Unit 4  Section 1 Exercise 1 The patient's experience William Styron
Clinical correlate #3 Diagnosing depression in primary care
Read the following segments from William Styron's description of depression, and answer the study questions.
William Styron, Darkness Visible (excerpts)
Depression is a disorder of mood, so mysteriously painful and elusive in the way it becomes known to the self—to the mediating intellect—as too verge close to being beyond description, It thus remains nearly incomprehensible to those who have not experienced it in its extreme mode, although the gloom, “the blues” which people go through occasionally and associate with the general hassle of everyday existence are of such prevalence that they do give many individuals a hint of the illness in its catastrophic form. But at the time of which I write I had descended far past those familiar, manageable doldrums.
I had come to a point where I was carefully monitoring each phase of my deteriorating condition. My acceptance of the illness followed several months of denial during which, at first, I had ascribed the malaise and restlessness and sudden fits of anxiety to withdrawal from alcohol; I had abruptly abandoned whiskey and all other intoxicants that June.
pp.16-18
I was feeling in my mind a sensation close to, but indescribably different from, actual pain. This leads me to touch again on the elusive nature of such distress. That the word “indescribable” should present itself is no fortuitous, since it has to be emphasized that if the pain were readily describable most of the countless sufferers from this ancient affliction would have been able to confidently depict for their friends and loved ones (even their physicians) some of the actual dimensions of their torment, and perhaps elicit a comprehension that has been generally lacking; such incomprehension has usually been due not to a failure of sympathy but to the basic inability of healthy people to imagine a form of torment so alien to everyday experience. For myself, the pain is most closely connected to drowning or suffocation—but even these images are off the mark. William James, who battled depression for many years, gave up the search for an adequate portrayal, implying it near-impossibility when he wrote in The Varieties of Religious Experience: “It is a positive and active anguish, a sort of psychical neuralgia wholly unknown to normal life.”
The pain persisted during my museum tour and reached crescendo in the next few hours when, back at the hotel, I fell onto the bed and lay gazing at the ceiling, nearly immobilized and in a trance of supreme discomfort. Rational thought was usually absent from my mind at such times, hence trance. I can think of no more apposite word for this state of being, a condition of helpless stupor in which cognition was replaced by that “positive and active anguish.” And one of the most unendurable aspects of such an interlude was the inability to sleep. It had been my custom of a near-lifetime, to settle myself into a soothing nap in the late afternoon, but the disruption of normal sleep patterns is a notoriously devastating feature of depression; to the injurious sleeplessness with which I had been afflicted each night was added the insult of this afternoon insomnia, diminutive by comparison but all the more horrendous because it struck during the hours of the most intense misery. It had become clear that I would never be granted even a few minutes’ relief from my full-time exhaustion. I clearly recall thinking, as I lay there while Rose sat nearby reading, that my afternoons and evenings were becoming almost measurably worse, and that this episode was the worst to date.
36-38
When I was aware that I had been laid low by the disease, I felt a need, among other things, to register a strong protest against the word “depression.” Depression, most people know, used to be termed ‘melancholia,” a word which appears in English as early as the year 1305 and crops up more than once in Chaucer, who in his usage seemed to be aware of its pathological nuances. “Melancholia” would still appear to be a far more apt and evocative word for the blacker forms of this disorder, but it was usurped by a noun with a bland tonality and lacking any magisterial presence, used indifferently to describe an economic decline or a rut in the ground, a true wimp of a word for such a major illness. It may be that the scientist generally held responsible for its currency in modern times, a Johns Hopkins Medical School faculty member justly venerated—the Swiss-born Adolf Meyer—had a tin ear for the finer rhythms of English and therefore was unaware of the semantic damage he had inflicted by offering “Depression” as a descriptive noun for such a dreadful and raging disease. Nonetheless, for over seventy-five years the word had slithered innocuously through the language like a slug, leaving little trace of its intrinsic malevolence and preventing, by its very insipidity, a general awareness of the horrible intensity of the disease when out of control.
As one who has suffered from the malady in extremis yet returned to tell the tale, I would lobby for a truly arresting designation. “Brainstorm,” for instance, has unfortunately been preempted to describe, somewhat jocularly, intellectual inspiration. But something along these lines is needed. Told that someone’s mood disorder has evolved into a storm—a veritable howling tempest in the brain, which is indeed what a clinical depression resembles like nothing else—even the uninformed layman might display sympathy rather than the standard reaction that ‘depression” evokes, something akin to So what?” pr “You’ll pull out of it” or “We all have bad days. The phrase “nervous breakdown” seems on its way out, certainly deservedly so, owing to its insinuation of a vague spinelessness, but we still seem destined to be saddled with “depression” until a better, sturdier name is created.
pp 43-50.
I felt a kind of numbness, an enervation, but more particularly an odd fragility—as if my body had actually become frail, hypersensitive and somehow disjointed and clumsy, lacking normal coordination. And soon I was in the throes of a pervasive hypochondria. Nothing felt quite right with my corporeal self there were twitches and pains, sometimes intermittent, often seemingly constant, that seemed to presage all sorts of dire infirmities. (Given these signs, one can understand how, as far back as the seventeenth century-in the notes of contemporary physicians, and in the perceptions of John Dryden and others—a connection is made between melancholia and hypochondria; the words are often interchangeable, and so were used until the nineteenth century by writers as various as Sir Walter Scott and the Brontes, who also linked melancholy to a preoccupation with bodily ills.) It is easy to see how this condition is part of the psyche’s apparatus of defense: unwilling to accept its own gathering deterioration, the mind announces to its indwelling consciousness that it is the body with its perhaps correctable defects—not the precious and irreplaceable mind—that is going haywire. In my case, the overall effect was immensely disturbing, augmenting the anxiety that was by now never quite absent from my waking hours and fueling still another strange behavior pattern—a fidgety recklessness that kept me on the move, somewhat to the perplexity of my family and friends.
…By now I had moved back to my house in Connecticut. It was October, and one of the unforgettable features of this stage of my disorder was the way in which my own farmhouse, my beloved home for thirty years, took on for me at that point when my spirits regularly sank to their nadir an almost palpable quality of ominousness. The fading evening light—akin to that famous “slant of light” of Emily Dickinson’s, which spoke to her of death, of chill extinction—had none of its familiar autumnal loveliness, but ensnared me in a suffocating gloom. I wondered how this friendly place, teeming with such memories of (again in her words) “Lads and Girls,” of “laughter and ability and Sighing,/ And frocks and Curls,” could almost perceptibly seem so hostile and forbidding. Physically, I was not alone. As always Rose was present and listened with unflagging patience to my complaints. But I felt an immense and aching solitude. I could no longer concentrate during those afternoon hours, which for years had been my working time, and the act of writing itself, becoming more and more difficult and exhausting, stalled, then finally ceased.
There were also dreadful, pouncing seizures of anxiety. One bright day on a walk through the woods with my dog I heard a flock of Canada geese honking high above trees ablaze with foliage; ordinarily a sight and sound that caused me to stop, riveted with fear, and I stood stranded there, helpless, shivering, aware for the first time that I had been stricken by no mere pangs of withdrawal but a serious illness whose name and actuality I was able finally acknowledge. Going home, I couldn’t rid my mind of Baudelaire’s, dredged up from the distant past, that for several days had been skittering around at the edge of my consciousness: “I have felt the wind of the wing of madness.”
Our perhaps understandable modern need to dull the sawtooth edges of so many afflictions we are heir to had led us to banish the harsh old-fashioned words: madhouse, asylum, insanity, melancholia, lunatic, madness. But never let it be doubted that depression, in its extreme form, is madness. The madness results from an aberrant biochemical process. It has been established with reasonable certainty (after strong resistance from many psychiatrists, and not all that long ago) that such madness is chemically induced amid the neurotransmitters of the brain, probably as the result of systemic stress, which for unknown reasons causes a depletion of the chemicals norepinephrine and serotonin, and the increase of a hormone, cortisol. With all this upheaval in the brain tissues, the alternate drenching and deprivation, it is no wonder that the mind begins to feel aggrieved, stricken, and the muddied thought processes register the distress of an organ in conclusion. Sometimes, though not very often, such a disturbed mind will turn to violent thoughts regarding others. But with their minds turned agonizingly inward, people with depression are usually only dangerous to themselves. The madness of depression is, generally speaking, the antithesis of violence. It is a storm indeed, but a storm of murk. Soon evident are the slowed-down responses, near paralysis, psychic energy throttled back close to zero. Ultimately, the body is affected and feels sapped, drained.
That fall, as the disorder gradually took full possession of my system, I began to conceive that my mind itself was like one of those out-moded small-town telephone exchanges, being gradually inundated by floodwaters: one by one, the normal circuits began to drown, causing some of the functions of the body and nearly all those of the instinct and intellect to slowly disconnect.
There is a well-known checklist of some of these functions and their failures. Mine conked out fairly close to schedule, many of them following the pattern of depressive seizures. I particularly remember the lamentable near-disappearance of my voice. It underwent a strange transformation, becoming at times quite faint, wheezy and spasmodic—a friend observed later that it was the voice of a ninety-year-old. The libido also made an early exit, as it does in most major illnesses—it is the superfluous need of a body in beleaguered emergency. Many people lose all appetite; mine was relatively normal, but I found myself eating only for subsistence: food, like everything else within the scope of sensation, was utterly without savor. Most distressing of all the instinctual disruptions was that of sleep, along with a complete absence of dreams..
…my few hours of sleep were usually terminated at three or four in the morning, when I stared up into yawning darkness, wondering and writhing at the devastation taking place in my mind, and awaiting the dawn, which usually permitted me a feverish, dreamless nap. I’m fairly certain that it was during one of these insomniac trances that there came over me the knowledge—a weird and shocking revelation, like that of some long-beshrouded metaphysical truth—that this condition would cost me my life if it continued on such a course….
What I had begun to discover is that, mysteriously and in ways that are totally remote from normal experience, the gray drizzle of horror induced by depression takes on the quality of physical pain., like that of a broken limb. It may be more accurate to say that despair, owing to some evil trick played upon the sick brain by the inhabiting psyche, comes to resemble the diabolical discomfort of being imprisoned in a fiercely overheated room. And because no breeze sites this caldron, because there is no escape from this smothering confinement, it is entirely natural that the victim begins to think ceaselessly of oblivion.
pp 62-63
In depression the faith in deliverance, in ultimate restoration, is absent. The pain is unrelenting, and what makes the condition intolerable is the foreknowledge that no remedy will come—not in a day, an hour, a month, or a minute. If there is mild relief, one knows that it is only temporary; more pain will follow. It is hopelessness even more than pain that crushes the soul. So the decision-making of daily life involves not, as in normal affairs, shifting from one annoying situation to another less annoying—or from discomfort to relative comfort, or from boredom to activity—but moving from pain to pain. One does not abandon, even briefly, one’s bed of nails, but is attached to it wherever one goes, And this results in a striking experience—one which I have called, borrowing military terminology, the situation of the walking wounded. For in virtually any other serious sickness, a patient who felt similar devastation would be lying flat in bed, possibly sedated and hooked up to the tubes and wires of life-support systems, but at the very least in a posture of repose and in an isolated setting. His invalidism would be necessary, unquestioned and honorably attained. However, the sufferer from depression has no such option and therefore finds himself, like a walking casualty of war, thrust into the most intolerable social and family situations. There he must, despite the anguish devouring his brain, present a face approximating the one that is associated with ordinary events and companionship. He must ry to utter small talk, and be responsive to questions, and knowingly nod and frown and, God help him, even smile. But it is a fierce trial attempting to speak a few simple words.
That December evening, for example, I could have remained in bed as usual during those worst hours, or agreed to the dinner party my wife had arranged downstairs. But the very idea of a decision was academic. Either course was torture, and I chose the dinner not out of any particular merit but through indifference to what I knew would be indistinguishable ordeals of fogbound horrors. At dinner I was barely able to speak, but the quartet of guests, who were all good friends, were aware of my condition and politely ignored my catatonic muteness. Then, after dinner, sitting in the living room, I experienced a curious inner convulsion that I can describe only as despair beyond despair. It came out of the cold night. I did not think such anguish possible.
Study Questions
- Why is the “mental pain” of depression so difficult to describe to those who have not experienced it? Why is it necessary for Styron to write in metaphors, e.g., drowning or suffocation, to try to describe this?
- Why does Styron feel a need to “register a strong protest against the word ‘depression’”?
- What do you make of Styron’s claim that depression, in its extreme form, is madness? Why have we banished this, and other harsh old-fashioned words relating to mental illness (e.g., asylum, insanity, melancholia, lunatic)?
- In Styron’s estimation, why is suicide so closely linked to depression?
- Why is the depressed person in the situation of the “walking wounded”? How does this affect others’ understanding of the depressed person’s illness?
- Does Kenyon’s poem (above) capture aspects of the experience of depression that cannot be articulated in Styron’s prose? Is the reverse also the case?
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