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Living with Schizoaffective Disorder

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The Schizophrenic Symptom
of Flat Affect

How I compensate for my inability to express my feelings directly
by expressing them through writing and music instead.

Michael David Crawford
mdcrawford@gmail.com

August 16, 2006

Copyright © 2006 Michael David Crawford.

Creative Commons License
This work is licensed under a Creative Commons Attribution-NoDerivs 2.5 License.

I am often warned that my time here at Kuro5hin exacerbates my symptoms of mental illness. But in one very important way Kuro5hin serves as a medical device that enables me to enjoy a certain very important component of sanity that would otherwise be largely unavailable to me.

It enables me, for a time, to live free of a devasting symptom that was notably absent from my list of symptoms that I published three years ago in Living with Schizoaffective Disorder because I was at the time so completely in its grip as to be unaware even of its existence. While I had by then undergone over a decade of psychotherapy, I had not yet gained the insight necessary to recognize this symptom, let alone do anything about it.

As I will explain, it is also one of the most difficult symptoms for mental health practitioners to treat. While some claim that some newer medications can help, that's not my own experience. I have found that talk therapy helps, but only very slowly, over a period of years.


Contents

What Kuro5hin Does for Me

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What Is Kuro5hin?

Kuro5hin (pronounced "corrosion") is a community discussion website that focusses on technology and culture. The articles published there are written and edited by the members, who also vote whether to accept or reject each article submitted. It is located at:

www.kuro5hin.org

(Yes, that's a five in the URL).

This essay was featured on Kuro5hin's front page in August 2006. Kuro5hin's copy of this essay also includes a followup discussion.

An article at the Campaigns Wikia discusses Kuro5hin's history and culture.

What kind of sanity can Kuro5hin possibly give me that my doctors, with all their years of training cannot? Simple: the expression of human emotion. My schizoaffective disorder renders me largely incapable of it.

You will surely protest that my writing clearly demonstrates that I am by no means an unemotional person. And that's the very point I'm trying to make. If it weren't for my writing, which takes place mostly at Kuro5hin, I would be almost completely incapable of expressing any emotion whatsoever.

The symptom is known clinically as "flat affect". "Affect" is the clinical psychological term for one's emotional expression; for one's affect to be flat means that one is devoid of any emotional expression.

And if any of my Kuro5hin friends were ever to encounter me in Meatspace, that would be by far your overwhelming impression of me: I am a blank slate, hardly ever able to crack the barest of smiles, even when I try.

But you see, flat affect is not the absence of emotion. I am under the impression that even many mental health practitioners don't know it's true nature, as those of us who experience it are so unable to make our feelings known to our therapists. No, flat affect is not the absence of emotion, but our inability to express it outwardly, publicly, in such a way that other people are able to connect to us.

I am unable even to express my feelings towards my own wife Bonita. She has always found me disturbing because she is normally quite keenly attuned to human feelings; she can read the feelings of anyone like the pages of a book.

But not my feelings. To her I am, in her words, "an enigma".

Imagine my lifetime of torment, when I tell you that for my entire existence I have known the very heights of passion, that most tranquil of joys, the lustiest of libidos, the sweetest of sorrows, the torment of seemingly-endless despair, furious anger, well you get my drift, my list could go on and on. I am a helpless little boat tossed constantly by the stormy sea of my feelings.

My Kuro5hin friends will already know from my writing that I am among the most emotional of men, quite often irrationally so. So you must certainly understand my lifetime of repeated, inevitable disappointment that my overwhelming experience in trying to relate to other human beings has always been an absolute...

Utter...

Failure...

To connect.

Because so much of human relationships are based so intimately on our emotional expression, our empathy with the emotions of others, or our fearful reactions to their wrath.

For all my life, I have been largely unable to even register 1.0 on the Emotional Richter scale.

Except when I write.

It didn't come automatically; I had to work hard, over a period of years, to learn to express my feelings through my writing. Thus most of my earlier written work is purely technical, meant to inform but not to convince or to convey any sort of feeling.

I often despaired at my inability to express my feelings in writing, but one way or another I learned to do so. It wasn't by any educational method I set out to practice.

It was largely by writing diaries, and followup comments to the diaries and stories of others, at first at Advogato, and then here at Kuro5hin.

Just as riding a bicycle is a skill one can learn but cannot be taught, I learned to express my feelings right here in Kuro5hin, in my writing.

Just ask trane and Orion Blastar Again - they are schizoaffective too. Orion Blastar Again experiences flat affect. I don't know as again I never asked, but I suspect trane's notorious misogyny is the result of his inability to ever connect emotionally with a woman.

Another Way Out

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There is one other way I can express my feelings, and I am able to do so in a way that far exceeds any expression I can accomplish with my writing. Hence my endless diaries espousing its importance to me, my struggles against its seemingly-insurmountable difficulties, my grand plans to go back to school at well-over forty years old to study...

Music

I was able to express myself in my music for many years before I could do so in my writing. My piece Recursion, my own personal favorite of my own compositions, was composed during a period in my early twenties when I was almost continuously suicidal for a period of several years.

By expressing my sorrow through playing Recursion, I was able to find some meaning in my seemingly-endless torment of despair. The worst torment can be borne by almost anyone if it serves some higher purpose. The worst torment of all is to suffer for no good reason whatsoever.

How Music Expresses Emotion

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nombre claims that one cannot really express emotion through music. Most people are certain that music expresses emotion because of their own experiences with it, but that's not a rigorous argument. The fact that one can, and how it is expressed, is well-known.

I discussed this a while back in an essay called I Have So Many Questions About Music. I considered the question of why music matters so much to us. The reason I gave is that music makes us feel connected to others. To feel connected is a desperate need, not just of humans but of many animals as well. It is a need that can be satiated for a time through music, but that can never be completely fulfilled:

Thousands of years ago, the Buddha explained that the fact that we are ultimately all alone in the Universe is the cause of much of humanity's despair. Many of the ways we seek to fill this void, such as striving for wealth or love, ultimately cause even more sorrow than they cure. Buddha's solution is to simply accept our loneliness. Such acceptance is the cause of the deep, abiding sadness many Buddhists feel.

But we can forgot our sorrow for a little while by using music to connect ourselves to each other. I explain how we are connected by quoting Philip Dorrell:

In order for the listener to perceive patterns of neural activity in the speaker's brain, there would have to be some relationship between neural activity patterns in the speaker's brain and neural activity patterns in the listener's brain, in a way which preserves the geometric nature of those patterns, at least to a sufficient extent that the patterns can be perceived. This implies some form of "neural mirroring". The mirroring does not necessarily have to be very accurate - it just has to be accurate enough that some observation can be made of the patterns of activity in the speaker's brain.

Then I explained:

Music makes us feel connected because it transports a complex and time-varying neurological and psychological process from the brain of the performer to the brain of the listener. It enables us to think the thoughts, and to feel the feelings of another living being. It enables us to become one with them, and in this way pierce the boundaries that separate us, so that for a few fleeting minutes we no longer feel so alone.

I'm afraid I never finished that essay. After my wife read my explanation of Why I Write, she said "You're chasing a White Rabbit down its rabbit-hole". She was right: five days later I went to the emergency room. I told the doctor that every previous time I felt the way I did then, I soon required admission to a psychiatric inpatient unit. He sent me on my way with enough Librium to stun an ox.

My psychiatrist called me later that day. After I told him what happened, he said "If you're having some kind of psychotherapeutic breakthrough, taking medicine for anxiety will lessen its effect."

Heeding his advice, I did not take any more.

Schizophrenia's Negative Symptoms

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I wrote in Living with Schizoaffective Disorder that being schizoaffective was like being manic depressive and schizophrenic at the same time. (There is also a more common form of schizoaffective disorder that is like being a "unipolar" depressive rather than manic depressive.) The symptoms I described included mania, depression, dissociation, auditory and visual hallucinations and paranoia.

Mania and depression are the symptoms I share with manic depressives. It turns out that dissociation is a symptom of neurosis, not schizophrenia as I first thought. The hallucinations and paranoia are the symptoms I share with schizophrenics; these are known as "psychotic" symptoms, or disorders in thought, while mania and depression are "affective" symptoms, or disorders in mood.

Each of these psychotic symptoms are classified as positive symptoms, in that they add something to my experience that should not normally be there. Completely unmentioned in my essay are the negative symptoms, so-called because an experience or behaviour that is normally present is missing or diminished.

Flat affect is such a negative symptom: emotional expression that is normally present is missing. One can also be missing emotion entirely, which happens to me sometimes, but flat affect is still present even when my emotions are otherwise normal.

One cannot tell by watching someone whether they really feel flat or just appear that way. My affect is flat when I feel joy but cannot smile, or feel sad but cannot cry; instead I show only a pokerface. I may try to force a smile to show others my happiness, but it won't appear genuine. They will have the sense that I'm just faking it. Bonita often expresses frustration at being unable to get any reaction out of me. I tell her "I really am happy to see you. I'm just not able to show it."

Flat emotion isn't the simple absence of emotion: everyone is calm at times. Instead feelings don't appear in response to events that would normally stimulate them. One reacts to news both happy and tragic with dispassion or disinterest. One no longer finds pleasure in activities that one once enjoyed.

Some of the other negative symptoms are catatonia, poor or inappropriate social skills, difficulty in speaking or thinking logically, and social isolation.

Some of the negative symptoms, especially flattened affect, lack of emotions and social isolation are also symptoms of severe depression. It is often difficult to correctly diagnose many mental illnesses because some symptoms are common to several possible diagnoses. Most symptoms come and go over time, so one must observe the patient over a long period of time to see if new symptoms eventually show themselves.

More Serious Than You Would Expect

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You might ask whether flat affect is really all that serious, given that one can still experience normal emotions, just not express them. Am I not able to enjoy life just like mentally healthy people?

Yes one can, but is unlikely to unless one finds a way to overcome or compensate for flat affect. Left untreated, flat affect all by itself can be devastating or even fatal.

Flat affect prevents us from forming or enjoying normal human relationships. Schizophrenics and schizoaffectives have difficulty finding friends, enjoying the company of other people, starting or maintaining romantic relationships, and getting or holding jobs.

It's actually worse than that. Flat affect makes us sicker than we would otherwise be.

Schizophrenia can have a sudden or slow onset. Slow onset schizophrenia is very common, with the transition from health to full sickness often taking a number of years. Quite often the appearance of new symptoms is so slow as to be unnoticable, with the first sign of trouble being that the sufferrer has become so crazy as to be brought to a psychiatric inpatient unit by the police.

The reason that one's friends and family do not notice is that the sufferrer gradually withdraws from human contact. Sometimes subtle paranoia causes one to distrust strangers who might otherwise become friends. Flat affect prevents others from enjoying our company, so others withdraw from us.

Social isolation is very dangerous to the mentally ill. One way sane people stay sane is that others around us let us know when we are straying from the rational path. If I were to post something crazy here at K5, one of you would probably say "Hey Mike, what you just said is crazy". If I'm not too delusional, that may be all the treatment I need to stay healthy.

If others don't enjoy my company, I won't enjoy theirs. Thus flat affect leads schizophrenics to avoid even trying to make friends, even if we are not paranoid. Eventually there is no one to correct our delusional thinking, and our thoughts stray farther and farther from reality.

I claimed flat affect can be fatal: suicide is very common among schizophrenics. Complete isolation is a very lonely experience, often a heavier burden to bear than we are capable of carrying.

At my first therapy session after my first hospitalization in November of 1984, my therapist urged me always to live with other people, never to get a house or apartment where I lived alone.

The Therapeutic Treatment of Flat Affect

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All of the negative symptoms are notoriously difficult to treat. It is much easier to stop something abnormal than to add something which is missing.

While antipsychotic medication has been available for decades, it didn't work very well at first. "Classic" antipsychotics like thorazine and haloperidol require such large doses that they often cause terrible, debilitating side effects. Some patients found them so unbearible they refused medication, preferring their delusions and hallucinations to the tremors, seizures and sedation caused by their medications.

Treatment of schizophrenia was revolutionized with the discovery of the "atypical antipsychotics", starting with Clozapine, licensed by the FDA in 1989. Lori Schiller wrote in her book The Quiet Room that her severe schizophrenia so resisted treatment that she was hospitalized for many years before being accepted for treatment with Clozapine during its experimental trials. She now lives independently and is able to hold a job.

I myself have taken Risperdal since my hospitalization for mania and psychosis in the Spring of 1994. It is also recommended for bipolar mania. At the time of my hospitalization, it had been on the market for only a few months, and seemed to be regarded by the hospital staff as a wonder drug.

All the antipsychotics reduce the activity of the neurotransmitter dopamine as an excess of it is the immediate cause of psychotic symptoms. The atypical ones also effect serotonin and sometimes other neurotransmitters.

The classic antipsychotics were largely ineffective for treating negative symptoms. Atypical antipsychotics are thought to be somewhat helpful, but I cannot tell if there is any difference as a result of my Risperdal. I'm not usually aware when I don't express my feelings though, and emotional expression is often subtle, so it is quite possible that it helps me without my being able to tell.

However, I have come a long way in overcoming flat affect: when I commenced psychotherapy back in Santa Cruz in 1986, my complaint was that I was unable ever to get a date, let alone a girlfriend. When I terminated therapy in 2000, I did so because I was moving to Newfoundland for my wedding to Bonita. We recently celebrated our sixth anniversary.

Not often, but sometimes, I am able to bust out and jump for joy. And sometimes, when overcome with grief, I am able to cry.

What made the difference? Practice: one can learn to express emotion through conscious effort. With enough conscious practice, affective expression can become unconcious and natural. However, even after all these years I usually seem stoic and unemotional. That is, except when I play music or write, or am incredibly overcome.

My therapist warned that it was likely to take some time to reach my goal, but she asked me to regard every attempt to attract a woman as practice towards gaining the skills I needed to succeed someday. And friends, that's what I did: during some sessions she assigned me the task of chatting up a strange girl, and at the next we would discuss my experience, as well as how I could do better next time.

While consciously forcing a smile appears insincere, with enough practice and experience one can learn to smile spontaneously. I doubt I will ever be as expressive as I would have been had I never gotten sick, but at least I can now live a more or less normal life.

To Know My Passion

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At a very young age I chose to lead a life of the mind: I wanted to be a scientist when I grew up. I was accepted to the California Institute of Technology to study astronomy in 1982; my lifetime goal was the Nobel Prize in Physics. Things looked promising at first, as I was hired by a Caltech astronomer to help with his data analysis and observing work. We coauthored a few papers in the Astrophysical Journal and spent time at the sixty and two hundred inch telescopes at Palomar Mountain. I had it all!

Or so it seemed. It all came crashing down when I had my first manic episode in the Summer of 1984. My first hospitalization was in November, for acute anxiety. I was diagnosed with schizoaffective disorder in July of 1985, during a six-week hospitalization for profoundly severe mania.

Very few who share my diagnosis are able to provide for themselves as I do. Most have to get by on their government disability checks, be cared for by their families, or try to make it on the street, homeless and tormented by madness and despair.

My madness took all I had from me: my education, my career, my reputation and many dear friends, most of whom refused ever to speak to me again. But I was determined not to let it take everything: I wanted my life back.

While I was accepted to transfer to the University of California Santa Cruz, I often got poor grades because of my illness. My therapist quickly realized I must find a job to support myself.

At the time I looked, dressed and acted just like any other crazy street person, so she was astounded when I showed her my resume one day. As a career in Physics no longer seemed a possibility, our therapy began to focus on finding a new career. I began to teach myself to program computers from books using a Macintosh 512k my roommate and I bought secondhand. I got my first career programming job in November of 1987; I have since been steadily employed as a software engineer for nineteen years. I received my B.A. in Physics from UCSC in 1993.

But I had a problem: as a software engineer, I still lived a life of the mind. That's not good for someone with flat affect, or any kind of mental illness. As I recovered I began to enjoy the experience of my own thoughts and feelings more, but I experienced little of the real world, and other people experienced little from me. It didn't help that I was a hopeless geek.

My wife and I met online in late 1997. During my first visit in January of '98, Bonita noticed my tendency to "space out", or retreat into my thoughts, which was so severe at times that I became completely unaware of my surroundings, unable even to hear her speaking to me. When she urged me to live in the real world, I protested that I had a vivid imagination, and preferred living in my head. A Shambhala Buddhist, she urged me to meditate that I might learn to be mindful. She pointed that I was particularly unmindful as I was prone to bump into other people because I was unaware of their presence.

While reluctant to leave my inner world, I discussed my tendency to space out with my therapist upon my return. She too urged me to give it up.

I am not clear what made the difference, but I don't space out anymore. Most likely it's from being with Bonita, as I previously spent very little time speaking with other people.

After a hiatus of several years, I took up my piano again when we moved to Nova Scotia in the Fall of 2003. Stress from my consulting work caused my paranoia and hallucinations to appear again for the first time since 1994. I knew that playing my piano was one of the few things that I could do completely on my own to comfort myself when I was wigging. I have been taking piano lessons since January of '94, and a few months ago started appearing at a local Open Mic. While I am a long way from passing my music school audition, I am very determined.

These last three years have been a struggle for my wife and myself. While I avoided the hospital, I have required emergency room treatment five times since moving to Canada, the last time just a couple weeks ago. Many times I did not earn enough to get by.

But on the whole, I am improving. If you saw me today you would never suspect I was just in the emergency. I just got a good consulting contract, and this morning will be turning down a highly paid permanent position that I was offerred because I like my new client's work better.

Along with my music, my writing, especially that published at Kuro5hin, was a critical component to my recovery.

Music alone is not enough, you see. My piano so far is only a one-way emotional expression, as I am only just beginning to feel I play well enough to jam with other musicians or play in a band. I am eager to do so: I know very well how much better it feels to play music with others as I used to play the conga in drum circles at the beaches of Santa Cruz.

While I can express feelings by playing piano, even complex feeling, being instrumental music those feelings are raw and pure, with no factual content. It is only through my writing that I am able to explain why I feel the way I do, and to emote in a conversational way, by carrying on discussions with all of you.

All You Need To Know

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For over twenty years I desperately sought the key to happiness . It's easy for me to tell you what that key is; to obtain it is quite another matter. Timothy Miller explained it on page 80 of his book How To Want What You Have:

A sincere and scholarly religious seeker occasionally experimented with mescaline. While spending an evening in his study amid his books, music, and works of art, rapturously intoxicated, he suddenly figured out the secret of happiness. After recovering from his initial exhiliration, he realized he could not trust himself to remember the secret, so he wrote it on a slip of paper where he would be sure to find it later. Sure enough, he felt groggy the following morning, recalling only dimly that he had discovered something momentous. When he eventually came across the slip of paper, he recalled that he had written the secret of happiness on it, and that he had felt quite certain of its power and correctness at the time he had written it. Hands trembling with anticipation, he unfolded the scrap of paper. He had written, "Think in different patterns".

I know you won't believe me, but after twenty years spent learning how, I can reassure you that all it really does take to be happy is to think in different patterns. There are many ways to learn: for me there is therapy, medicine, music and writing. (And yes, meditation, but I'm afraid I'm not a very good Buddhist.) But you must understand that to think in different patterns must be a lifelong quest, as we otherwise slip back into the bad old unhappy thought patterns. One must seek endlessly because the path itself is the goal.

If you are unhappy, I urge you too to learn to think in different patterns.

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