Out of mind

Schizophrenic states of mind seem to deny either access or empathy. What does it mean to know how someone else feels?
October 20, 2006

George's black eye was almost perfectly oval, as if he'd made himself up as a mime artist. He stood there in his flat eerily unmoving and at an uncomfortable-looking angle, frozen somewhere in between meaningful gestures. After a dozen or so meetings, the young psychiatrist visiting him still wasn't sure exactly what he felt about his patient. Every time something was subtly different. What he felt now was an odd, unprofessional irritation at George's inability, or refusal, to explain how he had got the black eye.

The young psychiatrist had got to know George a few months earlier, while he was plunging through a florid, psychotic episode. Their meetings at the time seemed memorable because the two of them looked so alike—both professional men in their mid-thirties, the same height, a similar wiry build, blond hair, and some faint quality of mutual recognition. George had once been an estate agent. But the sharp suits had gradually become crumpled, the behaviour increasingly erratic, and he had ended up in a locked ward after ransacking one of his old offices at night and hoarding up the window cards, oblivious to the burglar alarm he had triggered.

By the time he was referred to the young psychiatrist, George had written out pages of notes gleaned from estate agent windows and websites. These looked like dense equations of property prices, postcodes, square footage, distances from tube stations and a variety of other increasingly bizarre items of urban data. George had at one point claimed that out of these equations, he could identify a set of codes for what he called his "caste system" for Londoners. Properties under £75,000 would generally condemn their owners to "untouchable" status; over £5m, and they would likely belong to a secret sect whose members possessed mystical powers.



But the young psychiatrist was now uncertain whether this was just his own interpretation of a garbled mix of meaningless ideas. The delusions went further, involving a conspiracy in which George either had the power to create the codes himself, or was being pursued by higher beings seeking to destroy him. The psychiatrist might perceive in this a distorted response to the stress and paranoia of the London property market, but George's mindset probably belonged to a more general form of paranoia and solipsism common to schizophrenia.

The likeliest explanation for George's illness was the simple old fatalistic one—that madness ran in his family. His uncle and more than one of his grandparents had been diagnosed with schizophrenia. Prescribed the antipsychotic drug Quetiepine, George's more extreme symptoms had abated, and he was able to move out of hospital into a small flat, in an area that he might previously have described as "untouchable."

Still, the young psychiatrist felt that his job had to combine pharmacological treatment with an aptitude for empathy. One of the pioneers of 20th-century psychiatry, the German philosopher Karl Jaspers, had distinguished between two kinds of madness: that which could be understood, and that which could only be explained. In some kinds of mental illness it is possible to recognise familiar emotions, even if exaggerated and distorted, and it is therefore possible to empathise with the sufferer. Yet there are other kinds in which a complete psychotic break has taken place and the sufferer is propelled, like an outlying planet, into a remote and unreachable psychic orbit. Jaspers called such states "autochthonous," because they seemed to have arisen out of themselves.

What does it mean to know how someone else feels? Two years ago, neuroscience discovered what was marketed as an empathy cell—the mirror neuron. Performing an action and seeing someone else perform it fires the same cell. There is a seductive idea in this: that when we see somebody else's tears, the same cells are being fired up as when we ourselves cry.

Sometime after leaving hospital, George had stopped taking his antipsychotic medication and had disappeared into the "negative" symptoms of schizophrenia—an emptiness left behind in a retreat from the world and the self. The young psychiatrist looked around the flat which was empty, except for a mattress and an old suitcase. He found himself tilting sideways into the same awkward posture as George, like another mime artist, trying to extract a reaction. "It's a nice place you've got here," he said provocatively.

Suddenly, George jolted out of position. "I introduced myself to the neighbours last night," he said.

"Oh really? What time was that?"

"About three."

"In the morning?" The young psychiatrist pointed to George's black eye. "Did someone hit you?"

George ignored the question. "I think I'm getting sick again."

"How have you been feeling recently?" the young psychiatrist asked.

"I don't know," George replied. "I can't remember. I think my problem is actually a memory problem."

This struggle for insight was something new. A glimpse of vulnerability switched the psychiatrist's irritation to pity. But was George really crying out for meaning, or was that merely what the young psychiatrist wanted from him?

"Would you like to come back to hospital for a bit?" the psychiatrist asked.

"OK," George replied.