the muse and the mad hatter : Reflections on the currren state of psychiatry

TL;DR

TL;DR

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• Negative Public Perception: The stigma associated with psychiatric diagnoses like schizophrenia and bipolar disorder contributes to negative societal attitudes, often linking these conditions with violence and detachment from reality. This stigma intensifies the personal and social struggles of those affected.
• Misinterpretation of Hallucinations: Traditional psychiatric models label hallucinations as maladaptive and uncontrollable, but recent neuroimaging research suggests these experiences might be more about neural activity patterns rather than distinct pathological processes. Hallucinations could be viewed as unique perceptual constructions rather than purely symptoms of mental illness.
• Lack of Consideration for Personal Experience: Psychiatry often overlooks the personal significance of hallucinatory experiences, focusing instead on symptom management through medication. This approach can undermine the potential value of these experiences, which may include creative and insightful content.
• Potential for Creativity in Schizophrenia: Research indicates that schizotypal thinking, often present in individuals with schizophrenia, may be linked to creative cognition. Efforts to enhance cognitive functions through targeted interventions could improve both creative output and cognitive symptoms, challenging the notion of schizophrenia solely as a debilitating brain disease.
  
  

The current state of psychiatry can be seen as lamentable and fatalistic. Public sentiment regarding clinical labels like “schizophrenia”, “bipolar”, and “depression” encompasses a pejorative chime and sometimes carries unjustified associations with violence and disconnect from the consensus reality.

Schizophrenia and its notorious symptom cluster (i.e., hallucinations, delusions, emotional blunting, anhedonia, and cognitive deficits), in particular, has been erroneously and absolutely identified as a veritable brain disease with a chronic degenerative course, lifelong deficits and impairments, and devastating psychosocial implications for both those with the condition and their immediate relatives. Then there is the social stigmatization that comes hand-in-hand with the gravity of that label. Individuals with schizophrenia are often fighting two discrete but interconnected battles — an internal civil war between conflicting and disparate aspects of self and the war against social cues that reinforce feelings of alienation and marginalization.

Such invalidation is, too, deeply entrenched in the professional consensus and in the long history of neuropsychiatry itself. For example, hallucinatory phenomena, often appraised as hallmarks of schizophrenia, have been subject to empirical investigations for around 150 years now. They are defined as percept-like experiences occurring in the absence of corresponding sensory stimuli according to the traditional biomedical model. This model also decrees that they aren’t amenable to conscious control and can’t be differentiated from veridical perceptions. But because vision is a constructive process guiding adaptive behavior and none of our perceptions are objectively “true” anyway, it would be more appropriate to define them as idiosyncratic perceptual constructions occurring in the absence of appropriate contexts. 

This approach would be complemented well by neuroimaging studies which implicate the same neural networks to be active during both a sense perception of stimuli and a corresponding hallucinatory phenomenon. They may be visual, auditory, musical, tactile, olfactory, gustatory, synesthetic, or pain-oriented in nature, and occur in both clinical and nonclinical populations.

For instance, the neurosurgeon Wilder Penfield and his associate Phenor Perot stimulated the visual and auditory cortices of patients who were undergoing surgery for intractable epilepsy with a small electrode, triggering complex visual and auditory hallucinations; hallucinations in an explicit sensory modality manifested when cortical real estate responsible for processing sensory stimuli in that same modality was activated. Hence hyperactivation of the association visual cortices might translate to the experience of marching lithe-bodied Lilliputian Matryoshka dolls across one’s visual field on the phenomenological level. In my opinion the clinical–nonclinical binary system in psychiatry is somewhat misleading and will soon become antiquated.

The delegitimization of experience and its personal significance can also be witnessed in the treatment of individuals that experience hallucination. Hallucinatory content, in particular, is not given much credence as psychiatrists and other general practitioners rush to treat positive symptoms with a prescription of antipsychotic medications, many of which block dopamine D-2 receptors in the limbic system. 

Approaching clinical phenomena with the curiosity, respect, and non-judgment they deserve seems to be the (approach or initiative) of a select few. Wilson Van Dusen, a clinical psychologist who worked with the mentally ill at Mendocino State Hospital in California for approximately seventeen years, belongs to this magnanimous cohort. He launched a comprehensive investigation into the nature of his patients’ hallucinations, finding that the ratio of higher-order to lower-order content was around 1:5.

In his clinical appraisal he defined higher-order sensory experiences as feeling-related, nonverbal, and symbolic or allegorical; more often than not he found that experiences of this type possessed intellectual, instructive, and creative merit, far surpassing the implicit understanding and IQ level of the individual they’d manifested through. These hallucinations — if one could call them that — expressed the utmost respect for volition and usually broadened the patient’s values. On the other hand, the lower-order types were micromanagerial, malicious, and punitive voices with mutable qualities, a simple and limited vocabulary, and expressed themselves as running critiques that undermined, ridiculed, threatened, and beleaguered the patient.

What I am attempting to underscore here is the enduring distortion of an innocuous idiosyncratic neurocognitive profile that parades under the banner of “schizophrenia”. Pathological magnification can be seen in the zealous overprescription of labels (and psychotropic drugs for that matter) and in the minimization and devaluation of phenomenology, that being the personal significance of direct experience and the integral role it plays in therapeutic contexts.

I would confidently declare that my book, “The Creative Advantages of Schizophrenia: The Muse and the Mad Hatter”, is an epiphenomenal child of this injustice, birthed from an inner desire to compensate for the historically disproportionate emphasis on pathological aspects of the disorder. Yes, the gaping deficits in working memory capacity, attention span, defocusing, and perspective-taking are blatantly obvious for those of us who know someone with schizophrenia. We know about the occasions of heightened paranoid ideation, for instance believing that the neighbors are conspiring with the FBI or CIA to incarcerate them. We know how these situations can incapacitate them and render them unfit for any vocation or role in society.

From an evolutionary psychology perspective, these patently maladaptive deficits are nothing but vehicles of evolutionary disadvantage when it comes to the “survival of the fittest” hypothesis. A heterogenous neurocognitive profile connected with the schizospectrum or psychotic disorders and its genetic footprints should have either been attenuated or eradicated from the gene pool by now, but it has not. 

One popular theory is that schizotypal thinking, a form of creative cognition punctuated by hyperassociation and making nonconventional connections between objects and ideas, is common in individuals with schizophrenia (and some other clinical populations) and confers compensatory advantages. There are two sides to each coin, and in this case each neurocognitive profile. Is the nebulous swamp that births the demons of psychopathology also the spring of the Muses from whence the gold nuggets of exceptional ingenuity and inspiration come forth? Are the people who are overcome, possessed, and seized by the throes of “madness” also those that create novel products praised for their inventiveness, aesthetic beauty, unprecedented utility, and the sheer ineffable awe they can evoke in the sophisticated and layperson alike?

This topic is integral and fundamental to both my personal and professional identity. I come from a family with ancestral neurodiversity (i.e., positive and negative schizotypy) where such advantages were not always acknowledged or validated. This piqued my curiosity to the degree that I dedicated a significant proportion of my subsequent research as well as my doctoral dissertation on the compensatory advantages of schizotypal thinking in individuals who are diagnosed with schizospectrum disorders. My dissertation research was intimately concerned with how existing creative potential can be nurtured, nourished, and further enhanced in individuals diagnosed with schizospectrum disorders. 

I strongly believe existing creative potential can be nurtured by running individuals through a cognitive remediation training program targeting improvement and rehabilitation of intrinsic factors like working memory and executive functioning. A similar program had been used in the past by the Vinogradov Schizophrenia Research Lab based at UCSF in San Francisco to improve what they called “prefrontal cortical efficiency” in a cohort of patients with schizophrenia.

I went one step further and asked the question of whether sustained engagement with this program would also improve their creative cognition. I was able to show through a battery of psychometric tests administered before and after the intervention that the functional gains led to improvements in the quality of their creative output [creative writing]. The results were far-reaching and compelling in a clinical sense because they challenge the idea of schizophrenia as a “brain disease” and underscore that a specific intervention strategy might disproportionately enhance creative output or channel it and reduce cognitive symptoms which functionally disable the individual.

It is absolutely imperative to illuminate positives and focus on individual strengths when it comes to social adaptation or rehabilitation of existing functional deficits. We are all different; differences should be celebrated, not pitted up against a normative “standard”, and under no circumstances construed as disabled or defective.