‘“Psychiatric drugs restored Nia’s sanity and destroyed her beauty, and she doesn’t mind.” This narrative co-authored by a young psychiatrist depicts the poignancy of a 17 year-old young woman whose tormenting psychotic symptoms are treated with the antipsychotic drug olanzapine at the price of obesity. The psychiatrist is concerned, makes an unsuccessful attempt to switch the patient to a different antipsychotic drug, resulting in a reemergence of her symptoms, and reluctantly resumes the use of the olanzapine. He feels the patient is caught in a Faustian dilemma of being either ‘beautiful and mad’ or ‘fat and sane.’ This article is being savaged around the web as an illustration of the psychiatrist’s sexist attitude and a reflection of society’s prejudicial attitude about obesity. As a psychiatrist, I am feeling a wee bit defensive, and, with all due respect and support for the senses in which “fat is” indeed “a feminist issue”, I feel that is not a fair characterization of the article or its point.
First, let me say that the authors can certainly be faulted for the flavor of salivating over the young woman’s beauty, but they are partially depicting the way others in her life saw her. The psychiatrist, in puzzling over her Faustian tradeoff, is not so much imposing his feelings about the value of her physical attractiveness as he is curious about the fact that, when she responds to the medicine and puts the weight on, she does not seem to be bothered. The feminist critics assume that that is because her beauty is unimportant to her compared to her sanity, and fault the psychiatrist for being unable to accept that. But to my reading, he is troubled not by the fact that she accepts her weight gain but that she does not notice it.
The author may not have articulated it all that well, but speaking for him it seems that the issue is really that the impoverishment in schizophrenic illness is largely about a growing impairment in social reciprocity and empathic connection with others. One’s feelings about one’s attractiveness are essentially reactions, for better or worse, to an awareness of how others see us. It has been called The Gaze, the way men have of turning a woman into an object, a body. Consciousness-raising about fat and body image requires first that one be aware that one is reacting in a fixed way to societal attitudes and that one has the choice not to any longer. One has to be aware of The Gaze to protest against the objectification. But the faculties of social awareness and social discretion progressively wither as schizophrenic illness progresses. (That is why so much of the illness involves social inappropriateness or bizarreness, with apparent disregard for the effect one is having on others around one. Despite their characterization as irreverent and courageous icons unconcerned with the morés of society and willing to be iconoclasts, schizophrenics are not making a deliberate defiant countercultural statement, they are not being heroes in subverting the dominant paradigms of their society. They are hurting unbearably. They cannot help being unconcerned with social norms because their faculties for interpersonal perception and conformity with norms are progressively deteriorating. Most of them would like nothing better than to fit in. Was it James Joyce who said that the difference between his thought processes and those of his schizophrenic daughter were like the difference between swimming in a strong current and drowning in it?) The psychiatrist, seeing the patient’s apparent indifference to her weight gain, goes the distance in wondering if she is really as better as she is said to be, in the sense I have just laid out, not the sexist one.
A parallel way to understand the schizophrenic process is that the person comes to treat herself and her body as an object. How can a woman rebel against societal objectification if the disease is doing it to her?
One further point should be made. The reason for the prescriber to be leery of the effect a medication like olanzapine has, especially on a young adult, extends far beyond the vanity issue of body weight. The newer antipsychotics were developed to be “cleaner” medications free of many of the side effects of the prior generation of medications for psychotic illness. And, indeed, they do largely avoid the older drugs’ longlasting and disfiguring neurological side effects. But it became evident that many of the so-called benign newer drugs caused a rash of effects of which weight gain is just the tip of the iceberg. These include glucose intolerance, the development or acceleration of diabetes, lipid and triglyceride disturbances, and cardiac and endocrine complications. The article does a disservice by anguishing only over the patient’s weight gain, too inarticulately to convey a more thorough and sophisticated range of concerns, and leaving itself open to being a straw man for a well-intentioned but misguided feminist outcry.
Finally, the psychiatrist considers only a rather limited set of options for treating the young woman. There are other medications and other strategies that stand a chance of combining effective treatment response with avoidance of the metabolic effects the olanzapine had caused. On the other hand, there is an inescapable sense, for anyone who has practiced medicine for any length of time, that there is no free lunch. Treatment choices are almost always nuanced and poignant cost-benefit decisions without unambiguous answers for either the patient or the prescriber. That is where I thought the article in question was going when I began to read it. Sadly, it missed the opportunity to get that deep. (Prospect)