Searching for a Language for Depression

The Vocabulary of Diagnosis Isn't Telling Our Stories

Joshua Wolf Shenk

When I was a small child, about eight I think, I ripped apart my bedroom in a frenzy. I threw the pencil sharpener off my desk. I pulled the sheets and blankets off my bed and turned over the mattress. I pulled clothes out of their drawers, drawers out of the bureau. Eventually the bureau itself toppled. A few moments later, my mom stood in my doorway and said, with aplomb, "Looks like a tornado has been through here."

Five years later, I stood on the lawn of my father's house, just home from summer camp. My oldest brother drove up the dead-end street in his gray Fiat, and turned left into the short driveway. I ran over to see him. I recall, as I ran, feeling a false expansiveness. I wore a too-wide smile, like a clown scripted for a pratfall. As I began toward the car, my brother leaned over and rolled up the window on the Fiat's passenger side. Then he backed down the driveway and drove away.

When I was seventeen, I carried these and other fragments up the stairs of an old Victorian home in Cincinnati. As I sat in the waiting room of a psychiatry practice, I knew I was lonely, unhappy, even desperate. I did not know I was depressed. But that was the word that waited for me, a diagnosis that physicians since Hippocrates have been trying to elucidate and one that I would inherit.

The Hippocratic writers believed that gloom, abnegation, and misanthropy could be traced to excesses of black bile. Unlike the other three bodily humors (blood, phlegm, and yellow bile), black bile was never actually observed. Today, we know no such substance ever existed. Still, the Greek words—for black (melan) and bile (khole)—dominated the language of inner states for more than two millennia.

In 1905, the influential American psychiatrist Adolf Meyer proposed that "melancholy" and "melancholia" be retired from the clinical vocabulary. He believed that the terms were used too broadly. They described "many dissimilar conditions" and also "implied a knowledge of something that we did not possess"—that is, the causal role of black bile. Meyer preferred the word depression. Other physicians followed him, as did medical texts and the lay culture.

I'd like to suggest another possibility: That what we call "depression," like the mythical black bile, is a chimera. That it is cobbled together of so many different parts, causes, experiences, and affects as to render the word ineffectual and perhaps even noxious to a full, true narrative.

What transpired over the century can be counted among the great tragicomedies in the history of language: Somehow, we have come to believe that "depression" is the art, is the phantasm of special effects, is the evocative detail or phrase or story rather than a mere placeholder. The DSM-IV lists only a few qualifiers for "major depressive disorder." Psychiatrists and medical texts treat depression as a discrete entity, and assume it adheres to a particular course and treatment. Ads for drugs, herbal remedies, and nutritional supplements refer to depression as though it is a foreign invader, unrelated to the authentic self.

In lay culture, meanwhile, the word is often used with no context at all. A New York Times report on the rising suicide rate in Japan notes that the cause might be "depression," but does not offer even a single phrase to elaborate. In conversation, otherwise imaginative, articulate speakers toss around the words "depressive" and "depressed" as if they capture a person's essence. In his story "The Depressed Person," David Foster Wallace gives the eponymous character no other name, which I take as sardonic reflection on the way we drape over diverse sufferers a label that hides more than it reveals.

It is inevitable that we abbreviate and simplify. (It is apparent even in this essay that I see no way around the words "depression" and "melancholy.") But it is one thing to use shorthand while straining against the limits of language. It is quite another to mistake such brevities for the face of suffering. Each year, seventeen million Americans and one hundred million people worldwide experience clinical depression. What does this mean, exactly? Perhaps they all have deficits of serotonin, feel hopeless, ruminate on suicide. But why? What wrinkles crease their minds? How are they impaired? For how long--two weeks? A month each year? An entire life? And from where does this depression come?

Rather than acknowledge these variations and uncertainties, many react against them, taking comfort in language that raises the fewest questions, provokes the least fear of the unknown. Such is the case with the equation of emotional problems and mechanical failure. Phrases like "running out of gas," "neurotransmitter deficits," "biochemical malfunctions," and "biological brain disease" are terribly common, and are favored by well-intentioned activists who seek parity between emotional and somatic illnesses. Pharmaceutical companies also like machine imagery, since they manufacture the oils, coolants, and fuels that are supposed to make us run without knocks or stalls.

This language not only reflects, but constructs, our reality. When we funnel a sea of human experience into the linguistic equivalent of a laboratory beaker, when we discuss suffering in simple terms of broken and fixed, mad and sane, depressed and "treated successfully," we choke the long streams of breath needed to tell of a life in whole.

Metaphor

Just as we hear music through intervals, experience is often easiest to understand in terms of contrast. And so despair is often best expressed in terms of what has changed. "I used to relish crowds on the street, but now people repulse me." Or, "I used to wake up with a feeling of expectancy. Now I can only wrap the pillow around my head and pray for more sleep."

When I began psychotherapy late in high school, I had a clear and persistent sense that something was wrong with me, but no vocabulary with which to describe it. I could not draw on contrast because I didn't remember a time when I felt differently or better. I did not have seasons of happiness followed by epochs of misery, or fall off cliffs and climb back up among the daisies. I felt as I felt for as long as I could remember. I did not go to therapy to understand, or to get through, an episode. I needed to understand and get through my life.

Since my "condition" is so deeply rooted, much of my personality grew out of it and developed to cloak it. This made expressing myself even harder. I did well in school, stayed out of trouble, behaved like a son my parents could be proud of. I wrapped myself in a skin of normalcy and success but grew more hidden, from others and from myself.

In therapy, I tried to express the relentless stream of criticism that I directed at myself and others, the way I felt split in two, the dull and sharp aches that moved around my body as though taunting me. I wished to plug a probe from my brain to the doctor's, so that he could see—without mediation—how I stood outside myself, watching and criticizing, and could never fully participate in a moment. How I felt bewildered, anguished, horrified.

Instead, I often found myself silent. When I spoke, it was with stumbles and stammers. Words— unhappy, anxious, lonely—seemed plainly inadequate, as did modifiers: all the time, without relief. Ordinary phrases such as I feel bad or I am unhappy seemed pallid. Evocative metaphors—My soul is like burnt skin, aching at any touch; I have the emotional equivalent of a dislocated limb—were garish. Though this language hinted at how bad I felt, it could not express what it felt like to be me.

I suppose the combination of words, body language, and silence did in some measure convey the message, because my first therapist was able to offer me a helpful phrase. "Is it," he asked, "as though you have a soundtrack of negative thoughts in your head—the volume rising or falling, but never going silent?" I pictured an old reel-to-reel tape machine, sitting alone on a table in an empty room. I lingered over the image, comforted especially by the acknowledgment that it never stopped. And I felt a spark of recognition, a kind of introduction to the meaning of my own experience.

The soundtrack image was an imperfect one, as I do not "hear voices" in the sense of hallucination; nor are the bad feelings that echo inside me always in words; nor can I always discern the difference between "self-criticism" and observation, between a gratuitous self-slap and a guide to truth.

But of several hundred afternoons in that Cincinnati office, this moment stands out—the offer and acceptance of a liberating, idiosyncratic metaphor, one that would need many revisions, but at least got me on the page. By contrast, I have no memory of hearing the word "depressed," which was how I was described at that time to my parents and to insurance companies.

I remind myself: An imperfect word is sometimes better than silence, a pale metaphor better than suicide. Researchers and therapists want to understand problems in their broad dimensions; families and friends want to make sense of their afflicted loved ones; and, of course, those who suffer in isolation, starved for connection, mad with the sense that they will never be understood and never find relief, need to say something, even if it's wrong, or not wholly right.

Still, while we cannot be silent, or forsake the available word or metaphor for the perfect one that eludes us, we also cannot stop at those less-than-perfect words and metaphors. Insufficient or overused phrases—which resolve eventually into clichés—lose their power to evoke a fresh, startling image. They stop tapping into the field of primal meaning that precedes language and to which, through language, we are forever trying to return. Worse, poor language can cripple the capacity to imagine. "A man may take to drink because he feels himself to be a failure," George Orwell writes, "and then fail all the more completely because he drinks."

The failure begins when words intended to codify or categorize, what Maurice Merleau-Ponty calls "empirical speech," actually disrupts or preempts "creative speech," or "that which frees the meaning captive in a thing." Every breath and word is an effort at translation and, at times, that effort can seem impossible. But poems, lyrics, stories can do an end run around the stubborn distance that separates us, helping us feel what it is to be alive. Words can create meaning, teach us our own thoughts, and perhaps even describe a life. But we have to plumb, with curiosity sustained over time, with toleration of uncertainty, the unsettling, elusive stories that make us who we are.

Story

When I tried to let out my own feelings—tearing apart that room, for instance—my family pretended they were invisible. I learned to not speak how I felt, soon stopped knowing, and slowly but certainly developed a way of being—a sense of being split, an aching numbness, a cascade of critical voices—that would keep things that way. Some psychiatrists have described this as "depersonalization." It is a diagnosis listed in the DSM-IV in the category of dissociative disorders, along with post-traumatic stress and what used to be called multiple-personality disorder. Depersonalization, the manual says, is characterized by persistent or recurring feelings of "detachment or estrangement from one's self, a sensation of being an outside observer of one's mental process, one's body, or parts of one's body."

"Often," the manual continues, "individuals with Depersonalization Disorder may have difficulty describing their symptoms."

No diagnosis can tell my story. Still, depersonalization has the advantage of nicely announcing what is missing. To treat this "disorder" requires nothing less than removing the "de" to find the person—whatever is real beneath.

This is a truncated memoir, an introduction to my own introduction to my story. I still need to imagine my life, to find my story by living it, following moments of emotional clarity through life's maze. I look for help in therapy, in relationships, and faith in its broadest sense—the faith of the gardener, the faith of the lover, the faith of the writer. The faith that I can experience what is real about the world, that I can hurt plainly, love ravenously, feel purely, and be strong enough to go on.

***

This blog is excerpted from "A Melancholy of My Own," by Joshua Wolf Shenk. The full version is available in the July/August 2001 issue, The Future of Psychotherapy: What the Mental Health Marketplace Has in Store for You.

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Topic: Anxiety/Depression

Tags: 2008 | brain science | childhood depression | chronic depression | coping with depression | dealing with depression | depression | Depression & Grief | depression diagnosis | depression symptoms | depressive disorder | diagnoses in dsm | diagnosing | Diagnostic and Statistical Manual | diagnostic system | DSM | feeling | feelings | help depression | recovery | symptoms of depression

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