The Best American Essays 2016 (22 page)

Over the years doctors have prescribed nine medications in various combinations, as well as talk therapy, exposure therapy, cognitive behavioral therapy, and electroconvulsive shock therapy, all with meager results. Her case is, to use their terminology, “intractable.” She had to sign all manner of paperwork formally acknowledging this, attesting, for example, that she knows what the word
intractable
means, before she could find herself in this room with Frankensteinian screws in her temples, counting the ceiling tiles. She consented to everything without hesitation.

The first electrode’s transversal produces soft, whooshy noises from the monitor in the corner. These noises are her brain waves, tracked by the exploratory electrode, which will forge the correct path before the doctor inserts the permanent electrode. His target is two and a half or three millimeters wide. Once he’s reached it, he will remove the exploratory electrode and thread in the one that will be wired to a battery pack sewn in under her collarbone. It will pulse electricity into Area 24 at a constant rhythm for several years, until the battery dies and needs to be changed. She has to be awake during the insertion so that she can tell them what it feels like.

The patient is not altogether articulate about what it feels like. She has been strapped down to prevent her from bolting or fighting or trying to tear the metal cage off her head. This is both terrifying and comforting, as the thoughts are coming in inexorable waves now and she is grateful for anything that will help her keep them from coming true. This is a familiar scene: the afflicted tied down while being ministered to by some credentialed man in a robe carrying an instrument. It used to be books and crucifixes. There used to be prayer and incantation. Now there are only the muted sounds of her brainwaves, the rhythmic beeps and clicks of the vitals monitor, and the voice of the doctor as he murmurs to her through her thought torrent. He sounds calm.

The goal is to alter her experience of reality “with minimal side effects.” No one has been able to tell her whether or why this will work. Only a few dozen people have ever had this treatment for a psychological condition, and so every new patient is an experiment. Initially, doctors hypothesized that the electricity would curb overactive neurons; now they suspect it may actually stimulate neurons, or change the types of information neural pathways can transmit, but they’re not sure, just as they’re unsure precisely where in her brain to place the electrodes for best results. They are learning as they go; once this is all over, her experience will be another data point.

What the doctors do know is what the anterior cingulate cortex does, generally speaking. It houses consciousness, in the existential sense, and emotional pain. It regulates motivation, impulse control, and the anticipation of both delight and catastrophe. Francis Crick proposed it as the center of free will. It’s also responsible, in part, for the human capacity for empathy.

There are, naturally, a number of things that could go wrong. Possible but unlikely: hemorrhage, brain damage, stroke, seizure, infection, death. Possible but slightly more likely: memory “problems,” trouble speaking, depression, and mania. These latter risks have an aftertaste of irony. The electrode might turn her from a person who speaks compulsively to strangers to a person who cannot speak well at all; it may transform her mind from one reduced to four obsessive thoughts to one hyperexpansive with mania. She wonders what it would be like to go from having one mind to another and then remembers she has already done that.

The doctor in the paper bonnet interrupts this line of thinking to announce that they’re ready to begin testing voltages. The electrode has arrived at what they think will be the right place, and now it is time to see what happens to her mind when they turn it on.

She closes her eyes and waits.

This procedure is called deep brain stimulation (DBS). The patient described above is a composite of people I’ve met, people I’ve read about, and people whose surgeries I’ve seen in videos. She is fashioned after the few dozen patients who have undergone DBS to treat severe obsessive-compulsive disorder, an experimental application now in clinical trials at Mount Sinai Hospital in New York, Brown University, the University of Rochester, and a handful of other medical centers. Her symptoms aren’t so much fictional as typical: thousands of people are crippled by fears of hurting others. It is shocking how many have thrown out their knives.

Deep brain stimulation has been used for years to diminish tremors in people with Parkinson’s disease, but it’s experimental and controversial as a treatment for psychiatric disorders.
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Only a few OCD patients have undergone it (roughly two dozen so far in the current, FDA-approved study, and no more than a hundred in the U.S. total), and like many historical attempts to alter the mind, it seems halfway magical because no one really understands its mechanisms. Obsessive-compulsive disorder is not like Parkinson’s disease—the symptoms aren’t visible and physical (trembling hands) so much as experiential and behavioral—so neurosurgery-as-treatment becomes more existential in its implications. Compounding this is the fact that, neurochemically, obsessive-compulsive disorder bears a conspicuous resemblance to falling in love. Scientists have scanned the brains of the pathologically obsessive and held them up next to brain scans of the love-struck, and the images turned colors in the same places. Doctors drew blood and found the same chemical imbalances—namely, a serotonin deficit. The philosophical distinction between deactivating a part of someone’s brain and deactivating some part of their mind or self begins to blur.

I’ve done months of research about deep brain stimulation—reviewing articles, deciphering studies, interviewing physicians, scrolling through procedure videos on YouTube—for no special reason other than what you might call—ahem—a persistent curiosity. While reading the literature, it’s easy to think in clinical abstractions, but then I watched a video of an older woman undergoing the procedure and was struck by the way her voice was muffled by the nest of equipment. The doctors kept having to ask her to speak up during the adjustment phase, when she was supposed to be reporting changes in her psychological state. “I said I almost just laughed,” she repeated, gazing at the equipment before her with an expression of wonder. “I haven’t laughed in . . . a very long time.” The doctor nodded dispassionately. “Can you describe that for us?”

It seems important to cling to the concrete, to remember that illness is not a metaphor or a study but a phenomenon unfolding in (and on) real bodies in real rooms. Its qualia, the crinkly paper hospital gown and metallic adrenaline taste, the mutable and inexpressible shades of pain, demand articulation because they matter. We work so hard at telling others
what it is like
to be sick in whichever particular way we are sick; we are reassured to hear that our particulars fit within larger known narratives of illness. With sickness as with anything else, communicating what it is like so others can know, or understanding others in precisely the way they wish we could, is next to impossible. We try anyway.

Admittedly, most OCD patients are not like my imagined girl. Usually, the disease is damaging but not devastating in a relationship-ruining, inpatient-care, life-disintegrating way. It is considered a less challenging diagnosis than, for example, bipolar disorder, schizophrenia, or any of the personality disorders.
*
It is “neurosis,” not “psychosis,” “mental illness” as opposed to “insanity.” The existence of the DBS study, though, and the interest it draws from patients and practitioners alike, subtly undermines this differentiation. Extreme treatment reflects the disease’s extreme power to cripple. Neurologically, OCD seems to act on similar parts of the brain as schizophrenia; experientially, both diseases are marked by foreign-seeming intrusions on the mind. Both patients are overcome with thoughts, images, and impulses that are, to use the clinical word, ego-dystonic: they feel alien to and in conflict with the self. They feel other. In obsessive-compulsive patients, these thoughts tend to be violent or violating, obscene, immoral, or some other shade of horrifying.

What distinguishes obsessive-compulsive patients from schizophrenic patients is their ability to live inside a paradox: the thoughts hijacking their minds feel urgently not “theirs,” but the thoughts are nevertheless something going on in their own minds and bodies. These thoughts are alien, but they have not been planted by aliens. In the medical community, this is known as “insight.”

Having insight is not enough to make the thoughts go away. A little while ago, I was talking to a writer who has to touch things—all the slats on the staircase, all the poles as he walks down the street. He knows this doesn’t make sense. Sometimes, though not terribly often, he has to go back home to make sure that he didn’t leave a cigarette burning, even when he can remember perfectly well that he didn’t. He only has to do this when alone. When he’s with people, he doesn’t have to touch anything.

He told me that since childhood he’s been fascinated with the idea that everyone is God. I asked him what he meant, and he said that he had a suspicion that God was everywhere and everyone, and all our souls are the same soul, God’s soul, but we’re just walking around in different meat suits. That’s how he said it: “We’re all stuck in our own meat suits.”

I suddenly felt very aware of how different he and I look—his height and beard and age, his ruddiness, his tie; my stringy arms, bitten nails, and freckles. He is older than I am, and bigger, and embodied in a sort of ragged, robust way that I am not. At first I couldn’t quite tell whether he was fucking with me when he leaned in and looked into my brown eyes with his blue ones and said, “What I’m saying is that maybe we’re all the same, we just don’t know it because we’re separated into our own bodies,” but then I decided that he was not fucking with me and was serious, at least partly, about this hypothetical.

And part of me was thinking,
Get a grip
.

Another part was thinking,
Well, exactly
.

Which did not signal that I was on board with the meat-suit theory per se, only that I was not surprised, even a little, to discover another person with OCD who’d been worrying his whole life about the distinctions and correspondences between himself and other people, and between himself and God. You don’t have to have OCD or any mental illness to have concerns like this, but the urgency of locating the boundaries of the self, the distinction between what is inside and outside, you and not-you, becomes particularly acute when your mind seems a little too permeable.

Obsession
was initially a term of warfare. In Latin,
obsessio
indicated the first phase of a siege on a city, when the city was surrounded on all sides but its citadel remained intact.
Obsessio
was followed by
possessio
, when the attacker breached the walls and took the city from the inside. In
Obsession: A History
, Lennard Davis explains the way these two words were adapted to explain demonic possession in the third century: “In the case of
obsession
, that person was aware of being besieged by the devil since the demon did not have complete control, had not entered the city of the soul, and the victim could therefore attempt to resist.” Demonology was, for many centuries thereafter, the only language available for explaining obsession and other insanities. Obsession was understood as a torment of the soul and, often, a spiritual punishment. The cure was exorcism.

This went on for more than a thousand years, until some Protestant churches began to retreat from the idea of possession (piqued at the way the Catholic Church had, per Davis, “the inside track on exorcisms”). In 1731, the English Parliament repealed laws banning witchcraft, which had been the most common grounds for exorcism. Modern medicine was in its nascent stages, and as it developed it annexed mental affliction, recategorizing madness as a physical rather than a spiritual problem. The demonological model was replaced by the medical model. Scientists discovered the nervous system and, with it, “nerves,” and the possibility of a physiological source of mental states.
*
Davis notes, “The nerves are the physical link to the mental—they are dissectible, discernible, and physical, yet their effects are metaphysical, symbolic, and affective.”

In the same era, roughly the late seventeenth to early eighteenth century, the notion of “partial madness” emerged to accommodate people who were mentally ill but tethered enough to reality to recognize their illness or sane enough to function within society. One could be “a conscious ‘I’ who is watching an obsessed self instead of a deranged and unconscious self dwelling in a lunatic.” Sanity went from a binary category (sane/insane) to a triad: you could be lucid, a lunatic, or a neurotic. The “monomaniacs,” as obsessives came to be known, were the stars of this new formulation. The monomaniac tended to be high functioning and highly thought of. Davis writes, “A certain cachet developed, a notion of being fashionable, in having one of these partial, intermittent conditions.” Neurosis was constructed as intrinsic to character, but as a possible asset. It was a sign of advancement, complexity, genius, cosmopolitanism, and, so to speak,
heightened sensibilities
.
*

Such was the case with Sigmund Freud’s most famous obsessive. The Rat Man, as Freud nicknamed him to protect his identity, was clever and charming, a successful professional man who was nevertheless ruled by disturbing fantasies of rodents attacking his father and fiancée. Freud, writing in 1909, took a therapeutic approach to the Rat Man that became typical for a time: the man’s problems were purely issues of the psyche. His obsessions stemmed from the fact that he’d been punished for masturbating as a child, and had formed as a defense mechanism against the anger, aggression, and anxiety he felt in his adult relationships. The cure: analysis.

A hundred years later, we don’t think of the mind as something that can be entered, invaded, or deciphered so much as something that can be altered and adjusted. The mind is less the point, actually—Freud’s methods have become passé. Now we talk about the brain, which is not parametric in that our metaphors for it do not indicate that the brain has parameters that can be violated. Insanity is now more biological than spiritual. “Mental illness” is no longer a breach of the self but a neurochemical event happening to—but separate from—the self. Like hypertension, it happens in our cells, and we swallow pills to get rid of it.
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