Clocks

We all know how to draw a clock. We have known to draw circles since we were six years old. Most adults do it without thinking or even looking up from the table. That is why the doctors use this test. To draw a clock- a brain must hold a concept in mind, translate it into spatial understanding, sequence numbers accurately, judge distances, coordinate one`s hand and monitor the output. It sounds simple for a healthy brain because it happens almost automatically. 

This article and the figure from JAMA Psychiatry made me think- how we talk about mental illness in statistics- one in hundred people develop Schizophrenia, thousands are hospitalized, and billions are spent on treatment. These clock drawings tell a different story. There is a person who has been hospitalized for 43 years. And I wonder, they must have come in as a young, probably hopeful, adult. The world outside the hospital must have changed beyond recognition (technology wise, culture wise, politics wise) but this person must have been inside, with their illness, drawing clocks that no longer look like clocks. 

When you look at the chaotic ones- the circles filled with frantic overlapping lines, numbers fighting for space- it tells me about someone with a treatment-resistant disease who did not give up.  

And then, the one who wrote the words, ‘ten past eleven’ outside the clock. That person knew the answer. His knowledge was intact, but he simply could not build the bridge between knowing and showing. 

Medicine is extremely good at measuring what is lost. Medicine is an extraordinary discipline, but it has a blind spot: it is so good at measuring what is lost than honoring what remains. MoCA score 2. MoCA score 5. Severe cognitive impairment. Treatment resistant. We have so many terms.  But it will rarely tell you what it feels like to sit across from another human being, pick up a pen and try to draw something as simple as a clock and finding out- that you cannot. We have always talked about severe mental illnesses from the outside. We talk about the burden of disease and hospital beds and compliance and costs. We sometimes forget to talk about what it means to the patients. 

Psychiatry, in particular, has a painful irony- unlike almost any other field of medicine, the illness and self are not separable. The disease does not sit in a tumor or a blocked artery. It sits in the place where the person lives and experiences his whole life. And this figure, for me, beyond its clinical purpose, is a portrait of human persistence. 

-Dhruvi Joshi