One has the advantage during one’s own breakdown of being in it, where one can see what’s happening. From the outside, one can only guess; but since depression is cyclical, it can be fruitful to learn forbearance and recognition. Eve Kahn, an old friend, told me about the toll her father’s depression took on her family: “My father had a hard time, starting early on. My grandfather died, and my grandmother banned religion from the house. She said, if God could take my husband and leave me with four children like this, there is no God. And so she began serving shrimp and ham on all the Jewish holidays! Platters of shrimp and ham! My father’s six foot three, two hundred twenty pounds, was undefeated at handball and also a baseball and soccer player in college, the sort of guy you can’t imagine being fragile. He became a psychologist. Then, I guess when he was thirty-eight or so—the chronology is all messed up because my mother doesn’t want to talk about it and my father doesn’t really remember it and I was a toddler when it started—one day somebody from the clinic where he was working calls my mother and says that my father has disappeared, has left the job, and they don’t know where he is. And so my mother piles us all into the car and we drive around and drive around until we eventually find him leaning against a mailbox and crying. He had electroconvulsive therapy immediately thereafter, and when they were done with him, they told my mother to divorce him because he would never be the same. ‘Your kids won’t recognize him,’ they said. Though she didn’t really believe them, she sat in the car while driving him home from treatment and cried. When he woke up he was like a Xeroxed version of himself. A little fuzzy around the edges, memory not great, more careful with himself, less interested in us. Supposedly he’d been a really engaged father when we were tiny—came home early to see what we learned that day and brought us toys all the time. After the ECT, he was a little bit removed. And then it happened again four years later. They tried medications and more ECT. He had to give up work for a while. Most of the time he was down. His face wasn’t recognizable; his chin had receded into his face. He would get out of bed and kind of helplessly go around the house with his hands shaking, these big hands just hanging there beside his body. You understand where theories of demon possession come in, because someone had taken over my father’s body. I was five years old and I could see it. I remember it really well. He looked the same but there was nobody home.
“Then he seemed to get better and he had a high period for about two years, and then he crashed again. And then he stayed down and down and down. He got a little better eventually and then he crashed again, and then again. He crashed the car around that time, when I was about fifteen years old, because he was so woozy or because he was suicidal—who knows? It happened again my freshman year of college. I got the call; I had to miss an exam and go down to see him in the hospital. They had taken his belt and taken his tie, the whole thing. And then he was in again five years later. And then he just retired. And he restructured his life. He takes a lot of vitamins and he gets a lot of exercise and he doesn’t work. And anytime anything stresses him out, he leaves the room. My baby daughter cries? He puts on his hat and goes home. But my mother stayed with him through all of this and when he was sane, he was a great husband to her. He had ten good years through the nineties, until a stroke sent him tumbling down again in early 2001.”
Eve has been determined not to put her family through the same problems. “I’ve been through a couple of terrible episodes myself,” she says. “By the time I was thirty or so, I had a pattern of working way too hard, taking on way too much, finishing it, and then staying in bed for a week totally unable to deal. I had been on nortriptyline at one point, which did nothing but make me gain weight. Then in September 1995, my husband got a job in Budapest and we had to move, and I went on Prozac to deal with the stress of moving. Over there, I just lost it completely. I was either in bed all day or irrational. The stress of being nowhere with no friends—and my husband had to work fifteen hours a day when we arrived because some deal had just kicked in. By the time that was finished, four months later, I was completely crazed. I came back to the U.S. to see doctors and I went on a huge cocktail: Klonopin, lithium, Prozac. It was impossible to have dreams or be creative and I had to carry around a gigantic pill case all the time, with pills marked morning, noon, afternoon, and evening because I couldn’t remember what was going on. Eventually, I made a life over there, found some good friends, and got an okay job, so I lowered the meds until I was popping just a couple of pills a night. Then I got pregnant, went off all the drugs, and felt great. We moved back home, and then after I had the baby all those wonderful hormones wore off, and having an infant—I didn’t have a decent night’s sleep for a year—I began to fall apart again. I was determined not to put my daughter through that. I’m on Depakote, which I find less dulling and which is apparently a safe medication to take while breast-feeding. I will do whatever I have to do to give my daughter a stable environment, not to disappear on her, not to walk out all the time.”
Two good years followed my second breakdown. I was content, and overjoyed to be content. Then in September 1999, I had a terrible experience of abandonment in love, by someone I had thought would be with me forever, and became sad—not depressed, just sad. And then a month later, I slipped on the stairs in my own house and dislocated my shoulder badly, ripping a great deal of muscle tissue. I headed up to the hospital. I attempted to explain to the staff of the ambulance and then to the staff of the emergency room that I was eager to thwart a recurrence of depression. I explained about the kidney stones and how they had triggered a previous episode. I promised to fill out every form in the book and to answer questions on every subject from the colonial history of Zanzibar on down if they would only alleviate a physical agony that I knew was far too powerful for my mind’s peace. I explained that I had a history of severe breakdowns and asked that they look up my files. It took more than an hour to get any pain medication at all; and at that point I received a dose of IV morphine too small to alleviate my pain. A dislocated shoulder is a straightforward matter, but mine was not repositioned until eight hours after I had arrived in the hospital. I did finally have some meaningful pain relief, with Dilaudid, four hours and thirty minutes after my arrival—so the last three and a half hours were not quite so awful as what had gone before.
Attempting to remain calm during the early stages of all this, I requested a psychiatric consultation. The doctor who was supervising told me, “Dislocated shoulders are painful and it’s going to be painful until we have it back in place, and you’ve just got to be patient with it and stop carrying on.” She also said, “You are exercising no self-control, are getting angry, are hyperventilating, and I’m not going to do a thing for you until you pull yourself together.” I was told that “we don’t know you from Adam,” that “we don’t just give out strong pain medicine,” and that I should “try breathing deeply and imagining yourself on a beach with the sound of water in your ears and the feeling of sand between your toes.” One of the doctors told me, “Pull yourself together and stop feeling so sorry for yourself. There are people in this emergency room who are going through worse things than you are.” And when I said that I knew I had to go through the pain but wanted to take the edge off it before we proceeded, that I didn’t even mind this physical pain so much but was worried about psychiatric complications, I was told that I was being “childish” and “uncooperative.” When I said that I had a history of mental illness, I was told that in that case I could not well expect anyone to take my views on these things seriously. “I’m a trained professional and I’m here to help you,” the doctor said. When I said that I was an experienced patient and knew that what she was doing was in fact injurious to me, she told me that I had not been to medical school and would just have to proceed according to what she judged an appropriate protocol.
I repeated my requests for a psychiatric consult, but no such thing was offered. Psychiatric records are not available in emergency rooms, and so there was no way to
check on my complaints, though the hospital where I found myself is the one with which all my primary-care physicians and my psychiatrist are associated. I believe that the emergency room policy in which saying “I have had severe psychotic depression exacerbated by extreme pain” is treated much the same as saying “I have to have a woolly teddy bear with me before you can use sutures” is unacceptable. The standard textbook on emergency room practice in the United States does not deal with the psychiatric aspects of somatic illness. No one in the emergency room was remotely equipped to deal with psychiatric complications. I was asking for steak at the fishmonger’s.
Pain accumulates. Five hours of pain are at least six times as painful as one hour of pain. I remarked that physical trauma is among the primary triggers for psychiatric trauma, that to cure one in such a way that you generate the other is an act of medical stupidity. Of course the longer the pain went on, the more it wore me out; the more overstimulated my nerves became; the more serious the situation grew. The blood under the skin had pooled until my shoulder looked as if I’d borrowed it from a leopard. I was giddy by the time the Dilaudid came along. There were indeed people in that emergency room whose acute injuries were more serious than mine; why should any of us have endured gratuitous pain?
Within three days of my emergency room ordeal, I had acute suicidal feelings of a kind I had not experienced since my first severe episode; and if I had not been under twenty-four-hour watch by my family and friends, I would have arrived at levels of physical and psychic pain that were beyond unbearable and I would have sought immediate relief of the most extreme kind. It was the tree and the vine all over again. If you see a little shoot coming out of the ground and recognize it as the shoot of a heavy vine, you can pull it out of the ground with your thumb and forefinger and all will be well. If you wait until the vine has got a firm hold on the tree, you need to have saws and perhaps an ax and a shovel to get rid of the thing and dig out the roots. It is unlikely that you can remove the vine without breaking some of the branches of the tree. I am usually able to control suicidality in myself, but, as I pointed out to the hospital staff after the whole episode was finished, refusing to treat the psychiatric complaints of patients can take a relatively insignificant matter such as a dislocated shoulder and make it a fatal disease. If someone says that he is suffering, emergency room staff should respond accordingly. Suicides take place in this country because of the conservatism of doctors such as the ones I encountered in that emergency room, who deal with intolerance for extreme pain (physical and psychological) as a weakness of character.
The following week, I went to pieces again. I had had the problem of tears during previous episodes, but never in the way that I had them now. I cried all the time, like a stalactite. It was incredibly tiring to be synthesizing all those tears, so many of them that my face became chapped. It seemed to take the most colossal effort to do simple things. I remember bursting into tears because I had used up the cake of soap that was in the shower. I cried because one of the keys stuck for a second on my computer. I found everything excruciatingly difficult, and so, for example, the prospect of lifting the telephone receiver seemed to me like bench-pressing four hundred pounds. The reality that I had to put on not just one but two socks and then two shoes so overwhelmed me that I wanted to go back to bed. Though I did not have the acute anxiety that had characterized previous episodes, paranoia began to set in as well: I started to fear, every time my dog left the room, that it was because he wasn’t interested in me.
There was an extra horror in this breakdown. My previous two breakdowns had taken place when I was not on medication. After the second one, I had accepted that I would have to be on medication permanently if I was to avoid further episodes. At considerable psychic cost, I had taken my medication every day for four years. Now I found myself having a total collapse despite the fact that I was on Effexor, BuSpar, and Wellbutrin. What could this mean? In working on this book, I had met some people who had had an episode or two, then gone on medication and been fine. I had also met people who got a year out of one medication, had a collapse, got a few months out of another one—people who could never put their depression into the safety of the past tense. I had believed myself to be in the first category. I now suddenly seemed to be in the second category. I had seen these lives in which mental health was never more than occasional. It was quite possible that I had outlived my capacity to be helped by Effexor—people do exhaust these drugs. If this were so, it was a terrible world I was joining. In my mind I saw a year on one thing, a year on another, until finally I had used up all the available options.
I now have procedures in place for breakdowns. I know which doctors to call and what to say. I know when it’s time to put away the razor blades and keep walking the dog. I called around and said straight out that I was depressed. Some dear friends, recently married, moved into my house and stayed with me for two months, getting me through the difficult parts of the days, talking through my anxieties and fears, telling me stories, seeing to it that I was eating, mitigating the loneliness—they made themselves my soul mates for life. My brother flew in from California and surprised me on my doorstep just when I was at my lowest. My father snapped to attention. Here’s what I knew that saved me: act fast; have a good doctor prepared to hear from you; know your own patterns really clearly; regulate sleep and eating no matter how odious the task may be; lift stresses at once; exercise; mobilize love.
I called my agent as soon as I could and said that I was doing badly and that I would be suspending work on this book. I said I had no idea what the course of my disaster would be. “Pretend I was hit by a car yesterday,” I said, “and that I’m in the hospital in traction waiting for the results of the X rays. Who knows when I’ll be typing again?” I took Xanax even when it made me feel spaced-out and groggy, because I knew that if I let the anxiety that was in my lungs and stomach run free, it would grow worse and I would be in trouble. I had not lost my mind, I explained to friends and family, but I had most certainly mislaid it. I felt like wartime Dresden, like a city that was being destroyed and could not shield itself from the bombs, that was simply caving in, leaving only the barest remnants of gold shimmering in the midst of rubble.
Weeping embarrassingly even in the elevator at the hospital where my psychopharmacologist keeps his office, I went to ask whether anything could be done. To my surprise, my psychopharmacologist didn’t see the situation in nearly such dire terms as I did. He said he was not going to take me off Effexor—“it’s been working for you for a long time and there’s no reason for it to stop now.” He put me on Zyprexa, an antipsychotic that has antianxiety effects as well. He increased the dose of Effexor because, he said, you should never ever switch away from the product that is helping you unless you absolutely have to do so. Effexor had done it before and maybe with a boost it would do it again? He lowered my dose of Wellbutrin because Wellbutrin is activating, and in the face of high anxiety I needed to be less activated. We left the BuSpar alone. My psychopharmacologist was adding things and subtracting things and reading my responses and my self-descriptions and constructing a somehow “true” version of me, perhaps just like the old one, perhaps a little bit different. I had a lot of expertise by now and read up on the products I took (though I avoided finding out about the side effects of anything until I’d been taking it for a while; knowing the side effects is more or less a guarantee of developing the side effects). Still, it was all a vague science of smells and flavors and blends. My therapist helped me to survive the experiments: he was a champion of continuity, calming me into a belief that the future would at the very least prove equal to the past.
The night after I started on Zyprexa, I was supposed to give a lecture on Virginia Woolf. I love Virginia Woolf. Giving a lecture on Virginia Woolf and reading aloud passages from her writing was for me comparable to giving a lecture on chocolate and eating my way through. I was giving this lecture at the home of friends, to a friendly group of perhaps fifty of t
heir associates. It was a sort of charity function for a cause in which I believed. Under ordinary circumstances, it would have been wonderful fun and little effort, and I would have been able to bask in the spotlight—which is something I rather like doing when my mood is right. One might have expected that the lecture would exacerbate my problems, but actually I was so screaming meemies that the lecture was neither here nor there: it was nerve-racking being awake, and nothing could really make things worse. So I arrived and made a little bit of polite conversation during cocktails and then stood up with my notes and found myself calm, eerily calm, as though I were merely volunteering some ideas at the dinner table, and in a strange out-of-body sort of way I watched myself deliver a reasonably coherent lecture on Woolf from memory and the written text.
After the lecture, I went with a group of friends and the people who’d organized the event to dinner in a nearby restaurant. The evening included enough varied people so that some effort was required to muster the appearance of perfect politesse, but under ordinary circumstances it would have been a pleasure. As it was, it seemed as though the air around me was setting, the way glue sets, into a weird rigidity, so that people’s voices all seemed to be breaking and cracking through the solid air, and that cracking noise made it hard to hear what they were saying. I had to break through just to lift my fork. I ordered the salmon and began to be aware that my odd situation was showing. I was slightly mortified but didn’t know what to do about it. Those situations are embarrassing, no matter how many people you know who have taken Prozac, no matter how wonderfully at ease everyone is supposed to be with depression. Everyone at the table knew I was writing a book on the subject and most of them had read my articles. It didn’t help. I mumbled and apologized my way through dinner like a Cold War diplomat. “So sorry if I seem a bit unfocused, but you know I’ve just been having another go-around with depression,” I might have said, but then everyone would have felt obliged to ask about specific symptoms and causes and to attempt to reassure me, and those reassurances would in fact have exacerbated the depression. Or, “I’m afraid I can’t actually follow what you’re saying because I’ve been taking five milligrams of Xanax every day, though I’m of course not addicted, and have also just begun a new antipsychotic which I believe has strong sedating properties. Is your salad good?” On the other hand, I had a feeling that if I went on saying nothing, people were going to notice how peculiar I was being.
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