Madness in Good Company: Great Literary Portrayals of Brain Disorders

“Nobody else suspected he was going crazy,” reﬂects Billy Pilgrim in Kurt Vonnegut’s Slaughterhouse 5. “Now he was in the hospital. The doctors agreed: He was going crazy.”

As Billy gradually manifests the classic symptoms of full-blown post-traumatic stress disorder (PTSD), Vonnegut’s novel takes us deep inside a disordered mind. If the best nonﬁction, including “The Great Brain Books” (Cerebrum, Spring 1999), can inform and inspire, great ﬁction can recreate for us the experience of madness. With the generous help of scientists, scholars, and editors, we have culled a baker’s dozen of the most compelling novels, short stories, and ﬁctionalized memoirs of the past 200 years that create characters with what (at least in retrospect) we can identify as brain disorders. We particularly thank Richard Restak, M.D., for many helpful insights and suggestions relating to the literary selections and the brain disorders discussed in this article.

Some authors write from direct personal experience: Fyodor Dostoevsky of epilepsy, Sylvia Plath of depression, F. Scott Fitzgerald of alcoholism, and William Burroughs of heroin addiction. Others rely on observation, imaginative projection, and perhaps partial identiﬁcation: Vonnegut’s portrayal of post-traumatic stress in Slaughterhouse 5 or Conrad Aiken’s short story of a child’s withdrawal into an autistic state in “Silent Snow, Secret Snow.”

Still others achieve unique insights through the eyes of schizophrenics (Timothy Findley’s Headhunter) or the mentally retarded (Daniel Keyes’s Flowers for Algernon), and even discover humor in the afﬂicted character (Charles Dickens’s narcoleptic servant boy, Joe, in The Pickwick Papers, who “goes on errands fast asleep, and snores as he waits at table”).

Ours is far from an exhaustive account of brain diseases in literature (Shakespeare alone could yield nearly as many), but these selections constitute a respectable cross section of popular 19th- and 20th-century ﬁction in which brain disease plays a prominent role.

Stories of characters who struggle with mental illnesses—from alcohol and drug addiction to depression and post-traumatic stress—continue to resonate with readers. Many of these works were best-sellers. The novels of Kurt Vonnegut and Sylvia Plath became icons of the antiwar and feminist movements; Kafka and Burroughs, while appealing to a narrower and more literary audience, still sell respectably; the works of Dickens and Dostoyevsky are, of course, classics. The characters described here are indeed, as the poet C. Day Lewis terms it, going “mad in good company.”

The works are discussed here in historical order, each author’s understanding of a character’s problems reﬂecting the era in which that author wrote. The recent extraordinary explosion of knowledge about the brain means that even a work as recent as Mark Vonnegut’s The Eden Express (1975) includes what psychiatrists would now term a misdiagnosis (in this case, bipolar disorder is mistaken for schizophrenia). To put these works in a current clinical context, we have compared the characteristics and behavior of the characters to the symptoms described in the 1994 edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, or DSM-IV, the standard descriptive and cataloging text for mental ailments.

The Pickwick Papers

BY CHARLES DICKENS, 1837

Among the most memorable of the many comic characters Dickens introduces in The Pickwick Papers is Joe, the narcoleptic servant of Mr. Tupman. Pickwick ﬁrst meets Joe on the back of Tupman’s carriage during an outdoor festival that includes a mock battle.

“On the box sat a fat and red-faced boy, in a state of somnolency” who, immediately after he got down to open the door of the carriage, “waddled to the same perch and fell fast asleep instantly…as if the roaring of cannon were his ordinary lullaby.” Mr. Tupman has thoughtfully equipped the back of his carriage with a safety device for Joe, who, “if there had been a footboard instead, would have rolled off and killed himself in his very ﬁrst nap.”

As a servant, Joe has obvious drawbacks.

“Very extraordinary boy, that…does he always sleep in this way?” Mr. Pickwick wonders.

“Sleep,” said the old gentleman, “he’s always fast asleep. Goes on errands fast asleep, and snores as he waits at table.”

Sent to ﬁnd someone for Mr. Tupman, Joe bangs on the door of a room.

The object that presented itself to the eyes of the astonished clerk was a boy— a wonderfully fat boy—habited as a serving lad, standing upright on the mat, with his eyes closed as if in sleep. He had never seen such a fat boy, in or out of a traveling caravan…
“What’s the matter?” inquired the clerk.
The extraordinary boy replied not a word; but he nodded once, and seemed, to the clerk’s imagination, to snore feebly.
“What the devil did you knock in that way for?” inquired the clerk, angrily. “Because master said I wasn’t to leave off knocking till they opened the door, for fear I should go to sleep,” said the boy.

According to the DSM-IV, Joe’s symptoms closely match those of narcolepsy: “repeated irresistible attacks of refreshing sleep.” The element of irresistibility is critical to the syndrome, and the sufferer’s sleep episodes are said to last 10 to 20 minutes but can go on for as long as an hour. Joe’s ability to function may also be tied to what the DSM describes as “automatic behavior, in which the individual engages in activity without full awareness…individuals may drive, converse or even work.”

Despite Joe’s faults, his employer seems to value him. Says Mr. Tupman, “I’m proud of that boy—wouldn’t part with him on any account—he’s a natural curiosity.”

Perhaps the “natural curiosity” arises from the novelty of Joe’s condition. According to the DSM-IV, narcolepsy–particularly in the extreme form exhibited by Joe—is rare; it would have occurred in as few as 3,600 of the approximately 18 million people in England and Wales at the midpoint of the 19th century.

The Idiot

BY FYODOR DOSTOEVSKY, 1869

As The Idiot opens, Prince Myshkin is returning to Russia from Switzerland, where he has been living for more than four years, for medical reasons. “His eyes were large and pale blue, and their intent gaze held at once something gentle and saturnine, ﬁlled as they were with that odd expression by which some people can detect epilepsy at a glance.” Later, Dostoevsky describes Myshkin about to be attacked by a man with a knife:

Then all at once everything seemed to open up before him: an extraordinary inner light flooded his soul. That instant lasted, perhaps, half a second, yet he clearly and consciously remembered the beginning, the first sound of a dreadful scream which burst from his chest of its own accord and which no effort of his could have suppressed. Then consciousness was extinguished instantly and total darkness came upon him.

He had suffered an epileptic fit, the first for a very long time. As is well known, attacks of epilepsy, the notorious falling sickness, occur instantaneously. In that one instant the face suddenly becomes horribly contorted, especially the eyes. Spasms and convulsions rack the entire body and all the facial features. A frightful, unimaginable scream, quite unlike anything else, bursts from the chest.

The ﬁt saves Myshkin’s life. Unnerved by the sight of his convulsions, the attacker ﬂees.

Myshkin’s epilepsy is both a medical problem and a metaphor for the innocence that sets him apart, an otherworldliness that contrasts with the competitiveness and materialism of the people around him. This is consistent with the sense of transcendence that often affects people (like Dostoevsky himself) who have temporal lobe epilepsy:

Amid the sadness, spiritual darkness and oppression, there were moments when his brain seemed to flare up momentarily and all his vital forces tense themselves at once in an extraordinary surge. The sensation of being alive and self-aware increased almost tenfold…His mind and heart were bathed in an extraordinary illumination…all his doubts and anxieties seemed to be instantly reconciled and resolved into a lofty serenity, filled with pure, harmonious gladness and hope… with the consciousness of the ultimate cause of all things.

Unfortunately, these moments “were merely the prelude to that ﬁnal second (never more than a second) which marked the onset of the actual ﬁt.”

Born in 1821, Dostoevsky became linked with the forces of political reform in Russia. He and a group of friends were arrested for political activity, tried, and sentenced to death. In a dreadful charade, as he was about to be executed, the sentence was commuted and he was sent to prison in Siberia. There he experienced his ﬁrst epileptic seizure. Although he was a Russian nationalist, he left Russia for Europe in 1868 and there wrote The Idiot to help pay off his gambling debts. Dostoevsky’s own epilepsy was particularly acute as he was writing the novel.

“A Hunger Artist”

BY FRANZ KAFKA, 1924

“During these last decades the interest in professional fasting has markedly diminished,” begins Franz Kafka in his short story “A Hunger Artist.” He goes on to paint a world where at one time “the whole town took a lively interest in the hunger artist… everybody wanted to see him at least once a day” in his barred cage set up in some prominent place, a public production orchestrated by “the impresario”:

The longest period of fasting was set up by his impresario at forty days, beyond that he was not allowed to go, not even in great cities, and there was good reason for it, too. Experience had proved that for about forty days the interest of the public could be stimulated by a steadily increasing pressure of advertisement, but after that the town began to lose interest.

So frail would Kafka’s hunger artist become by the end of his performance that he could not stand. He would have to be helped out of his cage and to a table upon which was laid “a carefully chosen invalid repast.” The artist, “in a kind of half-fainting trance,” would force himself to eat to the accompaniment of band music, after which “the spectators melted away, and no one had any cause to be dissatisﬁed with the proceedings, no one except the hunger artist himself.” His dissatisfaction is not from the starvation, though, but from annoyance with the audience’s failure to appreciate the deep nature of his art and with the rules that prevent him from taking his fast beyond 40 days.

We would not expect to ﬁnd a great deal of clinical detail in “The Hunger Artist,” which is really an extended metaphor, but Kafka is accurate in noting, through the reﬂections of bystanders at the performance, that the artist’s “melancholy was probably caused by fasting.” When this is pointed out to him, however, the artist reacts “with an outburst of fury and to the general alarm beg[ins] to shake the bars of his cage like a wild animal.”

Those who willingly starve themselves are deﬁned by the DSM-IV as having anorexia nervosa. There are two major types: patients who restrict what they eat and patients who engage in binge eating and then purging, either by vomiting or using laxatives. Certainly the hunger artist exhibits behaviors mentioned in the DSM, including “depressive symptoms such as depressed mood, social withdrawal, irritability, insomnia.”

Anorexia is most prevalent among girls and young women, peaking in individuals between 14 and 18 years of age. The disorder is serious; among patients admitted to university hospitals, long-term mortality is more than 10 percent. Kafka’s hunger artist, freed from the restraints imposed by his impresario, starves himself to death.

Mrs. Dalloway

BY VIRGINIA WOOLF, 1925

Mrs. Dalloway takes us through one day in the life of Clarissa Dalloway, an upper-class Englishwoman married to a government minister. Although beneath her serene exterior ﬂow currents of conﬂict and unhappiness, Mrs. Dalloway’s life is contrasted with the tragic story of another major character, Septimus Warren Smith.

The novel is set in 1923, ﬁve years after the end of World War I (the “Great War” to the English at the time). Smith had served in the war, and “developed manliness; he drew the attention, indeed the affection of his ofﬁcer, Evans by name.” Yet “when Evans was killed, just before the Armistice, in Italy, Septimus, far from showing any emotion or recognizing that here was the end of a friendship, congratulated himself upon feeling very little and very reasonably.”

The effects of his experience creep up on him after the war, however. “For now that it was all over, truce signed, and the dead buried, he had, especially in the evening, these sudden thunder-claps of fear…There were moments of waking in the early morning. The bed was falling; he was falling.”

His reaction becomes worse when he returns to England; even the literature that had once meant so much to him has lost its appeal. Reading Shakespeare, he discovers “the message hidden in the beauty of words. The secret signal which one generation passes, under disguise, to the next is loathing, hatred, despair.”

A day in a London park overwhelms him. “A sparrow chirped Septimus, Septimus, four or ﬁve times over and went on, drawing its notes out, to sing fresh and piercingly in Greek words how there is no crime …from trees in the meadow of life beyond a river where the dead walk, how there is no death.”

He hears people talking behind the bedroom walls, sees a woman’s head in the middle of a fern, talks constantly of death and suicide. His doctor thinks Smith suffers only from obsessive introspection; his Italian wife is mystiﬁed and overwhelmed by his mental problems. “Now we will kill ourselves,” he announces as they are standing by a river, “and he looked at it with a look which she had seen in his eyes…a look as if something fascinated him; and she felt he was going from her and she caught him by the arm.” After contemplating suicide by knife, razor, and gas, Smith eventually throws himself out a window.

Given the lack of symptoms before his military service, and the stresses of combat, it seems obvious that Septimus Smith is suffering from “shell shock,” the term then applied to post-traumatic stress disorder. The DSM lists “intense psychological distress,” along with “markedly diminished interest in signiﬁcant activities” and “detachment or estrangement from others,” as part of that syndrome.

The vivid passages describing Smith’s depression and hallucinations no doubt owe much to Virginia Woolf’s own bouts with depression and perhaps schizophrenia. Woolf had two nervous breakdowns in her youth, and in 1913 attempted suicide. She was in and out of mental institutions for two years, but recovered and went back to writing. By the late 1920s, she had become a signiﬁcant literary ﬁgure, though continually struggling with health problems, including debilitating headaches and insomnia. In 1941, feeling a return of the voices and delusions that had earlier so troubled her mind, she ﬁlled the pockets of her dress with rocks and walked into a river to drown.

“Silent Snow, Secret Snow”

BY CONRAD AIKEN, 1934

In his short story “Silent Snow, Secret Snow,” Conrad Aiken portrays a 12-year-old boy, Paul Haselman, slipping into an autistic state—a progression from apparent normality to a state of consciousness that excludes all contact with the world.

As Paul is overtaken by autism, we see the world through his eyes—the little girl who sits in front of him in school has “a funny little constellation of freckles in the back of her neck, exactly like the Big Dipper”—and through his ears: the postman’s footsteps are closer but softer because of the secret snow that begins to ﬁll the world.

Although it is not winter, every day the snow accumulates, making that world more silent, more remote. Paul surrenders as though to a delicious secret that envelopes his consciousness. His parents, though concerned, become increasingly peripheral to him. Paul sees his condition progressing and knows that he will lose one world as he is drawn into another.

He does not have conventional infantile autism, which strikes very young children, who are never symptom-free after the age of two. Aiken’s evocation of the state seems accurate, however, especially the portrayal of Paul’s inability to communicate or sustain relationships at even a minimal level.

The story ends with Paul’s interrogation and examination by the family doctor in the presence of his parents. Paul avoids the doctor’s eyes (“marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze” is one of the DSM’s criteria for autism) or else he stares, preoccupied with the light in his pupils. Finally he stands sideways, smiling at the secret snow ﬁlling the corners of the room. His father becomes “the brown slippers” with the “well-known punishment voice, resonant and cruel.” His laughter horriﬁes his mother.

Paul ﬂees to his room, where the snow encompasses him in a roar. His mother’s efforts to pull him back ﬁll him with loathing. He experiences them as cruel, and withdraws from her into the cold, remote, and peaceful snow—to sleep.

As a child, Aiken saw his father kill his mother and then commit suicide. He was raised by relatives, graduated from Harvard in 1910, and became a successful writer. It is easy to speculate that this exquisitely written account is his imaginative projection of an autistic state he may have begun to enter in the wake of his awful trauma— to shelter himself from his pain and the morbid curiosity of others.

While no traumatic event is mentioned in “Silent Snow, Secret Snow,” the story could be describing a post-traumatic stress reaction in the form of an autistic state. The course of Aiken’s life suggests that he did not withdraw from the world as Paul did, but his temptation to do so may well have become the realistic kernel of this haunting narrative.

Tender is the Night

BY F. SCOTT FITZGERALD, 1934

When Nicole and Dick Diver meet in Tender is the Night, he is a young psychiatrist with a brilliant career and she is a beautiful 16-year-old girl deposited in a Swiss mental hospital by her wealthy father, who declares “she is not right in the head.”

To Nicole, all men are evil (she accuses Dick’s valet of improper advances, for example). She has been diagnosed as schizophrenic, but her doctor, sensing a falsity in her father, has his doubts about this diagnosis of “the young bird with wings crushed.” He demands a return visit from her father who, confronted, confesses incest with Nicole. Her doctors take action to protect her from her father and release her to Dick Diver, with whom she has been corresponding (and creating a psychodynamic “father transference”). Dick restrains himself, at ﬁrst, but then succumbs to his desire for her and they marry. The compromise in his professional ethics begins his decline; he is doomed to be the incestuous father ﬁgure in their marriage.

Nicole alternately clings, goes mad, and recovers. Dick blames and reproaches her, refuses to take responsibility for his own actions, and begins drinking. We observe the downward spiral and professional ruin of a man once full of promise.

Fitzgerald suffered from alcoholism; his wife, Zelda, was diagnosed as schizophrenic and hospitalized. Fitzgerald seems to want us to believe that Dick’s drinking, although problematic, is his way of coping with problems outside his control, rather than (as deﬁned by the DSM-IV) a serious, progressive disease in and of itself. Dick insults friends when he is inebriated. A patient accuses him of having alcohol on his breath, and his associate, Dr. Gregorious, asks him to take “a leave of abstinence.” The DSM-IV criteria for diagnosis of substance abuse include “failure to fulﬁll major role obligations at work.”

This is the death knell for Dick Diver professionally. His drinking increases, his problems multiply. Close friends become alienated, as in the DSM-IV description: “persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance.” Beneath the surface of all Dick’s drinking and partying is desperation. Nicole comes to see him as weak and ﬂawed and leaves him for a man with whom she has no history of psychological transference. Dick is left to a life of small jobs in small towns, punctuated by scandals.

Tender Is the Night, published in 1934, was the last novel Fitzgerald completed. His life had taken a downward turn, personally and professionally, after publication of The Great Gatsby in 1925. He ended up in Hollywood, writing movie scripts.

Junky

BY WILLIAM S. BURROUGHS, 1953

“Junk is not a kick. It is a way of life,” says novelist William S. Burroughs in Junky, his “memoir of a life of addiction”:

The addict himself has a special blind spot as far as the progress of his habit is concerned. He generally does not realize that he is getting a habit at all…I have talked to many addicts and they all say they were surprised when they discovered they actually had the first habit. Many of them attributed their symptoms to some other cause.

Burroughs’s plain language and matter-of-fact tone cast his recollections in an unsparing light:

You become a narcotics addict because you do not have strong motivations in any other direction. Junk wins by default.

I tried it as a matter of curiosity. I drifted along taking shots when I could score. I ended up hooked…You don’t decide to be an addict. One morning you wake up sick and you’re an addict.

Burroughs grew up in a middle-class family in the Midwest, graduated from college, drifted around Europe in the mid1930s on the proceeds of a trust fund, and ﬁnally returned to the United States. He started using morphine stolen from a shipyard during World War II, then graduated to more and different drugs. His memoir omits few of the DSM IV signs of the substance abuser, including “failure to fulﬁll major role obligations at work, school, or home,” not to mention “recurrent substance-related legal problems” and “continued substance use despite having persistent or recurrent…problems caused or exacerbated by the effects of the substance.”

Much of Junky deals with the seamy side of hustling for the drug, scrapes with the law, and the trauma of repeated withdrawals from addiction:

It is possible to detach yourself from most pain…From junk sickness there seems to be no escape. Junk sickness is the reverse side of junk kick…I was too weak to get out of bed. I could not lie still. In junk sickness, any conceivable line of action or inaction seems intolerable. A man might simply die because he could not stand to stay in his body.

Junky follows Burroughs through years of on-and-off addiction and “cures,” including a session at the federal hospital at Lexington, Kentucky, which specialized in treating narcotics addiction. Junky was published in 1953 under the pseudonym William Lee.

Burroughs is regarded as a standard-bearer of the Beat movement. He went on to write Naked Lunch and other works, including The Yage Letters—a collection of correspondence between him and the Beat poet Allen Ginsberg, as Burroughs pursued in South America an Amazonian hallucinogen known as yage.

In the 1930s, Burroughs went through three years of psychoanalysis. “Analysis removed inhibitions and anxiety so that I could live the way I wanted to live,” he wrote. “Much of my progress in analysis was accomplished in spite of my analyst… I was more pleased with the results than he was.”

The Bell Jar

BY SYLVIA PLATH, 1963

The Bell Jar is the story of Esther Greenwood, a young lady of respectable New England background but limited economic means, whose sojourn in Manhattan one summer during college is made possible by winning a contest sponsored by a fashion magazine. In Esther’s opening words: “It was a queer, sultry summer, the summer they electrocuted the Rosenbergs, and I didn’t know what I was doing in New York.”

The novel follows Esther through her adventures in the New York City of the 1950s, dating experiences that leave her empty, her return home to the Boston.

“As I approached the bottom of the bottle, red and blue lights began to flash before my eyes. The bottle slid from my fingers and I lay down.” suburbs to her widowed mother, and a long mental decline. In the aftermath of rejection from a writing program, she becomes too depressed to sleep or even read. Staring at her book, she begins to hallucinate:

The letters grew barbs and rams’ horns. I watched them separate, each from the other, and jiggle up and down in a silly way. Then they associated themselves in fantastic, untranslatable shapes, like Arabic or Chinese.

At the beach with friends, she feels her rigid exterior cracking. “I was afraid that any moment my control would snap, and I would start babbling about how I couldn’t read and couldn’t write and how I must be just about the only person who had stayed awake for a solid month without dropping dead from exhaustion.”

Esther ﬁts many of the DSM criteria for depressive personality disorder, including “dejection, cheerlessness, joylessness” and being “brooding and given to worry.” She begins electroshock therapy as an outpatient, but her obsession with thoughts of death worsens. She contemplates suicide by opening her veins, but cannot go through with it; by drowning herself in the ocean, but she keeps bobbing to the surface; by hanging herself, but she is unable to ﬁnd a way to do it effectively.

Finally, when her mother is out of the house, she discovers a bottle of sleeping pills that her mother has locked away. She pours herself a glass of water and retreats to the basement, where she starts swallowing the pills:

At first nothing happened, but as I approached the bottom of the bottle, red and blue lights began to flash before my eyes. The bottle slid from my fingers and I lay down. The silence drew off, baring the pebbles and shells and the tatty wreckage of my life. Then, at the rim of vision, it gathered itself, and in one sweeping tide, rushed me to sleep.

This suicide attempt fails, too, but sets off a long round of hospitalizations and treatments, including insulin therapy and more electroshock.

The Bell Jar, originally published in England under the pseudonym Victoria Lucas, is thinly disguised autobiography. In 1953, Plath, a successful student at Smith College, spent part of the summer working for Mademoiselle magazine in Manhattan, returned to suburban Boston to a mental breakdown, then was hospitalized. She eventually returned to Smith, graduated summa cum laude, and won a Fulbright grant. In England, she married the British poet Ted Hughes, and began writing poems herself. She was separated from him, and living in a house in London where the Irish poet William Butler Yeats had once lived, when she killed herself in 1963.

For all its grim subject matter, The Bell Jar is full of humor, particularly in its opening passages, and has been described as a female version of the adolescent rite-of-passage novel A Catcher in the Rye. Enormously popular, it has sold more than three million copies.

Flowers for Algernon

BY DANIEL KEYES, 1966

Charlie Gordon is a 32-year-old retarded man who becomes a genius, thanks to a sketchily described new treatment, only to have the process reverse itself. Charlie himself narrates his transformation from a bakery janitor with an intelligence quotient of 68 to a man with an “intelligence that can’t really be calculated.”

From the crude spelling and painful effort of his ﬁrst journals, the reader follows him through an intellectual explosion that takes him well beyond the capabilities of the neurosurgeons who created his new mind. But the emotional isolation that he knew as a retarded man accompanies him in his new life, since his intelligence is so great that he has no one with whom he can communicate as an intellectual equal. Ironically, his brilliance also enables him to detect a ﬂaw in the experimental method used to increase his IQ. He anticipates— and then lives through—a gradual decline back to his low level of intelligence.

I want to be smart. My name is Charlie Gordon I werk in Donners bakery where Mr Donner gives me 11 dollers a week and bred or cake if I want. I am 32 yeres old and next munth is my birthday. I tolld dr Strauss and perfesser Nemur I cant rite good but he says it don’t matter he says I shud rite just like I talk…

The same thing happened when I tried to discuss Chaucer with an American literature specialist, questioned an Orientalist about the Trobriand Islanders, and tried to focus on the problems of automation-caused unemployment with a social psychologist who specialized in public opinion polls on adolescent behavior. They would always find excuses to slip away, afraid to reveal the narrowness of their knowledge…

Anyway I bet Im the frist dumb persen in the world who found some thing inportent for sience. I did somthing but I don’t remembir what…

Flowers for Algernon (the name refers to a mouse that underwent the same experimental brain treatment) was originally published in 1959 as a short story in The Magazine of Fantasy and Science Fiction, and won a Hugo science ﬁction award. Widely anthologized, it was ﬁrst adapted as a drama for the U.S. Steel Hour on television as The Two Worlds of Charlie Gordon, starring Cliff Robertson, then as a feature ﬁlm for which Robertson won an Academy Award. It was adapted again for television in 1999.

An individual with an IQ of 68 would be classiﬁed under DSM 317, Mild Mental Retardation. “As a group, people with this level of Mental Retardation typically develop social and communication skills… have minimal impairment in sensorimotor areas…can acquire academic skills up to approximately the sixth-grade level…usually achieve social and vocational skills adequate for minimum self-support.” The DSM-IV lists both biological and psychosocial factors as potential causes of mental retardation. These include genetic abnormalities; prenatal changes due to toxins; pregnancy problems such as fetal malnutrition; childhood trauma such as lead poisoning; and environmental inﬂuences, including deprivation of nurturance and of social, linguistic, and other stimulation.

Among other books by Daniel Keyes, who earned his undergraduate degree in psychology, is The Minds of Billy Milligan, a nonﬁction book about a man with multiple personality disorder.

Slaughterhouse 5

BY KURT VONNEGUT, 1969

In World War II, Kurt Vonnegut served in the U.S. Army, was captured in the Battle of the Bulge, and was a prisoner of war in the German city of Dresden when the city was utterly destroyed by round-the-clock raids from British and American bombers. As many as 135,000 people may have died in the ﬁrebombing, a death toll worse than in Hiroshima.

This novel tells in a nonlinear narrative of the capture of a young soldier, Billy Pilgrim, and his survival in a meat locker deep below the place where the prisoners are billeted. This is Schlachthof-funf, or Slaughterhouse 5. The story also bounces back and forth between Billy’s life after the war as an optometrist in upstate New York and (being as well a kind of science ﬁction) his kidnaping by aliens to the planet Tralfamadore.

Twice in the novel Billy Pilgrim ﬁnds himself hospitalized. The ﬁrst time is after he has been separated from his unit, wandered for three days in the snow, been captured, nearly died in a freight car stuffed with other prisoners, and ﬁnally found himself in a prison camp where a group of English prisoners of war entertain their new companions with a stage show. “Billy… not only laughed—he shrieked. He went on shrieking until he was carried out of the shed and into another, where the hospital was…Billy was put to bed and tied down, and given a shot of morphine.”

The second hospitalization comes several years after the war, as he contemplates a career in which he has no interest and marriage to a rich young woman whom he ﬁnds repellent. “He knew he was going crazy when he heard himself proposing marriage to her.” Unable to come to terms with witnessing “the greatest massacre in European history,” Billy had committed himself “in the middle of his ﬁnal year at the Ilium School of Optometry. Nobody else suspected he was going crazy. Everybody else thought he looked ﬁne and was acting ﬁne. Now he was in the hospital. The doctors agreed: He was going crazy.”

While in the hospital, he befriends another veteran. “They both found life meaningless, partly because of what they had seen in the war…So they were trying to re-invent themselves and their universe.”

“Recurrent and intrusive distressing recollections,” a classic symptom of posttraumatic stress disorder (PTSD), according to the DSM-IV, could well describe this novel, although it is written in what Vonnegut describes as a “telegraphic schizophrenic manner” and with a tone of detached and saddened wonder. Billy’s passivity certainly ﬁts in with other DSM criteria for PTSD, such as “numbing of general responsiveness” and “markedly diminished interest or participation in signiﬁcant activities,” along with a feeling of “estrangement from others.” Another indicator is a sense of “foreshortened future,” in which one does not expect to have a normal career, marriage, or life span.

In the novel Billy believes in predestination: “he has seen his own death many times, has described it into a tape recorder. I, Billy Pilgrim, the tape begins, will die, have died and always will die on February thirteenth, 1976.”

Slaughterhouse 5 was published in 1969 and became, like Joseph Heller’s Catch-22, an icon of the antiwar movement

The Eden Express

BY MARK VONNEGUT, 1975

This is an autobiographical account of Mark Vonnegut’s descent into madness, diagnosed at the time (1970) as schizophrenia. His story is unsentimental, poignant, and brutally honest. He neither condemns nor excuses himself, his family, his friends, or the mental health practitioners he encounters.

In retrospect, Vonnegut realizes that he was always “different,” a judgment with which all who knew him concurred. When he is called to take a physical for the draft for Vietnam, he describes going in “so hyped and furious” that he was classiﬁed 4F (undraftable), even without the usual letter from a psychiatrist. “My friends said I should get an Academy Award for my act.”

Drug use was common in his circle at college, but Vonnegut, sensing his vulnerability, for the most part avoided hallucinogens. Adding to his sense of psychological distress was his newly famous counterculture father, Kurt Vonnegut, who had left his mother and moved in with a younger woman. Mark describes himself as “more and more desperately unhappy and self-conscious,” imagining that strangers feel contempt, or more often compassion, for him. But he is always left with a feeling of loneliness.

Complicating his situation was the way the counterculture was challenging the established order during this period. Any action could be deﬁned as political, and anything that opposed authority had merit. At the same time, “hippie” culture provided a safe, nurturing environment, along with permission to see madness as enlightenment.

To help ﬁnd a purpose and a structure for his life, Mark decides to homestead in British Columbia with a group of friends. For some people in the 1970s, this was a social-political experiment. To Mark, however, it was a desperate attempt to forestall what he later determined to be the inevitable.

His ﬁrst psychotic break occurs on a trip back East, where he beat a drug arrest, and consists of episodes of uncontrolled crying, shaking, and social blunders. The symptoms abate when he returns to the farm. He then takes a mescaline trip, ending up in a manic period in which he sees the farm as Eden. Filled with grandiosity, he stops sleeping and eating, writes long letters, and tries to work but loses all coordination. This combination of depressive and manic episodes would probably be attributed today to bipolar disorder (DSM 296.89) rather than schizophrenia—the diagnosis at the time

Mark attempts to fend off a second break by smoking a great deal of marijuana, but eventually his fears grow and his symptoms worsen. The title The Eden Express comes from his feeling of hurtling out of control. “This train is bound for glory. The brakeman has resigned.”

He stops being able to talk—only screams, gestures, masturbates, and tries to kill himself. Exhausted by the 24-hour watch it takes to guard him, his friends reluctantly have him admitted to a mental hospital, where he hears voices, sees visions, and tries to strangle himself. He is treated with thorazine and electroshock.

When he was released from the hospital, Vonnegut adopted a life structure and regimen intended to keep himself balanced: consuming a high-protein diet, avoiding caffeine and recreational drugs, and taking high doses of vitamins and minerals. In fact, Vonnegut “went back to school to learn more about the biochemistry I was suddenly so enthusiastic about” and eventually became a physician.

The Accidental Tourist

BY ANNE TYLER, 1985

Macon Levy, in Anne Tyler’s The Accidental Tourist, has suffered a profound loss. His 12-year-old son, Ethan, has been senselessly murdered in a holdup. Macon’s reaction is simply to carry on as before. He creates a world of routines, rituals, and dependable habits that get him through each day and hold his grief at bay. His wife, Sarah, who is openly experiencing the pain of their loss, becomes more and more resentful and angry at his aloof, methodical exterior.

When Sarah announces she is leaving him, Macon’s response is to pull the car over and “rub his knees with his palms.” Sarah moves out, and Macon reacts by creating yet more rituals aimed at economy and efﬁciency. He washes his clothes by trampling them underfoot as he showers; he sews sheets together to form a seven-layer sleeping bag that provides clean sheets every night for a week. Instead of running the dishwasher, he deposits dirty dishes in the sink in water spiked with chlorine bleach, which he changes on alternate days.

Macon, who makes his living writing a series of “Accidental Tourist” books for traveling businessmen who wish to be insulated from anything foreign or unknown, does question whether he has carried things too far with his “fondness for method.” Had Sarah’s messiness balanced his orderliness? He takes some comfort from knowing that he came from a family of methodical people—his sister and brothers all adhered to strict routines, as did their grandparents, who raised them. But Sarah saw their methodical behavior in a different light. “They have to have their six glasses of water every day. Their precious baked potatoes every night. They don’t believe in ball-point pens or electric typewriters or automatic transmissions. They don’t believe in hello and goodbye.”

The DSM-IV, category 300.3, describes obsessive-compulsive disorder as manifesting repetitive behaviors that a person feels driven to perform, behaviors that are aimed—however unrealistically— at preventing or reducing distress or at forestalling some dreaded event or situation.

When he ﬁrst met Sarah at a college mixer, Macon had reﬂected how sought-after she was, yet it was she who approached him. He decided that the only way to get her was to play it cool, to withhold. Now he felt “locked inside the stand-ofﬁsh self he’d assumed…He was frozen there.”

On the night Ethan died, it was the chitchat in the car on the way to the morgue that he remembers. He ﬂossed his teeth before going to bed. He began clearing out Ethan’s possessions immediately, so they would not be wasted. It was a shock to him that others found this cold.

Now he is left asking himself: “I’m all alone; it’s just me; it seems everyone’s just…ﬂed from me. I don’t know, I’ve lost them, I’m left standing here saying, ‘Where’d they go? Where is everybody?’”

The catalyst for change in his life is Muriel, a zany dog trainer. She is everything that Macon is not—unpredictable, exuberant, youthful. After spending time with her and her boy, Macon begins to realize “that what mattered was the pattern of her life; that although he did not love her he loved the surprise of her, and also the surprise of himself when he was with her.” Muriel gives Macon a photo of herself as a toddler, showing “her spikey, pugnacious ﬁerceness.” It is that ﬁerceness that dissolves his ossiﬁcation. They are both scarred, he realizes. A “sorrow sweep[s] through him” and “his life regain[s] its old perils,” as he falls in love with Muriel and her young son, Alexander.

Headhunter

BY TIMOTHY FINDLEY, 1993

Lilah Kemp, a principal character in Timothy Findley’s novel Headhunter, is a childless former librarian who walks the streets of Toronto pushing an empty baby carriage. She believes that she has the power to bring forth into real life the characters she ﬁnds in books. “I require some news of Kurtz,” she thinks. “I have released him out of Heart of Darkness. He has disappeared and I am afraid. Kurtz, if he puts his mind to it, can destroy the world—and only I can prevent him.”

The medical center where Lilah goes for psychiatric treatment includes a central mall:

There was a swimming pool off to one side where—so it was believed—recreation therapists drowned their charges. And a basketball court where murderers were turned loose every day and allowed to kill one another. Out in the Mall itself, tables were provided for cannibals and other types of feeders to bring their cups of blood and paper plates of human entrails and to sit there feasting, day unto day, on one another.

Lilah, reared in an abusive home, apparently developed her worst symptoms later in life. “That had been before the onslaught of schizophrenia and its distortions—before the shadows of trees had begun to crash in her path and the vines had begun to crawl through the windows to steal the food from her table.”

Findley describes how “Lilah…was subjected to methods considered to be advanced and innovative…forced conﬁnement and massive doses of various neuroleptic drugs…The object of the conﬁnement had been to separate Lilah from her ’imaginary’ companions. The drugs were meant to eliminate these companions altogether.”

But Lilah ﬁnds herself “deprived of her world of wonders…No one understands what I have in here she said to her kitchen one day. I am an open door through which the dead can come and go at will.”

According to the DSM-IV, schizophrenia manifests as a combination of delusions, hallucinations, disorganized speech (frequent derailment or incoherence), and grossly disorganized or catatonic behavior. Among the sufferers are people whose delusions are bizarre or whose hallucinations consist of a voice keeping up a running commentary on the person’s behavior or thoughts, or two or more voices conversing with each other. Subtypes of schizophrenia include catatonic, disorganized (referring to disorganized speech and behavior, ﬂat or inappropriate affect), and paranoid. The essential feature of the paranoid type, from which Lilah suffers, is “the presence of prominent delusions or auditory hallucinations in the presence of relative preservation of cognitive functioning and affect; delusions are typically persecutory or grandiose, or both.”

Paranoid schizophrenia often appears in adulthood; its victims, properly medicated and treated, can retain the ability to lead independent lives, as indeed does Lilah Kemp.

Findley is a well-known Canadian writer. His interest in issues of mental health was obvious in the title of his first novel, published 1967: The Last of the Crazy People.

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Madness in Good Company: Great Literary Portrayals of Brain Disorders

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Junky

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