The Art of Psychiatry

By Dr David Laing Dawson

The Eyes, ahh, the Eyes.

Some years ago a psychiatrist asked me to see one of his patients on the ward of the mental hospital. She had been admitted in a state of psychosis; he had prescribed appropriate medication, and then later increased that medication, and now she sat alone all day, communicating with no one. Was the dose too high? Had he made her toxic? Should he stop the medication?

In her room the woman sat fully clothed on the side of her bed staring straight ahead. I introduced myself and talked with her. I sat beside her on the bed and talked to her. I received no answer, verbal or non-verbal. I looked closely at her eyes.

I left her room and talked with her doctor. Increase her medication I told him. He raised his eyebrows. No, I said, I’m sure.

He did so and the patient recovered, first in small ways, acknowledging the presence of others, and then talking, engaging, and plans for discharge were made.

Her eyes told me she was in a state of high arousal, not drugged at all, but rather in turmoil, flooded by fears and anxieties to the point of immobility. Her eyes were alive but focused internally.

It is easier to be a poet than a scientist when it comes to eyes. A nurse might say to me about a patient, “The lights are on but nobody’s home.” It is an apt phrase, so accurately describing a state of dementia. In early dementia the right image, phrase or music might bring that person back home for a while, but then she will leave home again, and, eventually, not return.

And then there is the stare of the true believer, aroused and focused, all knowing, all seeing. They are the same eyes one sees in delusional states. Perhaps they are daring one to challenge them. They send no signal of welcome, no invitation for discourse, no flicker of doubt. They are the easiest to imitate.

Boys on the ASD spectrum avoid eye contact, and when they are coaxed into making such “contact”, the eyes quickly touch and then slip away, as we do when we glance at the sun.

The girls, the ASD girls sometimes stare fixedly, unblinking. They make “good” eye contact we notice, but the dance is wrong, the movement static, the intent unreadable; my smile goes unanswered by her eyes.

The eyes of the man with schizophrenia are similar, but often flit from certainty to perplexity and back again, as if they are trying to decipher a very difficult passage in an ancient text.

Depression is always present in the eyes. The light is dimmed, the person home, but slow to answer the door. Sometimes they are hooded and dull, but other times, in agitated depression, fearful and searching.

And then mania. If it is an angry mania I sit low in my chair and make only fleeting eye contact, for fear of adding fuel to the blazing fire within my patient’s eyes. If it is a grandiose mania, I watch the eyes of delusion and true belief and wait for a moment of doubt, a shadow to cross those eyes, before I offer a comforting smile and some medication.