Twin Realities

The Sisters Were Identical, Until The Voices Began.

By Kathleen Megan

December 14 2003

The thing about twins is they invite comparison. Even though they may look identical, one usually has the edge -- a little more confidence, a quicker smile, perhaps a bit more talent.

As babies and little girls, Pam Wagner and Carolyn Spiro were like that. They danced and acted and held promise that delighted their parents. They loved it when people mixed them up. They were a tight club of two.

And then in adolescence, Pam, the one with the edge, lost touch with her own mind. Life became confusing and the twins's lives took separate paths, diverging and then intersecting repeatedly, as they once again do now. Pam is a poet and Carolyn a psychiatrist. In midlife, they've come together to write a book, to try to capture their story for the benefit of others, and also for themselves.

Their story is a tale of the inseparable bond of sisters, of twins, and their struggle when their lives became anything but identical.

• • •

When you enter Pam's apartment you can't escape the photo test: two adorable baby girls, ribbons in downy hair, one gazing intently, the other head-tilted, tentative. Both bright-eyed, identical. Which is which? Which is Pammy and which is her twin, Lynnie?

You can't tell. Is that thoughtful tilt a Lynnie trait? The more focused expression Pammy's? Impossible to say, so you guess and you guess wrong.

And you wonder, was the die already cast at so young an age? Were they already - though indistinguishable on the outside - so very divergent on the inside? The seed of illness, perhaps, already planted; the roles of caretaker and cared-for so early ordained. You try to reconcile these photos - these identical babies and later, mirror-image school girls - with all you see a half-century later.

So very different are they now. How do they live with this, the undoing of their twinhood? And, how has their family, so accomplished and talented, coped with the slap of fate? That one became psychotic, the other a psychiatrist. Pam catches you staring at the beguiling babies. "You know," she says, "I was well once."

The Hospital, June

Pam seems frightened, lying in her hospital bed, with the covers pulled up almost to her eyes. Her dark glasses, she believes, protect her from evil influences, while also shielding innocent people from her. The burn on her forehead - which she has seared with cigarettes - is a fierce pink. "The devil's mark," she calls it, and hopes it warns people away.

Her sister, Carolyn, composed and caring, perches on a chair at the foot of the bed and they talk about why Pam has landed in the psychiatric unit again. The voices are back - the voices that never really disappear despite the myriad medications.

The voices have been telling her she's no good, she's fat, she should burn herself, should kill herself.

"Why don't you say, `Go f--- yourself, I'm not going to do anything you tell me to do'?" asks Carolyn.

"I feel like I deserve it." Pam says. "The carping, the yelling, as soon as they start with `Burn, baby, burn' - that's the point of no return."

Twins. For more than 50 years, their lives have been as inextricably linked as they have been drastically different. That's part of what concerns Pam about this story and about the book she and Carolyn are writing about their lives: No matter how you try to avoid it, twins invite comparison, contrast, juxtaposition.

Pam is nervous that their lives will be reduced to this: the good twin and the evil twin. That's how she often sees it.

Carolyn Spiro - Lynnie to her family - is the twin who went to Harvard Medical School, got married, had two children. She is the psychiatrist in Wilton and is a dedicated ballet and ballroom dancer.

She has strawberry blond hair, stylish clothes, eloquence, sensitivity and humor. She has a good relationship with both her parents and is now divorced.

Most important, in Pam's eyes, she is absolutely reed-thin. She is the good twin.

Pamela Spiro Wagner is the twin who went off to Brown University, brilliant and promising, but became depressed, suicidal, psychotic during her freshman year. She has been in and out of hospitals for much of her adult life - diagnosed with schizoaffective disorder, a mix of schizophrenia and what has been known as manic depression.

Even so, she graduated Phi Beta Kappa, completed more than a year of medical school, writes prize-winning poetry and essays, and lives in a high-rise in Wethersfield. She is the twin who hasn't spoken to her father in years, her illness wedged between them.

When she is feeling well - and often even when she's not - she is witty, acerbic, insightful. She has shoulder-length dark graying hair, and often hides herself beneath roomy thrift-store purchases and floppy hats.

For seven years, she has been on a drug called Zyprexa that has done more than any other medication to free her of voices and enable her to write, read and think. But the drug comes with a side effect that would be troublesome for anyone, but is excruciating for Pam. It has added dozens of pounds to her once tiny body, the body she has wished would vanish.

She fears people will see her as the fat twin, the evil twin.

Only a few months ago, Pam was convinced that the 70 or so pounds she had gained were, if not acceptable, at least a bearable price for sanity. But the extra weight is proving too great a burden.

That's why she has landed in the hospital again. She has been tinkering with her medications hoping she might lose weight. But instead, the voices returned, calling her "Fatso! Pig! Lardass!" and goading her into harming herself.

"Why would you think that anybody would have a right to tell you to hurt yourself?" asks Carolyn.

Pam answers, "Because they are very authoritative in some ways ... I feel that I will be gotten back at if I pull anything."

"You do it to yourself," asks Carolyn, "because you know the consequences?"

"Absolutely," Pam answers. "I don't know that there's ever been a time when they said, `Burn, baby, burn,' when I haven't actually done it."

The conversation turns to the clothes Carolyn has brought for Pam - tunic tops and pants. Pam may be unable to ignore the disparaging voices, but she doesn't forget the niceties.

She rolls out of bed to try the clothes on and suddenly they are sisters anywhere. She thanks Carolyn and says the colors are just right - dark shades, not red or pink. She slips them on and loves the shirts, but the pants, alas. They are capris and Pam is not a capris sort of person. Carolyn promises to exchange them.

Then Pam says that she is convinced the nurses and aides are out to get her, planning her demise.

"You should have heard me last night," she says, back on the bed, but sitting up straighter. She was tied down and fought back the only way she could. She yelled every obscenity she knew: "Bitch, prick, mother- ... "

"They came in and said, `If you don't quiet down ... if you don't quiet down ... "

"What?" asks Carolyn.

"They're going to kill me?" Pam asks, with a twinkle in her eye. "Unfortunately, it's never as funny when it's happening. When it's happening, it's not funny."

"I'm aware of this," says Carolyn. "I have seen you."

"Not when I'm tied down, you haven't."

Twin Beginnings Our first word, after `mama' was `we,' which meant `I': we weren't merely similar and separate: we were, we knew, one. -From "Solo for Two," by Pamela Spiro Wagner

Ever since the beginning, Carolyn and Pam say, it has been as if they have occupied one space in the universe. They

weren't two beings stuck together. No, it was as if they had one place and therefore had to divide up the territory.

And from the start - as with many twins - it was somehow important that Pammy was the older and slightly bigger twin. Older by minutes. Bigger by 6 ounces.

Such family folklore can shape expectations, can set the stage for what is to come.

In this case, Pammy was "the smart one," the golden girl who wasn't quite sure herself why she always got A's. She was the one for whom her parents had the highest hopes, the one her father called his "most intellectual child."

Both girls were shy, but Pammy was the leader and Lynnie would hide behind her. She would push Pammy ahead of her into the room when her parents had guests. At nursery school, where the theory was that the girls should not be in the same class, Pammy was put in the class with the slightly older kids.

As Lynnie viewed it, Pammy won every award imaginable: She was an excellent writer, musician, artist.

Lynnie saw herself in cutthroat competition with Pammy, while Pammy had no idea that Lynnie lived in awe of her. All she experienced was simply being twins and being the best at whatever she tried.

On an exam, Pam might get 99.99 while Lynnie got 99.98. "Of course that meant that she was second rate in my family," said Pam. "`Lynnie, you're just no good - forget it. You're all washed up. You only got 99.98 percent.'"

Carolyn says now, "I idolized her, obviously, but I also got to hide behind her: Everything was expected of her, and as far as I knew, not too much was expected of me."

Still, the girls loved being twins. They loved wearing the same clothes and having people mix them up. But sometime around middle school, things shifted.

When Everything Changed, November 1963

When you peel back all the layers, layer after layer, when you finally get back to the reason Pammy feels like poison, the reason she feels unworthy, the reason she feels the voices are right, you find yourself back at President Kennedy's death.

The girls were 11 when the "strangeness" began for Pammy, when she first heard the voices, and when Lynnie got so mad at her sister's odd behavior.

For Pammy, John F. Kennedy was more movie star than president. When his son Patrick died, she wrote a poem about it and mailed it to the White House. She received a form letter back, but it had President Kennedy's signature and Pammy showed it all over the neighborhood. The White House knew Pammy Spiro.

She was in art class when her teacher, dabbing her eyes with a tissue, told them. "Girls ... There's bad news. President Kennedy has been shot. In Dallas."

"Yeah, sure," Pammy thought. This was an adult's idea of a joke, though she didn't quite get it. Nothing that bad could happen to JFK.

But when Pammy began to see that this was no joke, she felt herself sinking into a different reality. A realm of heightened sensitivity where the world shimmered and everything took on a vibration of signi-ficance.

As she left art, turning to go down a hallway back to her regular classroom, the principal's voice came over the intercom announcing that President Kennedy was dead. Her knees buckled and it seemed people were whispering her name, like they did on the television show "Password."

When she got back to her classroom, she started crying and couldn't stop. She began to understand that the scary voices were blaming her. Saying that she had killed Kennedy. Not that she had actually pulled the trigger, but that she was responsible. She couldn't disagree.

Her teacher tried to calm Pammy and finally called her mother, Marian Spiro, who came to take her home.

All weekend, Pammy cried. She couldn't tell anyone what was wrong - that she was to blame - and no one could understand. Often her emotions were bigger or different from others. Excessive, her family would say. They would say she was pulling "a Sarah Bernhardt."

Lynnie grew steadily more irritated with her sister. "So the president died. Presidents are old. Presidents die - what's the big deal?" is how Lynnie remembers her feelings. She knew Pammy was just scheming to get attention. Didn't Pammy already have ALL the attention?

Marian says now, "It was very surprising that [Pam would] be so upset ... but watching Pam overreact was not a new thing."

All weekend Pammy heard the voices blaming her. When Jack Ruby killed Lee Harvey Oswald, she thought, OK, they killed the wrong person. "They killed the trigger man, trigger man, trigger man," the voices said.

She had no idea why she'd done it or how she'd done it. But she knew that in some way, the blame would be laid at her door, as she would say later, "like the butterfly who flaps its wings in Peking and starts a storm in LA."

That was when she first felt like poison, when she wanted to disappear, when she wanted to take up as little space as possible until she died.

Writing Partners, Last Winter

As soon as Carolyn enters Pam's tiny one-bedroom apartment, the banter starts.

"You stole my spinning wheel!" Pam accuses her. It's a ritual that Pam, especially, enjoys. "Every time we meet, the first thing we do is fight over the spinning wheel."

"What about this carpet?" asks Carolyn, pointing to a small Oriental rug on the floor.

"Mommy gave it to me from Turkey," says Pam. "But I didn't get a thing when my parents moved out of our childhood home."

"What did I get?" Carolyn asks.

"Well, you got whatever you wanted."

"Well, I don't know that I got anything of mine."

"But you could have."

Pam is in fine spirits today, and Carolyn, too. It's not always easy for the sisters to work together. There are times when Carolyn's schedule won't permit it, times when Pam's illness is talking. And even when both are available, the process of dredging up the sediment of their lives can be painful.

Often they rely on e-mail or phone, but today they lean over each other's manuscripts. Pam is in the dark green velvet-soft recliner that dominates her living room, a kind of command central with coffee and Carltons balanced on the arm; Carolyn folds herself into a fold-up rocking chair.

Several years ago, Pam wrote her autobiography and sent chapters to nationally known Virginia psychiatrist E. Fuller Torrey for his opinion. Torrey knew of Pam's sister and suggested that it would be far more powerful to include Carolyn's perspective as well. Early this year the sisters got a contract from St. Martin's Press and a deadline: Jan. 1. They hope their book, which they have tentatively titled, "Solo for Two," will help people understand mental illness.

So Carolyn has been writing and Pam has been rewriting. Each chapter is divided between their life stories, but Carolyn is planning to include some expert information about mental illness - she is, after all, a psychiatrist.

"Actually, that would weaken your chapter when you include all that stuff," says Pam, the expert on writing. "I can show you how and why. It slows down the action every time you interject an editorial comment."

Carolyn suggests that Pam can also write as an expert on the patient's point of view. "You know how psychiatrists used to say: `Well, she's refusing to take her medication,' like `she doesn't want to get better.' They don't say: `It causes this intolerable grogginess - and no wonder she doesn't want to take it.'"

The sisters dive into their reading, and Carolyn reaches the part where Pam writes about how hard she tried to be happy when her twin got into Harvard. Instantly, Carolyn dissolves into tears.

"No, no, no, you can't," Pam commands.

"I can't?"

"You said to be honest," says Pam. "All right, now STOP it. Your nose is getting red."

"But it's true," says Carolyn. "You know, I'm not hurt. I'm moved. It's true, this whole thing about me going to Harvard Medical School."

"What about it?

"Just how painful it was," Carolyn replies. "To tell you, to want you to know, but to know that I would hurt you."

"But you didn't hurt me," Pam says.

This doesn't stop Carolyn's tears, and Pam looks concerned. "I'm OK, you're not hurting me," Carolyn tells her. "My crying is not because you hurt me. My crying is because I'm remembering."

Pam leans back into command central and covers her face with Carolyn's manuscript. "Geez," she asks, "How can you be a freaking psychiatrist?"

"I don't know. I cry," says Carolyn.

"You do?"

"Oh yeah."

"Geez," Pam sighs.

"Stop covering your face," Carolyn instructs.

"I'm afraid I'm making you feel bad," says Pam from beneath the manuscript.

"You're making me feel bad," Carolyn says, "because you're writing well enough to make me cry."

Growing up a Spiro

If Marian Spiro had stopped after the twins, she might have doubted the existence of "a mother's instincts."

Pammy and Lynnie were collicky and hard to soothe. It seemed to the young mother - far from home on an Army base in Washington state - that as soon as she calmed one down, the other would kick up.

Marian and Howard had met in the late '40s at Harvard University; she was a technician in the lab where he was doing medical research.

A Fall River, Mass., native with a Mayflower Pilgrim in her lineage, Marian, then 21, was strong-minded though shy.

Howard Spiro (pronounced SPY-ro), 25, whose father was a Lithuanian immigrant and lawyer, grew up in Newton, Mass., and had excelled: He went to Harvard College and on to Harvard Medical School.

At first, Marian was irritated by Howard. She found him bossy - how dare he tell her the Friday after Thanksgiving was a workday? "It's not a workday for me because I'm going home," she announced.

But the fireworks between them had more to do with attraction than aversion. They married in 1951. He joined the Army and they moved to Tacoma, Wash., where the twins were born on Nov. 17, 1952.

Two years later, Phil, dubbed Chipper, arrived. And then in three years Martha came. By then the family had moved to Connecticut and Howard was teaching at Yale School of Medicine.

Marian found it far easier to mother her younger children. She was more likely to talk to them one to one. And they were more likely to come to her with their troubles.

Pam and Lynnie turned to each other for comfort. It was difficult for Marian to bond individually with them because they were such a twosome. It was always: Chipper, Martha and "the girls."

Carolyn says now, "No question, our mother felt left out, pushed out, kept out."

During those early years, Marian was a stay-at-home mom with diverse interests - all of which she shared with her children.

She taught them basketball, tennis, swimming, sailing. She took a geology course, and led her children on walks to help them identify mica or shale.

When Lynnie didn't care for reading, Marian could understand why. What's interesting about Dick, Jane and Sally? So Marian wrote stories that would pique Lynnie's interest, and put up a ballet bar and mirrors in the cellar when the girls took dance. She built them a small stage in a bedroom for their dramas.

At Yale, Howard was acquiring prestige and success. He was writing what would become the textbook on gastroenterology for many years.

Howard loved his tiny flock, insisting when they were small that they be kept awake until he got home from the office. To him, Pammy and Chipper were the ones with the most promise; later they would say they could never do well enough to please him. Lynnie was more timid, more likely to cry. Martha, the youngest, was the most easygoing. Pam's interests ran most parallel to her father's: literature, history, religion.

Often, Howard would gather his children on his lap to tell them Bible stories and Greek myths. The stories were sometimes frightening - particularly one of the Greek myths. Pam thought her father was talking about her: "Pam-dora's Box."

Fall from Grace, Mid-1960s

When Pam gets to junior high, she is scared of everything: the cool ninth-graders, the gossipy girls, the social scene.

There is also the "strangeness," the feeling that she is evil.

She wants to talk to Lynnie, or maybe to her mother, but she doesn't know where to begin, how to tell them she feels "something's odd - within," words she would find much later in an Emily Dickinson poem. But the truth is that, even if someone had asked her what was wrong, she would have snapped, "Leave me alone!"

How can she tell anyone about this sense she's had for a while, that she isn't going to make it? A premonition that she'll never be the sort of grown-up who marries, has kids, holds a job. She is fearful and anxious and clings to Lynnie. She knows this annoys Lynnie - because Pam is supposed to be the one Lynnie leans on. Not the reverse.

Lynnie looks down the junior high hallway and admits to herself: Pammy looks weird. She squishes up against the wall, her arms hanging awkwardly by her side. Her hair is greasy, her clothes mismatched.

Always, in the past, Lynnie has felt flattered when people confused her with Pam. In fact, she has half-wondered why a boy would ever like her, if he could be with Pam. Pam was a version of her, only one step better.

Now Lynnie doesn't want to be associated with Pammy. "Why don't you wash your hair? It's dirty," she would say.

"But I washed it last week," Pam would tell her. She'd wonder to herself, "How do you know it's dirty? What is dirty hair?" and "How did Lynnie know so much about makeup and boys?"

Pammy's grades begin to slump. Concerned, Howard and Marian offer the girls a chance for private school. Both girls apply to Day Prospect Hill School in New Haven.

Pammy is delighted with the offer. The classes are smaller, the girls don't wear makeup. No one has to take a shower after gym. Lynnie scarcely considers it - if there are no boys, she's not interested.

About the age of 13, the girls begin to eat less and less. First Lynnie, who is copying a friend. Then Pammy joins in to keep up with Lynnie, but also for darker reasons related to Kennedy's death and her wish to disappear. By not eating, she hopes to be "one with the wind" or "a pair of ears on the wall."

Sisterly competition takes over. If Pammy has half an apple, Lynnie wants a quarter. The girls eat so many carrots - and so little of anything else - that their skin takes on a yellowish cast.

Dinners are nightmares. While everyone else tries to enjoy their meal, Pammy and Lynnie eat a quarter of a graham cracker and a half a carrot stick.

Inevitably, an argument breaks out. No one remembers exactly why. Looking back, it seems to Pam and Carolyn that their father believed they were eating so little just to annoy him. Often, Howard would make a comment that would send the twins storming from the table. Marian would leave the table angrily, tearfully.

Eventually, only Phil and Martha would be left. "We'd be wondering where everyone went," says Martha. The younger siblings would finish their meal quietly and play table football with a matchbook.

Everyone in the family remembers this time as turbulent. "I'd say in some ways we were worse, in some ways we were better than the average '60s dysfunctional family," says Phil.

The understanding of anorexia was limited then, and it doesn't occur to anyone to get help for the girls. Marian said she and Howard were simply hoping it would pass. "We blamed Twiggy." Thin was very in.

As the girls lose weight, Marian is worried, particularly about Pammy. She is becoming more and more withdrawn while Lynnie is growing more socially adept. The girls at Day Prospect are calling Pammy "zombie" because she avoids eye contact and looks zoned out.

When Pam refuses to serve hors d'oeuvres at her parents' parties, her father scolds her. "Stop this nonsense," he says.

Years later, Marian will wonder if that shyness was an early symptom of Pammy's illness. She also wonders, if Pammy hadn't been a twin, would mother and daughter have talked more? Would she have understood what was going on in her daughter's mind?

Reclaiming a Mind

There is a sparkle of glee in Pam's eye as she opens the door to her 12th-floor apartment on a wintry day last February and pulls out her latest project.

She has enlarged and laminated copies of The Nation cover - the one with George Bush pictured as MAD magazine's Alfred E. Newman with a pin on his lapel that exhorts: "Worry." And, she has purchased a few dart guns.

"Would you like a set?" she asks. They are for target practice.

It's only relatively recently that Pam - a fierce critic of Bush and his war plans - has been well enough to have political opinions. It's because of Zyprexa, she says. Before then, she could barely read at all, let alone maintain an interest in politics.

The most she could do was read poetry - because it was short - and occasionally write it because she could get down the skeleton of a poem in one sitting.

"It really has given me back a life that I thought was lost to me forever," Pam wrote in an e-mail. "Just the notion that I can get up in the morning and EXPECT that I should be able to read and write rather than wonder if I shall."

For Pam, writing has long been "the life's breath. ... When I get a poem right, it feels like the top has come off a champagne bottle. It's just this incredible, bubbly, fizzy sensation of just: Wow!"

She first noticed that she could read again when she picked up a copy of The Nation. "Hey, this is good," she told the librarian. She would have figured she'd be a "lefty," but her eyes used to glaze over when anyone talked politics. Since then, Pam says, "I am gorging. It is like the movie `The Awakening,' it really is."

Her friend Joe, who lives two floors down from her and is visiting this morning, agrees that she was a different person before Zyprexa. "Yeah, you were struggling with your poetry and everything was difficult," he said.

The evidence of this breakthrough is everywhere in the tiny apartment: the shelves filled with poetry, literature, history and mythology, and the floor piled with copies of Scientific American, The New Yorker, The Atlantic Monthly and other magazines. She has educational tapes in physics and economics and a huge collection of videos ranging in topic from "La Bohème" to plant life. Affixed to her curtain rods are pull-down maps: the world, the Mideast.

This is clearly home to a formidable, eclectic intellect.

Pam feels the medication has also made a difference in her relationship with Joe, who asked that his last name not be used.

A decade ago, Joe met Pam when they were patients at Hartford Hospital. Pam was doing a lot of angry screaming at the time and Joe, a truly gentle man, admired her spirit. He thought: "That's the girl I want to meet."

A Cornell-educated engineer, Joe also has schizophrenia, but not as severely as Pam. Every morning he can, he comes up to Pam's place for their ritual: watching "Dr. Phil." He is more friend than boyfriend.

Pam and Joe's illnesses are very different. Pam is far more often psychotic and subject to mood swings. Unlike Joe, she has been self-destructive: Her mottled arms bear witness to the times that she has burned herself with cigarettes or cut her wrists. She has tried suicide, just a year ago almost managing to hang herself. Only the thought of Carolyn stopped her.

"I think schizophrenia is a wastebasket label," Pam said, "for things they don't know how to define."

Her health is further complicated with narcolepsy - the sleeping disorder- and a case of Lyme disease that affected her neurologically.

Pam needs help with the little tasks of daily living. While she won the 2002 BBC World Service Poetry Competition, she has trouble getting the dishes washed, the laundry done, picking up the mail. Simply brushing her teeth or taking a shower can be overwhelmingly difficult.

To help her take her medication, she has a nurse who comes twice daily; an occupational therapist helps her devise plans to get chores done. A housekeeper comes when she can get one.

Joe and Pam also have very different ideas about the roots of their illness. Joe tends to talk about who did what to him, while Pam sees it as her psychiatrist, Dr. Mary O'Malley of Fairfield, does.

"She says, `Pam, you think this way because your amygdala or something is firing off a message to be afraid,'" says Pam. "`We need to get this under control because your brain is sending off the wrong message.'

"She just neatly, you know, separates the illness from the person. And doesn't blame me and so I can't stand it when Joe wants to say this person's to blame and that person's to blame because if they are to blame, so am I!

"The only thing I've ever blamed my parents for at all is for rejecting me because I was ill - not because of the illness."

On Pam's suggestion, O'Malley vastly increased her dosage of Zyprexa a couple of months ago. The voices have been quieter since then, and most significantly, she doesn't now have the urge to go off the medication - despite her weight gain.

"I take it simply because I realize I need it. No matter how fat it has made me. Fat is just fat. But insanity, psychosis, is unbearable."

But then Pam moves into her bedroom to watch "Dr. Phil." And there, above her bed, is a canopy: a metallic blanket and tinfoil. The silvery cocoon protects her from the mind readers, the CIA, the deadly radiation. But wasn't she talking about Bush and foreign policy and war in Iraq?

Pam's fantasies remain part of her reality, even when she seems so lucid. As she explains it, when she is well, she is able to put various paranoid beliefs "on the shelf," but on some deep level, she still holds them.

So though she has been well and productive lately, the tinfoil stays up.

And though she realizes, when she really thinks about it, that she didn't kill Kennedy, the feeling that she is evil remains.

Dancing through Mid-Life

Carolyn and her boyfriend, Tim Pritchett, are caught up in an intense discussion with their dance teacher, Terri Boucher. At their last competition, a couple had hindered their performance by crowding them.

"You two need more competitive experience - as frequently as possible," Boucher tells them.

Tim also needs a new tuxedo - custom-ordered from the West Coast or England. The world of ballroom dancing is acutely appearance-aware.

"He did not look as nice as I knew he was dancing," says Carolyn, smiling at him.

"You have to dress and dance like you want first place - not like you've just come to participate," says Boucher.

But enough with the talking, Carolyn says. "Hey, Tim, we can talk or we can choreograph!" At $30 each an hour, they start dancing.

Tall, blond and with ramrod posture, Tim sweeps Carolyn into a head-snapping tango under the watchful eye of their teacher. In a T-shirt and black spandex capris, very thin but also very strong, Carolyn dances with the suppleness of a much younger woman.

The pair found each other through ballroom dancing. Tim said there were lots of possible partners, but that Carolyn was the only one who wanted to work as hard as he did.

The art fosters closeness between them, but can also strain. To dance smoothly, Carolyn must be moving backward just as Tim steps forward. The steps are exacting and tempers can flare if one partner isn't there for the other.

"A couple can dance only as well as the weakest partner," Carolyn explains.

They take ballroom dancing on Sundays and Mondays - alternating weekly between Brookfield with Boucher and a teacher in Maryland near Tim's home. About every month or two, they compete in a weekend contest - usually somewhere between Boston and Washington, D.C.

Besides ballroom, Carolyn sandwiches five ballet lessons a week between therapy sessions, often sponging off to rush the quarter-mile from ballet studio to office.

She'll finish at the office by 3 and get home the same time her son, Jeremy, 16, returns from high school. Her daughter, Allie, 20, is a New York University student studying in Prague.

While Carolyn's routine may seem exhausting to the average person, it has helped her navigate difficult middle years.

Three years ago, Carolyn ended her troubled marriage of 18 years. That meant leaving a four-bedroom colonial with a swimming pool and an office across the breezeway. She now lives in a condominium near Wilton Center.

When Carolyn met Tim two years ago, she found in him not only a dance partner, but an introduction to his religion, Catholicism. Raised a Unitarian, Carolyn had always felt left out. Her Catholic friends had First Communion and Jesus and Mary and heaven - what did Unitarians get? Not much, certainly no answers to her questions about God.

This discovery of the church has marked her midlife - which seemed to be about things falling apart - with the sense of a new beginning. (She was baptized last Easter.) She calls it a "wonderful blessing" and says that even if she and Tim were to part ways, she would remain a Catholic.

Her parents, siblings and kids are a bit puzzled by her conversion, but Pam says, "I think it's amazing what it's done for her ... She's a nicer person."

Carolyn says religion is something she's done for herself. "So much of my life had to do with what Pam was or wasn't."

Sominex and Sleep, 1971

On a dismal day in January, Pam buys a large bottle of Sominex. Her plan is to take a few every day, just to stay asleep, out of pain.

She and Lynnie are freshmen at Brown University. They didn't set out to go to college together, but neither got into her first-choice school - Hampshire for Pam and Wesleyan for Lynnie. Brown was No. 2 for both.

They arrive at Brown eager to establish their own lives - especially Lynnie. As part of her new image, she has discarded "Lynnie" for "Carolyn." The girls are put in the same dorm but have their own friends.

However, since September, the strangeness has been growing in Pam. She thinks the pharmacist at the local drugstore is watching her, and aiming his radiation at her. She'll walk blocks out of the way to avoid him. She believes that when her roommate wears a red sweater, she and her friends are plotting against Pam. Should she let them know she's aware of the plot, she wonders, or is it safer to pretend she doesn't know?

Carolyn is aware that Pam is becoming more bizarre. When Pam goes down to the lounge to read, she doesn't just sit on the couch or a chair. She moves a wing chair behind a wide drape and sits there hidden.

Pam arrives with her Sominex back at the dorm, where she sees her roommate. They argue and Pam, feeling as if she's lost her last friend, takes the entire bottle.

She leaves the bottle open and empty. Beside it is a note: "I've taken a few too many pills." She writes that she'll probably sleep them off, "but just in case, I'll be in the downstairs lounge."

She heads down the winding dorm stairs and suddenly, there is Lynnie coming up. She takes one look at Pam and knows her sister isn't right.

Pam hands her sister her room key and tells her she might want to check out the note she's left there. Carolyn hurries to her sister's room, finds the note. She grabs Pam's jacket and darts down to the lounge. She finds Pam behind the drape and tells her, "We're going to the infirmary."

The nurse gives Pam ipecac, but Pam is convinced she's going to die. She keeps telling the nurse to get Carolyn out of there. "I didn't want Lynnie to see me dead," Pam says now. "I didn't want that to be her last sight of me."

And Carolyn wants to leave. With Pam delivered to the infirmary, her job is done. When the nurse tells her to go back to the dorm, she does. She isn't really worried. She trusts that Pam will be fine. She doesn't call her parents. The nurses do. The next day, she doesn't check on Pam or visit. Years later, she wonders at her seeming unconcern, while also understanding it.

"I had a life. I had a boyfriend," she says. "I wanted the grown-ups to take care of her now."

Psychiatry and Blame, 1971

When Howard arrives at the Brown infirmary after Pam's overdose, he finds her much worse than he expected. She is clearly psychotic. He sobs when he sees her, but in her confused state Pam thinks he is laughing.

He takes Pam to Yale-New Haven Hospital - which is at the tail end of a benighted era. It is a time when psychiatrists talk about the "schizophrenogenic mother" - the mother who causes her child's psychosis. No one mentions schizophrenia to the Spiros - they don't want to label. To Howard and Marian, the blame seems to be directed at them, particularly Howard. Pam has been so angry at him.

This drives Howard away. He has some experience with mental illness - an aunt suffered with it. Now, he is upset with the psychiatric system and with Pam. "To be blamed for your own illness is bad enough," Howard says years later. "To be blamed for your daughter's illness ..."

Marian, who never trusted psychiatrists to begin with - she grew up believing that they chose their specialty because of their own problems - has her doubts confirmed. The psychiatrists can't seem to help her daughter, her husband, her or the rest of her family.

With no mention of schizophrenia or of any serious mental illness, Marian is convinced that this is just a setback for Pam, a stumbling block on the road to adulthood. Both parents are hoping Pam will get through this and back to Brown soon.

But as the weeks in the hospital turn into months for Pam, Carolyn is flourishing back at Brown. Marian doesn't call her with worrisome updates about Pam. She doesn't demand that Carolyn show up for family therapy sessions at Yale. She lets Carolyn live her life - something for which Carolyn will be forever grateful.

Martha, in the eighth grade, is far more caught up in the family maelstrom. "I learned that the world is a dark place for some folks," Martha says now, "and my role was to try to make it a better place for people."

Often, Martha, now a nurse practitioner living with her two children in Northampton, Mass., was the one who comforted her mother when Marian would return from the hospital in tears.

Phil, then a junior in high school, remembers being baffled by Pam's suicide attempt and thinking that she was acting up on purpose. "I experienced it as irritating," he says, "and we had to go to these silly family meetings and I just wanted everybody to be OK." Phil, who is also a psychiatrist now, lives with his wife and two daughters in North Carolina.

If someone had explained that his sister was seriously ill, he says, he might have reacted differently. As it was, he says, with his parents' attention diverted, he had more freedom than he should have had.

After five months in the hospital, Pam recovers enough to return to school, but decides instead to transfer to Kirkland College. Later, she'll return to Brown, but by then, Carolyn will have left for Sarah Lawrence.

During this time, the sisters phone each other occasionally - mostly to check on schedules. Neither wants to be home when the other is. Pam is functioning, but not well.

Both young women need their own space now. Especially Carolyn. Now that Pam is ill - now that it seems as if she won't be able to lead the life always expected for her - a door has opened for Carolyn. Once so consumed by dance, she suddenly finds herself intrigued by pre-med.

"Hey, there's someone else who's smart in the world," she remembers thinking. "I'll be the person Pammy isn't able to be."

UConn Med School, 1978

Pam is sitting on the examining table at UConn when the doctor notices her arms. The scarring from all the burning and cutting is obvious. The doctor doesn't ask Pam where the scars came from. She simply observes, "You must be in a lot of pain."

A decade after her suicide attempt at Brown, Pam is making a go at the life that had not seemed possible. She is a student at the University of Connecticut School of Medicine.

But it's not going well. She can't look anyone in the eye, she feels as if she'll be electrocuted if she touches anyone. The voices have been telling her to hurt herself and she has.

That she was admitted to the medical school - despite a second hospitalization and many ups and downs - is remarkable. Through it all, she tended to her academic life, graduating with honors from Brown in 1975. The medical admissions people told her they were willing to take a risk on her because her verbal scores were so high.

Carolyn, now at Harvard Medical School, is happy for Pam, but also worried. Howard and Marian are hoping that perhaps, finally, Pam's life will straighten out.

For years, Pam's relationship with her father has been poor, but her illness has driven them farther apart. She feels that he sees it as a rebellion against him - that somehow she is acting sick to provoke him.

Because of her anger at her father, Pam has recently changed her name. No longer is she Pamela Spiro. She tells a judge in New Haven that she wants to change to her mother's maiden name - Wagner - because, with her father and sister, there will be too many Dr. Spiros. But whether there will ever be a Dr. Pamela Wagner is doubtful now.

A minor health problem has brought her to the doctor and her secret is revealed. She is referred to a psychiatrist who gives her medication, but her troubles soon overtake her.

On the night before she is to give a physical to another medical student, she can't sleep. How can she give someone a physical if she can't touch them? In the morning, she marches into the dean's office and demands: "Get me out of here!"

Ousting the Ogre, March

Pam is standing on the scale backward with her hands covering her eyes in O'Malley's office in Fairfield.

"Don't tell me anything, don't tell me anything, DON'T TELL ME ANYTHING!" says Pam. The scale belongs to Pam, but she leaves it in O'Malley's office because she can't bear having it at home.

Her midwinter resolve to stay on the Zyprexa and endure the extra weight has now melted with the snow.

She can no longer go on being fat. Since she can't cut out Zyprexa, she's decided to cut out food. For several days now, she has been drinking only soup and coffee. O'Malley has decided to get a baseline on her weight - to see if she's actually gaining or losing.

O'Malley checks the scale and Pam pleads: "Don't even tell me." And when O'Malley is done, "Take it away, take it away, take it away."

"Let me ask you, Pam, what do you think you weigh?"

Pam doesn't know and doesn't want to know.

"Is it too scary?" asks O'Malley.

"Yes."

O'Malley tells her that her heaviness has nothing to do with being evil or lazy. "It's not that you lack discipline. It's different from someone who is just casual about their weight," O'Malley tells her.

"No one is casual about their weight," Pam retorts.

"Lots of people don't pay attention to their bodies - believe it or not. But for you, it doesn't seem possible because it's such an important thing."

"Yes, because it's making me evil."

"No."

"Yes, it's making me fat and it's making me take up too much space in the world. It's making me into the ogre that ate Manhattan."

"No it's just making you heavier. All those other things are your add-ons. Zyprexa is helping you to function. Being heavier does not make you evil. It does not make you the ogre that ate Manhattan. It does not make you poison."

Pam pulls the brim of her black derby down over her eyes and folds her arms close to her.

"No one in the world - certainly I don't - feels that you're evil for having gained weight, but, Pam, that's your belief. ... Are you hearing voices commenting about that?"

"Yes."

"Do you talk back?

"Yes," Pam says. "I'll have a conversation with them and then realize: What the HELL am I doing?"

"That's awful, Pam. You know you didn't ask for this, Pam. You really didn't. And the voices are your illness."

Pam says that maybe it was seeing Lynnie recently - so slender - that made her feel worse about her own weight gain. O'Malley urges her to think logically.

"Lynnie isn't on Zyprexa and she does a lot of dancing. She works at her weight and she works at her body," says O'Malley. "She isn't thin because she's good or perfect."

Twins Undone, 1983

When Carolyn looks back, the time she probably most longed for Pam to be well was when her daughter, Allie, was born, in 1983.

Carolyn had called Pam soon after the birth, wishing her sister could hop in the car and visit, but the news left Pam in tears. "She thought Allie replaced her," is how Carolyn remembers it. "But a daughter doesn't replace a twin. How could she think that?"

Pam remembers it differently. "I was crying because Lynnie had everything, including a daughter, which was what I desperately wanted: a daughter. It was never anything I could even begin to have.

"It was the icing on the cake ... It was just a really difficult thing for me to accept that my chance had come and gone and would never come again."

Carolyn is left wishing her twin were there. Isn't this the promise of twin-ness? A life-long duet of shared birthdays, of having someone just like you beside you for each milestone. A mirror in which you see yourself reflected.

Pam looks in the mirror and sees all that might have been: a doctor, wife, now a mother. Carolyn looks in the mirror and wonders: Why Pammy, why not me?

The milestones they should have shared are pushing up between them. Carolyn's wedding - Pam wasn't there. Every step forward for Carolyn takes her farther from Pam, every gain for Carolyn illuminates Pam's losses.

Carolyn and Pam believe they are identical twins, but have never wanted to take the genetic test to know for certain. If one sibling has schizophrenia, there is a 10 percent to 15 percent chance the other will. If one identical twin has it, the chance the other will rises to 40 percent to 50 percent.

Like hypertension or coronary heart disease, schizophrenia seems genetically predisposed, but genes alone do not determine who gets it. What activates the disorder in one twin and not another is unknown. The catalyst could be insufficient nutrition, a virus or other factors that might intrude as early as in the womb or later, during childhood. Like many diseases, there is a time-release element. The disease doesn't usually surface until the late teens or 20s.

When imaging is done on the brain of the twin with schizophrenia, abnormalities are apparent. The well twin's brain usually does not share those anomalies but may not be completely normal either. Not much research has been done on the topic, but often it seems that the well twin - and other close relatives of people with schizophrenia - are likely to experience milder forms of dysfunction: attention deficit disorder, depression or simply eccentricities.

Carolyn never worried about developing schizophrenia, but it did cross her mind to worry about having children. If she were an identical twin, she would have the same chance of having children with schizophrenia as Pam would have: 15 percent. For ordinary siblings of someone with schizophrenia, the chance is much smaller, 2 percent to 5 percent.

Soon after Allie's arrival, Pam declines and is hospitalized. Both sisters believe it is because of the birth. Aunt Pam won't be able to visit for several months.

Free Fall, About 1990

It's not until Carolyn walks into Pam's triple-decker in the South End of Hartford that she truly realizes how poorly her twin is doing. The place is overflowing with garbage, dirty laundry, plates filled with moldy food, old cat litter.

After Pam dropped out of medical school, she has been in and out of hospitals. Her life has been in a kind of free fall. Carolyn has been in phone contact with Pam but hasn't seen her much. No one in the family really understands what's happened to her.

Marian has felt caught in the middle. For years, she felt Howard acted as if Pam's illness was voluntary. Marian knows it

irritates him if she sees Pam. She feels she is being forced to choose between her husband and her daughter. She also is working full time now as a high school teacher. With these impediments, Marian sees Pam, but perhaps not as often as she might.

Neither Phil nor Martha has seen her much either. For them, it's partly the natural pulling away from family and leaving home for college and career. Phil hadn't been that close to Pam growing up and with her illness, he says now, "She was difficult to be with."

For Martha, it is about the heartbreak and confusion of seeing her sister so ill. Pam would tell her the police were monitoring her mind, and ask for Martha's help. "I didn't know anything to do," Martha says.

Now a unit chief at the Yale Psychiatric Institute, Carolyn drives up from New Haven and finds Pam hearing voices, cursing at them, rambling on about the "radiation" and the "five people" who are after her.

Carolyn puts her in her car and drives her to Cambridge, Mass., to see one of Harvard's most esteemed professors. After a 10-minute exam, the professor's words are cold and detached.

"Your sister is a chronic paranoid schizophrenic. There's not much else to do," he says.

Carolyn is shocked at his callousness.

A Shrink with Insight

Almost 15 years later, Carolyn sits on her couch in her elegant, spare living room - with a friend's orginial artwork on the walls and the coveted spinning wheel nearby.

While her Harvard professor's diagnosis of Pam was unquestionably correct, his assessment of her life prospects was overly harsh and angers Carolyn to this day.

If there is anything she has learned from her work as a psychiatrist and her lifetime as Pam's sister, it is that there is far more to a patient than a diagnosis. "From my point of view, I'm not just dealing with depression and anxiety: I'm dealing with a person who's experiencing this illness or that condition.

"The person who says: `I'm the devil' - that's obviously not the whole story."

Through her experience with Pam, Carolyn knows about the importance of involving a patient's family in their care. She talks scathingly of the era when parents - her own parents - were blamed for a child's illness.

"Unfortunately, I think my profession has done significant damage ... around this issue," says Carolyn. "There's no question that families contribute in positive and negative ways to pyschiatric illness, but they don't cause schizophrenia."

Of her father's reaction to Pam's illness, she says, "He was terrorized beyond coping to see his firstborn this way."

Carolyn also makes it a point to listen to her patients and make their care a collaborative effort.

"When a patient comes in and says she is gaining weight on a medication, I'm not inclined to argue," Carolyn says. "It's not whether the issue is right or wrong, it's can we do anything about it?"

Carolyn also knows - personally - how much the right medication helps. Since childhood, she has found it difficult to sit still and read or study. Often, she daydreamed or even drifted off to sleep. For years as a young adult, she ignored the problem. It was the way the world was divided: If Pammy was sick, then Carolyn had to be well. Her attitude was: "Hey, I'm OK, I can handle it."

But a few years ago, Carolyn decided to see a psychiatrist. She wanted to write and she was having trouble concentrating. She was diagnosed with the "inattentive" form of attention deficit disorder and was prescribed medication. She says it helps her writing and her focus in dance. It's also given her a shade more understanding of Pam and her patients.

When she is asked why she became a psychiatrist, Carolyn says it wasn't because of Pam, at least not consciously. She didn't know how sick Pam was when she made the decision. Rather, it was because she found it fascinating.

(Her father tried to talk her out of it. Psychiatrists were not "RD's" - real doctors - in his mind, Carolyn says, but she was hooked.)

Carolyn was at first hesitant to get involved in Pam's care - not wanting to "blur boundaries" or step on professional toes. But she came to see that she could really help Pam and has been instrumental in linking her to excellent care - which Pam appreciates.

"I mean look, you are singlehandedly responsible for everything - I mean everything good in the past 10 years," Pam told Carolyn one afternoon. "You rescued me."

Often people ask Carolyn how she can stand to listen to people's troubles all day, but she has learned to keep a certain distance from her patients. She also knows to take a break from Pam.

"I don't have to live with her illness," she says. "I am able to hang up the phone, shut the door, drive away."

A Visit from Mom, June

The visit starts out happily enough. Pam is showing her mother the life-size llama she's made out of bubble wrap, mailing tubes and papier-mâché. Marian, who loves crafts and has a well-stocked wood shop, is amused and interested.

The Dalai Lama has been in the news, and Pam jokes that her creation is called "Dolly the Llama."

"Guess what I used for the legs?" Pam asks her mom. Marian hesitates and Pam tells her: upside down TV tables.

Lately, Pam's energy has been running high. She still has trouble carrying out the small tasks of life - whether brushing her teeth or doing dishes. But she has plenty of energy for her artwork.

Now, she is midway in the creation of a religious triptych - which she wants to give to Carolyn - and is logging long hours on her llama.

While her enthusiasm for her work is catching, her energy is beginning to have a manic edge.

When the conversation with her mother turns to her father, Pam's intensity grows. She has tried to reconcile with him, written him letters, but she hasn't gotten anywhere.

"I don't understand why you stand up for him - a man who has treated your daughter this way for 30 years," Pammy shouts.

"He was wrong, Pammy, there's no excuse for his behavior," Marian says.

Lately, Marian has been making a more concerted effort to see Pam. While Howard still does not see his daughter, he no longer makes it uncomfortable for Marian to do so. However, Marian sometimes hesitates because "if she's doing well, I'm afraid I'll rock the boat and if she's not, I'm afraid she'll rock mine ..."

Phil and Martha are also a more regular part of Pam's life. Whenever Phil's family visits from North Carolina, they see Pam. Like her mother, Martha can feel overwhelmed when Pam's illness flares. She prefers it if she has something concrete to do - cleaning Pam's apartment - when she comes to visit.

Pam starts to wonder aloud whether she'll go to her father's funeral and then tells her mother, "I will because I'll want to comfort you. I'm not going to your funeral because I don't want to comfort him."

"I really don't want to talk about this," Marian says. She adds that perhaps she should go out and check on her dog, Procyon, named for Orion's puppy, in the car.

"Please don't go! Please don't go!" Pammy begs. "I didn't mean to embarrass you. I love you!"

Marian stays and the visit is salvaged. Later, Pam says her mother is a wonderful woman who has grown greatly in recent years. Although Pam has spent much of her life angry at her father - she files his books in the Holocaust section on her shelf - it's clear she would like to have him in her life.

She doesn't need an apology she says. Just talking about The Nation together would suffice.

It's little surprise when Pam is hospitalized again. She has been manic and easily irritated, and recently has fiddled with her medications, hoping to lose weight.

Carolyn is going to visit Pam and her apprehensions spill out. As a psychiatrist, Carolyn knows she should be used to visiting psych wards, but when she visits Pam, she comes as a sister. The sister who is OK.

Seeing Pammy, her idol, in two hospital johnnies behind the sunglasses - worn to protect her from evil - is always a shock. "Can you imagine gaining all that weight?" she asks. "It's so unfair - the whole thing."

And there are the burns on Pam's forehead and arms. "It's like those are my arms. How can you scar my arms?"

Harder to understand is why having Pammy in the hospital - Pammy sick again - prompts Carolyn's ancient feelings, the fossilized permanent sense of always being second best. All the discussion over Pammy, with Pammy, the talk of her brilliance. "She's a colorful paperback and I'm the staid leatherbound classic on the shelf. I feel like the ordinary colors standing next to a rainbow."

If she tells this to anyone, they are, of course, startled. And when Carolyn sees Pam in the hospital, sees how little she has, she feels ashamed.

"I started out feeling the universe is divided and then - Geez, I've gotten 95 percent of it.

"I don't blame myself, but it is true that because Pammy got sick, I got a life. Maybe it's true that I would have a life anyway, but it would have been different ... I didn't make her ill, but I profited by her illness."

Fireworks, July

From the moment Carolyn enters Pam's apartment, Pam seems on edge and irritable. She has been out of the hospital for a few weeks now, but isn't quite stable. Neither the fasting she did nor the juggling of medications has reduced her weight, and she is deeply frustrated by this.

She doesn't want to see people who knew her at 100 pounds. "I know what their first thoughts are: `Holy shit, is that Pam?' They don't know why, they only know, `holy shit,' and I can't exactly go up to everyone and say, `This isn't really me.'"

The sisters begin work on their book when the discussion turns to Pam's use of her old autobiographical manuscript as the framework for their new book. In the past, the sisters have agreed that their book should be a new creation - not simply Pam's manuscript with Carolyn's add-ons.

No one seems angry until Pam tells Carolyn, "What makes you angry is when I talk about having written a book before!"

Carolyn, who wasn't upset, but is starting to heat up, asks, "Is this THAT book or is this a DIFFERENT book?"

"This is THAT book with your parts put in," Pam says.

This ignites Carolyn, who abandons her role as sisterly shrink for pure sister: "That's what I figured. That this is really about you."

Pam pulls her black straw hat down low over her eyes and folds her arms. Shutdown. Carolyn turns away, her eyes glistening, and walks into the kitchen muttering expletives.

Carolyn calls from the kitchen: "I don't understand ... What do you want?"

Pam explodes, "YOU WANT ME NEVER TO HAVE LIVED!!"

"Oh, I see. I see," Carolyn replies. "It's all or nothing. It's either you're alive or I'm alive. Is that what it is?"

Pam: "According to you."

Carolyn: "This has been my dilemma. I have to go into the f---ing background so that YOU can be alive."

"No, Lynnie," Pam says, "who's been in the background?"

"I've been in the background my entire life - it doesn't matter what I do," Carolyn says. "Martha talks about you. Chipper talks about you. Mommy and Daddy talk about you."

"They don't talk to ME!" Pam says.

"Yeah, they talk to me about you," Carolyn says.

There are a few more exchanges, a long pause and then, somehow, calm is restored.

"Anyway," Carolyn asks, "you want to talk about writing?"

"Yes," Pam replies. "I want to talk about writing."

Back in the Hospital, September

Pam is in seclusion, lying on a mattress on the hospital floor wrapped in a sheet spattered with drops of blood from the cuts on her forehead. Scribbled on the wall above her is her own graffiti: Kill me. I'm sorry. The Ogre that Ate Manhattan Must Die.

Carolyn comes in and sits down beside her. Pam, pale and irritable, peers out from under the sheet. "I apologize that I didn't have something sharper," Pam says, referring to the piece of plastic she used to cut herself. "I found the sharpest thing I could."

Recently, O'Malley agreed to let Pam replace the Zyprexa with another anti-psychotic. During that transition, her mind became sort of chemically stuck: catatonic. She was aware of what was happening around her, but could not speak and could move only with help.

The doctors considered electroshock to jolt her out of it, but Carolyn said no, fearing that it might affect Pam's memory. What's a memoir without a memory?

Eventually, medication brought Pam back, but voices are still telling her to kill herself. The doctors put Pam back on Zyprexa, but when she's released she goes off it again. Soon she's rehospitalized.

Tired and Discouraged

It's not often, but on this October day Carolyn is downcast. Though rationally she knows that Pam doesn't decide to have a setback, part of her feels as if she does.

This is how it always seems to go, Carolyn says. Pam starts to get better. Carolyn starts to relax. "Oh, good, I can have a regular relationship. I can go back to my fantasy. Everything is going to be OK and then I hear from her or someone else: No, something else has happened.

"Part of me wants to get angry and tell her to think about me for once in her life," says Carolyn. Often, Carolyn has used this rationale when talking to Pam about suicide. "You can't kill yourself," she'll say. "Because if you kill yourself, you're killing me."

It is an argument Pam has listened to in the past, but now she is obsessed with a presence - a visual hallucination - that is so strong that she can't be released from the hospital until it is extinguished. When she looks at the biohazardous material stickers on waste containers, she sees the face of a frightening man with a mustache. She calls him the "Bio-Haz-Mat Man" and says she can't ignore his command to hurt herself.

"I keep thinking I should be able to reason her out of it," Carolyn says, knowing as she says it that it isn't possible.

Where the man has come from, no one is sure. Perhaps he is the result of her switch to another anti-psychotic that doesn't seem quite as effective.

Pam has voluntarily agreed to try electroshock therapy, to try to zap "Mr. Bio-Haz-Mat" out of her thoughts. Carolyn is concerned about this, but says, "At least it won't put on weight."

The First Dr. Spiro, October

There is a knock at the front door of his New Haven townhouse and Dr. Howard Spiro jumps up. With white hair and a goatee, he is distinguished at 79. Who could it be, he wonders. He isn't expecting anyone just now.

He opens the door and a man with dark curly hair is there. Oh, you want the newspapers, Howard says. He hands them over and reminds his caller that he'll be abroad for three weeks.

It's the young man Howard has been helping out. He is the son of a colleague. A young man with schizophrenia who doesn't get along with his own father very well. Often it is this way with mental illness. The disease exhausts and splits families in ways other illnesses don't.

So Howard has stepped in, has lunch with him, tries to help him.

"It's useful to me to help him," Howard says, after shutting the door. "It gives me a chance to feel that I'm helping someone."

So why can't Howard talk to his own daughter? Why hasn't he had a real relationship with Pam for decades?

"This is making me very uncomfortable," he says. But these are questions that gnaw at every member of the Spiro family; everyone would like to see a peace of some sort between father and daughter.

A few months ago, Howard said that his retreat from Pam began at the beginning, when he drove her from Brown to Yale and realized, then, that she had schizophrenia.

As a doctor, he knew it was an illness that could consume not only her, but the entire family. "To myself I've used the word `encapsulate,'" he says, "so that it doesn't too much affect the way everybody lives. It may sound hard-hearted, but you have to understand, I knew it was a lifetime illness."

Could he explain why he hasn't reopened communication since then? Howard said his feelings would remain secret. "It's not helpful to get into it. I would like to draw a veil over it. It was self-protection, but denial is a pretty good thing."

But Howard's account is not consistent with Marian's. Marian says neither of them saw how serious Pam's condition was. If they had, they would have reacted differently. They would have treated Pammy as a person with a devastating lifelong illness, rather than as a child who was passing through a troublesome adolescence. If they had understood the seriousness, Marian says, Howard wouldn't have treated Pam as if she could snap out of it at will.

Howard nods now and says that Marian is also right. He did feel - on an emotional level - that Pam had some control over the illness. That somehow her illness was a rebellion against him, even though he also understood that the illness is biochemical.

He says that a year or so ago, he thought he and Pam were moving toward a kind of rapprochement, but then there was an angry call from her.

"I'm clearly woven into her psychosis. I was the center of her aggressions as far as I could see."

Marian and Carolyn have told him that they too have been the target of Pam's ire, but that often it is not Pam talking; it's the disease. Howard understands that, but "the reality is I get attacked."

Howard says that if he had been treated differently by Yale doctors way back in the '70s, if he hadn't felt blamed for Pam's illness, family history may have gone differently. "Both of us [his wife and him] would not have suffered so much. It left us with the feeling that the family was responsible. If the family was responsible, then we could cure her.

"I didn't know what to do. I felt absolutely powerless and paralyzed."

Howard says he is grateful to Carolyn and to his wife for taking care of Pam when he could not. "I owe it [to them] for complete protection from the depredations of the disease. I believe Lynnie has extraordinary strength to function as a psychiatrist, to be aware of the genetic influence and parallels and the dangers of having a twin with schizophrenia, the risks of having children.

"I had my work - work is a great panacea," but "my wife and Lynnie are the heroines."

Howard says he is convinced that the twins have a "mystical connection." He likens them to the twin stars, Castor and Pollux, "continually circling each other, continually influencing each other."

If he wasn't their father, he would like to write about them, he says. "Write a story about hope," he suggests. "That Lynnie has not lost her hope and Pam has not lost her hope. Leave out the anger and the sorrow. Focus on the heroines."

But what about the question. Will he see Pam again?

He doesn't know.

Pam-dora's Box, October

Pam is worried that her memory is deteriorating. She has had six electroshock treatments.

She has taken to keeping a list of what's important: her name, her doctors' names, that she is writing a book and will be in a Northeast magazine story.

Today, Carolyn has come to visit, bringing chocolate chip muffins, fruit salad, scones and sticky buns.

"I don't remember anything," Pam says.

"Do you remember that I am Martha?" Carolyn asks with a wry smile.

"Martha - who's that?" answers Pam, deadpan.

"Your memory will come back," Carolyn tells her "but this gives me license. I can tell you anything I want."

"You can say you brought me scones and fruit and muffins."

The conversation turns to weight, as it so often does. Carolyn tells Pam she looks as if she's lost 30 or 40 pounds. "Just from being in here?" asks Pam.

"And from not being on the Zyprexa," Carolyn tells her. It has been an unusually onerous last few months for Pam. While fluctuations are routine, she had never been catatonic for so long, she's never needed electroshock.

But this news that she has lost weight brings a fresh smile to her face. "That makes it all worthwhile," she says.

Carolyn sighs and asks Pam if she's still seeing the Bio-Haz-Mat Man. "Do you actually see him as real as I am?"

"Almost as real as you - yeah," says Pam.

Pam says an occupational therapist has given her an oversized silver Altoids box and suggested that she catch "Mr. Bio-Haz-Mat in that box."

"The problem is, he won't go in there," Pam says, seemingly serious. "If I caught him, I could just chop him up and put him in there ... Will you help me get the guy into the box?"

"How can I? I don't see him," Carolyn asks. "Can you see him?"

"No, he's not there," Pam replies, and then she ponders, "I wonder if I already got him in the box."

Carolyn suggests she go get the box in her room, which Pam does, and then confides: "I can't believe this is happening. If this were a movie, I'd say this isn't how people with schizophrenia behave."

Pam returns and Carolyn points to a slight bulge in the box and says, "This is a real Pam-dora's Box."

"I feel like he's in there," Pam says. "I need to tape it up and make sure he's in there. How did I get him there? Promise you won't open it."

"Me? Open this?" asks Carolyn. "Nothing I'd like better than to have this guy locked up. We're talking multiple boxes, chains, bicycle locks ..."

"You won't untape it, just to see if it's real?"

"Pammy, I want you better," Carolyn tells her. "I'm the one who wants you to get out of here!"

As if suddenly remembering, Pam asks, "So we can write a book?"

Carolyn: "You forgot?"

Pam: "I forgot, but now I remember."

51st Birthday, Nov. 17

It's the twins' birthday, and each is marking the day in her own way.

Pam is OK about being 51. She is glad to be out of the hospital, happy to be home. Ever since she put the Bio-Haz-Mat man in the box, he hasn't returned. In fact, she's been hearing no voices, seeing no hallucinations.

It's tempting to ask questions. Did the electroshock help put him in the box? Does she actually believe he's locked in the box or was it a mental device or metaphor? But asking might undo the magic of this remedy.

The burns on Pam's forehead have healed, leaving a scar that's barely noticeable. Soon after her arrival home, Pam took down the baby photos and gave them to Carolyn. At first, Carolyn was concerned. "Does this mean you're intending not to be around?" she asked. No it didn't.

"She wanted them and I didn't need them," Pam says today. She's left up the schoolgirl photos.

Her apartment is immaculate. Martha visited a few days ago and cleaned it up. A visiting nurse suggests covering up the tinfoil with fabric. Pam thanks her for "the fashion tip."

Pam's memory - except for parts of her hospitalization - has returned and she is back to writing and editing. She is hoping to stay well.

A birthday is a victory for her. "I'm happy to have made it. It's another milestone. I might not have made it this far ... Why would I want to go back to so many years of misery?"

The signs of aging don't concern her, either. "I like my wrinkles, I like the drooping jowls. They don't bother me in the least."

Carolyn has been less fond of birthdays, particularly last year's. She considers visiting Pam on their birthday. Pam is ready to work and the two could edit side by side, but ultimately she decides not to. She has a two-hour ballroom lesson with Tim and then two hours more of practice, and it's dreary and raining.

Pam is not surprised: "I know she's avoiding her birthday. She thinks I'll make something of it - and I will, little as it is."

As Pam settles down in her recliner with a large mug of tea, the phone rings.

It's Carolyn, singing into the phone: "Happy birthday to me, Happy birthday to you ..."