The Man Who Wasn't There: Investigations into the Strange New Science of the Self (17 page)

To dig deeper into this problem, Ford and her colleagues looked at a network of brain regions in 186 patients with schizophrenia who heard voices, each of whom was scanned while resting inside an fMRI scanner for six minutes. This data was compared with data from 176 healthy volunteers. In the case of healthy volunteers, mind wandering while at rest showed activity in a network of the following brain regions:
the medial prefrontal cortex (MPFC)
, which is the most active region when your brain is at rest and is part of the default mode network, and is also strongly correlated to self-referential mental activity (it lights up, so to speak, when you detach from focusing on an external task and are thinking about yourself);
Broca’s area
, in the frontal part of the left hemisphere, which is implicated in speech production;
the putamen
, which as we just saw is involved in the conscious perception of speech;
the amygdala
, which is deep inside the temporal lobe and is involved in the fear and threat response;
the parahippocampal gyrus
, which is known to be more active when someone becomes suspicious; and
the auditory cortex
, which, as the name suggests, is involved in hearing.

But in patients who hear voices, the scans showed that all these brain regions are hyperconnected: the MPFC is hyperconnected to Broca’s area, the putamen, and the auditory cortex; and the putamen is hyperconnected to the auditory cortex. All of this, Ford and colleagues speculate, could be turning the idle thoughts of healthy mind wandering into the pathological, audible voices of schizophrenia. And what about the negative tone of these voices? It could be that the hyperconnected amygdala and parahippocampal gyrus—both of which are normally involved in the fear response—increase the levels of fear, uncertainty, and suspicion associated with these voices.

There’s one final piece to this puzzle. Why do these voices feel as if they belong to someone else? As we saw earlier, Ford’s work with EEG signals has shown that the efference copy/corollary discharge mechanism is disrupted in people with schizophrenia. And in these fMRI studies, the researchers found that in patients who hear voices,
Broca’s area and the auditory cortex are less well connected—possibly corroding the pathway for the efference copy to reach the auditory cortex. So the voices, which for healthy people would at least seem to be their own, sound foreign in schizophrenia.

“The raw material of auditory verbal hallucinations, I maintain, is not [willed] inner speech, but unbidden thoughts,” said Ford. And later, in an email, she expressed it more personally, referring to her deceased mother. “In fact, when my mind is wandering and unbidden thoughts are becoming conscious, I can hear the tonality, prosody, and affect of my mother’s voice telling me ‘you are trying to do too much, dear’. I do not think she is speaking to me from her grave,” she wrote. “But, if I were psychotic, I might.”

In a psychotic person, then, a hyperconnected network might be turning unbidden thoughts into audible voices, voices that have a dark
tone about them. A disturbed sense of agency makes these voices seem to belong to others.

At the heart of this malfunctioning system is what’s increasingly being referred to as the “predictive brain.” Generating the sense of agency is one example of how the brain’s predictive mechanisms work to create our sense of self. This idea is gaining ground. Could the entire brain be a prediction machine, generating not just the sense of agency but even emotional feeling states that give us our sense of being embodied? As we’ll see in the coming chapters, neuroscientists are applying such ideas to explain depersonalization disorder and even something as complex as autism.

It is one thing to experimentally study the disturbed feeling of agency, and another thing to explain the full panoply of symptoms that this supposedly begets in schizophrenia. This baffling and often terrifying diversity is captured by psychologist and therapist Lauren Slater in her book
Welcome to My Country
. This is how she describes her first meeting with a group of six chronic schizophrenia patients:

There is Tran, nicknamed Moxi, a small, cocoa-colored Vietnamese who came to this country after the war, and who bows to invisible Buddhas all day in the corridors. There is Joseph, with a mangy beard, a green-and-khaki combat helmet he puts on the pillow next to him when he sleeps. Charles is forty-two years old and dying of AIDS. Lenny once stood naked in Harvard Yard and recited poetry. Robert believes fruits none of us can see are exploding all around him. And then there is Oscar, 366 pounds,
and claiming constant blow jobs from such diverse females as the Queen of England and Chrissy, the Shih Tzu dog next door.

When confronted with such patients, many find it hard to accept that a mere disturbance of the sense of agency could be responsible for all the devastating symptoms of schizophrenia, as Chris Frith hypothesized when he first put forth his comparator model. Soon after Frith’s proposal, it became clear that the feeling of having others’ thoughts in your own head was hard to explain using his model. Today, even he admits that his model fails to account for thought insertion. Synofzik, Vosgerau, and colleagues think that their model, which splits the sense of agency into a feeling and a judgment, does a better job of explaining thought insertion; in their view, an impaired judgment of agency leads to the feeling of having alien thoughts in one’s head.

Others are not convinced either way. Louis Sass, for instance, while he agrees that the neurobiology of a disturbed sense of agency is consistent with the idea that schizophrenia is a basic disturbance of the self, questions whether the impaired brain mechanisms are the
cause
of schizophrenia. He calls that a “materialist” assumption. What if you could alter the way healthy people relate to their own experience—maybe through intense introspection or meditation—and show that their brains also undergo the same kinds of neurobiological changes as those seen in people with schizophrenia? That would show that such changes are correlated, not causative.

Ralph Hoffman has similar things to say about schizophrenia. Yes, scientists (including him) have found neural-system dysfunction and gross anatomical changes in the brains of many schizophrenic patients. But are these changes the
cause
of schizophrenia, or are the observed
changes the result of “oftentimes profound withdrawal from social interactions, work and school” that can pre-date the onset of schizophrenia? “So, if you take somebody during their late adolescence and early adulthood and have them go into that stage of withdrawal and have them continue that way for years . . . what’s going to happen to brain systems in the absence of cognitive enrichment and task engagement?” says Hoffman. “I hypothesize that at least some of what we end up crediting to ‘neurodegenerative processes’ may be the downstream consequences of the state of withdrawal that these people go into.”

Hoffman is struck by the fact that psychotic symptoms are a form of interaction of the self with others. He hypothesizes that in individuals deprived of meaningful social interaction, psychotic experiences flood in to fill the void. “What happens is that in the absence of being linked into a set of real-world meanings and role specifications and places to really engage, the person becomes increasingly preoccupied with the psychotic experience that then causes further withdrawal,” says Hoffman. “The internally generated experience becomes more and more prominent and it can happen relatively quickly. It kind of challenges the old breakdowns of mind, body, and brain.”

It also challenges any notion of there being only a one-way interaction between the extended narrative self and the more basic self-as-subject (Sass and Parnas’s
ipseity
, or Zahavi’s
minimal self
): it’s not necessary that only the perturbations of the self-as-subject lead to disturbances of the narrative self; the effects could flow the other way too. Also, schizophrenia is telling us that the sense of agency—which goes unquestioned when it’s working well—is an aspect of the self, a constituent of the self-as-object. Even in the direst cases of schizophrenia, there is a self-as-subject that is experiencing psychosis. Who or what is that “I”?

For someone with schizophrenia, all of this philosophizing is cold comfort. And for insightful, high-functioning adults like Laurie and Sophie, an awareness of their condition can be a burden. For instance, if you are able to sometimes see through your psychosis, but not at other times, how do you tell when you are being psychotic? “One doesn’t lose all the biographical, semantic, perceptual, and body memory of the past, of what the world should feel like,” said Sophie. “It’s that disconnect between what things are like now and what your entire life before [psychosis] was like.”

There’s even an official term for this quandary: “double bookkeeping”—a concept from early-twentieth-century psychiatry that has been elaborated in recent years by Sass, often in dialogue with Sophie and other persons who have experienced schizophrenic psychosis. Patients are forced to deal with two, even multiple, versions of reality. “You are almost constantly forced to make decisions that other people aren’t going to make. What are you going to prioritize, which possible version of reality are you going to privilege?” said Sophie. “What are you going to act on?” Confronted with such dilemmas, patients often lapse into total inaction. This phenomenon hints at the power of the narrative self: without a coherent story about oneself, one seems unable to act; it seems that we need our narrative to function.

Laurie, too, is well aware that the voices in her head, her paranoia, the messages she thinks she’s receiving from outside, are all, in some sense, a product of her altered self. “But that insight is a paradox. Without the insight you fear the external; with the insight you fear yourself,” she told me. “Without insight, you think everybody else is after you, or someone else is [responsible for your actions], but with insight, you realize it’s all in your head. That’s also scary, so you can’t
win.”

I AM AS IF A DREAM

THE ROLE OF EMOTIONS IN THE MAKING OF THE SELF

How far do our feelings take their colour from the dive underground? I mean, what is the reality of any feeling?

—Virginia Woolf

Forever I shall be a stranger to myself.

—Albert Camus

W
hen I told Nicholas I’d come visit him, I had badly underestimated Canada’s vastness. It took me six hours to fly from San Francisco to Boston, then came a ten-hour-long road trip from Boston to Saint John, New Brunswick (thanks to two wrong turns in remote parts of Maine), a three-hour smooth ferry ride across the Bay of Fundy to Nova Scotia, and then another hour and a bit to drive to Kingston, where twenty-three-year-old Nicholas lived with his fiancée and their daughter, a toddler at the time.

Once the ferry reached Nova Scotia, I drove to the village of
Kingston on a highway that ran the length of the valley carved by the Annapolis River. It was late June, early summer. The countryside was lush green. The land had shed its springtime sparkle and was bursting with rude health. Purple lupines lined the road. I reached Kingston within a few minutes of exiting the highway and found my destination—a split-level white apartment building behind a 24/7 convenience store. Nicholas was expecting me and came out to greet me.

I, however, wasn’t expecting to see someone with as many tattoos as Nicholas. Those covering his neck made it seem like he was wearing a T-shirt under his light blue dress shirt. And despite his rolled-up sleeves, the skin was barely visible on his right hand and forearm. There was an intricate Koi fish on the forearm, a symbol of overcoming adversity. Farther down, on the hand, was a compass for “finding direction in life,” and a diamond, because “they stand up well to pressure.” “Pretty clichéd,” he admitted. On his left wrist were the initials of the members of his foster family, who had taken him in as their own after he finished rehab at the age of sixteen, and where he felt he belonged for the first time in his life. “It was almost like a normal childhood,” crammed into three or four years.

When he closed his fists and held them together, below the knuckle on each finger was a letter; the words they formed read
SINK
and
SWIM
. Another cliché, he said. “It’s very basic, and it’s what it comes down to for me, especially with this disorder. I’m either going to continue fighting to get better, and hopefully be in remission again at some point. Or . . . I don’t know . . . sink . . . not fight anymore.” He struggled to elaborate on what “sink” would mean. “Maybe it’s suicide. Maybe it is simply not trying anymore.”

Nicholas’s earliest memories are from when his sister was born. He was four years old at the time. The parents and the two siblings were all living together. But it was hardly a happy family. Both his parents were addicts. His father, who mainly did roofing and other construction work, was an alcoholic. His mother, who stayed home, was a heavy drinker and addicted to opiates like Oxycontin and Dilaudid. Nicholas had already spent a year in foster care by the time he was three years old, only to be returned to his parents by a judge. A year later, his sister was born. But nothing changed. Their parents continued doing drugs, drinking alcohol, fighting, and even disappearing for days on end, leaving the kids with other family members.

Then, their mother left their father. “And my father passed out for a couple of days, in a semiconscious state, from what I remember,” Nicholas told me. The foster-care agency came to take the kids away. They found little Nicholas trying to take care of his sister (“She was so, so little”). He recalled that he had tried to make her cereal. When the foster agency workers arrived, he was standing on a chair at the kitchen sink, trying to wash dishes. The children spent the next few years in foster homes.

Around the time Nicholas was nine, the kids returned to their mother, who had since remarried. The situation with their stepfather wasn’t any better. The couple had moved on to harder drugs, like crack cocaine. They screamed and fought all the time, drugs fueling their paranoid delusions, as each accused the other of hiding pills or smoking the last of the crack cocaine. Dramatic scenes were routine, but some are etched in Nicholas’s memory more than others. Once, a few hours past midnight, Nicholas and his sister woke up to shouting from their parents’ bedroom. The siblings walked over. Nicholas told his sister to wait at the door while he went in. He watched his stepfather
push his mother against an old television set, which fell down. Another time, his stepfather chased his mother with a machete. She ran into the bedroom and locked herself in. “I don’t know if he had any intent to hurt her or just scare her,” said Nicholas. His stepfather ended up burying the machete into the door of the linen closet.

Their house was in a tranquil, upscale neighborhood in Bridgewater, Nova Scotia, where people kept the lawns of their “quarter-million-dollar” homes neatly mowed. The house Nicholas lived in was the odd one out. It was smaller than the rest. The family had been put there by a social program that provided housing to those with low income. Most of the time, the shenanigans inside the house were hidden to the outside world: Nicholas’s parents were careful to cover the windows with blankets.

In addition to the neglect from his early years, Nicholas was now dealing with an abusive mother and stepfather. Much of it was verbal and emotional abuse. “‘You are a fucking idiot, can’t you do anything right? What’s wrong with you?’ Stuff like that . . . very strong words,” Nicholas said. Very occasionally his stepfather would beat him. “Luckily that was rare. I am really glad for that, although sometimes you wonder which lasts longer, the physical or the emotional.” Was he sexually abused? I asked. “No,” he said. “I’m thankful for that as well.”

By the time he was about ten or eleven, Nicholas had started having brief, transient episodes of dissociation—maybe lasting about ten seconds—episodes that happened at random, sometimes when he was on the school bus, sometimes while singing the national anthem at school. “I’d describe it as feeling absolutely disconnected from the physical body altogether,” said Nicholas. “It almost renders you unable to communicate, to do anything for those ten seconds.”

It came to a head when Nicholas was about twelve years old. He
and his sister were in their bedroom when they heard a scream from the kitchen. It was their aunt. She and their mother might have been smoking crack; Nicholas doesn’t remember. What he does remember is the sight of his mother convulsing on the kitchen floor. She was having a seizure. She had hit her head on a cupboard handle as she fell and was bleeding. She was foaming at the mouth. Nicholas’s stepfather came running and turned her onto her side, so she wouldn’t choke on her vomit. For Nicholas, it was a pivotal moment. “I remember taking about three or four steps [toward] her, and everything completely changed,” Nicholas said. “It was like I went from a normal waking state to a dream state immediately. Everything became very foggy. Everything looked unfamiliar, out of place.”

For the next four years, Nicholas lived in this foglike state: where everything—the things around him and his own body and self—felt unreal. An extended, disturbing dream.

In a book published in 1845, the German psychiatrist Wilhelm Griesinger wrote about a letter from a patient to the eminent French psychiatrist Jean-Étienne Dominique Esquirol.

Even though I am surrounded by all that can render life happy and agreeable, in me the faculty of enjoyment and sensation is wanting or have become physical impossibilities. In everything, even in the most tender caresses of my children, I find only bitterness, I cover them with kisses, but there is something between their lips and mine; and this horrid something is between me and the enjoyments of life. My existence is incomplete. . . . Each of my senses, each part of my proper self is
as if it were separated from me and can no longer afford me any sensation. . . . I no longer experience the internal feeling of the air when I breath[e]. . . . My eyes see and my spirit perceives, but the sensation of what I see is completely absent.

Esquirol himself had written about other such patients and their experiences: “
An abyss, they say, separates them from the external world, I hear, I see, I touch . . . but I am not as I formerly was. Objects do not come to me, they do not identify themselves with my being; a thick cloud, a veil changes the hue and aspect of objects.”

What these patients were describing would today be called
depersonalization
. The word itself entered the psychiatric lexicon in the 1890s, when French psychologist Ludovic Dugas used it to describe “
a state in which the feelings or sensations which normally accompany mental activity seem absent from the self.” Dugas chanced upon the word in the diaries of Swiss philosopher Henri-Frédéric Amiel. In his book
Journal Intime
, which was published after his death, Amiel wrote: “
I find myself regarding existence as though from beyond the tomb, from another world; all is strange to me; I am, as it were, outside my own body and individuality; I am
depersonalized
, detached, cut adrift. Is this madness?”

The twentieth-century German psychiatrist Karl Jaspers gave a particularly clear description of what might be happening when a person is feeling depersonalized. Everything that manifests itself in our mind, “
whether perception, bodily sensation, memory, idea, thought or feeling carries
this particular aspect of ‘being mine’
of having an ‘I’ quality, of ‘personally belonging,’ of it being one’s own doing. This has been termed
personalization.
 . . . If these psychic manifestations are accompanied by the awareness that they are not mine, but are alien,
automatic, independent, arriving from elsewhere, they are called
depersonalization
.”

There are some who argue that transient depersonalization is an evolutionary adaptation to extreme danger. In the mid-1970s, Russell Noyes Jr. and Roy Kletti of the University of Iowa College of Medicine interviewed sixty-one people who had responded to an ad in the student newspaper asking for “accounts of subjective experiences during moments of life-threatening danger.” A typical response was that of a twenty-four-year-old man who recounted the moments during which his Volkswagen skidded while cornering a “rain-slicked curve” into the opposite lane with oncoming traffic. “
As the car was spinning I had a relaxed kind of feeling like being stoned on ‘pot’ or something,” the man reported. “I gave no consideration to the danger, it just didn’t exist. I had a sensation of floating. It was almost like stepping out of reality. I seemed to step out of this world, where you feel the sensation of your body in the seat and the air you breathe, into some other state.”

Based on their interviews, Noyes and Kletti concluded: “
The interpretation of depersonalization as a defense against the threat of extreme danger or its associated anxiety seems inescapable. . . . Thus, in the face of life-threatening danger, persons become observers of that which is taking place and effectively remove themselves from danger. Detachment appears to be a major adaptive mechanism which, in the depersonalized state, is seen in bold relief.”

If depersonalization is indeed an evolutionary adaptation, it makes sense that we would all have the intrinsic ability to enter such a state in which we become strangers to ourselves. Given that such neurobiological mechanisms exist, it also makes sense that some of us would slip into it more easily than others. Call this predisposition (nature). Then environment (nurture) would play its part in tipping some over.
For instance, an abusive childhood and the resulting trauma could lead to depersonalization, as likely happened with Nicholas. Drugs can do it too.