Madness and Method – January 16, 2011

In the aftermath of the tragic shootings in Tucson, Arizona, a lot has been said and written about a climate of political hatred. While hatred and unrestrained speech are ugly things in themselves and usually mask a person’s willful blindness, it’s still not clear to me that the shooter was motivated by any clear political agenda. Mixing Mein Kampf and The Communist Manifesto among your influences suggests more confusion than commitment.

It’s also not certain that this young man had a severe mental illness. Certainly, he exhibited schizophrenic tendencies and behavior strange enough to make the people around him nervous. His school asked him to leave and not come back until he got treatment. But aside from suggestions of paranoia and the disorganized thinking displayed on his internet posts, there’s no record that he was ever diagnosed or taken into custody under Arizona’s equivalent of the California Welfare and Institutions Code 5150 as “a danger to others, or to himself or herself, or gravely disabled” before the shootings. And the fact he was able to arm himself and in a short span fire 31 shots, hit twenty people including a difficult headshot on his principal target, and kill six of them indicates a certain presence of mind and ability to focus.

I have only minor concern that one political party or another will be tarnished by this incident, but I greatly fear that people struggling with mental illness will be further stigmatized. After 17 years of writing the Speaker Notes for the National Alliance on Mental Illness – East Bay Chapter, I’ve learned a thing or two about brain disorders. I’d like to share them.

It’s popular to talk about criminal masterminds, serial killers, and those who go on shooting rampages as “psychotics.” But they are better described as sociopaths. They have little human feeling and tend to treat the people around them as objects rather than living beings. The kindest thing that can be said for these people is that they lack empathy.

But people with mental illnesses such as schizophrenia and biopolar disorder are not sociopaths. When a person with schizophrenia is having a psychotic episode—which is just that, a discrete if recurring event, not a permanent conscious state—he or she is agitated, disorganized, confused, and terrified. Although the language of Section 5150 cites “danger to others or to self,” the latter is more often the case. People in a breakdown are more likely to hurt themselves, either through inattention or under the impulse of voices they hear ridiculing and damning them,1 than they are to lash out and hurt another person. Their actions may be wild and violent, but they are not usually directed against a second party. The paranoia does not usually lead to planned acts and organized retaliation.

When a person with bipolar disorder is in his or her manic phase, he or she will have grandiose ideas, towering ambitions, and a self-perception of having great power and skill. To the extent this is dangerous, it’s usually a danger to the person with the delusion. He or she will take risks, overspend money, deplete resources, and wear her- or himself out. Violence against a second party is usually not part of the pattern.

In either case, the person so afflicted is far more concerned with the brainstorm going on inside his or her head than with the doings of other people. And she or he usually cares very little about identifying the faults and transgressions of others—even against themselves—and punishing them. The mind is turned inward upon itself and its perceptions.

Both of these illnesses have their quiet states, too, marked by withdrawal and absence of activity and ability. At these times, the person with schizophrenia exhibits what are called the “negative symptoms”: flatness of expression, lack of organized and coherent thought, inability to enjoy or feel much. The person with bipolar will enter a state of severe depression, unable to think or feel, wanting only to die.

This is not to say that people with brain disorders cannot cause harm, or that their paranoia does not sometimes cause them to stalk and injure or kill another person. (Or that the shooter in the Tucson case did not have an untreated mental illness.) But violence against others is not the dominant feature of severe mental illness.

The good news is that several categories of medications are available to help the person control the mood swings, stabilize the psychosis, and relieve the depression. And several varieties of “talk therapy” are available to help the person understand the illness, address the symptoms, and make a good and useful life for him- or herself. There has never been a better time for a person with a brain disorder to seek help and get treatment that can make a real difference in the life experience.

The better news is that many communities are beginning to treat the needs of people with brain and behavioral disorders in a coordinated fashion. They have come to understand that people with mental illness often try to self-medicate with alcohol or drugs, and so proper treatment includes help for and understanding of substance abuse issues as well as the medical problem. They are combining and coordinating health and social services that used to be offered separately and haphazardly, so that people with mental illness and substance abuse have easy access to housing, income support, rehabilitation, and training.2

Brain disorders are scary for many people. The most difficult part to understand is that one of the symptoms of mental illness is anosognosia—the inability of the person to understand that he or she is ill and needs treatment. After all, people with a broken leg need and want help. People with diabetes learn to take their insulin. So why do people with brain disorders have such a hard time acknowledging that they’re sick and keeping up with their medication?3 When the illness denies itself, treatment becomes very difficult.

Medical science still has a long way to go in fully understanding the interplay between chemical and electrical impulses in the brain and thoughts in the mind. It’s a mystery that invites speculation about the human soul. Until we have a map and a mechanism that relates the two spheres inside a normal and healthy human head, we’re not going to have a final answer about what happens when things go wrong. But we’re getting closer.

It would be a terrible shame if the tragedy that occurred in Tucson were to put any more pressure on the people—and the families who love and care for them—who are battling a brain disorder and trying to make sense of their lives.

1. When a person with schizophrenia hears voices and experiences other hallucinations, what seems to be going on is that the part of the brain which normally interprets the “waterfall” of sensory stimulation we all experience—including auditory stimuli—malfunctions and misinterprets the signals. The brain is constantly trying to make sense of the world, and so when the signals get scrambled, the brain tries to find meaning in them. The circulation of air in the room may be mistaken for whispers, and the whispers become words. Because the schizophrenia also gives rise to paranoia, and the person may still have some residual sense that something is wrong with him or her, these words are usually threatening, belittling, and emotionally damaging. The person with schizophrenia is more likely to hate and fear the words and their power than to accept and trust them as some kind of siren song to appropriate action.

2. To understand how important this is, consider the thicket of laws and regulations that face the average citizen in trying to understand his or her Social Security and Medicare benefits. Now multiply that by Federal rules on Section 8 housing assistance and the Supplemental Security Income program, and local rules governing mental health treatment and jobs programs. Now imagine that you have an illness that keeps you from listening attentively and thinking clearly, and that robs you of the motivation to tie your shoes in the morning. Now go out and try to take advantage of all the programs that are supposed to help you. Good luck!

3. One part of that isn’t hard to understand. Most psychotropic medications have physical side effects of one kind or another, from dry mouth and constipation, to involuntary muscle spasms and weight gain. Even the newer “atypical” medications have some persistent side effects. And every patient responds differently to the medications in each class: there is no one perfect elixir that works for everyone. So, after the crazy thoughts and delusions have gone away, and you think you’re cured, you still have this flocky taste in your mouth and your lips are twitching uncontrollably. Anyone would be tempted to stop taking those pills.