Alexander LinklaterNia was too beautiful to be in a psychiatric ward. That's what everyone secretly felt, including the blunt, unsentimental nurses. She was willowy and dark-eyed --- not just blandly attractive like teenagers can be. Her parents had delayed signing her into the ward on a section for as long as possible. They couldn't bear the thought that their beautiful girl was going mad.It was Nia's younger sister who used to be the special one, with a gift for the piano that had no precedent in the family. There weren't any family precedents for what would happen to Nia either. As a child, she had been neither unusually pretty nor particularly unhappy. But adolescence can precipitate unexpected metamorphoses. In Nia, it created a transfixing physical gift and unleashed a terrible mental flaw.At first her parents thought it was merely a teenage phase. Nia had become aware of the effect she had on schoolmates and teachers. She would either preen under the attention or become twitchy and resentful. It scarcely seemed to be unnatural behaviour --- not at first. She would spend hours in her bedroom or stay out late with her boyfriend in Cardiff. Her school reports began to slide. These weren't excessive problems for an adolescent, especially not for one who had come to realize that people viewed her as special.Then, as she turned 17, Nia's teenage behaviour began to become something else. She started crying out, shouting at invisible persecutors who came into her room. Her parents didn't know what to do. They were a close family and at first avoided the thought of doctors. They tried to love her more. It wasn't until Nia stopped going to school altogether that they broached the subject with their GP. He immediately referred her to a psychiatrist.
Nia had revealed little to her parents of what was really going on inside her head. But the soft-spoken psychiatrist at the local adolescent mental health centre won her confidence and she began to tell him about the trains. A railway line ran a few hundred yards past the bottom of their garden, far enough away for the family to ignore it. Nevertheless, Nia said she could hear people talking about her inside the painted steel carriages. In the clank of heavy rolling stock she could pick out snatches of conversations about her --- derogatory insinuations that crept into her room through the plastic veneer of the double-glazing. She also told him that she had seen things on television. The newsreaders had begun looking at her. In the corners of their eyes she began to read signs. They were sending her messages; messages that linked up with the voices on the trains.
Nia told the psychiatrist all the things that she had kept secret from her parents. But by the end of the session she began to doubt the wisdom of doing so. She glanced at him with suspicion. He too was insinuating something. There were meanings to be found everywhere in her world. The psychiatrist gave Nia a prescription, which her parents collected from the chemist. She refused to touch it.
On the day before her admission to hospital, Nia had stood at her parents' front door, unmoving, for five hours. They could get no explanation out of her. There seemed to be no explanation for any of this. Nia was disheveled, and had stopped paying attention to her appearance, but that still couldn't disguise her beauty. At their wits' end, her parents agreed to her being forced to accept treatment. Nia procrastinated for an hour outside the mental health trust. Unable to make a decision, she was frozen between following her mother into the gabled entrance and getting back in the car. Her father felt so ambivalent that it was hard to know how to persuade her. The admitting junior psychiatrist asked her mother whether or not there had been a family history of this sort of thing. She thought not. Eventually coming back out to the car, she snapped. "We can't cope with it any more, Derek." Two nurses, a man and a woman, gently took their daughter's arms. The locked door indicated that the decision was made. The section papers were simply a formality. The unit, a regional centre for young people with severe mental illness, provided curtained individual rooms for the clients. Despite this homely benefit, something of the Victorian institution still hung over the wide linoleum corridors, high ceilings and exposed pipes. Sitting in one of the interview rooms opposite the new arrival, the junior psychiatrist was struck by the patient's beauty: shoulder-length brown hair, slender in hipster jeans and a fitted T-shirt. Apart from her distracted eyes she didn't look unwell. He felt himself giving her more time than usual, fascinated by the experiences she related. Third-person auditory hallucinations, delusions of reference, ambitendency --- it was as if this teenager had read a psychiatry textbook.
Afterwards, he discussed Nia with the unit's consultant, a man of compromise with a small chin. He was interested in these symptoms when they appeared in those under 18. Early-onset psychosis, usually a fairly rare phenomenon, was, behind these doors, commonplace. "Does she smoke cannabis?" he asked. Like all her friends, Nia had done the odd spliff. "Hard to tell if it's drug-induced or something more sinister." They decided to observe her without medication. "If it's cannabis, she might improve."
Nia spent the days isolated in her room. The other young people in the unit found her intriguing. One boy of similar age who had been admitted with mania became instantly infatuated with her. His adolescent urges and manic disinhibition were a fertile mix and the staff found him trying every trick in the book to get into her bedroom. It's remarkable what can be contrived, even in a locked ward. One night, they were found in bed together. Nia was put on one-to-one observation.
In fact she got worse. She wouldn't talk to the staff and her meals were brought to her room. For hours on end she lay with her head under the pillow, the radio quietly on. The clinical team was now faced with the difficult decision of which medication to prescribe. Antipsychotics were discovered almost by chance in the middle of the 20th century. Now, at the beginning of the 21st, they comprise a broad church of chemical compounds that all have the effect of dampening, if not completely removing, the symptoms of psychosis.
Psychopharmacological research has shown that dopamine, widely distributed in the brain, is a central component in psychotic reactions. This has led to the classical dopamine hypothesis of schizophrenia, which sees psychosis as being caused by a chemical disorder. The deeper dilemmas of causation --- of whether a problem begins in the brain and extends to the mind, or vice versa --- need not detain psychiatrists working at the front line of mental illness. It is known that antipsychotics can block D2, one of the five dopamine receptors in the brain, and that this has an effect. Very often, the main effect is beneficial. Equally often, the side-effects are troubling.
The consultant favoured Olanzapine for Nia; he had found the drug to work well in her age group despite concerns about weight gain and diabetes. Other modern choices include Quetiapine, though many clinicians think it a weaker drug, and Risperidone, which can also cause weight gain and stiffness. The older drugs like Chlorpromazine and Haloperidol were felt to be "dirtier" and to have worse side effects, including the irreversible lip-smacking and protruding tongue movements of tardive dyskinesia. Seasoned skeptics argue that not much, fundamentally, has changed since the 1950s, apart from refining the choice of side-effects. The young psychiatrist wrote Nia up for Olanzapine --- 10mg, the regular dose. The drug being a sedative, Nia took it at night. She began to sleep.
Not much changed for five days. Then, one morning, Nia was transformed. She left her bedroom, came to meals, had normal conversations with staff. Her face filled out with ordinary human expressions. A day later she was even laughing. A young woman, an intelligent teenager, had reappeared; the psychosis seemed to have left her. To see a patient respond to a drug in this way made the young psychiatrist feel like a real doctor. Almost ashamed of himself for feeling this, he noticed that he felt grateful towards Nia --- for getting better.
What the staff didn't pick up immediately was Nia's hunger. The nurses were so encouraged by her regular appearance in the dining room that they didn't question the heap of beans and potatoes. But soon it became apparent that insanity had been replaced by appetite. Within three weeks she put on three stone [approximately forty pounds]. Now, for the first time, Nia's features were being corrupted. She started to take on the shape of many of the chronically mentally ill. Her jawline collapsed below puffed-out cheeks. Her stomach sagged above her jeans. Even the consultant found the contrast alarming. "Get a dietitian to see her; tell the staff to watch what she eats; change her to Quetiapine." The Olanzapine leached out of the tissue of Nia's central nervous system and made way for the new compound, Quetiapine. But now the illness began to resurface. She was eating less, but the paranoia had returned. "Put up the dose," said the consultant. "Quetiapine hardly ever works below 750mg."
Despite a month-long trial on the highest dose, the relapse of Nia's psychosis was untouched. She became so vulnerable that one-to-one nursing became necessary. Isolated in her room, the voices tormented her.
The young psychiatrist's early optimism collapsed under the grinding reality of Nia's dilemma. The first drug had worked. But the change in her appearance seemed intolerable --- and potentially devastating for the self-esteem of a 17-year-old girl. The second drug hadn't made her fat, but nor had it treated her illness. The consultant felt there was no option but to put her back on the Olanzapine. Again, it worked. The terrors of persecution vanished, the voices quietened down. Even her parents said that this was the old Nia. They cried over her.
The desire to experiment further with her medication left the consultant and the young psychiatrist. It was likely that the weight gain associated with Olanzapine would be very difficult to treat and that Nia would be fat, if not obese. But more disconcerting to the young psychiatrist was Nia's apparent indifference to her predicament. While those around her worried about the beauty she had lost, she seemed unconcerned. Was she really as well as her family suggested? Had she really rejoined the image-conscious world of her peers? The dietitians came and went to little effect.
As the weeks went by, the routine of the ward took over. Other patients were admitted and discharged. Nia was herself, but not herself. She blended in, lumpenly. Her leave at home was increased. Her section was rescinded. Eventually she was discharged. Classically, in schizophrenia, it is said that your chances can be divided into thirds. A third remain well, even coming off medication; a third continue to relapse and remit; and another third never get better. Those with an early-onset psychosis tend to fare worst.
If Nia did remain well, how would her old friends, and her boyfriend, have responded to her? She had been advised to stay on the Olanzapine for the foreseeable future. For a while the young psychiatrist worried about the consequences of the choices they had made in treating her. They had removed a stigma of the mind and replaced it with a stigma of the body. It struck him as strange that the patient had been the only one not to worry about a loss that the team around her found so tragic. Perhaps it didn't matter. Perhaps, in fact, this was a merciful side-effect of medication, or even of the disorder itself; one that liberated Nia from the need to live up to the standards of an image-obsessed world.
The young psychiatrist wasn't sure. The treatment had reversed a Faustian pact in which Nia had been beautiful and mad, and replaced it with another --- in which she was fat and sane. But was it really a blessing that Nia seemed to have no conception of what she had lost?--- This article is from the
February 2006 issue of
2 Bloomsbury Place
London WC1A 2QA
Robert Drummond is a psychiatrist.
Alexander Linklater is deputy editor of "Prospect."
Names, details and locations have been changed.