have experienced psychosis myself Not that I ever actually displayed any thought disorder at the time.
I’ll tell one last story. I see my psychiatrist for half an hour once every three or four months. I never have any idea what to talk about. The consequence is that I may sometimes seem to exhibit thought disorder in his eyes even if I don’t display any thought disorder when talking with friends and family. At my first appointment with him I had told him I wanted a job and a girlfriend. Relatively recently I had an appointment with him at which my mother, key worker, and a medical student were present. I can’t remember the conversation precisely but he started off by asking me how I was getting on getting a girlfriend and then in a weird awkward way opened up the question to include the possibility of me getting a boyfriend. I suspect he was modelling current ‘best practice’ to the medical student, modelling the idea that psychiatrists should keep an open mind and not be homophobic. He opened up this question despite the fact that I have been saying I am only sexually attracted to women since 2013. I told him that I was only attracted to young women, that my difficulty was that I was too shy with girls and said that I was “on the opposite end of the continuum from Donald Trump.” My mother told me later that she understood exactly what I meant but the psychiatrist somehow got it into his head that I was saying that I wanted to fuck Donald Trump. So I had to clarify again that I am only sexually attracted to women by recounting how in 2013 I had heard a voice that said, “You’ll get a girlfriend when you’r forty” and how my fortieth had rolled around and it didn't happen. After I said this the trainee doctor gave off a small of shit, something I have learned to associate with men who feel some feeling like shame or guilt, who feel implicated in proceedings that are mendacious or corrupt. The person who displayed signs of insanity during that consultation wasn’t me, it was the psychiatrist.
Having told these stories about my own life I want to spell out the problems with your discussion of schizophrenia in Determined. You seem to be part of a movement to define schizophrenia less in terms of hallucinations and delusions and more in terms of thought disorder. The problem is no one can be sure that someone is exhibiting thought disorder because such observations are so easily biased. There is a bigger problem. You seem to be suggesting that schizophrenia is caused by an interaction between genes and childhood development and that it is a permanent lifelong condition. Robert, this view is evil. You’re interested in biological determinism whereas I am interested in cultural determinism. The reason people don’t recover from ‘schizophrenia' is that no-one thinks they can. A person who has had a single psychotic episode is stamped with the lifelong label “schizophrenic” and told that he or she has to take antipsychotics for the rest of his or her life even though these drugs potentially cause brain damage and definitely cause cognitive impairment. To look back on a person’s childhood and try to find predictive factors is like finding meaning in a Rorschach test, finding patterns in random data; in reality the causes of psychosis are different for every single person. The term ‘schizophrenia’ should be retired and drugs, if used at all, should be used sparingly, only for the duration of the psychotic episode.
Despite these misgivings I found your book very interesting. But I regard it as a philosophical argument which can be challenged in a number of places. I do not take it as gospel. I hope this email makes you reconsider your understanding of ‘schizophrenia’ a little.
The above is the letter I wrote to Robert Sapolsky. In the next post I intend to discuss other arguments in his book, particularly his arguments concerning quantum physics, and also correct and expatiate on the argument concerning quantum physics I presented in the previous post.
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