The Man with a Microphone in his Ear takes you inside the mind of a very inexperienced, psychiatric resident. On his 2nd day of residency, he is assigned to treat a violent, psychotic man. Overcoming his own fear was just the first step…
The more I got to know Jerome, the more confused I became. From my reading and limited experience, paranoid schizophrenia was described as a global emotional disease, where almost all aspects of a patient’s personality were impaired. Jerome wasn’t this way at all. His personality was warm and caring and not at all like the patients that were described in the texts by Kraeplin, Bleuler and a half dozen other authorities that I studied. After the Thorazine began to work, Jerome had only two symptoms.
The first was the delusion that there was a microphone in his ear (Delusions are fixed, false beliefs that are unshakeable by logic). The second was an auditory hallucination that voices were talking to him through the heat register, then later through the microphone in his ear (Hallucinations are false perceptions, usually auditory but infrequently visual or olfactory).
When Jerome and I talked about subjects other than the microphone in his ear, he was normal and had a full range of emotions. In essence, unlike a schizophrenic, his personality was intact. He continued to be a whole person, but had an island of psychosis that logic and medication could not touch. The microphone in his ear was not going away.
* * *
Two months after his initial hospitalization, the psychiatric patient government that included all thirty patients, the three resident psychiatrists, Doctor Newman, and a dozen nurses and other staff, voted for Jerome to be discharged. The way it worked was that when a treating psychiatrist recommended discharge, the government usually went along with the recommendation. All governments should work so efficiently. So, Jerome, after a warm thank you and handshake, a prescription for Thorazine in his pocket, and the promise that he would see me as an outpatient, left the hospital with his wife.
Every week, Jerome came to the hospital to see me. After two months he still believed there was a microphone in his ear, but said that the voices were gone. He theorized that the wires from the microphone were cut. In essence, the auditory hallucinations were gone and only the delusion that there was a microphone in his ear remained. I made Jerome promise not to tell anyone but me about the microphone.
Over the next two years, Jerome and I continued to meet. We discussed how important it was for him to spend quality time with his son and wife, and not retaliate if his son showed anger. We spent many sessions discussing how anger was a normal human emotion, and that we all felt it. We worked on appropriate ways to handle anger, various child-rearing practices, and new ways to deal with his boss. Weeks later, Jerome told his boss that the tone he used talking to him in front of the other employees was not kind. The next day, the boss actually apologized to Jerome and said he wouldn’t do it again.
Jerome spent time with his son, continued to do well at his job, and came on time for his sessions. The microphone never left his ear and the hallucinations only recurred when he was under extreme stress.
On our last psychotherapy visit, before I moved to California to finish my residency, I told Jerome, “Remember, don’t tell anyone except your next psychiatrist about the microphone.”
He nodded, firmly grasped my hand, and said, “I’m goin’ to miss you, Doc. You helped me a lot. You helped my whole family.”
“I’m going to miss you too, Mister Cotton. I’ll never forget our work together.”
As we shook hands, our eyes filled with tears. I realized that it didn’t really matter whether Jerome had a microphone in his ear, his nose, or anywhere else. What was important was that the quality of his life was improved and he was a really good person. I helped him become a healthier person and he helped me become a better psychiatrist. I learned numerous things, but what I remembered most was the day I approached him in full restraints. When I was able to recapture the memory and the feelings of when I was placed in full restraints (wrapped in a sheet), I knew what to say and how to help Jerome, because I really understood what he was going through. It is a wonderful example of what is called, “Listening with the Third Ear” — using our memories and feelings to get beneath the surface and truly understand what someone’s trying to say.
Jerome’s initial diagnosis of schizophrenia was an error because the pervasive personality flaws usually present in schizophrenia were absent. Jerome was able to relate warmly to his wife and children, able to hold a job, take appropriate responsibility for his behavior, and was able to connect emotionally to people outside of his family. He was a man who did quite well in most aspects of his life, except when it came to dealing with that tiny microphone. Why he developed the problem was probably a combination of stress regarding his son’s problems, stress at work, and an underlying biological predisposition to paranoid thinking. Jerome’s final diagnosis was paranoia, today known as a Paranoid Delusional Disorder. Researchers currently believe that there is probably no overlap between Paranoid Schizophrenia and Paranoid Delusional Disorder; they are two distinct entities. The etiology is unknown.
The DSM-IV (Diagnostic Statistical Manual) defines the core feature of delusional disorder as persistent non-bizarre delusions (for at least one month) with no indication of schizophrenia or a mood disorder. With delusional thinking the patient interprets his life experiences to fit the delusion. For example: even though the x-rays of Jerome’s ear were normal, Jerome interpreted the results to mean that the people who put the microphone in his ear had secretly taken the microphone out right before the x-rays were taken.
Paranoid ideas are explained by a psychological defense mechanism called projection. We still don’t know exactly how projection works, but we do know that there is an underlying biochemical/genetic abnormality in the brain that allows it to happen. Just as a movie projector beams a picture across a room, a paranoid patient beams his feelings into another person. Feelings that the patient finds unacceptable are attributed to others. Jerome isn’t angry with his boss for not giving him a promotion. In Jerome’s mind, the boss and other unidentifiable people are angry with him. Jerome is convinced of this because the microphone in his ear is transmitting bad words, words that criticize him, angry words that he’s sure are not coming from him. This mechanism of projection takes Jerome off the psychological hook. He isn’t angry; other people are angry. The fact that he ran around the dayroom trying to smash people with two heavy piano legs is conveniently repressed or forgotten.
Neurotransmitters in Jerome’s brain functioned abnormally and created an environment where auditory hallucinations and paranoid delusions could exist. We still don’t fully understand how this occurs, but a prevalent theory is that it’s caused by a genetic flaw. It is similar to diabetes, where a genetic flaw creates a situation where the pancreas can’t produce enough insulin resulting in an unstable blood sugar.
In most of us, projection doesn’t turn into paranoid thinking. A person might project his feelings and think that people are looking at the pimple on his nose, but he doesn’t hear voices talking about his pimple. It’s a matter of degree. Jerome crossed the line into overt psychosis and lost contact with reality. The auditory hallucinations (the voices), and delusional thinking (the microphone in his ear) are evidence of a psychotic state. Logic and rational discussion were useless in combating Jerome’s psychosis. They are useless in any psychosis.
Thorazine, a vintage antipsychotic medication, removed Jerome’s auditory hallucinations, but was unable to remove the delusion. Though I haven’t seen or heard from Jerome in decades, I expect that the microphone is still alive and well. If Jerome stopped his medication, there is the possibility that he may have needed re-hospitalization. Even if Jerome continued seeing a psychiatrist and was placed on one of the newer atypical antipsychotic medications, he would still have his little microphone. As good as the new medications are, and they are very good, even they cannot cure a pure delusional disorder.
Fortunately, delusional disorders are rare. In thirty years, I have treated only four. Since people who have delusional disorders often don’t come to psychiatrists, there may be a lot more of them out there than we know. How about your neighbor, Tony, the guy you’ve seen three or four times a week for fifteen years? He takes the kids to Sunday school, mows the grass, and goes to the movies with his family. Then one day, he wakes up and shoots his wife, his three children, and himself. When the police question you, you say what a nice guy Tony was and how you’re absolutely shocked. There is every reason you should be shocked. If Tony had a paranoid delusional disorder, there would be no way for anyone to know, unless Tony talked about it. Chances are he didn’t talk about it. A part of him knew that if he mentioned how the aliens were going to capture and torture his family, people would scoff.
Tony knew, deep down in his gut, that he was perfectly sane. He knew, that by shooting his family before the spaceship landed, he would save them from torture and pain.
SOME NOTES FROM THE AUTHOR
The Man With A Microphone In His Ear portrays what it was like for a clueless, first-year, psychiatric resident to treat a violent, paranoid man in the early 1970s. It’s all true, except that The Man With The Microphone In His Ear is a combination of two patients that I treated during this era. Everything else is accurate, as much as one can expect when writing something decades after the fact.
In 1835, “Old Blockley” was a combination of four buildings — a poorhouse, a hospital, an orphanage, and an insane asylum. It was renamed PGH (Philadelphia General Hospital) in 1919. In the 1950s it was used as a city public hospital and a nursing home for the indigent. The hospital was closed in 1977. Today the site is occupied by part of Children’s Hospital of Philadelphia, the University of Pennsylvania Health System and the Veterans Health Administration.
The cover picture is The State Hospital in Scranton, Pennsylvania
ABOUT THE AUTHOR
Dr. Art Smukler is a psychiatrist in private practice and on the teaching faculty at UCLA. He has won the coveted Golden Ear Award for teaching senior psychiatric residents and the award for Distinguished Writing at the Santa Barbara Writer’s Conference.