During my graduate school days in New York City I lived along the East River, and at times when I felt like indulging a simultaneous sense of adventure and melancholy I would visit Roosevelt Island. The island is a sliver of land in the river, two and a half miles long, connected to Manhattan by a pleasing aerial tramway. Today most of Roosevelt Island is filled with high-rise apartment buildings. But in earlier times it was the dumping ground for various incorrigible or unmanageable members of society. At the very northern tip of the island are some remnants of those times-- the rubble of a mental asylum abandoned in the first half of this century.
A decade ago it was still possible to climb around in those ruins. You could shin up the banister of a staircase whose steps had long since decayed away, push open creaking metal doors half off their hinges, and enter a room without a roof. You could then tiptoe through a third- floor hallway about to give way and send you plunging through the splinters into the basement (and, you were sure, into a nest of rats the size of pit bulls).
It was impossible to inch through the debris without being moved by the events that must have taken place in this ghost of Bedlam. There were doors marked insulin shock room, rusted gurneys with restraining straps teetering halfway through holes in the floor, and bloodstains on the walls. Even on a warm autumn day with the sun shining on the roofless building, the whole place still felt dank and shadowed, the walls humid with the screams of misery and sadness.
Contemplating the treatment of an insane person from a century ago is something of a Rorschach test for us. Do we focus on the vast progress that has been made in psychiatry? Or do we see no difference at all from our own miserably inadequate treatment of the mentally ill?
Some things remain depressingly the same across the centuries: in so many times and places, the mentally ill give the rest of us the willies, and they are carefully isolated and ostracized. Yet many other things have changed. When we discuss treatments now, we think of drugs to manipulate brain chemicals such as neurotransmitters, while in earlier times it was lobotomies and insulin-induced comas, and still earlier, restraint and ice baths. Our notions of causes have changed as well. Now we discuss receptor regulation and genes, while earlier we would have blamed mothers sending conflicting signals of love and hate to impressionable young children.
What has changed most palpably, however, is our attitude toward abnormal behavior. We have become far more subtle when we consider the thorny issues of blame for disturbed actions. Centuries ago epileptics were persecuted for their presumed bewitchment. We no longer do that, nor would any rational person prosecute an epileptic for assault and battery should that epileptic injure someone while flailing during a seizure. We have been trained to think: This is not a violent person. This is a person whose arms swing uncontrollably at times because of a disease. We have drawn a line between the essence of a person and the neuropsychiatric disorder that distorts that essence.
But precisely where this line is drawn is still shifting. And some astonishing new trends in neuropsychiatry and behavioral biology indicate that the line is going to have to shift in directions we never would have guessed. This shift affects much more than our understanding of the biological imperatives that drive a small group of us to monstrous behavior. It also affects how we view the quirks and idiosyncrasies that make each of us a healthy individual.
To me, one of the most intriguing changes has occurred in the way we see schizotypal individuals. A few decades ago a team headed by psychiatrist Seymour Kety of Massachusetts General Hospital initiated studies that demonstrated a genetic component to the disordered jumble of thoughts known as schizophrenia. The scientists examined adoption records meticulously maintained in Denmark, reviewing the cases of children adopted from their biological parents very early in life. If a child of a schizophrenic parent was adopted by healthy parents, Kety wanted to know, was the child at greater than average risk for schizophrenia? Conversely, did any child of healthy biological parents raised in a household with a schizophrenic adoptive parent have an increased risk for the illness?
Kety’s work showed that genetics does in fact increase the likelihood of the disorder. But to get that answer, doctors had to conduct intensive psychiatric interviews with the various biological and adoptive parents. This involved thousands of people and years of work. No one had ever studied the relatives of schizophrenics in such numbers before. And along the way someone noticed something: a lot of these folks were quirky. These relatives were not themselves schizophrenic--just a bit socially detached and with a train of thought that was sometimes a little hard to follow when they spoke. It was something subtle, and not the sort of thing you’d note in talking to the family members of a few schizophrenics, but it suddenly stuck out when you dealt with thousands of them. They believed in strange things and were often overly concerned with magical or fantasy thinking. Oh, nothing certifiably crazy--maybe a heavy interest in science fiction and fantasy, or a firm belief in some New Age mumbo jumbo or astrology, or maybe a very literal, fundamentalist belief in biblical miracles.
None of these are illnesses. Many adults go to Star Trek conventions, presidents’ wives consult astrologers, and others believe that Jesus literally brought people back to life. But today psychiatrists call the collection of traits seen by Kety schizotypal personality disorder, especially the emphasis on magical thinking and the loosely connected thoughts. Apparently, if you have a certain genetic makeup, you’re predisposed to schizophrenia. Have a milder version of this genetic makeup, and you may be predisposed to placing a strong faith in magical ideas that are not particularly based on fact. Is there a gene for believing in the Force and Obi-Wan Kenobi? Certainly not, but perhaps there’s something closer to it than we ever would have imagined.
Behavioral biology is also revealing the workings of our normal inhibitions. Over the course of an average day there must be a dozen times in which you have a thought--perhaps lustful or angry or petulant or self- pitying--that you would never, ever say. Damage a certain part of your brain’s frontal cortex and you now say those things. Phineas Gage, a nineteenth-century railroad worker, became a celebrated neurological patient and fairground exhibit after his left frontal cortex was destroyed in a freak accident. He was transformed from a taciturn man to a pugnacious loudmouth who told everyone just what he thought.
Some neuroscientists even use the word frontal in a sardonic sense: A terrified student gives a quavering lecture to his elders, and some insensitive big shot gets up and savages the kid over some minor point, taking the opportunity to toot his own horn while he’s at it. Christ, someone will mutter in the back of the lecture hall, he’s getting more frontal all the time.
Blow away that part of the brain and you can still remember the name of your kindergarten teacher, still do a polka, still feel what all of us feel. You just let other people know about it far more often than do most of us. Is it absurd to hypothesize that there is something a little bit wrong with the frontal cortex of the insensitive big shot in the lecture hall?
Some epileptics undergo a shift toward the opposite behavioral extreme: inhibition and embarrassment. Roughly defined, an epileptic seizure is an abnormal electrical discharge in the brain. Neurologists have known for a long time that just before the onset of a seizure there will often be a strange sensation, or aura, and the location of the seizure in the brain can influence the type of aura--for example, epileptics will typically have a sensory aura, perhaps imagining a particular smell. But auras can be far odder than that, and documented cases of them include feeling an intense sense of embarrassment, a surge of religious conviction, or in one case, always hearing the same few bars of Beethoven’s Fifth Symphony. The existence of auras demonstrates the not very surprising fact that sudden bursts of electrical activity in different parts of the brain will influence thought and sensation. Now neurologists are coming to recognize that different types of epilepsy also affect personalities-- influencing the person all the time, not merely seconds before a seizure.
People with a type of temporal lobe epilepsy, for example, tend to be extraordinarily serious, humorless, and rigid in their ways. They tend to be phobic about doing new things, and instead perseverate on old behaviors and tastes. Such people also tend to be especially interested in religion or philosophy. And, characteristically, they not only think obsessively about their problems, they write about them--endlessly. Temporal lobe epileptics are renowned among neurologists for this hypergraphia. In a typical scenario, someone first seeing a new neurologist will present the doctor with a carefully handwritten 80-page diary, insisting that reading it will give the doctor vital insight into the patient. At the next visit the epileptic will return with a new, 50- page addendum.
There’s another version of a constrained life that is being defined biologically. At some time each of us has, to our irritation, left on a trip and felt such nagging doubt as to whether or not we locked the door that we returned home to check. Or after dropping a letter into a mailbox, we have peeked in a second time just to make sure it went down. This is normal and common. But among people with obsessive-compulsive disorder, these thoughts dominate and ruin their lives. They miss vacations because they return home repeatedly to check if the oven was turned off. They lose their jobs because they are late each day, spending hours each morning washing their hands. They torture them-selves by obsessively counting numbers in their heads. For most of us, little rituals of thought or behavior can calm us and provide structure at an anxious time. For someone with obsessive-compulsive disorder--now thought to be caused by an imbalance of brain chemicals, possibly serotonin and dopamine--there are no limits, and the person becomes a creature of these rituals.
What does this tour of neuropsychiatric oddities mean? We are beginning to learn what certain parts of the brain, what specific genes, or what our early development has to do with some of the odder corners of human behavior and thought. In the process we are extending our definition of illness. For some time we have generally accepted that people who rave and gibber are ill, that they cannot control these things, are made miserable by them, and deserve care, protection, and forgiveness. Slowly we are coming to recognize that you can also be made miserable by a ceaseless march of number counting in your head, or by paralyzing fears of anything new, and that these too can be uncontrollable illnesses that demand understanding and treatment.
As we gain more labels and explain more biology, eventually we might be able to cure some of these maladies. But something else is going to happen: we will find we have moved far beyond the realm of disease and mental illness. Things will have gotten closer to home--and as we all know, even if everyone else is crazy, me and thee are just fine.
I recognize facets of myself in these pages. At times when I am overworked and anxious, I develop a facial tic and I count stairs as I climb them. I tend to wear flannel shirts all the time. In Chinese restaurants I always order broccoli with garlic sauce. Invariably I think, I’ll get broccoli and garlic sauce, then I think, Nah, order something different, then I think Why? I enjoyed broccoli last time, why get something different? and then I think Careful, I’m becoming a perseverating drudge, and then the waiter is standing there and I get flustered and order broccoli with garlic sauce.
I do not have temporal lobe epilepsy, obsessive-compulsive disorder, or any of the other problems I have discussed. Yet it is reasonable to assume that there is some sort of continuum of underlying biology here--whatever it is about the temporal lobe of some epileptics that makes them perseverate may share some similarity with my own temporal lobe, at least when it is menaced with options like Buddha’s Delight or General Po’s Szechuan Chicken. Perhaps whatever neurochemical abnormality makes a schizophrenic believe that voices are proclaiming her the empress of California is the same abnormality that, in a milder form, leads a schizotypal person to believe that Jesus literally walked on water. In an even milder form it may allow us to pass a few minutes daydreaming that we are close friends with some appealing movie character.
What if we eventually understand the genetics, the neurochemistry, and the hormonal bases of clothing preference, of who votes Democratic, of religiosity, or of why some worry too much about money and others too little? Some of these are irritating traits or, at worst, character weaknesses, but nothing more pathological. Slowly we will be leaving the realm of disorders and disabilities. We will be defining instead a biology of our strengths and weaknesses, of our potentials and constraints. We will be approaching the reductionist basis of our individuality.
Last summer the newspapers were teeming with stories about one such advance. For years scientists have searched for differences between heterosexual and homosexual men, and nothing very consistent has ever turned up. But last August the prestigious journal Science published a paper by neurobiologist Simon LeVay demonstrating just such a difference. And it’s a whopper of an interesting one. It concerns the hypothal-amus, a part of the brain central to sexual behavior. The size of one subregion at the front of the hypothalamus, known by the not terribly titillating title of the third interstitial nucleus, differs by sex; males have a larger one than do females. LeVay reported that homosexual men have smaller nuclei than do heterosexual men--as small, in fact, as those found in women.
For some homophobes this is a bellwether observation: You see, there is something wrong with their brains. For some gays it is an affirmation: You see, I’ve always told you I just felt gay. This is what I was meant to be. Predictably, the scientific jury is still out: while LeVay is a superb neuroscientist, his sample size was small, and the brain tissue he examined came from AIDS patients, so the disease might have altered it. Also, LeVay doesn’t know if the small size is the cause or the result of sexual orientation.
But suppose his finding turns out to be accurate. And suppose a small nucleus in a male turns out to be more a cause than a consequence of homosexuality. What will happen when brain imaging techniques improve to the point, as they inevitably will, where we can measure the size of this brain structure in a person sitting in a doctor’s office? Being gay is not a disease, it is a sexual taste. (If you don’t believe me, just ask the American Psychiatric Association. Being gay used to be a mental illness until the APA, in a spasm of political correctness and enlightenment, changed its mind and struck homosexuality from its bible, the Diagnostic and Statistical Manual of Mental Disorders. Overnight, millions of people had one less disease, which is a pretty impressive outcome of a committee meeting.) Do we inform adolescents of their nucleus size when they have not yet become sexually active and haven’t expressed a sexual preference? What do we do with an openly and happily gay or straight adult whose nucleus is the wrong kind? What will we make of nuclei of intermediate sizes? And will the Food and Drug Administration move to squelch the predictable festering of quacks flogging their methods of changing nucleus size?
This new world of understanding will be rife with old dangers. With scientific understanding comes the potential for manipulation, and the temptation to judge and correct is never far behind. Those who would use behavioral biology in the future to rid us of whatever facets of individuality are deemed unacceptable will probably be as common as were the brownshirts of the past, whose biological template was an Aryan profile.
But this new knowledge would be rife with promise as well. Recognizing the continuity between the workings of our benign little personality quirks and the versions that might qualify as disease would benefit those with the latter. When science teaches us repeatedly that there but for the grace of God go I, when we learn to recognize kinship in neurochemistry, we will have to become compassionate and tolerant, whether looking at an illness, a quirk, or a mere difference. And when this recognition becomes commonplace, we will have learned that drawing a boundary between the essence of a person and the biological distortion of that essence is artificial. It is simply a convenient way to classify the biological limitations common to most of us and other, rarer limitations. Being healthy, it has been said, really consists of having the same disease as everyone else.