The Center Cannot Hold: My Journey Through Madness

Capgras syndrome refers to a delusional misidentification condition characterized by a false belief that someone close to the patient has been replaced with an identical duplicate. This specific delusion can occur in individuals with psychiatric and non-psychiatric illnesses, in cases of brain damage with respect to the latter. Owing to its rarity, it has not been addressed in the Diagnostic and Statistical Manual of Mental Disorders (DSM). Elyn describes experiencing the Capgras delusion the very last time she reduces her medication, when she believes Kaplan and Steve have been replaced by imposters.

Cognitive Behavioral Therapy (CBT) is a kind of psychological intervention that works at reducing symptoms of a variety of mental illnesses by helping identify and change underlying thought patterns that are resulting in maladaptive behaviors. CBT is primarily found to be effective with anxiety disorders and depression. Elyn approaches a cognitive behavioral psychologist in one of her attempts to reduce her Navane dosage without Kaplan’s approval or supervision.

In the context of mental illness, a delusion refers to a fixed, false belief that persists in the face of contrary evidence. Delusions present as symptoms in a variety of mental illnesses, including but not restricted to schizophrenia, bipolar disorder, and substance abuse. Delusions can also present in non-psychiatric cases such as cases of brain damage. Elyn experiences a variety of delusions as a part of her illness, including the Capgras delusion, and that of the houses in her hometown sending her messages.

In the context of mental illness, disorganization refers to a specific psychotic symptom, especially in the case of schizophrenia, involving incoherent and illogical thoughts and behaviors. In the past, schizophrenia used to be characterized into subtypes, one of which was disorganized schizophrenia. Although the DSM has done away with subtypes for schizophrenia, disorganization is still considered to be one of the major symptoms of the illness. In Elyn’s case, disorganization is often one of the first symptoms to appear each time she has a psychotic episode.

Dissociative disorders refer to a category of mental illnesses as described in the DSM characterized by a detachment from reality by way of disconnection between thoughts, memories, surroundings, actions, and even identities. These disorders feature issues with memory, identity, emotion, perception, behavior, and sense of self. What was previously known as “multiple personality disorder”, something that Elyn refers to in the book and even writes a book on, is currently known as Dissociative Identity Disorder (DID) and falls under this category. Elyn mentions watching videos of patients being administered the Structured Clinical Interview for Dissociative Disorders, which is a semi structured interview used by clinicians to diagnose and draw treatment plans for dissociative disorders.

A hallucination refers to the perception of a sensory experience in the absence of an external stimulus. Hallucinations can occur as a result of a neurological disturbance (such as in the case of schizophrenia or Parkinson’s disease), or in response to psychoactive substances (such as the drug LSD). Hallucinations make frequent appearances as part of Elyn’s illness; however, she also experiences them in a non-psychiatric instance, when she takes the psychoactive drug Mescaline as an adolescent.

Hypochondria refers to an obsession with the idea of having a serious, undiagnosed medical condition. Hypochondria is one of the ways in which anxiety can manifest, and Illness Anxiety Disorder, which falls under the category of anxiety disorders, is characterized by hypochondria (the condition was previously termed hypochondriasis). Elyn begins to develop hypochondriacal tendencies during her time working with Mrs. Jones; these tendencies are seen to resurface later in her life as well, such as when she obsessively worries that she has Marfan syndrome.

Kleinian analysis is "an offshoot of Freudian analysis developed by Melanie Klein, an Austrian psychoanalyst” (90). The traditional school of psychoanalysis, as developed by Freud, does not believe that people with psychosis could benefit from analysis, as they are believed to be too “inward-looking”, which hinders the development of transference. However, Melanie Klein believed differently—not only did she think that individuals with psychosis could benefit from psychoanalysis, but also that the necessary transference would develop. In addition, she theorized that individuals with psychosis are driven by great anxiety and addressing the deep sources of this anxiety would provide relief. The way to do so was through the psychoanalytic method, or “Kleinian analysis,” as her particular offshoot is termed. Kleinian analysts remain anonymous to their patients, acting as a blank slate that repeats and reflects the patient’s thoughts while helping them explore further. This allows transference to develop with minimal interference, allowing the patient insight into the inner workings of their mind. Mrs. Jones is a Kleinian analyst, and her confidence in the efficacy of the method for someone like Elyn is proven right in this case.

Mental retardation is the outdated term for intellectual disability (ID) and refers to the condition of below-average intelligence or mental ability and a lack of skills necessary for daily living. ID is a neurodevelopment disorder, though depending on the severity of ID, individuals with the condition may be able to learn certain skills; however, the pace of learning will be slower, and the assimilation of these skills will usually be incomplete as compared to a neurotypical population. Genetic disorders can cause ID, though there are still a large number of cases in which the cause is undetermined. Jefferson, the patient Elyn and Steve advocate for, is described as having “mental retardation” or ID.

Mood disorders, also known as affective disorders, are a category of mental illnesses of which the primary feature is a disturbance in the person’s emotional state or mood. Various types of depression fall under this category, as does bipolar disorder. A number of times in the early part of her journey with mental illness, Elyn is believed to have depression. She presents her condition as such to her parents initially and is even administered medication for the same. When Elyn is later faced with a diagnosis of schizophrenia, she is disturbed by the fact that she has a thought disorder, and not a mood disorder, as she mistakenly believes the latter to be more conquerable by force of will.

A psychiatrist is a doctor who specializes in psychiatry, which is the branch of medicine concerned with the diagnosis and treatment of mental illness. A psychiatrist holds a Doctor of Medicine (M.D.) degree and has the authority to prescribe medication. Some of the clinical practitioners Elyn sees for her illness are psychiatrists, though not all; Mrs. Jones is a notable exception.

A psychoanalyst is a mental health professional trained in a specific school of therapy, namely psychoanalysis, which is rooted in Freudian psychological theory. Psychoanalysts are not medical doctors, i.e., they do not independently hold the authority to prescribe mediation, even if they use the title “Dr.” acquired by the completion of a doctoral degree. However, psychiatrists may further train in psychoanalysis, as is the case with Dr. White whom Elyn consults with in New Haven. Mrs. Jones, on the other hand, is purely a psychoanalyst, hence does not use the title “Dr.”

A psychologist is a professional who has studied and practices in the field of psychology, and whose areas of interest include (but are not limited to) mental states, cognitive and perpetual processes, emotions, social interactions, and general human behavior. The term “psychologist” is broad. It could refer to professionals involved purely in research (social and personality psychologists) or professionals working in corporate or industrial settings (industrial organizational psychologists), to those working with mental illness in clinical settings (clinical psychologists). When Elyn refers to consulting with psychologists in the book, she is likely referring to clinical psychologists who are trained in and practice diagnosis and treatment of mental illness.

A psychopharmacologist is a practitioner of the field of psychopharmacology, which is concerned with the effects of drugs on emotions, sensations, cognition, and behavior. A psychopharmacologist looks to develop and use drugs for behavior modification and symptom alleviation, specifically in the treatment of mental illness. All psychopharmacologists are also psychiatrists, however, not all psychiatrists are psychopharmacologists, as the latter involves a further specialization in medication. Thus, a psychopharmacologist may work closely with the pharmaceutical industry in order to research and develop new drugs but may also choose to work with individual patients to help with medical treatment of mental illness. Dr. Gitlin, whom Elyn begins to consult with alongside Dr. Freed, is a psychopharmacologist.

Psychosis is a condition in which an individual faces a disconnect from reality. It is an abnormal condition of the mind which leaves one unable to distinguish between external or objective reality and one’s own perceptions. Psychosis can be caused by a number of underlying conditions ranging across mental illnesses like schizophrenia and bipolar disorder, as well as sleep deprivation, or the use of certain classes of drugs. In cases where psychosis is caused by mental illness, antipsychotic medication is usually administered, in combination with psychotherapeutic interventions, for treatment. As more clarity around Elyn’s condition and diagnosis emerges, she is prescribed antipsychotic medication by the various clinicians she sees.

Schizoaffective disorder is a mental illness characterized by the concurrent appearance of symptoms of schizophrenia alongside a major mood episode, either mania or depression. Earlier versions of the DSM listed schizoaffective disorder as a sub-type of schizophrenia; however, this was done away with, and schizoaffective disorder came to be listed as an independent diagnosis. 

Schizophrenia is a serious mental illness that is characterized by psychosis, hampering the individual’s ability to think, feel, behave, and relate clearly and appropriately. Schizophrenia presents with a range of symptoms, which can be categorized into three kinds: positive symptoms, e.g., the presence of hallucinations and delusions; negative symptoms, e.g., the loss of speech, pleasure, or the ability to express emotions; and disorganized symptoms, e.g., confused and disoriented thought and behavior. The presentation of schizophrenia can vary across individuals with respect to the type of symptoms, as well as their severity. In general, cases presenting with negative symptoms are believed to have a poorer prognosis than those with positive symptoms. Elyn’s condition presents largely with positive and disorganized symptoms.

Talk therapy is a broad term applied to all forms of psychotherapy that involve dialogue between the analyst and the patient. Talk therapy aims to help the patient identify and work through the root causes of their psychological difficulties or illness, which are believed to stem from past experiences; thus, the therapist helps the patient explore their memories, and how they may be impacting current thought and behavior patterns. Psychoanalysis, or the psychodynamic approach, is one form of talk therapy; CBT is another form, as is client-centered therapy (CCT) which is derived from the humanistic school of thought. As part of the management and treatment of her condition, Elyn is prescribed intensive talk therapy that she must attend possibly for the rest of her life (while concurrently taking medication). While initially exposed to Kleinian analysis, Elyn eventually undergoes psychoanalysis; she also explores CBT when she tries to reduce her Navane dosage without Kaplan’s help.