In the months that followed Napa, Kitty found it a great relief to have Harry back at home but also a constant stress to see him lost in his madness. "I would be bringing people in the house and I never knew when he might emerge," Kitty said. "He often went off his meds and had to be rehospitalized. I would look around his room. It was the reverse of people who are addicts. If I didn't see any bottles, I was really worried." He soon moved back to his own apartment. "I would go ring the bell and he wouldn't answer, so I'd let myself in," Kitty said. "I had to go up a very steep staircase, and he would loom at the top. I was pretty sure he wouldn't push me down the stairs, but he would scream and it was scary." Pamela said, "He was hugely fat, incredibly hostile and angry, and didn't believe a word anyone said. His disdain was so evident that it was terrible to talk to him. He was becoming like Jim Morrison in his later years, holed up in the house, filling salad bowls with pasta and eating them in front of the television set. It was hard to imagine him functioning in any way, shape, or form."

Three years after Napa, when Harry was thirty-two, Kitty wanted to give him a fresh start, and she chose McLean, the mental hospital affiliated with Harvard, as the place to do it. "Getting him out of San Francisco and to McLean was an amazing achievement," Pamela said. "I still don't quite know how my mother did that. He was so ensconced in his little hole in San Francisco, and she had to persuade him to go along with it because she didn't have any legal power to make him do it." Harry was admitted as a long-term inpatient. He began new meds and started working with the therapist he has seen ever since. Harry, who is not tall, weighed 220 pounds; the doctors convinced him that this was neither smart nor healthy, and after about six months, he put himself on a diet and started running. Other patients would hum the theme from ensconced in his little hole in San Francisco, and she had to persuade him to go along with it because she didn't have any legal power to make him do it." Harry was admitted as a long-term inpatient. He began new meds and started working with the therapist he has seen ever since. Harry, who is not tall, weighed 220 pounds; the doctors convinced him that this was neither smart nor healthy, and after about six months, he put himself on a diet and started running. Other patients would hum the theme from Rocky Rocky as he went sprinting across McLean's grassy campus. as he went sprinting across McLean's grassy campus.

"It was hard lugging all that blubber around," Kitty said. "Suddenly it dawned on me, why isn't there a fitness center there?" Kitty raised the money to build one. Harry helped pick out the equipment. Kitty's motivation was partly that she believes in fitness, but it also gave her an excuse to be in and out of the hospital without Harry's perceiving that she was constantly checking up on him. The fitness center now receives some seven hundred visits a month. Harry has lost sixty pounds since he went to McLean. "He runs every day," Pamela said. "He talks of having an illness. Frankly, if you had presented me with this scenario before he left San Francisco, it would have seemed like an impossibly upbeat outcome." But the years between his first hints of psychosis and McLean have taken their toll. "Not only was there time lost, but also the brain's not what it was after fifteen years of psychosis," Pamela explained. "He's a very damaged guy, but you can see how smart, articulate, and amusing he is, and what an interesting and dynamic life he might have had. He's sick enough that he can't really do anything, but well enough that he understands how much he's missing. He's well enough to know that he shouldn't tell other people the voices are real, but not well enough to believe it himself. He told me he was worried that 'the board' was going to make these terrible decisions about him. I said, 'God, the thing about these voices that's so unimpressive is how boring and dumb they are. I mean, the board board? The cheesiest TV show could do better.' Then we can laugh. He and I also discuss a real hurdle he has not overcome, which is that he doesn't really want to stop listening to them. Even though they scare him, they've been friends." Kitty said simply, "Harry is having a tough time deciding whether he wants to be in the real world or that other world."

Harry now lives on his own in an apartment in Cambridge. He runs every day for an hour, watches television, and goes to a lot of movies and coffee shops. He sees his therapist. He's interested in fish and has a saltwater and a freshwater tank. He also had a job working in a greenhouse that is part of McLean's vocational program. But in Harry's world, nothing is stable for long, and on one of my later visits with Kitty, she revealed that he had stopped going to the greenhouse. "His world has plateaued at the smallness that it's at," she said. Kitty, she revealed that he had stopped going to the greenhouse. "His world has plateaued at the smallness that it's at," she said.

Kitty wears herself down with the relentless quest to help Harry up, and though she has been more successful than anyone could have hoped, her restless frustration takes a toll. "Having my own children was very freeing," Pamela said, "because I just couldn't live and breathe this every day." While she was saying this to me, Pamela put her cell phone on the table between us. "I have this as much for him as for my kids. He calls me when he's feeling deluded and needs to be talked out of it. I know that if I'm not hearing from him, things are okay." Kitty recognizes the advantages to this situation, but is also frustrated by it. "I had hoped Pamela would be more involved," she said. At the same time, Kitty feels that she should shoulder as much of Harry's care as she can for as long as she can. "He's very lonely, but as soon as anybody tries to befriend him, he starts to have paranoid thoughts about them," she said. "He told me he went running, and this guy says, 'Harry, Harry.' It's the guy who makes pancakes in the diner where he goes. They talked for a while. 'I felt like I was a member of a community,' he said." But Harry and his mother also joke. Kitty has kept a hand in at McLean by redesigning inpatient rooms. Harry said to her, "Gee, Ma, it looks like I've brought you a whole new career opportunity."

Finding the balance between encouragement and pressure remains almost impossible. "He's really doing the most he can right now," Pamela said. "Somehow, I feel like we're twins. There's been almost nothing he's explained that I haven't felt I could extrapolate from my own experience. I'm a fiction writer, and he is also a fiction writer, in his way. He creates other worlds; at times he's lived lived in other worlds. There are characters; there are planets. He has a great aesthetic sense, and that infuses his delusions. It's a very dangerous, scary, lonely world, but it also has moments of beauty in it. My mother deserves huge credit-for just never giving up. My stepfather couldn't stay in there, fighting; it was too painful for him, but it brought out the warrior in my mother. It's my mother, the doctors-and, most of all, Harry. He turns out to have a lot of grit. He's a hero to me. He's someone who's been in Vietnam for fifteen years. He still gets up and finds things to be joyful about. Would I have the stomach for the life he has? I'm not sure I would." in other worlds. There are characters; there are planets. He has a great aesthetic sense, and that infuses his delusions. It's a very dangerous, scary, lonely world, but it also has moments of beauty in it. My mother deserves huge credit-for just never giving up. My stepfather couldn't stay in there, fighting; it was too painful for him, but it brought out the warrior in my mother. It's my mother, the doctors-and, most of all, Harry. He turns out to have a lot of grit. He's a hero to me. He's someone who's been in Vietnam for fifteen years. He still gets up and finds things to be joyful about. Would I have the stomach for the life he has? I'm not sure I would."

Kitty led long stretches of a charmed life before Harry got sick. "I was a lot more frivolous before I was dragged kicking and screaming into the world of mental illness," she said. "Now, I'm always helping people out or offering advice or finding them doctors. I'm sure it's been character-building, but frankly, I preferred being happy and frivolous." She knows that Harry feels guilty about the effect he's had on her life, so she tries to minimize it. I asked her how much of her time and emotional energy Harry occupied, and her eyes filled with tears. She shrugged, and forced a smile. "All of it. All of it," she said, almost guiltily. "I can't help it." She knows that Harry feels guilty about the effect he's had on her life, so she tries to minimize it. I asked her how much of her time and emotional energy Harry occupied, and her eyes filled with tears. She shrugged, and forced a smile. "All of it. All of it," she said, almost guiltily. "I can't help it."

Schizophrenia is broadly categorized as having positive symptoms-the presence of psychotic hallucinations-and negative and cognitive symptoms-psychic disorganization, absence of motivation, blunted affect, loss of language (called alogia alogia), withdrawal, compromised memory, and general decrease in functionality. One expert described it to me as "autism plus delusions," which is an inadequate but not unilluminating description. Here is a patient's description of her positive symptoms: "I could find no rest, for horrible images assailed me, so vivid that I experienced actual physical sensation. I cannot say that I really saw images; they did not represent anything. Rather I felt them. It seemed that my mouth was full of birds which I crunched between my teeth, and their feathers, their blood and broken bones were choking me. Or I saw people whom I had entombed in milk bottles, putrefying, and I was consuming their rotten cadavers. Or I was devouring the head of a cat which meanwhile gnawed at my vitals. It was ghastly, intolerable."

Here, by contrast, is another patient describing the experience of the negative and cognitive symptoms: "I am all the time losing my emotional contact with everything, including myself. What remains is only an abstract knowledge of what goes on around me and of the internal happenings in myself. Even this illness which pierces to the centre of my whole life I can regard only objectively. I cannot picture anything more frightful than for a well-endowed cultivated human being to live through his own gradual deterioration fully aware of it all the time. But that is what is happening to me." The Nobel laureate Eric Kandel described how schizophrenia takes away the wanting of enjoyment. "Imagine someone who has a great time whenever he goes out to dinner, but who has absolutely no interest in doing it," he said. The pleasure principle says that we will always seek gratification and avoid suffering, but for people with schizophrenia, at least half of this is untrue.

Emily Dickinson described such a descent into psychosis with terrifying clarity: I felt a Cleaving in my Mind-As if my Brain had split-I tried to match it-Seam by Seam-But could not make it fit.The thought behind, I strove to joinUnto the thought before-But Sequence ravelled out of SoundLike Balls-upon a Floor.

Though most people experience schizophrenia as just such a sudden cleaving, it appears in fact to be a developmental disorder that is inscribed in the brain even before birth. It is degenerative, unlike autism, which, albeit pervasive and persistent, does not generally become increasingly debilitating over time. There is a rare syndrome of schizophrenia in preadolescence and childhood. The usual course for the condition, however, is that it unfolds through five predictable stages. It is asymptomatic until puberty in the premorbid phase, premorbid phase, though recent research points to delays in walking and talking, more isolated play, poor school performance, social anxiety, and poor verbal short-term memory. This is followed by a though recent research points to delays in walking and talking, more isolated play, poor school performance, social anxiety, and poor verbal short-term memory. This is followed by a prodromal phase, prodromal phase, which lasts for four years on average, in which positive symptoms begin gradually to appear. The adolescent or young adult in this phase experiences changes in cognition, perception, volition, and motor function; has strange thoughts flash across his mind; struggles to understand whether illogical beliefs are true; and becomes suspicious and wary. Some people who will develop schizophrenia seem curiously detached from the real world even in childhood and gradually slip into psychosis. Most appear to have a dramatic break, sometimes in reaction to trauma and sometimes with no obvious trigger, in which they are suddenly transformed beyond recognition. This marks entry into the which lasts for four years on average, in which positive symptoms begin gradually to appear. The adolescent or young adult in this phase experiences changes in cognition, perception, volition, and motor function; has strange thoughts flash across his mind; struggles to understand whether illogical beliefs are true; and becomes suspicious and wary. Some people who will develop schizophrenia seem curiously detached from the real world even in childhood and gradually slip into psychosis. Most appear to have a dramatic break, sometimes in reaction to trauma and sometimes with no obvious trigger, in which they are suddenly transformed beyond recognition. This marks entry into the psychotic phase, psychotic phase, with the onset of hallucinations or bizarre delusions, including delusions of control, thought insertion, thought broadcasting, and thought withdrawal. This usually occurs between ages fifteen and thirty and lasts for about two years. with the onset of hallucinations or bizarre delusions, including delusions of control, thought insertion, thought broadcasting, and thought withdrawal. This usually occurs between ages fifteen and thirty and lasts for about two years.

No one has yet been able to discover what maturational event triggers psychosis. There are three primary possibilities. One is that the teenage rush of hormones changes gene expression in the brain. The second is that myelination, the adolescent process in which the brain wraps neuronal cables in a sheath so that they become maximally functional, goes wrong. The third is that synaptic elimination, or pruning, malfunctions. During normal brain development in infancy, new cells migrate within the brain, position themselves, and establish synaptic connections. An excess of these connections is made; during adolescence, only those that have been strengthened through repetition-that appear useful in the particular person-become enduring neural structures. An unhealthy brain may prune too much, not enough, or in the wrong places. only those that have been strengthened through repetition-that appear useful in the particular person-become enduring neural structures. An unhealthy brain may prune too much, not enough, or in the wrong places.

After somebody becomes ill, further changes occur in the progressive phase, progressive phase, which leads to clinical deterioration except when effectively controlled with medication. As the patient has repeated psychotic episodes, the condition worsens, finding its level after five years or so and settling into the which leads to clinical deterioration except when effectively controlled with medication. As the patient has repeated psychotic episodes, the condition worsens, finding its level after five years or so and settling into the chronic and residual phase chronic and residual phase. By this time, there has been an irrecoverable loss of grey matter in the brain. Positive symptoms tend to fade somewhat, while negative ones become more pronounced. Patients remain disabled, and persistently symptomatic. While more than 80 percent of patients respond well to antipsychotics during a first episode, only half of those treated at this stage show a comparable response.

When Janice Lieber was born, in 1953, her mother, Connie, had preeclampsia, a potentially fatal rise in maternal blood pressure, and the birth was rough. Janice seemed disengaged from the start. Connie thought she might be autistic; the pediatricians said she was mentally retarded. As it became clear that she was gifted at mathematics, the autism diagnosis stuck. At twenty-two, she had a psychotic break during her final year of college. Her father, Steve, brought her home; when she got there, she threw everything she loved out the window because a voice told her to do so. Connie called her doctor, who prescribed Mellaril, an early antipsychotic, for the weekend. Monday, Janice saw a psychiatrist and received a diagnosis.

Connie decided to learn all about schizophrenia, but not much information was out there. Then she and Steve went to Columbia for a meeting on schizophrenia and heard about NARSAD, the National Alliance for Research on Schizophrenia and Depression. NARSAD had at that time raised a total of $50,000 to support scientific investigation. Connie soon became president, a post she held for nearly twenty years; when she stepped down, Steve, who runs an investment fund, took over as chairman. The Liebers built NARSAD into the world's largest private funder of psychiatric and brain research; by 2011, it had given more than three thousand grants totaling almost $300 million to scientists in thirty-one countries. The Liebers personally review over a thousand research applications every year. They focus on original proposals by young researchers who cannot secure other funds. Herbert Pardes, president of NewYork-Presbyterian Hospital, said, "Most Nobel Prize winners could learn science from the Liebers."

Connie and Steve were messianically busy with NARSAD. One of Janice's psychiatrists asked her if she minded her parents being so occupied, and Janice said, "I don't see my mother as much as I'd like, but I know what she's doing. She's giving of herself for me and others. For mankind." Steve felt that their dedication affirmed for Janice how central she was in their lives, while also relieving some of the pressure that goes along with being an ill child. "She was the emblem of the challenge, and that was healthier than being the entire challenge herself," he said. When they began, the Liebers thought it would take ten years to reach a scientific breakthrough that could change their daughter's life. As this did not occur, they wanted to help Janice directly, and in 2007 they opened the Lieber Clinic at Columbia, which provides rehabilitative services. Janice goes to a day program there that teaches interpersonal sensitivity and other practical skills to people with schizophrenia. She has done remarkably well given the ongoing psychosis she faces, and now lives independently.

Connie has advised thousands of parents. "My name was on a lot of materials," she said. "And we never had an unlisted phone number; I don't believe in that. Anyone could find us, and if I could help them, I would." She smiled. "Some people take advantage, but I listen to them."

Schizophrenia, like like autism, autism, is a blanket term. Eugen Bleuler, who coined the word in 1908, actually referred to is a blanket term. Eugen Bleuler, who coined the word in 1908, actually referred to schizophrenias schizophrenias. In 1972, the eminent neurologist Frederick Plum famously said, "Schizophrenia is the graveyard of neuropathologists," meaning that no one had understood or would understand its etiology. We now understand more of schizophrenia than we do of autism. It is unclear whether schizophrenia should be subtyped according to biology (genotype) or behavior (phenotype). Despite the variety of genotypes and phenotypes for schizophrenia, no particular form or course of the disease has been linked to a particular set of genetic markers. Some people without the gene defects have the illness, and some people with these mutations do not; they are markers for vulnerability rather than guarantees of disease. One member of a family with a defective gene can be schizophrenic, but another member with the same gene defect might be bipolar or severely depressed.

Schizophrenia clearly runs in families; the most reliable predictor of developing the condition is having a first-degree relative who has it. But most who develop schizophrenia don't have such a relative. "Fact one: most schizophrenics do not have a schizophrenic parent," Deborah Levy, a practicing psychologist and a professor at Harvard, said. "Fact two: the incidence of schizophrenia is not decreasing, and in some places it is actually increasing. Fact three: schizophrenics have a very low reproductive rate. So how do we account for the persistence of the genes that give rise to it? One possible explanation is that most carriers and transmitters of schizophrenia genes are not schizophrenic." Identical twins show only a slightly higher than 50 percent concordance rate-the shared vulnerability is enormous, but the consequences of that vulnerability are by no means predestined. The children of the well twin and those of the ill twin are at the same escalated risk for the disease. So a person can have the susceptibility genes, not express them as schizophrenia, then transmit them to his or her children, who may develop schizophrenia. Nobody knows what protects some gene carriers from the condition. One mechanism of psychosis is an imbalance in neurotransmitters, particularly dopamine. Schizophrenic brains show reduced volume in the frontal cortex and hippocampus, and dysregulation of the striatum. Genetics most likely mix with environment to cause a shift in biochemistry, which then has a degenerative effect on brain structures. New work suggests that a genetic vulnerability may be activated by a parasite. places it is actually increasing. Fact three: schizophrenics have a very low reproductive rate. So how do we account for the persistence of the genes that give rise to it? One possible explanation is that most carriers and transmitters of schizophrenia genes are not schizophrenic." Identical twins show only a slightly higher than 50 percent concordance rate-the shared vulnerability is enormous, but the consequences of that vulnerability are by no means predestined. The children of the well twin and those of the ill twin are at the same escalated risk for the disease. So a person can have the susceptibility genes, not express them as schizophrenia, then transmit them to his or her children, who may develop schizophrenia. Nobody knows what protects some gene carriers from the condition. One mechanism of psychosis is an imbalance in neurotransmitters, particularly dopamine. Schizophrenic brains show reduced volume in the frontal cortex and hippocampus, and dysregulation of the striatum. Genetics most likely mix with environment to cause a shift in biochemistry, which then has a degenerative effect on brain structures. New work suggests that a genetic vulnerability may be activated by a parasite.

Everyone has a blueprint of thirty thousand or so genes, but the way those are expressed depends on the way the chromosomes are configured and on how external processes suppress or enable gene expression. A great deal of biochemistry determines when, how, whether, and to what extent a gene will be activated, and schizophrenia genes may go unexpressed, while protective genes may be overexpressed. As in autism, instead of a single genetic anomaly accounting for a large proportion of cases, a multiplicity of so-called private mutations private mutations-many, copy-number variations-may each be sufficient to cause the illness. These occur more often in offspring of older parents, especially older fathers. Another mechanism is spontaneous genetic mutation, the same process responsible for most occurrences of Down syndrome. It is now emerging that some spontaneous genetic defects, be they changes in copy number or single gene mutations, are found in schizophrenia, autism, and bipolar disorder. Is mental illness on a single spectrum, rather than a set of discrete disease entities? "I'd say it's more like a grid," said John Krystal, chairman of Yale's Department of Psychiatry and editor of the preeminent journal Biological Psychiatry Biological Psychiatry.

The best way to determine what the gene defects are actually doing is to insert them artificially into the genomes of lab mice. The animals are observed to see if they mimic aspects of the illness in humans; then researchers try to understand how the gene is affecting brain development. Of course we have no way to tell if mice are hallucinating. Some such transgenic mice, however, become reclusive, hyperaggressive, or asocial; some refuse to affiliate with animals of the opposite gender or recoil from strangers. Many refuse to do work rewarded with food, giving up on tasks that normal mice will gamely pursue-a startlingly good approximation of the demotivation of schizophrenic people. Eric Kandel, who conceived and is designing some of these vast research protocols, has come to what he terms a "paradigm shift for schizophrenia." Many illnesses arise from the way a gene expresses itself ongoing; turn off the gene, and the symptoms vanish. Schizophrenia may originate in genes, but turning them off will not mitigate the illness; once it's in play, it must play itself out. asocial; some refuse to affiliate with animals of the opposite gender or recoil from strangers. Many refuse to do work rewarded with food, giving up on tasks that normal mice will gamely pursue-a startlingly good approximation of the demotivation of schizophrenic people. Eric Kandel, who conceived and is designing some of these vast research protocols, has come to what he terms a "paradigm shift for schizophrenia." Many illnesses arise from the way a gene expresses itself ongoing; turn off the gene, and the symptoms vanish. Schizophrenia may originate in genes, but turning them off will not mitigate the illness; once it's in play, it must play itself out.

In 2011, I was privy to a conversation between a biotech executive and James Watson, the Nobel Laureate who, with Francis Crick, discovered the structure of DNA, and who has a son with schizophrenia. The executive opined that schizophrenia research was diffuse and chaotic; he had a grand scheme for getting everyone to collaborate, so people could each benefit from the knowledge of others. He had hoped he could inspire a breakthrough if he raised $400 million to address the problem. Watson said, "We're nowhere near the stage where collaboration is useful. We don't know enough; there's nothing anyone has figured out for anyone else to build on. We need an insight, not a refinement. If I had your four hundred million dollars, I'd find a hundred bright young scientists and give each of them four million. If I chose right, one of them would come up with something."

Every family member of a person with schizophrenia whom I met was scared by these genetic vagaries. One man told me that his girlfriend had refused to marry him because his schizophrenic brother represented a risk to his future children. "The history of schizophrenia is the history of blame," Maryellen Walsh has written in her guidebook for families and friends of people with the condition. Mothers have borne the brunt of such blame. Freud never suggested that early trauma engenders schizophrenia and did not advocate psychoanalysis for psychotic disorders. The poisonous term schizophrenogenic mother schizophrenogenic mother was put forward by the Freudian analyst Frieda Fromm-Reichmann in 1948. In her wake came theories of schizophrenia in which the entire family was to blame. One author wrote, "The patient's function is similar to that of an unsuccessful mediator of the emotional differences between the parents." Another, Gregory Bateson, said that schizophrenia is likely to occur for "a child whose mother becomes anxious and withdraws if the child responds to her as a loving mother." Such thinking was an antecedent to systems-oriented family therapy, based on the idea that the psychopathology of an entire family was manifested in a single individual as psychosis. was put forward by the Freudian analyst Frieda Fromm-Reichmann in 1948. In her wake came theories of schizophrenia in which the entire family was to blame. One author wrote, "The patient's function is similar to that of an unsuccessful mediator of the emotional differences between the parents." Another, Gregory Bateson, said that schizophrenia is likely to occur for "a child whose mother becomes anxious and withdraws if the child responds to her as a loving mother." Such thinking was an antecedent to systems-oriented family therapy, based on the idea that the psychopathology of an entire family was manifested in a single individual as psychosis.

Thomas Insel, director of the National Institute of Mental Health, said that the most notable progress since the 1950s has been the end of the "blame and shame" game, but in my experience of people dealing with schizophrenia, both blame and shame remain highly operative. In 1996, two decades after the family systems theory had slipped out of vogue in professional circles, a national survey found that 57 percent of respondents still believed that schizophrenia was caused by parental behavior. An epidemic of self-help books such as the runaway bestseller The Secret The Secret argue that mental health is simply a matter of positive thinking. William James called earlier versions of this philosophy, written into Christian Science and other American metaphysical movements of the nineteenth century, "the religion of the healthy minded," celebrating "the conquering efficacy of courage, hope, and trust, and a correlative contempt for doubt, fear, worry." This concept is popular for its suggestion that healthy people have earned their health through personal courage. For those who are unwell, however, the suggestion that flawed discipline and weak character are the source of their psychosis is torture. argue that mental health is simply a matter of positive thinking. William James called earlier versions of this philosophy, written into Christian Science and other American metaphysical movements of the nineteenth century, "the religion of the healthy minded," celebrating "the conquering efficacy of courage, hope, and trust, and a correlative contempt for doubt, fear, worry." This concept is popular for its suggestion that healthy people have earned their health through personal courage. For those who are unwell, however, the suggestion that flawed discipline and weak character are the source of their psychosis is torture.

When mothers internalize blame, it interferes with the very support that people with schizophrenia most need. "I sometimes felt as though I wore a scarlet letter 'S' emblazoned upon my chest," wrote the bioethicist Patricia Backlar, who has a schizophrenic son. "That 'S' might stand for schizophrenogenic, but is as likely to impute personal shame." Another mother wrote, "An entire generation of mental health professionals was educated to believe that families cause schizophrenia. Some are still treating our sons and daughters. And still mistreating us." The psychiatrist E. Fuller Torrey, founder of the Treatment Advocacy Center, finds the blame problem absurd. "Any parent who has raised a child knows that parents are not powerful enough to cause a disease like schizophrenia simply by favoring one child over another or giving the child inconsistent messages," he wrote.

When the doctors at Long Island Jewish Hospital wanted to recruit Philip and Bobby Smithers for a genetic study of schizophrenia in the 1990s, their mother fought to keep them out of it. "What's in it for us?" she asked. In the first decade of the new millennium, Philip, Bobby, and their unaffected older brother, Paul, were in their thirties, and Paul's wife, Freda, wanted to know how vulnerable her children might be. As Freda began investigating the extended family, she found illness everywhere: Paul's aunt had been institutionalized her entire adult life with "postpartum depression," an uncle was "sick in the head," and many "quirky" cousins could barely function. Although Paul and Freda were high school sweethearts, Freda had met Paul's father only once before their marriage, because Paul kept everyone away from him. "You'd think that when Paul's brothers both started acting strange," Freda said, "their mother would have told the doctor that there's a family history of schizophrenia. But that's not the way they do it, so it took years for them to be diagnosed." were high school sweethearts, Freda had met Paul's father only once before their marriage, because Paul kept everyone away from him. "You'd think that when Paul's brothers both started acting strange," Freda said, "their mother would have told the doctor that there's a family history of schizophrenia. But that's not the way they do it, so it took years for them to be diagnosed."

Secrecy is a difficult habit to break. "Every year we have a Thanksgiving for Freda's family, and then we have one for mine," Paul said. "If we mix the two, I'm defensive, my mom is defensive of my brothers, and it's upsetting to Freda's family to see these sick people. I don't discuss this with even my closest friends. I'm not in denial, like the rest of my family. I just don't like talking about it. I have an emotional connection with my brothers. I think about them every day. But do I have a relationship with them? Not really. They're very highly medicated."

Paul and Freda, who now have two sons, live in terror of seeing them develop schizophrenia. They considered using a sperm donor, but couldn't bring themselves to do so. "We're making genetic rolls of the dice," Paul said. Freda described her fear as a constant mental drain. She added, "We torture them in some ways. I read an article saying that people who develop schizophrenia have particular traits. We strip them naked; we're going through their whole bodies looking for webbed toes. Someone said more schizophrenics are born in the winter, so we timed it to have summer babies. Nutty, I know. In some ways, it's very liberating. Everyone wants their kid to be the smartest and the most athletic. We really don't care. As long as they're healthy." In 2008, Paul and Freda agreed to participate in a survey on schizophrenia genetics. "We sit by the phone," Freda said, "waiting to find out what the gene is, so we can test the kids."

In 1668, John Bunyan wrote, "Let them...recover one to his wits that was mad...and he that can do thus...shall have the name and fame he desires; he may lay abed till noon." There was little progress between Bunyan's times and modernity; for centuries, treatments for schizophrenia were ineffectual, barbaric, or both. In the nineteenth century, they included pulling teeth; in the middle years of the twentieth, they included lobotomy.

The development of antipsychotic medications, beginning with Thorazine in 1950, has been a miraculous breakthrough in treating schizophrenia's positive symptoms. Unfortunately, these medications have negligible effects on negative symptoms. As Helen Mayberg, chair of neuroimaging at Emory, said, "It's as though you've got a house that's burning down; you come in with the fire trucks and pump the place full of water; you put out the conflagration. It's still charred, smoke-damaged, flooded, structurally unstable, and pretty much uninhabitable, even if flames are no longer licking the walls." the place full of water; you put out the conflagration. It's still charred, smoke-damaged, flooded, structurally unstable, and pretty much uninhabitable, even if flames are no longer licking the walls."

The damage done by the disease persists, and the techniques for mitigating that damage constitute their own ordeal. Thorazine flattens personalities much as lobotomy did, and while newer medications are somewhat better, the number of people with schizophrenia who go off their medications indicates how detested they are by the patients who must take them. In the 1970s, the Soviets administered antipsychotics for torture and subjugation and were able to induce symptoms of psychological disability with them. "One loses his individuality, his mind is dulled, his emotions destroyed, his memory lost as a result of the treatment, all the subtle distinctiveness of a person is wiped away," said one survivor of such treatment at a Senate hearing on Soviet abuses of psychopharmacology. "Although I am afraid of death, let them shoot me rather than this." A patient named Janet Gotkin described her contemporaneous treatment in the American psychiatric system in similar terms: "I became alienated from my self, my thoughts, my life, a prisoner of drugs and psychiatric mystification; my body, heavy as a bear's, lumbered and lurched as I tried to maneuver the curves of my outside world. These drugs are used not to heal or help, but to torture and control." Another patient said, "The muscles of your jawbone go berserk, so that you bite the inside of your mouth and your jaw locks and the pain throbs. Your spinal column stiffens so that you can hardly move your head or your neck, and sometimes your back bends like a bow and you cannot stand up. The pain grinds grinds into your into your fiber. fiber. You ache with restlessness, so you feel you have to walk, to pace. Then as soon as you start pacing, the opposite occurs to you; you must sit and rest." These accounts relate to older antipsychotics and neuroleptics, but the side effects of modern medications differ more in degree than in nature. You ache with restlessness, so you feel you have to walk, to pace. Then as soon as you start pacing, the opposite occurs to you; you must sit and rest." These accounts relate to older antipsychotics and neuroleptics, but the side effects of modern medications differ more in degree than in nature.

By the time I began to meet members of his family, Malcolm Pease was dead at fifty-two, but it was not yet clear why he had died. The previous twelve years had been the best of his adult life. Then one day a nurse at his group home found him curled up in what looked like a comfortable position, cold and dead. "He was very overweight," his brother Doug said, "largely from the medication. He had a lifetime of heavy smoking behind him. Because he was young, there were police; pretty much on the spot they ruled out suicide."

Of seventeen children in Malcolm's generation, siblings and cousins, four have severe mental illness. Many prefer not to discuss it, a position for which Penny Pease, Malcolm's mother, eighty-five when he died, has disdain. "I talk about it all the time, with a lot of people," she said. for which Penny Pease, Malcolm's mother, eighty-five when he died, has disdain. "I talk about it all the time, with a lot of people," she said.

In high school Malcolm had no meaningful signs of illness. "He was a really good athlete," Penny recalled. "He was a fantastic bridge player, and cribbage, and, oh, boy, was he competitive. He loved skiing; he loved everything. We had no clue." During his freshman year at Franklin Pierce, in the winter of 1975, he began hearing voices and developing paranoid fantasies. In March, his roommate called to tell the Peases that something was horribly wrong, and Malcolm's parents brought him home. "We knew he was in trouble," Penny said. "He wasn't making much sense." His brother Doug said, "He was completely out of control, didn't know why, and we didn't, either." The following November, Malcolm assaulted his father. "My parents sent him to the Institute of Living in Hartford, Connecticut, which was among the better private mental hospitals," Doug said. "It was captivity, really. They were feeding him sedatives. Your brother is a ghost in his former body, whom you can't reach because he's so dulled down. The other patients look like Night of the Living Dead Night of the Living Dead." Malcolm soon signed himself out against advice, and his parents initiated a proceeding to have him committed. Over the years, he had to be recommitted dozens of times.

When he was not hospitalized, Malcolm lived with his parents. "My parents tried to love him back to health," said Malcolm's other brother, Peter. But Malcolm wouldn't stay on his medication. Their sister, Polly, said, "Once he was feeling normal, he would think, 'I don't need to take these anymore.' Then you crash and burn again. And again. And again." When he wasn't taking his drugs, he would become paranoid. "Everybody who came near, he would think, 'Oh, you're just trying to put me in the hospital and force me to take antipsychotics,'" Peter said. "Of course, he was right."

Everyone tried to keep up as much normality as possible. "All you can do is tell him what reality is, in a loving way," Doug said. Polly remembered, "Some of it was just funny. I remember he asked my mother where she was when Martin Luther King was shot and whether she could prove she didn't do it." Sometimes poetry crept in, too. When asked at one of his admissions what he was thinking, he said, "I do not like sex or French kissing. There is gas outside of the Indian Ocean, and there are diamonds up in the North Pole." Despite the madness, he sustained a central coherence. "He didn't disappear," Penny said. "He still liked animals, and playing cards. He missed the friends he'd had before he became sick." Polly said, "The thing that made him himself was always there. It just wasn't where you could find it all the time."

The hospitalizations became increasingly frequent. "The ongoing discussion, year after year, was, 'You have to stay on medication,' and Malcolm refused," Doug said. "Off the meds, he felt freer, more alive. Sort of high. Also mostly distraught. Would you rather be awake and alive, or a walking zombie? He would try to find the sweet spot in the middle." When Malcolm's father developed cancer, Peter decided that it was time to step in. "I carried the essence of who Malcolm was with me and never let who he became take that over," Peter said. discussion, year after year, was, 'You have to stay on medication,' and Malcolm refused," Doug said. "Off the meds, he felt freer, more alive. Sort of high. Also mostly distraught. Would you rather be awake and alive, or a walking zombie? He would try to find the sweet spot in the middle." When Malcolm's father developed cancer, Peter decided that it was time to step in. "I carried the essence of who Malcolm was with me and never let who he became take that over," Peter said.

One of the first antipsychotics, clozapine, had been taken off the market in 1975 because it can reduce the concentration of white blood cells, a condition called agranulocytosis agranulocytosis. Researchers eventually realized that clozapine was the most effective treatment for schizophrenia, and that for many patients its efficacy outweighed the side-effect risk. Malcolm started on clozapine when it returned to the market in 1990. Peter said, "There was always enough of who he really was for me to love, but sometimes it got squeezed rather mightily. Then with clozapine, it came back. The smile, the laugh, the sense of humor. If you know who somebody is, you can lead them back to themselves." In his human relationships, Malcolm remained deeply caring. "He was always just worried about everybody else," Polly said. Doug expressed enormous sympathy for Malcolm's reality: "He always felt he had wronged people along the way. We found a letter dated 2002 from his original doctor. Thirty years later, it says, 'Dear Malcolm, To the best of my knowledge, no, you never hurt anyone. Hope you are well. Sincerely, Dr. Koff.'" Penny said, "He never changed that way. I never loved him less because he was sick; I never loved him more; I never even loved him differently."

At thirty-nine, Malcolm graduated to a supported home in Framingham and got a job bagging groceries at the Stop & Shop. "That's what he could handle, and it was awesome," Doug said. "We were dancing in the streets." Malcolm had done well on the clozapine for about five years, and then it all began to come apart again. "He was always tinkering with his medication," Doug said. "He had to be hospitalized again. I was in the hospital to visit him, and the doctor says, 'Well, Malcolm is heading home now. He'll be just fine.' So I take him back to Framingham. He makes a suicide attempt that evening, ingesting laundry detergent." Malcolm was rushed back to the hospital. "It's ridiculous to try to commit suicide by eating Tide," Peter said. "The imagery, though, is interesting. I'm gonna wash this disease right out of my body!"

Polly's first husband and Peter's first wife had been afraid of and intolerant of Malcolm, and it had created tension in those marriages, both of which ultimately dissolved. However, all of Malcolm's nieces and nephews loved him. "He's just his own particular strong essence," Peter said. "There was no other weirdness going on than his being crazy. When he was well, we had great times." Malcolm's years in Framingham were relatively happy. He had refused to drive for decades, but after he went on clozapine, that changed, and Peter bought him a Ford Ranger. "That was one of the best days of my whole life, to see him driving out of that dealership with this huge smile on his face," Peter said. Malcolm was beloved at the Framingham home. One of the other residents told Peter, "Every morning, Malcolm would come down to the common room and say, 'Maurice, where can I take you today?'" Peter said, "Part of his ministry was driving people in his red truck, like a taxi service." and nephews loved him. "He's just his own particular strong essence," Peter said. "There was no other weirdness going on than his being crazy. When he was well, we had great times." Malcolm's years in Framingham were relatively happy. He had refused to drive for decades, but after he went on clozapine, that changed, and Peter bought him a Ford Ranger. "That was one of the best days of my whole life, to see him driving out of that dealership with this huge smile on his face," Peter said. Malcolm was beloved at the Framingham home. One of the other residents told Peter, "Every morning, Malcolm would come down to the common room and say, 'Maurice, where can I take you today?'" Peter said, "Part of his ministry was driving people in his red truck, like a taxi service."

No one expected Malcolm to die when he did. Peter said, "Of course the illness reduces your life expectancy, and the medication, even though it's helping you, reduces your life expectancy, too. But at least he got himself to the best place he could. We'll take this death because of the quality of life he had."

Malcolm had been part of a McLean study on the genetics of schizophrenia. After he died, researchers there said they'd like his brain to study. Penny endorsed the idea. Doug enjoys repeating his comment at the memorial service: "Malcolm didn't complete college because of his illness. But he finally got into Harvard, and he's teaching the neuroscientists." The coroner's office took blood samples, just to rule out the possibility of wrongdoing. A few months later, the family learned that clozapine ended the same life it had redeemed. "We didn't realize death by clozapine was even possible, but are gradually learning more about it," Peter wrote to me. "It seems that toxic levels of clozapine built up over time because his liver was not processing it. Some have suggested to us that liver function should be tested regularly to make sure there is not a buildup in toxicity, and that this is a matter of standard practice. So it is probably a malpractice issue, which we won't pursue. At high levels, apparently clozapine can cause heart arrhythmia, and coma/respiratory arrest. Now we are left with the final tragedy-the medications we forced him to take, which he railed against and fought with all his spirit for most of his life, killed him. It is probably good that we did not know the cause of death before we celebrated his life and had the memorial service. This news beats us down, and it is very hard to rise up singing."

The liberation movements of the 1960s questioned the very concept of mental illness. Michel Foucault mounted a systematic assault on the idea that insanity was anything more than a power play by self-declared sane people. Erving Goffman maintained that mental hospitals made people crazy. R. D. Laing said, "There is no such 'condition' as schizophrenia but the label is a social fact and political event," spoke of schizophrenia as a "special strategy that a person invents in order to live in an unlivable situation," and maintained, "Madness need not be all breakdown. It may also be breakthrough. It is potentially liberation and renewal, as well as enslavement and existential death." Thomas Szasz emerged as the great apologist for the idea that schizophrenia is always a fiction. sane people. Erving Goffman maintained that mental hospitals made people crazy. R. D. Laing said, "There is no such 'condition' as schizophrenia but the label is a social fact and political event," spoke of schizophrenia as a "special strategy that a person invents in order to live in an unlivable situation," and maintained, "Madness need not be all breakdown. It may also be breakthrough. It is potentially liberation and renewal, as well as enslavement and existential death." Thomas Szasz emerged as the great apologist for the idea that schizophrenia is always a fiction.

The last generation has witnessed a great social experiment called deinstitutionalization, deinstitutionalization, which has removed people with acute mental illness from large state institutions, reducing the number of schizophrenics in long-term custodial care in the United States from more than half a million in 1950 to some forty thousand today. This movement draws on a curious mix of valid optimism, economic expediency, and ideological rigidity. While previous treatment of schizophrenics was inhumane, current treatment is often negligible. Money and personnel were never shifted to the community facilities that were supposed to provide services after the institutions were closed; federal guidelines are incredibly vague, and oversight is virtually nonexistent. which has removed people with acute mental illness from large state institutions, reducing the number of schizophrenics in long-term custodial care in the United States from more than half a million in 1950 to some forty thousand today. This movement draws on a curious mix of valid optimism, economic expediency, and ideological rigidity. While previous treatment of schizophrenics was inhumane, current treatment is often negligible. Money and personnel were never shifted to the community facilities that were supposed to provide services after the institutions were closed; federal guidelines are incredibly vague, and oversight is virtually nonexistent.

The vision of treatment as a mechanism of social control infuriates people who are trying to advance encompassing treatment policies. E. Fuller Torrey, perhaps the most prominent critic of the social realities around schizophrenia, has said, "Freedom to be insane is an illusory freedom, a cruel hoax perpetrated on those who cannot think clearly by those who will not think clearly." Judge Berel Caesar wrote bitingly in 1990, "The right to treatment has become the right to no treatment," with the result that "we have consigned many persons to lives of quiet desperation, have destroyed the mental and emotional health of those who love and care for them, and have destroyed families-to the ultimate detriment and even destruction of the disabled person."

The therapist Ann Braden Johnson, author of Out of Bedlam: The Truth About Deinstitutionalization, Out of Bedlam: The Truth About Deinstitutionalization, complains of "the myth that mental illness is a myth" and argues that deinstitutionalization was the result of a politics that emerged as ideas about deviants changed, which was in turn the result of the emergence of biological psychiatry, which made it logical to spend mental health dollars on something other than custodial care. Near-universal institutionalization was ruinous, but near-universal deinstitutionalization is equally bad. The schizophrenia researcher Nancy Andreasen points out that state hospitals were "small communities unto themselves, where patients lived together as a family complains of "the myth that mental illness is a myth" and argues that deinstitutionalization was the result of a politics that emerged as ideas about deviants changed, which was in turn the result of the emergence of biological psychiatry, which made it logical to spend mental health dollars on something other than custodial care. Near-universal institutionalization was ruinous, but near-universal deinstitutionalization is equally bad. The schizophrenia researcher Nancy Andreasen points out that state hospitals were "small communities unto themselves, where patients lived together as a family and were given a chance to be productively employed by the hospital farm, kitchen, or laundry." One of the new system's fallacies is its ambition to order. "The patients I see don't fit readily into most existing programs, and programs they might fit in simply don't exist," Johnson wrote. "Bureaucrats who drew up programs often have never seen a patient, much less treated one." A vacuum of empathy exists in any system that returns people who don't know how to be in a community to communities that may not be prepared to handle them. The lack of support and erratic access to medication often result in rapid deterioration, but family members who attempt to arrest that are frustrated by the courts. The elderly father of one schizophrenic said, "The authorities say it is their choice and their right to live like stray animals. Why is rapid suicide illegal and gradual suicide a right?" and were given a chance to be productively employed by the hospital farm, kitchen, or laundry." One of the new system's fallacies is its ambition to order. "The patients I see don't fit readily into most existing programs, and programs they might fit in simply don't exist," Johnson wrote. "Bureaucrats who drew up programs often have never seen a patient, much less treated one." A vacuum of empathy exists in any system that returns people who don't know how to be in a community to communities that may not be prepared to handle them. The lack of support and erratic access to medication often result in rapid deterioration, but family members who attempt to arrest that are frustrated by the courts. The elderly father of one schizophrenic said, "The authorities say it is their choice and their right to live like stray animals. Why is rapid suicide illegal and gradual suicide a right?"

When Madeline Grammont's brother William began to act erratically, their father refused to acknowledge what was going on. William had earned a perfect score on his math SATs and had been admitted to Harvard as a sophomore. By the end of his junior year he had to leave. "My father was mortified," Madeline said. William went up to his family's country place in New Hampshire. "He was subsisting on raw garlic and had knives sitting everywhere," Madeline said. "He was sleeping on the floor. My father found a small house for him in the woods, away from the summer community, so no one would see him. In fact, my father saw him only three times in thirty years." Once a week, William walked down to the town general store, usually clothed in just a towel, talking to himself; local teenagers would taunt him. His father maintained that he was just a touch eccentric, but his sister worried, and as their domineering father grew feeble in old age, she went up to see William. "Mice and rat turds everywhere, mayonnaise jars opened and rotting," she said. "Broken dishes everywhere. His bedroom was truly disgusting. He looked at me curiously, but he had lost his language. He made little squeaking sounds, and that was it."

So Madeline took over the case. She sought legal guardianship, obtained a diagnosis of schizophrenia, and brought him to a residential care center. There he began using rudimentary speech again. "I brought him flowers once-some lilies-and he leaned over and smelled them," she said. "I brought them every single time thereafter and I still do. I take him out every two or three weeks. He can't initiate conversation and he talks very little, but he seems increasingly able to understand. He basically saw his first treatment at age fifty-two. That kind of denial, the way my father was-it ate him alive, and now he's just a hollow wreck. A whole life slipped away, that didn't have to."

The brain is composed of grey matter, made of cell bodies; white matter, the axons that connect the cell bodies and create synapses; and ventricles, fluid-containing spaces that allow for circulation of the cerebrospinal fluid. When you lose brain tissue, you have bigger ventricles, and a cardinal feature of schizophrenia is enlargement of the lateral ventricles. While autism is characterized by an overabundance of synaptic connectivity, schizophrenia is marked by a dearth of it. People with schizophrenia also have fewer dendritic spines, which form synapses, and fewer interneurons, a type of brain cell that regulates mental activity. The positive symptoms of schizophrenia appear to be tied to abnormalities in the temporal lobe, where auditory and emotional perception are located. The negative symptoms appear to be tied to damage to the frontal and prefrontal lobes, where cognition and attention are based.

Genetic vulnerability to schizophrenia is subject to precipitating traumas, including variations in the uterine environment. Obstetrical, labor, and delivery complications are bad for a developing fetal brain, and schizophrenia patients are more likely to have a history of them. Maternal infections such as rubella and influenza during pregnancy also increase risk; the high rate of winter births of people who develop schizophrenia is probably linked to increased second-trimester maternal viral infections. Stressful events during pregnancy have been correlated with schizophrenia; the rate is higher, for example, for children of women who lived through a military invasion while carrying, or whose spouses died during their pregnancies. Famine in Holland during World War II led to a dramatic increase in the incidence of schizophrenia twenty years later. Scientists have proposed that prenatal stress results in the release of hormones that disturb fetal neurodevelopment; stress can activate the mother's dopamine system, and that may dysregulate the fetus's.

Postnatal events such as a head trauma in early childhood increase the risk of developing schizophrenia. Lifetime stress plays a role, too; the risk is particularly high among immigrants who go from underdeveloped settings to cities-people confronting exponential unfamiliarity. The most consistent postuterine environmental factor associated with a worsening of psychotic symptoms is the abuse of recreational drugs, including alcohol, methamphetamines, hallucinogens, cocaine, and marijuana, particularly in adolescence. When the Japanese gave methamphetamines to workers to increase productivity during the postwar recovery, they provoked epidemic levels of psychosis; although many people recovered after they stopped using the drugs, others had transient recurrence, and some had prolonged and even permanent impairment. A seminal study done in the 1980s with some fifty thousand Swedish conscripts showed that those who had used marijuana more than fifty times were six times more likely to develop schizophrenia. "The relationship between drug abuse and psychosis is perhaps like that between smoking and lung cancer," said Cyril D'Souza, a psychiatrist at Yale. "It's a contributing, not a necessary, cause. But some studies suggest that if you were able to eliminate cannabis, you could reduce world rates of schizophrenia by at least ten percent." transient recurrence, and some had prolonged and even permanent impairment. A seminal study done in the 1980s with some fifty thousand Swedish conscripts showed that those who had used marijuana more than fifty times were six times more likely to develop schizophrenia. "The relationship between drug abuse and psychosis is perhaps like that between smoking and lung cancer," said Cyril D'Souza, a psychiatrist at Yale. "It's a contributing, not a necessary, cause. But some studies suggest that if you were able to eliminate cannabis, you could reduce world rates of schizophrenia by at least ten percent."

In schizophrenia, some gene-environment combination causes the neurotransmitters dopamine, glutamate, norepinephrine, serotonin, and GABA to become dysregulated, leading to excess activity in one dopamine pathway. This induces psychosis and other positive symptoms. Artificially releasing too much dopamine can provoke the symptoms of schizophrenia even in healthy subjects; suppressing it can mitigate those symptoms. Underactivity in another dopamine pathway creates impaired cognition and other negative symptoms. Antipsychotic medications block the ability of the brain to process high levels of neurotransmitters in some areas; they mimic controlled levels of those neurotransmitters in others. All successful antipsychotics lower dopamine levels, but lowering dopamine is not by itself enough consistently to remit all of the symptoms of schizophrenia, and new research focuses on drugs that will affect particular receptors for glutamate and other transmitters. Anissa Abi-Dargham at Columbia University is delineating which dopamine receptors are overstimulated and which are understimulated, to map ever more specific goals for medications.

Nonchemical interventions can play a meaningful secondary role. Talk therapies can help in the management of symptoms that do not respond to medication. Though cognitive behavioral therapy (CBT), which teaches people to redirect their present thoughts and behaviors, has the strongest track record, many other talk therapies have powerful exponents, and the law professor Elyn Saks has written movingly of her redeeming experiences with psychoanalysis in her battle with schizophrenia. What you do with your brain changes it, and if you can get someone with schizophrenia into a rational mode for some time, the positive effects are substantive. The theory is that much as someone who loses speech in a stroke can relearn talking through speech therapy, someone with psychosis may be able to train his way partially out of it.

Since the disease is associated with a progressive loss of grey matter in the brain, it makes sense that if you identify people quickly, treat them, and keep them well, you can limit the morbidity of the illness and prevent people from becoming irreversibly impaired. "The therapeutic nihilism that pervaded the field for the better part of the twentieth century is really no longer warranted," said Jeffrey Lieberman, chairman of the Department of Psychiatry at Columbia and director of the New York State Psychiatric Institute. "There is no better time in the history of mankind to have a mental illness than now, as long as you know where and how to obtain good treatment fast." As with autism, early detection and intervention may be key, an idea that has now engendered an International Early Psychosis Association. Early behavioral intervention in autism can diminish the expression of symptoms; the training seems to affect the brain's actual development. Early intervention may be equally promising in schizophrenia, even if them, and keep them well, you can limit the morbidity of the illness and prevent people from becoming irreversibly impaired. "The therapeutic nihilism that pervaded the field for the better part of the twentieth century is really no longer warranted," said Jeffrey Lieberman, chairman of the Department of Psychiatry at Columbia and director of the New York State Psychiatric Institute. "There is no better time in the history of mankind to have a mental illness than now, as long as you know where and how to obtain good treatment fast." As with autism, early detection and intervention may be key, an idea that has now engendered an International Early Psychosis Association. Early behavioral intervention in autism can diminish the expression of symptoms; the training seems to affect the brain's actual development. Early intervention may be equally promising in schizophrenia, even if early early means age eighteen years rather than age eighteen months. Thomas McGlashan, a professor of psychiatry at Yale, has proposed that earlier diagnosis and medication during someone's first dip into psychosis may actually truncate the brain degeneration that otherwise characterizes advancing schizophrenia. means age eighteen years rather than age eighteen months. Thomas McGlashan, a professor of psychiatry at Yale, has proposed that earlier diagnosis and medication during someone's first dip into psychosis may actually truncate the brain degeneration that otherwise characterizes advancing schizophrenia.

Given the inadequacy of cures, the increasing focus is on getting in even earlier-on prevention at the prodromal (pre-psychotic) stage. Patients are in what Lieberman calls a "Humpty Dumpty situation," in which "with our current tools it's easier to prevent the morbidity of schizophrenia from occurring than to restore people after it's happened." As Jack Barchas, chairman of the Department of Psychiatry at Cornell, points out, the longer you can keep someone functioning, the more solid psychic history he has to fall back on-so even delaying the onset of schizophrenia would have value. Experts have devised a menu of symptoms that indicate the prodromal stage: suspiciousness; unusual, magical, or bizarre thinking; extreme changes in behavior patterns; decreased functioning; inability to go to school or function at a job. Confusingly, many of these are also symptoms of ordinary adolescence. In studies that have followed subjects identified as prodromal, only a third have actually developed schizophrenia, though many others will develop serious disturbances. Starting in 2003, McGlashan tried giving the antipsychotic olanzapine (Zyprexa) to apparently prodromal people and showed that the rate of developing schizophrenia was somewhat reduced; it also made many people who might not have gone on to develop the syndrome obese, sluggish, and glassy-eyed. "The positive result was only marginally significant, and the negative result was clear," he said. It's difficult to figure out what to do with these mathematics, because while powerful medications may block the onset of psychosis, those medications have too many undesirable effects to be used on people who may just be presently grumpy, and we cannot now tell the difference. be used on people who may just be presently grumpy, and we cannot now tell the difference.

Studies in England and Australia show that cognitive-behavioral and other nonbiological therapies can diminish or delay the onset of symptoms. Antioxidants and other neuroprotectants such as omega-3 fatty acids may delay the onset of psychosis without side effects. "It doesn't seem to matter what the intervention is," McGlashan said. "The psychocognitive behavioral intervention was just as good as medication. If you can keep them engaged, and relating, and challenging their symptomatic experiences, you can delay this crescendo into an acute psychotic episode. It could be that you are helping to prevent loss of learned connections in the brain." The families of people at high risk of developing schizophrenia should learn what to watch for, and doctors should meet frequently with patients, since they can escalate to psychosis in a few days. While antipsychotics are not recommended until psychosis sets in, aggressive response to anxiety and depression is in order.

A strong movement to categorize the prodromal phase as its own illness in the DSM-5 DSM-5-the diagnostic and statistical manual that is psychiatry's bible-as "psychosis risk syndrome" or "attenuated psychosis syndrome" was abandoned in the spring of 2012. The diagnosis would have given doctors protections and compensation for treating patients aggressively-but because the degree of psychosis risk in any individual is so difficult to quantify, the framers of the new DSM DSM eventually determined that there was too much potential for unnecessary, stigmatizing, and harmful treatment. It makes sense that someone at risk for developing schizophrenia be treated with benign interventions and close monitoring, but the issue of stigma cannot be ignored, as it pertains to both self-image and medical insurance. McGlashan wrote, "The bottom line for me is that the psychosis-risk syndrome should be treated as a bona fide psychiatric disorder; it is real, and it can be very dangerous if ignored." John Krystal, however, pointed out, "The earlier you are in any mental disease process, the less you know what you're dealing with. Earlier intervention is almost always preferable and harder-sometimes so hard that it's not preferable. What they do in the eventually determined that there was too much potential for unnecessary, stigmatizing, and harmful treatment. It makes sense that someone at risk for developing schizophrenia be treated with benign interventions and close monitoring, but the issue of stigma cannot be ignored, as it pertains to both self-image and medical insurance. McGlashan wrote, "The bottom line for me is that the psychosis-risk syndrome should be treated as a bona fide psychiatric disorder; it is real, and it can be very dangerous if ignored." John Krystal, however, pointed out, "The earlier you are in any mental disease process, the less you know what you're dealing with. Earlier intervention is almost always preferable and harder-sometimes so hard that it's not preferable. What they do in the DSM DSM is a fashion question, like skirt lengths. But we have a dichotomous medical system. Good clinicians will lie about their patients' symptoms to get them insurance coverage and treatment if they seem to be sick, while poor ones will punish patients on this checklist basis." is a fashion question, like skirt lengths. But we have a dichotomous medical system. Good clinicians will lie about their patients' symptoms to get them insurance coverage and treatment if they seem to be sick, while poor ones will punish patients on this checklist basis."

Even with early identification, it can be a challenge to sustain treatment over the life span. Lieberman tells of a patient he treated early in his career: "He was twenty-one years old, Ivy League school, top of his class, popular, athlete, seemed to be destined for greatness. He developed psychotic symptoms, and I diagnosed schizophrenia and gave him medication. He had almost complete remission. Then he wanted to go back to school, and he didn't like the medication, so he stopped taking it. He became sick again, came back, we treated him, he improved, went back to school, and relapsed again. We treated him, and he made progress. Repeated again. The next time, he didn't get better. He never recovered." psychotic symptoms, and I diagnosed schizophrenia and gave him medication. He had almost complete remission. Then he wanted to go back to school, and he didn't like the medication, so he stopped taking it. He became sick again, came back, we treated him, he improved, went back to school, and relapsed again. We treated him, and he made progress. Repeated again. The next time, he didn't get better. He never recovered."

George Clark is a physicist at MIT who works on theoretical astrophysics; he is both kind and almost entirely occupied by intellect. His wife, Charlotte, is capable of toughness after a tough existence, at once judgmental and sympathetic, as though it were her habit to find weakness everywhere around her and then forgive it. She has bright blue eyes behind wire-rimmed spectacles, snow-white hair neatly kept, and capable hands that she uses for punctuation when she speaks. They were both in their eighties when we met, and I saw with what gratitude George handed difficulty over to Charlotte.

When George and Charlotte married in 1980, each had a problematic daughter. George had Jackie, then nineteen, diagnosed with schizophrenia four years earlier. Charlotte's daughter Electa, the same age as Jackie, was disjointed and bewildering, but would not receive a diagnosis for another eighteen years. Charlotte told me that George had had a harder time than she because Jackie had once been so promising, whereas Electa had been odd all along. "I knew the day I gave birth that she was different," Charlotte said. "She was limp, like a bag of sugar." Charlotte tried to be the same mother to this child that she had been to her other children, but the connection was effortful. "She was oblivious. Other children were afraid of her; they saw that something was strange there." The family was living in Pakistan because Electa's father was working for USAID. The older children thrived at the international schools, but at five, Electa couldn't follow what was going on. A year later, her father was transferred to Jordan. She went to the American school in Amman, had a remedial tutor, and was coached by Charlotte. "By eight, she could read," Charlotte said. "But she wasn't interested; in fact, she wasn't interested in anything."

When Electa was nine, her father died suddenly of a heart attack, and Charlotte moved the family to Washington, DC. Electa was bullied in the local fourth grade; Charlotte put her in a special school, which helped briefly. By fourteen, she was out of control. "She was fucking, if you'll excuse the expression, anybody who would, and she was flunking out," her mother recalled. "So I sent her to boarding school. She was very unhappy there. I said, 'I was unhappy when you were here. You have to graduate from high school.' So she earned her GED. Then she said she would be a hairdresser. I thought, 'Hairdresser?' But she loved it and did well at it. Those were her best days. But slowly, slowly, she was going crazy." have to graduate from high school.' So she earned her GED. Then she said she would be a hairdresser. I thought, 'Hairdresser?' But she loved it and did well at it. Those were her best days. But slowly, slowly, she was going crazy."

One bright October morning, Charlotte called Electa, then thirty-seven, and Electa said, "I can't talk on the phone." Charlotte said, "Come over and have a cup of coffee." When Electa arrived, she said, "I can't talk in the house." So Charlotte said, "Let's go for a walk." Electa explained that she couldn't talk on the pavement, either; she could talk only if they walked in the middle of the road. So they dodged cars while Electa explained that the Mafia at MIT was after George, and that he might be part of it. A few months later, Charlotte received a call: one of Electa's friends had found her at the gym curled up in the fetal position, crying. The friend took her to the emergency room, where the doctors tried to do an EKG. Electa began screaming and thrashing and ended up in the psychiatric ward, where she finally received a schizophrenia diagnosis; she was also an alcoholic.

Over the following years, Electa's psychosis was contained by medication, but she suffered endless side effects. Her weight ballooned to over three hundred pounds. "She can hardly walk," Charlotte said. "She used to be the beauty of the family." Her enunciation was slowed, and she slept long hours. She met another schizophrenic, Tammy, who became her romantic partner. Then after ten years on clozapine, Electa's condition began to deteriorate in early 2006. "I remember saying to her, 'You're not taking your meds, are you?'" Charlotte recalled. "She said, 'I don't need my meds,' in a very aggressive tone." By October, she wouldn't answer the door, and her phone was disconnected. Neither Tammy nor Charlotte could find out what was going on. "She had a credit card on my account," Charlotte said, "and I yearned for the bill so that I could see where she had been and know that she was still alive, but when the bill hit ten thousand dollars, I had to cancel it."

Charlotte finally convinced a judge to authorize the police to break in. "The sink was stopped up, and there was food all over the place and it was crawling with maggots. I had to go back to court twice to have her committed, and when she went to the hospital, they couldn't even get her into a shower. Two nurses had to hold her down when they were washing her. But gradually the medication took hold. She began washing herself, and then she began being happy to see us." Electa, now fifty, hasn't worked since the breakdown. "She still can cut hair, but not as well as she used to," Charlotte said. "I encourage her to cut my hair once in a while, and she cuts Tammy's. It keeps some part of her alive."

Charlotte and George were childhood friends long out of touch; when Charlotte was widowed and George was divorced, they were reintroduced. They deliberately bought a house that didn't have enough space for Jackie and Electa to live with them. "Jackie had been beautiful, highly energetic, and popular," Charlotte said. "She showed early signs of her father's intellect. She was a brilliant flautist, and a champion chess player." When Jackie was fifteen, the math that had come so easily to her a year earlier was suddenly incomprehensible, and George found that he could not explain to her the simple equations that she could once have explained to him. George went to see the chief therapist at MIT, who said that Jackie was schizophrenic. Jackie's mother walked out on them both, leaving a marriage that was already in disarray.

When Charlotte and George got together, Jackie was nineteen and had just been evicted from a group home. "This was when I was deciding whether I wanted to live with George myself," Charlotte said. "I decided I was up for it. Jackie was supposedly taking Thorazine. She was actually flushing it down the toilet. Over dinner the first night after I moved in, Jackie took a plate and threw it across the room. Nobody's ever done that before or since at my table." Charlotte began to lay down ground rules. Shortly after Jackie turned twenty, Charlotte told her to make her bed, and she blew up. George heard her shouting and came downstairs. "He's very strong," Charlotte said. "So is she. He took her by both wrists; she was spitting in his face. He kept holding her. Finally she said, 'Dad, I don't know what's wrong.'"

A few months later, Jackie hitchhiked from Massachusetts to New York to surprise her estranged mother. When her mother asked her how the trip was, she said she was "only raped five times." Charlotte said, "Of course, you never know what to believe. You don't know what happened and neither does she." In the years that followed, Jackie was in and out of mental hospitals, group homes, and other protective arrangements that varied with the fluctuations of her psychosis. Eventually, clozapine came along. "She's very sweet, now that she's medicated," Charlotte said.

By the time I met Jackie, she was forty-nine and had been on clozapine for fifteen years, and she was living in a group home with seven other women. She spent her days at a day program that she referred to as "the club." If her caseworker deemed it necessary, she was hospitalized for a few days or weeks. Unlike most schizophrenics, Jackie did not become obese on antipsychotic medications. She plays tennis, swims a mile every day, and does yoga. She is antithetical to Electa's melancholy sluggishness.

Every Saturday, Charlotte and George have Jackie and Electa over. Electa often brings Tammy; Jackie sometimes brings one of the other women from "the club" or the group home. "Thankfully, Jackie and Electa like each other as much as schizophrenics ever like anybody," Charlotte said. "I don't want to say I don't want to be their mother anymore. But there comes a point when you're eighty-one and should not have to be taking care of your children as if they were five-year-old tiddlywinkies. I'm not even convinced it's making them happy. Electa remembers how it was to be well, which gets in the way of her being happy. Jackie is too out of it to be happy."

I went to one of Charlotte's lunches. Jackie was instantly engaged, intense and full of questions, while Electa was a manatee, vast, slow-moving, benign. Jackie substituted words for no particular reason, calling her car "my visa," for example. She began lunch by reciting Rilke at a breakneck pace and without expression, but when Charlotte asked her to repeat the poems more clearly, she said, "I can't; it's too painful." She told me proudly how she memorized poetry in the bathtub: "I recite to myself in cold water." She talked persuasively about the importance of physical exercise in the treatment of mental illness, then added, "When I play tennis with my sister, I can tell when she's cheating. She has this way of planning for the future. That's cheating."

Then things lapsed into true chaos. When I asked Jackie about her medications, she explained that she couldn't take birth control pills because she didn't want to have varicose veins. "But I don't think any man except my dad's spirit could make me pregnant," she said. "It says so in the Bible that he wrote. I feel responsible, just like Jesus Christ felt responsible when he handed out two thousand cigarettes. They weren't pans of bread. They were cigarettes, in my opinion. That's why she keeps killing my daughters that I had with my dad's spirit. One of them is ten years older than me for some reason. The other one I gave a dollar and twenty-five cents for a soda. I much prefer to have babies off women. Most people don't admit that they're gay, and they are. They're all gay in my opinion."

Then she looked at me closely and suddenly said, "Would you like more cucumbers?" and offered me the dish. I took some more cucumbers. "I really like my day program," she said, "and I have a real connection to poetry, too. I love making art. It's a real pleasure in my life these days." As seamlessly as we had crossed into psychosis, we were back on solid ground. Jackie was clearly unaware of the shift. Charlotte later said, "It comes and goes. It doesn't seem to be much harm to anyone, including her, though it takes some getting used to."

Electa has few intrusive delusions. "If what Jackie has is schizophrenia," Charlotte said, "I am inclined to think Electa is being medicated for an illness she doesn't have. But of course she does, really; it's just such a diffuse condition." Electa's negative symptoms are far more pronounced. "I just feel lethargic," she said. "I have to really psych myself up for grocery shopping. I can only do it once a month. So I eat a lot of stale things." When I asked Electa about the time when she had gone off her meds and been so ill, tears welled up in her eyes. "I wanted to feel high again," she said. Charlotte said, "I am inclined to think Electa is being medicated for an illness she doesn't have. But of course she does, really; it's just such a diffuse condition." Electa's negative symptoms are far more pronounced. "I just feel lethargic," she said. "I have to really psych myself up for grocery shopping. I can only do it once a month. So I eat a lot of stale things." When I asked Electa about the time when she had gone off her meds and been so ill, tears welled up in her eyes. "I wanted to feel high again," she said.

"I'll help you!" Jackie interrupted. "Wait here," she ordered, and ran off to find copies of her own recent poems. One of them was nearly gibberish, but the other contained these lines: And when I tried to find thelover to show her how much Iloved her, all I found wasemptiness and frenzywith that loud sound in thebackground drowning out myvoice every four seconds...

The "loud sound" is the intrusive voices, rising relentlessly and constantly over any attempt at a rational mind-and a rational mind wrote this poem, which seems startlingly full of self-knowledge for the work of someone who believed she had conceived four hundred babies with her father. I thought of the Erinyes in pursuit of Orestes, the senseless anguish of a ceaseless, externalized torture. I said to Charlotte, "You do have your hands full."

"Sometimes life isn't about choices," she replied.

When a patient's resolve to continue with a detested medication fails, family members are often the first to notice and intervene-despite the obstacles the patient may devise. The parents' affection always aspires to reawaken a comparable emotion in its object. Like those who have autism, people with schizophrenia are often described as incapable of emotional attachment, but this is seldom true. "The blunted affect or emotional vacancy that's become a stereotype of schizophrenia is not blunted all the time and in many cases is not blunted most of the time," Deborah Levy said. Schizophrenia experts Larry Davidson and David Stayner write, "While perhaps appearing as wooden and vacant to others, and perhaps also feeling at an extreme emotional distance even from themselves, people with schizophrenia continue to describe a fervent wish for love and relationships that contrasts starkly with the empty shell image." Parents would do well to know that to most schizophrenics, a penumbra of affection is reassuring, even if it does not seem to penetrate their isolation. the empty shell image." Parents would do well to know that to most schizophrenics, a penumbra of affection is reassuring, even if it does not seem to penetrate their isolation.

Patients who have a trusting relationship with someone-a parent, a friend, a doctor-are more likely to take their medication. "About forty to fifty percent of my patients are noncompliant," said Jeanne Frazier, who works primarily with younger patients at McLean. "Sometimes they will come to me and say, 'Dr. Frazier, I'm feeling better and I want to stop my medication.' It becomes very clear with some that if I don't join them in their wish, they are going to do it anyway. So I say, 'I don't think it's the wisest thing to do, because you will run the risk of recurrence. But maybe at this point in your treatment it's important to find out for sure.' Then we come up with a plan to taper their medication by about thirty percent every week. I'll say, 'I want to support you in what you feel needs to happen. But you have to promise that you and/or your parents will page me immediately if you start hallucinating. You need to agree that if that happens, you're going right back on your medication.' I tell the families about the potential for suicidal ideation. Almost all of them have recurrence of symptoms and realize that they really need the medication. It's a learning process. If you really are decompensated, you lose all self-knowledge, but when you are beginning to decompensate, you know that there's something wrong. They become scared. Then, hopefully, they tell me."

The mother of one schizophrenic told me that her son's therapist had him write out a motto and post it on his refrigerator. "It says, 'I am a good person and other people think I'm good, too,' and it has had an enormous effect on him," she said.

George Marcolo had a lot of friends in high school in New Jersey. He had been a pothead in his teens, and in his senior year he took LSD. A few weeks later, he decided to try it again, but instead of taking one tab, he took four. "After that, things sort of felt weird," he recalled. "I think the acid sped up the progress of the disease, which I guess was already in me." In college, George was a brilliant physicist. "He is the smartest person in our family," his father, Giuseppe, said. George remembered, "November first, 1991, when I was at Boston College, I woke up and I felt like I was on acid. I had not taken anything or done anything. That didn't go away for eight years." George went to a doctor on campus, who said that it would pass. At the time, George accepted that; now he is outraged. "If I heard somebody say, 'I feel like I'm on drugs, but I'm not on drugs,' I'd be like, 'We'd better get you checked out.'"

He was loath to tell his parents or friends what was going on. "I was afraid they'd think I was insane. I substituted alcohol and pot for medicine. Everything was amplified. Food tasted really bad. If I had taken meds back then, I could have avoided eight years of that." Despite his symptoms, he kept up a 3.7 average in physics. "But it is progressive," George said. "The voices became more and more prominent." He took a job with a dot-com start-up on Wall Street. After a few months, he stopped going to work, and nothing his parents could say or do would get him to go back. George's parents had divorced when he was in high school, and he was living with his mother, Bridget. She explained to me, "Young men get out of college and somebody has to kick-start them because they don't realize that they are supposed to make a life. I thought he was in an extreme form of that. I was concerned, sometimes exasperated. But I didn't see the real problem." Things grew stranger. "He said he knew what the neighbors were thinking about down the street," Giuseppe recalled. Bridget was bemused. "Still, I didn't think there was psychosis," she said. afraid they'd think I was insane. I substituted alcohol and pot for medicine. Everything was amplified. Food tasted really bad. If I had taken meds back then, I could have avoided eight years of that." Despite his symptoms, he kept up a 3.7 average in physics. "But it is progressive," George said. "The voices became more and more prominent." He took a job with a dot-com start-up on Wall Street. After a few months, he stopped going to work, and nothing his parents could say or do would get him to go back. George's parents had divorced when he was in high school, and he was living with his mother, Bridget. She explained to me, "Young men get out of college and somebody has to kick-start them because they don't realize that they are supposed to make a life. I thought he was in an extreme form of that. I was concerned, sometimes exasperated. But I didn't see the real problem." Things grew stranger. "He said he knew what the neighbors were thinking about down the street," Giuseppe recalled. Bridget was bemused. "Still, I didn't think there was psychosis," she said.

The Marcolos insisted that George see a therapist, and after about four months he shared that he had been hearing voices. "I was so frightened that I didn't even think of the word schizophrenia, schizophrenia," Bridget said. It took some months for the Marcolos to find their way to David Nathan, a Princeton psychiatrist who has worked with people with thought disorders; he instantly recognized the severity of George's illness and put him on medication. George has not had a job since that postcollege stint on Wall Street.

George used to hide pills in the side of his mouth and spit them out when his parents weren't looking. During a relapse, he crashed his car three times. He finally became medication-compliant after a decade. His voices are persistent, but somewhat banal. "Sometimes they say critical things, but I can ignore that," he said. "Some voices are jerks, you know? You end up having the same conversations sometimes, with a new voice that doesn't know what you told the old voices. At first, I thought the voices were people around me. Then I realized that they didn't even do what they said they were going to do. So now, I hear them, I talk to them, but I don't believe they're going to do anything. While I'm talking to you, I can ignore them. The medication has never made them go away, but it makes it easier for me to deal with them. There's some I like to talk to and some that I can't stand. Even though I hate the whole thing, there are some voices I would definitely miss if they went away."

George moved in some years ago with Giuseppe, who has focused his life almost entirely around his youngest son. "I wouldn't date because I can't afford other distractions," Giuseppe said. "I have to do what I have to do for George." George's older brother has indicated that he will take care of George when Giuseppe is gone. George, thirty-five when we met, was on clozapine and had regular blood tests. "I'm better than I used to be," he said. "I still get a little paranoid when I'm in public, but I can function. My parents have been very vigilant on my medicines, and they pay good attention to my behavior. I don't do too much. I basically talk to the voices all day long. If Dad's home and I'm going to talk to them, I go in another room. I don't like it when people see me talking to myself, even my father." Giuseppe has found ways to deal with the voices. He said, "George is laughing with them and I say, 'George, cut me in, let me know what everyone's saying,' and we joke a bit about it." Bridget said, "It doesn't seem like a very high-level conversation. Like guys standing on a street corner. It upsets me to hear it, but I take a deep breath and I never tell him to stop." have to do for George." George's older brother has indicated that he will take care of George when Giuseppe is gone. George, thirty-five when we met, was on clozapine and had regular blood tests. "I'm better than I used to be," he said. "I still get a little paranoid when I'm in public, but I can function. My parents have been very vigilant on my medicines, and they pay good attention to my behavior. I don't do too much. I basically talk to the voices all day long. If Dad's home and I'm going to talk to them, I go in another room. I don't like it when people see me talking to myself, even my father." Giuseppe has found ways to deal with the voices. He said, "George is laughing with them and I say, 'George, cut me in, let me know what everyone's saying,' and we joke a bit about it." Bridget said, "It doesn't seem like a very high-level conversation. Like guys standing on a street corner. It upsets me to hear it, but I take a deep breath and I never tell him to stop."

George sees Dr. Nathan every week, and Giuseppe usually goes along and sits through the session. George likes the arrangement, which saves him the trouble of explaining everything twice, to his father and to his doctor. "There's not much I can do other than take the meds, see the doctor," George said. "Just hope that the bad events keep to a minimum. My situation is obviously stressful for both of my parents, and I know it's not my fault, but I feel bad about it."

Giuseppe said, "I don't care what it's done to me. But I sit in my room and cry because of what he's missing. What life ought to be about, could be about, and isn't about for him." Bridget said, "He's such a wonderful person-decent, kind, gentle. He deserves so much better. At the beginning, I thought, 'He'll never have a normal life.' You just think, 'What is a normal life? Who has a normal life? What are any of us doing here?' I am so proud of my three sons for what they've accomplished. My oldest son, he's so talented and determined. My youngest son, he's so good at what he does. But George is so decent. Look at all he does with this going on in his head. I might be proudest of him."

Emerging with the early-intervention movement is the recovery movement, which proposes biological treatment to address positive symptoms, and psychosocial methods to ameliorate negative and cognitive symptoms. The focus is on improving the quality of life even for those whose clinical condition is poor, emphasizing that impaired people still have capacities that should be maximized. Case management makes certain that even patients who suffer continued psychotic symptoms, erosion of cognitive ability, and social limitations have somebody to handle their health insurance, take them to doctors' appointments, ensure that they have a place to live. Patients are helped in finding a workplace where their deficits are tolerated and supported; some are given rehabilitation training to develop job skills. Social skills training teaches them how to interact with others in more acceptable ways. Patients do computer-based brain exercises that enhance memory, decision-making, and attention. Any way that people can be knitted into the social fabric is precious. One mother whose son had recently been diagnosed described pulling into a gas station and looking at the teenager working the pump. "Two years ago, I would have thought he was living a sad, wasted, pointless life," she said. "Now I thought, 'Oh, if only my son could be like him.'" in finding a workplace where their deficits are tolerated and supported; some are given rehabilitation training to develop job skills. Social skills training teaches them how to interact with others in more acceptable ways. Patients do computer-based brain exercises that enhance memory, decision-making, and attention. Any way that people can be knitted into the social fabric is precious. One mother whose son had recently been diagnosed described pulling into a gas station and looking at the teenager working the pump. "Two years ago, I would have thought he was living a sad, wasted, pointless life," she said. "Now I thought, 'Oh, if only my son could be like him.'"