Mental illness seems to be an important and growing concern in our societies. In the US we are bombarded by advertising on conditions such as depression, anxiety, and bipolar disorder, conditions that are claimed to have pharmaceutical remedies. Are these categories representative of what people in distress are actually experiencing, or are they merely categories with which psychiatrists and drug companies believe they can deal? How much of our mental distress is inflicted by cultural or social experiences and how much is due to physical disorder? What treatments are available, and do they work? Rachel Aviv discusses the issues associated with what are considered mental illnesses by considering five case histories, including her own, in Strangers to Ourselves: Unsettled Minds and the Stories That Make Us.
Rachel Aviv is best known as a talented staff writer for The New Yorker. In that role she has covered issues related to mental illness in the past. In her book she presents several case studies of individuals whose behavior was viewed as stemming from mental illness by doctors and acquaintances, describing their interactions with them as they struggled to understand themselves. She chose people whose struggle for understanding moved them to keep diaries or write otherwise about their lives. One of her choices was herself.
Aviv’s studies have driven her to emphasize that activities that would be considered indicative of mental illness have complex origins.
“…mental illness is caused by an interplay between biological, genetic, psychological, and environmental factors…”
Given the complexity of that interplay, one can likely assume that each individual is unique with a unique set of issues. When does a person with issues become a person with a mental illness. Since there are no physical diagnostics that can determine such a state, the characterization is somewhat arbitrary. A group of psychiatrists gets together every few years and defines what is normal behavior and how much of a deviation from normal can be classified as a specific mental illness. These conclusions are published in the Diagnostic and Statistical Manual of Mental Disorders (DSM). Sets of symptoms are associated with each disorder. Since there are many disorders, the symptom sets are not always unique for a specific disorder. While there are always a few people so out of control that they clearly need help of some kind, it is easy for the rest of us to be captured by a system that views sadness and shyness as symptoms of mental illness.
What emerges from Aviv’s case studies is the ease with which our understanding of ourselves can be corrupted by the act of diagnosis. A patient’s uniqueness can disappear as a psychiatrist tries to fit her in a specific illness category in order to suggest a treatment. Conversely, a uniquely troubled person can seek understanding by examining illness categories and conclude that she must fit into one, leading to an imitation of a defined set of symptoms.
“Psychiatrists know remarkably little about why some people with mental illnesses recover and others with the same diagnosis go on to have an illness ‘career.’ Answering the question, I think, requires paying more attention to the distance between the psychiatric models that explain illness and the stories through which people find meaning themselves.”
“There are stories that save us, and stories that trap us, and in the midst of an illness it can be very hard to know which is which.”
Of all Aviv’s case studies, her own history is perhaps the most relevant. When she was age six, she suddenly stopped eating. She doesn’t recall much about her reasoning at the time, but she suggests she may have been influenced by the Jewish Yom Kippur tradition which calls for people to reject food and liquids for a full day as a means of cleansing body and spirit. She recalls feeling proud of her ability to turn away from food and remembers thinking it was important to her to feel like she had become a better person. She also remembers being pleased by the reaction of her parents and the attention she received. Aviv’s parents were recently divorced and were fighting over her custody. She ended up in a hospital where she and other girls were treated as sufferers of anorexia. Rachel was the youngest girl anyone could recall suffering from this condition. During this period the malady was not well understood, and her doctors tried to apply psychanalytic techniques to discover the sources of her problem.
Psychoanalysts led the way in addressing mental illness by focusing on psychological and environmental factors. Their success was quite limited, and they were mostly superseded by psychiatrists who focused on biological and genetic factors and attempted to treat patients with medications. Their success has, by many measures, been quite limited as well. At age six, the influence of the psychiatrist who treated her was small, but the effect of being confined with girls who were deeply in the clutches of anorexia had a dangerously large influence on her. She was made to feel welcome by the older girls and she, in turn, felt it appropriate to imitate their behaviors and think of them as mentors. She was taught that in addition to limiting eating, one could lose weight by exercising. She would try to keep up with the exercises done by the older girls and followed their lead by standing and moving around all day, only stopping at bedtime.
Aviv was lucky to drift into this mode of behavior at such a young age. It did not manage to capture her because she did not fully possess the consciousness and experiences of the older girls. She was not allowed to see her parents while confined unless she ate a certain amount of food. This provided enough motivation to get her eating again and she was soon released. However, she continued to be affected by the experience. The need to remain standing all day long followed her as she resumed school. It would be around a month before she felt comfortable sitting down like the other children.
Imitation is an important factor in determining the manner in which people respond to situations. Aviv provides a startling example that occurred in Sweden.
“A few years ago, I went to Sweden to report a story about a condition known as ‘resignation syndrome.’ Hundreds of children from former Soviet and Yugoslav states who had been denied asylum in Sweden had taken to their beds. They refused food. They stopped talking. Eventually, they seemed to lose the ability to move. Many had to be given feeding tubes. Some gradually slipped into states resembling comas.”
This only happened in Sweden, not in any other Nordic countries where similar refugees were attempting to settle. It seemed that in Sweden one child chose the anorexic-like response, probably as an act of protest, and others copied the behavior. But the behavior, initially voluntary, can become intrinsic and compulsive. This seems to be the path by which anorexia captures its victims.
“Something about the mute, fasting children in Sweden felt familiar to me. For a child, solipsistic by nature, there are limits to the ways that despair can be communicated. Culture shapes the scripts that expressions of distress will follow. In both anorexia and resignation syndrome, children embody anger and a sense of powerlessness by refusing food, one of the few methods of protest available to them. Experts tell these children that they are behaving in a recognizable way that has a label. The children then make adjustments, conscious and unconscious, to the way they’ve been classified. Over time, a willed pattern of behavior becomes increasingly involuntary and ingrained.”
“The philosopher Ian Hacking uses the term ‘looping effect’ to describe the way that people get caught in self-fulfilling stories about illness. A new diagnosis can change ‘the space of possibilities for personhood,’ he writes. ‘We make ourselves in our own scientific image of the kinds of people it is possible to be.’…We find a way to express our distress through imitation until, eventually, we ‘have “learned” or—better—“acquired” a new psychic state’.”
What this describes is mental illness as a fad or as a cultural construct. People in distress need a way to express their distress that will gather them attention and perhaps sympathy or help. Embracing a recognizable, well-known mental illness is a surefire way to gain attention. For centuries female hysteria was considered a form of mental illness. It has disappeared. There was no cure, it just went out of style.
Aviv’s personal experience with mental illness would return when she was an adult. By that time psychiatrists had mainly moved on to focusing on biological explanations for mental problems and the use of medications to treat issues. This shift created new stories that people could tell about themselves and new stories that psychiatrists could tell their patients.
One of the case studies Aviv included in her book involved a woman named Laura. She seemed destined for a charmed life, equipped with the characteristics expected of high performers, but she never found satisfaction with the life towards which she was headed. She was diagnosed initially with bipolar disorder (later renamed bipolar depression). Aviv uses her “career” in mental illness as an example of a “diagnosis trap” that can emerge when using medications to treat mental illness. She would ultimately find satisfaction by freeing herself from her dependence on these drugs and spend her time helping others follow her example. Aviv would provide a description of what she refers to as biological psychiatry and go on to discuss her own attempt to use antidepressants to solve her issues.
Laura, at first, welcomed the diagnosis that her problems were being caused by a chemical imbalance in her brain. That allowed her to quit questioning her own responsibility and just wait for a medication to correct the imbalance. She began with moderate doses of Prozac, an antidepressant drug. That did not help. Any solution was not going to be simple.
“Her psychiatrist raised her Prozac prescription to 80 milligrams, the maximum dose. The Prozac made her drowsy, so he prescribed her 400 milligrams of Provigil, a drug for narcolepsy often taken by soldiers and truck drivers to stay awake for long shifts…When the Provigil made it hard for Laura to sleep, her pharmacologist described Ambien [a sedative], which she took every night. In the course of a year, her doctors had created what’s known as a ‘prescription cascade’: the side effects of one prescription are diagnosed as symptoms of another condition, leading to a succession of new prescriptions.”
The search for the correct combination of drugs for Laura would go on indefinitely if she allowed it to happen. The drugs prescribed were psychotropic: they altered her brain function. Modifying symptoms were all they could claim to do. It is possible to minimize symptoms and claim an effective treatment, but in the process, the patient may no longer be the same person who began the treatment, and the patient may have become addicted to the drugs.
“In fourteen years, she had taken nineteen different medications. ‘I never had a baseline sense of myself, of who I am,’ she said. She wanted to somehow strip away the framework that had been imposed on her identity.”
Laura was influenced by a book by Robert Whitaker: Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America.
“The book prompted Laura to begin reading about the history of psychiatry. She hadn’t realized that the idea that depression was caused by a chemical imbalance was just a theory—‘at best a reductionistic oversimplification,’ as Schildkraut, the scientist at the National Institute for Mental Health, had put it…For more than fifty years, scientists have searched for the genetic or neurobiological origins of mental illness, spending billions of dollars on research, but they have not been able to locate a specific biological or genetic marker associated with any diagnosis. It is still unclear why antidepressants work. The theory of the chemical imbalance, which had become widespread by the nineties, has survived for so long perhaps because the reality—that mental illness is caused by an interplay between biological, genetic, psychological, and environmental factors—is more difficult to conceptualize, so nothing has taken its place. In 2022, Thomas Insel, who directed the National Institute for Mental Health for thirteen years, published a book lamenting that, despite great advances in neuroscience, when he left the position in 2015, he realized, ‘Nothing my colleagues and I were doing addressed the ever-increasing urgency or magnitude of the suffering millions of Americans were living through—and dying from’.”
Laura attempted to gradually eliminate the medications she was taking. Her body responded in difficult, unpleasant ways. There is much money spent on producing pills in large quantities, and producing new ones to generate additional prescriptions, but little or no effort is being made to help people shed the burden of these drugs. Laura connected with an online forum of people who were in exactly the same situation as her as she eventually managed the transition. Laura’s exit from her drug-induced state does not mean she has become “normal,” whatever that might mean. She still endures the emotional highs and lows, the anxieties and doubts that might make others seek a pill for assistance. But she endures them and has a life she found satisfying. Having spent many years in that drug-induced state has become part of the story she tells about herself, one that does not require psychotropic drugs. Interestingly, Aviv, would also be introduced to a drug that proved beneficial for her, and she would ultimately choose to continue to take the drug in spite of the lessons that might have been learned from Laura’s experience.
Aviv has written: “It is still unclear why antidepressants work.” That is not true. Pharmaceutical companies and psychiatrists have known for years that antidepressants work mostly, if not entirely, via a placebo effect. If one tells a person that she might receive a pill that will make them feel better, they will most likely feel better if they believe that they actually received the pill containing the drug. When a double-blind clinical trial is run, about the same number of people given a placebo (perhaps a sugar pill) claim to have benefited from the pill as those that have received the antidepressant. The arguments have gone on for decades as to whether or not antidepressants actually provide a benefit. This issue is discussed in Antidepressant Drugs versus Placebos. Most popular antidepressants are SSRIs (Selective Serotonin Reuptake Inhibitors) designed to increase the level of serotonin in the brain. The hypothesis that the serotonin might control depression was the basis for the chemical imbalance hypothesis. Every several years researchers look for proof that serotonin has an effect on depression. No connection has ever been found. A recent study confirming the lack of any relationship is discussed in Depressing News About Depression and Antidepressants. Many people who hear such news refuse to believe it. How could such a situation exist? People are being helped; it can’t be true. But it is. What is sad is that the strength of the placebo effect should be an incentive to devise more effective, simpler, and less dangerous treatments. Instead, there is more money to be made ignoring the issue and searching for ever more expensive drugs. And people should note that pharmaceutical companies have been fined billions of dollars for telling lies about their psychotropic drugs.
Aviv does understand how the system works. Psychotropic drugs are intended to alter symptoms, not cure an ailment. Aviv was prescribed what she referred to as an antidepressant. Her symptoms did not seem to be consistent with depression. She suffered anxiety over her performance as a writer and as an individual member of society. She was prescribed Lexapro, an SSRI antidepressant that is said to be effective also in countering anxiety. She was thrilled with the result.
“My first six months on Lexapro were probably the best half year of my life. I was what psychiatrists call a ‘good responder.’ My brain suddenly felt like a fun, fresh place to be. ‘Today: nothing I’m feeling shame for,’ I wrote in my journal. I began writing jokey emails to people for no other reason than that I was briming with warmth for them.”
Aviv became the person she wanted to be. Soon she was recommending Lexapro to friends who would then also be satisfied with the results. Eventually she began to worry about the possible consequences of long-term use and discovered that she couldn’t stop taking the drug, or at least did not want to badly enough. She had withdrawal symptoms and feared that the medication might have changed her intrinsically such that she would not get back to her original self and might end up in even worse shape without the drug. So, she has continued using it.
Aviv made an interesting observation.
“Helen and I kept discovering new Lexapro users, both colleagues and friends. We became unnerved by how many of us—mostly white women—were taking the same drug. ‘These more and more seem like Make the Ambitious Ladies More Tolerable Pills,’ Helen wrote me…I told Dr Hall that nearly all my female friends were on Lexapro and thriving, a fact that made me think we were swept up in a cultural phenomenon, rather than suffering from the same disease…”
Does our patriarchal heritage produce women who are anxious about their place in society or do psychiatrists assume women need chemical assistance in managing their ambitions. This is an issue that arises several times in Aviv’s book.
“In rejecting the authority of psychoanalysis, psychiatrists hoped to rid themselves of the sway of culture and the fundamental subjectivity it implied. But the history of biological psychiatry has been marked by biases about gender and race just as psychoanalysis had been. The benzodiazepines, a class of tranquilizer celebrated as a replacement for psychoanalysis, was marketed in the seventies especially to women, to give them personalities congenial to husbands. In ads called ’35 and single’ in the Archives of General Psychiatry in 1970, the pharmaceutical company Roche encouraged doctors to give Valium to the kind of highly strung patient who ‘realizes she is in a losing pattern—and that she may never marry.’ Between 1969 and 1982, Valium was the most widely prescribed medication in America, and roughly three-quarters of its users were women. In an editorial in the French journal L’Encéphale, two psychiatrists from the largest psychiatric hospital in Paris warned, ‘Benzodiazepines have lost their status as medications…and become simple domestic helpers’.”
“Serotonin reuptake inhibitors, or SSRIs—most prominently Prozac and Zoloft—were created in the eighties, filling a gap in the market opened by concerns that benzodiazepines were addictive. They were soon prescribed for not just depression but the anxieties that benzodiazepines had previously addressed. Now more than one in five white women in America take antidepressants. Peter Kramer, the author of Listening to Prozac, told me that the SSRIs were ‘eerily consonant with what the culture required of women: less fragility, more juggling outside of the home.’ An early advertisement for Zoloft showed a white woman in a pantsuit, holding the hands of her two children, and the phrase ‘Power that speaks softly.’ An ad for Prozac, which ran for two and a half years, showed another white woman, her wedding ring visible, and the slogan ‘For both restful nights and productive days’.”
“While black women tend to be undermedicated for depression, white women, especially ambitious ones, are often overmedicated, in order to ‘have it all’: a family and a thriving career. And yet, a common side effect of the drugs is loss of sexuality, an experience perhaps more compatible with contemporary gender roles than we would like to imagine.”
Is it that our patriarchal traditions are more easily preserved in a society where female sexual drive is inhibited a bit? Do men feel more comfortable in such a situation?
“Allen Frances, an emeritus professor of psychiatry at Duke who chaired the task force for the fourth edition of the DSM, in 1994, told me, ‘It was very apparent early on that the SSRIs have a fairly dramatic impact on sexual interest and performance. It has always puzzled me that this was not more of a disqualifying aspect of their wide popularity’.”
“Audrey Bahrick, a psychologist at the University of Iowa Counseling service who has published papers on the way that SSRIs affect sexuality, says she sees thousands of college students each year, many of whom have been taking SSRIs since adolescence. She told me, ‘I seem to have the expectation that young people would be quite distressed about the sexual side effects, but my observation clinically is that these young people don’t yet know what sexuality really means or why it is such a driving force. They start to look a little behind their peers with regard to having crushes or being sexually motivated’.”
The stories we tell ourselves….. and the stories psychiatrists
tell us…..
