A Guy, a Car: Beyond Schizophrenia

RONALD PIES, M.D. NEW YORK TIMES

Harry was one of the lucky ones. After a lifetime of schizophrenia — hallucinations, hospitalizations and all the attendant miseries — he was a genuinely new man.
This was about 20 years ago, and clozapine — then viewed as a miracle antipsychotic drug — seemed to have wrought some deep, transforming magic. True, he had put on 20 pounds and complained of mild drowsiness. But the crippling fears and fearsome voices had been quieted. We were able to discharge him from the hospital and arrange for placement in a neighborhood residence.
At his first outpatient appointment, Harry looked cheerful. He seemed to be adjusting to a life of relative normalcy. This was more than I had hoped for, given his disease and its devastation.
When the German psychiatrist Emil Kraepelin described what we now recognize as schizophrenia, he called it “dementia praecox” — premature dementia. For decades, the condition was thought to have an inevitable downhill course, much as we still see with Alzheimer’s disease. Even during my residency in the early 1980s, most of us were gloomy about schizophrenia.
We now believe that schizophrenia comprises several different disease processes and often has a more benign course. We have begun to speak not only of remission, but even of recovery — and hope.
Hope is what Harry presented to me at his most recent appointment — along with a request that raised the hairs on the back of my neck. He wanted me to sign off on his application for a driver’s license.
Suddenly, I was caught between two conflicting visions: one of my patient obeying some malign voice behind the wheel, with who knows what consequences; and another of a young man yearning to get his life back.
Driving is what guys do, Harry reminded me — guys with a real life! And a guy who drives has a fighting chance — he put this in cruder terms — to make a good impression on the ladies.
I understood completely. Long before I was of age to drive, I had experienced the exhilaration, the sense of unbridled possibility, when I sat in my father’s lap and steered our 1962 Bonneville while he worked the gas and brake. And I remembered what my widowed mother had told me, while in her late 80s, living alone in Florida: “The first thing the women ask about a man down here is, does he drive?”
A patchwork of state regulations governs the driving privileges of patients who may have neurological or behavioral problems. Some states, like California and Utah, require physicians to report a patient’s “cognitive impairment” for driving purposes.
While schizophrenia may increase the likelihood of an accident, research in the 1980s by Dr. Russell Noyes suggested that, among patients with psychiatric disorders, those with alcoholism and antisocial personality traits accounted for most of the risk. The Utah Department of Public Safety asserts that most people under active treatment for schizophrenia are “relatively safe” drivers, and clearly says that one’s accident and violation record is a better predictor of driving risk than is a psychiatric diagnosis.
Still, drugs like clozapine can impair driving skills. And the doctor’s-office-based assessment of a patient’s driving skills is only moderately correlated with scores on standardized road tests.
The part of me steeped in Kraepelin’s pessimistic paradigm did not want to sign off on Harry’s certification. The part of me that had sat in my father’s lap, feeling the first flush of manhood as we drove together, wanted to help my patient move forward with his life.
I asked Harry how he would respond if one of his “voices” commanded him to do something dangerous while driving. “I wouldn’t listen, Doc,” he replied, looking me straight in the eye.
We decided on a plan: if Harry could pass a certified driver education course, I would sign off on his license application. “Deal!” Harry exclaimed, pumping my hand.
As he walked away, I mumbled a prayer, hoping that I had made the right call. Roughly a month later, Harry strode into my office looking about four inches taller and handed me an embossed certificate from a driving school. He had passed the course “with distinction,” and I had my part of our bargain to keep.
After all, driving is what guys do — guys with a real life.
Ronald Pies, a psychiatrist, is the author of “Everything Has Two Handles: The Stoic’s Guide to the Art of Living.”