1 Boring Old Man

At the end of the ninrteenth century, a German Neuropathologist named Emil Kraepelin reviewed the records of a large sanatorium, and defined two types of severe mental illness. The first, Manic Depressive Illness [Bipolar Disorder] related to a group of patients who had intermittant madness, either severe depression or mania at intervals, but in the intervening years were sane and left the hospital. The second group, Dementia Praecox, were people who became mad as young adults, entered the hospital and deteriorated over time leading to an early death in the hospital. At the turn of the twentieth century, Eugene Bleuler, a Neuropsychiatrist in Switzerland focused on this second group – people he called Schizophrenic. He actually saw the patients rather than just their records, and his descriptions of the illness remain as clear a picture as any written today.

He described people who in earlier life seemed shy and reclusive, but not so far from the norm. They tended towards pursuits that took them away from people rather than towards them. He called them "schizoid" though it is completely clear that only a small number of such people develop Schizophrenia. Somewhere in young adulthood, such people enter a state called "trema" in the older literature – which may last for hours, or months, or years. In this state, they seem troubled, confused, things just aren’t right. In our City hospital, one could often see a "blue line" in the patient’s medical chart in the period before the Schizophrenic Break. The blue line was a number of pages from emergency clinic visits [the pages were blue] in which nothing was found – a manifestation of this sense that "something’s wrong."

The Schizophrenic Break, called the "apophany" often progresses in a matter of hours. It begins with emotional confusion, agitation, hearing the first "voice," or having the first paranoid idea. So a shy, odd person suddenly becomes agitated and begins to do crazy things. Noi one knows what to do, and the patient ends up in the hospital or in a jail somewhere. Internally, it’s a terrible experience – the "Break" is a break with reality. Bleuler was much less gloomy about the outcome than Kraepelin. Even in the days before there was treatment, some 50% recovered and went on to live a somewhat normal life. Two examples that come to mind – Johnathan Winters and Ian Fleming. The remainder developed one of the chronic forms of the illness and deteriorated.

Beginning in the 1950’s, medications became available that controlled these dramatic symptoms – the antipsychotics. But what happened before? Huge mental hospitals, the one’s we grew up joking about. "You keep acting like that, you’ll end up in Central State! [or Saint Elizabeth’s, or whatever they were called in your State]. They were the place of ECT, and Insulin Coma Therapy, and Pre-frontal Lobotomy as desparate measures were tried to treat the desparate illness Chronic Psychosis can become. With the advent of effective medications, these hospitals were shut down. Unfortunately, the medications are only symptomatic, not curative, and over the years, funding for mental health care for the mentally ill has disappeared. The Chronic Schizophrenics live on the streets or in other Institutions [L.A. County Jail is currently the country’s largest mental hospital].

What happened at Virginia Tech? A shy young man who lived as a recluse began to show signs of being troubled. His teachers saw it in his writings [see Teacher warned Authorities About Va. Tech Shooter and More details emerge in Virginia Tech attack]. His dorm counsellors saw it in his behavior – stalking, setting fires, withdrawal. And so he had a distantly observed trip into madness. He leaves a crazy note, has some crazy personal symbol scratched on his arm, and set out to kill his tormentors. He says "you caused me to do this" referring to the perceived tormentors that are part of most Psychotic Breaks. No one is really at fault other than that we are a country unwilling to fund a mental health system for such people. It would help to have seminars for counsellors and faculty on the early detection of a Psychotic Break, but as we see in this case, there aren’t many real resources for definitive action any more.

If there’s a message here, it’s a wake up call that the mentally ill, particularly those with devastating psychotic illnesses, are our forgetten citizens. Best we know, they are born into their illness. Many do quite well, but those who don’t are not afforded the ongoing care and careful observation that’s needed, because we just don’t particularly want to pay for it. There’s nothing new to learn here. Just another chapter in the national tragedy of our unwillingness to care for the mentally ill.

It’s a very old, old story. As old as mankind…