Too little life: negative symptoms, fragmentation & vacuousness of self
First-person narrative is a prerequisite to tell the full story when a character has shut down mentally from the outside world. Palmer (2009) points out that “mad people have unreadable minds […] a complete, self-contained, solipsistic world that sane people are not able to enter” (296). So this is one area where fiction can triumph over reality, by giving an insight into the mind of the sufferer – somewhere medicine is not able to go.
When a psychotic patient shuts down, they can experience what are often called ‘negative symptoms’ – characteristics “that do not appear in individuals with [psychosis], but do appear in healthy individuals” (Kuperberg, 2010: 2). To an onlooker, negative symptoms display as “a loss or diminution of function: something is missing that you expect to be there” (Freudenreich, 2008: 193). This can manifest itself as a loss of “the independent drive, the curiosity about the world” or a loss of “the facial expressions and body language that we take for granted when we engage somebody in dialogue.” (ibid: 193).
Sufferers can also experience fragmentation – the “loss of the sense of connectedness that usually exists between self and world” (Le Lievre et al, 2012: 192). As this detachment increases, they can become “preoccupied with metaphysical understanding and existential re-orientations in an attempt to make meaning of their experience” (ibid: 191).
Psychosis can also cause existential fragility, leading to ‘vacuousness of self’ where, “if one cannot find oneself or be oneself and so has no idea who one is, one solution is to take on different roles and personas” (Chadwick, 2014: 484).
These various forms of disconnection from the world can be found in the language of sufferers too. As Hart (2002) explains, “gradually or suddenly our language can become frail, fragmented, reduced, hard to use or to understand; it can seem to be going haywire, we feel one thing and what we say comes out as something else” (137).
Since the story of the sufferer became part of the medical narrative of psychotic conditions, these medical accounts are now supported by a range of personal ones. Geekie et al (2012: 177) give an account of how one sufferer “provides us with clear evidence of the stark contrast between how she felt (overwhelmed by emotion) and how she appeared to others (vacant and disinterested)”.
This ‘vacant and disinterested’ stance can be seen in the personal accounts of others. Murphy (1997: 542), for example, describes how she suffered from so many negative symptoms, it was “extremely hard to motivate myself or perform any task or job” adding that “it has been hard to become interested in anything”. And Chadwick (2014: 483) explains he “had lost count of the number of people who had said that I often was far away, not aware, miles away, or remote”.
Williams (2015: 24) describes it as a “paradigm shift of experience”, whereas for Lauveng (2012: 80) it was more like “a fog appearing on a sunny day” where “even the things near me seemed more and more cloudy and unreal”. And Longden (2012: 182) remembers being “fearful and wordless, burning in obliterating, outraged silence”.
Medical diagnoses can explain what is going on inside a person with psychosis, and personal accounts can explain how a sufferer remembers feeling at that point. But neither can allow us to experience it ourselves. This is where autobiography and postmodern first-person fiction can attempt to achieve something real life cannot.
Elyn Saks’ 2007 autobiography The Centre Cannot Hold is named after symptoms of fragmentation she experienced as part of schizophrenia. As Saks explains: “Consciousness gradually loses its coherence. One’s centre gives way. The centre cannot hold. The ‘me’ becomes a haze, and the solid centre from which one experiences reality breaks up like a bad radio signal” (13).
Davidson (2012: 25) describes Saks’ account as “experiences of cognitive impairments and anomalies that initially robbed her of her sense of being an autonomous agent in a predictable world”. For Crawford & Baker (2009: 248), Saks’ work is one example of where an autobiography can “help to dispel myths about mental illness and depathologise – to an extent – certain experiences”.
Not everyone appreciates the skewed reality of an autobiography written by someone suffering from psychosis. Adams (2005) questions the validity of Susanna Kaysen’s account in her 1993 autobiography Girl, Interrupted, as she has been diagnosed with Borderline Personality Disorder – sufferers of which have “difficulty maintaining boundaries between a consistent sense of reality and their own sense of self” (121). But it is this very situation that makes her account interesting.
And Cochenet (1993) believes Kaysen’s account give a fairly even-handed” treatment of the ‘good guys’ and ‘bad guys’ on the ward of a psychiatric hospital.
Kaysen’s observations of other patients – and about madness itself – give insight into why you cannot judge from external symptoms alone. She talks about madness as having two speeds – and that “an observer can’t tell if a person is silent and still because inner life has stalled or because inner life in transfixingly busy” (Kaysen, 1993: 77).
One example of fragmentation and the vacuousness of self in fiction is that of the character Spider, in McGrath’s 1990 novel of the same name. Written as a first-person account from Spider’s point of view, we learn Spider has developed what he refers to as a “two-headed system”.
“The front of my head was what I used with other people in the house, the back of my head was for when I was alone. My mother lived in the back of my head, but not the front […] I was in the back, that’s where Spider lived, up the front was Dennis. […] and when my father took me down to the coal cellar it was Dennis who went with him […] while all the time Spider was upstairs in his bedroom!” (McGrath, 1990: 98).
Oyebode (2004: 141) highlights that, in Spider, McGrath “examines the way that psychotic experience interferes with how the world is perceived”. Clarke (2009) underlines this point, saying McGrath wants to show that “much of what has seemed bizarre and irrational can be made to fit into a coherent psychological pattern, a flawed and tragic pattern, to be sure, but a pattern nonetheless” (22).
McGrath’s Spider is an excellent example of an unreliable narrator. His psychosis has stopped him from being able to separate truth from his own warped belief system. Often, an unreliable narrator is such because they are trying to deceive us, but Spider is one example where “we can’t rely on the narrator to tell the truth because, in truth, he doesn’t know the truth either” (ibid: 186).
Too much life: mania, delusions & paranoia
A psychotic individual exhibiting potentially agitated or aggressive symptoms is far more commonly assessed by the medical world and far more commonly portrayed – in both autobiography and fiction – than that of what Leader (2011: 9) calls “quiet madness”.
It is symptoms such as these that the medical profession need to assess in order to establish whether or not a sufferer is a danger to themselves or others. And in fiction, these are the symptoms that breed fear into other characters. Such symptoms include mania and the outward signs of delusions and paranoia.
Leader (2011: 94) explains that, with manic elation, “everything seems possible, and the person has a sense of communication with the world, of being part of another person or process”. Rzecki (1996: 54), builds on this, explaining it is where “the senses are so heightened that inanimate objects suddenly seem to have a life force of their own, where sounds take on a new dimension and colours have a richness never perceived before”.
For the medical profession, understanding mania from a patient’s perspective is difficult because they rarely seem to be able to give a full and rounded account of their experiences while in a manic state. As Bentall (2003: 272) explains, “although I have spent many hours listening to recovered manic patients attempting to describe their experiences, their accounts have often seemed curiously incomplete”.
Autobiographical accounts of mania focus on how the writer saw life while experiencing mania, but again don’t paint a complete picture of what it is like to live within the midst of a manic phase. In her 1994 autobiography The Quiet Room, Lori Schiller describes it as being “overwhelmed by what life had to offer” – “I could not run fast enough, could not swim far enough, could not stay up late enough into the night to take in everything I wanted to experience”.
Although this gives us a sense of how she felt, it does not give accounts of her running fast, swimming far and staying up late and how she was during that state – she is looking back after the fact. Her lack of ability to record these instances at the time is understandable considering how mania affects the body. Her lack of ability to recall them after the fact is harder to explain.
Bentall (2003: 272) ponders whether this is because mania is “too frightening to recall” and so the patient buries the memories. So fictional accounts of mania are borne from an idea of what someone could be experiencing internally when exhibiting such symptoms, rather than turning to personal and autobiographical accounts.
Delusions are “beliefs that are held with great conviction even in the face of overwhelming evidence to the contrary” and are often “grotesque exacerbations of surrounding beliefs” (Freudenreich, 2008: 3). Leader (2011: 71) explains delusions are often “preceded by a period in which the person feels there is some kind of meaning in the world, although it remains imprecise and elusive” – examples of this could be “a poster on the tube, an article in the paper or a TV advertisement”.
Paranoia can form part of the structure of a ‘persecutory delusion’, where the person experiencing a delusion knows “there is a plot against them, they have a mission to accomplish, a message to disseminate” (Leader: 77). It is what Leader (2011) refers to as “the building up of a knowledge which structures that person’s relation to the world” (77).
In her 2012 autobiography Brain on Fire: My Month of Madness, Susannah Cahalan explains how she sees one delusion she experiences as proof of her position as a higher being: “I stare at the doctor’s cheekbones and pretty olive skin. [and I create] wrinkles, first just around her eyes, and then around her mouth and across her cheeks, now line her entire face. Her cheeks sink in, and her teeth turn yellow […] I have a gift. I can age people with my mind. This is who I am. And they cannot take this away from me” (85).
Lori Schiller remembers connecting with a regional newsreader: “When Walter Cronkite appeared on the screen, he began talking directly to me. As he spoke, he gave me great responsibility. He told me of all the problems of the world, and what I must do to fix them” (1994: 18).
Whereas Susanna Kaysen found additional meanings in patterns: “Oriental rugs, tiled floors, printed curtains […] when I looked at these things, I saw other things within them. That sounds as though I was hallucinating, and I wasn’t. I knew I was looking at a floor or a curtain. But all patterns seemed to contain potential representations” (1993: 40-41).
In The Trick is to Keep Breathing, Galloway presents a character, Joy, who seems to have very little interaction with other people. She hints at the mania Joy experiences through her interaction with inanimate objects – such as her need to interact with a can of soup which leads to the delusion that she doesn’t need food. “The next thing I knew, I’d pushed my hand right inside the can. The semi-solid mush seethed and slumped over the sides. […] I was learning something as I stared at what I was doing; the most obvious thing yet it had never dawned on me till I stood here, bug-eyed at the sink, congealing soup up to my wrists. I didn’t need to eat.” (Galloway, 1989: 38).
This is also witnessed in the novella The Yellow Wallpaper, where Gilman attempts to enter the mind of a character who sees life growing within the wallpaper: “You think you have mastered it, but just as you get well underway in following, it turns a back-somersault and there you are. It slaps you in the face, knocks you down, and tramples upon you” (1892: 25). As Clarke (2009: 69) explains, you are “invited to ‘listen in’ to a nameless, bedridden woman as she develops a fascination with the yellow wallpaper in her room and how this paper acts as a reflector of the demons in her mind”.
The delusions experienced by a catatonic patient, Peter, in Sayer’s The Comforts of Madness are fascinating. When the patient in the bed next to him attempts suicide, Peter believes he will be blamed – even though he has been a victim of complete catatonia for a significant period: “I had thoughts only for the repercussions of the man’s actions among the staff. I sensed I was to be implicated, ah God, I knew I was. Their wish to find a scapegoat for the night nurse’s inefficiency would be irresistible” (Sayer, 1988: 16).
Peter could also be described as suffering from mania in his ability to see life in inanimate objects: “The house with its many small rooms, heavy wide doors, angled windows, mirrors and paintings, seemed to be absorbing me in some way, pressing in on me, constricting, trying to digest me, always watchful” (ibid: 48).
In Spider, McGrath inflicts a persecutory delusion upon his protagonist, resulting in him killing his own parents: “Hilda and my father would sometimes watch me from the corners of their eyes, and I could sense them doing it tonight. What used to drive me mad was that as soon as I became conscious of it they’d be looking elsewhere and behaving perfectly normally – too normally” (McGrath 1990: 117).
Spider also suffers from periods of mania, which exhibit themselves as excessive energy and joy: “My fingers were drumming, my feet were tapping, I was smiling at the world” (ibid: 46); “I am seized […] with a feeling so intense as to make me laugh out loud […] I hop from foot to foot and try to stifle waves of inexplicable joy” (ibid: 167).
All the sights: visual hallucinations
Hallucinations are “false perceptions: there is perception without an external object” where people “express symbolically an inner transformation of the world experienced through the deprivation, anger, pain, and guilt that have become the only emotional means of engaging with it”, according to Freudenreich (2008: 6) and Feder (1980: 26) respectively.
Hallucinations in film and TV are often visual because a scene can shift from the view of one character to another, with and without the visual distortion, clarifying what is real and what only the mentally ill character can see. In fiction, they are also easy to establish as such in third-person narrative. However, hallucinations of any kind in first-person fiction become part of the mental processing of the narrator – and an extreme example of the unreliable narrator.
Referring to Saks’ autobiography The Centre Cannot Hold, Davidson (2012: 26) explains that “people struggling to emerge from active psychosis, like Saks, may have lost any sense of an anchor point amidst the cacophony of sounds and kaleidoscope of visual sensations bombarding them from every direction”. Saks’ account includes the common hallucination of there being some sort of murderous monster: “The faceless creatures hovering near, invisible to everyone but me, were about to tear me to pieces” (2007: 129).
In Spider, hallucinations are carefully woven in with other symptoms in a way that Oyebode (2004) describes as “a study of the architecture of psychotic experience. The struts and girders upon which illusions, hallucinations and delusions are built are exposed” (141).
One example of such a visual hallucination is when Spider is at dinner with his parents: “I cut into my potato, and dead in the middle of the halved potato there was a dark stain. I stared at it with some unease. Then a syrupy fluid began to ooze out of the potato, the thick, show discharge of what after a moment or two I recognised as blood” (McGrath, 1990: 117).
In The Shock of the Fall, Filer (2013) describes hallucinations as a breakdown between dreams and reality: “It’s like we each have a wall that separates our dreams from reality, but mine has cracks in it. The dreams can wriggle and squeeze their way through, until it’s hard to know the difference” (21-22).
After the death of his brother Simon, Matt starts to see visions of his brother: “I looked in the rain clouds, fallen leaves, sideways glances. I searched for him I the places I had come to expect him. In running tap water. In spilled salt. I listened in the spaces between words” (276).
As her psychosis develops, the unnamed woman in The Yellow Wallpaper starts to see a woman trapped behind the pattern within the wallpaper: “In the very bright spots she keeps still, and in the very shady spots she just takes hold of the bars and shakes them hard. And she is all the time trying to climb through. But nobody could climb through that pattern – it strangles so; I think that is why it has so many heads” (Gilman, 1892: 30).
All the sounds: auditory hallucinations
Many sufferers of psychosis experience auditory false perceptions which “typically are voices, more often unpleasant than pleasant” and which are “different from thoughts or inner dialogue”, according to Freudenreich (2008: 7) and Beavan (2012: 147) respectively. Beavan (2012: 146) explains hearing voices is a personal experience and requires “descriptions and definitions provided by voice-hearers themselves” to be understood.
Such personal accounts include those by Lauveng (2012), Murphy (1997) and Chadwick (2014). With Lauveng (2012: 80) it was the levels of noise that affected her perception of the world. She became aware that the sounds she wanted to concentrate on, such as lectures or conversations with friends became “low and blurry”, while background sounds she used to easily ignore got loud and scary and took away the focus from the things I was supposed to concentrate on”.
Murphy (1997: 542) heard voices, but not specifically human ones: “Sometimes the voices came from machines. A running vacuum cleaner called me filthy names. Laundry machines, air conditioners, cars, and motorcycles all taunted me. The flame on the gas stove also spoke”. Whereas Chadwick (2014: 483-4) talks about a “vague and subtle inner noise” – one that created a “hemmed in feeling in my head as if I didn’t have much space to move in, but in a tunnel vision sense, I could see forward but only forward”.
In her autobiography, Lori Schiller (1994) describes how the voices she hears escalate as she sinks into a psychotic state. “On the surface, things seemed great. Underneath, though, they were beginning to fall apart. The Voices were coming louder and faster, startling me with their surprise visits to my brain” (21); “The Voices were beginning to command me to hurt people, and I was starting to fear I might obey” (24).
In The Shock of the Fall, the protagonist, Matt, hears his brother’s voice – he “listened in the spaces between words” (Filer, 2013: 276) for him as well as looking for him in random places such as running water and spilt salt.
It is almost with contempt that he parrots the psychiatrist’s questions about his experiences – “do you hear it inside your head, or does it seem to come from the outside, and what exactly does it say, and does it tell you to do things or just comment on what you’re doing already” (ibid: 88) – due to the simplistic approach of their questioning.
In Spider, the main character also hears noises, although he doesn’t explain the ‘who’ causing the problem: “I too have felt them clacking and clicking round the back of my head like the teeth of a hound, like a cloud of chattering gnats, in fact the sound is rarely absent though most of the time it is mercifully subdued” (McGrath, 1990: 88)
In O’Farrell’s After You’d Gone, Alice is in a coma after trying to commit suicide. In rare sections of first-person narrative, she explains how she is feeling – and it is difficult to tell where the coma ends and what the mental illness begins.
Her not being sure of whether or not she is hearing voices is a beautiful way to capture this uncertainty. “Is this my voice I can hear? It is as if I’m living in a radio, floating up and down on airwaves, each with the different voices – some I recognise and some I don’t. I can’t choose the bandwidth. […] Some voices I can distinguish as outside myself, those that sound farther off, as if through water” (O’Farrell, 2000: 26).
All the smells: olfactory hallucinations
Olfactory false perceptions seem rare in both medicine and in fiction. Leader (2011: 104) explains that an individual with psychosis can see themselves as a ‘rotten’ person – and therefore “hallucinates a disgusting odour coming from his body”. Leader describes this as a breakdown between the abstract and the concrete; “as if the abstract idea of being rotten is turned into the concrete idea of the odour” (104).
In her personal account of suffering psychosis, Boevink (2012: 121) explains she has experienced “a stench that penetrates everything, even my body” – a hallucination that can last days or weeks. It is similar to the hallucination experienced by Spider (in the book by the same name), who believes his body is emitting the smell of gas. “It was a long night. I still don’t know how I got through it, for it was probably the worst one yet.
Despite further layers of brown paper taped onto my torso, despite the layers of vests and shirts and jerseys on top, the smell of gas was with me until dawn (McGrath, 1990: 154-155). And the unnamed woman in The Yellow Wallpaper notices the wallpaper has developed a smell too: “There is something else about that paper – the smell! I noticed it the moment we came into the room, but with so much air and sun it was not bad. Now we have had a wee of fog and rain, and whether the windows are open or not, the smell is here. It creeps all over the house” (Gilman, 1892: 28).
Fractured mind, dissociated voice
Whether seemingly internal or external, whether negative symptoms or mania, delusions or hallucinations, the range of symptoms each individual with psychosis suffers is a unique pattern to that individual. However, even with these idiosyncratic patterns, there are significant links between how symptoms are assessed and understood by the medical profession, explained by sufferers and expressed in fiction.
Where novels break the pattern is in the cycling of these symptoms. Although real life sufferers of psychosis can shift between negative symptoms and other more manic ones, fictional characters seem more likely to sit in one camp or the other. And although both fictional groups may suffer from delusions and hallucinations, those with negative symptoms only share them internally – with the reader – relying wholly on first-person narrative to tell their story.
First-person narrative is also the choice for writers who wish to focus on the internal workings of their characters, even when these characters have more outward symptoms.