What is Schizophrenia?

Alexander Cockburn writes: In 2002 my nephew Henry was diagnosed with schizophrenia at the age of 20. Harrowing times for Henry, his parents ? Patrick Cockburn and Jan Montefiore ? and his younger brother Alexander followed. Henry was expert at escaping from the various institutions in which he was supposedly secured. He would flee into the countryside around Canterbury east of London, often naked in the depth of winter  (as described below in one of his closest brushes with death)  and our whole family would wait bleakly for news, as the police searched for him and the snow fell.

After five years Henry started to recover. Patrick, as he writes in the preface to “Henry’s Demons”, “began to think he and I should write about our experiences. He was ideally placed to write from the inside about what it was like to have an acute mental illness in which trees and bushes spoke and voices called him to flee into the night or to plunge into icy water where he might drown. I believed that Henry and I could serve a broader public purpose by making schizophrenia and illness in general less of a mystery which people are embarrassed to discuss.”

Henry liked the plan.  As he overcame bouts of self-doubt the words flowed and as Patrick rightly  says, “his style had a sort of radiant simplicity and truthfulness about his actions.”  Earlier this year “Henry’s Demons” was published, to great acclaim, on both sides of the Atlantic. There were chapters by Henry and by Patrick , also a long, striking excerpt from his mother Jan’s journal.

Beyond the raw immediacy of the family’s recollected experiences “Henry’s Demons” raises serious issues  about the treatment of schizophrenia,  whether by therapy or drugs. In the first of three excerpts we start here with Henry’s account of his escape into the winter countryside and his experiences in some of the institutions where he was locked up.

Henry might have died like his friend Toby during any of his disappearances or nighttime wanderings through Brighton and the countryside around Canterbury. He did not completely lose his instinct for self-preservation and occasionally sought the help of others, but his survival in the face of so many dangers was largely a matter of luck. I learned later that not everybody who had been admitted to the Priory in Hove, where he had first been taken, had been so lucky.

In February 2001, a year before Henry was there, a young guitarist named Desmond King, aged twenty-six, who was in the grip of a strong psychosis, also had a bed in the hospital. He had been brought there by his father, a tough and energetic retired Irish businessman with the same name as his son, who was convinced that his son would not receive satisfactory treatment at their local National Health hospital. His father supposed his son would be safe in the Priory, behind two sets of locked doors. Five nights later, he received an unexpected telephone call from another hospital in Brighton, the Royal Sussex, saying they had his son, who had been in an accident. “I was totally shocked,” says his father. It turned out that the younger Desmond had gotten out of the Priory. “When I got to the hospital, I was told by the surgeon that it was unlikely that Desmond would survive his massive head injury . . . all his bones were broken down his right side, and both his lungs had collapsed. He was put on a life support machine, but he was not expected to come round. We found out later that he had jumped from the roof of Hove [multistory] car park.”

Fortunately, he was to survive his severe injuries, though he had to endure frequent operations and long months in the hospital. His father, whose courage and determination to help his son I came to admire deeply, was soon to suffer a further calamity. “One morning,” he recalls, “the phone rang at home as I was getting ready to go to the hospital, and it was my brother-in-law. He said, ‘I’m really sorry, but he is dead!’ I sat down on the floor and cried and asked him how he knew Desmond was in the hospital, and it turned out he did not know: He was telling me that my eldest son had died in a motorcycle accident in Smithfield, London.”

This terrible story illustrates the physical perils stemming from mental disorder that threaten anybody suffering from schizophrenia. Many die young. I wanted Henry to get better, but I knew that to do so, he would have to survive self-inflicted dangers, and Jan and I did not think he would do that unless he was legally prevented from leaving whatever hospital he was in. However, he was less safe there than we hoped, and he was to disappear many times despite locked doors and high fences. Fear for his life and a belief that it was only in the hospital that he would get treatment for his disorder were our main reasons for agreeing that he should be legally confined under Section 3 of the Mental Health Act. Grim statistics, mostly from the U.S. but also, to a lesser extent, from Britain, showed what was likely to happen if he was not protected. Of young Americans diagnosed with schizophrenia, some 10 to 13 per cent die, mostly by suicide, within ten years of their diagnosis. In addition to those who succeed in killing themselves, some 40 per cent of men and women schizophrenics attempt suicide at least once, the percentage for males alone rising to 60 percent. Henry himself says that several times he thought of killing himself and once even wrote a suicide note. Even if suicide was not his intention, he did very dangerous things, such as climbing high buildings, walking near railway tracks, swimming in ice-cold water, or running naked through the snow, any of which might have led to his death.

People with schizophrenia are periodically demonized as potentially violent by television and newspapers, but the sad reality is that their violence is directed mostly towards themselves. The high suicide rate is only the most visible peak towering over a mountain of pain. “While schizophrenia is by no means the most common mental illness,” a report from the National Institute of Mental Health in the U.S. recorded in 1986, “it is probably the most devastating in terms of human suffering.” Unfortunately, this remains as true now as it was then. The suffering is so great because for many, schizophrenia is a lifetime sentence preventing them from holding a job and often reducing them to poverty on the margins of society. The mentally ill are not only feared but deemed, consciously or unconsciously, as not human in the fullest sense.

Dehumanisation opens the door to cruelty and disregard by the rest of society. Of the six hundred thousand homeless living rough on the streets or in shelters in the U.S., fully one third have schizophrenia or bipolar disorder. In jails in America, as many as a fifth of the 2.1 million prisoners have a mental illness, and most of these have been incarcerated for minor crimes such as trespassing. A slightly smaller number of schizophrenics are in hospitals than in shelters or jails, though many bounce miserably among these three places.
As I previously mentioned, I was surprised to discover that so many of my friends had close relatives with schizophrenia. Though I initially suspected that the stigma of mental illness was the reason for their silence, I later saw that there was another explanation. The illness had inflicted such pain on them and their families that they did not want to talk about the details or expose them to public view even decades later. One of those I had told of Henry’s schizophrenia soon after it was diagnosed was a journalist of the highest caliber and a friend for many years. A highly sympathetic and intelligent man, he told me about the dreadful fate of his sister-in-law, who was a talented woman but suffered from severe mental illness. Unfortunately, she was receiving psychotherapy from a pupil of R. D. Laing, the controversial Scottish psychiatrist who had the virtue of listening to what his patients told him but argued that parental persecution was an important factor in provoking schizophrenia and that madness itself was a creative experience. She tried to battle through a severe psychosis?in other words, a prolonged bout of madness?without being hospitalized. One day in 1973, she poured petrol over herself and lit it, badly burning over three quarters of her body. It took her weeks to die in agony. My journalist friend saw Laing and his acolytes as being at least partly to blame.

This story made me even more wary of people who suggested that Henry might survive without medication. Writing this book, I asked my friend if I could repeat his account of his sister-in-law’s death. Although the event took place almost forty years ago, the wound was still too raw, and he said he would prefer the identities of those involved to be concealed. He told me, however, that a full and accurate account of the tragedy, entitled Anna, had been written by his brother in the form of a novel under the pseudonym David Reed. Based on his brother’s diaries, it remains one of the most detailed and moving accounts I’ve seen of the madness of an individual and its impact on a family. In most countries, the majority of the mentally ill are ill tended, poor, and without health insurance. Aside from people who have suffered a breakdown, most of those receiving professional psychological help are well-to-do. It is as if, on the battlefield of mental health, the psychiatrists and psychologists will treat only lightly wounded members of the officer class, and the majority of casualties are disregarded as untreatable. Dr. John A. Talbot, a former president of the American Psychiatric Association, admitted that psychiatry is “one of the few specialties where the most skilled practitioners take care of the least impaired patients.” Though 1.1 percent of the world’s population is estimated to have schizophrenia, limited funds are spent on research by governments. In the U.S., HIV (including AIDS) research receives $2,241 per person affected, compared to just $75 per person affected by schizophrenia.

I was struck by the big difference between attitudes to mental and physical illness. The dire effects of polio, about which I knew a lot, were well publicized. I caught the virus at the age of six in 1956, during what was to be almost the last epidemic to hit Western Europe, one year after an effective vaccine had been introduced by Dr. Jonas Salk in the U.S. People were frightened by polio because it threatened their children to a degree that today is matched only by AIDS, but they were certainly not scared of people crippled by the disease, the most celebrated example being President Franklin D. Roosevelt. Contrast this with the impact on a politician who has the slightest hint of mental ill health. In the 1972 U.S. presidential election, the revelation that Senator Thomas Eagleton had received electric shock treatment and had once checked himself into a hospital because of psychological problems was enough to get him sacked as the Democratic vice presidential candidate.

In raising money for polio research, the March of Dimes posters showed polio victims in their wheelchairs or on crutches in the correct expectation that their plight would provoke sympathy and contributions. The research was so heavily funded by the late 1940s that Dr. Salk started his successful search for a vaccine, since it was the best way to get the money to keep his laboratory open. When it was announced that his serum had been successfully tested in 1955, church bells rang out in celebration across America. By comparison, the sight of victims of schizophrenia, insofar as they are ever seen, generally elicits fear and revulsion. The stereotypical mentally ill person is a raggedly dressed man or woman muttering to him or herself, pushing a supermarket cart loaded with old clothes and plastic bags along the sidewalk. In the UK, more than one in three people think that those with schizophrenia will be violent, according to an opinion poll by YouGov. In reports on television news and in films, the typical schizophrenic often comes across as a Jekyll-and- Hyde figure, outwardly harmless and normal but in reality dangerous and mad.

Fear of mental illness has fostered public ignorance. But parallel to this is the experts’ own continuing lack of understanding about what goes on in the brain to produce mental illness. Ironically, doctors often noted that Henry had lack of insight into his disorder, which meant that he did not acknowledge there was anything wrong with him. But the insight of the professionals was also limited. Over the last century, psychiatrists and psychologists have proved singularly unsuccessful in finding either causes or cures for mental disorders. Their failure is all the more glaring compared to the great advances in physical medicine, which, in a relatively short period, has seen past killers like cholera, typhus, TB, malaria, and yellow fever either eliminated or controlled. Polio has all but disappeared, and the cure for leprosy is known. Cancer is no longer the killer it once was. But treatment of mental illness boasts few such victories. The most important success was the accidental discovery in the 1950s of antipsychotic drugs, also called neuroleptics, which reduce but do not eliminate some of the worst symptoms of schizophrenia and other mental conditions. The traditional explanation of why these drugs work?though they do not always do so?is that they reduce an excess of dopamine in the brain. But the mechanism through which the most dramatic psychotic symptoms can be reduced remains elusive. A newer generation of drugs, the so-called atypical antipsychotics, is not necessarily proving more effective than their predecessors, according to recent trials, though their side effects are less debilitating. The long-term effectiveness of any kind of medication is severely undermined because at least 50 per cent of people with schizophrenia stop taking it after leaving the hospital, and 20 percent stop while they are still hospitalized.

Possibly because of frustration by the lack of real progress, the treatment of mental health has also seen a frightening number of false breakthroughs and dangerous fads, often of great barbarity, such as prefrontal lobotomy, introduced by the Portuguese surgeon Egas Moniz in the 1930s. This crude brain operation was widely practised and consisted of smashing into the front of the brain above the eyes with an instrument like an ice pick. Its most enthusiastic practitioner in the U.S., the neurosurgeon Dr. Walter Freeman, used to drive from hospital to hospital carrying out numerous operations in a morning. So dissatisfied was one victim of Moniz’s pioneering operation that he shot and wounded the Nobel-prizewinning doctor.

Electroconvulsive therapy (ECT), or electric shock treatment, was once normal in mental hospitals, though there is no verifiable scientific evidence that it benefits patients. A reason why the husband of “Anna”?my friend’s sister-in-law who burned herself to death?went along with the recommendation of R. D. Laing was his desperate and entirely understandable hope that therapy might enable his wife to break out of a vicious circle of repeated breakdowns and hospitalisations. When Anna was in the hospital, her doctors had demanded that she receive ECT, despite anguished objections from her husband. Laing’s insistence on hearing the complaints of people who heard voices, suffered from hallucinations, and were filled with paranoid fears was well ahead of his time. Otherwise, his approach was intellectually self-indulgent, unscientific, and damaging to those he sought to help. Patients’ families suffered appallingly because he blamed them for their children’s insanity. Unfortunately, the failure of Laingian therapies to help patients discredited “talk therapy” as a whole and encouraged total reliance on medication as a treatment.

The wheel has now turned full circle since the 1970s, and today it is the purely biological explanations for schizophrenia that are being questioned as never before. These hypotheses about the cause and course of mental disorders have not been scientifically proved despite many tests and trials. Critics of the psychiatric establishment, particularly in Europe, allege that its diagnoses?even the distinction between schizophrenia and bipolar disorder?are artificial constructs and do not correspond to verifiable categories. Even so, these diseases have dominated psychiatry for a hundred years, ever since they were first described in the pioneering work of the German doctor and researcher Emil Kraepelin, born in 1856. Far more influential than Freud’s ideas in establishing the intellectual framework by which psychosis was diagnosed and studied, Kraepelin’s conception of mental illness now seems schematic in form but vague on specifics. Schizophrenia and bipolar disorder are often spoken of by laypeople? I used to do so myself?as if they were definitions as precise as those for hepatitis or appendicitis. In reality, the names are no more than those given to a collection of symptoms observable at a certain moment in time. A person is diagnosed as having some type of mental disorder depending on which items in a checklist of symptoms appear applicable to his or her condition. These diagnoses are very hazy compared to those in physical medicine, though the family of the person examined may think they are as precise as the diagnosis of a broken leg.

For example, paranoid schizophrenia is typified by exaggerated suspicions of others and fear of persecutory schemes. Disorganized or hebephrenic schizophrenia is signified by verbal incoherence and moods and emotions not appropriate to a situation. But the dividing wall between the two conditions is curiously permeable, as they often are between other categories of mental illness; they are in fact loose and all-embracing. Schizoaffective disorder, for instance, is a mix of symptoms of schizophrenia and a mood disorder such as a serious depression. “The conventional approach to understanding madness is deeply flawed,” believes Richard P. Bentall, a professor of clinical psychology at the University of Bangor in Wales and a leading critic of the traditional approach. “This is why there has been so little progress in the treatment of psychiatric disorders since the time of Kraepelin. Most researchers and clinicians have been stuck at the end of the blind alley into which he led us a century ago.”

Some of what I thought I was learning about schizophrenia under ten years ago is unravelling as tests become more rigorous and scientific. I had read with great interest in early 2002, when Henry was first ill, that the incidence of schizophrenia was 1 per cent of the population in all countries, according to a World Health Organization (WHO) study. The figure remained the same whether you were in Nairobi or New York, Copenhagen or Jakarta, the third or developed world. I found this extraordinary, since I did not know of any other ailment which had such a uniform incidence. If true, the statistical uniformity must mean that differing environment plays no role in determining whether or not somebody would develop schizophrenia. If the children of Wall Street bankers and Australian aborigines are equally prone, then the propensity to suffer from the disorder is hardwired into everybody’s genes. Given that the aborigines arrived in Australia tens of thousands of years ago, this hardwiring happened at an early stage in the history of the human race.

Like so many apparently hard facts about schizophrenia, the WHO figures turned out to be dubious. It appears that the incidence of the disorder differs not only between countries but also within countries and between people who live in cities, towns, and villages. Environmental factors demonstrably interact with a genetic predisposition to trigger different variants of a mental disorder that cannot have a solely biological origin. For instance, numerous surveys and tests all show that West Indian immigrants to Britain are six times more likely to get schizophrenia than whites long resident there. West Indians who remain living in the Caribbean have normal levels of the disorder. Other studies show that migrant communities in different parts of the world are likewise highly vulnerable to schizophrenia. Presumably, enhanced insecurity?familial, social, economic, and political?must play a role. Explaining why this should be so is made all the more difficult because diagnoses around the world employ almost comically different criteria. The highly authoritative manual of the American Psychiatric Association says that a diagnosis of schizophrenia should come only after six months’ observation, while the WHO’s criteria, used in Europe and much of the rest of the world, allows for a diagnosis after only one month. Not surpris- ingly, diagnosed Europeans are far more resilient than Americans in recovering from schizophrenia, as they have been suffering from it for a shorter period.

A further worrying sign that traditional diagnoses are highly arbitrary is that the same individual may receive radically different diagnoses at different times. Dr. Robin Murray, one of the pioneers of new thinking about schizophrenia, says that it is not uncommon to see somebody who has been admitted to a hospital many times, and “maybe five times they had a diagnosis of schizophrenia, three times they had a diagnosis of schizo-affective disorder, and a couple of times they’ve had a diagnosis of bipolar disorder.” He recalls exclaiming angrily about one case, “It’s absolutely clear this is bipolar disorder. Who are the idiots who diagnosed schizophrenia in the past?” A grinning doctor pointed out that Dr. Murray had made the original diagnosis himself. The problem with schizophrenia, he adds, is that “like pain or breathlessness, it’s purely a symptomatic process.”

A new picture of schizophrenia has begun to emerge over the last ten years, portraying it as having a series of causes rather than one single cause. There is undoubtedly a large genetic component. However, it appears that it is not the creation of a dominant gene but of a significant number of less powerful genes which interact with one another and with environmental factors. The genes do not cause schizophrenia but come into play when they are triggered by events. In other words, possession of these inherited genes does not doom a person to insanity, though it does make him or her vulnerable. Environmental factors that have been shown to play a role include obstetric problems; living in the city rather than the country; taking particular drugs such as cannabis, cocaine, or amphetamines; or being a newly arrived immigrant.

Nothing in schizophrenia is simple, and cause and effect can be interpreted in different ways. Poor people living in the centre of cities have a greater incidence of the disorder. This may be because the poor suffer the stresses of poverty, and in some this triggers schizophrenia; it could also mean that people who have it cannot work and become impoverished. There are other signs that accentuated social and psychological stresses trigger a psychotic crisis in young men, which may explain the high proportion of breakdowns during their first year away from home at school or university or doing military service. In the case of cannabis, three quarters of consumers may be able to take it with no ill effect, but the remaining quarter, the genetically vulnerable, play Russian roulette.

Research is starting to deepen our understanding of how brain chemistry, when altered and confused for whatever biological, social, or psychological reason, produces the symptoms which lead to breakdown. One of the most dramatic and interesting symptoms is “hearing voices,” and these auditory hallucinations were central to Henry’s psychosis. To him, his voices and visions were as real as conversations with me or his friends, while to doctors and nurses they were signs that he was still sick and should probably receive a higher dose of medication. Brain imaging shows how people with schizophrenia really do hear voices, but they are a misdirection of the “inner speech” we all create and listen to. Such speech is made up of verbalised but unexpressed thoughts, imaginary conversations and arguments, bits of dialogue which are never spoken. In the case of somebody suffering from schizophrenia, this inner speech is received through the part of the brain handling the reception of external speech, so it appears to come from a separate entity. No wonder that to Henry, the commands and comments of trees and bushes, as well as the voices of friends both alive and dead, sounded so real. When he saw a golden Buddha hovering over Brighton Beach, or climbed to reach the Hanging Gardens of Babylon on the other side of a rail- way viaduct, these were dreams made flesh, part of a magical world he found deeply attractive.

The distinction between schizophrenia and other mental disorders appears much less solid today than it did during most of the twentieth century. So, too, does the belief that there is a deep divide between madness and normality; the symptoms of the former are often evident at a lower intensity in people who see no reason ever to go near a psychiatrist or a mental hospital. The picture is different from that traditionally portrayed in the New Testament or in scenes in medieval glass, where the insane are possessed by devils until these are evicted through divine power. In reality, some 10 to 20 percent of the population occupies an intermediate zone between normality and psychosis. As many as one in ten people hear voices not dissimilar from those Henry heard urging him on his barefoot journeys through the countryside. Others harbor irrational suspicions of their neighbors or colleagues, see themselves as victims of persecution, or have an exaggerated conviction that their phone is bugged and they are being followed by the CIA.

This intermediate stage is variously called schizotypal, schizoid, schizophrenia spectrum, or schizotaxic and is difficult to investigate because people fear that if they are too forthcoming about voices or exotic fears and suspicions, they will be seen as mad.

Doctors are becoming less categorical about immediately prescribing medication for those admitting to hearing external voices. Some, such as Henry, need medication as swiftly as possible, and fullblown schizophrenia and psychosis do exist, but psychosis no longer appears as an island of insanity cut off by deep channels from the normal and the sane. People who develop schizophrenia have often previously shown schizoid tendencies, which, in some cases, become highly intensified and destructive. Many mental health practitioners Jan and I spoke to said there was no therapy for schizophrenia but medication and that this would not provide a total cure. But we wondered if there was a road back from full-blown schizophrenia to an intermediate zone where the gusts of irrationality were less strong and where something closer to a normal life could be lived.

One man who has made this difficult journey successfully is Mark Lawrence, who today runs a small pharmaceutical company in Oxford. An articulate and perceptive man, he told me of his experience of schizophrenia after reading an article about it by Henry and me. Mark said his experience was somewhat similar to Henry’s, though he has since recovered from his psychosis with a minimum of clinical intervention. He was twenty-six years old when his hallucinations started, and he believes his symptoms were as florid as Henry’s. Possibly his age, compared to Henry’s twenty years at the onset of his disorder, made all the difference in Mark’s ability to survive outside a hospital.

“I was a dope-smoking artist squatting in Berlin,” recalls Mark. “I was convinced that my visions were a spiritual awakening and not symptomatic of any illness.” He believes that at the time he had every known symptom of schizophrenia. “Yet I want to emphasize to you,” he adds, “that the spiritual reckoning?and the ascetic phase I went through?were important to my recovery. As Henry says of his condition, the state I was in produced the best time of my life. Compare it to a wild love affair, and you might begin to appreciate the sense of deep enchantment and motivation I felt.” He recognizes now that his mind was deeply disordered. “I was once convinced,” he says, “that if I didn’t walk to Bosham Harbour and perform a ritual by four p.m., the world was going to end.”

Mark’s road to recovery gives weight to the thesis that many aspects of schizophrenia are highly exaggerated forms of ordinary human behavior. He says, “The key was finding the space to explore my mind without further distortion from prescription drugs or from concerned relatives. As it happens, this was not a mental hospital but a job as an evening steward in an army officers’ mess, a job so quiet and undemanding that it was practically a sinecure. I spent evenings sitting in an armchair, reading, thinking, and very occasionally serving officers. Many psychiatrists would shy away from this approach, fearing that it feeds delusions, but I simply meditated and bided my time.” Mark felt that his beliefs?though a psychiatrist might view them as irrational?were not so different from traditional religious or spiritual beliefs.

His father, an atheist, was horrified by this notion and “saw my eccentric spiritual interests or pronouncements as totally delusional. But they weren’t quite, at least not totally.” Mark visited monasteries and found speaking to monks useful in establishing a balance between his spiritual feelings and the real world. “Like anybody settling down in any good relationship, the monks themselves are often veterans of implacable fervor that inevitably gives way to something less foolhardy. Quakers are a good source of support, too. You can hardly feel yourself to be an outsider when an entire meetinghouse of people is silently engaged in dwelling on the otherworldly and the inspirational.”

Mark recovered from his psychoses, produced a dissertation on the physiology of hearing voices for his bachelor’s of science, and went to Oxford to carry out clinical research in this area. He got married, set up his company, and says, “I generally enjoy my sanity.” His meetings with monks and Quakers helped him put his own experiences in a more manageable context. “Meeting monks didn’t make me want to become one, but they did make me realise that intense spiritual/artistic feelings need a counterbalance in ordinary life.” It was important for him to be with people who took the idea of spiritual visions seriously as a path towards self-knowledge and did not see them in purely medical terms. This was never going to happen at any of the hospitals Henry was in. Mark remarks, “NHS psychiatrists and nurses are akin to foreign correspondents, in that the occupational hazard is being jaded and cynical.” He says he is not anti-psychiatrist, but to see schizophrenia as a purely medical problem is too limited and itself becomes an obstacle to a return to normal life. A further benefit of seeing personal voices and visions in the context of generally accepted spiritual or religious life is that it makes these phenomena appear less outr?, easing the way for somebody suffering from a mental disorder to escape the terrible fear that he has indeed gone mad.

Mark’s description of his visions and voices was very similar to Henry’s. I wondered if Henry, too, would one day escape his psychosis. I also wondered if there had ever been a time when he could have gotten better without medication and being sent to a mental hospital. The difference between him and Mark was that when Henry did not take his medication and was not in the hospital, his condition rapidly grew worse. Even at his best, he could not have coped with light duties in an officers’ mess because his mind was too chaotic. Jan and I were always frightened when he ran away, but we looked hopefully for signs that he could care for himself only to find that time and again he slid into dementia within a couple of days.

The picture I have today of schizophrenia is very different from the one I had soon after Henry was diagnosed. Its nature is far more elusive and difficult to define than I imagined. It is even possible for two people to be diagnosed as suffering from schizophrenia without having a single symptom in common. The same cannot be said of any physical ailment.

Excerpted from HENRY’S DEMONS

Patrick Cockburn’s past columns can now be found at The I. Patrick Cockburn is the author of War in the Age of Trump (Verso).