For those still reeling from the reclassification of a category-four dickhead to a sufferer of mental illness, the shifting of a personality disorder’s terms away from social dysfunction and toward impaired self-image is further bad news. In the same way that the descriptions of these disorders can also be read as guidelines for how a person should be, to define a personality outside of a social context or a shared reality is to change the definition of what a person is. We were told that a focus group of nurse practitioners had revolted against the idea of refocusing personality disorders around a self-directed, self-reported checklist. The nurses called interpersonal function the “bread and butter” of a PD diagnosis. The study also raised the intriguing but rather hopeless question of whether a social worker would define “self” and “identity” differently from, say, a neuropharmacologist, or a psychotherapist, and on and on and on.
“That’s not my reality” is already the mantra of the self-involved. Most of us have a hard enough time overthrowing the idea that we are located at the center of the universe—I don’t know about you, but everything about my experience of the world would seem to confirm it. Personality and the terms of a social, adult existence are really all that are keeping us from becoming a race of self-reinforcing oligarchs. Must they now become their own privately experienced realities as well?
The next week, on a train from Los Angeles to San Diego, I listened from across the aisle and against my will as a young man described and defended the terms of his personality. He was a kind of public broadcaster, speaking to his seatmate without pause and with the diaphragmatic gusto of someone certain that everyone within his signal radius was interested in whatever he had to say. Had I not been so wrecked by an overnight flight, I would have obeyed my instinct and switched seats. After about fifteen minutes another woman did just that, and it really ticked the young man off.
“I bet you one hundred million dollars she left because of my talking,” he interrupted himself to complain. I hadn’t noticed the exit-in-progress before that point. Though he feigned oblivion to putting on the foregoing performance, the young man was closely monitoring its effect, all while eating Maruchan instant lunch out of a cup. The woman with the blond bob’s escape was an insult to his personality, and further evidence of the declining state of “social etiquacy.” You got the feeling this had happened before.
“Honestly, this is me,” he sighed, tired of explaining an obvious point to a world too slow or too stupid to grasp it. “And we’re in public. This is not like a freaking movie, this is public transportation.” His friend, a young woman, replied softly, “Yeah, but nobody else is talking.”
“It’s not just her,” he snapped. “I’m expressing myself about people who are like that.” The way he saw it, Blond Bob would be talking too if she had two friends in the world to rub together. That Blond Bob had relocated with the stealth of a navy SEAL, making the opposite of a scene, wasn’t the point. Maruchan felt judged, and that was wrong. He fielded creditor calls throughout the trip. After losing his job during the recession he ran up a sizable debt, mostly on clothes made necessary by a move into California’s convoluted weather patterns. The creditors were threatened with lawsuits and bankruptcy, alternately; he had done the research. He couldn’t find a job, and whose fault was that?
In San Diego I mentioned the most unsettling part of the personality-disorders symposium to Allen Frances: Very often someone with a personality disorder will shed the terms of the illness—the criteria that led to diagnosis—without improving her social or professional function. Frances shrugged. “Compulsive features of the personality tend to mellow out with age,” he said. “People, as they get older, get less tense; the rough edges are smoothed by time and experience. Their expectations go down, so that may be part of it. The Sturm and Drang, the suicide attempts and all of that, get better with time. But that doesn’t mean they feel completely comfortable in their skin or will have great interpersonal relationships.”
In other words, with treatment and the considerable passage of time, you too can transition from meeting the psychiatric definition of antisocial to merely embodying that of your peers and the Oxford English Dictionary.
* * *
I washed out of “Cities as Creators of Madness,” but you may be interested to confirm that urban centers are considered risk factors for mental illness. Only the Europeans seemed interested in telling this story. I made it through a Dutchman and a German before replacing my sunglasses and heading for the door. There was something profoundly dejecting about finally hearing what I’d been longing to hear—we live too alone, too quickly, too incoherently—only to realize I wanted more. The Netherlands—where they treat heroin addicts with heroin; it’s mostly the tourists who OD, anyway—is currently dismantling its public-health care, which means its studied and socially conscious policies are soon to follow. I was in low spirits going in, having been particularly blighted overnight by whatever detergent, pollutant, or local heavy metal was tormenting my lymphatic system, but this news bottomed me out.
Following the “Cities” session I drifted onto the convention center’s exhibition floor, where a wall of psychiatry texts gave way to a kind of pharmaceutical wonderland. As far as the eye could see, twenty-foot mobiles made slow, serene revolutions high above the village of branded pavilions below. The uniformity of the logos suggested a gold aesthetic standard had taken shape: copious white space set off by hushed primaries and Easter-egg pastels. They advertised the bigger names—Eli Lilly, Pfizer, Merck, GlaxoSmithKline—and showcased star products with soothingly abstract insignias and, in the case of Nuedexta—a new drug for chronic weeping and/or laughing—an inscrutable nesting-doll theme. Extensive carpeting gave the space a soundless, sealed-in quality, enhancing the exhibit floor’s vacuum-sealed futurity. Marketing literature flowed, but few drug reps patrolled the stations. This battle had been won, and the drowsy mobiles appeared less like representatives of contending products than coolly presiding flags planted in Hawaii’s heavily scarred soil.
The exception to this deceptively soft sell was the most ambitious display on the floor, for a drug called Latuda. Another antipsychotic, Latuda is made by Dainippon Sumitomo, a Japanese company recently expanded into the United States. The tunneled centerpiece of their display was designed to create a “virtual” experience of mental illness—specifically schizophrenia. It was more immediately successful as an answer to the question of what would happen if The North Face attempted to build a giant, Gore-Tex vagina.
About forty feet long with a curve in the middle, the tunnel was dark enough to conceal the speakers rigged throughout the passage—above your head, by your feet, and at points in between—each one blasting a different voice. As the chanted symptoms of schizophrenia ricocheted around you, various actors on various screens testified to the pain of mental illness, and the miracle of Latuda. I stood alone in the middle of the schizophrenia tunnel and closed my eyes for a moment. Dumped together the voices formed an aural hash, and the rapid-fire words flashing on yet more screens registered as faint white bursts through my eyelids. If this was insanity, it did indeed feel a lot like Times Square on a Friday night.
Upon exiting the tunnel I circled, semiconsciously, back to its start. As I stood gawping into the abyss, a pale teenage girl in a Latuda golf shirt asked me if I had enjoyed the ride. An import from some mall’s accessories kiosk, she was taller than I am, which is kind of rare and vaguely irritating, with dark eyes and even darker eye makeup. I asked if the tunnel was really meant to mimic psychosis.
“Totally,” she said, nodding gravely. “It’s just to remind you of … you know.” We looked at each other, and she stopped nodding. “But I’m sure it’s not like that. I’m sure it’s much more … intense.”
* * *
Along with Archbishop Desmond Tutu, one of the conference’s big-ticket speakers was Lorraine Bracco, the Brooklyn actress who played a mob boss’s therapist on the previous decade’s most celebrated television s
eries, The Sopranos. The grand ballroom’s stage had been decorated like a psychiatrist’s office (or perhaps its more famous relation, the talk-show set) for her appearance, complete with symmetric ferns. The scheduled chat with an APA point woman, sponsored by AstraZeneca, drew a crowd of a couple hundred to the convention center’s airy top floor.
Bracco is more of a Pfizer woman herself and made frequent mention of its biggest seller, the antidepressant Zoloft—a pill she has also endorsed in Web and television ads. I remember two other things from the hour, the first being that the actress’s bare, glossy legs gave off a retina-singeing glare. Rather than actual Lorraine, many of the camera phones held up in the audience were pointed at her blown-up image on the thirty-foot screens flanking the stage. On the smartphone screen in front of me, her shins had turned to lightning streaks. The second thing I remember is that, despite the conversation’s general cushiness, Bracco managed to graze every pressure point on psychiatry’s embattled body.
Throughout the interview, Bracco demonstrated the earnest, understandable confusion that characterizes a larger attitude toward mental health. She was careful, for instance, to explain the story behind the depression she suffered over the past decade: divorce and a custody battle had overshadowed her success; her parents had died within ten days of each other. It sounded painful and complex, but from there Bracco segued into the idea that “mental illness” (a term she implored her audience to soften) is no different from a toothache—a medical problem with a medical solution. She hailed the miracle of pharmacology and discussed her resistance to talk therapy before citing an Oprah gem about self-awareness as her mantra. When the interviewer asked if Bracco could tell the audience how to better do their jobs—a peak in the afternoon’s refractive irreality—she was adamant that the psychiatrists in the room treat their patients with affection and love, like family members, ideally.
“I think that’s very, very important,” Bracco said, turning to address the fifty or so rows of rapt, sunburned shrinks. “I think you being vulnerable was very helpful for me.” And a century’s worth of debate over the psychoanalytical dynamic passed by with a wave of her bangled arm.
Coming out as mentally ill has become an endorsement boon for the famous. In one of that spring’s heavily rotated television commercials, a reedy-voiced rock star urges anyone who was diagnosed with ADHD—attention-deficit/hyperactivity disorder—back in childhood to check that they don’t (i.e., do) still have it now. “It’s your ADHD,” he says, alternating between moody profiles and meaningful eye contact. “Own it.”
Curious about the six-question website quiz (where the presence of the commercial’s sponsor, the drug company Shire, is consigned to a modest corner logo), I selected “sometimes” in response to questions about difficulty getting organized, beginning or completing tasks, remembering appointments, or sitting still when stuck in one place for long periods. My result: “ADHD may be likely.” Two short paragraphs of conditional jujitsu explained that people who answered as I did have been diagnosed with ADHD, and that although this result was most definitely not a diagnosis, it would be “advisable and likely beneficial” to seek out “further diagnosis” from a doctor.
The doctor’s intake form wouldn’t look much different from Shire’s point-and-click checklist. Devised to restore an aura of reliability to the field, a few minutes with a DSM checklist emphasizes the extent to which symptoms of a mental illness are synonymous with the disorder they describe. The first symptom is often the helplessly obvious one: Are you depressed? Do you binge eat? Are you sometimes distracted? Have you been ambushed by the producers of Hoarders?
DSM-IV checklists are how Ted “Unabomber” Kaczynski, a man who spent seventeen years maiming and murdering people with homemade bombs before his capture in 1996, was diagnosed as a paranoid schizophrenic. Kaczynski, who objected passionately to a psychiatric defense (“Science has no business probing the workings of the human mind,” he said, echoing Freud), refused to submit to the evaluation his lawyers sought to help stave off a death sentence. However, to dismiss his defense team, Kaczynski had to be deemed competent to represent himself and was thus subjected to the process he had sought to avoid. Dr. Sally Johnson made the diagnosis, the same psychiatrist who helped ensure that President Reagan’s would-be assassin was found not guilty by reason of insanity.
Thirty years later, John Hinckley still spends his days strumming a guitar in a Washington, D.C., mental hospital, but the insanity defense was tightly restricted in the wake of his nonconviction. Kaczynski, anyway, would rather have died than be called crazy: although he was deemed competent to represent himself, the judge denied his request; he decided to plead guilty rather than be portrayed as a lunatic in court. Justice seemed to have been done, which has always been the most we can ask of the legal system. Symbolically, however, the case of Ted Kaczynski—by almost every account an exceptionally intelligent, coherent, and remorseless criminal—furthered the idea that rejecting technology’s course was an act of insanity, as the Hinckley case enforced the idea of confronting authority as madmen’s work.
As the APA conference began, back in Arizona the latest high-profile criminal to receive a schizophrenia diagnosis—the twenty-two-year-old college student who killed six people in his attempt to assassinate Democratic congresswoman Gabrielle Giffords—was resisting the forced consumption of antipsychotic medication that psychiatrists claimed would allow him to stand trial in a state that doesn’t much care for the insanity defense. (The APA no longer cares for insanity either. Like neurotic, the term was exhausted by decades of being bounce-passed throughout the culture, becoming too plastic for a field that depends on perceived authority.) Conferring legal competence is a new side effect for antipsychotics with brave new brand names like Abilify and Seroquel, but it’s not as if they need the boost. In a nation filled with unruly children, unloved criminals, and untended old people, antipsychotics are among the highest grossing class of medications, clearing sixteen billion dollars in 2010.
* * *
Now might be the time to mention that the seventeen years since the DSM’s last major revision encompassed the most radical technological and psychosocial shifts in human history. Along with the Internet and its rampancy—of information, gaming, social networks, pornography—we have invented new and strikingly metaphorical ways to manifest the same old human sadness and invert pursuits of happiness into grim, pellet-seeking perversions of themselves.
If we have created a fresh and unfamiliar reality, we still lack a common poetry to describe it, and the DSM has filled that void by default. The idiom of dysfunction, disorder, and addiction—the action nouns of modern life—has become a shared language. “Internet, Video Games, and Mental Health,” a seminar that touched on “Facebook sadness” and other aspirational toxicities in its discussion of online addictions, was the only time the psychiatrists in the audience asked not about best practices or problem patients but their children. Just how worried should they be?
“I won’t get into it,” said neuropharmacologist and chair of the DSM-5 addiction committee Charles O’Brien during his “Behavior Addictions: A New Category” talk, “but we’ve figured out what a mental disorder is.”
This is not as uncommon an admission as you might imagine; because the APA habitually tweaks the meaning of words like addiction and disorder, task forcers tend to float possible definitions like test balloons. The small room holding the seminar was crammed back to the doors with young faces and the odd soldier in fatigues. Behavioral addictions, a newly proposed category, is conspicuous in part because it would seem to ratify the connection between the way we live and how messed up we feel. Sex, food, shopping, work, exercise, and Internet addiction were all considered for inclusion; although the latter earned a spot in the appendix, only gambling will be included in DSM-5. The inception of “gambling disorder” was largely dependent on the finding that opiate antagonists have the same effect on the brains of compulsive gamblers as on the brains of alcoho
lics.
O’Brien told us that behavioral addiction is an intuitive frontier for neuroscience. A variety of biomarkers have been identified for substance addiction—animals model well for the studies, dopamine patterns have been established, and successful drug treatments have been developed. It’s convenient to just carry them over. Because the time/money/will wasn’t there to validate the other candidates, several of them are destined for DSM-5’s appendix, referred to elsewhere at the conference as “a respectable graveyard.” And if you don’t like it, O’Brien said in conclusion, get out there and do your own research. In the meantime, maybe begin memorizing the insurance code for behavioral addiction (NOS).
Copresenter Ken Rosenberg opened with his own definition of addiction—“a failure to bond”—and the announcement that we are now dealing with behaviors that didn’t exist in 1991. Rosenberg’s beat was sex, and he was sorry to tell us that he has seen the future sitting in his office, and it’s hairy as all hell. “We have a tsunami coming,” Rosenberg said, citing statistics about eleven-year-olds switching between homework and online porn as a matter of course and warning of the addictive neuro-pathways that kind of behavior creates.
As the gap between the kids’ learning how to control their impulses and the guardians’ trying to figure them out widens, the idea of what’s normal threatens to find a new level inside it. Can we stop that from happening? Should we? “We as a profession cannot duck it,” Rosenberg said of the coming wave of misfits, if not the culture creating them. Yet treating apparently “new” emotional and behavioral disturbances like biological events would seem to be another evasion of a problem the 12-step program makes plain. It feels significant that the first thing someone seeking that program’s help does is walk into a room filled with other people.
This Is Running for Your Life Page 18
