Chapter One
THE DESCENT INTO HELL
“The journey to higher awareness is not a direct flight. Challenges, struggles and tests confront the traveler along the way. Eventually, no matter who you are or how far you have come along the path, you must experience your ‘dark night of the soul.’ ”
–Douglas Bloch, Words That Heal
The notebook by the side of my bed was finally being put to use. Given to me by a friend so that I could record my dreams, the lined yellow paper had remained untouched for months, as my sleeping medication made dream recollection all but impossible.
“Oh, well,” I mused. “It won't matter much after today.”
I looked out the window. It was another of those oppressive Oregon winter skies that moves in like an unwanted house guest at the beginning of November and doesn't depart until the first of July. The black clouds overhead mirrored those inside my head. I was suffering from a mental disorder known as clinical depression.
Slowly, I reached for the pen and began to write.
November 12, 1996
To my friends and family,
I know that this is wrong, but I can no longer endure the pain of living with this mental illness. Further hospitalizations will not help, as my condition is too deep-seated and advanced to uproot. On some deeper level, I know that my work on the planet is finished, and that it is time to move on.
Douglas
I reached over for the bottle of pills that I had secretly saved for this occasion, slowly twisted off the cap and imagined the sweet slumber that awaited me. My reverie was interrupted by a loud knock at the door.
“Who can that be?” I wondered. “Can't a man commit suicide in peace?”
I turned over in bed and spied my friend Stuart entering the living room.
“Just thought I'd check in and see if you made it off to day treatment,” he said cheerfully as he made his way to the bedroom.
I quickly hid the pills, wondering if I should tell Stuart about my note. Meanwhile, I could feel the stirrings of another anxiety attack. It began with the involuntary twitching of my legs, then violent shaking, until my whole body went into convulsions. Not able to contain the huge amount of energy that was surging through me, I jumped out of bed and began to pace. Back and forth, back and forth I stumbled across the living room, hitting myself in the head and screaming, “Electric shock for Douglas Bloch. Electric shock for Douglas Bloch.”
I had not always been so disturbed. Just ten weeks earlier, on September 4, 1996, I had taken a new Prozac-related medication in the hopes of alleviating a two-year, chronic, low-grade depression which was brought on by a painful divorce and a bad case of writer's block. Instead of mellowing me out, however, the drug produced an adverse reaction—a state of intense agitation that catapulted me into the psychiatric ward of a local hospital.
Although it took only 24 hours for the adverse drug reaction to totally disable me, the roots of my depression extended far into the past. Although I have never formally investigated my genealogy, I know that the illness has run rampant in my family for at least three generations. Five of my family members have suffered from chronic depression; one developed an eating disorder and another a gambling addiction. One uncle died of starvation in the midst of a depressive episode. My mother suffered two major depressive episodes in a three-year period before she was saved at the eleventh hour by electroconvulsive therapy (ECT). I strongly suspect that both of my grandmothers lived with untreated depression all of their lives.1
Although one may be genetically and temperamentally predisposed to depression, it normally takes a stressor (personal loss, illness, financial setback, etc.) to activate the illness. A person with a low susceptibility to depression can endure a fair amount of mental or emotional stress and not become ill. A person with a high degree of vulnerability, however, has only a thin cushion of protection. The slightest insult to the system can initiate a depressive episode.
For me, this insult took place in the spring of 1996 when my wife and I divorced and I found myself too depressed to write. My mental decline was further exacerbated by recurrent bouts of cellulitis—a strep infection of the soft tissue in my lower right leg—for which I was hospitalized and given massive doses of antibiotics. (Streptococcal bacteria have since been linked to anxiety attacks and obsessive-compulsive disorders.) Shortly afterwards, I developed chronic insomnia, a malady that had preceded my previous depressive episodes.
By summer's end, I was, in the words of a friend, “barely limping along.” Although previous trials of antidepressants had been unsuccessful, on the advice of a psychiatrist, I decided to try a new Prozac-related medication which had recently been approved by the FDA. Instead of calming me down, however, the drug catapulted me into an “agitated depression”—a state of acute anxiety alternating with dark moods of hopelessness and despair.
It soon became clear that taking this antidepressant had created a permanent shift in my body/mind. Before ingesting the drug, I felt crummy, but not crazy; emotionally down, but still able to function. My suffering was intense—but not enough to disable me, not enough to make me suicidal. Now, I had entered a whole new realm of torment. The drug's assault on my brain caused something inside me to snap, sending me into an emotional freefall and creating a life-threatening biochemical disorder. The closest analogy I can use to describe my state is that I was on a bad LSD trip—except that I didn't “come down” after the customary eight hours. In fact, the nightmare was just beginning.
Diagnostic Criteria for a Major Depressive Episode
A depressive illness is a “whole body” illness, involving one's body, mood, thoughts and behavior. It affects the way you eat and sleep, the way you feel about yourself and think about things. It is not a passing blue mood or a sign of personal weakness.
Depressive illnesses come in different forms, the most serious of which is major depression. The following criteria for major depression are taken from the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). If you or someone you know fits these criteria, seek professional help.
A. Five or more of these symptoms should be present during the same two-week period and represent a change from previous functioning.
1. Depressed mood most of the day
2. Markedly diminished interest in pleasure
3. Significant change in appetite, leading to weight loss or weight gain
4. Insomnia or hypersomnia (too much sleep) nearly every day
5. Psychomotor agitation or retardation nearly every day
6. Fatigue or loss of energy nearly every day
7. Feelings of worthlessness or excessive or inappropriate guilt
8. Diminished ability to think or concentrate, or indecisiveness
9. Recurrent thoughts of death, recurrent suicidal thoughts without a specific plan, suicide attempts, or specific plans for committing suicide
B. In addition, these symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning.
There were two things about my predicament that made it different from anything I had ever experienced—the sheer intensity of the pain and its seeming nonstop assault on my nervous system. During my hospitalization, I discovered that my official diagnosis was “major depression” combined with a “generalized anxiety disorder.” Here is what I learned when I asked my doctor about these terms.
Major Depression
“If there is hell on earth, it is to be found in the heart of a melancholy man.”
Before I describe my own experience of major depression (also known as clinical depression), I would like to delineate the difference between the medical term “clinical depression” and the word “depression” as it is used by most people. Folks say they are depressed when they experience some disappointment or personal setback—e.g., the stock market drops, they fail to get a raise, or there's trouble at home with the kids. While I would never want to minimize anyone's pain, clinical depression takes this kind of suffering to a whole new level, making these hurts look like a mild sunburn.
Major depression can be distinguished from “the blues” of everyday life in that a depressive illness is a “whole body” disorder, involving one's physiology, biochemistry, mood, thoughts, and behavior. It affects the way you eat and sleep, the way you think and feel about yourself, others and the world. Clinical depression is not a passing blue mood or a sign of personal weakness. Subtle changes inside the brain's chemistry create a terrible malaise in the body-mind-spirit that can affect every dimension of one's being.
Gustave Dore's illustration of purgatory in Dante's Divine Comedy
On page 6, I have listed the official symptoms of major depression, taken from the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), the official diagnostic resource of the mental health profession. Describing how depression actually feels, however—especially to someone who has never “been there”—is not so straightforward. If I told you that I had been held hostage, put in solitary confinement and beaten, you might receive a graphic image of my suffering. But how does one describe a “black hole of the soul” where the tormentors are invisible?
I remember a diagram from my high school biology class depicting what happens when you put your hand on a hot stove. The nerve receptors in the skin send a message up the arm and spinal column to the brain, which interprets the situation as “Ouch, that's hot!” The brain then sends a message back down the spine telling the hand to remove itself from the burner. All of this takes place in a fraction of a second.
The pain of depression is not so easy to track. It cannot be described as stabbing, shooting or burning; neither can its sensations be localized to any one part of the body. It is an all-encompassing malignancy—a crucifying pain that slowly permeates every fiber of one's being. Being consumed by depression is not like being gored by a bull; it is more akin to being stung to death by an army of swarming wasps.
When one is clinically depressed, the capacity for (and the memory of) pleasure vanishes. The best that one can hope for is a kind of “negative happiness” that results from the temporary absence of distress. Life fluctuates between the horrible and the miserable. A sense of humor, that wonderful analgesic that existed even among some concentration camp prisoners, is completely absent. (Many friends marked the beginning of my depression as when I lost the ability to laugh.)
Even though depression is called a mood disorder, mood is only one of the many bodily functions that are disrupted by a disorganized, misfiring brain. Eating and sleeping are disrupted (along with one's sex drive), and energy levels dwindle so low that even the simplest task can seem impossible.2
For me, this lethargy manifested as a heaviness in my body, as if I were trying to walk through a vat of molasses. In other instances, I experienced a massive, suffocating pressure in my chest, like being pinned to the ground by a 350-pound wrestler. During such times, I was so exhausted that I would crawl into a fetal position and lie there for hours. “A slug,” I thought to myself, “has more energy than I do.”
“If you want to get an idea of what depression feels like,” says UCLA neuropsychiatrist Peter Whybrow, “combine the anguish of profound grief with bodily sensations of severe jet lag.” That's how it felt to me—like breaking up with my first true love and then being run over by a truck.
William Styron, whose memoir Darkness Visible chronicles his descent into a major depressive episode, describes the agony of depression this way:
It is not an immediately identifiable pain, like that of a broken limb. It may be more accurate to say that despair, owing to some evil trick played on 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 stirs this cauldron, because there is no escape from this smothering confinement, it is entirely natural that the victim begins to ceaselessly think of oblivion.
“Melancholy,” by Edvard Munch
Time on the Cross
“I am now the most miserable man living. If what I feel were equally distributed to the whole human family, there would not be one cheerful face on earth.”
The pain of depression is not only agonizing; it is chronic, persistent and seemingly unremitting—like having an “emotional toothache.” Although psychological factors may trigger a major depressive episode, at some point the disorder manifests as a biological illness. Hence, I could not “will” or affirm myself out of my malaise. Positive thinking was useless. Nor could I apply any metaphysical, psychological or self-help techniques to stop the pain. There was no inner child to nurture or heal. I was ill at the biochemical core.
In the past, if I were in a funk, the simplest way to improve my condition would be to enjoy the beauty of nature. Thus, I was taken aback when on a beautiful summer's day, I hiked in a pristine old- growth forest, and my mind, in its continued downward spiral, persisted in contemplating suicide. Though the environment was heavenly, it could not assuage my inner suffering. The pain was just too intense, as if some invisible phantom were clanging a pair of cymbals inside my brain. I now understood the meaning of “endogenous” depression (i.e., a depression that arises from within). I was at the mercy of a deranged biochemistry that I could neither understand nor control.
When asked by Art Buchwald whether his depression was improved by being in the country, William Styron replied:
It's all the same. You're carrying the thing around with you. It's like a crucifixion. It doesn't matter where you are; nothing in the outer world can alter it. You could be in the sublimest place you could possibly imagine. For example, [Mike] Wallace went down to St. Martin which is a wonderfully attractive place. But he had his darkest moments there.
As Styron knew only too well, there is little respite from the hell of a major depression. You cannot curl up in bed with a few good videos, drink chicken soup and expect to feel better in seven to ten days. Unlike most physical ailments, depression does not improve with rest. Being alone in bed actually makes matters worse, as the mind turns further inward and tortures itself with imaginary demons.
I felt as if some sadist were twisting my arm behind my back and would not relent even after I yelled “Uncle!” With each unfolding day, the pain seemed to increase. I complained to my friends, “This is the worst I've ever felt!”
“But that's what you say every day,” they countered.
It didn't matter. There was something freshly horrible about the pain, as if I were being kicked in the stomach once every minute.
I felt as if someone had created a cruel parody of Psalm 139 in which David says to God, “Where can I go from your spirit? Or where can I flee from your presence? If I ascend into heaven you are there…If I take the wings of the morning and dwell in the uttermost parts of the sea, even there your hand shall lead me and your right hand shall hold me…” except that in depression it is not God, but the Devil who follows you everywhere. And there is no escape.3
Generalized Anxiety Disorder
“There may be no rest for the wicked, but compared to the rest that anxious people get, the wicked undoubtedly have a pastoral life.”
“If you're facing terror every day, it's gonna bring Hannibal to his knees.”
Although no one knows exactly why, a great number of depressions are also accompanied by anxiety. In one study, 85 percent of those with major depression were also diagnosed with generalized anxiety disorder (see symptoms listed on facing page) while 35 percent had symptoms of a panic disorder. Because they so often go hand in hand, anxiety and depression are considered the fraternal twins of mood disorders.
Believed to be caused in part by a malfunction of brain chemistry, generalized anxiety is not the normal apprehension that one feels before taking a test or awaiting the outcome of a biopsy. A person with an anxiety disorder suffers from what President Franklin Roosevelt called “fear itself.” For a reason that is only partially known, the brain's fight-or-flight mechanism becomes activated, even when no real threat exists. Being chronically anxious is like being stalked by an imaginary tiger. The feeling of being in danger never goes away.
Diagnostic Criteria for Generalized Anxiety Disorder
How do you know if you are suffering from clinical anxiety? The following criteria are taken from the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). If you, or someone you know is experiencing these symptoms seek professional assistance.
A. Excessive anxiety and worry occurring more days than not for at least six months.
B. Difficulty in controlling the worry and anxiety.
C. The anxiety and worry are associated with three (or more) of the following six symptoms:
1. Restlessness or feeling keyed up or on edge
2. Being easily fatigued
3. Difficulty concentrating or mind going blank
4. Irritability
5. Muscle tension
6. Sleep disturbances (difficulty falling or staying asleep, or restless, unsatisfying sleep)
D. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning.
E. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug abuse or a medication) or a general medical condition (e.g., hyperthyroidism).
Even more than the depression, it was my anxiety and agitation that became the defining symptoms of my illness. Like epileptic seizures, a series of frenzied anxiety attacks would descend upon me without warning. My body was possessed by a chaotic, demonic force which led to my shaking, pacing and violently hitting myself across the chest or in the head. This self-flagellation seemed to provide a physical outlet for my invisible torment, as if I were letting steam out of a pressure cooker.
The force of my symptoms was so great that I considered the possibility that I might be possessed by some malevolent demon. I remembered the film “The Exorcist” and set up an appointment with a priest who specialized in satanic possession. After taking a thorough case history and questioning me about my religious beliefs, the priest concluded that I was not possessed by the Devil.
“It certainly feels that way,” I replied.
I then consulted a psychiatrist who told me that my symptoms were not those of a panic disorder. I did not experience palpitations, pounding heart, sweating, trembling, shortness of breath, chest pain, fear of dying, etc. The word “agitation” was the closest I could come to describing the feeling of wanting to jump out of my skin. Hence my disorder was eventually diagnosed as “agitated depression.”
Agitated depression is not a good diagnosis to have. Clinicians have observed that when anxiety occurs “comorbidly” with depression, the symptoms of both the depression and anxiety are more severe compared to when those disorders occur independently. Moreover, the symptoms of the depression take longer to resolve, making the illness more chronic and more resistant to treatment. Finally, depression exacerbated by anxiety has a much higher suicide rate than depression alone. (In one study, 92 percent of depressed patients who had attempted suicide were also plagued by severe anxiety.4) Like alcohol and barbiturates, depression and anxiety are a deadly combination when taken together.
More than any other image, Edvard Munch's “The Scream” depicts the out-of-control anxiety that was threatening to destroy me.
In addition to physical agitation, my anxiety was accompanied by obsessively rhyming voices. In my book Words That Heal, I suggested that people rhyme their affirmations because “words that rhyme make a more powerful impression on the subconscious than blank verse.” Now, my own subconscious had decided, in a malicious way, to take my advice to heart. Rhymes such as “electric shock for Douglas Bloch,” “the River Styx in ’96,” and “suicidal ideation is a hit across the nation” flooded my mind.5 When my anxiety became extreme, I shouted these rhymes out loud, further upsetting myself and those around me. Although I did not actually hear these verses—they were more like obsessive thoughts—their presence led my doctors to give me a final diagnosis of agitated depression with psychotic features.
Because my anxiety emerged from a disordered brain it, like the depression, was outside my conscious control. Yet virtually everyone—my friends, family, men's group members, and even health professionals—interpreted the anxiety as some sort of “acting out” that I could modify at will; they did not understand that I was sick. Some people even became angry and abusive in response to my distress. The most dramatic illustration of this occurred on the night of my first hospitalization.
The day had begun with a major anxiety attack, an aftershock from the overly anxious reaction to an antidepressant I had taken two days earlier. At my request, my ex-wife Joan telephoned the on-call psychiatrist who advised that I hospitalize myself, given the extremity of my symptoms. It took most of the day for my managed care insurance to pre-certify my admission, so that by the time we left for the hospital it was already late in the evening.
As Joan and I made our way out the Sunset Highway, my terror escalated as I recalled the trauma of my previous psychiatric hospitalizations. Five blocks from the unit, realizing that history was about to repeat itself, I attempted to jump out of the car and was prevented only by the automatic door locks which Joan activated from the driver's side.
We arrived on the psychiatric ward at midnight, and after being searched and having my belongings confiscated, I was led to a stark, barren room with a hospital cot and a glaring overhead light.
“What did you expect?” the night nurse commented, when she saw the distress on my face.
From her tone of voice, I could sense that order, not compassion, was this woman's priority. She spoke in carefully measured phrases, as if competing with a metronome to see who could keep the most exact beat.
“Isn't there a reading lamp here?” I asked timidly. “It helps me to relax if I can curl up in bed with a book.”
“Lamps are not allowed in the rooms,” she replied. “We can't risk having our patients strangle themselves with the cord.”
Pondering that morbid remark, I asked the nurse for a tranquilizer to help me get to sleep.
“You don't need medication,” she replied in a clinical voice. “Take some deep breaths and try to control yourself.”
“I'd like to, but I can't,” I responded. That is why I was admitted to the hospital—because I'm out of control. Please call the psychiatrist and ask him to order me a sleeping pill.”
Big Nurse was unmoved. My anxiety escalated and I began to pace the floor. “Whack! Whack!” I hit myself in the head, then across the chest.
“If you can't restrain yourself,” she warned in a high-pitched voice, “I'm going to call security and tell them to strap you down.”
Upon hearing these words my mind raced forward to a scene of being forcibly put in a straightjacket. I felt myself suffocating, and was filled with terror. My worst fear was about to come true—I was going to die in a mental hospital. I spotted a bottle of tranquilizers that was sitting unattended at the nurse's station and moved toward it. “I'd rather get it over with now than die of fright,” I decided.
Fortunately, Joan was still on the unit. Sensing my distress, she grabbed me by the arm and escorted me for a long walk around the ward. When we returned, the on-call psychiatrist had ordered a 50-milligram tablet of Mellaril (an antipsychotic tranquilizer in the same family as Thorazine). With a prayer of thanksgiving, I gulped down the medicine.
Even with the Mellaril, I still felt a bit agitated, and so I asked Joan to rock me to sleep. When the nurse made her rounds a few hours later, she spotted Joan and became livid. “What are you doing here?” she howled. “I thought I told you to leave!” At that moment, I realized that the notorious Nurse Ratched (from the book and movie One Flew Over the Cuckoo's Nest) was not just a fictional character.
This illustration depicts two types of restraints commonly used in 19th-century hospitals. Modern day methods are more humane and are used only when a person is a danger to himself or others.
Unfortunately, this experience was repeated two months later in a different hospital. My anxiety in the new environment was exacerbated by the fact that I was residing in a locked unit. The only outdoor space available for exercise was a small courtyard surrounded by barbed wire. Here, restless patients took their smoke breaks. The air was so full of secondhand smoke, that I could hardly breathe, let alone jog or run in place. My exercise options all but eliminated, I paced back and forth in the halls for hours at a time.
One day, upon witnessing my agitation, a mental health therapist took me aside.
“Why don't you practice the cognitive therapy techniques you learned in your behavior modification group?” he asked.
“I think a Klonopin would be more effective.” (Klonopin is an anti-seizure medication which is also used to treat anxiety.)
“You can control your thoughts and your behaviors without medication,” he insisted.
“Don't you understand?” I replied emphatically. “I AM NOT IN CONTROL OF MY NERVOUS SYSTEM. I AM NOT IN CONTROL OF MY NERVOUS SYSTEM.”
Instead of a straightjacket, the nurses and therapist decided to put me in the “quiet room”—a euphemism for a padded cell with no windows. “Just what a claustrophobic needs to calm his anxiety,” I mused.
Such lack of compassion on the part of trained professionals shows their ignorance of a basic medical fact—that in extreme cases of anxiety, the agitation chemically interferes with the brain's ability to hold positive thoughts over a sustained period.
It was not until six months later that the legitimacy of my symptoms was validated by a savvy nurse-practitioner who taught stress-reduction to patients with chronic pain. “When your brain gets wacked out to this extreme,” Teresa advised, “you literally need to burn off those agitating chemicals; I recommend intense exercise.” Following her counsel, whenever my anxiety began to escalate, I ran down to my neighborhood pool and swam a mile or more until I dropped. (I called this ritual “swimming for my life.”)
Meanwhile, I was living in the inferno, a concentration camp of the mind. I felt as if my brain were being batted back and forth by two drunken Ping-Pong players—one named anxiety and the other called depression. I had never believed that hell was a place you went to after death, but rather a state of consciousness that one could experience here on earth. Now I had the living proof. About four months after my first hospitalization, my psychiatrist asked, “Douglas, are you afraid that if these symptoms persist, you will become chronically mentally ill?”
“What do you mean?” I replied incredulously. “I already am chronically mentally ill.”
1 The tendency of depression to run in families is probably a combination of both genetic predisposition and family culture. Through observing and imprinting on family dynamics, children learn ways of coping that support or impede mental health. (An example of the latter is the well-documented phenomenon of “learned helplessness.”)
2 In the words of one depressive, “Pouring milk over my cereal feels like climbing Mt. Everest.”
3 Not all depressions are this severe. People can be mildly to moderately depressed or suffer from low-grade, chronic depression known as “dysthymia.” To learn more about the many other types of depression, refer to Appendix A.
4 Clinical Psychiatry News 27(6):25, 1999.
5 The rhyme “electric shock for Douglas Bloch” was an allusion to ECT, electroconvulsive therapy.