Cleo’s Story: Focusing in on ADHD
As a girl, Cleo talked so much people would joke that she had swallowed a radio, and she was so active she often bruised herself in falls or by banging into walls. At school, she rocked in her chair and had trouble following her teacher but still managed to be the best student in the class.
Cleo’s parents were both professors of Lebanese background who had migrated to Australia when she was an infant. They felt overwhelmed by their daughter, hired a nanny whose sole job was containing her, and decided not to have any more children. “I didn’t get diagnosed because my parents had a cultural bias against accepting mental illness and the school was satisfied, since I was doing so well academically. Also they didn’t know what a normal Arab was like, let alone an abnormal one.”
Things deteriorated when Cleo was fifteen. She became depressed, doubted herself, feared failure, felt cut off from family, was without friends, and had suicidal thoughts. “My parents again rejected the notion of mental illness, so I had to deal with mine alone. Being sheltered made me unprepared and vulnerable for a world that seemed so cruel. Even seeing happy people made me burst into tears, I so desperately wanted to be like them.”
Despite her inner turmoil, Cleo graduated from high school six months early and began college—majoring in psychology because she hoped to understand herself better and help others. But, at seventeen, she wasn’t ready. “Gone were my A’s! Everything was so much harder. For the first time in my life I was a C student, distracted by the simplest things, and my mind kept hopping from one thought to another. I’d start writing notes, then realize the lecturer had changed slides, my sentence was incomplete, and I had forgotten what he’d just said. I could barely read a page before I lost track of what I was reading and had to put a ruler under each line because I kept losing my place. Other thoughts would pop into my head and I kept getting up to do other things, then remembered I was supposed to be reading. No matter how hard I tried, I could not achieve the grades I was used to. I felt like a failure.”
Cleo was referred for treatment but didn’t like her therapist. “I found the lack of clarity in my diagnosis or discussion about it unacceptable and frustrating. I could not make sense of the chaos that was created by my disorder. I felt that to treat my illness, I’d have to know what it was.”
Cleo got a second opinion and the new therapist explained ADHD and how it was impacting her life. “Receiving a definitive diagnosis gave me a huge sense of relief, and I felt I was finally understood. I also realized I was not a freak, that there were others like me, and that it was not my fault that some things about me irritated others. My therapist helped me understand what it means to have ADHD and introduced me to many strategies and study techniques. He lent me books on ADHD and referred me to many useful Web sites. I began to educate myself, researched my disorder, and became more aware of my symptoms and how to deal with them.”
Cleo improved greatly and graduated from college. But she still had considerable difficulty concentrating and began taking Ritalin to help with it. “The results were astounding. My attention span and focus were dramatically increased, and I found myself being able to sit down and type at a computer for three hours.” Cleo successfully completed her degree with first-class honors. “After a decade of experiencing a disparity between my actual abilities and my academic grades, I finally felt like I was meeting my potential. I finally felt like myself again. The combination of medication and psychotherapy worked perfectly for me. Receiving the correct diagnosis has helped me deal with my distress, take responsibility, and feel in control of my life.” Cleo is now an educational psychologist helping others meet their potential.
Henry’s Story: Living with Schizophrenia
Henry was a shy and introverted child who grew up to be a decidedly peculiar teenager obsessed by spiritualism, science fiction, and conspiracy theories. By age eighteen, Henry had elaborated the unshakable conviction that he could communicate with the souls of his dead ancestors by receiving their voice commands and decoding special messages from them on the Internet. He believed he had been given the special assignment of protecting the United States from the dilution of its Caucasian stock and the hostile takeover by a foreign power or the United Nations. Henry was fearful, hypervigilant, and could not ever let down his guard. His enemies had gained control of many government agencies, acquiring technology that allowed them to observe his movements, monitor his thoughts, and exert control over his actions.
Henry slept by day, read conspiracy literature and searched the Internet by night. He dropped out of school, increasingly withdrew from the real world, and remained in more or less constant contact with his voices and in thrall to his delusions. His parents shared Henry’s general political orientation but were alarmed by his increasingly extreme and bizarre thoughts and behavior. They felt paralyzed. “Henry was retreating into another world we couldn’t enter. He would become very angry and shout us down when we tried to talk to him or get him to do anything. He refused to go to the doctor, and we were really afraid of him. We got rid of our guns because we were worried he might become violent.”
The crisis came when Henry’s mother tried to clean his room because she felt it had become a health and fire hazard. Henry took this as a hostile act and assumed she was now acting under orders from the enemy. He pushed her out the door violently and threatened her with a knife—but then felt terribly guilty, began crying uncontrollably, and shouted his intention to kill himself.
An ambulance was called, and Henry was admitted to a psychiatric hospital. The diagnosis was schizophrenia and he was started on an antipsychotic. The medicine worked well, and Henry calmed down quickly. But recovering reality has been a much slower process that is not complete five years later. “I still have the voices, especially when I am stressed or have nothing to do. But I can usually tell they aren’t real. It is a big relief not feeling watched and controlled all the time, but I get sad sometimes that I don’t really have a special mission to save my country. It is a letdown not having a clear purpose anymore. I am trying to find other things to do and ways of keeping busy.”
Henry was able to develop a trusting relationship with his psychiatrist. The treatment combines medication with weekly psychotherapy focused on reality testing and social skills training. Henry graduated from high school, has had only one additional brief hospitalization, and works very hard at therapy and at making a good life for himself. He turned his abiding interest in science fiction to great advantage, earning money buying and selling memorabilia on the Internet and making friends at science fiction conventions. Recently he began dating a girl who is also a science fiction fan.
Brandy’s Story: Getting off the Roller Coaster of Borderline Personality Disorder
Brandy was an emotionally intense, impulsive, and self-destructive young woman who led a troubled and tumultuous life. She never had the slightest difficulty getting into relationships but was consistently unable to end them without feeling furious and deeply hurt. The same pattern recurred over and over again. Brandy expected too much, would get too close too soon, become fearful of rejection, and act in an angrily manipulative way that guaranteed that her worst fears would be realized. “Then when I was abandoned, I couldn’t control myself and did really stupid things. Losing a boyfriend made me feel like I was being torn apart inside a black hole. Cutting myself calmed me down—physical pain beats emotional pain any day.”
Brandy’s school, family, and social life were almost as erratic as her love life. She is really smart but couldn’t stick to the task at hand and was always disappointing and disappointed. At twenty-five, she was thirty credits short of graduation after attending four different colleges and having dustups at each. Except for one sister, Brandy was not on speaking terms with her family, and her friendships usually lasted only months before ending stormily. Therapy hadn’t been the least bit helpful—many promising beginnings that all ended badly.
Things hit bottom when Brandy made
an impulsive suicide attempt, taking ten sleeping pills. She was admitted to the hospital overnight and referred to an outpatient program that specializes in dialectic behavior therapy. “I felt different about DBT from minute one. The people understood and accepted me but also expected me to change and to take more responsibility for myself and my actions. I couldn’t manipulate or fool them, but I felt they really cared and knew how to help me help myself. I like my therapist and want to be more like her.”
Brandy was taught concrete ways of reducing her self-destructiveness. She flicked rubber bands on her wrists instead of cutting them with a razor. She practiced going slow at the start of relationships, having fewer expectations during them, and ending them on a calm note. Brandy finished college and is now working on a master’s degree in counseling. “I still have a temper and can be fragile, but I am maturing fast and think I am almost ready to use my experiences to help other people.”
Adam’s Story: Overcoming Obsessive-Compulsive Disorder
Adam was the perpetual ABD—an “all-but-dissertation” PhD candidate who had been working on his research project for seven years and seemed incapable of ever completing it. Each time his adviser said that it was ready for submission, Adam would become obsessed with what to him seemed its glaring imperfections and was always convinced it needed a lot of reordering and cleaning up. He would churn all night with anxious thoughts of failure that were neutralized only when he began an extensive revision—adding new material, scrapping chapters and references, adding new ones—essentially guaranteeing that he could never wind up the work and have to hand it in for review.
“I knew it was crazy and counterproductive to keep redoing my dissertation, but I felt stuck and like I had no control over the process. Constantly revising was stupid, but I got too anxious if I didn’t. And it wasn’t just the dissertation. I had to spend an hour every day getting myself dressed—following a complicated ritual that had to be repeated perfectly from start to finish if I didn’t get each and every step just right. My day was also filled with dumb eating and sleep rituals, and I had to spend a lot of time praying.”
Adam’s rituals had begun in childhood and had gradually accumulated throughout his life so that they increasingly occupied almost all of his time. All along he had resisted treatment—fearing it would make him even more anxious by interfering with his rituals. But he finally reached the point of no return when his dissertation adviser threatened to drop him from the PhD program if he didn’t meet the next deadline for submission.
“The psychiatrist was a good guy and understood the pressures I was under. He explained that the only way to beat OCD is to face the anxiety, not neutralize it with rituals. Getting my PhD was simple but scary—I just had to hand in the latest draft of my dissertation without rereading a page of it. He helped teach me techniques for dealing with the anxiety. I really had no choice and took the plunge. It was a terrifying few weeks, but the committee quickly approved my PhD and I was on my way.”
Adam’s many other rituals proved more intransigent because they were so built into his daily life and were less obviously destructive. But two years of therapy and medication gradually gave him his day back. “I still have a few pet rituals, but they don’t take up much time and I feel like a free man for the first time on years.”
Getting It Right
Done poorly, psychiatric diagnosis can be an unmitigated disaster leading to aggressive treatments with horrible complications and life-shattering impact. Some of the worst mistakes are made by clinicians who combine ignorance with arrogance—who don’t know what they are doing but charge ahead as if they do. Often they are misled by fads, foolishly following their pet theories rather than learning from their patients. They overdiagnose because they see (or imagine) only the sickness in their patients and are oblivious to the health. Mistakes are also frequent when diagnoses are made casually by the undertrained and unqualified. Psychiatric diagnosis is a serious business with major and often lifelong consequences. It requires training, experience, time, empathy, and (above all) modesty.
Done well, psychiatric diagnosis can be the life-changing beginning of a successful treatment. The key ingredients to getting it right are not mysterious: a clinician with appropriate training, experience, and people skills; a patient who presents an honest and thorough description of problems; the development of a positive therapeutic relationship between them; and sufficient time to explore the past and see how things are developing in the present. If the situation is unclear, definitive diagnosis should be postponed—uncertainty is far better than false certainty. A diagnosis should always be careful—arrived at after thorough consideration, backed by solid evidence, and amenable to change as new evidence accumulates. The people helped by treatment were all confused and floundering before the moment of accurate diagnosis. Each felt helpless, unable to make sense of what was happening, uniquely damned, alone in the present, and hopeless about the future. The act of diagnosis provided a helper, an explanation, a community of fellow sufferers, a call to action, a sense of predictability, and hope for the future. Previously unmanageable problems suddenly seem manageable. An accurate diagnosis (along with education about it that is sensitive and sensible) provides great relief and a big head start toward recovery. One of the best predictors of the success of any treatment is the quality of the relationship that forms between clinician and patient. A great relationship certainly doesn’t guarantee a quick cure and a lousy one doesn’t foreclose it, but on average the better the relationship, the better the result. And a well-done diagnosis is one of the best ways of cementing a solid therapeutic relationship.
EPILOGUE
God must have an inordinate love of beetles because he created so many different kinds of them.
J. B. S. HALDANE
BEETLES WILL ALMOST certainly inherit the earth. Think of the scorecard—several hundred thousand, highly diversified species of beetle versus only one increasing homogenized type of man. The smart money has to be on the bugs—not their betters—to survive to the end of our young millennium.
Nature has rolled these dice trillions and trillions of times and has learned to pick diversity as the best long-term bet. An acre of rain forest has hundreds of different species with wildly different genetic heritages. All the trees look alike to the untrained eye as they struggle to gain their little place in the sun at the top of the canopy. It would have been far less complicated to go with one species, but nature has consistently been willing to pay a hefty price to keep its options open. You never know what’s coming down the pike and which genetic potential will be most needed to meet the next environmental challenge.
Nature takes the long view, mankind the short. Nature picks diversity; we pick standardization. We are homogenizing our crops and homogenizing our people. Ignoring the cautionary tale of the rain forest, mankind is now staking its destiny on a really bad bet promoted by Big Agriculture. Our food supply, once so heterogeneous, now depends on a vast global monoculture of genetically homogeneous plants and animals. Learning nothing whatever from the nightmares of the Irish potato famine, we are discounting nature’s abundant and proven powers to come up with an aggressive bug that will eat our collective lunch.
And Big Pharma seems intent on pursuing a parallel attempt to create its own brand of human monoculture. With an assist from an overly ambitious psychiatry, all human difference is being transmuted into chemical imbalance that is meant to be treated with a handy pill. Turning difference into illness was among the great strokes of marketing genius accomplished in our time—up there with Apple and Facebook. But much less helpful, much more potentially harmful.
I once saw a piece of conceptual art that bore a really chilling Brave New World message. The artist had painstakingly measured all the wavelengths reflected off a richly detailed and brilliantly chromatic Renaissance painting. Averaging these wavelengths, she used the color that represented their mean to paint a large monochromatic canvas in what could only be described as excreme
ntal brown. It is that easy to wash out vivid difference, but how dreary the result. All the great characters in myths, novels, and plays have endured the test of time precisely because they drift so colorfully away from the mean. Do we really want to put Oedipus on the couch, give Hamlet a quick course of behavior therapy, start Lear on antipsychotics?
I think not. Human diversity has its purposes or it would not have survived the evolutionary rat race. Our ancestors made it because the tribe combined a wide variety of talents and inclinations. There were leaders high on their own narcissism and followers content enough to be dependent on them; people who were paranoid enough to sniff out hidden threats, compulsive enough to get the job done, and exhibitionistic enough to attract mates. It was good to have some who would avoid dangers, others who could ruthlessly exploit them. Perhaps the healthiest individuals were those who best balanced all these traits somewhere near the golden mean, but the best bet for the group was to have outliers always ready to step up to the plate as the particular occasion demanded. Just like all those different species of beetles and trees in the rain forest.
Darwin quickly tumbled to the idea that our brain functioning, and the human behaviors it produces, is just as much the product of natural selection as are the shape of our bodies and the workings of our digestive system. To understand ourselves, he suggested we study baboons, not books of philosophy or psychology. And he watched his children develop day to day with the practiced eye of a brilliantly thorough naturalist. He understood that if we are capable of sadness, anxiety, panic, disgust, or rage—it is because these all have high survival value and are an inevitable and existential part of human life. We need to grieve the loss of loved ones or we would never fully love them. We need to worry about the consequences of our actions or those actions will get us into trouble. We need to order our environments or chaos will ensue. Illness lurks only at the far extremes, distant from the golden mean. Most of what we do, we do for good reason. Most of us are normal.
Saving Normal : An Insider's Revolt Against Out-of-control Psychiatric Diagnosis, Dsm-5, Big Pharma, and the Medicalization of Ordinary Life (9780062229274) Page 29