Autodidact: self-taught

Dec
11
2012

II

by V. L. Craven

-0069- I complained to the selfsame analyst that a loss of feeling, a numbness, had infected all my human relations. I didn’t care about love; about my work; about family; about friends. My writing slowed, then stopped. “I know nothing,” the painter Gerhard Richter once wrote. “I can do nothing. I understand nothing. I know nothing. Nothing. And all this misery does not even make me particularly unhappy.” So I too found all strong emotion gone, except for a certain nagging anxiety.
-0070- I went to parties and tried and failed to have fun; I saw friends and tried and failed to connect; I bought expensive things I’d wanted in the past and had no satisfaction from them; and I pushed on with previously untried extremes to reawaken my libido, attending pornographic films and in extremis soliciting prostitutes for their services. I was not particularly horrified by any of these new behaviors, but I was also unable to get any pleasure, or even release, from them. My analyst and i discussed the situation: I was depressed. We tried to get to the root of the problem while I felt the disconnect slowly but relentlessly increasing. I began to complain that I was overwhelmed by the messages on my answering machine and I fixated on that: I saw the calls, often from friends, as an impossible weight. Every time I returned the calls, more would come in.
-0071- In June 1994, I began to be constantly bored. … I found myself burdened by social events, even by conversation. It all seemed like more effort than it was worth. The subway proved intolerable.
-0072- I had begun to feel that no one could love me and that I would never be in a relationship again. I had no sexual feelings at all. I began eating irregularly because I seldom felt hungry.
-0073- Major depression has a number of defining factors–mostly having to do with withdrawal, though agitated or atypical depression may have an intense negativity rather than a flattened passivity–and is usually fairly easy to recognize; it deranges sleep, appetites, and energy. it tends to increase sensitivity to rejection, and it may be accompanied by a loss of self-confidence and self-regard. It seems to depend on both hypothalamic functions (which regulate sleep, appetites, and energy) and cortical functions (which translate experience into philosophy and worldview). The depression that occurs as a phase in manic-depressive (or bipolar) illness is much more strongly genetically determined (about 80 percent) than is standard depression (about 10 to 50 percent); though it is more broadly treatment-responsive, it is not easier to control, especially since antidepressant drugs may launch mania. The greatest danger with manic-depressive illness it that it sometimes bursts into what are called mixed states, where one is manically depressed–full of negative feeling and grandiose about them. That is a prime condition for suicide, and it too can be brought on by the use of antidepressant medications without the mood stabilizers that are necessary parts of bipolar medication. Depression can be enervating or atypical/agitated. In the first, you don’t feel like doing anything; in the second, you feel like killing yourself. A breakdown is a crossover into madness. It is, to borrow a metaphor from physics, uncharacteristic behavior of matter that is determined by hidden variables. It is also a cumulative effect: whether you can see them or not, the factors leading to a depressive breakdown gather over the years, usually over a lifetime. There is no life that does not have the material for despair in it, but some people go too close to the edge and others manage to stay sometimes sad in a safe clearing far from the cliffs. Once you cross over, the rules all change. Everything that had written in English is now in Chinese; everything that went fast is now show; sleep is the clarity while wakefulness is a sequence of unconnected, senseless images. Your sense slowly abandon you in depression.
-0074- When I was thirty, my first novel was published, and I had scheduled a reading tour, and I was hating the idea. A good friend had volunteered to throw a book party for me on October 11. I love parties and I love books, and I knew I should have been ecstatic, but in fact I was too lackluster to invite manu people and too tired to stand up much during the party. {PN: v like Styron’s DV}
-0075- Memory functions and emotional functions are distributed through the brain, but the frontal cortex and limbic systems are key to both, and when you affect the limbic system, which controls emotion, you also touch on memory. I remember that partly only in ghostly outlines and washed-out colors: grey food, beige people, muddy light in the rooms. i do remember that i was sweating horribly during it, and that I was dying to leave.
-0076- I did not sleep much that night, and I could not get up the following day. I knew I could not go to any restaurant. i wanted to call my friends and cancel, but I couldn’t. I lay very still and thought about speaking, trying to figure out how to do it. I moved my tongue but there were no sounds. I had forgotten how to talk. Then I began to cry, but there were no tears, only a heaving incoherence. I was on my back. I wanted to turn over, but I couldn’t remember how to do that either. I tried to think about it, but the task seemed colossal. I thought that perhaps I’d had a stroke, and then I cried again for a while. At about three o’clock that afternoon, i managed to get out of bed and go to the bathroom. I returned to bed shivering. Fortunately, my father called. i answered the phone. “You have to cancel tonight,” I said, my voice shaky. “What’s wrong?” he kept asking, but I didn’t know.
-0077- There is a moment, if you trip or slip, before your hand shoots out of break your fall, when you feel the earth rushing up at you and you cannot help yourself, a passing, fraction-of-a-section terror. i felt that way hour after hour after hour. Being anxious at this extreme level is bizarre. You feel all the time that you want to do something, that there is some affect that is unavailable to you, that there’s a physical need of impossible urgency and discomfort for which there is no releif, as though you were constantly vomiting from your stomach but had no mouth. With the depression, your vision narrows and begins to close down; it is like trying to watch TV through terrible static, where you can sort of see the picture but not really; where you cannot ever see people’s faces, except almost if there is a close-up; where nothing has edges. The air seems thick and resistant, as though it were full of mushed-up bread. Becoming depressed is like going blind, the darkness is at first gradual, the ensompassing; it is like going deaf, hearing less and less until a terrible silence is all around you, until you cannot make any sound of your own to penetrate the quiet. It is like feeling your clothing slowly turning into wood on your body, a stiffness in the elbows and the knees progressing to a terrible weight and an isoltaing immobility that will atrophy you and in time destory you.
-0078- In the 1950s, in keeping with the thinking of his time, a psychoanalyst I know was told by his supervisor that if he wanted to start a patient on medication, he would have to stop the analysis.
-0079- The psychopharmacologist seemed to have come out of some movie about shrinks: his office had fading mustard-colored silk wallpaper and old-fashioned sconces on the walls and was piled high with books with titles such as Addicted to Misery and Suicidal Behavior: The Search for Psychic Economy . He was in his seventies, smoked cigars, had a Central European accent, and wore carpet slippers. He was elegant prewar manners and a kindly smile. He asked me a rapid strong of specific questions–how did I feel in the morning versus the afternoon? How difficult was it for me to laugh about anything? Did I know what I was afraid of? Had my sleep patterns and appetite shifted?–and I did my best to answer him. “Well, well,” he said calmly as i trotted out my horrors. “Very classic indeed. Don’t you worry, we’ll soon have you well.” He wrote out a prescription for Xanax, then burrowed around to find a starter kit of Zoloft. He gave me detailed instructions on how to begin taking it. “You’ll come back tomorrow,” he said with a smile. “The Zoloft will not work for some time. The Xanax will alleviate your anxiety immediately. Do not worry about its addictive qualities and so on, as these are not your problems at the moment. Once we have lifted the anxiety somewhat, we will be able to see the depression more clearly and take care of that. Don’t worry, you have a very normal group of symptoms.” {PN: possible characters? Perhaps a mentor of Diana’s}
-0080- For the moment, the panic was my only sensation. The Xanax would relieve the panic if I took enough of it was enough to make me collapse completely into a thick, confusing, dream-heavy sleep. The days were like this: I would wake up, knowing that I was experiencing extreme panic. What I wanted was only to take enough panic medication to allow me to go back to sleep, and that I wanted to sleep until I got well. When I would wake up a few hours later, I wanted to take more sleeping pills. Killing myself, like dressing myself, was much too elaborate an agenda to enter my mind; I did not spend hours imagining how I would do such a thing. All I wanted was for “it” to stop; I could not have managed even to be so specific as to say what “it” was. I could not manage to say much; words, with which I have always been intimate, seemed suddenly very elaborate, difficult metaphors the use of which entailed much more energy than I could possibly muster. “Melancholia ends up in loss of meaning…I become silent and I die,” Julia Kristeva one wrote. “Melancholy persons are foreigners in their mother tongue. The dead language they speak foreshadows their suicide.” Depression, like love, trades in cliches, and it is difficult to speak of it without lapsing into the rhetoric of saccharine pop tunes; it is so vivid when it is experienced that the notion that others have known anything similar seems altogether implausible. Emily Dickinson wrote perhaps the most eloquent description of a breakdown ever committed to the page:

I felt a Funeral, in my Brain,
And Mourners to and fro
Kept treading–treading–till it seemed
That Sense was breaking through–

An when they all were seated,
A Service, like a Drum–
Kept beating–beating–till I thought
My Mind was going numb–

And then I heard them life a Box
And creak across my Soul
With those same Boots of Lead, again,
Then Space–began to toll,

As if the Heavens were a Bell,
And Being, but an Ear,
And I, and Silence, some strange Race
Wrecked, solitary, here–

And then a Plan in Reason, broke,
And I dropped down, and down–
And hit a World, at every plunge,
And Finished knowing–then–

There has been relatively little written about the fact that breakdowns are preposterous; seeking dignity, and seeking to dignify the sufferings of others, one can easily overlooks this fact. It is, however, real and true, and obvious when you are depressed. Depression minutes are like dog years, based on some artificial notion of time. I can remember lying frozen in bed, crying because I was too frightened to shower, and at the same time knowing that showers are not scary. I kept running through the individual steps in my mind: you turn and put your feet on the floor; you stand; you walk from here to the bathroom; you open the bathroom door; you walk to the edge of the tub; you turn on the water; you step under the water; you rub yourself with soap; you rinse; you step out; you dry yourself; you walk back to the bed. Twelve steps, which sounded to me then as onerous as a tour through the stations of the cross. But I knew, logically, that showers were easy, that for years I had taken a shower every day and that I had done it so quickly and so matter-of-factly that it had not even warranted comment. I knew that those twelve wteps were really quite manageable. I knew that I could even get someone else to help me with some of them. I would have a few seconds of relief contemplating that thought. Someone else could open the bathroom door. I knew I could probably manage two or three steps, so with all the force in my body I would sit up; I would turn and put my feet on the floor; and then I would feel so incapacitated and so frightend that i would roll over and lie facedown, my feet still on the floor. I would sometimes start to cry again, weeping not only because of what I could not do, but because the fact that I could not do it seemed so idiotic to me. All over the world people were taking showers. Why, oh why, could I not be one of them? And then I would reflect that those people also had families and jobs and bank accounts and passports and dinner plans and problems, real problems, cancer and hunger and the death of their children and isolating loneliness and failure; and I had so few problems by comparison, except that I couldn’t turn over again , until a few hours later, when my father or friend would come in and help to hoist my feet back up onto the bed. By then, the idea of a shower would not have some to seem foolish and unrealistic, and I would be relieved to have been able to get my feet back up, and I would lie int he safety of the bed and feel ridiculous. And sometimes in some quiet part of me there was a little bit of laughter at the ridiculousness, and my ability to see this, is, I think, what got me through. Always at the back of my mind there was a voice, calm and clear, that said, don’t be so maudlin; don’t so anything melodramatic. Take off your clothes, put on your pajamas, go to bed; in the morning, get up, get dressed, and do whatever it is that you’re supposed to do. I heard that voice all the time, that voice like my mother’s. There was a sadness and a terrible loneliness as I contemplated what was lost. “Did anyone–not just the red-hot cultural center, but anyone, even my dentist–care that i had withdrawn from the fray?’ Daphne merkin wrote in a confessional essay on her own depressions. “Would people mourn me if I never returned, never took up my place again?”
-0081- Most depression of circadian, improving during the day and then descending again by morning. At dinner, i would feel unable to eat, but I could get up and sit in the dining room with my father, who canceled all other plans to be with me. {PN: Darkness Visible}
-0082- My father would assure me, sunnily, that I would be able to do it all again, soon. He could as well have told me that I would soon be able to build myself a helicopter out of cookie dough and fly on it to Neptune, so clear did it seem to me that my real life, the one I had lived before, was now definitely over.
-0083- It was hellishly embarrassing to tell people I was depressed, when my life seemed to have so much good and love and material comfort in it…
-0084- A poet friend, Elizabeth Prince, wrote:

The night
was late and soggy: It was
New York in July
I was in my room, hiding,
hating the need to swallow.

–Later, I read in Leonard Woolf’s diary his description of Virginia’s depressions: “If left to herself, she would have eaten nothing at all the would have gradually starved to death. It was extraordinarily difficult ever to get her to eat enough to keep her strong and well. Pervading her insanity generally there was always a sense of some guilt, the origin and exact nature of which I could never discover; but it was attached in some peculiar way particularly to food and eating. In the early acute, suicidal stage of the depression, she would sit for hours overwhelmed with hopeless melancholia, silent, making no response to anything said to her. When the time for a meal came, she would pay no attention whatsoever to the plate of food put before her. I could usually induce her to eat a certain amount, but it was a terrible process. Every meal took an hour or two; I had to sit by her side, put a spoon or fork in heer hand, and every now and again ask her very quietly to eat and at the same time touch her arm or hand. Every five minutes or so she might automatically eat a spoonful.”
-0085- You are constantly told in depression that your judgment is compromised, but part of depression is that it touches cognition. That you are having a breakdown does not mean that your life isn’t a mess. If there are issues you have successfully skirted or avoided for years, they come cropping back up and stare you full in the face, and one aspect of depression is a deep knowledge that the comforting doctors who assure you that your judgment is bad are wrong. You are in touch with the real terribleness of your life. You can accept rationally that later, after the medication sets in, you will be better able to deal with the terribleness, but you will not be free of it. When you are depressed, the past and future are absorbed entirely by the present moment, as in the world of a three-year-old. You cannot remember a time when you felt better, at least not clearly; and you certainly cannot imagine a future time when you will feel better. Being upset,, even profoundly upset, is a temporal experience, while depression is atemporal. Breakdowns leave you with no point of view.
-0086- There’s a lot going on during a depressive episode. There are changes in neurotransmitter function; changes in synaptic function; increased or decreased excitability between neurons; alterations of gene expression; hypometabolism in the frontal cortex (usually) or hypermetabolism in the same area; raised levels of thyroid releasing hormone (TRH); disruption of function in the amygdala and possibly the hypothalamus (areas within the brain); altered levels of melatonin (a hormone that the pineal gland makes from serotonin); increased prolactin (increased lactate in anxiety-prone individuals will bring on panic attacks); flattening of twenty-four-hour body temperature; distortion of twenty-four-hour cortisol secretion; disruption of the circuit that links the thalamus, basal ganglia, and frontal lobes (again, centers in the brain); increased blood flow to the frontal lobe of the dominant hemisphere; decreased blood flow to the occipital lobe (which controls vision); lowering of gastric secretions. It is difficult to know what to make of all of these phenomena. Which are causes of depression; which are symptoms; which are merely coincidental? You might think that the raised levels of TRH mean that TRH causes bad feelings, but in fact administering high doses of TRH may be a temporarily useful treatment of depression. As it turns out, the body begins producing TRH during depression for its antidepressant capacities. And TRH, which is not generally an antidepressant, can be utilized as an antidepressant immediately after a major depressive episode because the brain, though it is having a lot of problems in a depression, also becomes super-sensitive to the things that can help to solve those problems. Brain cells change their functions readily, and during an episode, the ratio between the pathological changes (which cause depression) and the adaptive ones (which fight it) determines whether you stay sick or get better. If you have medications that exploit or aid the adaptive factors enough to put down the pathological ones once and for all, then you break free of the cycle and your brain can get on with its usual routines.
-0087- The more episodes you have, the more likely you are to have more episodes, and in general the episodes, over a lifetime, get worse and closer together. This acceleration is a clue to how the disease works. The initial onset of depression is usually connected either to kindling events or to tragedy; people with a genetic predisposition to develop depression are, as Kay Jamison–a charismatic psychologist whose texts, academic and popular, have done a great deal to change thinking about mood disorders–has observed, ‘like dry and brittle pyres, unshielded against the inevitable sparks thrown off by living.’ The recurrences at some point break free of circumstance. If you stimulate seizures in an animal every day, the seizures eventually become automatic; the animal will go on having them once a day even if you withdraw the stimulation. In much the same way, the brain that has gone into depression a few times will continue to return to depression over and over. This suggests that depression, even if it is occasioned by external tragedy, ultimately changes the structure, as well as the biochemistry, of the brain. ‘So it’s not as benign an illness as we used to suppose,’ explains Robert Post, chief of the Biological Psychiatry Branch of the National Institute of Mental Health (NIMH). ‘It tends to be recurrent; it tends to run downhill; and so one should in the face of several episodes consider long-term preventative treatment to avoid all the horrible consequences.’ Kay Jamison thumps the table when she gets going on this subject. ‘It’s not like depression’s an innocuous thing. You know, in addition to being a miserable, awful, nonconstructive state, for the most part, it also kills people. Not only through suicide, but also through higher heart disease, lowered immune response, and so on.’ Frequently, patients who are medication-responsive cease to be responsive if they keep cycling on and off the medications; with each episode, there is an increased 10 percent risk that the depression will become chronic and inescapable. ‘It’s sort of like a primary cancer that’s very drug-responsive, but then once it metastasizes, it doesn’t respond at all,’ Post explains. ‘If you have too many episodes, it changes your biochemistry for the bad, possibly permanently. At that point, many therapists are still looking in completely the wrong direction. If the episode now occurs on automatic, what good is it to worry about the stressor that kicked off the original process? It’s just too late for that.’ That which is mended is but patched and can never be whole again.
-0088- Three separate events–decrease in serotonin receptors; rise in cortisol, a stress hormone; and depression–are coincident. Their sequence is unknown: it’s a sort of chicken and chick and egg mystery. if you lesion the serotonin system in an animal brain, the levels of cortisol go up. If you raise levels of cortisol, serotonin seems to go down. If you stress a person, corticotropin releasing factor (CRF) goes up and causes the level of cortisol to go up. If you depress a person, levels of serotonin go down. What does this mean? The substance of the decade has been serotonin, and the treatments most frequently used for depression in the United States are ones that raise the functional level of serotonin in the brain. Every time you affect serotonin, you also modify the stress systems and change the level of cortisol in the brain. ‘I wouldn’t say that cortisol causes depression,’ says Elizabeth Young, who works on this field at the University of Michigan, ‘but it may well exacerbate a minor condition and create a real syndrome.’ Cortisol, once it is produced, binds to glucocorticoid receptors–which then absorb the excess cortisol that is floating around up there. This is extremely important for overall body regulation. The glucocorticoid receptors actually turn on and off some genes, and when you have relatively few receptors being swamped with a lot of cortisol, the system goes into overdrive. ‘It’s like having a heating system,’ Young says. ‘If the temperature sensor for the thermostat is in a spot that’s become drafty, the heat will never turn off even though the room is scalding. if you add a few more sensors located around the room, you can get the system back under control.’
-0089- Under ordinary circumstances, cortisol levels stick to fairly straight-forward rules. Cortisol’s circadian pattern is to be up in the morning (it’s what gets you out of bed) and then to go down during the day. In depressed patients, cortisol tends to remain elevated throughout the day. Something’s wrong with the inhibitory circuits that should be turning off the production of cortisol as the dday wears on, and this may be part of why the jolted feeling that is usual first thing in the morning continues so far into the day for depressed people. It may be possible to regulate depression by addressing the cortisol system directly; instead of working through the serotonin system. Building on basic research done at Michigan, investigators elsewhere have treated treatment-resistent depression patients with ketoconazole, a cortisol-reducing medication, and almost 70 percent of these patients showed marked improvement. At the moment, ketoconazole causes too many side effects to be attractive an an antidepressant, but several major pharmaceutical companies are investigating related medications that may not have these negative side effects. Such treatment must be carefully regulated, however, since cortisol is necessary for fight-or-flight responses; for that adrenal energy that helps one to struggle on in the face of difficulty; for anti-inflammatory action; for decision making and resolution; and most importantly, for knocking the immune system into action in the face of an infectious disease.
-0090- Cortisol patterning studies have recently been done on baboons and air traffic controllers. The baboons who had long-term high cortisol tended to be paranoid, unable to distinguish between a real threat and a mildly uncomfortable situation, likely to fight as desperately over a banana next to a tree heavy with ripe fruit as over their life. Among air traffic controllers, those who were psychologically healthy had an exact correlation between the extent to which they were overworked and their level of cortisol, while those who were in poor condition had their cortisol skyrocketing and peaking all over the place. Once the cortisol/stress correlation gets distorted, you can get hysterical about bananas; you will find that everything that happens to you is stressful. ‘And that is a form of depression, and then of course being depressed is itself stressful,’ observes Young. ‘A downward spiral.’
-0091- Once you’ve had a stress sufficient to cause a protracted increase of your cortisol levels, your cortisol system is damaged, and in the future it will not readily turn off once it has been activated. Thereafter, the elevation of cortisol after a small trauma may not normalize as it would under ordinary circumstances. Like anything that has been broken once, the cortisol system is prone to break again and again, with less and less external pressure. People who have had myocardial infarction after great physical strain are subject to relapse even while sitting in an armchair–the heart is now a bit worn-out, and sometimes it just gives up even without much strain. The same thing can happen to the mind.
-0092- The fact that something is medical doesn’t contravene its having psychosocial origins. ‘My wife is an endocrinologist,’ says Juan Lopez, who works with Young, ‘and she sees kids with diabetes. Well, diabetes is clearly a disease of the pancreas, but external factors influence it. Not only what you eat, but also how stressed you are–kids in really bad homes get frantic and their blood sugar goes haywire. The fact that this happens doesn’t make diabetes a psychological disease.’ In the field of depression, psychological stress transduces to biological change, and vice versa. If a person subjects himself to extreme stress, CRF is released and often helps bring about the biological reality of depression. The psychological techniques for preventing yourself from getting too stressed can help to keep down your levels of CRF, and so of cortisol. ‘You’ve got your genes,’ Lopez says, ‘and there’s nothing you can do about them. But you can sometimes control how they express themselves.’
-0093- In his research work, Lopez went back to the most straightfoward animal models. ‘If you stress the hell out of a rat,’ he says, ‘that rat will have high levels of stress hormone. If you look at his serotonin receptors, they’ve clearly screwed up by stress. The brain of a highly stressed rat looks very much like the brain of a very depressed rat. If you give him serotonin-altering antidepressant, his cortisol eventually normalizes. It is likely that some depression is more seratonergic,’ Lopez says, ‘and some is more tightly linked to cortisol, and most mixes these two sensitivities in some way. The cross talk between these two systems is part of the same pathophysiology.’ The rat experiments have been revealing, but the prefrontal cortex, that area of the brain that humans have and that makes us moree developed than rats, also contains many cortisol receptors, and those are probably implicated in the complexities of human depression. The brains of human suicides show extremely high levels of CRF– ‘it’s hyper, like they’ve been pumping this stuff.’ Their adrenal glands are larger than those of people who die from other causes because the high level of CRF has actually caused the expansion of the adrenal system. Lopez most recent work indicates that suicide victims actually show significant decrease in cortisol receptors in the prefrontal cortex (which means that the cortisol in that area is not mopped up as quickly as it should be). The next step, Lopez says, is to look at the brains of people who can be subjected to huge amounts of stress and who can keep going despite it. ‘what is the biochemistry of their coping mechanism?’ Lopez, asks. ‘How do they sustain such resilience? What are the patterns of CRF release in their brains? What do their receptors look like?’
-0094- John Greden, department chair for Lopez and Young, focuses on the long-term effects of sustained stress and sustained depressive episodes. If you have too much stress and too high a level of cortisol for too long, you start destroying the very neurons that should regulate the feedback loop and turn down the cortisol level after the stress is resolved. Ultimately, this results in lesions to the hippocampus and the amygdala, a loss of neuronal networking tissue. The longer you remain in a depressed state, the more likely you are ot have significan lesioning, which can lead to peripheral neuropathy: your vision starts to fade and all kinds of other things can go wrong. “This reflects the obvious fact that we need not only to treat depression when it occurs, ” sau Greden, “but also to prevent it from recurring. Our public health approach at the moment is just wrong. People with recurrent depression must stay on medication permanently, not cycle on and off it, because beyond the unpleasantness of heving to survive multiple painful depressive episodes, such people are actually ravaging their own neuronal tissue.” Greden looks to a future in which out understanding of the physical consequences of depression may lead us to strategies to reverse them. “Maybe we’ll br trying selective injection of neurotropis growth factors into certain regions of the brain to make some kind of tissure proliferate and grow. Maybe we’ll be able to use othef kinds of stimualtion, magnetic or electric, to encourage growth in certain areas.”
-0095- Taking the pills is costly–not only financially but also psychically. It is humiliating to be reliant on them. It is inconvenient to have to keep track of them and to stock up on prescriptions. And it is toxic to know that without these perpetual interventions you are not yourself as you have understood yourself. I’m not sure why i ffeel this way–I wear contact lenses and without them am virtually blind, and I do not feel shamed by my lenses or by my need for them (though given my druthers, I’d choose perfect vision). The constant presence of the medications is for me a reminder of frailty and imperfection.
-0096- Though the initial effects of anti depressants begin after about a week, it takes as much as six months to get the full benefits. Zoloft made me feel awful, and so my doctors switched me to Paxil after a few weeks. I was not wild about Paxil, but it did seem to work and it had fewer side effects for me. I did not learn until much later on that while more than 80 percent of depressed patients are responsive to medication, only 50 percent are responsive to their first medication–or, indeed, to any particular medication. In the meanwhile, there is a terrible cycle: the symptoms of depression cause depression. Loneliness is depressing, but depression also causes loneliness. If you cannot function, your life becomes as much of a mess as you had supposed it was; it you cannot speak and have no sexual urges, your romantic and social life disappear, and this is authentically depressing. I was, more of the time, too upset by everything to be upset by anything in particular; that is the only way I could tolerate the losses of affect, pleasure, and dignity that the illness brought my way.
-0097- Then I want and read [at a book reading] . I felt as though i had baby powder in my mouth, and I couldn’t hear well, and I kept thinking I might faint, but I managed to do it.
-0098- 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…
-0099- “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…”
-0100- Life events are often 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 like-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 people, 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 of loss.
-0101- 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.
-0102- “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.”
-0103- What remains unclear is when depression triggers life events, and when life events trigger depression. Syndrome and symptom blur together and cause each other…
-0104- 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 defence, for people with a biological vulnerability, is a “good enough” marriage, which absorbs external humiliations and minimises them. “The psychosocial creates biological changes,” Brown acknowledges. “The thing is that the vulnerability must initially be triggered by external events.”
-0105- Just before my reading tour began, I started taking Navane, an anti-psychotic with anti-anxiety effects, which, we hoped, would allow me to take the Xanax less often.
-0106- 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 life. We sat in the big, cozy dining room of our hotel, and I chose my own food. … 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.
-0107- 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.
-0108- 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 disablement as it existed then, but it was a bit as I have imagined being very old.
-0109- Emerging from 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.

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