The Face and the Person

I carry the plenum of proof, and everything else, in my face.

Walt Whitman, Leaves of Grass

The importance of the face in human interactions from the day we are born
cannot be overstated.

Infants, even if they are blind, communicate their feelings to
their parents in large part through facial expressions. For children and adults, so much of what we comprehend about people’s feelings
involves interpreting a glance, a smirk, or raised eyebrows. And there has been research suggesting that our own facial expressions can affect how we feel — what is called the “facial feedback hypothesis.”

I didn’t fully understand the importance of facial communication, though,
until I met patients with illnesses — such as

Parkinson’s Disease
 (PD),

depression
, and

schizophrenia
 — that drastically alter a person’s ability to express thoughts and feelings
through small movements of facial muscles. When meeting patients afflicted in this manner, I don’t know how
they receive my questions or explanations. I don’t know if they’re upset. I
can’t tell what they’re going to say next. The emotionless face, so empty
and devoid of character, can be frightening; a person
seemingly unaffected by emotion is capable of almost anything. Of course, these
patients experience emotions of all kinds. Their faces just don’t exhibit
them.

Leon Kass writes in Toward a More Natural Science about the
importance of emotions expressed through the face, for instance in blushing. This can help us to think about patients with
limited facial communication.

Blushing, like many facial expressions, “is not under our control.” Moreover, blushing is the “involuntary outward bodily manifestation of a very
complex psychophysical phenomenon.” Mental states induce blushing: shyness,
modesty, embarrassment, shame. Many of us blush when we’ve done something
wrong, know we’ve done something wrong, and are scolded for doing so. It is,
in certain respects, a public proclamation of shame. Similarly, the
furrowing of the brow, a smile, and a frown are also public manifestations of
mental states. All
this indicates that we are social beings and cognizant of those
around us. To wit, Kass argues that blushing requires a notion of the self,
a concern of how one appears to others, and an “awareness that one is on
display.”

The same is not always true about every facial expression, but
it is certainly applicable in most circumstances. When we laugh at someone
else’s joke, or cry when wronged in some way, we can do so alone. But more
frequently we do so in front of others and in response to others. In the
case of crying, we may try to be alone when we sob because we are concerned
about appearing fragile or weak. With smiling or laughing, we are
recognizing that someone else said something funny. These are social
reactions that require cognizance or acknowledgement of other human beings, and many of our facial expressions take place within the context of
social relationships. “The face,” Kass writes, “is not only the organ of
self-expression and self-presentation, the source of our voice and
transmitter of our moods; it also contains the chief organs for beholding
other selves.”

Because of the significance of the face in our social interactions, it is
“most highly regarded, both in the sense of most looked at and in
the sense of most esteemed.” Attention, wanted and unwanted, centers on the
face. Yes, some superficial aspects of ourselves can reveal much
beneath the surface: our deepest worries, fears, and joys. Such an
understanding ought to give us new appreciation for the kinds of
difficulties patients without facial expressions confront. They are
handicapped in their interactions with others. They inadvertently block a
vital mode of communication. They cannot indicate how they feel without
using words. As physicians we treat the symptomatic aspects of diseases
like Parkinson’s, but we cannot change someone’s face; even while patients
are on their PD medications, their facial deficits persist. It is one of
those debilitating aspects of illness that one can easily forget when thinking about people who suffer from these illnesses but that one cannot ignore when facing them in person.

Practicing Medicine Turns One

As I look back on the first year of this blog and reflect on my four years of medical school, I am amazed at how much I have learned and how much
I have seen. All of it has informed what I have written about here on Practicing Medicine. And many of the issues I have raised remain vital to my experience within the hospital.
Medicine forces physicians to ask questions; questions beyond which IV fluids to give or which antibiotic to use. Medicine demands that we ask the same
questions that any student of human history might ask: What makes us human? What is so humorous about human suffering and pain? Why
do we become numb to human forms of sufferingWhat is the process by which we die? And is it dignified?

How should we view the place of the mentally ill in our society
?

I have also made other, perhaps less broad and less grand, attempts at explicating the practice of medicine. My first post explained why I decided to blog and the awkward place
of medical students within the medical field. This piece
discussed the potent smells of the hospital — they are unavoidable and yet we adjust to them. Stepping into the ED for the very first time, I
explained how a trauma code works and the horrors that
trauma patients face. The kidney-failure patient also faces difficulties,
but they are of a chronic nature due to dialysis, a miracle of modern science with its own drawbacks.

I compared
George Orwell’s experiences in a French hospital in the early twentieth century to my own experiences in a hospital in the early twenty-first; yes, there are major differences, but there are also similarities. This is a pragmatic post on how we ought to think about
scientific studies and evidence-based medicine. I have written about depression and schizophrenia. And, in a more recent post that would have
pleased me greatly as a younger reader, I wrote about Sir Arthur Conan Doyle’s eponymous detective, Sherlock Holmes — it turns out his methods are relevant to physicians today.

Over the next year I hope to continue to write about the big questions and bring up others in relation to what I see and do. I also have a few bigger writing projects in the works, which I will mention here on the blog. If you have suggestions or
comments, please feel free to send them my way. My e-mail address and Twitter handle can be found at the right.

Denying and Romanticizing Mental Illness

Reactions to mental illnesses or disorders vary. (I wrote about some of them
in a 2012 essay in
the pages of The New Atlantis
.) I’ve noticed, however, that some of
the responses among physicians differ from their reactions to other medical
pathologies. There are several reasons why this might be the case, having to do
with the fact that psychiatric pathology is far more difficult to comprehend
and thus more easily misunderstood than the pathology of other diseases we
usually associate only with the body, such as cancer or pneumonia.

Image via Shutterstock

Unlike bodily illnesses, mental disorders primarily affect patients’
emotions and actions. As a consequence, our implicitly held beliefs about human
behavior, especially our views of free will, can color how we react to people
suffering from mental illness. A strong belief in free will helps validate a
sense of justice and morality: generally speaking, people choose their actions
and are thus responsible for them. So if a person with a psychiatric diagnosis
commits suicide, kills another person, or runs onto a highway screaming at
imaginary beings, it is easiest to hold the person morally responsible if we
believe he acted freely. Or, in the case of suicide, we might say that the
person “should have done” this or that to make life better: he should have seen
a psychiatrist, or he should have realized how wonderful his life was. We want
to hold the person responsible for his actions rather than deal with an illness
that so often makes people completely irrational and incapable of choosing
their actions.

Additionally, the fact that most medical pathology is visible to us makes it
simpler to understand. In the emergency room we easily see the
effects of a chopped-off leg
. We can feel
a large spleen
, hear an irregular heartbeat, or view an abnormal lab
finding. Psychiatric pathology, however, is not palpable in the same way. With
schizophrenic patients, for example, we cannot see the beings they see. We do
not inhabit the world they inhabit. Nor can we easily visualize their brain
chemistry. It is as if we are looking for the culprit in a pitch-black world.

With these difficulties in understanding psychiatric disease, some
physicians, patients and observers dismiss mental illness as a product of the
weak-willed or obstreperous. Or they romanticize it, focusing on the
interesting and provocative aspects of mental illness. These are minority
views, but they are not without influence — which is unfortunate, because if
they are followed, they can lead us to deny treatment to those who need it.

Dr. Robert Youngson, a British doctor-turned-author,
is an instructive example of someone espousing dangerous views of this sort. In
his 1999 book, The
Madness of Prince Hamlet and Other Extraordinary States of Mind
, he
writes:

Doctors and lay people talk, quite casually, of ‘mental
illness,’ the implication being that conditions like schizophrenia are much the
same as conditions like tuberculosis or meningitis. In fact, they are not.
Mental disorders have hardly anything in common with organic physical
disease…. The observable changes occurring in the body — including the brain —
in the course of organic disease are called pathology. So far as current
research can demonstrate, there are no corresponding organic changes causing
schizophrenia.

Dr. Youngson goes on to assert that we classify schizophrenia as an illness
in order to maintain a society of “normal” people. He claims that British
psychiatrists “carry out a tidying-up function much more closely equated with
that of the police and the judiciary than with that of the medical profession.”
Then he asks, disturbingly, whether there is “really any difference between
what happened in Russia, when political dissidents were deemed to be mad and
were incarcerated in mental hospitals, and what happens in Britain and America
when people who do not conform to current social mores are legally certified
and locked up.”

For support of his position, Dr. Youngson refers the reader to the work of the
late Thomas Szasz, who,
as a professor of psychiatry at the State University of New York Upstate
Medical University at Syracuse, New York, published a number of controversial
books arguing that mental illness is a myth. The status quo of medical practice
that considers mental conditions like schizophrenia as illnesses, Dr. Youngson
writes, is a “convenient fiction about a state of the mind.” (A critical essay
about Dr. Szasz appeared
in The New Atlantis
in 2006.)

But Dr. Youngson’s premise, that schizophrenic patients lack cerebral
pathology, is wrong. We know, for example, that patients with schizophrenia
have a disruption in certain neurotransmitters in their brains. Dopamine is
increased in patients with schizophrenia, and this possibly relates to the
effects of genetic alterations. There are specific (and multiple) gene
variants associated
with this disease. Furthermore, medications do sometimes
work, as I explained in another
recent post
. They inhibit dopamine’s actions on certain receptors in the
brain and, despite their side effects, can rid patients of awful and
belligerent visions and voices. If there were truly no pathology, why would
blocking receptors work? If there were truly no pathology, why would there be
significant elevations of certain neurotransmitters? There is indeed pathology
here — Youngson apparently just chooses to ignore it because it contradicts his
preferred explanations.

Dr. Paul McHugh, a
professor of psychiatry at Johns Hopkins University School of Medicine, wrote
about this particular topic in a 1995
issue of The American Scholar
. He argues that “the context of a life
should not be confused with the cause of all mental disorders or made the sole
focus of therapeutic attention as though guidance were always synonymous with
cure.” Unfortunately, “the assumption that something must have happened
if a mental disorder is present has provided an entry for zealots and
charlatans into psychiatry.” If we believe that mental disorders like
schizophrenia or depression are always rooted in life experiences and never in physical
pathology, we can easily misunderstand patients, their families, and the
possibilities for therapies. Not only is Dr. Youngson’s view wrong; it is injurious
to those whom it is meant to help.

Dr. McHugh also addresses the romanticization of depression in a 2005 Commentary
essay
(which I quoted in another
recent post
). McHugh reviews Andrew Solomon’s book The
Noonday Demon: An Atlas of Depression
(2001), in which Solomon writes
about his own experiences with depression. Solomon, McHugh argues, romanticizes
depression by making it seem mysterious like sex and curable most effectively
by a sheer act of will. Similar to Dr. Youngson, Solomon mischaracterizes a
terrible sickness. As McHugh writes,

the particular disorder at issue here is a disease,
an affliction that disrupts a natural function of emotional control. This
disease, like other diseases both physical and mental, renders the afflicted
person impaired in ways that are essentially the same from case to case….
[Depression] is not a you but an it, a thing unto itself and not
just the dark side of human emotion.

Again, depression, like schizophrenia, clearly involves pathologies in the
brain. It is a real disease that tears apart human lives.

What’s so striking about these cases is that those who are denying or
romanticizing mental illnesses are familiar with the diseases. Surely, Dr.
Youngson saw schizophrenics in his family practice. Solomon experienced
depression himself. And Dr. Szasz also saw patients with these disorders.
Seeing or experiencing the illness, then, is not enough to understand it. An
understanding of disorders of the mind requires that we not only learn about
symptoms, social context, and pharmacology, but also that we understand the
underlying pathology.

A World of Nightmares

O Rose thou art sick.
The invisible worm,
That flies in the night
In the howling storm:

Has found out thy bed
Of crimson joy:
And his dark secret love
Does thy life destroy.
—William Blake, “The Sick Rose

As I rotate through psychiatry, I have noticed that certain facial features and dispositions uniquely characterize diseases. I wrote this in a previous post about a depressed patient:

Corridor of psychiatric hospital Saint Anne, Paris.
By Jules Gaildrau, 1868.
Image via Shutterstock

I need not speak to him to know he is not well. A simple glance tells me all. The patient’s unshaven face wears no smile and, at once, no frown. His vapid
gaze lingers longer than it should on various objects or people or nothing at all…. His visage is neither pale nor tan nor some variation on one of these —
it is like a bare tree on a late and chilly fall day. His brow barely responds even when he speaks and his susurrant replies to our questions are scarcely
audible over the ambient sounds in the room.

Much of this description also applies to a schizophrenic patient whom I saw, a young adult in his twenties whose life had been thrown into disarray by psychiatric disease.
But there are some differences. The schizophrenic patient was far more active than the depressed patient, rocking back and forth the way some Orthodox Jews shuckle when they pray. And while his façade was inexpressive, we could tell when speaking with him
that his mind was as active as ever. He stared, not lazily or vapidly, but intensely, as if analyzing each of our movements and expressions.

The hospital staff had taken the shoelaces out of his sneakers so he could not use them to strangle himself. He was not allowed to shave with a razor
because of the risk of suicide. Not being able to grow a full beard, a five o’clock shadow grew only over his upper lip. His fingernails were cut and
neatly blunted (again, a safety measure) and he had been wearing the same clothes for weeks. When he did get up, he simply paced around the psychiatric
unit, occasionally muttering to himself as he stared at the ground. He ignored everyone else around him even though many of the other patients were manic,
depressed, or bombastic. He believed that aliens were coming down from outer space and putting thoughts into his head; other ghost-like creatures told him
to do “violent things” to himself. As he rocked back and forth he seemed to be entreating the voices to go away.

It is tempting when hearing descriptions like this to laugh. The claims are so absurd and so beyond the realm of normalcy that they drag us into the land
of poorly made sci-fi movies. However, patients with schizophrenia sincerely believe in these sorts of delusions and hallucinations.

Schizophrenia
usually occurs in younger adults and involves paranoid delusions, hallucinations (mostly auditory), social withdrawal, disorganized speech and other
symptoms. Here is a video of a schizophrenic patient which gives a sense of the illness. The
voices which patients hear demand, in many cases, that the patient hurt himself, leading eventually to suicide (the voices more rarely implore the patient
to hurt others). Patients have no control over these and don’t comprehend that they are fictitious. These victims are secluded from reality and trapped by
their minds.

The pathophysiology of this disease, as is true of depression, is not completely clear. But we do know that patients have an unusually increased amount of dopamine within the brain. Additionally, the brains of persistent schizophrenics shrink and the ventricles of the brain, which contain cerebrospinal fluid, enlarge. The etiology of schizophrenia is also complex, with
genetic and environmental factors both presumably playing a role

Abandoned building from the Manteno State Mental Hospital,
Manteno, Illinois.
Image via Shutterstock

The prognosis can be devastating. In this case, a young adult in the middle of a budding career in academia could no longer work, attend university, or interact
with fellow human beings. Fearful of violent outbursts his family had no choice but to place him in a psychiatry ward. According to the numbers, this is not a singular outcome. Only 15 percent of patients with the diagnosis eventually function again at their pre-illness level, while one third are
severely and permanently debilitated. About 80 percent of patients with schizophrenia at some point in life also experience major depression, and substance abuse plays an important role in about 50 percent of patients.

The prognosis is not necessarily better for those who take antipsychotic medications, which block dopamine receptors in the brain. The treatments
themselves can affect the patient negatively. Side effects from antipsychotic medications like OlanzapineChlorpromazineClozapine, and Risperidone include diabetes, decreased white blood cell counts, myocarditis (inflammation of the heart), tic-like
movements, sedation, and neuroleptic malignant syndrome (a syndrome consisting of
fever, altered mental status, and muscle rigidity). No wonder, then, that patients frequently dislike taking their medications.

The patient we saw on the psychiatry ward did not respond to any of these pharmaceutical options. In fact, no matter what medication he took, the voices
continued to haunt him, telling him to do terrible things to himself. In an act of desperation we turned to electroconvulsive therapy (ECT, which I
wrote about here). After the first couple of treatments,
the patient improved slightly. But the illness quickly came roaring back. The attending physician proposed other combinations of medical therapies and more
ECT. But at this point, we persevered in searching for treatments only to delay lifelong institutionalization and a helpless retreat to a dark world of nightmares.

In the Clutches of Depression

Oh, that this too, too sullied flesh would melt,

Thaw, and resolve itself into a dew,

Or that the Everlasting had not fixed

His canon ’gainst self-slaughter! O God, God!

How weary, stale, flat, and unprofitable

Seem to me all the uses of this world!

Fie on ’t, ah fie! ’Tis an unweeded garden

That grows to seed. Things rank and gross in nature

Possess it merely. That it should come to this.

Hamlet

I need not speak to him to know he is not well. A simple glance tells me all. The patient’s unshaven face wears no smile and, at once, no frown. His vapid gaze
lingers longer than it should on various objects or people or nothing at all. The slippers, pajama pants, and torn t-shirt express the disposition of their
owner, unkempt and exhausted. His visage is neither pale nor tan nor some variation on one of these — it is like a bare tree on a late and chilly fall day.
His brow barely responds even when he speaks and his susurrant replies to our questions are scarcely audible over the ambient sounds in the room. In
conversation he rests his hands on his knees, palms up as if hoping to receive something to make this all end. I can only claim that he exists in physical
form.

We, the psychiatry team, confronted in this patient a true disease of the mind; unchecked and unmitigated depression, eating away at the soul and
destroying its possessor. One doesn’t require the Diagnostic and Statistical Manual of Mental Disorders
(DSM) of the American Psychiatric Association to diagnose this young father with depression. But if we wanted to, we could look through it for criteria on diagnosis and treatment of this disease. A
diagnosis of Major Depressive Disorder requires five of nine specific symptoms,
which include depressed mood, decreased pleasure, change in appetite, change in sleep, and others, present nearly every day for more than two weeks. This
makes the diagnosis “official,” though the definition and the name of the diagnosis lack the descriptive power to characterize its severity (and perhaps also a crispness that one wants out of any definition). Algis Valiunas, a
fellow at the Ethics and Public Policy Center and a contributing editor to this journal, points this out in a wonderful 2007 essay in The New Atlantis, “Melancholy’s Whole Physician.” He writes that the term “depression” was “never appropriately ferocious to begin with, suggesting a mere dip in the road rather than the sulfurous sinkhole that engulfs you and all
you love and sends you into infernal freefall like the host of wicked angels, plummeting in terror with no end in sight, no hope of seeing the beautiful
face of God again.”

Still, we’ve chosen “depression” as the name for it and unfortunately this gives a false sense of innocuousness to the whole experience. We also, frankly,
overuse the term which may contribute to that perception. Whenever we feel down or something hasn’t gone our way we claim depression, as if getting a flat
tire marks a trough in our lives. But to see someone truly depressed gives new meaning to the word.

There was no triggering factor for this particular patient. He had dealt with depression his whole life. He never attempted suicide but his illness waxed
and waned, sometimes waxing so powerfully that he could not work, love, or live outside of the pseudo-security of a dark room under his blanket.

Nobody is sure about the exact pathophysiology of depression, but physicians suspect it has to do with an imbalance of neurotransmitters, small molecules that
bind receptors in the brain affecting happiness, sadness, and desire. Specifically, depressed patients often lack the neurotransmitter called serotonin, which functions in many different biological activities including vomiting, memory, blood
pressure, pain, and others. Therefore, psychiatrists often begin treating depression with an SSRI (Selective Serotonin Reuptake Inhibitor) as well as
cognitive behavioral therapy, which in combination are better than either alone. SSRIs work by preventing neurons from absorbing serotonin after they have transmitted a neural impulse, which allows serotonin to remain active for a longer period of time. And there is a

60–70 percent response rate
to initial therapy with antidepressants. Other medications can be tried if these fail, including multiple SSRIs, tricyclic antidepressants, monoamine oxidase inhibitors, and others.

After seeing multiple psychiatrists the patient had unsuccessfully tried many of these medications. Dr. Paul McHugh, former psychiatrist-in-chief at Johns Hopkins Hospital, describes the
kind of hopelessness a patient like this feels when confronted with depression in a wonderful essay for Commentary Magazine. (A collection of his essays can be found in The Mind Has Mountains, a fascinating
collection reviewed here in The New Atlantis). “You cannot choose for
or against this disease. It chooses you, just as does epilepsy, cancer, or heart disease. It turns you into a stereotyped copy of every other person
afflicted with it. You are not in charge of it, you are not to blame for it, and you can do little about it except seek the help that may enable you to
escape its clutches.” When the medical help fails as it had for this patient, imagine the tightening of clutches, the sheer hopelessness compounded with
the underlying pathology.

Image via Shutterstock

The next option for this patient was Electroconvulsive Therapy (ECT). This is
an effective last-ditch possibility for some patients with intractable depression as well as some patients with schizophrenia. (I will write about a schizophrenic patient in the next
couple of posts.) The side effects of ECT include some ephemeral cognitive decline and memory loss. Anesthesiologists sedate the patient and the psychiatrist
hooks the patient up to a machine and sends a series of electrical waves through the patient’s brain. The response to this therapy, which is relatively
safe despite the possible conception of it as some barbaric torture method, depends on the individual. Some patients respond and feel better after one
treatment. Others may need multiple treatments. Psychiatrists don’t fully understand why this works. Also, ECT does not always permanently fix depression; it often merely
gives a brief respite, sometimes half a year, before the disease comes roaring back.

And this persistence of disease leads to even more problems, as Valiunas explains in his essay — it actually causes anatomical changes that further
exacerbate depression, a vicious cycle. Examples of changes include destruction of glia, which supply
nutrients to neurons and clean up their garbage, and atrophy of the hippocampus
and amygdala, parts of the brain involved in memory and emotion.
This, of course, is why
treatment of depression is so important and it explains why this disease, as Dr. McHugh points out, is not due to some “great personal or moral flaw, one
that can be corrected if only [patients] would not let their emotions run amok.” No, the disease is very real and vicious.

I don’t know if ECT ever worked for this particular patient because, as seems to be so common a trope in this blog, I left the psychiatry service before I
got to see the procedure performed on him. But I cross my fingers that when I run into him again I won’t recognize him at all.