1
Terri’s approaching 50 now. Her psychiatric history reaches back into adolescence with suicide attempts, hospitalizations, drug abuse, jail-time. There were children taken away by the State along the way. I met her a couple of years ago in the clinic, brought by her husband, a disabled man who doted on her. The first time I saw her in the clinic, the diagnosis was easy – coma. She was so over medicated that I couldn’t interview her. All I knew was that she was on at least one [or more] drug from each class of psychiatric medications and spent her days in bed. I told her husband to bring her back next time I was in the clinic and hold off on all of her medications that morning.
When she returned, she was awake. She had at least one or more symptoms from each category of psychiatric illness and spoke of herself in terms of diagnoses – "my bipolar" "my depression" etc. There was only one disorder she failed to mention – Schizophrenia – the disorder she actually had. Terri’s illness began in high school and from that time forward she’s on and off "heard voices" – primarily attacking her – "you’re no good" "you mess everything up" "you couldn’t be a mother" "you should just die" etc. She just didn’t tell people [including doctors] about the voices ["embarassing"]. She responded to Haldol, but felt like a "tree." She did better on Risperdal [3.0 mg/day] and stayed hallucination free down to 1.5 mg/day. It was funny. After the fact, I learned that the whole household had been ruled by her "voices." Whenever she was upset, they talked loud ["it helps her if we talk loud"]. The way they got her to sleep was to put a t.v. in her room and turn it up "real loud." When she got upset, she screamed at people – also "real loud." All of these things were apparently to "drown out" the voices.
I wondered how I was going to get her off of all those other medicines, but it was not a problem. She stopped them on her own [including the Seroquel, which hadn’t stopped the hallucinations]. She retained the Xanax, the Trazodone, and the Risperdal. It’s a appalachian kind of story. Her husband went off to jail on a technical parole violation and she stayed with his mother. She was followed by a parole officer from Mental Health Court [something invented for people in the community who need "seeing after"]. The only big snafu in the last several years was a time when the clinic failed to order her Risperdal. I was on a trip and came back to find her as I met her, trying to get better on "meth." Putting her back on medication resolved things fairly quickly. She’s taking care of the activities of daily living and now lives alone in a trailer across the road from her mother-in-law though she visits frequently [ironically, it was "too noisy over there"]. She’s looking forward to her husband getting out of jail soon.
For those of you who’ve been in mental health, she’s like many Chronic Schizophrenic people – pleasant, with a number of preconscious automatisms [mannerisms]. Her emotions are flat. She’s very concrete, literal. When there’s emotional turmoil, she’s usually unclear where it’s coming from until it is cleared up by someone else – invariably some fairly simple interpersonal conflict that needs talking through and clarifying. While she sometimes laughs and even teases, she lives in a mostly anhedonic [pleasureless] world. We helped her apply for SSI [disability] which she got on the first round [as she should’ve]. We’ll not be able to see her in our clinic now that she’s insured, and I have my fingers crossed that she won’t be over-medicated again in private care. I’ll miss seeing her…
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![Jean Piaget [1896-1980]](http://1boringoldman.com/images/piaget-1968.jpg "Jean Piaget [1896-1980]")
Jean Piaget’s discipline is hard to define – education, psychology, epistomology – it was whatever he said it was. His beginnings came from his observations of his own children as they learned to know things. That lead to his theories [called
genetic epistomology]. He followed the development of his children’s reasoning skills – their increasing ability to know things as they matured. He schematized this sequence of their cognitive development as occurring in
stages:
Sensorimotor [0-2]:
The child can know that objects are permanent, separate entities that exist even when unseen.
Preoperational [2-7]:
The child can use symbols and imagination, develop language – but cannot use operations. Conservational understanding is absent. The classic example: pouring water from a wide glass into a thin, tall glass is "more."
Concrete Operations [7-11]:
The child can perform discrete operations [like the water example], but has difficulty applying multiple operations. One proposition at a time. Logic still tied to perception.
Formal Operations [11-16]:
Logic can be applied internally, with multiple propositions. "Knowing" is an "inside job" [See below].
Where’s the genius? What did Piaget see that hadn’t been seen before? I’d call it the structure of intuition for lack of better. In that last jump, he saw that the mind’s ability to reason moved beyond the symbolic logic of the Greeks to another cognitive organization – a knowing that actually skips the classic syllogisms and propositions along the way. He characterized it in terms of mathematical structures groupments and lattices – and while many argue with those explanations, what he saw transcends his equations. Like with Einstein, most of us dally at the edge of understanding Piaget’s explanations, if even that. So understanding his critics is beyond our my reach. And just because a kid has turned eleven doesn’t mean that a child has adult intelligence. It just means that it’s possible. The age ranges are the periods in which the world is reconfigured based on the new capacity. An example:
When my daughter was twelve or thirteen, she returned from a choir bus trip in something of an agitated state. One of the choir members had been telling stories on the trip home that our daughter knew weren’t true – stories that aggrandized her father and, by proxy, the child herself. "Tracy’s a liar!" she said with disgust. We attempted to offer possible reasons Tracy was lying [insecurity, etc] since we knew Tracy and her family well enough to know that the stories were false. But our daughter was not engaged by our discussion. Her point was that Tracy was lying and that was a bad thing to do. We were on the "why?" She was on the "what".
A couple of days later, we were on the porch and my wife mentioned that a friend had reported that another girl in the neighborhood [adopted at birth] was announcing to anyone that would listen that she’d met her birth mother who was a "party girl." We were both worried about this particular kid and where she was headed [for good reason], and began to talk about it. We knew she had not met her birth mother. Our daughter was on the other end of the porch reading a magazine. Somewhere in our discussion, our daughter looked up and said something like "Oh, that’s not true. That’s just something Elizabeth wishes were true." She went back to her reading [while her parents looked at each other with mild disbelief].
The next day, the three of us went sailing. It was a perfect sailing day and we were on a long tack, quietly enjoying the run in the way one does on a perfect sailing day. Our daughter was on the front of the boat. Suddenly, she turned and said, "All lies are wishes. I’m pretty sure I’m right about that." Parental jaws drop at that point. We wanted to ask about how she figured that out, but she wanted us to argue against the premise and give counter-examples so she could apply this new-found cosmic truth and shoot down our objections. We complied and a good time was had by all.
My question, "How did you figure that out?" was blindness to what Piaget was able to see. She didn’t figure it out, she just knew it. Of course her anger at Tracy was a starting place and introduced the question of the nature of liars. She knew Elizabeth and her story much better [and liked her more] – so the meaning behind the mis-statements in Elizabeth’s case were more apparent. And soon she just knew that it generalized. She didn’t figure it out. It just popped into her formal-operations-equipped-mind as a knowing. That was Piaget’s genius. He saw that there was a final mental structuralization that allowed for this kind of knowing – a database of databases, a logic of logics, a network of possibilities – real and hypothetical:
Formal Operations In this final stage of intellectual development there is a fundamental reorganization and reorientation. What is real is now subordinate to what is possible. This entails a reversal: the empirical becomes viewed as merely one possibility among many; the real becomes a subset, albeit a special one, of what is possible. This makes possible reasoning that is hypothetico-deductive, that deals with hypothetical entities and states of affairs. Reasoning that is combinatorial, able to generate all the possibilities. Reasoning that is propositional, that operates not on objects and events or their properties, but on propositions [that’s to say, statements or assertions]. We can say that such propositions were the results of concrete operations; reasoning can now operate on the results, the products, of its earlier forms. The adolescent is now able to solve tasks in which several factors are varied at once: such as the four liquids task and the pizza problem. Formally, such reasoning now forms a fully integrated complete lattice and complete group. Its substructure is formed by formal operational schemas: The adolescent can reason about such matters as proportions, probability, conservation [frictionless medium], mechanical equilibrium. The lattice is a network of hypothetical possibilities; a logic of propositions rather than simply class properties…
Piaget called this knowing the Cognitive Unconscious, because it operates automatically. It’s not a series of separate operations. It’s a developed cognitive structure that allows a knowing that is not a sequence of independent propositions, but rather a tool applied en masse to the domain of hypotheticals and may generate near immediate answers, or perhaps other questions. It’s hard to describe, but easily observed as the everyday intuition of life. And it’s the kind of intuition that’s deficient in Chronic Schizophrenia.
3
Like everyone else, I don’t know what causes Schizophrenia. I think of it two ways – like a medical disease with a physical cause and like a psychological illness. Having been with a number of people like Terri, I think of treatment two ways too. I think of medications when there are florid psychotic symptoms. I am sort of in Robert Whitacker’s camp in that many patients do well when they can take medications only during psychotic periods. Others are like Terri, who seems to need them most of the time. It took 3 mg to control her symptoms, and now she’s down to 1.5 mg. I hope her next doctor continues to slowly lower the dose [if he/she can read, I certainly wrote it enough places]. Those "voices" are her positive symptoms. Like many chronic patients, the medication does nothing for her negative symptoms. I’ve read the drug studies and ads claiming that this-and-that medication improves negative symptoms. I don’t believe that to be true no matter what the rating scales say, because I’ve not seen that happen myself.
To me, the negative symptoms are "primary." After years of being around, one gets a rhythm about how to help people like Terri. Always keep an eye out for "a disturbance in the force" – beginning psychosis, agitation, confusion, symptom return, fuzzy thinking, etc. At the first sign, start looking for a contemporary problem in their life that can only be understood abstractly, find it and translate it into as concrete a set of terms as possible, then help them find a solution instead of spiraling out of control. If you know the patient well, it’s often pretty easy to do. These patients just don’t have a full complement of that "everyday intuition of life." People like to call it negative symptoms or a cognitive problem, all sorts of things, but in the end, that last stage Piaget talks about just hasn’t really fully happened – intuitive knowing is relatively defunct. I’d bet money that it could be tested psychometrically, and that Dr. McGorry’s "pre-psychotic" patients would flunk.
4
I wrote this because I’ve been so down on J&J’s Risperdal and I wanted to balance that with a case where I thought it was actually helpful. Although Terri responded to Haldol [a first generation drug], it was clear that it made her feel bad and it was likely she’d stop taking it. Changing to Risperdal did the trick in her case. Following a patient like Terri is never a static exercise, always trying to back off on the medication to prevent long term adverse effects, using medications like Xanax that you might not use in other cases but are willing to use here because it helps keep the Risperdal dose minimized. One is always watching for situations where the more basic intuitive defect starts to cause problems. There’s never a right thing to do, so one does the best case wrong thing and watches to make sure it doesn’t misfire. A hundred years ago, Terri would have spent her life in an institution, probably died young. In the eyes of many, the life she has now might not seem much better, but if you asked her, she’d quickly tell you otherwise. She likes being awake, out and about, "voices:-free. I have no idea why she tolerates Risperdal better than Haldol. There are plenty of other cases where the opposite is true. J&J used deceit to make Risperdal into a panacea, a blockbuster, but it’s just a plain old antipsychotic helpful in the treatment of some Schizophrenic patients. That’s all it is – all it ever was…
Your theory is interesting, but I think that it might not be that there is a deficiency in intuiting, but in selection, in choosing. I have been “diagnosed” as being someone with some psychotic symptoms, but not full blown anything. My father, especially with age, edges closer, but is still a bit sane. One thing I noticed in him when I was a child, and in myself as I age, is that it is difficult to organize, and to initiate activity, but that, with a plan, or with another’s presence, the difficulty lessens, because I can piggyback on their selection. Otherwise, very little accretes enough to initiate action. Roughly, I see many possibilities, but cannot choose, which does seem to with what you are saying, but is an important distinction.
Thanks for giving me something to think about, and “enjoy” the trial. And thanks for all of your hard work.
Dr. Mickey, one would think utilizing the lowest effective dose of a powerful psychoactive drug would be standard practice in psychiatry. Thanks again for demonstrating sensible and compassionate care.