The Center Cannot Hold: My Journey Through Madness

#214
Title: The Center Cannot Hold: My Journey Through Madness
Author: Elyn R. Saks
Publisher: Hyperion
Year: 2008
351 pages

In the tradition of Kay Redfield Jamison, Elyn Saks, a person with a major psychiatric disorder, presents her own history from childhood to her present status as a successful professional specializing in that disorder. In Saks's case, that disorder is schizophrenia, a diagnosis with a much poorer prognosis for a successful adulthood than many other others.

Saks's account is both readable and meticulous, with only a few editing problems. She is careful neither to overdramatize nor underplay her psychotic episodes or her progress and great accomplishments. Anyone who has been forcibly put into mechanical restraints in the last couple of decades and been evaluated frequently for a lower level intervention (or has successfully pursued a grievance if they were not) has Saks to thank for her legal advocacy.

I would have liked to know more about the quality and character of her relationships with family and friends, but recognize that memoirists may choose to protect aspect of their own and others' privacy. I also would have liked to have a better sense of her psychosis. This is an area where Saks tells more than she shows.

Saks suggests, and I agree, that there may be many causes of schizophrenic spectrum disorders; this in turn implies that different people will have different constellations of disordered thinking, some more pernicious, some more dangerous, and some more treatable. When she is psychotic, Saks experiences what seems to be poor judgment, low insight, disorganization, and a relatively consistent set of paranoid delusions. At the same time, she seems to have good or very good responses to several medications, to recompensate quickly, to return to her high level of baseline functioning, to maintain meaningful and complex relationships, and to have a good emotional range. Since she also describes a variety of other physical problems, it would not surprise me if her schizophrenia were related to a greater underlying physical problem.

As a side note, I enjoyed reading about Saks's long friendship with her law school friend Steven Behnke. Behnke is now the head of the American Psychological Association's Ethics Office and I've attended a number of his workshops. I'd be interested to know how he would tell the story of his friendship with Saks, as Ann Patchett did with Lucy Grealy in Truth and Beauty.

I am not sure why Saks's diagnosis is schizophrenia rather than schizoaffective disorder. The big difference between these schizophrenic spectrum diagnoses is the presence of a mood disorder simultaneous with an episode of the thought disorder, and Saks is often diagnosed as depressed while she apparently is also psychotic. Since she works in psychiatry, I assume that she is accurate and that the evidence for this differential diagnosis is not reported in her memoir.