Unthinkable

by Helen Thomson

  He gets up from his seat and looks at Hamdy, who greets him warmly.

  “This is Helen,” says Hamdy. I stretch out my hand and Matar shakes it gently.

  We walk as a group through the hospital to a wing of empty offices. At the end of the corridor is a tiny study containing a single desk and four chairs. Hamdy asks us to take a seat while he goes in search of some water. Matar chooses the chair nearest the door, while I sit at a right angle to him. Rafia leaves us briefly to check on something in her office.

  Alone together, I smile at Matar and thank him for coming into the hospital to see me. He stares at me, then tilts his head to the side, looking momentarily puzzled. I ask him how he is. Once again, he gives little indication that he understands what I am saying. I know that Matar isn’t fluent in English, but I was under the impression that he knew a little. I smile and nod at the door. “I’ll wait for Hamdy.”

  As we sit there in silence, I think back to what I already know about Matar. He was sixteen when he was diagnosed with schizophrenia. At the time, he had frequent admissions to the local psychiatry inpatient unit. Once, he had called the police because he believed that the UAE was under attack, after experiencing auditory and visual hallucinations of bombs exploding. Based on his call, the army was mobilized. He was later arrested for making false charges.

  As an adult, Matar told his doctors that alongside his regular hallucinations, he had begun to turn into a tiger at night. He said he felt claws starting to appear from his hands and feet and that he would roar around the room. When it happened, he would lock himself in his room because he feared that if he went outside he might eat someone. He had told Hamdy how one day he felt himself turn into a tiger while having his hair cut; he jumped up from the chair and tried to bite the barber.

  SCHIZOPHRENIA IS OFTEN SAID to be one of the most complex of all human disorders. It affects about one in one hundred people and common symptoms include paranoia, hallucinations, disorganized thinking and lack of motivation. Despite a strong genetic component (people who have immediate family members with schizophrenia have a much higher risk of having the disorder themselves), as well as clear environmental triggers such as trauma and drug use, we still do not know exactly why it occurs.

  Some of the genetic research points to a mutation on chromosome 22, within a region known to be involved in the development and maturation of neurons. When researchers at the RIKEN Brain Science Institute in Japan grew neurons from stem cells obtained from people with this mutation, they found that fewer neurons grew, and those that did grow migrated over shorter distances, than did stem cells taken from people without the mutation.5 It suggests that the mutation could cause abnormal growth and development in the earliest stages of life, which may affect how different neural networks within the brain communicate.

  With such a wide constellation of symptoms, it has been difficult to pinpoint which neural networks are most affected. However, in recent years, it has been suggested that some symptoms of schizophrenia may arise from disruption to networks that allow us to distinguish between things that are generated by our self and things that belong to our external world.

  We tend to give little thought to this distinction. Most of us instinctively know, for instance, that when we stick out our leg or tell a joke it is our own leg that’s moving and our own words that we can hear. But the reason we are able to come to this conclusion is because our brain can predict the sensory consequences of our own actions, which gives us the feeling of being in control of the things we say and do. Since the late 1980s, Chris Frith at University College London and his colleagues have been developing a model for how this sense of agency arises and how it might explain some of the symptoms of schizophrenia.6

  Let’s use your leg as an example: give it a wiggle. To make this movement, your motor cortex—a region toward the top of the brain—sends messages to the muscles in your leg instructing them to move back and forth. According to Frith’s model, at the same time, a copy of this message gets sent to other areas of the brain, which create a mental representation of the intended movement—a prediction of the consequences of this action. Once your leg wiggles, all the sensations that it creates—from the sight of your leg moving to the sensations that arise from the movement of your skin, tendons and joints—are compared to this prediction. If they match, you gain a sense of agency over the action.

  These self-generated movements are registered in the brain less acutely than those sensations initiated by someone else. It’s a clever adaptation—it means we don’t jump out of our skin every time we touch our own arm as we might if someone else unexpectedly grabs us. In much the same way, when we speak, the brain appears to send a copy of the instruction to move our vocal cords to the auditory cortex. A few hundred milliseconds after we speak, our auditory cortex is dampened down. This doesn’t happen when you hear someone else speak. It suggests that the brain predicts what sound you intend to make based on your vocal movements and compares this prediction to incoming sounds. If the two match, the sound is understood as your own, and somewhat ignored.

  But if any part of this system goes awry, perhaps because of poor communication or bad internal timing mechanisms, we can no longer link our intentions with our actions and their predicted consequences. The brain is then forced to produce some other explanation for why these things are happening.

  In 2016, Anne-Laure Lemaitre and her colleagues at the University of Lille, France, tested the theory that this is what is happening in schizophrenia with a simple experiment that you can try at home. All you have to do is remove your top, stretch your left arm up to the sky and, with your right hand, reach into your armpit and give yourself a little tickle. It probably has zero effect—it’s really hard to tickle yourself. That’s because our brain is predicting the consequences of the movements of our right hand and suppressing our reaction to them. The element of expectation and surprise—necessary for a good tickle—is gone. But when Lemaitre tested the ability of people with schizophrenic-like traits to tickle themselves with a feather, she found they were much more likely to report a ticklish sensation than a non-schizophrenic control group.7 The results support the theory that people with schizophrenia are less able to predict the sensory consequences of their actions, which may lead to problems differentiating between sensations that arise from themselves and those that are externally produced.

  We also see disruptions in the mechanisms that help us predict the sound of our own voice in people with schizophrenia, suggesting their brains cannot readily distinguish between internally and externally generated voices. It doesn’t take a great leap of imagination to see how these disruptions could lead to a person concluding that they are not in control of their actions or that an internal monologue is coming not from themselves but from somewhere else.

  * * *

  Hamdy interrupts my thoughts, returning with small pots of water for all of us. He sits down next to me, shortly followed by Rafia, who takes a seat behind the desk.

  Hamdy acts as translator while I thank Matar for coming to the hospital that day. He hadn’t needed an appointment. He lives in a nearby village with his mum and sister, and had traveled in alone especially to speak with me.

  I ask Matar whether he is happy to tell me a bit about his background, where he grew up, whether he has a partner. He thinks about the question for a second or two, and begins to speak softly, telling me that he has a wife. But almost immediately he hesitates. I have read that people who have suffered from lycanthropy can often show signs of shyness, so I turn to Hamdy. “Please let him know that he doesn’t have to answer any questions he doesn’t feel comfortable with.”

  Suddenly Matar grimaces, throws his head back and produces a strange sound. I’m momentarily startled, before realizing that he is sobbing. He looks up at the ceiling while his shoulders rise up and down. Rafia grabs a box of tissues and slips them across the desk. Matar dries his eyes and apologizes. He says the reason he is upset is because he has two children whom he no
longer sees. One is fourteen years old and the other is eight, he thinks. He says he doesn’t know exactly, because he hasn’t seen them properly for a long time.

  “My wife doesn’t want me to see them at the moment,” he says. “They live quite far away.”

  Hamdy turns to me and explains that Matar’s wife took their children away after Matar started experiencing symptoms of lycanthropy, believing he might be a danger to them. I nod, trying to present some kind of understanding through my actions, if not my speech.

  After a few moments, Hamdy asks Matar if he would like to continue with his interview. He says yes, so I ask him how his symptoms began, and what they felt like.

  “My schizophrenia started with visual hallucinations,” he says. “I saw people coming and going that weren’t really there. I could feel men and women and children grabbing at my legs and then falling to the floor.”

  His hallucinations grew worse over time. “It felt like people were starting to control my speech, that they could read my mind. They weren’t allowing me to talk.”

  Suddenly Matar stops and looks at me strangely. He says something to Hamdy and jabs his finger in my direction.

  I look at Hamdy.

  “He says he’s suspicious of you because you’re British,” he says.

  “Why?”

  Hamdy turns to Matar and asks him to explain his reasoning.

  “We’re all talking too much English,” says Hamdy. “It’s making him anxious.”

  The two of them chat for a while in Arabic. At the end of the conversation, Matar seems calm. He says he actually really likes the UK. He tells me that he got a scholarship to study at a British university, but that he needs to learn the language better. He says he’d like to study there one day.

  He seems more at ease so I ask him whether he can explain what used to happen when he felt like he was turning into a tiger. Matar thinks for a moment and then points to his head and neck. “I feel it in my thoughts and in my body,” he says.

  He rolls up his sleeve and shows me his arm. He pulls at his thick black hairs, making them stand on end.

  “When it starts to happen, all my hairs stand upright. The hair all over my body becomes erect. Then I get a spiky, itchy feeling over my body and my beard. It starts with a pain in my left leg, then it moves to my right leg, then to my arms. I start to feel an electric-like sensation going through my body. Then it feels like I want to bite someone. I can’t control it, I just know that I am turning into a tiger.”

  He pauses and touches his throat, then looks directly at me and says something I don’t understand in Arabic.

  I glance at Hamdy, who looks puzzled.

  “Matar says he has that feeling now.”

  ALL TOO OFTEN, the media are guilty of portraying people with schizophrenia as being violent. In fact, there is little scientific evidence for this at all. When Beth McGinty at Johns Hopkins Bloomberg School of Public Health and her colleagues analyzed news coverage from 1995 to 2014, they found that 40 percent of all news stories about mental illness focused on a link between mental illness and violence. That’s highly disproportionate to the actual rates of violence among people with mental illness.

  In the UK, for instance, homicides due to mental disorders peaked in 1973, and then declined to a rate of 0.07 per 100,000 people in 2004—the last year for which data was analyzed. That compares to total homicides, which increased over the same period and peaked in 2004 at 1.5 per 100,000 people.8

  It’s a dangerous misperception among reporters, the public and policymakers that mental illness is at the root of violence. Needless to say, sometimes it is: the high-profile assassination attempt on the American politician Gabrielle Giffords, for example, was carried out by Jared Lee Loughner, who was subsequently diagnosed with paranoid schizophrenia. But most acts of violence are the result not of the hallucinations and paranoia that accompany schizophrenia, but of anger and emotional issues, drug and alcohol use. “Most people with mental illness are not violent toward others and most violence is not caused by mental illness,” says McGinty.

  These thoughts comfort me. I look at Hamdy and Rafia for direction. They both speak to Matar quietly. They tell him to relax, that there is no need to feel anxious in here, that we are all friends.

  The room is silent for what feels like several minutes. Matar seems to be fighting some kind of internal civil war. Suddenly he grips his legs.

  “Do you feel like you want to attack?” Hamdy asks, breaking the silence.

  Matar looks up at him. “How did you know that? Are you reading my mind?”

  Hamdy assures him that he cannot read his mind, and that he is just asking how he is feeling.

  Matar looks at him with suspicion. Then he says something in Arabic that makes Hamdy laugh softly.

  “What’s going on?” I ask.

  “Matar asked me if I am really the Hamdy he knows. He thinks I might be an impostor. He says the Hamdy he remembers is really fat.”

  Matar nods. “The Hamdy I know is obese,” he says.

  I raise an eyebrow at Hamdy. “No, he’s right,” he says, smiling. “I haven’t seen Matar in person for a year or so and when I last saw him, I really was obese.”

  Hamdy explains to Matar that he’s lost a lot of weight recently and that surely he recognizes both him and Rafia.

  “The Hamdy I knew was more kind,” says Matar.

  Hamdy smiles and chats to Matar for a little while longer. He asks if he wants to stop or carry on. Suddenly Matar’s shoulders relax, and his eyes become more focused.

  “Yes, let’s continue,” he says.

  I take a deep breath and ask Matar what it is about his delusions that made him feel like a tiger, rather than, say, a cat or some other animal.

  “I feel like you are eating my legs, like a Kentucky drumstick,” Matar says, ignoring my question. “You feel like a lion to me, I want to attack you before you attack me.”

  My gut clenches. There is no getting around it, Matar is clearly in the midst of a terrible relapse. He takes a sudden intake of breath and looks down into his lap, and a deep and incredibly realistic growl rumbles from his mouth.

  My pen hovers above my notepad and I find myself imagining what a predator and prey might do in this situation. Hamdy is sitting on my left and the door is to my right. But I don’t want to move; I don’t want to startle him. Matar has both hands clenched on the tops of his legs and his fingers have begun flexing as if they have claws. The growling is directed at me. When Hamdy tries to speak, the growls turn toward him.

  “Are you wanting to attack us?” asks Hamdy.

  “All three of you,” says Matar.

  Both doctors glance at each other. They start to talk at once in English and Arabic.

  “Relax, Matar, it’s okay. You know who we are and why we’re here. You wanted to come and talk to Helen about your condition, remember?”

  Matar nods. He seems to be trying to fight the urge to attack. He takes a few deep breaths and suddenly becomes quite lucid again. He says he needs a cigarette. Rafia slips from behind the desk and helps him out of the room.

  With Matar gone, I turn to Hamdy and ask his opinion about what has just happened.

  “I don’t think he has taken his medication,” Hamdy replies. Matar usually takes a mixture of antipsychotics, antidepressants and antianxiety drugs, he says, which help control his symptoms. “Something must have happened to make him stop taking them. I don’t think we are safe in this room.”

  I agree, and suggest we end the interview here. Hamdy disagrees; he says we should just move to a bigger room.

  “You should sit by the door so you can run out if you need to.”

  I am feeling terrible about the possibility of making Matar’s relapse worse, but follow doctor’s orders. I get the feeling that this is a rare opportunity for Hamdy and Rafia to find out more about the condition, to understand it better. We walk to a large seminar room, set out with rows of chairs.

  While we wait, I ask Ham
dy why it is that Matar’s schizophrenia has manifested itself in this rare belief that he can turn into a tiger. Why does this happen to him, but not to others with the condition?

  Hamdy says that is the million-dollar question. “There’s something different going on,” he says. “People with lycanthropy see their bodies not as human, but as animal. We have to ask, ‘How is that possible?’”

  We may not be able to find out the answer from studying people with lycanthropy—there are just too few around—but that’s not to say we can’t make some inroads. You don’t need to be suffering from lycanthropy to feel as though your body is changing shape, or altered in some way. There are many strange disorders in which people feel like their limbs are unwanted, are present when they’re not, or have grown smaller or larger. Some of these can give us clues to what might be happening to Matar. But to find out more, we need to travel back to 1934, where a young man is lying in an operating room, head shaved, brain exposed—and wide awake.

  * * *

  Wilder Penfield gripped the tiny electrode and lowered it onto the surface of the young man’s brain. He pressed a button and a tiny current ran through the metal rod, giving the surface of the brain below a small jolt.

  “What do you feel?” he asked his patient.

  “I feel a tingling sensation on my jaw,” he said.

  Penfield’s assistant made a note of the result and placed a marker onto the area of the brain that had just been stimulated. Penfield moved the electrode a fraction of an inch and began the process again. This time the patient felt a sensation of being touched on his upper arm.

  We met Penfield in Bob’s chapter, when he was stimulating an area close to the hippocampus to produce flashes of memories in his patients. This time, he was trying to identify which areas of his patient’s brain were causing epileptic activity and needed to be removed, and which healthy tissue he should avoid. He would often start such an operation by identifying the central sulcus, a prominent indentation at the top of the brain that separates the frontal lobe from the parietal lobe. Just in front of this landmark is the primary motor cortex, a strip of tissue that contains cells that travel down into the spinal cord, where they connect with motor neurons that terminate in our muscles. Just behind the central sulcus is the parietal lobe, which contains a similar strip of tissue called the primary somatosensory cortex. This contains cells that receive information about tactile sensations from all around the body. When Penfield stimulated the primary motor cortex, his patient would feel the sensation of movement of a specific muscle. When the somatosensory cortex was stimulated, he would feel the sensation of being touched.9