Emergence is usually slow, and people stop at various stages of it. One mental health worker described her own constant struggle with depression: “It never really leaves me, but I battle with it every day. I’m on medication, and that helps, and I have just determined that I will not let myself give in to it. You see, I have a son who suffers from this disease, and I don’t want him to think that it’s a reason for not having a good life. I get up every single day, and I make breakfast for my kids. Some days I can keep going, and some days I have to go back to bed afterwards, but I get up every day. I come into this office at some point every day. Sometimes I miss a few hours, but I’ve never missed a whole day from depression.” She had tears rolling down her face as we spoke, but her jaw was set and she went right on speaking. “One day last week I woke up and it was really bad. I managed to get out of bed, to walk to the kitchen, counting every step, to open the refrigerator. And then all the breakfast things were near the back of the refrigerator, and I just couldn’t reach that far. When my kids came in, I was just standing there, staring into the refrigerator. I hate being like that, being like that in front of them.” We talked about the day-to-day battle: “Someone like Kay Jamison, or someone like you, gets through this with so much support,” she said. “My parents are both dead, and I’m divorced, and I don’t find it easy to reach out.”
Life events are often the triggers for depression. “One is much less likely to experience depression in a stable situation than in an unstable one,” Melvin McInnis of Johns Hopkins says. George Brown, of the University of London, is the founder of the field of life-events research and says, “Our view is that most depression is antisocial in origin; there is a disease entity as well, but most people are able to produce major depression given a particular set of circumstances. Level of vulnerability varies, of course, but I think at least two-thirds of the population has a sufficient level of vulnerability.” According to the exhaustive research he has done over twenty-five years, severely threatening life events are responsible for triggering initial depression. These events typically involve loss—of a valued person, of a role, of an idea about yourself—and are at their worst when they involve humiliation or a sense of being trapped. Depression can also be caused by positive change. Having a baby, getting a promotion, or getting married are almost as likely to kindle depression as a death or loss.
Traditionally, a line has been drawn between the endogenous and reactive models of depression, the endogenous starting at random from within, while the reactive is an extreme response to a sad situation. The distinction has fallen apart in the last decade, as it has become clear that most depression mixes reactive and internal factors. Russell Goddard, of Yale University, told me the story of his battles with depression: “I took Asendin and it resulted in psychosis; my wife had to rush me to the hospital.” He had better results with Dexedrine. His depression often escalated around family events. “I knew that my son’s wedding would be emotional,” he told me, “and that anything emotional, good or bad, sets me off. I wanted to be prepared. I’d always hated the idea of electroshock therapy, but I went and had it anyway. But it didn’t do any good. By the time the wedding came, I couldn’t even get out of bed. It broke my heart, but there was no way I could get there.” This puts a terrible strain on family and on family relations. “My wife knew she couldn’t do anything,” Goddard explained. “She’s learned to leave me alone, thank God.” But family and friends are often unable to do that, and unable to understand. Some are almost too indulgent. If you treat someone as totally disabled, he will see himself as totally disabled, and that can cause him to be totally disabled, perhaps more totally disabled than he need be. The existence of medication has increased social intolerance. “You got a problem?” I once heard a woman say to her son in a hospital. “You get on that Prozac and get over it and then you give me a call.” To set the correct level of tolerance is necessary not only for the patient but also for the family. “Families must guard themselves,” Kay Jamison once said to me, “against the contagion of hopelessness.”
What remains unclear is when depression triggers life events, and when life events trigger depression. Syndrome and symptom blur together and cause each other: bad marriages cause bad life events cause depression causes bad attachments, which are bad marriages. According to studies done in Pittsburgh, the first episode of major depression is usually closely tied to life events; the second, somewhat less; and by the fourth and fifth episodes life events seem to play no part at all. Brown agrees that beyond a certain point, depression “takes off on its own steam” and becomes random and endogenous, dissociated from life events. Though most people with depression have survived certain characteristic events, only about one in five who have experienced those events will develop depression. It is clear that stress drives up rates of depression. The biggest stress is humiliation; the second is loss. The best defense, for people with a biological vulnerability, is a “good enough” marriage, which absorbs external humiliations and minimizes them. “The psychosocial creates biological changes,” Brown acknowledges. “The thing is that the vulnerability must initially be triggered by external events.”
Just before my reading tour began, I started taking Navane, an antipsychotic with antianxiety effects, which, we hoped, would allow me to take the Xanax less often. My next engagements were out in California. I thought I could not go; I knew that I could not go alone. In the end, my father took me there; while I was in a Xanax haze, he got me on and off the plane, out of the airport, to the hotel. I was so drugged up that I was almost asleep, but in this state I could manage these changes, which would have been inconceivable to me a week earlier. I knew that the more I managed to do, the less I would want to die, so it seemed important to go. When we arrived in San Francisco, I went to bed and slept for about twelve hours. Then, during my first dinner there, I suddenly felt it lift. We sat in the big, cozy dining room of our hotel, and I chose my own food. I had been spending days on end with my father, but I had no idea what had been happening in his life, except me; we talked that night as though we were catching up after months apart. Upstairs, we sat talking further until late, and when I finally went to bed, I was almost ecstatic. I ate some chocolates from my minibar, wrote a letter, read a few pages of a novel I’d brought with me, cut my nails. I felt ready for the world.
The next morning, I felt just as bad as I had ever felt. My father helped me to get out of bed, turned on the shower. He tried to get me to eat, but I was too frightened to chew. I managed to drink some milk. I almost threw up several times, but not quite. I was afflicted with a sense of bleak misery, like what one would experience if one had just dropped and smashed a precious object. These days, a quarter milligram of Xanax will put me to sleep for twelve hours. That day, I took eight milligrams of Xanax and was still so tense I couldn’t sit still. In the evening I felt better but not much. That’s what a breakdown is like at that stage: one step forward, two steps back, two steps forward, one step back. A box step, if you will.
During the period that followed, the symptoms began to lift. I felt better earlier, and for longer, and more often. Soon, I could feed myself. It’s hard to explain the quality of the disablement as it existed then, but it was a bit as I have imagined being very old. My great-aunt Beatrice was remarkable at age ninety-eight, because she was ninety-nine and yet every day, she got up and got dressed. If the weather was agreeable, she walked as much as eight blocks. She still cared about her clothes, and she liked to talk on the phone for hours. She remembered everyone’s birthday and she occasionally went out to lunch. Emerging from a depression, you are at the point at which you get up and get dressed every day. If the weather is nice, you can go for a walk, and perhaps you can even have lunch. You talk on the phone. Aunt Bea was not gasping for breath at the end of one of her walks; she went a little slowly, but she had a nice time and was glad to have been out. So it is that when you are in the emerging stage of a depression, it is not the case that your being perfectly norma
l at lunch is like being all better, any more than Aunt Bea’s ability to walk eight blocks meant that she was the all-night dancer she was at seventeen.
You don’t get over breakdowns quickly or easily. Things go on being bumpy. Though certain depression symptoms seemed to be improving, I had an unfortunate, unusual cumulative adverse response to Navane. By the end of the third week on it, I had begun to lose the capacity to remain upright. I would walk for a few minutes and then I would have to lie down. I could no more control that need than I could the need to breathe. I would go off to do a reading and I would cling to the podium. Halfway through the reading, I would start skipping paragraphs so that I could just get through. When I was done, I would sit in a chair and hold on to the seat. As soon as I could leave the room, sometimes pretending I needed a bathroom, I would lie down again. I had no idea what was going on. I remember going out for a walk with a friend near the Berkeley campus, because she suggested that nature might do me good. We walked for a few minutes and then I began to feel tired. I forced myself on, thinking the weather and the air would help; I had been in bed for the previous fifty hours or so. Since I’d reduced my Xanax substantially, to stop sleeping fifty hours at a stretch, I was beginning to experience high anxiety again. If you have never experienced anxiety, think of it as the opposite of peace. All the peace—inward and outward—was stripped from my life at that moment.
Much depression incorporates anxiety symptoms. It’s possible to read anxiety and depression separately, but according to James Ballenger of the Medical College of South Carolina, a leading expert in anxiety, “they’re fraternal twins.” George Brown said succinctly, “Depression is a response to past loss, and anxiety is a response to future loss.” Thomas Aquinas proposed that fear is to sadness as hope is to pleasure; or, in other words, that anxiety is the precursor form of depression. I experienced so much anxiety when I was depressed, and felt so depressed when I was anxious, that I came to understand the withdrawal and the fear as inseparable. Anxiety is not paranoia; people with anxiety disorders assess their own position in the world much as do people without. What changes in anxiety is how one feels about that assessment. About half of patients with pure anxiety disorders develop major depression within five years. Insofar as depression and anxiety are genetically determined, they share a single set of genes (which are tied to the genes for alcoholism). Depression exacerbated by anxiety has a much higher suicide rate than depression alone, and it is much harder to recover from. “If you’re having several panic attacks every day,” says Ballenger, “it’s gonna bring Hannibal to his knees. People are beaten into a pulp, into a fetal position in bed.”
Between 10 and 15 percent of Americans suffer from some sort of anxiety disorder. In part, scientists think, because the locus coeruleus in the brain controls both norepinephrine production and the lower bowel, at least half of anxiety-disorder patients have irritable bowel syndrome as well; and anyone who has had really intense anxiety knows just how fast and furiously food can run through the digestive system. Both norepinephrine and serotonin are implicated in anxiety. “Two out of three times, life events are implicated, and it’s always a loss of security,” Ballenger says. About a third of panic attacks, endemic to some depression, occur during sleep, in deep, dreamless delta sleep. “In fact, panic disorders are kindled by things that make us all nervous,” says Ballenger. “When we cure them, it’s as though we’ve brought people to normal anxiety.” The panic disorders are really disorders of scale. Walking in a crowd, for example, is somewhat distressing to most people even when they do not have an anxiety disorder; but if they do have an anxiety disorder, it may be unspeakably terrifying. We all exercise some care when we consider crossing a bridge—will it bear the weight? is it safe?—but for a person with an anxiety disorder, crossing a solid steel bridge that has borne a lot of traffic for decades may be as scary as crossing the Grand Canyon on a tightrope would be for the rest of us.
At my pitch of anxiety, my friend in Berkeley and I set out for a bit of exercise and we walked on and on and then I couldn’t go farther. I lay down, fully dressed in perfectly nice clothes, in the mud. “Come on, get up on a log anyway,” she said. I felt paralyzed. “Please let me stay here,” I said, and I felt the crying start again. For an hour I lay in that mud, feeling the water seeping through, and then my friend pretty much carried me back to the car. Those same nerves that had been scraped raw at one point now seemed to be wrapped in lead. I knew it was a disaster, but that knowledge was meaningless. Sylvia Plath wrote in The Bell Jar, her wonderful evocation of her own breakdown: “I couldn’t get myself to react. I felt very still and very empty, the way the eye of a tornado must feel, moving dully along in the middle of the surrounding hullabaloo.” I felt as if my head had been encaged in Lucite, like one of those butterflies trapped forever in the thick transparency of a paperweight.
Doing those readings was the most difficult endeavor of my life: it was harder than any challenge I have faced before or since. The publicist who had organized my reading tour came with me herself for more than half of it and has since been a cherished friend. My father joined me for many of the trips; when we were apart, he called me every few hours. A few close friends took on responsibility for me, and I was never alone. I can tell you that I was not a fun companion; and that deep love and the knowledge of deep love were not by themselves the cure. I can also say that without deep love and the knowledge of deep love, I would not have found it in myself to go through with that tour. I would have found a place to lie down in the woods and I would have stayed there until I froze and died.
The terror lifted in December. Whether that was because the drugs had kicked in or because the reading tour was over, I do not know. In the end, I had canceled only one reading; between November 1 and December 15, I had managed to visit eleven cities. I had had a few random windows through the depression, like when the mist clears. Jane Kenyon, a poet who suffered severe depression through much of her life, has written about the emergence:
. . . With the wonder
and bitterness of someone pardoned
for a crime she did not commit
I come back to marriage and friends,
to pink fringed hollyhocks; come back
to my desk, books, and chair.
So on December 4, I walked into a friend’s house on the Upper West Side, and I had an okay time there. For the next few weeks, I took pleasure not in the okay time I was having, but in the fact that I was having it. I made it through Christmas and New Year’s and I was acting like some semblance of myself. I had lost about fifteen pounds, and now I began to put on weight again. My father and my friends all congratulated me on my astonishing progress. I thanked them. In my private self, however, I knew that what had gone away were only symptoms. I hated taking my pills every day. I hated that I had had a breakdown and lost my mind. I hated that unfashionable but relevant word breakdown, with its implication of the machinery giving in. I was relieved to have made it through the reading tour, but I was exhausted by all the things I had yet to make it through. I was overpowered being in the world, by other people and their lives I couldn’t lead, their jobs I couldn’t do—overpowered even by jobs I would never want or need to do. I was back to about where I had been in September, only now I understood how bad it could get. I was determined never again to go through such a thing.
This phase of half-recovery can last for a long time. It is the dangerous time. During the worst of my depression, when I could hardly cut up a lamb chop, I could not have done myself real harm. In this emerging period, I was feeling well enough for suicide. I could by now do pretty much all of what I had always been able to do, except that I was still in anhedonia, the inability to experience pleasure at all. I kept pushing myself for form’s sake, but now that I had the energy to wonder why I was pushing myself, I could find no good reasons. I remember one evening in particular, when an acquaintance had convinced me that I should go out to the movies with him. I went along to prove my own gai
ety and for several hours kept up every appearance of the fun the others were having, though I was pained by the episodes that they found funny. When I came home, I felt a return of panic, and a sadness of dinosaur proportions. I went into the bathroom and threw up repeatedly, as though my acute understanding of my loneliness were a virus in my system. I thought that I would die alone, and that there was no good reason to stay alive, and I thought that the normal and real world in which I had grown up, and in which I believed that other people lived, would never open itself up to receive me. And as these revelations burst into my head like shots, I retched on the bathroom floor, and the acid rode up the length of my esophagus, and when I tried to catch my breath, I inhaled my own bile. I had been eating big meals to try to put weight back on, and I felt as though all of them were coming back up, as though my stomach were going to turn itself inside out and hang limp in the toilet.
I lay on the bathroom floor for about twenty minutes, then crawled out and lay down on my bed. It was clear to my rational mind that I was going crazy again, and the awareness tired me further; but I knew that it was a bad plan to let the craziness run wild. I needed to hear another voice, even if only briefly, that could penetrate my fearful isolation. I did not want to call my father because I knew he would worry, and because I hoped the situation was temporary. I wanted to talk to someone sane and comforting (a poor impulse: crazy people are better friends when you are crazy; they know how crazy feels). I picked up the phone and dialed one of my oldest friends. We had talked previously about the medications, about the panic, and she had been smart and liberating in her responses.
The Noonday Demon Page 9
