An Unquiet Mind - Part 2

Part 1

The hospitalization was involuntary. They interviewed her for about an hour, a process that felt like a clinical excavation, questions designed to map the terrain of a mind that did not know it had drifted, and then they gave her an injection. She woke up the next day without the manic energy that had gripped her. The days in the hospital are a blank to her. She has no memories of them. I have thought about that often: part of how treatment works is by interrupting the very faculty that would remember it. What is lost in those days is not incidental. It is part of what was sick.

She went home and was prescribed a cocktail of medications. They did not work well at first, and there is a particular cruelty in that: to survive the episode, survive the hospitalization, and then find that the treatment is also a struggle. Her parents watched her refuse the medications and then offered homeopathy as an alternative. I have thought about whether that was the right choice. I think it was not, and I also think their response was a human one to someone they loved asking for a gentler path. I remember visiting her during that time. She refused to see me, later telling me it was because I wore red that day. 

For months she paced the house. It was a large house, which helped or did not help depending on how you look at it. She talked to herself, or to whoever was in her head with her. She learned Russian. She watched mathematics videos. The content of her delusions had a coherence: she believed she was married to Vladimir Putin, so Russia made sense, and so did the mathematics, because the mind even in psychosis is not arbitrary. It is constructing a world that holds together by its own internal logic. Dopamine dysregulation does not produce noise. It produces signal that is not indexed to external reality. The pattern-detection machinery is running. The patterns are real to the person finding them.

Then, about five months in, she found a crack in the world she had built. She had believed Putin’s patronymic was Alexandrovich. It is Vladimirovich. A small factual error, the kind another person might absorb and rationalize away. She did not dismiss it. She looked at it, and something gave. If she had been wrong about something so specific and verifiable, perhaps she was not in fact his wife. And then, more or less, she was fine.

I do not know what to do with this neuroscientifically. The literature on remission from manic or psychotic episodes is extensive, but the phenomenology of remission, what it feels like from the inside when the certainty lifts, is harder to study. From watching her I know the crack was not made by an argument. Nobody telling her the truth did it, which had been tried. It was made by a specific, checkable fact that her own mind could not absorb into the system. The error-correction machinery came back through a detail, not a confrontation.

She got a job and moved to another city. She was still not medicated. A cousin who is a psychiatrist called and told her what would happen if she stayed unmedicated, and she began taking what he prescribed, not consistently, not rigorously, but some. As predicted, she had another episode. She resigned from the job and left.

But this is where she met the doctors who could reach her, and she does not regret the job or the move because of that. They managed to reach her in a way no one had before. That matters more than it might sound. Getting through to someone in psychosis is not primarily a persuasion problem. It is a relationship and timing problem: finding the moment when the internal logic has softened enough to admit outside information and being the right kind of presence when that moment comes. These doctors were that presence. They began her on a course of medication designed to bring her back to reality gradually, titrating the distance between her world and the shared one rather than forcing an abrupt crossing.

During this episode she believed she was married to a famous mathematician. Again, not arbitrary. The mind was building a world organized around what it values. She values mathematics. She always has.

The doctors sent that psychosis packing and sent her home. She got another job. Another episode followed. This time she took sick leave rather than resigning and returned to work after. But her brain did not come back as easily. It took several months and a medication switch to bring her back properly. She came back. She is still here, in the job that was kind enough to give her time when she needed it.

That is the clinical arc. It is not the whole story.

She told me something recently that I did not know what to do with and still do not. During the episode when she believed she was married to the mathematician, she felt a love at an intensity she had never experienced before or since. She did not know it was possible to feel that much. So if you asked her whether she hated the psychosis, she would say no. Resoundingly, no.

I have turned this over many times. The neuroscience is not mysterious: mania involves not just elevated dopamine but a kind of amplification of the entire affective system, emotion experienced at a volume the ordinary mind never reaches. What she felt was real, in the sense that all felt experience is real. It was also the product of a brain in crisis. These two truths are not contradictory, and the fact that they co-exist is, I think, the hardest thing about this illness to hold.

Jamison writes that she would not give up her illness if she could, not entirely, because she cannot untangle it from who she is. N doesn't say the same. But I think she would say something near to it: that the illness gave her something even as it took. That the love was real. That the mathematics was real. That the mind which found messages in Facebook posts, married her to a mathematician, and learned Russian in a large house over five months is the same mind now doing theoretical physics, medicated and calibrated and still unmistakably hers.