Autodidact: self-taught

Nov
25
2012

Noonday Demon I

by V. L. Craven

Noonday Demon I

The Noonday Demon: An Atlas of Depression by Andrew Solomon
-0001- From the blurbs: Naomi Wolf says women are the more likely gender to experience lasting depression, whose grief is so often trivialized, (The Noonday Demon) will be a valued sourcebook, even a lifeline.
-0002- The melancholic, Freud observed, has ‘a keener eye for truth than others,’ — from (The New Yorker) review.
-0003- Everything passes away–suffering, pain, blood, hunger, pestilence. The sword will pass away too, but the stars will still remain when the shadows of our presence and our deeds have vanished from the earth. There is no man who does not know that. Why, then, will we not turn our eyes toward the star? Why? –Mikhail Bulgakov, (The White Guard)
-0004- In a book one of the aims of which is to remove the burden of stigma from mental illness, it is important not to play to that stigma by hiding the identities of depressed people.
-0005- The members of Mood Disorders Support Groups (MDSG) …
-0006- Graham Greene once said, “I sometimes wonder how all those who do not write, compose, or paint can manage to escape the madness, the melancholia, the panic fear which is inherent in the human situation.” I think he vastly underestimated the number of people who do write in one way or another to alleviate melancholia and panic fear.
-0007- It is frighteningly easy to accumulate material about depression. I felt in the end that what was missing in the field of depression studies was synthesis. Science, philosophy, law, psychology, literature, art, history, and many other disciplines have independently taken up the cause of depression. So many interesting things are happening to so many interesting people and so many interesting things are being said and being published—and there is chaos in the kingdom.
-0008- My finding, in general, is that statistics in this field are inconsistent and that many authors select statistics to make an attractive ensemble in support of preexisting theories. I found one major study, for example, that showed that depressed people who abuse substances nearly always choose stimulants; and another, equally convincing one that demonstrated that depressed people who abuse substances invariably use opiates. Many authors derive a rather nauseous are of invincibility from statistics, as though showing that something occurs 82.37 percent of the time is more palpable and true than showing that something occurs about three out of four times. It is my experience that the hard numbers are the ones that lie. The matters that they describe cannot be defined so clearly. The most accurate statement that can be made on the frequency of depression is that it occurs often and, directly or indirectly, affects the lives of everyone.
-0009- I was frequently asked, as I wrote this book, whether the writing was cathartic. It was not. My experience conforms to that of others who have written in this field. Writing on depression is painful, sad, lonely, and stressful. Nonetheless, the idea that I was doing something that might be useful to others was uplifting; and my increased knowledge has been useful to me. I hope it will become clear that the primary pleasure of this book is a literary pleasure of communication rather than the therapeutic release of self-expression.
-0010- Depression, under various names and in various guises, is and has always been ubiquitous for biochemical and social reasons. This book strives to capture the extent of depression’s temporal and geographical reach. If it sometimes seems that depression is the private affliction of the modern Western middle classes, that is because it is in this community that we are suddenly acquiring new sophistication to recognize depression, to name it, to treat it, and to accept it—and not because we have any special rights to the complaint itself. No book can span the reach of human suffering, but I hope that by indicating that reach, I will help to liberate some men and women who suffer from depression. We can never eliminate all unhappiness, and alleviating depression does not ensure happiness, but I hope the knowledge contained in this book will help to eliminate some pain for some people.
-0011- Life is fraught with sorrows: no matter what we do, we will in the end die; we are, each of us, held in the solitude of an autonomous body; time passes, and what has been will never be again. Pain is the first experience of world-helplessness, and it never leaves us.
-0012- But despite the enthusiastic claims of pharmaceutical science, depression cannot be wiped out so long as we are creatures conscious of our own selves. It can at best be contained—and containing is all current treatments for depression aim to do.
-0013- Highly politicized rhetoric has blurred the distinction between depression and its consequences—the distinction between how you feel and how you act in response. This is in part a social and medical phenomenon, but it is also the result of linguistic vagary attached to emotional vagary. Perhaps depression is not just a lot of pain; but too much pain can compost itself into depression. Grief is depression in proportion to circumstance; depression is grief out of proportion to circumstance. It is tumbleweed distress that thrives on thin air, growing despite its detachment from the nourishing earth. It can be described only in metaphor and allegory. Saint Anthony in the desert, asked how he could differentiate between angels who came to him humble and devils who came in rich disguise, said you could tell by how you felt after they had departed. When an angel left you, you felt strengthened by his presence; when a devil left, you felt horror. Grief is a humble angel who leaves you with strong, clear thoughts and a sense of your own depth. Depression is a demon who leaves you appalled.
-0014- Depression has been roughly divided into small (mild or disthymic) and large (major) depression. Mild depression is a gradual and sometimes permanent thing that undermines people the way rust weakens iron. It is too much grief at too slight a cause, pain that takes over from the other emotions and crowds them out. Such depression takes up bodily occupancy in the eyelids and in the muscles that keep the spine erect. It hurts your heart and lungs, making the contraction of involuntary muscles harder than it needs to be. Like physical pain that becomes chronic, it is miserable not so much because it is intolerable in the moment as because it is intolerable to have known it in the moments gone and to look forward only to knowing it in the moments to come. The present tense of mild depression envisages no alleviation because it feels like knowledge.
-0015- Virginia Woolf has written about this state with an eerie clarity: “Jacob went to the window and stood with his hands in his pockets. There he saw three Greeks in kilts; the masts of ships; idle or busy people of the lower classes strolling or stepping out briskly, or falling into groups and gesticulating with their hands. Their lack of concern for him was not the cause of his gloom; but some more profound conviction—it was not that he himself happened to be lonely, but that all people are.” In the same book, Jacob’s Room, she describes how “There rose in her mind a curious sadness, as if time and eternity showed through skirts and waistcoats, and she saw people passing tragically to destruction. Yet, heaven knows, Julia was no fool.” It is this acute awareness of transience and limitation that constitutes mild depression. Mild depression, for many years simply accommodated, is increasingly subject to treatment as doctors scrabble to address its diversity.
-0016- Large depression is the stuff of breakdowns. If one imagines a soul of iron that weathers with grief and rusts with mild depression, then major depression is the startling collapse of a whole structure. There are two models for depression: the dimensional and the categorical. The dimensional posits that depression sits on a continuum with sadness and represents an extreme version of something everyone has felt and known. The categorical describes depression as an illness totally separate from other emotions, much as a stomach virus is totally different from acid indigestion. Both are true. You go along the gradual path of the sudden trigger of emotion and they you get to a place that is genuinely different. It takes time for a rusting iron-framed building to collapse, but the rust is ceaselessly powdering the solid, thinning it, eviscerating it. The collapse, no matter how abrupt it may feel, is the cumulative consequence of decay. It is nonetheless a highly dramatic and visibly different event. It is a long time from the first rain to the point when rust has eaten through an iron girder. Sometimes the rusting is at such key points that the collapse seems total, but more often it is partial: this section collapses, knocks that section, shifts the balances in a dramatic way.
-0017- It is not pleasant to experience decay, to find yourself exposed to the ravages of an almost daily rain, and to know that you are turning into something feeble, that more and more of you will blow off with the first strong wind, making you less and less. Some people accumulate more emotional rust than others. Depression starts out insipid, fogs the days into a dull color, weakens ordinary actions until their clear shapes are obscured by the effort they require, leaves you tired and bored and self-obsessed—but you can get through all of that. Not happily, perhaps, but you can get through. No one has ever been able to define the collapse point that marks major depression, but when you get there, there’s not much mistaking it.
-0018- Major depression is a birth and a death: it both the new presence of something and the total disappearance of something.
-0019- Depression exists in time. A patient may say that he has spent certain months suffering major depression, but this is a way of imposing a measurement on the immeasurable. All that one can really say for certain is that one has known major depression, and that one does not happen to be experiencing it at any given present moment.
-0020- Fresh from a major depression in which I had hardly been able to take on board the idea of other people’s problems, I empathized with that tree. My depression had grown on me as that vine had conquered the oak; it had been a sucking thing that had wrapped itself around me ugly and more alive than I. It had had a life of its own that bit by bit asphyxiated all of my life out of me. At that worst stage of major depression, I had moods that I knew were not my moods: they belonged to the depression, as surely as the leaves on that tree’s high branches belonged to the vine. When I tried to think clearly about this, I felt that my mind was immured, that it couldn’t expand in any direction. I knew that the sun was rising and setting, but little of its light reached me. I felt myself sagging under what was much stronger than I; first I could not use my ankles, and then I could not control my knees, and then my waist began to break under the strain, and then my shoulders turned in, and in the end I was compacted and fetal, depleted by this thing that was crushing me without holding me. Its tendrils threatened to pulverized my mind and my courage and my stomach, and crack my bones and dessicate my body. It went on glutting itself on me when there seemed nothing left to feed it.
-0021- Maybe what is present usurps what becomes absent, and maybe the absence of obfuscatory things reveal what is present. Either way, you are less than yourself and in the clutches of something alien.
-0022- Psychiatry’s bible—the Diagnostic and Statistical Manual, fourth edition (DSM-IV)–ineptly defines depression as the presence of five or more on a list of nine symptoms. The problem with the definition is that it’s entirely arbitrary. There’s no particular reason to qualify five systems as constituting depression; four symptoms are more or less depression; and five symptoms are less severe as than six. Even one symptom is unpleasant. Having slight version of all the symptoms may be less of a problem than having severe versions of two symptoms. After enduring diagnosis, most people seek causation, despite the facy that knowing why you are sick has no immediate bearing on treating the sickness.
-0023- Illness of the mind is real illness. It can have severe effects on the body, People who show up at the offices of their doctors complaining about stomach cramps are frequently told, “Why, there’s nothing wrong with you except that you’re depressed!” Depression, if it is sufficiently severe to cause stomach cramps, is actually a really bad thing to have wrong with you, and it requires treatment. If you show up complaining that your breathing is troubled, no one says to you, “Why, there’s nothing wrong with you except that you have emphysema!” To the person who is experiencing them, psychosomatic complaints are as real as the stomach cramps of someone with food poisoning. They exist in the unconscious brain, and often enough the brain is sending inappropriate messages to the stomach, so they exist there as well. The diagnosis—whether something is rotten in your stomach or your appendix or your brain—matters determining treatment and is not trivial. As organs go, the brain is quite an important one, and its malfunctions should be addressed accordingly.
-0024- Chemistry is often called on to heal the rift between body and soul. The relied people express when a doctor says their depression is “chemical” is predicated on a belief that there is an integral self that exists across time, and on a fictional divide between the fully occasional sorrow and the utterly random one. The word chemical seems to assuage the feelings of response people have for the stressed out discontent of not liking their jobs, worrying about getting old, failing at love, hating their families. There is a pleasant freedom from guilt that has been attached to chemical. If your brain is predisposed to depression, you need not blame yourself for it. Well, blame yourself or evolution, but remember that blame itself can be understood as a chemical process, and that happiness too, is chemical. Chemistry and biology are not matters that impinge on the “real” self; depression cannot be separated from the person it affects. Treatment does not alleviate a disruption of identity, bringing you back to some kind of normality; it readjusts a multifarious identity, changing in some small way depress who you are.
-0025- Everything that happens in the brain has chemical manifestations and sources. If you close your eyes and thing hard about polar bears, that has a chemical effect on your brain. If you stick to a policy of opposing tax breaks for capital gains, that has a chemical effect on your brain. When you remember some episode from your past, you do so through the complex chemistry of memory. Childhood trauma and subsequent difficulty can alter brain chemistry.
-0026- If time lets you cycle out of a depression and feel better, the chemical changes are no less particular and complex than the ones that are brought about by taking antidepressants. The external determines the internal as much as the internal invents the external. What is so unattractive is the idea that in addition to all other lines being blurred, the boundaries of what makes us ourselves are blurry. There is no essential self that lies pure as a vein of gold under the chaos of experience and chemistry.
-0027- The cumulative results of the brain’s chemical effects are not well understood. In the 1989 edition of the standard Comprehensive Textbook of Psychiatry, for example, one finds this helpful formula: a depression score is equivalent to the level of 3-methoxy-4-hydroxphenylglycol (a compound found in the urine of all people and not apparently affected by depression): minus the level of 3-methoxy-4-hydroxymandelic acid: plus the level of norepinephrine; minus the level of normatanephrine plus the level of metanepherine, the sum of those divided by the level of 2-methoxy-4-hydroxymandelic acid; plus an specified conversion variable; or, as CTP puts it: “D-type score = C [1] (MHPG) – C [2] (VMA) + C [3] (NE) – C [4] (NMN + MN)/VMA + C [0] .” The score should come out between one for unipolar and zero for bipolar patients, so if you come up with something else–you’re doing it wrong.
-0028- To what extent specific experience has conduced to a particular depression is hard to determine; nor can we explain through what chemistry a person comes to respond to external circumstance with depression; nor can we work out what makes someone essentially depressive.
-0029- Depression is *not* the consquence of a reduced level of anything we can now measure. Raising levels of serotonin in the brain triggers a process that eventually helps many depressed people to feel better, but that is *not* because they have abnormally low levels of serotonin. Furthermore, serotonin does *not* have immediately salutary effects. You could pump a gallon of serotonin into the brain of a depressed person and it would not in the instant make him feel one iota better, though a long-term sustained raise in serotonin level has some effects that ameliorate depressive symptoms. “I’m depressed but it’s just chemical” is a sentence equivalent to “I’m murderous but it’s just chemical.” Everything about a person is just chemical if one wants to think in those terms.
-0030- Internal and external reality exist on a continuum. What happens and how you understand it to have happened and how you respond to its happening are usually linked, but no one is predictive of the others. If reality itself is often a relative thing, and the self is in a state of permanent flux, the passage from slight mood to extreme mood is a glissando. Illness, then, is extreme state of emotion, and one might reasonably describe emotion as a mild form of illness. If we all felt up and great (bit not delusionally manic) all the time, we could get more done and might have a happier time on earth, but that idea is creepy and terrifying (though, of course, if we felt up and great all the time we might forget all about creepiness and terror).
-0031- Influenza is straightforward: one day you do not have the responsible virus in your system, and another day you do. HIV passes from one person to another in a definable isolated split second. Depression? It’s like trying to come up with clinical parameters for hunger, which affects us all several times a day, but which in its extreme version is a tragedy that kills its victims. Some people need more food than others; some can function under circumstances of dire malnutrition; some grow weak rapidly and collapse in the streets. Similarly, depression hits different people in different ways: some are predisposed to resist or battle through it, while others are helpless in its grip. Willfullness and pride may allow one person to get through in a depression that would fell another whose personality is more gentle and acquiescent.
-0032- Often, the fight takes the form of seeking out the treatments that will be most effective in the battle. It involves making the most of the life you have between your most severe episodes. Some horrendously symptom-ridden people are able to achieve real success in life; and some people are utterly destroyed by the mildest forms of the illness.
-0033- Everyone has on occasion felt disproportionate emotion over a small matter or has felt emotions whose origin is obscure of that may have no origin at all. Sometimes the chemistry kicks in for no apparent external reason at all. Most people have had moments of inexplicable despair, ofthen in the middle of the night or in the early morning before the alarm clock sounds. If such feeling last ten minutes, they;re a strange, quick mood. If they last ten hours, they’re a disturbing febrility, and if they last ten years, they’re a crippling illness.
-0034- It is too often the quality of happiness that you feel at every moment its fragility, while depression seems when you are in it to be a state that will never pass. Even if you accept that moods change, that whatever you feel today will be different tomorrow, you cannot relax into happiness as you can into sadness. For me, sadness always has been and still is a more powerful feeling; and if that is not a universal experience, perhaps it is the base from which depression grows. I hated being depressed, but it was also in depression that I learned my own acreage, the full extent of my soul. When I am happy, I feel slightly distracted by happiness, as though it fails to use some part of my mind and brain that wants the exercise. Depression is something to do. My grasp tightens and becomes acute in moments of loss: I can see the beauty of glass objects fully at the moment when they slip from my hand toward the floor. “We find pleasure much less pleasurable, pain much more painful than we had anticipated,” Schopenhauer wrote. “We require at all times a certain quantity of care or sorrow or want, as a ship requires ballast, to keep on a straight course.”
-0035- There is a Russian expression: if you wake up feeling no pain, you know you’re dead. While life is not only about pain, the experience of pain, which is particular in its intensity, is one of the surest signs of the life force. Schopenhauer said, “Imagine that race transported to a Utopia where everything grows of its own accord and turkeys fly around ready-roasted, where lovers find one anothet without delay and keep one another without difficulty; in such a place some men would die of boredom or hand themselves, some would fight and kill one another, and thus they would create for themselves more suffering than nature inflicts on them as it is…the polar opposite of suffering [is] boredom.” I believe that pain needs to be transformed but not forgotten; gainsaid but not obliterated.
-0036- I am persuaded that some of the broadest figures for depression are based inreality. Though it is a mistake to confure numbers with truth, these figures tell an alerming story. According to recent research, about 3 percent of Americans–some 19 million–suffer from chronic depression. More then 2 million of those are children. Manic-depressive illness, often called bipolar illness because the mood of its victims caires from mania to depression, afflicts about 2.3 million and it the second-leadin killer of young women, the third of young men. Depression as described in DSM-IV is the leading cause of disability in the United States and abroad for persons over the age of five. Worldwide, including the developing world, depression accounts for more of the disease burden, as calculated by premature death plus healthy life–years lost to disability, than anything else but heart disease. Depression claims more years than war, cancer, and AIDS put together. Other illnesses, from alcoholiism to heart disease, mask depression when it causes them; if one takes that into consideration, deoression may be the biggest killer on earth.
-0037- Treatments for depression are proliferating now, but only half of Americans who have had major depression have ever sought help of any kind–even from clergyman or counselor. About 95 percent of that 50 percent go to primary-care physicians, who often don’t know much about psychiatric complaints. An American adult with depression would have illness recognized only about 40 percent of the time. Nonetheless, about 28 million Americans–one in every ten–are now on SSRIs (selective seronotin reuptake inhibitors–the class of drugs to which Prozac belongs), and a substantial number are on other medications. Less than half of those whose illness is recognized will get appropriate treatment. As definitions of depression have broadened to include more and more of the general population, it has become increasingly difficult to calculate an exact mortality figure. The statistic traditionally given is that 15 percent of depressed people will eventually commit suicide; this figure still holds for those with extreme illness. Recent studies that include milder depression show that 2 to 4 percent of depressives die by their own hand as a direct consequence of the illness. This is still a staggering figure. Twenty years ago, about 1.5 percent of the population had depression that required treatment; now it’s 5 percent; and as many as 10 percent of all Americans now living can expect to have a major depressive episode during their life. About 50 percent will experience some symptoms of depression.Clinical problems have increased; treatments have increased vastly more. Diagnosis is on the up, but that does not explain the scale of this problem. Incidents of depression are increasing across the developed world, particularly in children. Depression is occurring in younger people, making its first appearance when its victims are about twenty-six, ten years younger than a generation ago; bipolar disorder, or manic-depressive illness, sets in even earlier. Things are getting worse.
-0038- There are few conditions at once as undertreated and as overtreated as depression. People who become totally dysfunction are ultimately hospitalized and are likely to receive treatment, though sometimes their depression is confused with the physical ailments through which it is experienced. A world of people, however, are just barely holding on and continue, despite the great revolutions in psychiatric and psychopharmaceutical treatments, to suffer abject misery. More than half of those who do seek help–another 25 percent of the depressed population–receive no treatment. About half of those who do receive treatment–13 percent or so of the depressed population–receive unsuitable treatment, often tranquilizers or immaterial psychotherapies. Of those who are left, half–some 6 percent of the depressed population–receive inadequate dosage for an inadequate length of time. So that leaves about 6 percent of the depressed population who are getting adequate treatment. But many of these ultimately go off their medications, usually because of side effects. “It’s between 1 and 2 percent who get really optimal treatment,” says John Greden, director of the Mental Health Research Institute at the University of Michigan, “for an illness that can usually be well-controlled with relatively inexpensive medications that have few serious side effects.” Meanwhile, at the other end of the spectrum, people who suppose that bliss is their birthright pop cavalcades of pills in a futile bid to alleviate those mild discomforts that texture every life.
-0039- It has been fairly well established that the advent of the supermodel has damaged women’s images of themselves by setting unrealistic expectations. The psychological supermodel of the twenty-first century is even more dangerous than the physical one. People are constantly examining their own minds and rejecting their own moods. “It’s the Lourdes phenomenon,” say William Potter, who ran the psychopharmacological division of the National Institute of Mental Health (NIMH) through the seventies and eighties, when the new drugs were being developed. “When you expose very large numbers of people to what they perceive and have reason to believe is positive, you get reports of miracles–and also, of course, of tragedy.” Prozac is so easily tolerated that almost anyone can take it, and almost anyone does. It’s been used on people with slight complaints who would not have been game for the discomforts of the older antidepressants, the monoamine oxidase inhibitors (MAOIs) or tricyclics. Even if you’re not depressed, it might push back the edges of your sadness, and wouldn’t that be nicer than living with pain?
-0040- We pathologize the curable, and what can easily be modified comes to be treated as illness, even if it was previously treated as personality or mood. As soon as we have a drug for violence, violence will be an illness. There are many grey states between full-blown depression and a mild ache unaccompanied by changes of sleep, appetite, energy, or interest; we have begun to class more and more of these as illness because we have found more and more ways to ameliorate them. But the cutoff point remains arbitrary. We have decided that an IQ of 69 constitutes retardation, but someone with an IQ of 72 is not in great shape, and someone with an IQ of 65 can still kind of manage; we have said that cholesterol should be kept under 220, but if your cholesterol is 221, you probably won’t die from it, and if it’s 219, you need to be careful: 69 and 220 are arbitray numbers, and what we call illness is also really quite arbitrary; in the case of depression, it is also in perpetual flux.
-0041- Depressives use the phrase “over the edge” all the time to delineate the passage from pain to madness. This very physical description frequently entails falling “into the abyss.” It’s odd that so many people have such a consistent vocabulary, because the edge is really quite an abstracted metaphor. Few of us have ever fallen off the edge of anything, and certainly not into an abyss. The Grand Canyon? A Norwegian fjord? A South African diamond mine? It’s difficult to even _find_ an abyss to fall into. When asked, people describe the abyss pretty consistently. In the first place, it’s dark. You are falling away from the sunlight toward a place where the shadows are black. Inside it, you cannot see, and the dangers are everywhere (it’s neither soft-bottomed nor soft-sided, the abyss). While you are falling, you don’t know how deep you can go, or whether you can in any way stop yourself. You hit invisible things over and over again until you are shredded, and yet your environment is too unstable for you to catch onto anything.
-0042- I remember going with friends to Victoria Falls, where great heights of rock drop down sheer to the Zambezi River. We were young and were sort of challenging one another by posing for photos as close to the edge as we dared to go. Each of us, upon going too close to the edge, felt sick and paralytic. I think depression is not usually going over the edge itself (which soon makes you die), but drawing too close to the edge, getting to that moment of fear when you have gone so far, when dizziness has deprived you so entirely of your capacity for balance.
-0043- Depression relies heavily on a paralyzing sense of imminence. What you can do at an elevation of six inches you cannot do when the ground drops away to reveal a drop of a thousand feet. Terror of the fall grips you even if that terror is what might make you fall. What is happening to you in depression is horrible, but it seems to be very much wrapped up in what is about to happen to you. Among other things, you feel you are about to die. The dying would not be so bad, but living at the brink of dying, the not-quite-over-the-geographical-edge condition, is horrible. In a major depression, the hands that reach out to you are just out of reach. You cannot make it down onto your hands and knees because you feel that as soon as you lean, every away from the edge, you will lose your balance and plunge down.
-0044- Depression has gone too far when, despite a wide margin of safety, you cannot balance anymore. In depression, all that is happening in the present is the anticipation of pain in the future, and the present qua present no longer exists at all.
-0045- Depression is a condition that is almost unimaginable to anyone who has not known it.
-0046- It’s not an easy diagnosis because it depends on metaphors, and the metaphors one patient chooses are different from those selected by another patient. Not so much has changed since Antonio in The Merchant of Venice complained:
It wearies me, you say it wearies you;
But how I caught it, found it, or came by it
What stuff ’tis made of, whereof it is born
I am to learn;
And such a want-wit sadness makes of me,
That I have much ado to know myself.
-0047- Let us make no bones about it: We do not really know what causes depression. We do not really know what constitutes depression. We do not really know why certain treatments may be effective for depression. We do not know how depression made it through the evolutionary process. We do not know why one person gets a depression from circumstances that do not trouble another. We do not know how will operates in this context.
-0048- People around depressives expect them to get themselves together: our society has little room in it for moping. Spouses, parents, children, and friends are all subject to being brought down themselves, and they do not want to be close to measureless pain. No one can do anything but beg for help (if he can do even that) at the lowest depths of a major depression, but once the help is provided, it must also be accepted. We would all like Prozac to do it for us, but it my experience, Prozac doesn’t do it unless we help it along. Listen to the people who love you. Believe that they are worth living for even when you don’t believe it. Seek out the memories depression takes away and project them into the future. Be brave; be strong; take your pills. Exercise because it’s good for you even if ever step weighs a thousand pounds. Eat when food itself disgusts you. Reason with yourself when you have lost your reason. These fortune-cookie admonitions sound pat, but the surest way out of depression is to dislike it and not to let yourself grow accustomed to it. Block out the terrible thoughts that invade your mind.
-0049- I believe that words are strong, that they can overwhelm what we fear when fear seems more awful than life is good. I have turned, with an increasingly find attention, to love. Love is the other way forward.
-0050- It appears that depression has been around as long as man has been capable of self-conscious thought. It may be that depression existed even before that time, that monkeys and rats and perhaps octopi were suffering the disease before those first humanoids found their way into their caves. Certainly the symptomatology of our time is more or less indistinguishable from what was described by Hippocrates some twenty-five hundred years ago.
-0051- Sometimes it seems that the rate of illness and the number of cures are in a sort of competition to see which can outstrip the other.
-0052- We will balance treating illness with changing the circumstances that cause it.
-0053- … the despair psychology of wartime is usually frenzied, while the despair that follows devastation is more numb and all-encompassing. {PN: similar to personal trauma}
-0054- Everyone I met had a different explanation for how the Khmer Rouge could have happened there, but none of these explanations made sense, just as none of the explanations for the Cultural Revolution or for Stalinism or for Nazism makes sense. These things happen to societies, and in retrospect it is possible to understand why a nation was especially vulnerable to them; but where in the human imagination such behaviours originate is unknowable.
-0055- Five days before I left the country, I met with Phaly Nuon, a sometimes candidate for the Nobel Peace Prize, who has set up an orphanage and a centre for depressed women in Phnom Penh. She has achieved astonishing success in resuscitating women whose mental afflictions are such that other doctors have left them for dead. Indeed her success has been so enormous that her orphanage is almost entirely staffed by the women she has helped, who have formed a community of generosity around Phaly Nuon. If you save the women, it has been said, they will in turn save the children, and so by tracing a chain of influence one can save the country.
-0056- –Phaly Nuon made a special request to the aid workers and set up her hut in the camp as a sort of psychotherapy center. … She would take her patients to meditate, keeping in her house a Buddhist shrine with flowers in front of it. She would seduce the women into openness. First, she would take about three hours to get each woman to tell her story. Then she would make regular follow-up visits to try to get more of the story, until she finally got the full trust of the depressed woman. “I had to know the stories these women had to tell,” she explained, “because I wanted to understand very specifically what each one had to vanquish.”
–Once this initiation was concluded, she would move on to a formulaic system. “I take it in three steps,” she said. “First, I teach them to forget. We have exercises we do wach day, so that each day they can forget a little more of the things they will never forget entirely. During this time, I try to distract them with music or with embroidery or weaving, with concerts, with an occasionaly hour of television, with whatever seems to work, whatever they tell me they like. Depression is under the skin, all the surface of the body has the depression just below it, and we cannot take it out; but we can try to forget the depression even though it is right there.
–“When their minds are cleared of what they have forgotten, when they have learned forgetfulness well. I teach them to work. Whatever kind of work they want to do, I will find a way to teach it to them…. They must learn to do these things well and to have pride in them.
–“And then when they have mastered work, as last, I teach them to love. I built a sort of lean-to and made it a steam bath, and now in Phnom Penh I have a similar one that I use, a little better built. I take them there so that they become clean, and I teach them how to give one another manicures and pedicures and how to take care of their fingernails, because doing that makes them feel beautiful, and they want so much to feel beautiful. It also puts them in contact with the bodies of other people and makes them give up their bodies to the care of others. It rescues them from physical isolation, which is a usual affliction for them, and that leads to the breakdown of the emotional isolation. While they are together washing and putting on nail polish, they being to talk together, and bit by bit they learn to trust one another, and by the end of it all, they have learned how to make friends, so that they will never have to be so lonely and so alone again. Their stories, which they have told to no one but me–they begin to tell those stories to one another.”
-0057- Grooming is one of the primary forms of socialization among primates, and this return to grooming as a socializing force among human beings struck me as curiously organic. I told her that I thought it was difficult to teach ourselves or others how to forget, how to work, and how to love and be loved, but she said it was not so complicated if you could do those three things yourself.
-0058- “There is a final step,” she said to me after a long pause. “At the end, I teach them the most important thing. I teach them that these three skills–forgetting, working, and loving–are not three separate skills, but part of one enormous whole, and that it is the practice of these things together, each as a part of the others, that makes a difference. It is the hardest thing to convey”–she laughed–“but they all come to understand this, and when they do–why, then they are ready to go into the world again.”
-0059- To treat depression, one must understand the experience of a breakdown, the mode of action of medication, and the most common forms of talking therapy (psychoanalytic, interpersonal, and cognitive).
-0060- Intelligent treatment requires a close examination of specific populations: depression has noteworthy variants particular to children, to the elderly, and to each gender. Substance abusers form a large subcategory of their own. Suicide, in its many forms, is a complication of depression; it is critical to understand how a depression can become fatal.
-0061- These experiential matters lead to the epidemiological. It is fashionable to look at depression as a modern complaint, and this is a gross error, which a review of psychiatric history serves to clarify. It is also fashionable to think of the complaint as somehow middle-class and fairly consistent in its manifestations. This is not true. Looking at depression among the poor, we can see that taboos and prejudices are blocking us from helping a population that is singularly receptive to that help. The problem of depression among the poor leads naturally into specific politics. We legislate ideas of illness and treatment in and out of existence.
-0062- Biology is not destiny. There are ways to lead a good life with depression. Indeed, people who learn from their depression can develop a particular moral profundity from the experience, and this is the thing with feathers at the bottom of their box of miseries. There is a basic emotional spectrum from which we cannot and should not escape, and I believe that depression is in the spectrum, located near not only grief but also love. Indeed I believe that all the strong emotions stand together, and that every one of them is contingent on what we commonly think of as its opposite. I have for the moment managed to contain the disablement that depression causes, but the depression itself lives forever in the cipher of my brain. It is part of me. To wage war on depression is to fight against oneself, and it is important to know that in advance of the battles. I believe that depression can be eliminated only by undermining the emotional mechanisms that make us human.
-0063- “Welcome this pain,” Ovid once wrote, “for you will learn from it.” It is possible (though for the time being unlikely) that, through chemical manipulation, we might locate, control, and eliminate the brain’s circuitry of suffering. I hope we will never do it. To take it away would be to flatten out experience, to impinge on a complexity more valuable than any of its component parts are agonizing.
-0064- …pain is not acute depression; one loves and is loved in great pain, and one is alive in the experience of it. It is the walking-death quality of depression that I have tried to eliminate from my life…
-0065- I did not experience depression until after I had pretty much solved my problems. … It was when life was finally in order and all the excuses for despair had been used up that depression came slinking in on its little cat feet and spoiled everything, and I felt acutely that there was no excuse for it under the circumstances. To be depressed when you have experienced trauma or when your life is clearly a mess is one thing, but to sit around and be depressed when you are finally at a remove from trauma and your life is not a mess is awfully confusing and destabilizing. Of course you are aware of deep causes: the perennial existential crisis, the forgotten sorrows of a distant childhood, the slight wrongs done to people now dead, the loss of a certain friendships through your own negligence, the truth that you are not Tolstoy, the absence in this world of perfect love, the impulses of greed and uncharity that lie too close to the heart–that sort of thing. But now, as I ran through this inventory, I believed my depression was both a rational state, and an incurable state.
-0066- If my life had been more difficult, I would understand my depression very differently.
-0067- –When you start having major depression, you tend to look back for the roots of it. You wonder where it came from, whether it was always there, just under the surface, or whether it came on you are suddenly as food poisoning. Since the first breakdown, I’ve spent months on end cataloging early difficulties, such as they are. I was a breech birth, and some writers have linked breech birth to early trauma. … When I asked my mother to identify my earliest trauma, she said that walking had not come easily to me, that while my speech seemed to have been no effort at all, my motor control and balance were late and imperfect. I am told that I fell and fell and fell, that only with great encouragement did I even attempt to stand upright.
–… I remember one episode at summer camp when I was six, when I was suddenly and unreasonably overcome with fear. {PN: write about 8/9} … I was overcome with the knowledge that something awful was going to happen to me, now or later, and that, as long as I was alive, I wouldn’t be free. … It seemed to matter very much whether I went left or right or straight on, but I didn’t know which direction would save me, at least for the moment.
–…I think these things are not unusual for small children. Existential angst among adults, painful though it may be, usually has a gaming self-consciousness to it; … I have a poor memory, and after that episode at camp I became afraid of what is lost through time, and i would lie in bed at night trying to remember things from the day so that I could keep them–an incorporeal acquisitiveness.
-0068- If the first part of an emotional biography is precursor experiences, the second part is triggering experiences. Most severe depressions have precursor smaller depressions that have passed largely unnoticed or simply unexplained. Of course many people who never develop depression have experiences that would retrospectively be defined as precursor episodes if they had led to anything, and that get dropped out of memory only because what they might have foreshadowed never materializes.

2 Responses to “Noonday Demon I”

  1. Garrison Says:

    My wife is interested in reading “The Noonday Demon”, presumably due in part to your lengthy post; we both would like to know what font was used in the quote graphic.

  2. Autodidact Says:

    It’s great that she wants to read it–it’s an excellent book. I don’t know what font is in the graphic, unfortunately. The graphic was something I snagged from the internet ages ago.

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