Who am I? Identity crisis, distractibility & loss of interaction
When we talk of an individual suffering from psychosis, we are referring to someone who has, in some way, lost touch with reality. But that doesn’t mean the individual isn’t aware of this. And it is this very need to understand what is going on that can lead to an increased level of psychotic symptoms. Williams (2015: 24) explains the “drive to understand your own experience and explain it to yourself – particularly when it’s becoming increasingly at odds with others and the world about you – [can] accelerate the person into even more bizarre spirals of experience”.
Keitel (1989) refers to a psychotic episode as an “extreme form of an identity crisis” – something that “brings about radical changes in the affected person’s perception of himself” (3). Even if a psychosis sufferer is not fully aware their experiences are not the norm, as Lodge (2002) points out, “we not only have experiences, we are conscious of ourselves having them” (14).
For both Kean (2009) and Lauveng (2012), the feeling of having lost themselves was the most frightening symptom they experienced. In her personal accounts, Kean states she felt a “constant feeling that my self no longer belonged to me” (2009: 1), while Lauveng says she “often thought that I was a zombie, one of the living dead, or just a person in a book or in someone’s imagination” (2012: 79).
In her autobiography Susannah Cahalan also refers to this loss of self: “I remember only very few bits and pieces, mostly hallucinatory, from the time in hospital. Unlike before, there are now no glimmers of the reliable ‘I’, the Susannah I had been for the previous 24 years” (2012: 72).
These feelings of loss and attempts to understand them can lead to distractibility. Chadwick (2014: 484) describes ‘inner distractibility’ as having the effect of “confusing and blurring the inner cognitive processes of categorisation” and that this, in turn “leads to categories merging and coalescing into a totality rather than being separated and distinct”.
Felman (2003: 108) describes this merging in another way – as the “discontinuity between sign and signified: madness appears in discourse as a passion for the signifier, as a repetition of signs – without regard for what is signified”. In effect, what we usually take for granted can no longer be such and this “may shake the foundation of the framework we use for navigating the world” (Geekie, 2012: 87).
In his personal account, Byrne (2012) explains he often felt he was “losing control of my thoughts or forgetting how to think and act” (103); while Chadwick (2014: 483) describes what he calls his ‘inner analytical life’ as having “become so arid, drained as it was of all colour and feeling, that it seemed hardly a life at all”. He explains his existence became a “closed world of endless lines of reasoning and inner dialogue” (ibid: 483).
In her autobiography, Elyn Saks describes how “thoughts crashed into my mind like a fusillade of rocks someone (or something) was hurtling at me – fierce, angry, jagged round the edges, and uncontrollable” (2007: 83).
With their own identity in question, it is no surprise that many psychosis sufferers become unable to relate to others, and therefore unable to interact. As Clarke (2009) explains, “we size people up every day as we proceed through work and play [and] intuitive assumptions play their part. It is ‘guessing psychology’” (215).
And it is this ‘guessing psychology’ that Rzecki (1996) can remember losing: “I had to spend a lot of time contemplating what I thought other people were thinking, assessing their reactions, and analysing my own thoughts” (4).
This loss of self, loss of relatability and subsequent loss of interaction are gold dust for first-person narrative. They are states of mind that can only really be expressed by the character experiencing them. Goonan (2005: 10) believes such fiction attempts to create “the state of an individual’s awareness, many steps back from the artifices of fortune and society”.
For Feder (1980: 279) such writing allows the “increasing sense of aloneness in an indifferent universe [to be] symbolically transformed into assaults on the very notion of an autonomous self”.
In Sayer’s The Comforts of Madness, Peter – the protagonist – attempts to “reduce himself, his presence of the world, to a purely subjective construct” (Byatt, 2015: 40). The result is “a novel of pure voice” (ibid: 40) – simply his thoughts, perceptions, observations. Through this, Sayer is able to present a character who has chosen a loss of self and a loss of interaction.
“My ancient wish of becoming invisible stirred itself again – though I never really wanted to be completely invisible. It was just my head which, from time to time, I longed to have removed from my shoulders and placed on the end of a string, to have it dangled in my pocket that I might still hear, yet not bear full witness to, the musterings around me” (Sayer, 1988: 21).
The inability to relate to others is expressed in autobiography and fiction as people becoming inanimate objects. In her autobiography, Susannah Cahalan twice refers to a member of staff as “the purple lady” (2012: xii & 250). In The Trick is to Keep Breathing, Joy sees others merely as “damp coats” (Galloway, 1989: 109).
In his 2013 novel The Shock of the Fall, Filer paints a character who is losing touch with his sense of self, but desperately trying to hold on – even causing himself pain in order to hold on to what it feels like to be human: “This body isn’t my own, it merges into the space around me so that I cannot feel where I end and the rest of the world begins” (172); “I’ve stubbed a cigarette out on my forearm. That’s blistered too. I hoped the pain might keep me here, but I can’t grip the thread. Time falls through my fingers” (Filer, 2013: 255)
In After You’d Gone, O’Farrell (2000) draws a parallel between Alice’s state of mind before and after her suicide attempt – that it was her loss of sense of self that drove her to her attempt in the first place. Before the attempt: “I sat there for a long time, feeling so numb, as if all sound and sense had been switched off. What was left was a peculiar kind of peace: I felt hollow, as if my body was filled with nothing but smoke” (335); and afterwards: “I am somewhere. Drifting. Hiding. Thoughts running around tracks, random and unconnected as ball-bearing in the circuit of a pinball machine” (371).
If loss of interaction leads to silence, the only way this can be reported in fiction is for the narrator or another character to report it. In The Other Side of You, Vickers (2006) uses the first-person account from the perspective of the psychiatrist to describe the characteristics of Elizabeth’s silence. “My patient sat wrapped in her invisible mantle to protect the wounds which had brought her to me. […] There was no antagonism in her demeanour. It conveyed only a lacklustre indifference, as if I were part of the furniture of a cell – a nun’s or prisoner’s – an unregarded bystander to her pensive preoccupation” (16-17).
What am I? Depersonalisation & catatonia
The question of ‘What am I?” can be answered two different ways from the point of view of psychosis. If an individual suffering from depersonalisation attempts to answer this question, they are flummoxed – they come up empty-handed after spending hours pondering its meaning. However, if an individual has catatonia, their answer to ‘What am I?’ dismisses the body completely – they are the entity inside the shell.
Depersonalisation, by its very nature, is hard to define. Simon (2016: 47) describes it as “anomalous body experience and body distortion” and “alienation from surroundings”, while Sierra (2009: 1) lists the most commonly reported symptoms as “loss of emotions and feelings of estrangement or detachment from their thinking, their body or the real world”.
In his personal account, Abugel (2010) explains that, because the world seems unreal, “you close your eyes and turn inward”, but that this offers no respite as “the very thoughts running through your head seem different” and describes the act of thinking itself as “strange and unreal” (1).
In her autobiography, Susanna Kaysen experiences an acute episode of depersonalisation when she starts questioning the make-up of her own skeleton. “I started getting worried. Where were my bones? I put my hand in my mouth and bit it, to see if I crunched down on something hard. Everything slid away from me. There were nerves; there were blood vessels; there were tendons. All these things were slippery and elusive” (1993: 102).
Filer’s protagonist ‘loss of self’ results in depersonalisation rather than distractibility. Matt inflicts pain onto himself – “I would have to cut a little at my skin with a knife, or burn myself with a lighter” (2013: 131) – to ensure to himself that he is real.
Catatonia, on the other hand, is a shutting down of the body – at least externally.
However, as with negative symptoms, the lack of external response to stimuli doesn’t mean there is not internal response. The widely held belief that a catatonic patient cannot move at all is incorrect – hence why Freudenreich (2008: 12) refers to it as “catatonic stupor” – where the patient is “immobile and unresponsive to environment” but where patients often display “repetitive movement without goals”.
There are a number of personal accounts from psychosis sufferers who see their physical body as an inconvenience, such as Boevink (2012: 124) who describes herself “mainly as brains for which I need the rest of this body I am in” explaining that she “never was friends with the shell”. However, other accounts talk of “a paralysis of the will to do and to accomplish” (Deegan, 1994: 338), which would suggest the external result has a number of internal triggers.
In Brain on Fire: My Month of Madness, Susannah Cahalan is unaware of her catatonic episodes, and it is her boyfriend, Stephen, who has to relay them to her – which she then relays to us: “I turned to face him, staring past him like I was possessed. My arms suddenly whipped straight out in front of me, like a mummy, as my eyes rolled back and my body stiffened. I was gasping for air” (2012: 40).
We rarely get a personal account of a formerly catatonic patient – it is as if (as with mania) they cannot recall the instance after the event. This means any such fictional narratives “may be the closest we have to understanding and interpreting what seem to be incomprehensible and inexplicable experiences” (Crawford & Baker, 2009: 240).
In The Comforts of Madness, the protagonist is in a fixed catatonic state and tells his story from the point of what Byatt (2015: 40) calls “pure voice” – the first-person perspective of suffering from catatonia. As Crawford & Baker (2009: 240) point out, Sayer’s novel “may be able to inform us of what it may be like to be catatonic, but this may not represent an actual experience of catatonia”. And the point is actually this – we don’t know what it is like. It is a question that medicine and academia cannot answer.
Because of this, creative fiction can take us on a journey medicine can’t. Fiction can attempt to allow us to experience catatonia through the eyes of someone else without any fall-out from being wrong.
In the novel, Peter describes the point at which he chooses catatonia: “I could not move, had no strength, no desire to. Nothing was left in me at all [but I] allowed myself one last act, one last indulgence before the years that followed: I smiled.” (Sayer, 1988: 105). He also explains to us his fear of the death of his body – even though he has all but rejected it: “That this skin, these bones, eyes, teeth, organs, would also one day end up as ashes, as nothing, imparted in me a dread I had not known before” (ibid: 86-87).
Where am I? Dissociation & out-of-body experiences
While depersonalisation manifests itself as ‘unreal’ thoughts and feelings, and catatonia is an external shutting down of the body with no understanding of the internal, dissociation is where the body and mind become disconnected – where there is “a destruction of the body image in which the parts lose their link with the whole” (Soenen & Corveleyn, 2003: 28).
Leader (2011: 90) describes it as “the lack of a bodily consistency [which] suggests the imaginary and real dimensions have not been connected securely to the symbolic. There is nothing to pin down the body image, no internal framework that would provide a structure”. With dissociation, “the fragments of the body are no longer recognised by the subject as its own [and] the subject becomes entrapped and enclosed in a timeless, inhuman space” (Soenen & Corveleyn, 2003: 28-29).
In their personal accounts, both Lauveng (2012) and Rzecki (1996) describe what sounds like a textbook dissociation experiences. However, whereas Lauveng tells of her episode with some puzzlement, it is obvious that Rzecki’s experience was one of abject fear. “I was no longer a person, not able to recognise my self or to feel that I was an independent individual who could make my own choices or control my own actions” (Lauveng, 2012: 79). “I began to feel completely unnerved. My body seemed somehow detached and I watched, terrified, as my other self floundered, my head flooding with moments of dimming consciousness” (Rzecki, 1996: 13).
The idea that we can become detached like this is unimaginable for most of us. As Sacks (1985) explains, “What is more important for us, at an elemental level, than the control, the owning, the operation, of our own physical selves? And yet it is so automatic, so familiar, we never give it a thought” (47). But it is one both Galloway (2011) and McGrath (1990) capture in their characters.
In Galloway’s novel The Trick is to Keep Breathing, “part of the detachment from herself and the development of a distance towards her body is the presentation of perspective – Joy presents herself as a separated object” (Pannen, 2011: 114). Even standing is a momentous task. “I have to concentrate: one finger at a time, releasing pressure and rebalancing in the chair to accommodate the tilting, adjusting, redistributing pieces of myself. Hands are bastards: so many separate pieces. The muscles in the thighs tighten as the feet push down and the stomach clenching to take the weight then I’m out the chair, shaky but upright” (Galloway, 1989: 8).
In Spider, McGrath attempts to represent what he calls “the most appalling solitude any human being is ever likely to know” (2002: 141) – which in his main character becomes not just an inability to connect with other people, but the inability to connect with his own body. “The simplest things – eating, dressing, going to the lavatory – can sometimes pose near-insurmountable problems […] because I lose the easy, fluid sense of being-in-the-body that I once had; the linkage of brain and limb is a delicate mechanism, and often, now, for me, it becomes uncoupled” (McGrath, 1990: 10).
While dissociation refers to the feeling of being detached from one’s own body, an out-of-body experience (OBE) – where the sufferer sees themselves as outside their own body – is most likely to be a form of hallucination.
Carruthers (2013: 183) describes an OBE as “a distinction between the sense of oneself as an experiencing subject, a mental entity, and a sense of oneself as an embodied person, a bodily entity” but differing from dissociation in the fact that there is “considerable confusion regarding the apparent location of the experiencing subject; is it the ‘real mind’ in the body I seem to be looking out from, or is it in the body that I see?”
As with personal accounts of dissociation, those who experience OBE tell stories of both calming and terrifying experiences. In her autobiography, Susannah Cahalan explains one trip into hospital where she found an OBE to be rather soothing. “There I am on a gurney. There I am being loaded into the ambulance as Stephen holds my hands. There I am entering the hospital. Here I am. Floating above the scene, looking down. I am calm. There is no fear” (2012: 42).
Whereas Randal’s personal account is horrifying. “I was no longer in my body. I found myself trapped forever in this hell-like state of utter terror as if I had been totally obliterated yet was conscious of my non-existence” (2012: 59).
An OBE in fiction as a symptom of psychosis is an unusual one. The OBE seems to be the near-exclusive subject matter of the science fiction and fantasy genres. The Trick is to Keep Breathing is one of the exceptions. Here, the protagonist, Joy, describes herself as being able to watch from outside her body.
What isn’t clear from the narrative as the book continues, is whether she is talking literally – as in she is having an OBE – or if she is talking mentally, as in dissociation. “I watch myself from the corner of the room sitting in the armchair, at the foot of the stairwell” (Galloway, 1989: 7); “The nice thing is that I need not be present when I am working. I can be outside myself, watching from the corner of the room” (ibid: 12).
Why am I? Social factors & life traumas
To look at the symptoms of psychosis in isolation, without attempting to understand why certain individuals suffer from it, seems a little shortsighted. If there are a set of social factors or life traumas which make a person susceptible to psychosis, then a fictional character would need to experience these in order for their disassociated voice to be believable.
It is also very much believable that characters who experience psychosis would question why – as do sufferers in real life – and so looking at ‘how’ sufferers question why (and the answers they come up with) is also a useful resource for fictional character development.
When looking at social factors, it makes sense to start with the family. For Sigmund Freud – known as the father of psychoanalysis – an individual’s development in the early years of their life was at the core of the theories he developed in the first half of the 20th century. Psychiatrist R.D Laing – who also believed that childhood and the family could affect the mental health of an individual – was known for his unorthodox views on schizophrenia, which he saw as “a split between the true but hidden self and the false outer being whose chief functioning processes are determined by the need to adjust to the demands of society and the family” (Feder, 1980: 280).
Although psychological and psychiatric studies have moved on from Freud and Laing, family life is still recognised as a key trigger in the lives of those who develop mental illness. Read (2012: 127) states “research using a range of scientific methodologies has recently established that many social factors are significant risk factors for psychosis [including] insecure attachment in childhood […] dysfunctional parenting [and] childhood emotional or physical neglect”.
Clarke (2009) believes this is because we have little sense of identity as a child and it is “contact with significant others that provides us with the rudiments of a personality” (218). He also explains patients with psychosis can be affected by family interactions; that “patients subjected to negative, critical, emotion deteriorate, whereas those in more nurturing environments improve” (ibid: 191).
Whether or not family is present during the time of mental illness, an individual’s experiences of family life can hinder recovery. As Lauveng (2012) explains: “No child grows up and builds their identity in six months or one year – it takes a long time. And when the development of a safe identity has gone wrong, it will naturally take some time to get it right.” (84-85).
Psychosis itself can be an individual’s way of attempting to cope. Grosz (2013) explains if we have stories from our childhood that we “never found a way to voice” then “our story tells us – we dream these stories, we develop symptoms, or we find ourselves acting in ways we don’t understand” (10). This is certainly the case for Dillon (2012) who was astounded to discover “all of my so-called symptoms were in fact creative, life-saving survival strategies that made absolute sense within the extreme conditions in which they had developed” (18).
In The Trick is to Keep Breathing, Joy’s mental state and her relationship with her mother are intertwined. “When I was a teenager, my mother used to go looking for my diary. […] One day what she read made her burn it. When I came home she showed me the ashes and said I could never be trusted again” (Galloway, 1989: 189). “I pulled grey hairs and didn’t notice my mother’s because they’d always been there. When she got sick I didn’t believe it. When she died I didn’t want to know. She was more likely pretending to get attention, trying to make me feel guilty” (ibid: 193).
In Spider, Spider’s relationship with his parents drives his psychosis and his delusions. Spider shares with us how much he believes his father hates him and the delusion that his mother is dead and has been replaced by a prostitute. “No one would know, only I, only I, how intense, how venomous, was the hatred he felt towards me [but] I was never able to tell my mother […] for my father disguised his feelings so effectively she would have laughed to hear me explain what was really going on” (McGrath, 1990: 22). “‘Dennis!’ snapped my father. ‘Answer your mother when she asks you a question.’ This was rich. ‘Mother?’ I said […] staring straight at her through slitted eyes. ‘You’re not my mother.’” (ibid: 122).
There are those who believe this focus on family is too simplistic as there are many cases of psychosis in individuals who come from stable, loving families. However, Bentall (2003) suggests the issue is assuming it is only ‘bad’ parenting that can do damage – “we do not need to assume that the parents of future psychotic patients are wilfully neglectful, deranged or cruel in order to accept that they have some influence on their children’s mental health” (467).
A now well-known study carried out in 1998 by Carl Dweck and Claudia Mueller is an excellent example of how supposedly positive and encouraging parenting skills might in fact have negative and demotivating effects. In the study, children were either praised for being ‘clever’ or ‘working hard’ after completing a set of complex maths problems. As Grosz (2013) explains, “ultimately, the thrill created by being told ‘You’re so clever’ gave way to an increase in anxiety and a drop in self-esteem, motivation and performance” (19) – and those given approval for ‘working hard’ fared better in a second set of tests.
In their autobiographies, both Lori Schiller (1994) and Elyn Saks (2007) speak of having loving families. But they also speak of competitive family life with younger siblings and parents who expected them to achieve. Saks (2007) admits she had a ‘sibling rivalry’ with her brother: “I did my best to stay ahead of him, working to excel at things a younger brother couldn’t do yet” (7). When describing family life, Saks explains her parents “had high expectations for our behaviour, and when we missed the bar, they brought us up short” (9-10).
Schiller (1994) says as a child she had always felt ‘special’ as she was the oldest child and the only girl. The need to feel special can become addictive, driving Schiller to seek out attention. To get this, she “usually chose achievement” and so she struggled when she didn’t attain something – and that “whatever I did had to be done all the way” (13). Although not from a dysfunctional family, Schiller developed an abnormal coping strategy during her childhood.
Life trauma is when an event – such as death – triggers psychosis either as part of a coping strategy or as part of the grieving process. Crawford & Baker (2009: 242) believe we should consider the “relief” that psychosis might give someone facing an intolerable situation. Campbell & Morrison (2012: 173) agree, pointing out persecutory delusions can be “a psychological defence mechanism, the ultimate aim of which appears to be to protect the individual from harm”. And Dillon (2012: 21) believes there is “inherent meaning in madness” linked to “unresolved, traumatic experiences”.
In The Shock of the Fall, Matt’s psychosis and the death of his brother Simon are inextricably linked. Rajasingam (2014: 502) states it is “the depth of his [Matt’s] grief and guilt which is suggested to lie at the heart of his illness – keeping him forever trapped, as he tells us, by the pain of his own mind”. The result is that Matt hears his brother “in the spaces between words” and sees him “in running tap water” (Filer, 2013: 276).
Pannen (2011: 115) lists the life traumas Joy in The Trick is to Keep Breathing has suffered, the most recent and dramatic of which is the death of her lover. In full they are: “the separation from her first boyfriend, her mother’s suicide, and the sister whom Joy cannot relate to [plus] her father is not mentioned, her mother is dead, her lover passed away, and her best friend has gone to America”.
Joy describes when the shock and grief of her lover’s death first hits her as if she is describing it happening to her body, not to herself: “My body knew he was dead before I did. It shouted and yelled and punched the nurse who came with the needle, thumped its fists off the walls and screamed to try and wake up. My mouth promised whatever I did wrong I’d never do it again” (Galloway, 1989: 195).
Shattered self, dissociated voice
In fiction, the self cannot be viewed in isolation, but as a reflection of the other symptoms being suffered. For example, an identity crisis can lead to a character having an unrealistic view of themselves (such as Spider in Spider) rather than a feeling of emptiness (such as Joy in The Trick is to Keep Breathing).
In Spider’s case, his identity crisis is strongly linked to his delusions regarding his family, whereas Joy has a much stronger link to reality, and her suffering is linked to real grief – but for both their understanding of ‘self’ is intertwined with their state of mind. Symptoms such as depersonalisation, catatonia and dissociation work in very much the same way, reflecting on other elements of the self and the mind.