Falling Into the Fire: A Psychiatrist's Encounters with the Mind in Crisis

by Montross, Christine

  I call my mother, now that I cannot ask my grandmother for her own answers. “Didn’t Grandma have some reason not to like mockingbirds?” I ask my mother. No, she says. Not that she can remember. “Are you sure? I thought they laid eggs in other birds’ nests and then their babies grew bigger than the others and took all the food, and . . .” I’m thinking of cowbirds, my mother tells me, which, yes, Grandma loathed. But mockingbirds? Nothing rings a bell.

  My grandmother could be ruthless, in the way that nature also can. A cardinal built a nest outside her first-floor window, and I mentioned it to her, delighted. “If that bird is dumb enough to build its nest that low,” she scoffed, “it deserves to have its eggs eaten by a snake.” They had a garden and a little orchard at their rural Indiana home, and one Saturday of my childhood I ran to the blueberry bushes only to find a sparrow who had died after it got twisted in the netting around the bushes. “He shouldn’t have tried to eat my berries,” she said. Still, I noticed how tenderly she untangled him from the nylon threads. She held the body in her palm and had me look closely at what we rarely had the chance to see: beak, and wing, and claw.

  My brother and I took a garden spade and dug a grave for that sparrow beneath the peach tree, solemnly marking it with . . . what? The pink-white flower from a pea tendril? A fat zucchini blossom? Clover? I can’t recall. But for nights after, lying in my twin bed, I’d think not of the dying but of the struggle. How flight turned into entrapment. How little the poor bird must have understood. How the more it moved, the more tangled its feathers would have become.

  People who have schizophrenia are more prone to kill themselves in the early stages of the disease than at any other time. The theory is this: A person in his first psychotic break is in a kind of netherworld. He has had years—maybe eighteen, maybe twenty—of sanity. Then the voices come, or the visions, or the paranoia, and he begins to occupy a space in which the symptoms are present but so is his awareness of the stable life that is slipping from his grasp. It is a horrible kind of bridge—the interspace between sanity and brokenness. Schizo-, “to split.” -Phrenia, “mind.” Later—it’s awful to say—he likely won’t be as aware of what he’s lost. Yet in that first grip of madness’s net, in that first struggle and the sanity that comes after, he can understand the implications. The full impossibility of escape. I’m not sure about this existence, Colin had said to me. Are you?

  As we prepared him for discharge, Colin said he couldn’t promise us that he would continue the medication once at home. And the day he left, I felt unease in the pit of my stomach. I told Colin that I wished him well and reached out to shake his hand. He grasped my hand in both of his and held on, longer than he ought to have. He looked deeply into my eyes, as if he saw something there.

  “I wish the best for you, too, Dr. Montross,” he said earnestly, with a meditative smile. “I really do.”

  I worried for Colin after his discharge. I worry about many of my patients after they have left the hospital. “There are two kinds of psychiatrists,” wrote Robert I. Simon, himself a forensic psychiatrist. “Those who have had patients commit suicide and those who will.”

  • • •

  My most memorable patient encounters come from interactions with my schizophrenic patients. They tell me all kinds of things about myself.

  “Montross? Like ‘mantra,’” said one, smiling in adoration.

  “You will die in your sleep tonight by my hand,” said another. It can be unnerving.

  Once, from his jail cell, a man said to me, “I know you!” I thought perhaps he did. A past psychiatric admission, maybe. Something else. “We smoked crack together!” he announced triumphantly, as if I had simply forgotten.

  Riddled by voices, overcome by delusions, or persecuted by fear, these patients are pressed to take action in the world. And though the results of their actions can be ridiculous, or terrible, there is sometimes an unmistakable urge toward goodness behind their errant behavior. One of my patients bought hundreds of dollars’ worth of lighters in an attempt to stop gangs from setting fire to abandoned buildings. Another was brought in by police when, having caught a pigeon whose foot was injured, she held the bird in her lap with a fork and a pair of pliers to try to operate on it.

  Because the content of delusions is so frequently religious, my patients have all kinds of ideas, too, about God. They are God, or are sent by God, or are persecuted by him. He has told them to fast, or to take drugs, or to beware of me. When I’m with them in the midst of their torment, I wonder about God more than at any other time in my life. After the writer Annie Dillard read a book about human birth defects, she imagined herself “hollering at God the compassionate, the all-merciful, WHAT’S with the bird-headed dwarfs?” It’s a fair question.

  While I was treating Colin in the hospital, I learned a little bit about Amma the Hugging Saint. At first I hadn’t even been sure she was real; then, standing in line for coffee at a Providence bakery, I saw a bookmark-size flyer tacked to a community bulletin board. “Amma: Summer Tour,” it read, “Marlborough, MA. All programs held at the Best Western Royal Plaza Hotel.” An Indian woman beamed in a photograph on the flyer. Her hands were clasped in front of her face, as if she had just seen something that absolutely delighted her. “Programs include inspirational music, meditation, spiritual discourse, and personal blessings,” the flyer read. Beneath the photograph of Amma was a quote attributed to her: “God is deep within us. He dwells there in pure and innocent love.”

  There is plenty of footage of Amma on the Internet, and it turns out that she’s been covered by major newspapers. A 2006 movie was made about her, called Darshan: The Embrace. In 2010 she received an honorary degree from SUNY Buffalo in recognition of her humanitarian efforts.

  Amma was born in southern India. Her father was a poor fisherman. The New York Times reports that Amma “was said to have been born with a bluish hue to her skin and became an outcast. Her father withdrew her from school in the fourth grade and made her serve as a family slave.” As an explanation of her mission, Amma explains that her childhood meant that she “had direct experience with the suffering of others. . . . I always wanted to know the cause of misery and thought if sorrow is a truth then there must be a cause and a way out. I realized my purpose is to console, to personally wipe away tears through selfless love, compassion and service.” As a teenager she began hugging strangers on the streets of her village. In the opening minutes of the movie Darshan, a teenage Amma is shown with a man whose skin is covered in boils. The voice-over tells us that many of the boils were covered in pus. Young Amma delicately licks one after another after another, then looks into the face of the man with great compassion.

  These days her physical contact is limited to hugs, but devotees report that her hugs are life-changing, transformative. Even relative skeptics, such as Jenny Kleeman, a journalist who wrote for the Guardian about the experience of hugging Amma, described the encounter as “the most enjoyable hug I’ve had from a stranger.”

  In Hinduism the concept of darshan describes the reciprocal interaction between a deity or guru and his or her followers. The revered person is beheld, and the person who beholds her subsequently receives a blessing. Amma travels the world performing her darshan—the hugs—for up to fifty thousand people in a twenty-hour session. According to her followers, Amma has hugged more than 27 million people worldwide. “She never seems to tire,” reports the Times. “Speaking in Malayalam, the language of her native state, Kerala, and translated by her chief disciple, Swami Amritaswarup, she said, ‘People’s happiness is my rest.’” A 2006 article in USA Today about one of her sessions of darshan notes that Amma “never flinches from the tide of pain and confusion.”

  I had initially imagined Colin following Amma through the mountains of the American West on foot, a hiking disciple who followed a guru through rugged terrain by day and pitched a tent with her devotees at night. My image had been one of campf
ires and drum circles, not of banquet rooms in a string of suburban Best Westerns. Nonetheless, my questions about Colin’s experience—and the etiology of his symptoms—remained the same. Does a young man seek Amma the Hugging Saint because he is fragile, susceptible to unconditional acceptance and a persuasive atmosphere? Or is he delusional already and his sense of deep meaning and connection with her is derived wholly from an imbalance of neurotransmitters? Or what if—despite his fragility or illness—he is right after all and she is a deity or a saint? There is fervent faith and there is psychiatric hyperreligiosity. Both can be characterized by agonizing self-debasement. Both can bring about ecstatic joy. At what point does a transformation in one’s thoughts become something to be treated by medication? When does it become so severe as to impinge upon one’s liberty?

  • • •

  In the British Journal of Psychiatry, Yair Bar-El and his colleagues describe Jerusalem syndrome, an acute “psychotic decompensation” that afflicted 1,200 tourists to the Holy Land from 1980 to 1993. “On average,” the authors write, “100 such tourists are seen annually, 40 of them requiring admission to hospital.” The paper divides the patients into three categories. The first is made up of people who have already been diagnosed with a psychotic illness before traveling to Jerusalem. “Their motivation in coming to Israel,” the authors write, “is directly related to their mental condition,” frequently involving delusions. A subset of these patients “strongly identify with characters” from the Bible “or are convinced that they themselves are one of these characters.”

  Visitors in the second category lack a psychiatric diagnosis but have what the authors call “idiosyncratic ideations.” These are groups or individuals with “unusual ideas” who are “outside the mainstream of the established churches.” They settle in Jerusalem believing, for instance, that doing so will bring about the resurrection of Christ. They may “wear distinctive clothing which, according to them, is similar to that worn in the days of Christ.” At some point these patients shift from merely harboring extreme religious beliefs to engaging in behavior that becomes more problematic. Bar-El and his coauthors give the example of a man who set out to preach his message of “true religion” to the people of Jerusalem and eventually, in the Church of the Holy Sepulcher, “succumbed to an attack of psychomotor agitation and started shouting at the priests, accusing them of being pagans and barbarians and of worshipping graven images.” Eventually the altercation became physical, and the man began destroying paintings and statues in the church, resulting in his psychiatric evaluation. He was found to have no identifiable mental illness beyond his extreme religious beliefs, even three years after the episode.

  It is, however, the third category of tourists afflicted by Jerusalem syndrome that is the most mind-boggling. This category is described as a “pure” form of the syndrome, because its sufferers have no history of mental illness. These tourists experience an acute psychotic event while in Jerusalem; they recover “fairly spontaneously, and then, after leaving the country, apparently enjoy normality.” As a result they are considered to be mentally well, but for these isolated episodes. However, what episodes they are!

  Tourists with the third subtype of Jerusalem syndrome succumb to a sequence of identifiable stages that are consistent, characteristic, and highly specific.

  First, such sufferers exhibit “anxiety, agitation, nervousness and tension.” They then announce that they wish to split off from their tour group or family and explore Jerusalem on their own. The authors write, “Tourist guides aware of the Jerusalem syndrome and of the significance of such declarations may at this point [preemptively] refer the tourist . . . for psychiatric evaluation.” They add ominously, “If unattended, [the following] stages are usually unavoidable.”

  People afflicted by Jerusalem syndrome will then demonstrate a “need to be clean and pure,” becoming obsessed with bathing or compulsively cutting their finger- and toenails. Next is my favorite step in the sequence: the “preparation, often with the aid of hotel bed-linen, of a long, ankle-length, toga-like gown, which is always white.”

  Once appropriately clad, the person in question will proceed to “scream, shout, or sing out loud psalms, verses from the Bible, religious hymns or spirituals.” He or she will then proceed to a holy place within the city and deliver a sermon, which the authors describe as “usually very confused and based on an unrealistic plea to humankind to adopt a more wholesome, moral, simple way of life.”

  The affected person typically returns to normal within five to seven days, feels ashamed about his behavior, and recovers completely. Between 1980 and 1993, the authors report that forty-two cases met all the diagnostic criteria for this third subtype.

  Similar syndromes have been reported in Paris and Florence, each with its own odd specificities. Paris syndrome strikes Japanese tourists, sixty-three of whom were hospitalized with the condition between 1988 and 2004, according to a paper in the French psychiatric journal Nervure. Apparently the condition was common enough—and severe enough—that the Japanese embassy arranged for a Japanese psychiatrist to assist in treating cases at the Parisian psychiatric institution Hôpital Sainte-Anne. The Canadian philosopher Nadia Halim notes in her paper “Mad Tourists” that “Paris holds a ‘quasi-magical’ attraction for many Japanese tourists, being symbolic of all the aspects of European culture that are admired in Japan.” Tourists who fall victim to Paris syndrome “arrive in Paris with high, romanticized expectations, sometimes after years of anticipation, . . . unprepared for the reality of the city. The language barrier, the pronounced cultural differences in communication styles and public manners, and the quotidian banalities of contemporary Paris—the ways in which it is like any other 21st-century Western city—induce a profound culture shock” that results in symptoms ranging “from anxiety attacks accompanied by feelings of ‘strangeness’ and disassociation, to psychomotor issues, outbursts of violence, suicidal ideation and actions, and psychotic delusions.”

  In the 1980s Graziella Magherini, an Italian psychiatrist and psychoanalyst, identified a syndrome in Florence in which visitors to the city become emotionally unmoored by their encounters with its art and architecture. Magherini reports on 106 cases from Santa Maria Nuova Hospital over ten years. Symptoms include breathlessness, palpitations, panic attacks, and fainting or collapsing to the floor. Severe cases have involved persecutory delusions and paranoia.

  Nadia Halim writes in “Mad Tourists” that in many of Magherini’s case studies “patients report some sense of disintegration” or feel themselves breaking apart. After becoming transfixed by Caravaggio’s Bacchus, a fifty-three-year-old man felt “there was no longer any precise definition” in his life. The New York Times reports an event in front of the same painting, in which a man “collapsed onto the floor of the Uffizi, thrashing about madly. He was carried out on a stretcher, raving and disoriented.”

  Also according to the New York Times, a twenty-five-year-old woman named Martha “became ‘delirious’ after standing for a long time before the Fra Angelico paintings in San Marco. She returned to her hotel,” the Times reports, “and stood for a long time in a corner, mute and withdrawn.” A twenty-year-old woman was seized by terror in the Uffizi and screamed for help, believing that she felt “the anguish of breaking into a thousand pieces.” Halim writes that she was “so agitated she had to be physically restrained.”

  A 2009 paper in the British Medical Journal describes a seventy-two-year-old artist who went to Florence “to fulfill a lifelong wish to see the art and culture that so inspired him. He described some works of art as ‘like seeing old friends.’” The Ponte Vecchio apparently had a particular allure for him, being “the part of Florence he was most eager to visit.” Once he was standing upon it, he had a panic attack, became “disoriented in time,” and became floridly paranoid, believing, among other things, that his hotel room was bugged and that he was being monitored by international airlines. His sym
ptoms resolved in three weeks.

  Magherini dubbed the condition Stendhal syndrome after the French author of that name who became overwhelmed as a result of viewing the frescoes in the Church of Santa Croce. Stendhal wrote that as he exited the church, the sight of Brunelleschi’s dome on the Florence Cathedral nearly led him to madness. “I felt a pulsating in my heart,” he wrote about the experience. “Life was draining out of me. I walked with the fear of falling.” He was cured only by sitting down to read the poetry of Ugo Foscolo, who had written about Florence and hence was “a friendly voice to share my anguish.”

  The mere existence of these “city syndromes,” as Nadia Halim dubs them, is controversial. Many voices have weighed in to argue that these episodes are merely exacerbations of preexisting psychiatric disease or the initial onsets of mental illnesses that happen to occur in foreign cities. Still others have chalked up the circumstances to jet lag or some other mundane variety of travel-related disorientation. At this point no one knows.

  I didn’t meet Colin before he traveled with Amma across the American West. Which came first, the symptoms of his illness or the experience and promise of his transformation? He might have begun to exhibit subtle signs of mental dysregulation before he left to follow Amma, and then the stress and stimuli of travel caused his symptoms to explode. Or he might have been completely healthy before his trip and then gone to the mountains and taken some hallucinogens, at which point his bizarre beliefs and behavior began to emerge and his illness was unmasked. I got to see Colin only when he was already ill, without the benefit of knowing whether holiness, or place, or beauty had anything to do with the mental illness that had derailed him.