The Noonday Demon (16 page)

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 been to medical school and would just have to proceed according to what she judged an appropriate protocol.

I repeated my requests 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 room 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 the 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 recognize 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 ax 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.

The following week, I went to pieces again. I had had the problem of tears during previous episodes, but never in the way that I had them now. I cried all the time, like a stalactite. It was incredibly tiring to be synthesizing all those tears, so many of them that my face became chapped. It seemed to take the most colossal effort to do simple things. I
remember bursting into tears because I had used up the cake of soap that was in the shower. I cried because one of the keys stuck for a second on my computer. I found everything excruciatingly difficult, and so, for example, the prospect of lifting the telephone receiver seemed to me like bench-pressing four hundred pounds. 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. Though I did not have the acute anxiety that had characterized previous episodes, paranoia began to set in as well: I started to fear, every time my dog left the room, that it was because he wasn’t interested in me.

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.

I now have procedures in place for breakdowns. I know which doctors to call and what to say. I know when it’s time to put away the razor blades and keep walking the dog. I called around and said straight out that I was depressed. Some dear friends, recently married, moved into my house and stayed with me for two months, getting me through the difficult parts of the days, talking through my anxieties and fears, telling me stories, seeing to it that I was eating, mitigating the loneliness—they made themselves my soul mates for life. My brother flew in from California and surprised me on my doorstep just when I was at my lowest. My father snapped to attention. 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; mobilize love.

I called my agent as soon as I could and said that I was doing badly and that I would be suspending work on this book. I said I had no idea
what the course of my disaster would be. “Pretend I was hit by a car yesterday,” I said, “and that I’m in the hospital in traction waiting for the results of the X rays. Who knows when I’ll be typing again?” I took Xanax even when it made me feel spaced-out and groggy, because I knew that if I let the anxiety that was in my lungs and stomach run free, it would grow worse and I would be in trouble. 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.

Weeping embarrassingly even in the elevator at the hospital where my psychopharmacologist keeps his office, I went to ask whether anything could be done. To my surprise, my psychopharmacologist didn’t see the situation in nearly such dire terms as I did. He said he was not going to take me off Effexor—“it’s been working for you for a long time and there’s no reason for it to stop now.” He put me on Zyprexa, an antipsychotic that has antianxiety 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 psychopharmacologist 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 of anything until I’d been taking it for a while; knowing 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. My therapist helped me to survive the experiments: he was a champion of continuity, calming me into a belief that the future would at the very least prove equal to the past.

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. I was giving this lecture at the home of friends, to a friendly group of perhaps fifty of their associates. It was a sort of charity function for a cause in which I believed. Under ordinary circumstances, it would have been wonderful fun and little effort, and I would have been able to bask in the spotlight—which is something I rather like doing when my mood is right. One might have expected that the lecture would exacerbate my
problems, but actually I was so screaming meemies that the lecture was neither here nor there: it was nerve-racking being awake, and nothing could really make things worse. 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.

After the lecture, I went with a group of friends and the people who’d organized the event to dinner in a nearby restaurant. The evening included enough varied people so that some effort was required to muster the appearance of perfect politesse, but under ordinary circumstances it would have been a pleasure. As it was, it seemed as though the air around me was setting, the way glue sets, into a weird rigidity, so that people’s voices all seemed to be breaking and cracking through the solid air, and that cracking noise made it hard to hear what they were saying. I had to break through just to lift my fork. I ordered the salmon and began to be aware that my odd situation was showing. I was slightly mortified but didn’t know what to do about it. Those situations are embarrassing, no matter how many people you know who have taken Prozac, no matter how wonderfully at ease everyone is supposed to be with depression. Everyone at the table knew I was writing a book on the subject and most of them had read my articles. It didn’t help. I mumbled and apologized my way through dinner like a Cold War diplomat. “So sorry if I seem a bit unfocused, but you know I’ve just been having another go-around with depression,” I might have said, but then everyone would have felt obliged to ask about specific symptoms and causes and to attempt to reassure me, and those reassurances would in fact have exacerbated the depression. Or, “I’m afraid I can’t actually follow what you’re saying because I’ve been taking five milligrams of Xanax every day, though I’m of course not addicted, and have also just begun a new antipsychotic which I believe has strong sedating properties. Is your salad good?” On the other hand, I had a feeling that if I went on saying nothing, people were going to notice how peculiar I was being.

And then I found that the air was getting so hard and brittle that the words were coming through in stacatto noises that I couldn’t quite string together. Perhaps you have had the experience of attending a lecture and realizing that in order to follow the main points you need to keep paying attention; but your mind wanders a bit and then you can’t quite make sense of what is being said when you return to it. The logic is missing. So it was for me, but on a sentence-by-sentence basis. I felt the logic disappearing right out from under me. Someone had said something about
China, but I wasn’t sure what. I thought someone else had mentioned ivory, but I didn’t know whether it was the same person who’d been talking about China, though I did remember that the Chinese had made ivory things. Someone was asking me something about a fish, perhaps my fish? Whether I’d ordered fish? Whether I liked fishing? Was there something about Chinese fish? I heard someone repeat a question (I recognized the sentence pattern from the time before), and then I felt my eyes close and I thought quietly, it is not polite to fall asleep when someone asks you a question for the second time. I must wake up. So I pulled my head up from my chest and smiled in what was meant to be an I-didn’t-quite-catch-that way. I saw puzzled faces looking at me. “Are you okay?” someone asked again, and I said, “Possibly not,” and some friends who were there took me by the arms and led me outside.

“So sorry,” I kept saying, dimly aware that I had left everyone at the table thinking I was probably strung out on drugs, and wishing that I had simply said that I was depressed, hypermedicated, and unsure of how well I’d get through the evening. “So sorry,” and everyone kept saying that there was nothing to be sorry about. And the friends who had saved me got me home and up to my bed. I took out my contact lenses and then tried to chat for a few minutes, to reassure myself. “So how are you?” I said, but when my friend started to answer me, he became rather faint, like the Cheshire cat, and then I passed out again and went into a cavernous sleep for seventeen hours and dreamed of a great war. My God, I had forgotten the
intensity
of depression. It cuts so deep, so far! We are determined by sets of norms that are quite beyond us. The norms to which I was brought up and which I established for myself are quite high by world standards; if I do not feel able to write books, I feel something is wrong with me. Some people’s norms are much lower; those of other people are much higher. If George W. Bush wakes up one day feeling that he can’t be the leader of the free world, something’s wrong with him. But some people feel that they’re okay as long as they can feed themselves and keep on living. Collapsing at dinner is well outside of the range I count okay.