by Alexander Linklater & Robert Drummond
Nia 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 realise 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 dishevelled, 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 sceptics 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. 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 dietician 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 dieticians 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?
RESPONSES TO THIS ARTICLE
First published in the February 2006 issue of Prospect magazine, “Beautiful Madness” stirred up quite a transatlantic blogging storm, with commentator from the worlds of fat, feminist and psycho-blogs pitching in. It was, suitably enough, quite crazy, and went on for several weeks. Here is a selection of the more sensible letters that came directly to Prospect, and the response that Alexander Linklater and Robert Drummond wrote in reply.
Beautiful madness 1
31st January 2006
I was very disturbed by Robert Drummond and Alexander Linklater’s article “Beautiful Madness” (February). My disturbance was not caused by the “tragedy” that the authors found so uncomfortable, but by their interpretation of Nia’s story. Why was it considered so important that Nia was pretty, and why was it so troubling that during her recovery she put on weight? The authors refer repeatedly to Nia’s “loss”—about which neither Nia nor her parents seemed particularly concerned—rather than focusing on the success of her treatment. I was staggered that health professionals would place such an emphasis on a patient’s appearance and even more shocked that the objectification of a teenage girl by male doctors was thought a fitting article for Prospect. I love Prospect—it has a unique place among British media—but this story, alongside the lack of women to choose from in the list of top British intellectuals (July 2004) leads me to question whether there is perhaps a whiff of old-fashioned sexism among the editorial team.
Rosie Campbell
Birkbeck
Beautiful madness 2
8th February 2006
The real tragedy of the “Beautiful Madness” story is that even psychiatric professionals accept the “beauty at any cost” ideal of today’s society. Would the authors have felt the story as tragic if the girl had been anorexic? Or if they had had to watch her vibrant beauty slowly eaten away because she thought she was fat? Yes, this poor girl gained some weight—and found she was able to function.
Rachel Voglesong
Harderwijk, Netherlands
Beautiful madness 3
9th February 2006
I find it strange that the psychiatrist in “Beautiful Madness” put so much store by Nia’s beauty. Beauty is a curse as well as a blessing—and in my opinion something well worth giving up for emotional and mental wellbeing. I am a 22-year-old woman who is on lithium and olanzapine to treat my bipolar disorder, and I have gained 10kg since beginning my treatment. This brings me from the borderline of “overweight” (BMI=25) to the borderline of “obese” (BMI=30). However, thanks to my improving mood, I am a far more attractive, pleasant person to be around. I would happily gain another 10kg if needed to maintain this level of stability.
Sarah McCabe-Dansted
Western Australia
Beautiful madness 4
1st February 2006
I admired the immense compassion of this article. It focused upon the experience of a doctor and psychiatrist working with vulnerable young women, and highlighted the problems associated with the women’s social and healthcare needs. This is a particularly acute issue within the mental health sector, where very few clinical approaches actually turn out completely cut and dried as once believed. I feel reassured that psychiatrists like Robert Drummond still possess an enviable level of empathy and insight into the uncertain realm of adolescent female pathology.
I have a personal interest in this testimony, as many years ago, aged 19, I found myself on a psychiatric ward. My situation was slightly different to Nina’s, as treatment for psychotic disorders at that time did not stretch to the administration of “atypical” medication, so I did not encounter any significant problems with weight. It only became a problem when my condition became too difficult to manage on a negligible amount of Stelazine, and was advised by my psychiatrist to try Amisulpride. After a brief amount of time on this drug I became aware of rapidly accelerating weight. Since being discharged from hospital, I have managed to finish my education (I now have an English degree) and I have also attempted a series of jobs. It therefore seemed appropriate to conclude that my remission was complete. But despite this, my weight gain, coupled with unbearable nausea and digestive discomfort, was too unpleasant to continue with the treatment. I changed to Quetiapine and my weight seemed to plateau, and my stomach settled back to normal.
Psychiatrists should consider other underlying health conditions that prevent acceptable weight management—thyroid activity, pituitary disorders or other endocrine or gynaecological conditions). I know that in my case at least, a hormonal condition certainly hinders my weight control. Nonetheless, my exercise routine and diet has kept me within an acceptable level of fitness, and I am just grateful that my mental health condition is more manageable than before.
Deborah Brookes
Solihull
Reply by the authors
In response to the many letters we received about our article in the February 2006 issue of Prospect, entitled “Beautiful Madness”, we would like to offer the following clarifications. Some readers perceived a suggestion in the article that the patient (whom we called Nia) would suffer as much from being overweight as from being psychotic. This is to miss the point. Naturally, such a patient should be treated in the best way possible for a very serious condition—as she was in our account. The point is that even the best treatments available come at sometimes considerable cost. The cost is both physical and psychological. The dilemma raised in our article was not whether schizophrenia is somehow equivalent to being overweight (which we were not suggesting), and certainly not whether Nia would have been better off psychotic—but whether a patient can be seen to have fully recovered who shows little sign of self-awareness after such a dramatic transformation. We ourselves suggest that it might be a blessing for Nia that she ceases to be concerned with social pressures about weight and appearance, though we suspect this does not comprise a full explanation.
There is more to the case than just image-consciousness. Olanzapine does not cause patients merely to put on a few pounds. It can precipitate gain of 4 or 5 stone (56lbs-70lbs) and, in some cases, much more. Putting on 3 stone in 3 weeks would represent just the beginning for a patient such as Nia. There are serious health risks involved, as well as psychological implications, and the side-effects of antipsychotics are a grave issue for modern psychiatry. We refer readers to a letter in the American Journal of Psychiatry on the problems of Olanzapine, which describes an 85lb weight gain in an adolescent
At the same time, it is important to be clear that antipsychotics such as Olanzapine can be transformative, bringing people back from nightmare states of mind, and saving lives. And the side-effects vary enormously, with some patients experiencing them only mildly. It is the trade-off between effect and side-effect that we hoped to express in Nia. See here for reference to the recent largescale CATIE trials into the effectiveness and side effects of various antipsychotics.
Our article has been doing the rounds on interested blogs, and we have been asked by Paul McAleer, creator of Big Fat Blog (a weblog about fat acceptance), to clarify the extent to which Nia was an actual case study. By necessity, Nia is a composite of different people and incidents, and it is not possible for Robert Drummond to comment on specific case histories. However, it is possible to say that one source for our writing is Alexander Linklater’s brother, who suffers from chronic bi-polar disorder. (He is a willing, open and engaged participant in our researches.) During adolescence, Archie Linklater underwent much the kind of dramatic transformations in body weight described in the article, due to his medication. Like Nia, he was a beautiful child who underwent drastic, sometimes terrifying metamorphoses. It’s not just a matter of putting on weight, but of physiological distortions in the whole person. It is important to understand that this is due to illness and medication in combination with one another, and that in extreme psychiatric cases the physical and mental conditions of patients are not separable.
The question of beauty itself remains firmly lodged in the eye of the beholder, of course. We had no intention of creating offence, but nor do we apologise for raising the issue. Beauty is a matter of perception, of feeling, and of social conditioning, but it is a powerful force nevertheless. It is a force which can play into the tragedy of what patients, family and professionals experience. “What has happened to my beautiful child?” —boy or girl—is perhaps the question parents of mentally ill adolescents have asked most often. What happens in psychiatric wards everywhere is that people lose themselves, in various ways, due to various problems and conditions. We were highlighting just one kind of scenario, about the loss and tragedy bound up in the often irreconcilable forces that play into the realm of mental disorder. It is difficult in psychiatry to discuss the full human dimensions of the medical treatment of madness, because they are painful. But that is what we are attempting to do by writing, in combination, from both professional and personal perspectives.
Published in Prospect, February 2006. Dr Robert Drummond is a psychiatrist.
