503 literary analysis - wordpress.com · 2015-09-10 · as humans, we fear the unknown and saks not...
TRANSCRIPT
Running head: SCHIZOPHRENIA 1
The Center Cannot Hold: A Literary Analysis on Schizophrenia
Jacqueline Lagman
Rush University
SCHIZOPHRENIA 2
The Center Cannot Hold: A Literary Analysis on Schizophrenia
“But if, as our society seemed to suggest, good health was partly mind over matter, what
hope did someone with a broken mind have?” (Saks, 2007, p. 255) In her memoir, The Center
Cannot Hold, Elyn R. Saks helps restore hope to this forlorn mentality toward the mentally ill.
As humans, we fear the unknown and Saks not only dissipates that fear by shedding light into the
most severe psychotic illness, she establishes order in a tempestuous existence to discredit any
stigma held against a broken mind.
Mental Illness
Elyn R. Saks lives with schizophrenia, a thought disorder characterized by a loss of touch
with reality. According to Boyd, to be diagnosed schizophrenic by the Diagnostic and Statistical
Manual of Mental Disorders, the first criteria is to exhibit delusions, hallucinations, disorganized
speech, grossly disorganized behavior or negative symptoms for a significant portion of time
during a one month period; at least two of these symptoms must be present and one must be of
the first three (2013). This was witnessed during Saks’ hospitalization at Yale-New Haven
Hospital and Yale Psychiatric Institute, where she describes herself “floridly psychotic” during
the first six weeks. During this time she exhibited reference delusions and disorganized thinking,
characterized by flight of ideas, word salad and loose associations, “Voices went, tabernacle, out
to the edge of time. Time. Time is too low. Lower the boom. The TV is making fun of me. The
characters are laughing at me” (Saks, 2007, p. 92). She entertained grandiose and persecutory
delusions by continually warning of the devastations and horrible things she could do to
everyone with the power of her mind, and experienced illusions as she witnessed the walls
collapsing and ashtrays dancing. There were times that she hallucinated, seeing a man in the
kitchen with a knife that did not really exist (Saks, 2007). Even more notable were her consistent
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negative symptoms, easily confused with depression. She exhibited anhedonia, as few things
brought her pleasure, avolition, where she lacked motivation in certain areas such as self-care,
affect flattening and limited emotional range which took a toll on her relationships. For a
significant portion of her life she displayed apathy and social withdrawal, for instance, she
usually ate her meals alone in the dining hall (Saks, 2007). The isolation, limited ability to
communicate, stereotypy, and alogia could be seen in her everyday life as well as her
hospitalizations, “Disengaged from my surroundings, I sat in the dayroom for hours at a time,
jiggling my legs (I couldn’t sit still, no matter how I tried), not noticing who came in or out, not
speaking at all” (Saks, 2007, p. 65).
The second diagnostic criteria holds that in one or more social or occupational areas,
there is a decreased level of functioning markedly below the level achieved prior to onset (Boyd,
2007). While Saks was completing her undergraduate degree at Vanderbilt, the first symptoms
began to appear and her level of functioning in self-care began to decline. She was approached
by Susie, her roommate, with a hypothetical story of a girl that needed to shower more often,
brush her teeth and change her clothes; Susie’s story was in reference to her, but at the time, she
did not realize it. At Vanderbilt, and even more so during her graduate studies at Oxford, she had
trouble with interpersonal relationships. She could not hold conversations with new friends and
felt she did not deserve to speak with her family over the phone. She isolated herself, “With no
reference point outside my head (friends, familiarity, being able to accomplish anything at
school), I began to live entirely inside it” (Saks, 2007, p. 55). Saks’ illness had a huge impact on
her level of functioning at school. Due to her hospitalization, she was forced to withdraw from
her first year at Yale Law School. At this time she was given an IQ test and received a verbal
score of “dull normal” and a quantitative score of “borderline mentally retarded” (Saks, 2007).
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Other criteria includes continuous signs of the disturbance for at least 6 months (Boyd,
2013), Saks experienced symptoms for more than 6 months during acute episodes and has
continuously struggled with disturbances for the majority of her life. According to Boyd,
schizoaffective and depressive or bipolar disorder with psychotic features, and physiological
effects of a substance or medical condition must be ruled out (2013). She does not exhibit a
substantive mood disorder or experience a manic state, nor use a substance or have a medical
condition. Through her detailed memoirs, we recognize that she deals primarily with a thought
disorder, the symptoms she describes are congruent with schizophrenia.
Risk Factors and Etiologic Theories
There is no single known cause of schizophrenia, but there are biological theories.
According to Boyd, people with schizophrenia have a small total brain volume where the
thalamus, hippocampus, superior temporal and prefrontal cortices are smaller than usual, and the
lateral and third ventricles are larger. Positron emission tomography scans show decreased blood
flow and glucose metabolism in the prefrontal cortex, as well as dopamine hyperactivity at the
mesolimbic tract. Memory and emotion are regulated in this region, therefore the increased
dopamine is thought to cause hallucinations and delusions. The dysregulation of norepinephrine,
serotonin, glutamate, gamma-aminobutyric acid (GABA) are thought to be involved with the
symptoms of schizophrenia as well (2013). Risk factors pertaining to Saks are a genetic
predisposition and stressful life events (Boyd, 2013). Though no one else in her family deals
with schizophrenia, she does note that serious mental illness is common in her extended family
(Saks, 2007). Stressful life events can contribute to the development of the disorder and she
explains how moving and starting anew ranks high on the list of life stressors, similar to divorce,
serious illness, and death in the family (Saks, 2007). Saks experienced this for the first time
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when moving away to college where her first symptoms peaked through, and subsequently
whenever she packed up and moved to a new place, each of which caused her to relapse and
experience a psychotic episode.
Impact of Mental Illness
Mental illness can have a profound impact not only on the one suffering, but on friends
and family as well. Saks’ illness had no significant impact on her immediate family because she
stayed distant and kept her illness hidden. They did visit her during a few of her hospitalizations
and advocated for her transfer when she was mistreated at Yale-New Haven Hospital. Saks was
cautious with her friendships and disclosure of her mental illness, which lead to strong, solid
bonds among the relationships she formed. Her illness impacted Steve Behnke, her closest
friend, the most. They met in law school and found a common interest in serving the mentally ill.
Steve helped her through acute psychotic episodes, helped her make sense of things, brought her
to the hospital, and took care of her activities of daily living whenever in recovery. He constantly
provided support, be it with school, work or making decisions to go off medication. Even after
they were in separate cities, he continued to look out for her and talk to her every day. Jean and
Richard, friends living in London, would often get calls from confused acquaintances back in the
U.S whenever Saks would experience an acute episode. They would then make
recommendations to contact her therapist or bring her to a hospital. At present, her illness is well
managed, as it was by the time she met her husband, Will. The impact on him includes not being
able to have children together and, being that her threshold for unfamiliar environments is four
day, not being able to vacation longer than that. Whenever her psychosis breaks through, he is
there with support and love.
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Strengths
There is no recovery with schizophrenia, but with many internal and external factors,
Saks has been able to manage her illness quite successfully. Externally, Saks is fortunate to have
access to resources that many people do not. Her parents sent her to a prestige college where she
received an exceptional education. She had the resources to receive treatment and medication,
and access to talk therapy with trained and talented professionals. She has superb friends and
family that continue to help and support her day to day. She also spent two years at The Center,
where much credit of her willpower can be given as it “drilled into [her] an unflinching attitude
toward illness or weakness” (Saks, 2007, p. 32). Internally, among the willpower, she had a great
deal of stubbornness that worked in her favor. She would not let herself fail at anything, be that
graduating from college and law school with honors, acquiring tenure or being defeated by her
illness. Eventually she gained insight into her illness, she came to accept her diagnosis and
recognized that she needed medication. This insight brought forth the current maintenance phase
with few serious psychotic episodes allowing her to focus on matters she finds most important.
With her extraordinary intellect, she has built a successful career that not only provides the
structure she needs to stay sane, but gives purpose as she impacts the lives of others.
Response to Literature
Indeed my curiosity was sparked by many issues presented in this book. First the issue of
restraints, Saks’ encounter with restraints was inhumane and the thoughts and feelings she
experienced were horrid. It makes me wonder how many other people have and will go through
something similar. I found it interesting that British hospitals rarely use restraints and have not
for over a hundred years (Saks, 2007). Are the psychiatric patients different in Great Britain, or
is it the staff? Laws are put in place to protect patients, but humans carry out the tasks and, in
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that present moment, hold the power. She also brought up the issue of the right to refuse
medication. Both of these issues sparked my interest in questions concerning philosophy and
morality. Health care providers can decide whether a person is competent to make decisions for
him or herself, these decisions range from refusing medication to signing advance directives.
Seeing Saks’ side of these events made me question, at what point should someone be allowed to
make these decisions for another? It seems as if we hold a paternalistic stance when dealing with
difficult, mentally ill patients, a “we know what is best for you” approach and often use restraints
and medication because it is easy and efficient. Does every mentally ill patient that goes through
the health care system deserve the time and energy of the therapeutic care provided in the
hospitals of Great Britain, as portrayed in this book? Absolutely, but with few resources and little
funding, how do we find a balance? I am curious to discover how Great Britain’s system differs,
and that of other countries as well.
The Center Cannot Hold peaked my interest because schizophrenia is the most severe of
the psychotic disorders. Thought disorders are much less relatable than mood disorders, as many
of us have experienced depression symptoms and can relate in some way. Losing touch with
reality is a far-fetched concept that is difficult to grasp creating challenges for both patient and
health care provider. Through Saks’ memoirs of living with schizophrenia, I have gained insight
into how difficult it is living day-to-day life and how frightening it would be to have psychotic
thoughts, unable to distinguish what is real and what is not. I now see how vital a therapeutic
relationship is when working with psychotic patients. I have come to recognize how small a role
the actual diagnosis should have; mental illnesses can overlap, care should be patient-centered
and individualized. This book, coupled with being in the presence of psychotic patients on the
inpatient unit, has yielded me less frightened and more compassionate. Our society needs to be
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educated to assuage the fears and stigma, and consider Elyn Saks’ (2007) words, “The humanity
we all share is more important than the mental illness we may not” (p. 336).
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References
Boyd, M. A. (2013). Psychiatric nursing: Contemporary practice (5th ed.). Philadelphia:
Lippincott, William, Wilkens.
Saks, E. R. (2007). The Center Cannot Hold. Hyperion. Kindle Edition.