The Noonday Demon (77 page)

Some people have more highly activated left prefrontal cortexes and some people have more highly activated right prefrontal cortexes. (This has nothing to do with the question of hemispheric dominance that determines whether you are right-handed or left-handed, which occurs in other areas of the brain.) The majority of people have higher left-side activation. People with higher right-side activation tend to experience more negative emotion than people with higher left-side activation. Right-side activation also predicts how easily someone’s immune system will become depressed. The right-brain activation is also correlated with high baseline levels of cortisol, the stress hormone. Though the settled patterns of activation do not stabilize until adulthood, babies with greater right-side activation will become frantic when their mothers leave a room; babies with strong left-side activation will be more likely to explore the room without apparent distress. In babies, however, the balance is subject to change. “The likelihood,” Davidson says, “is that there’s more plasticity in the system in the early years of life, more opportunity for the environment to sculpt this circuitry.”

There are enormously interesting ideas to be adduced from putting together this thinking with some of Crow’s ideas about language. “One of the first things that you see when toddlers begin giving out single-word utterances is that they point,” Davidson says. “The utterance is a label for an object. And they point almost invariably, at first, with the right hand. The toddler is having a positive experience and is clearly interested in the object and is moving toward it. The initial use of language is very pleasurable to most toddlers. My intuition, which has not been studied in any systematic way, is that the left-hemisphere lateralization
for language may actually be a byproduct of the left-hemisphere lateralization for positive emotion.”

This intuition is, it would seem, the basis for a neuroanatomy of catharsis. Speech is positive; it remains positive. Speech is one of life’s greatest pleasures, and the will to communicate is enormously powerful in all of us (including those who cannot produce coherent vocal sound and therefore use sign language, gesture, or writing to express themselves). People who are depressed lose interest in talking; people who are manic talk incessantly. Across broad cultural divides, the most consistent mood-enhancer is speech. Dwelling on negative events can be painful, but talking about current pain helps to alleviate it. When I am asked, as I am constantly, about how best to treat depression, I tell people to talk about it—not to work themselves up into hysteria about it, but simply to keep articulating their feelings. Talk about it with family if they’ll listen. Talk about it with friends. Talk about it with a therapist. It may well be that Davidson and Crow are onto the mechanisms through which talk helps: it may well be that certain kinds of talking activate the same areas of the left brain whose underperformance is implicated in mental illness. The idea of articulation as release is absolutely fundamental to our society. Hamlet weeps that he “must, like a whore, unpack my heart with words”—and yet what we have evolved, along with our capacity for mental illness, is that capacity to unpack our hearts (or, as the case may be, our left prefrontal cortexes) with words.

Though effective treatments exist even for diseases we do not begin to understand, knowing how the components of a disease are related helps us to discern its immediate precipitants and address them. It helps us to understand a constellation of symptoms and to see in what ways one system may influence another. Most of the systems of explanation for illness—the biochemical, the psychoanalytic, the behavioral, and the sociocultural—are fragmentary and leave many things unexplained, and they suggest that even the combinatory approaches now in vogue are highly irregular and unsystematic. Why do particular feelings and particular actions correlate in illness but not in health? “Psychiatry’s most pressing need,” McGuire and Troisi write, “is to embrace evolutionary theory and to begin the process of identifying its most important data and of testing novel explanations of disorders. Attempts to explain behavior, normal or otherwise, without having an in-depth understanding of the species one is studying invite misinterpretation.”

I am not persuaded that knowing the evolution of depression will be particularly useful in treating it. It is critical, however, to making decisions about treating it. We know that tonsils have a limited use; we understand what they are doing in the body; we know that fighting infection in tonsils is more trouble than removing them and that removing them does little harm to the body. We know that the appendix can be removed rather than healed. On the other hand, we know that an infection of the liver needs to be treated because if you remove someone’s liver, that person will die. We know that it’s necessary to snip off skin cancers but that pimples do not cause systemic inflammation. We understand the mechanisms of these different areas of the physical self, and by and large we know what kind and degree of intervention is appropriate in the event of dysfunction.

It is eminently clear that there is no consensus on when to treat depression. Should depression be removed like a tonsil, treated like liver disease, or ignored like a pimple? Does it matter whether the depression is mild or severe? To answer these questions correctly, we need to know why the depression is there at all. If depression served a useful function for hunter-gatherers but is irrelevant to modern life, then it should probably be removed. If depression is a misfunction of the brain that involves circuitry we need for other crucial brain functions, then it should be treated. If some milder depression is a self-regulating mechanism, then it should be ignored. Evolution may offer something of a unified field theory, revealing structural relationships among the other schools of thought that are used in studying depression; that will allow us to make decisions about whether, when, and how to treat the complaint.

A
ngel Starkey has had a rough time of it. The youngest of seven children, she comes from a family in which she was seldom touched or hugged; she went on to be sexually abused by the janitor in her school; she was raped when she was thirteen. “I’ve been depressed since I was like three years old,” she says. As a child, she used to lock herself in the closet under the stairs and draw tombstones on the wall. Her father died of pancreatic cancer when she was seven. At thirty-eight, “I can still hear him screaming sometimes. Like I’m laying in my bed or just sitting in my room and I hear it again and it scares the shit out of me.” Her closest friend when she was little was a neighbor who hanged herself, it was subsequently revealed, while Angel was knocking on the front door. Angel has been hospitalized more or less full-time since she finished high school seventeen years ago, with brief moves out into supervised community housing. She has a schizo-affective disorder, which means that in addition to profound depression, she has hallucinations and hears voices instructing her to destroy herself. Panic blocks her from ordinary interactions in the world. No one can even remember how many times she has attempted suicide—but since she has been in an institution for most of her adult life, she has been saved over and over again, even when she has thrown herself in front of a car. Her arms are knotty with scars from the countless slicings; a doctor told her recently that she was out of pliable flesh, and that if she kept cutting herself, there would be no way to close the wounds. On her stomach, her skin is patchworked together because she has set herself on fire so many times. She has tried to strangle herself (with plastic bags, with a shoelace, with a blood-pressure cuff)—until “my head turned purple”—and she has the marks on her neck to prove it. Her eyelids are puckered where she has held lit cigarettes to them. Her hair is thin because she pulls it out, and her teeth have partly rotted as a side effect of her medications—
chronic dry mouth can lead to gingivitis. At the moment, her prescribed medications are Clozaril, 100 mg, five a day; Clozaril, 25 mg, five a day; Prilosec, 20 mg, one a day; Seroquel, 200 mg, two a day; Ditropan, 5mg, four a day; Lescol, 20 mg, one a day; BuSpar, 10 mg, six a day; Prozac, 20 mg, four a day; Neurontin, 300 mg, three per day; Topamax, 25 mg, one per day; and Cogentin, 2 mg, two per day.

I first met Angel at Norristown Hospital, the state facility I visited in Pennsylvania. She was a patient there. I was taken aback by the scarring, by the bloating her drugs caused, by the simple physical fact of her. But in a place where many eyes were as shallow as glass, she seemed to engage more. “She’s very needy,” one of her nurses told me, “but she’s also very sweet-natured. Angel is special.” Doubtless all people are special, but Angel has a moving quality of hopefulness that is extraordinary in someone with her biography. Underneath her suffering and its consequences is a warm, imaginative, and generous person, sufficiently appealing so that you are in the end distracted from the brutalized surface. Angel’s personality is obscured but not destroyed by her illness.

I was to become intimate with Angel and her patterns of self-mutilation. Her favorite implement for slicing herself is the top of a can. She once shredded her arms so badly that she required four hundred stitches. “Cutting myself is the only thing that gives me any pleasure,” she told me. When cans are not available, she has managed to uncurl the bottom of a toothpaste tube and use that to slice away ribbons of her flesh. She has done this even while she was going through a debridement—the surgical removal of devitalized tissue—for self-inflicted burns. In the small world of Norristown State Mental Hospital, “I’ve been going in and out of building fifty, the emergency center,” she told me. “I have to go in there if I cut myself. It used to be building sixteen, but now it’s building fifty. I’m living in building one, regular residential. For a break, I go to the karaoke nights in building thirty-three sometimes. I had to come into the hospital this time because I was getting these physical panic attacks constantly. And my mind wasn’t working good, you know? It was like I kept skipping; it scared me. And I had to keep running to the bathroom—it’s really weird the way my whole body reacts to just a little bit of anxiety! We went to the mall yesterday, and it was so scary. Even little stores. I had to take a bunch of Ativan and even that didn’t do it. I’m so paranoid about losing it. Yesterday I went in and out of the stores real fast and went to the bathroom about ten times. I couldn’t swallow. When I was leaving here to go there, I was afraid to go; but when it was time to come back, I was afraid to come back to the hospital.”

Physical pain has always been indispensable to her. “I tell them not to stitch me up and make it so easy,” she said. “Make it worse. It makes me
feel better when it’s hard. If I’m going to feel pain, I’d rather have physical pain than emotional pain. It’s a purging thing for me when I get so worn-out I can’t breathe. Stapling is nicer than stitches because it hurts more, but it doesn’t hurt long enough. When I cut myself, I want to die—who’s going to take care of me when I’m all ripped to pieces and burnt up and everything? See, I’m not a good person.” Angel was on one-to-one supervision—no privacy even to use the bathroom—for three years in a particularly acute period. She has had times when she had to be tied to a bed. She has been held on locked wards, and she has spent her share of time in a body net—a big piece of webbing that swaddles a violent patient into total immobility. She describes that experience as unutterably terrifying. She has learned all about the medications she takes. She is an informed patient. “One more thought about Clozaril,” she said, “and I’m going to start throwing them up, you know?” She has also had extensive ECT.

During a recent stay at Norristown, Angel told me she called her mother every day and went home to stay with her a couple of weekends every month. “I love my mother more than anything in the world. Much more than I love myself, you know. It’s hard for her. Sometimes I think, she’s got seven children, maybe she could do with six. It’s not like I’d be leaving her by herself. I’ve tortured her long enough. She doesn’t need me screwing up. I hurt her with the weight, the weight, and the embarrassment. My depression, her depression, my sisters’ depression, my brothers’, you know? It’s never going to end, I don’t think, until we all die. I just wish I could get a job and give her money. They say I worry about my mom too much, but you know, she’s seventy-three years old. I go there and I clean stuff. I go home in a frenzy and clean. I’m cleaning and cleaning and cleaning and freaking out. I get fanatic about it. I like to wash things. And my mom does appreciate that.”

The first time we met, Angel was clearly tense, and the memory problems that are endemic for her as a consequence of long-term ECT (she has had thirty rounds of treatment) and high dosages of medications were particularly disabling. She would forget herself halfway through a sentence. She talked about the little comforts of her small world. “I don’t understand why people are so nice to me,” she said. “I used to hate myself so bad. I hated everything I did. God must think something of me, because, I mean, I’ve gotten hit by two cars, and I’ve cut myself until I’d emptied out all my blood, and I’m still alive. I’m ugly. I’m very heavy. I can’t—my mind’s too messed up to even think sometimes. The hospital, that’s my life, you know? The symptoms, they’re not going to just end. The depression and the feelings of loneliness.”

Acutely aware of the difficulties in our communication, she sent me, a few weeks later, a letter “to be clear.” In it she wrote, “I’ve done so
many things to kill and hurt myself. Everything is getting very tiring. I don’t think I have a brain left. Sometimes if I start to cry, I’m afraid that I will never stop. I have lost and lost endlessly. There are so many people that I would love to help, even if it’s just a hug. Just that in itself makes me happy. Sometimes I write poetry. It tells me and others how sick I have been. But it shows there is Hope. love, Angel”