Sunday, January 30, 2011

Anosognosia and Objectification

Okay, what’s that first big word? From my work writing the Speaker Notes for the National Alliance on Mental Illness – East Bay Chapter, I’ve learned that one of the reasons brain disorders are so hard to treat is a symptom called “anosognosia.” That’s a newly invented1 compound noun from Greek root words that means lack of awareness of an illness or impairment.

Certain sections of the brain—in the prefrontal and parietal lobes—are responsible for our awareness of how we are feeling and functioning. When these brain cells work properly, they let us know when we’re having some difficulty. For example, if you are having temporary balance or memory problems, these cells make you aware of them and let you take precautions like holding the railing when climbing stairs or writing down your shopping list.

Many mental illnesses like schizophrenia, bipolar disorder, brain malfunctions like Alzheimer disease, and sometimes simple brain damage can cause changes in these cells. The patient is no longer aware of lapses in memory, emotional control, or a bodily dysfunction like paralysis. The patient does not believe he or she is ill and so resists treatment and medication as unwanted interference with a normal life.

Two things are important to note here. First, anosognosia is not like a light switch, flipping the patient from “I think I’m having a problem” to “Nope, I feel fine.” Instead, it can be range of awareness, from occasionally forgetting the deficit to angrily refusing any suggestion that it exists. Second, anosognosia is not simple denial. In denial, the patient knows there’s something wrong but refuses to deal with it out of pride, anger, or fear. With anosognosia, the patient is simply not aware.

While anosognosia seems to be safely consigned to the realm of serious illness—people with diagnosed brain and central nervous system disorders—I wonder if the condition isn’t a lot more common in daily life than anyone realizes. The fact that awareness of impairment is not complete or continuous, that it can include a range of patient responses, suggests that people without other notable symptoms may encounter a bit of anosognosia in everyday life.

Consider the problems associated with a sedentary lifestyle and obesity, especially as a person gets older.2 At some point, as you gain weight and the tissue builds up on your thighs, you can’t comfortably cross your legs at the knee. And then you can’t cross your legs at all. As your belly grows, you have trouble moving quickly and maintaining your footing. You compensate by slowing down. Then you have trouble bending to tie your shoes, and you compensate by putting one foot up on a step while tying the laces or gradually shifting to loafers and sandals. The realization comes rarely, if at all, that something is different. “Gee, I used to be able to do this. Now I can’t.”

We are constantly adapting. Our minds adapt to the limitations our bodies place on our lifestyle. It doesn’t take brain damage for a person to become comfortable with a body where you can no longer cross your legs, tie your shoes, or reach the center of your back with a fingertip and so need a backscratcher to chase an itch.3

More than that, our bodies are constantly adapting and changing. Bones are constantly building mass in response to the stresses we place on them through exercise. They also lose mass when those stresses go away. We build muscle and lose it depending on how we use our bodies. We gain fat and lose it depending on the calories we ingest and the physical work we do. Tendons extend or shrink depending on their daily use. Organs like the stomach, liver, and kidneys respond to the stresses and insults we give them by gradually losing function.

But aside from the occasional ache or pain, we usually remain unaware of these changes. Partly this may be due to a malfunction in brain cells, anosognosia. But just as much it may be our own perceptions of what the body actually is.

We tend to think of the body as an object, like a tool or an appliance. It works so long as it remains intact. When it breaks, it stops working and then needs repair. We don’t think of steel hammers as getting stronger when they’re put to use pounding nails and weaker when they sit in the toolbox. We think we are objects, just like hammers—always there when wanted, unless obviously broken. You don’t expect to walk on a broken leg, but once it’s healed you’ll be back in action.

When I’ve been working out regularly and I’m nice and flexible—when I can stand on one foot and raise the other to wash it in the shower, or bend to tie my shoes with both feet on the floor—I tend to think of this as my natural state. I feel good. So I can allow myself to skip a few workouts. I can sit and read my book instead. My body is an object that will always have this flexible condition. But a few workouts missed turns into a few weeks of sedentary relaxation, and suddenly I’m stiff again.

The changes in our bodies are most noticeable when we apply diet and exercise to body weight. The tide reverses—yes, it really does—and suddenly you become trim and slim again. But then you start thinking this is your natural state, the way the object that is your body should be, and you take a donut at the morning meeting, skip a workout, enjoy a big dinner with dessert. Then the weight comes back and the slim body goes away.

We have not accepted, deep down in our psyches where it makes a perceptual difference, that the body is not an object but a process.4 There is nothing objectified about human life. We are not, have never been, and will never be one thing whole and immutable. We started as a joining of egg and sperm into a fertilized egg and then grew into a baby. We changed again and again on the journey from infant to toddler to adolescent to adult. We will change again through maturity to middle and old age. At some point, the active processes of thought and motion will stop and the passive processes of dissolution and decay will start and continue until there is no trace of us left.

We are not things. We are processes and movements and functions. Our awareness rides these changes from moment to moment and considers them to be stable and enduring. But even our awareness—built up as it is from thoughts and sensations, experiences and reactions—is not a stable function. Some days and in some situations we may interpret and track an external, objective reality with great precision and think we understand the world. And sometimes we simply get confused.5 Then we fall asleep to dream and invent whole new versions of reality that never existed.

Awareness of bodily function may indeed be aided or inhibited by a cellular network in the prefrontal and parietal lobes. But it is also supported by a deeply held belief that the body is one thing, an object, which persists in a constant state from one week to the next, one year to the next. We believe in objects, things, states persisting in time. But even steel rusts, the ocean erodes the shore, mountains rise and fall, stars explode. The constant, in life as in the unverse, is change.

1. By French neurologist Joseph Babinski in 1914.

2. Truth time. As a writer, my “day job” incorporates a lot of sitting at the keyboard. And for relaxation I like to sit and read or watch movies. I also try to get in regular workouts with a karate regimen that addresses issues of balance and flexibility. So I understand a bit about weight gain and issues of diet and exercise.

3. For about 30 years I’ve been subject to muscle spasms in my lower back, another artifact of the interplay between weight and exercise. When a spasm has occurred and while it’s healing, I move guardedly against the pain. My gait is shortened. I transition slowly and with hand support from a standing to a sitting position, and from sitting to standing, always alert for the stab of pain that tells me the muscle in question is being forced beyond its limited range. Stangely, I only know that I’m healed when I suddenly realize—usually a day or two later—that I’m moving more freely, standing and sitting without a thought. This is a kind of “reverse anosognosia”: when the impairment is gone, I’m not aware of it until I catch myself moving freely once again.

4. See “Transporter Beaming” from August 22, 2010, in my blogs on Various Art Forms.

5. If you don’t believe this, ingest a large amount of ethanol, conduct a conversation with a friend, and have yourself videotaped during the process. Conscious thought is not an unbroken stream.

Sunday, January 23, 2011

On Writing: Outline and Chapter

I suppose you can write a short story in one or two sittings. The process is logistically simple: you get an idea, you think up characters and situations that fit, and then you write the story. Everything stays “hot” in your mind for the duration of the writing process.

A novel is different. It cannot be just a big short story. Or at least, that’s not the way I do things. Some writers I know seem to have a single idea that they just “write big.” That is, they create a main sequence of action—such as the coming together for a final battle—and create multiple characters and a handful of subplots around it.1 But I can’t write that way. For me, a novel has more than one twist, more than one point. It’s an interpretation of the main character’s life and all of his or her revealed and unrevealed actions. It requires interplay between multiple viewpoints and purposes.

Granted, I’m not very creative. Ideas don’t come to me often or quickly. So it takes me months and sometimes years to go from that initial spark of an idea to working out all the characters, their situations and relationships, the incidents, the timing, the reveals, the climax(es), and the denouement(s). Or, at least, having a satisfying preponderance of these details worked out. So I open a folder on the hard drive, keep a notepad at hand, and start collecting notions and ideas.

The process really doesn’t get under way until I have experienced at least one moment, usually two or more, of synthesis. That’s when I suddenly realize the action of this book folder over here really belongs with that set of characters over there. Then a little explosion takes place, like the slippage along an earthquake fault, my mental silt gets resuspended, and the creative process moves ahead.

When a folder is full of the notes I’ve taken, and the story is ready to unfold, then I have to make an outline. I know some authors can take an idea for a book and just start writing from the first incident. That action suggests the next incident, from which the third becomes clear, and so on, letting the story unfold for the writer as it does for the characters. But for me that seems too much like trusting to luck. And sometimes these writers get stuck: they’re heading across country, take a freeway off ramp in Salt Lake City, and spend whole chapters, sometimes the rest of the book, driving aimlessly around in the suburbs.

For me the outline is a necessary structure. It’s like planning your cross-country trip on a map, or flying over it fast from coast to coast, picking out where you’ll eat lunch and where you’ll stop for the night. It’s also like the scaffolding erected around a new ship or a building under construction: it provides shape and definition for the thing that is not there yet but will shortly appear.

Outlines are also necessary to suggest that first incident. Consider that, if you are crossing from San Francisco to Boston, your first choice is how to leave the Bay Area. Do you drive east on I-80, through the Sierras, over the Great Basin, and through the Rockies? Or south on I-580 and I-5, through the Mojave, across the Southwest, and up through Texas? The overall route dictates your first choices. And the same holds for book writing.

The outline doesn’t have to be complete. Some parts of the action may still be vague in my mind. But the main structure must extend from end to end. I try to have each part of the book covered at least in minimal detail, usually worked out at the chapter level. The outline can be written forward or backwards. Usually I hopscotch through it as the pieces come together. And then the actual writing process starts.

Since the facts and incidents of the story have to become a solid and definable “history” for the part that I’m writing at any one moment, I must do the production draft moving forward, from beginning to end. (I’ve tried to write the ending and work backwards, but that always feels like trying to walk on air.) Only when I’m sure that what I’ve written so far is solid and represents “what actually happened” can I then move ahead.

This also relieves pressure on the moment of writing, of creating that “what actually happens.” The bet with myself in writing is always to either achieve the outline or do something better. If the outline says, “the character tells what happened last night.” I can always have the scene go: “And then [character] said, ‘Well, what happened last night was …’ ” But usually my creativity steps in and finds some more interesting way to play the story.

The outline is never cast in stone. While the main chapters may be captured in a paragraph or two at the start of the production draft, as the moving “now” of the book approaches upcoming chapters—usually about three or four chapters out—I’ll refine them down to the scene level. To my way of thinking, a scene is a discrete piece of action from one character’s point of view.2 Scenes have a beginning, middle, and end, incorporate one main idea or piece of action, covered in one or more conversations or physical exchanges.3 Actual details of a scene depend on that growing “history” that’s defined by the story as developed to date.

So the outline is actually an interplay between my early thoughts and hopes for the book and the next logical step based on what’s actually happened in the production draft. No outline is perfect: sometimes a one-sentence description for a scene unfolds in the writing and requires two, three, or four separate scenes to work through the action and its implications. Sometimes a one-sentence description (my favorite is “the character jumps out the window and runs away”) turns out to be … just one sentence. Then I have to start shuffling things to accommodate this modest piece of action into a sequence that will be satisfying for the reader.

For me, the writing process is an iterative one. Back and forth, but growing more solid from the past to the future. And along the way, I both create the action and see it happening. At every stage, I have to step out of the creator’s role and into the reader’s. I have to decide for myself if the action of the story is “real.” Is it credible? Are there loopholes? Can I see more reasonable alternatives? Are the characters staying true to their natures? Is the main idea of the book coming out? Back and forth, like a spider spinning a web. I just can’t do all that at one sitting.

And at the end, if everything goes right, the result is more than a simple story you can read and put aside. If everything goes perfectly, I’ll have created a tiny universe, intricate and detailed from every perspective, that you can hold in the palm of you hand.

1. Come to think of it, isn’t that the story of Hamlet?

2. My writing style could be called “third person from the first person point of view.” That is, while the language is third person (“he said,” “she did”) the action of a scene takes place inside one character’s head, reflecting what he or she knows, perceives, understands, and does. The character may observe and interpret the actions and words of the other characters, but the reader is always seeing through one person’s eyes and occupying one person’s part of the story. The fun begins when another scene picks up the persona and world view of a different character—and it’s different from the views and reactions of the others. I dislike, to the level of phobia, jumping from one head to another during a conversation or piece of action. (I only did this once, and then the viewpoint traveled on the tip of the knife that slit the first character’s throat.) Jumping around from head to head seems like laziness, an unstructured approach to storytelling. And mixing and comparing the different character viewpoints approximates my own view of reality: we each make our own truth, inhabit our own world, and play out our own games. There may be a larger external reality, but it is always filtered through the individual minds of the participants. My task is then to show the various sides of the story and let the reader decide what actually happened and whom to believe.

3. The resemblance between a scene in one of my books and the notion of “scene” that shapes a film as a sequence of discrete actions and exchanges is more than coincidental. At heart, I tend to think in pictures and so tell the story in movie-style framing.

Monday, January 17, 2011

Madness and Method

In the aftermath of the tragic shootings in Tucson, Arizona, a lot has been said and written about a climate of political hatred. While hatred and unrestrained speech are ugly things in themselves and usually mask a person’s willful blindness, it’s still not clear to me that the shooter was motivated by any clear political agenda. Mixing Mein Kampf and The Communist Manifesto among your influences suggests more confusion than commitment.

It’s also not certain that this young man had a severe mental illness. Certainly, he exhibited schizophrenic tendencies and behavior strange enough to make the people around him nervous. His school asked him to leave and not come back until he got treatment. But aside from suggestions of paranoia and the disorganized thinking displayed on his internet posts, there’s no record that he was ever diagnosed or taken into custody under Arizona’s equivalent of the California Welfare and Institutions Code 5150 as “a danger to others, or to himself or herself, or gravely disabled” before the shootings. And the fact he was able to arm himself and in a short span fire 31 shots, hit twenty people including a difficult headshot on his principal target, and kill six of them indicates a certain presence of mind and ability to focus.

I have only minor concern that one political party or another will be tarnished by this incident, but I greatly fear that people struggling with mental illness will be further stigmatized. After 17 years of writing the Speaker Notes for the National Alliance on Mental Illness – East Bay Chapter, I’ve learned a thing or two about brain disorders. I’d like to share them.

It’s popular to talk about criminal masterminds, serial killers, and those who go on shooting rampages as “psychotics.” But they are better described as sociopaths. They have little human feeling and tend to treat the people around them as objects rather than living beings. The kindest thing that can be said for these people is that they lack empathy.

But people with mental illnesses such as schizophrenia and biopolar disorder are not sociopaths. When a person with schizophrenia is having a psychotic episode—which is just that, a discrete if recurring event, not a permanent conscious state—he or she is agitated, disorganized, confused, and terrified. Although the language of Section 5150 cites “danger to others or to self,” the latter is more often the case. People in a breakdown are more likely to hurt themselves, either through inattention or under the impulse of voices they hear ridiculing and damning them,1 than they are to lash out and hurt another person. Their actions may be wild and violent, but they are not usually directed against a second party. The paranoia does not usually lead to planned acts and organized retaliation.

When a person with bipolar disorder is in his or her manic phase, he or she will have grandiose ideas, towering ambitions, and a self-perception of having great power and skill. To the extent this is dangerous, it’s usually a danger to the person with the delusion. He or she will take risks, overspend money, deplete resources, and wear her- or himself out. Violence against a second party is usually not part of the pattern.

In either case, the person so afflicted is far more concerned with the brainstorm going on inside his or her head than with the doings of other people. And she or he usually cares very little about identifying the faults and transgressions of others—even against themselves—and punishing them. The mind is turned inward upon itself and its perceptions.

Both of these illnesses have their quiet states, too, marked by withdrawal and absence of activity and ability. At these times, the person with schizophrenia exhibits what are called the “negative symptoms”: flatness of expression, lack of organized and coherent thought, inability to enjoy or feel much. The person with bipolar will enter a state of severe depression, unable to think or feel, wanting only to die.

This is not to say that people with brain disorders cannot cause harm, or that their paranoia does not sometimes cause them to stalk and injure or kill another person. (Or that the shooter in the Tucson case did not have an untreated mental illness.) But violence against others is not the dominant feature of severe mental illness.

The good news is that several categories of medications are available to help the person control the mood swings, stabilize the psychosis, and relieve the depression. And several varieties of “talk therapy” are available to help the person understand the illness, address the symptoms, and make a good and useful life for him- or herself. There has never been a better time for a person with a brain disorder to seek help and get treatment that can make a real difference in the life experience.

The better news is that many communities are beginning to treat the needs of people with brain and behavioral disorders in a coordinated fashion. They have come to understand that people with mental illness often try to self-medicate with alcohol or drugs, and so proper treatment includes help for and understanding of substance abuse issues as well as the medical problem. They are combining and coordinating health and social services that used to be offered separately and haphazardly, so that people with mental illness and substance abuse have easy access to housing, income support, rehabilitation, and training.2

Brain disorders are scary for many people. The most difficult part to understand is that one of the symptoms of mental illness is anosognosia—the inability of the person to understand that he or she is ill and needs treatment. After all, people with a broken leg need and want help. People with diabetes learn to take their insulin. So why do people with brain disorders have such a hard time acknowledging that they’re sick and keeping up with their medication?3 When the illness denies itself, treatment becomes very difficult.

Medical science still has a long way to go in fully understanding the interplay between chemical and electrical impulses in the brain and thoughts in the mind. It’s a mystery that invites speculation about the human soul. Until we have a map and a mechanism that relates the two spheres inside a normal and healthy human head, we’re not going to have a final answer about what happens when things go wrong. But we’re getting closer.

It would be a terrible shame if the tragedy that occurred in Tucson were to put any more pressure on the people—and the families who love and care for them—who are battling a brain disorder and trying to make sense of their lives.

1. When a person with schizophrenia hears voices and experiences other hallucinations, what seems to be going on is that the part of the brain which normally interprets the “waterfall” of sensory stimulation we all experience—including auditory stimuli—malfunctions and misinterprets the signals. The brain is constantly trying to make sense of the world, and so when the signals get scrambled, the brain tries to find meaning in them. The circulation of air in the room may be mistaken for whispers, and the whispers become words. Because the schizophrenia also gives rise to paranoia, and the person may still have some residual sense that something is wrong with him or her, these words are usually threatening, belittling, and emotionally damaging. The person with schizophrenia is more likely to hate and fear the words and their power than to accept and trust them as some kind of siren song to appropriate action.

2. To understand how important this is, consider the thicket of laws and regulations that face the average citizen in trying to understand his or her Social Security and Medicare benefits. Now multiply that by Federal rules on Section 8 housing assistance and the Supplemental Security Income program, and local rules governing mental health treatment and jobs programs. Now imagine that you have an illness that keeps you from listening attentively and thinking clearly, and that robs you of the motivation to tie your shoes in the morning. Now go out and try to take advantage of all the programs that are supposed to help you. Good luck!

3. One part of that isn’t hard to understand. Most psychotropic medications have physical side effects of one kind or another, from dry mouth and constipation, to involuntary muscle spasms and weight gain. Even the newer “atypical” medications have some persistent side effects. And every patient responds differently to the medications in each class: there is no one perfect elixir that works for everyone. So, after the crazy thoughts and delusions have gone away, and you think you’re cured, you still have this flocky taste in your mouth and your lips are twitching uncontrollably. Anyone would be tempted to stop taking those pills.