Autodidact: self-taught

Dec
12
2012

III

by V. L. Craven

-0110- You don’t get over breakdowns quickly or easily. Things go on being bumpy. though certain depression symptoms seemed to be improving, I had an unfortunate, unusual cumulative adverse response to Navane. By the end of the third week of it, I had begun to lose the capacity to remain upright. I would walk for a few minutes and then I would have to lie down. I could no more control that need than I could the need to breathe.
-0111- If you have never experiences anxiety, think of it as the opposite of peace. All the peace–inward and outward–was stripped for my life at that moment.
-0112- Much depression incorporates anxiety symptoms. It’s possible to read anxiety and depression separately, but according to James Ballenger of the Medical College of South Carolina, a leading expert in anxiety, “they’re fraternal twins.’ George Brown said succinctly, ‘Depression is a response to past loss, and anxiety is a response to future loss.’ Thomas Aquinas proposed that fear is to sadness as hope is to pleasure; or, in other words, that anxiety is the precursor form of depression. I experienced so much anxiety when I was depressed, and felt so depressed when I was anxious, that I came to understand the withdrawal and the fear as inseparable. Anxiety is not paranoia; people with anxiety disorders assess their own position in the world much as do people without. What changes in anxiety is how one feels about that assessment. About half of patients with pure anxiety disorders develop major depression within five years. Insofar as depression and anxiety are genetically determined, they share a single set of genes (which are tied to the genes for alcoholism). Depression exacerbated by anxiety has a much higher suicide rate than depression alone, and it is much harder to recover from. “If you’re having several panic attacks every day,’ says Ballenger, ‘it’s gonna being Hannibal to his knees. People are beaten into a pulp, into a foetal position in bed.’
-0113- Between 10 and 15 percent of Americans suffer from some sort of anxiety disorder. In part, scientists think, because the locus coeruleus in the brain controls both norepinephrine production and the lower bowel, at least half of anxiety-disorder patients have irritable bowel syndrome as well; and anyone who has had really intense anxiety already knows just how fast and furiously food can run through the digestive system. Both norepinephrine and serotonin are implicated in anxiety. ‘Two out of three times, life events are implicated, and it’s always a loss of security,’ Ballenger says. About a third of panic attacks, endemic to some depression occur during sleep in a deep, dreamless delta sleep. ‘In fact, panic disorders are kindled by things that make us all nervous,’ says Ballenger. ‘When we cure them, it’s as though we’ve brought people to normal anxiety.’ The panic disorders are really disorders of scale. Walking in a crowd, for example, is something distressing to most people even when they do not have an anxiety disorder; but if they do have an anxiety disorder, it may be unspeakably terrifying.
-0114- Sylvia Plath wrote in The Bell Jar , her wonderful evocation of her own breakdown: ‘I couldn’t get myself to react. I felt very still and very empty, the way the eye of a tornado must feel, moving dully along in the middle of the surrounding hullabaloo.’ I felt as if my head had been encased in Lucite, like one of those butterflies trapped forever in the thick transparency of a paperweight.
-0115- …deep love and the knowledge of deep love were not by themselves the cure. I can also say that without deep love and the knowledge of deep love, I would not have found it in myself to go through with that [book] tour. I would have found a place to lie down in the woods and I would have stayed there until I froze and died.
-0116- I had had a few random windows through the depression, like when the mist clears. Jane Kenyon, a poet who suffered severe depression through much of her life, has written about the emergence:
…With the wonder
and the bitterness of someone pardoned
for a crime she did not commit I come back to marriage and friends,
to pink fringed hollyhocks; come back
to my desk, books, and chair.
-0117- So on December 4, I walked into a friend’s house on the Upper West Side, and I had an okay time there. For the next few weeks, I took pleasure not in the okay time I was having, but in the fact that I was having it.
-0118- In my private self, however, I knew that what had gone away were only symptoms.
-0119- I was exhausted by all the things I had yet to make it through. I was overpowered being in the world, by other people and their lives I couldn’t lead, their jobs I couldn’t do.
-0120- I was back to about where I had been in September, only now I understood how bad it could get. I was determined never again to go through such a thing.
-0121- This phase of half-recovery can last for a long time. It is the dangerous time. During the worst of my depression, when I could hardly cut up a lamb chop, I could not have done myself real harm. In this emerging period, I was feeling well enough for suicide. i could by now do pretty much all of what I had always been able to do, except that I was still in anhedonia, the inability to experience pleasure at all. I kept pushing myself for form’s sake, but now that I had the energy to wonder why I was pushing myself, I could find no good reasons.
-0122- I wanted to talk to someone sane and comforting (a poor impulse: crazy people are better friend when you are crazy; they know how crazy feels). I picked up the phone and dialled one of my oldest friends. We had talked previously about the medications, about the panic, and she had been smart and liberating in her responses.
-0123- I was also aware that if I didn’t allow myself the relief of considering suicide, I would soon explode from within and commit suicide. I felt the fatal tentacles of this despair wrapping themselves around my arms and legs. Soon they would hold the fingers I would need to take the right pills or to pull the trigger, and when I had died, they would be the only motion left. … I felt already some strange despairing ecstasy at the thought of the end.
-0124- My own awareness that depression is maudlin and laughable helped to get me off the roof.
-0125- The things that save you are as frequently trivial as monumental. One, certainly, is a sense of privacy; to kill yourself is to open your life’s misery up to the world.
-0126- Since the world is flawed, perfectionists tend to be depressed. Depression lowers self-esteem, but in many personalities, it does not eliminate pride, which is as good an engine for the fight as any I know. When you’re so far down that love seems almost meaningless, vanity and a sense of obligation can save your life.
-0127- Depression is hard on friends. You make what by the standards of the world are unreasonable demands on them, and often they don’t have the resilience of the flexibility or the knowledge of the inclination to cope. If you’re lucky some people will surprise you with their adaptability. You communicate what you can and hope. Slowly, I’ve learned to take people for why they are. Some friends can process a severe depression right up front, and some can’t. Most people don’t like one another’s unhappiness very much. Few can cope with the idea of a depression divorced from external reality; many would prefer to think that if you’re suffering, it’s with reason and subject to logical resolution.
-0128- A large proportion of my best friends are a little bit crazy. People have taken my frankness an an invitation to be frank themselves, and I have many friends with whom I have found a trust like that between schoolmates or former lovers, the ease of a vast mutual knowing. I try to be cautious with my friends who are too sane.
-0129- After any given depression, there’s the need for a lot of cleanup. I remember that I love friend I had thoughts of letting go. I try to rebuild what I have wasted. After any given depression comes the time to uncrack the eggs and to put the spilled milk back in the container.
-0130- When I stopped taking the drugs, I did it fast. I knew that this was dumb, but i just wanted desperately to be off medication. I thought I might be able to find out who I was again. It was not a good strategy. In the first place, I had never experienced anything like the withdrawal symptoms from the Xanax: I could not sleep properly, and I felt anxious and strangely tentative. I also felt the whole time as though I’d had several gallons of cheap cognac the night before. My eyes hurt and I had an upset stomach, which probably came from quitting the Paxil cold turkey. At night, when I was not really asleep, I had unrelenting terrifying nightmares, and I woke up with my heart pounding.
-0131- I felt a little bit like my old self, but the year had been so awful, had shaken me so deeply, that though I was now functioning again, I had also realised that I could not go on. This did not feel irrational, like the terror; it did not feel angry; it felt quite sensible. i had had enough of life, and I wanted to figure out how to end it with the least possible damage to the people around me. I needed something I believed in, something to show, so that everyone would understand how desperate I was. I had to give up the invisible impediment for a manifest one. There is little question in my mind that the particular behaviour i chose was highly individual and related to neuroses of my own, but the decision to behave with such hunger to be rid of the self was typical of agitated depression. All I had to do was get sick, and that would give me permission. The wish for a more visible illness was, i would later learn, a commonplace among depressives, who often engage in forms of self-mutilation to bring the physical state in line with the mental. i knew that my suicide would be devastating for my family and sad for my friends, but I felt they would all understand that I had had no choice.
-0132- The end was at hand. I had a new sense of efficiency. That depression of purposelessness was gone.
-0133- In the meanwhile, I went through boringly typical symptoms of agitated depression. I had had anxiety, which is sheer terror; this was much more full of hatred, anguish, guilt, self-loathing. I have never in my life felt so temporary. I slept badly, and I was ferociously irritable. I stopped speaking to at least six people, including one with whom I had thought i might be in love. i took to slamming down the phone when someone said something I didn’t like. I criticised everyone. It was hard to sleep because my mind was racing with tiny injustices from my past, which now seemed unforgivable. i could not really concentrate on anything: I am usually a voracious summer reader, but that summer I couldn’t make it through a magazine. I started doing my laundry every night while I was awake, to keep busy and distracted. When I got a mosquito bite, I picked at it until it bled, then picked off the scabs; i bit my nails so far down that my fingers were always bleeding too; I had open wounds and scratches everywhere, though I never actually cut myself. My situation was so different from the vegetative symptoms that had constituted my breakdown that it did not occur to me that I was still in the grip of the same illness as before.
-0134- The knowledge that I would die had also lifted the depression I’d felt and had even in a strange way diminished the wish to die. I put that period of my life behind me. I became gentler again. At my thirty-second birthday, I looked around at the many friends who had come for my party, and i was able to smile, knowing that this was the last one, that I would never have a birthday again, that i would soon die. The celebrations were tiring; the gifts I left in their paper wrapping. I calculated how long I would have to wait. I wrote a note to myself of the date in the March when six months would have elapsed from the last encounter, when I could get my test, my confirmation. And all the while, i acted fine.
I worked productively on some writing projects, organised both family Thanksgiving and Christmas, and was sentimental about my last holidays. Then a few weeks after New Year’s, I reviewed the details of my encounters with a friend who was an expert on HIV, and he told me that I might well be fine. At first i was dismayed, but then the period of my agitated depression, whatever had driven me to that behaviour, began to lift. I do not think that the HIV experiences were expiatory; time had just passed, suring the ill thinking that had driven me to such excess in the first place. Depression, which comes at you the the gale force of a breakdown, leaves gradually, quietly. My first breakdown was over.
-0135- The insistence on normality, the belief in an inner logic in the face of unmistakable abnormality, is endemic to depression. It is the everyman story of this book, one I have encountered time after time.
[PN: I don't understand this.]
-0136- The shape of each person’s normality, however, is unique: normality is perhaps an even more private idea than weirdness.
-0137- [Personal account from another person] I would wake up at three or four in the morning with these sort of rushed of anxiety that were so intense it would have been more pleasurable to jump out the window.
-0138- [Personal account] When you’re really bad, you have this sort of catatonic look on your face, as if you’ve been stunned.
-0139- [Personal account] I thought, at that point, that I would be mentally ill for the rest of my life. The episode lasted for more than a year. It seemed better to float with the down than to fight it. i think you have to let go and understand that the world will be re-created and may never again resemble what you knew previously.
-0140- [Story about another person] He finally signed in at Mt. Sinai Hospital in New York in September of 1986, and asked for electroconvulsive therapy. ECT had helped his father but failed to help him. “It was the most dehumanising place I can imagine, to go from life on the outside to not being allow to have your shaving kit or your nail clipper. Having to wear pyjamas. Having to eat dinner at four-thirty. Being talked down to, as if you’re retarded in addition to being depressed. Seeing other patients in padded cells. You can’t have a telephone in your room because you might strangle yourself with the cord and because they want to control your access to the outside world. This is not like a normal hospitalisation. You are deprived of your rights on the mental health ward. I don’t think the hospital is a place for depressives unless they’re totally helpless or desperately suicidal.
-0141- [Personal account] The physical process of the shock treatments was awful. “The man who administered them was a doctor who looked a lot like Herman Munster. The treatments were given in the basement of Mt Sinai. All the patients who were going to get them went down there, into the depths of hell, and all of us wore bathrobes, and it felt like we were in a chain gang. Since I kept my composure pretty well, they made me the last, and I stood around there trying to comfort all the terrified people who were waiting around, while the janitorial staff came in and shoved past us to get to their lockers, which were also located down there. If i were only Dante, I’d be great at explaining what it was like. I had wanted the treatments, but the room and the people–I felt like it was a barbaric Mengele scene of experimentation. If you’re going to do this stuff, do it on the fucking eighth floor with light windows and bright colours! i wouldn’t allow it now.
-0142- [Personal account] ‘I still mourn the loss of my memory,’ he says. ‘I had an exceptional memory, nearly photographic, and it has never come back. When I got out, I couldn’t remember my locker combination, my conversations.’ At first, when he came out, he also couldn’t even do filing at a volunteer job, but soon he began to function. He moved to Santa Fe for six months and stayed with friends. In the summer he returned to New York to live alone again. ‘Perhaps it is just as well that my memory was clearly suffering permanent deficits,’ he says. ‘It has helped me to blunt out some of the lows. I forget them as easily as I forget everything else.’ Recovery was gradual. ‘There is a lot of volition but you can’t control the recovery. You can’t figure out when it will happen, any more than you can predict when someone will die.’
-0143- Bill Stein is now on Effexor and lithium.
-0144- [Personal account] I always feel as though everyone wants a little piece of me. There’s just so much i can give and then I’ll get really, really tense. I think, perhaps wrongly, the people will think less of me if I am completely open about my experiences. I still remember being avoided. Life is always on the edge of falling down again. I’ve learned to hide it, to make it so no one can tell when I’m on three drugs and about to collapse. I don’t think I ever feel really happy. One can only expect that life not be miserable. When you’re hugely self-conscious, it’s hard to be fully happy.
-0145- I became overwhelmed by the need to pause. Life itself seemed so alarmingly exigent, to require so much of the self. It was too difficult to remember and think and express and understand–all the things I needed to be able to do to talk. To keep my face animated at the same time was insult added to injury. It was like trying to cook and roller-skate and skiing and type all at once. The Russian poet Daniil Kharms once described hunger: “Then begins the weakness. Then begins the boredom. Then comes the loss of the power of quick reason. Then comes the calmness. And then begins the horror.” In just such logical and terrible stages did the second bout of depression begin.
-0146- [Regarding on-coming bout of depression] I warned my father. I tried to make practical arrangements: losing my mind, like losing your car keys, is a real hassle. Out of the terror, I heard my voice holding on tight to irony when friends called. “I’m sorry, I’ll have to cancel Tuesday,” I said. “I’m afraid of lamb chops again.” The symptoms came fast and ominously. In about a month, I lost a fifth of my body weight, some thirty-five pounds.”
-0147- The psychopharmacologist thought that, since I had felt light-headed on Zoloft and highly strung on Paxil, it was worth trying something new, so he put me on effexor and BuSpar, both of which I am still taking, six years later. In the throes of depression, one reaches a strange point at which it is impossible to see the line between one’s own theatrically and the reality of madness. I discovered two conflicting qualities of character. I am melodramatic by nature; on the other hand, I can go out and “seem normal” under the abnormal of circumstances. Antonin Artaud wrote on one of his drawings, ‘Never real and always true,’ and that is how depression feels. You know that it is not real, that you are someone else, and yet you know that it is absolutely true. It’s very confusing.
-0148- As Gatsby said, “I tried hard to die but have an enchanted life.”
-0149- Years had passed since I had felt happiness at all, and i had forgotten what it is like to want to live, to enjoy the day you are in and to long for the next one, to know that you are one of the lucky people for whom life is the living of it.
-0150- I knew that episodes of pain might lie ahead, that depression is cyclical and returns to afflict its victims over and over. I felt safe from myself. I knew that eternal sadness, though very much within me, did not mitigate the happiness.
-0151-The poet Jane Kenyon wrote:
We try a new drug, a new combination
of drugs, and suddenly I fall into my life again

like a vole picked up by a storm
then dropped three valleys
and two mountains away from home.

I can find my way back. I know
I will recognize the store
where I used to buy milk and gas.

I remember the house and barn,
the rake, the blue cups and plates,
the Russian novels I loved so much,

and the black silk nightgown
that he once thrust
into the toe of my Christmas stocking.

And so it was for me that everything seemed to be returning, started strange, then went abruptly familiar, and I realized that a deep sadness had started when my mother got ill, had worsened when she died, had built beyond grief into despair, had disabled me, and was not disabling me anymore. I was still sad about the sad things, but I was myself again, as I used to be, as I always meant to go on being.
-0152- Since i am writing a book about depression, I am often asked in social situations to describe my own experiences, and I usually end by saying that I am on medication. “Still?” people ask. “But you seem fine!” To which i invariably reply that I seem fine because I am fine, and that I am fine in part because of medication. “So how long do you expect to go on taking this stuff?” people ask. When I say that I will be on medication indefinitely, people who have dealt calmly and sympathetically with the news of suicide attempts, catatonia, missed years of work, significant loss of body weight, and so on stare at me with alarm. “But it’s really bad to be on medication that way,” they say. “Surely now you are strong enough to be able to phase out some of these drugs!” if you say to them that this is like phasing the carburetor out of your car or the buttresses out of Notre Dame, they laugh. “So maybe you’ll stay on a really low maintenance dose?” they ask. You explain that the level of medication you take was chosen because it normalises the systems that can go haywire, and that a low dose of medication would be like removing half of your carburetor. You add that you have experienced almost no side effects from the medication you are taking, and that there is no evidence of negative effects of long-term medication. You say that you really don’t want to get sick again. But wellness is still, in the area, associated not with achieving control of your problem, but with discontinuation of medication: “Well, I sure hope you get off sometime soon,” they say.
-0153- “I may not know the exact effects of long-term medication,” says John Greden. “No one has yet taken Prozac for eighty years. But I certainly know the effects of nonmedication, or of going on and off medication, or of trying to reduce appropriate doses to inappropriate levels–and those effects are brain damage. You start to have consequences from chronicity. You have recurrences of increasing severity, levels of distress there is no reason for you ever to experience. We would never treat diabetes or hypertension in this on-again, off-again way; why do we do it with depression? Where has this weird social pressure come from? This illness has an eighty percent relapse rate within a year without medication, and an eighty percent wellness rate with medication.” Robert Post, of the NIMH, concurs: “People worry about side effects from staying on medication for a lifetime, but the side effects of doing that appear to be insubstantial, very insubstantial compared to the lethality or undertreated depression. If you have a relative or a patient on digitalis, what would you think of suggesting he go off it, see if he has another bout of congestive heart failure, and have his heart get so flabby that is can never get back into shape again? It’s not one iota different.” The side effects of these drugs are for most people much healthier than the illness they address.
-0154- There is evidence of people having adverse reactions to everything: certainly plenty of people have had adverse responses to Prozac. A certain amount of caution is appropriate when you decide to consume anything, from wild mushrooms to cough syrup.
-0155- People who take Prozac should watch in the early stages for adverse responses. The drug can cause facial tics and stiffening of muscles. Antidepressant drugs bring up questions around addiction, which i address later on in this book. The lowered libido, weird dreams, and other effects mentioned on the labelling of the SSRIs can be miserable. I am troubled by reports that some antidepressants have been associated with suicide; I believe that this has to do with the enabling quality of the drugs, which may give someone the wherewithal to do what he was previously too debilitated to contemplate.
-0156- Like childbirth, depression is a pain so severe as to be immemorial. I didn’t develop it when a relationship ended badly during the winter of 1997. It was a breakthrough, I told someone, not to have a breakdown during my breakup. But you are never the same once you have acquired the knowledge that there is no self that will not crumble. We are told to learn self-reliance, but it’s tricky if you have no self on which to rely.
-0157- It’s as if my self turned around and spit at me and said, don’t push it, don’t count on me for much, I have problems of my own to take care of.
-0158- One has the advantage during one’s own breakdown of being in it, where one can see what’s happening. From the outside, one can only guess; but since depression is cyclical, it can be fruitful to learn forbearance and recognition.
-0159- [Daughter's account of her father's depression] He had electroconvulsive therapy immediately thereafter, and when they were done with him, they told my mother to divorce him because he would never be the same. ‘Your kids won’t recognise him,’ they said. Though she didn’t really believe them, she sat in the car while driving him home from treatment and cried. When he woke up he was like a Xeroxed version of himself. A little fuzzy around the edges, memory not great, more careful with himself, less interested in us. Supposedly he’d been a really engaged father when we were tiny–came home early to see what we learned that day and brought us toys all the time. After the ECT, he was a little bit removed. And then it happened again four years later. They tried medications and more ECT. He had given up work for a while. Most of the time he was down. His face wasn’t recognisable; his chin had receded into his face. He would get out of bed and kind of helplessly go around the house with his hands shaking, these big hands just hanging there beside his body. You understand where theories of demon possession come in, because someone had taken over my father’s body. I was five years old and I could see it. I remember it really well. He looked the same but there was nobody home.
-0160- [Personal account] And he restructured his life. He takes a lot of vitamins and he gets a lot of exercise and he doesn’t work. And anytime anything stresses him out, he leaves the room. My baby daughter cries? He puts on his hat and goes home.
-0161- I came back to the U.S. to see doctors and I went on a huge cocktail: Klonopin, lithium, Prozac. It was impossible to have dreams or be creative and I had to carry around a gigantic pill case all the time, with pills marked morning, noon, afternoon, and evening because I couldn’t remember what was going on.
-0162- I slipped on the stairs in my own house and dislocated my shoulder badly, ripping a great deal of muscle tissue. I headed up to the hospital. I attempted to explain to the staff of the ambulance and then to the staff of the emergency room that I was eager to thwart a recurrence of depression. I explained about the kidney stones and how they had triggered a previous episode. I promised to fill out every form in the book and to answer questions on every subject from the colonial history of Zanzibar on down if they would only alleviate a physical agony that I knew was far too powerful for my mind’s peace. I explained that I had a history of severe breakdowns and asked that they look up my files. It took more that an hour to get any pain medication at all; and at that point I received a dose of morphine too small to alleviate my pain. A dislocated shoulder is a straightforward matter, but mine was not repositioned until eight hours after I had arrived in the hospital. I did finally have some meaningful relief, with Dilaudid, four hours and thirty minutes after my arrival–so the last three and a half hours were not quite so awful as what had gone before.
Attempting to remain calm during the early stages of all this, I requested a psychiatric consultation. The doctor who was supervising told me, ‘Dislocated shoulders are painful and it’s going to be painful until we have it back in place, and you’ve just got to be patient with it and stop carrying on.” She also said, “You are exercising no self-control, are getting angry, are hyperventilating, and I’m not going to do a thing for you until you pull yourself together.” i was told that “we don’t know you from Adam,” that “we don’t just give out strong pain medicine,” and that I should “try breathing deeply and imagining yourself on a beach with the sound of water in your ears and the feeling of sand between your toes.” One of the doctors told me, “Pull yourself together and stop feeling so sorry for yourself. There are people in this emergency room who are going through worse things than you are.” And when I said that I knew I had to go through the pain but wanted to take the edge off it before we proceeded, that I didn’t even mind this physical pain so much but was worried about psychiatric complications, I was told that I was being “childish” and “uncooperative.” When I said that I had a history of mental illness, I was told that in that case I could not well expect anyone to take my views on these things seriously. “I’m a trained professional and I’m here to help you,” the doctor said. When I said that I was an experienced patient and knew that what she was doing was in fact injurious to me, she told me that I had not being to medical school and would just have to proceed according to what she judged an appropriate protocol.
I repeated my request for a psychiatric consult, but no such thing was offered. Psychiatric records are not available in emergency rooms, and so there was no way to check on my complaints, though the hospital where i found myself is the one with which all my primary-care physicians and my psychiatrist are associated. I believe that the emergency room policy in which saying “I have had severe psychotic depression exacerbated by extreme pain” is treated much the same as saying “I have to have a woolly teddy bear with me before you can use sutures” is unacceptable. The standard textbook on emergency practice in the United States does not deal with the psychiatric aspects of somatic illness. No one in the emergency room was remotely equipped to deal with psychiatric complications. I was asking for steak at a fishmonger’s.
Pain accumulates. Five hours of pain are at least six times as painful as one hour of pain. I remarked that physical trauma is among the primary triggers for psychiatric trauma, that to cure one in such a way that you generate the other is an act of medical stupidity. Of course the longer the pain went on, the more it wore me out; the more overstimulated my nerves became; the more serious the situation grew. The blood under the skin had pooled until my shoulder looked as if I’d borrowed it from a leopard. I was giddy by the time the Dilaudid came along. There were indeed people in that emergency room whose acute injuries were more serious than mine; why should any of us have endured gratuitous pain?
Within three days of my emergency room ordeal, I had acute suicidal feelings of a kind I had not experienced since my first severe episode; and if I had not been under twenty-four-hour watch by my family and friends, I would have arrived at levels of physical and psychic pain that were beyond unbearable and I would have sought immediate relief of the most extreme kind. It was the tree and the vine all over again. If you see a little shoot coming out of the ground and recognise it as the shoot of a heavy vine, you can pull it out of the ground with your thumb and forefinger and all will be well. If you wait until the vine has got a firm hold on the tree, you need to have saws and perhaps an axe and a shovel to get rid of the thing and dig out the roots. It is unlikely that you can remove the vine without breaking some of the branches of the tree. I am usually able to control suicidality in myself, but, as I pointed out to the hospital staff after the whole episode was finished, refusing to treat the psychiatric complaints of patients can take a relatively insignificant matter such as a dislocated shoulder and make it a fatal disease. If someone says that he is suffering, emergency room staff should respond accordingly. Suicides take place in this country because of the conservatism of doctors such as the ones I encountered in that emergency room, who deal with intolerance for extreme pain (physical and psychological) as a weakness of character.
-0163- The reality that i had to put on not just one but two socks and then two shoes so overwhelmed me that I wanted to go back to bed.
-0164- There was an extra horror in this breakdown. My previous two breakdowns had taken place when I was not on medication. After the second one, i had accepted that I would have to be on medication permanently if I was to avoid further episodes. At considerable psychic cost, I had taken my medication every day for four years. Now I found myself having a total collapse despite the fact that I was on Effexor, BuSpar, and Wellbutrin. What could this mean? In working on this book, I had met some people who had had an episode or two, then gone on medication and been fine. i had also met people who got a year out of one medication, had a collapse, got a few months out of another one–people who could never put their depression into the safety of the past tense. I had believed myself to be in the first category. i now suddenly seemed to be in the second category. i had seen these lives in which mental health was never more than occasional. It was quite possible that i had outlived my capacity to be helped by Effexor–people do exhaust these drugs. If this were so, it was a terrible world I was joining. In my mind I saw a year on one thing, a year on another, until finally I had used up all the available options.
-0165- Here’s what I knew that saved me: act fast; have a good doctor prepared to hear from you; know your own patterns really clearly; regulate sleep and eating no matter how odious the task may be; lift stresses at once; exercise, mobilise love.
-0166- I had not lost my mind,, i explained to friends and family, but I had most certainly mislaid it. I felt like wartime Dresden, like a city that was being destroyed and could not shield itself from the bombs, that was simply caving in, {leaving only the barest remnants of gold shimmering in the midst of rubble.} [Writing note: evocative description]
-0167- He put me on Zyprexa, and anti-psychotic that has anti-anxiety effects as well. He increased the dose of Effexor because, he said, you should never ever switch away from the product that is helping you unless you absolutely have to do so. Effexor had done it before and maybe with a boost it would do it again? He lowered my dose of Wellbutrin because Wellbutrin is activating, and in the face of high anxiety I needed to be less activated. We left the BuSpar alone. My psycho-pharmacologist was adding things and subtracting things and reading my responses and my self-descriptions and constructing a somehow “true” version of me, perhaps just like the old one, perhaps a little bit different. I had a lot of expertise by now and read up on the products I took (though I avoided finding out about the side effects is more or less a guarantee of developing the side effects). Still, it was all a vague science of smells and flavors and blends.
-0168- The night after I started on Zyprexa, I was supposed to give a lecture on Virginia Woolf. I love Virginia Woolf. Giving a lecture on Virginia Woolf and reading aloud passages from her writing was for me comparable to giving a lecture on chocolate and eating my way through.
-169- So I arrived and made a little bit of polite conversation during cocktails and then stood up with my notes and found myself calm, eerily calm, as though I were merely volunteering some ideas at the dinner table, and in a strange out-of-body sort of way I watched myself deliver a reasonably coherent lecture on Woolf from memory and the written text.

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