Big-time agitation is way more than a bad case of the nerves. More than a little vibration caused by something that triggers your garden-variety adrenaline rush. It’s a high-frequency wave that radiates out from the base of your throat and throughout your whole body, pulsing a new charge every few seconds, with little relevance to or concern for what’s going on at the time. (“Oh my God, I don’t know whether to get a burrito or taco and the waitress is waiting!!!”)
Everybody has phobias. There are certainly enough to go around: ±600 of them—most of which, I’m happy to report, I’ve never had. For example, I’ve never been afraid of paper (papryophobia), progress (prosophobia), or puppets (pupaphobia)—although, as a child, Pinocchio was pretty frightening. I’d also prefer not to be in the presence of certain popes (papaphobia) or politicians (politicophobia), but neither would make me break out in a cold sweat. Remarkably, no one lists a writer’s worst phobia (typophobia), which rears its frenetic head anytime you realize there’s a typo in an email you already sent or a book that’s already been publised. (See what I mean?)
I don’t think the dosage of my inner adrenaline shots were any stronger than the kind anyone with a serious phobia experiences. The real difference is that, when you’re in the throes of agitated depression, you can have paralyzing phobic reactions to just about anything—or even the thought of anything … especially anything that can’t be remedied immediately. And, underlying all those phobias is the fear that someone around you might realize how dysfunctional you really are.
At their worst, the attacks feel like your whole body is under siege, the ramparts constantly assaulted by forces that cannot be denied. When it’s over, whether for a moment or an hour, you’re in a kind of shock, gasping for breath, relieved, but wary of what the next moment might bring.
True “mixed-states” are more than mood swings. When I’m manic, it’s like my brain is weightless. Ideas rise and soar out of it virtually untethered—zipping around my consciousness (and often out my mouth) as if they’re tripping across a high-wire. Ideas that roll over each other in exhilarating succession, multiple connections elaborating themselves in waves, often faster than words can identify them.
The subsequent crash, which can come a few hours, sometimes a day later, is a depression like that described above, only cranked up, or actually down, a few notches. When people talk about mood swings, it sounds like a kind of emotional pendulum. To get the full picture you’d also have to knock that pendulum’s base around once in a while so those swings remained unpredictable in frequency, duration, and intensity.
I wasn’t delusional—well, depends who you ask. And I was rarely catatonic. I couldn’t sit still long enough. Rather, I was somewhere in between … and not anywhere for long.
The first step in getting an official diagnosis is to fill out the dreaded “Patient Questionnaire.” Instead of pacing the waiting room floor … instead of gazing longingly at the drug company salesperson with his briefcase full of free samples … instead of just slumping in that metal chair with your head in your hands, so disassociated you can’t even get interested in People Magazine (what did happen to Lindsay Lohan?), you have to answer 132 personal questions on a scale from 0 (Not True) to 5 (Very True). Looking back, I seem to have seamlessly careened from painful honesty to shameless denial:
Question #10: Do you ever feel life isn’t worth living—that you have a hopeless outlook?
My answer? 5. (Very True.) Fair enough.
Questions #48/#53: Are you a worrier? Have you ever been bothered by persistent, unwelcome thoughts or images such as … that you would be responsible for things going wrong?
My answer? 1. Not true? Are you kidding me? C’mon, David, you’ve spent your whole life worried that you would be responsible for things going wrong. From the car not starting to the universe coming to a screeching halt.
Question #126: Do you tend to drive yourself pretty hard, like you need to do just a little more?
My answer? 5. That’s more like it.
Question #91 (Everyone’s favorite): In the past 12 months, have you had 3 or more drinks of alcohol within a 3-hour period on 3 or more occasions?
My answer? 1. 1??? This isn’t a job application, Dave. You’re trying to get help. I know it usually takes you four hours … even five, instead of three. But have you seen the sizes of those drinks?
Fortunately, my doctor based his diagnosis on a lot more than this highly suspect information. Here are some choice nuggets from one of my Psychiatric Evaluations:
• Identifying Data: 54Ymarwm; m28, 27y. No, he didn’t suspect me of having a sex-change operation at 28. He was referring to our, at the time, 28-year marriage and 27-year-old daughter.
• History of Present Mental Illness: Treated for depression for years, but not for mania. Historically: Either off/on; high-energy guy—but “loves my sleep.” Ups—few days. Downs—Few hours to days. Currently: Severe Major Depressive Disorder.
• Substance Abuse History: The notes indicate that he had suspicions of alcoholism but was withholding judgment. I told him that pot was never really my drug of choice. (True.) I admitted that I’d done a respectable amount of cocaine in the 1980s. I told him I had particularly liked it because it gave me “clarity of thought and vision.” I had a similar fondness for Ecstasy, which, as I remember, gave me that and a whole lot more. For some reason there’s nothing about the LSD I took in college, which must have had some effect on how my synapses were behaving. But either I was shy about those experiences or he’d run out of room on the page.
• Appearance and Behavior: Slight build, disheveled, unhappy, poor eye contact, restless, listless, somatic, poor coping skills. Wendy would probably have added that I needed a haircut.
• Speech: Soft spoken, flat.
• Mood and Affect: Dysphoric, despondent.
• Thought Process and Thought Content: WNY (within normal limits). I’m a little disappointed with myself there.
• Mini Mental Status Exam: Alert and Oriented.
• Potential for Destructiveness: [re suicide] I told him, “I wouldn’t … I’d just rather be dead than continue like this.” I’m happy to say, however, that I categorically denied having any interest in homicide.
• Strengths: Likable, intelligent. Don’t worry, they got drugs—or at least side-effects—for that too.
Which brings us to the final part of a psychiatric evaluation: the “Diagnostic Impression.” This is an entire category, all its own. To even begin to understand it, we have to go boldly forth where few laypeople have gone forth before: to the infamous Diagnostic and Statistical Manual of Mental Illness (DSM.)
The American Psychiatric Association publishes the DSM in a well-intentioned attempt to provide a linear classification system for our multidimensional minds. It’s 886 pages long, lists 297 disorders, and sits on most psychiatrists’ desks … or over on the bookshelf—even if she or he just uses the online version. It’s as important for establishing their credibility as those diplomas on the wall.
The Manual is based on extensive—one could say OCD—collaborations between psychiatric professionals all over the country. They analyze countless research reports, clinical trials, and various subjective criteria in order to assign labels to what ails us.
While those of us on the other side of the looking glass may rebel against the restraints of these labels, the criteria do at least give psychiatrists some kind of common language for discussing our behavior.
DSM-I was published in 1952, the year I was born. Which I consider prescient and timely, even though I wasn’t officially diagnosed until 47 years later. Based on an ever-evolving understanding of how our minds work (or don’t), they add, subtract, and merge diagnoses with each edition. If nothing else, this wreaks havoc with computers throughout the healthcare system.
As of this writing, DSM-V is about to be released. While some popular diagnoses may be eliminated or, more likely, lumped together, there will also be more total diagnoses. Many
people consider this a plot by the so-called “Medical Establishment” and “Big Pharma” to sell more drugs. But, clearly, they’re just suffering from Paranoid Personality Disorder (300.1).
There’s a lot of understandable disagreement about what should be included. Like Paraphilia NOS (302.9). While a bad case of paraphilia could easily interfere with your everyday functioning, being sexually obsessed with specific acts or objects seems technically okay as long as nobody and/or no-thing gets hurt. But Paraphilic Rape isn’t included, because if you call it a mental illness, then people convicted of it could plead insanity.
While on the subject, I’d like to bring up the issue of hypersexuality. All in favor raise their hands … or something. It’s sure a more polite term than what you’d hear in some bars or on talk radio to describe women whose interest in sex exceeds our society’s shifting and often self-serving norms. Plus, don’t guys also deserve a more polite way of being accused of thinking with our balls instead of our brains? Are they suggesting we should get our Viagra with a side order of Valium? And who was the hypersexual psychiatric clown who decided Hypoactive [low] Sexual Desire Disorder (302.71) and Sexual Aversion Disorder (302.79) do earn labels? After all, they say up to 10% of people are simply not interested in having sex. Of course, that doesn’t necessarily mean they don’t qualify for Voyeurism (302.82).
As much fun as it is to poke fun at the DSM, doing so is clearly a sign of Oppositional Defiant Disorder (313.81). More important, it’s another reflection of the challenge of treating us. If we’re going to talk about this stuff, we have to have a language to do so, and the DSM is a worthy attempt to create that language out of shimmering synaptic whole cloth. And, frankly, the terms are way more specific than nutty as a fruitcake, retard, head case, loony, mong, and bonkers.
NOTE: The most important thing about the DSM is that it gives doctors a code to put down when they’re billing your insurance company. No code … no reimbursement. (And don’t forget to check whether your prescriptions need pre-approval.) But I digress. See Avoidant Personality Disorder (301.82).
The key diagnostic tool within the DSM is a five-axis system. For perspective, or because I’m a little too narcissistic (301.81) for comfort, I’ve included some of the “ratings” I’ve earned over the years. (Note: R/O = “Rule Out.”)
Axis 1 describes the stuff that needs immediate attention: Major Depression; R/O Bipolar and ADHD. It seems I was able to stay on just this side of ADHD as well as alcoholism.
Axis 2 offers 10 possible personality disorders, such as paranoid, schizoid, histrionic, narcissistic, obsessive compulsive: Defer but R/O Panic Disorder and NOS (Not Otherwise Specified). There was really no reason to rule out Panic Disorder. I think the doctor was just being polite.
Axis 3 labels any general medical conditions that might be affecting your mental health. That’s where he mentioned the fact I’d lost 25 pounds.
Axis 4 specifies “psychosocial and environmental problems.” At my worst, he wrote: Severe; wearing on marriage. It did bend, but it didn’t break.
Axis 5 is a “Global Assessment of Functioning Scale,” an overall rating of a person’s ability to cope with normal life. My worst score was 35. That was depressing for two reasons: (1) I never got less than a B on any test in my life and, more troubling, (2) it was accurate: Some impairment in reality testing OR impairment in speech and communication OR serious impairment in several of the following: occupational or school functioning, interpersonal relationships, judgment, thinking, or mood.
Impairment is a pretty word for it.
For those who want to do a little self-evaluation, you can find the complete rating scale on the Internet. Suffice it to say that if you score 100: Person has no problems OR has superior functioning in several areas OR is admired and sought after by others due to positive qualities, there’s a good chance that, secretly, nobody really likes you.
Whereas if you score 1: Persistent danger of harming self or others OR persistent inability to maintain personal hygiene OR person has made a serious attempt at suicide, I pray you or the person nearest you picks up the phone and calls 1-800-273-8255 or 911.
Meanwhile, the rest of us will continue to muddle along somewhere between those two extremes.
Throughout history, people have been wrestling with how to categorize the causes and manifestations of mental illness. Non-traditional diagnoses may not meet the criteria of the DSM, but at least they capture the thing in flight, and give it names that reflect its fluid nature as much as its thing-ness. And they can be as descriptive as traditional diagnoses:
The Egyptians, for example, were suspicious of the influence of the planet Saturn on depression.
Folks like Hippocrates, Galen, and Aristotle would have said my black bile was totally out of whack, and my balance of yellow bile wasn’t anything to brag about either.
An “energetic” shiatsu massage therapist explained it in terms of kundalini energy:
What’s happening with the kundalini … it just gets all the hormones. It travels through the endocrine system. It travels through the central nervous system. So it feels like everything is just moving, moving, moving and there’s no place for you to put your feet.
A tarot reader also put it in more occult terms:
The first card we’re looking at here is the manifestation of your Crown Chakra area. The head centers. Pituitary, pineal glands. It’ll give us a picture of your connection to the Divine right now. [Turns card over] Oh boy … the Hangman.
Which certainly hit the nail on the noose, and was one of few things I found funny at the time.
Mystical and Jungian folks, along with Dante, chalk the experience up to a dark night of the soul—a process of inner transformation.
People who believe that all emotional problems are caused by toxins in our systems brought on by self-destructive lifestyles and poisonous diets, might suggest I’d been asking for trouble … and was continuing to ask for it.
Fire and brimstone aficionados would undoubtedly see me as someone with a demon that needed to be cast out (especially if they found out I gave credence to tarot readings). Sometimes, it did feel like being possessed. Although, ultimately, I was able to make this friend of the devil a friend of mine.
I don’t try to diagnose other people, but usually I can see it in their eyes. At first, it’s just the way they look in more than out. As the depression goes on longer or gets more serious, it invades the edges: drawing squint lines that resemble the “crinkles” of a smile and expose hints of skeletal structure. Eventually, you can gauge its severity just by standing near them.
One time I was at a workshop with a bunch of people, all of whom were very supportive of this haunted figure walking among them. There was a similarly afflicted woman there whom I’d known for years. I saw it in her eyes. She saw it in mine. There was nothing to say. But it made us both feel a little better. Like, if she can take it, I can take it. If I can take it, she can take it.
Then, there’s a picture I took of myself alone, in the middle of an Arizona canyon. In the middle of nowhere. All I see are the eyes. Looking through them, I can still hear my thoughts as they raced back and forth from “I’m still here” to “I’m okay” to “Oh, God, when will this end?”
But, of all the non-traditional diagnoses I received, the most accurate was, of all things, astrological.
The “fault,” dear Dave lies not in you, but in the stars. By July, 2006, “How long is this going to last, oh Lord?” had tied, “What’s should I try next, oh Lord?” and was threatening to overtake, “If you got something to say, why don’t you say it, oh Lord?” on my list of top 10 existential questions.
Which, from a theological point of view, represented at least some kind of progress for a lapsed Jew. So, when someone suggested I visit her favorite astrologer, I was more than happy to do so.
I like serious astrologers. As much for their descriptive as predictive powers—both of which have little relation to the mass-produced newspaper,
magazine, and short-form web variety.
In other words, I’m not talking about the, “your partner has different ideas how to spend money,” kind of description. (Wendy and I both know that.) I’m talking: “Pluto is coming opposite your ascendant, and will soon start moving toward your descendant … it’s kind of like a death and rebirth. And all you can do is surrender and align with the meaning.”
Even in a therapeutic context, I’ll take that kind of talk any day over: “What I hear you saying …” I know what you heard me saying. I just heard me saying it. But I never heard me saying that my problems were caused by Pluto. Besides, the experience did feel a whole lot like a death and, hopefully, rebirth.
She went on to explain that the purpose of this time in my life wouldn’t, “always be clear at the moment. So,” she continued ominously, “all your knowing is not useful here.”
That’s tough love for someone who prides himself on being able to scale tall cognitive dissonances in a single leap of logic. Still, in some small way, it put my mind at ease. At least it wasn’t going to have to take all the heat for this thing.
But, at the time, what mattered most to me was that she gave me a chronological timeline to cling to:
So you’re absolutely experiencing this Pluto transit now. There it is [she points to a place on my chart], opposing your Venus back in September 2005, then your rising sign and sun between October and December. It’s influencing them all last fall … this is long … and going all through December of this year [2006]. Looks like it’s moving off there … even when it comes back, it doesn’t come all the way back. So, as of the end of December, it’s moving away. Through this year, it’s going to be at its most intense. Meanwhile, Saturn is coming up to conjunct this natal Pluto from the end of August through early October, and it’s going to come back in March 2007 through June 2007. Then it’s gone.
David's Inferno Page 8