David's Inferno (13 page)

Which brings us to the final part of a psychiatric evaluation: the “Diagnostic Impression.” This is an entire category, all its own. To even begin to understand it, we have to go boldly forth where few laypeople have gone forth before: to the infamous
Diagnostic and Statistical Manual of Mental Illness
(DSM.)

The American Psychiatric Association publishes the DSM in a well-intentioned attempt to provide a linear classification system for our multidimensional minds. It's 886 pages long, lists 297 disorders, and sits on most psychiatrists' desks … or over on the bookshelf—
even if she or he just uses the online version. It's as important for establishing their credibility as those diplomas on the wall.

The Manual is based on extensive—one could say OCD—collaborations between psychiatric professionals all over the country. They analyze countless research reports, clinical trials, and various subjective criteria in order to assign labels to what ails us.

While those of us on the other side of the looking glass may rebel against the restraints of these labels, the criteria do at least give psychiatrists some kind of common language for discussing our behavior.

DSM-I was published in 1952, the year I was born. Which I consider prescient and timely, even though I wasn't officially diagnosed until 47 years later. Based on an ever-evolving understanding of how our minds work (or don't), they add, subtract, and merge diagnoses with each edition. If nothing else, this wreaks havoc with computers throughout the healthcare system.

As of this writing, DSM-V is about to be released. While some popular diagnoses may be eliminated or, more likely, lumped together, there will also be more total diagnoses. Many people consider this a plot by the so-called “Medical Establishment” and “Big Pharma” to sell more drugs. But, clearly, they're just suffering from Paranoid Personality Disorder (300.1).

There's a lot of understandable disagreement about what should be included. Like Paraphilia NOS (302.9). While a bad case of paraphilia could easily interfere with your everyday functioning, being sexually obsessed with specific acts or objects seems technically okay as long as nobody and/or no-thing gets hurt. But Paraphilic Rape isn't included, because if you call it a mental illness, then people convicted of it could plead insanity.

While on the subject, I'd like to bring up the issue of hypersexuality. All in favor raise their hands … or something. It's sure a more polite term than what you'd hear in some bars or on talk radio to describe women whose interest in sex exceeds our society's shifting and often self-serving norms. Plus, don't guys also deserve a more polite way of being accused of thinking with our balls instead of our brains? Are they suggesting we should get our Viagra
with a side order of Valium? And who was the hypersexual psychiatric clown who decided Hypoactive [low] Sexual Desire Disorder (302.71) and Sexual Aversion Disorder (302.79)
do
earn labels? After all, they say up to 10% of people are simply not interested in having sex. Of course, that doesn't necessarily mean they don't qualify for
Voyeurism
(302.82).

As much fun as it is to poke fun at the DSM, doing so is clearly a sign of Oppositional Defiant Disorder (313.81). More important, it's another reflection of the challenge of treating us. If we're going to talk about this stuff, we have to have a language to do so, and the DSM is a worthy attempt to create that language out of shimmering synaptic whole cloth. And, frankly, the terms are way more specific than
nutty as a fruitcake, retard, head case, loony, mong
, and
bonkers
.

NOTE:
The most important thing about the DSM is that it gives doctors a code to put down when they're billing your insurance company. No code … no reimbursement. (And don't forget to check whether your prescriptions need pre-approval.) But I digress. See Avoidant Personality Disorder (301.82).

The key diagnostic tool within the DSM is a five-axis system. For perspective, or because I'm a little too narcissistic (301.81) for comfort, I've included some of the “ratings” I've earned over the years. (Note: R/O = “Rule Out.”)

Axis 1
describes the stuff that needs immediate attention:
Major Depression; R/O Bipolar and ADHD
. It seems I was able to stay on just this side of ADHD as well as alcoholism.

Axis 2
offers 10 possible personality disorders, such as paranoid, schizoid, histrionic, narcissistic, obsessive compulsive:
Defer but R/O Panic Disorder and NOS
(Not Otherwise Specified). There was really no reason to rule out Panic Disorder. I think the doctor was just being polite.

Axis 3
labels any general medical conditions that might be affecting your mental health. That's where he mentioned the fact I'd lost 25 pounds.

Axis 4
specifies “psychosocial and environmental problems.” At
my worst, he wrote:
Severe; wearing on marriage
. It did bend, but it didn't break.

Axis 5
is a “Global Assessment of Functioning Scale,” an overall rating of a person's ability to cope with normal life. My worst score was 35. That was depressing for two reasons: (1) I never got less than a B on any test in my life and, more troubling, (2) it was accurate:
Some impairment in reality testing OR impairment in speech and communication OR serious impairment in several of the following: occupational or school functioning, interpersonal relationships, judgment, thinking, or mood
.

Impairment is a pretty word for it.

For those who want to do a little self-evaluation, you can find the complete rating scale on the Internet. Suffice it to say that if you score 100:
Person has no problems OR has superior functioning in several areas OR is admired and sought after by others due to positive qualities
, there's a good chance that, secretly, nobody really likes you.

Whereas if you score 1:
Persistent danger of harming self or others OR persistent inability to maintain personal hygiene OR person has made a serious attempt at suicide
, I pray you or the person nearest you picks up the phone and calls 1-800-273-8255 or 911.

Meanwhile, the rest of us will continue to muddle along somewhere between those two extremes.

Throughout history, people have been wrestling with how to categorize the causes and manifestations of mental illness. Non-traditional diagnoses may not meet the criteria of the DSM, but at least they capture the thing in flight, and give it names that reflect its fluid nature as much as its thing-ness. And they can be as descriptive as traditional diagnoses:

The Egyptians, for example, were suspicious of the influence of the planet Saturn on depression.

Folks like Hippocrates, Galen, and Aristotle would have said my black bile was totally out of whack, and my balance of yellow bile wasn't anything to brag about either.

An “energetic” shiatsu massage therapist explained it in terms of
kundalini
energy:

A tarot reader also put it in more occult terms:

Which certainly hit the nail on the noose, and was one of few things I found funny at the time.

Mystical and Jungian folks, along with Dante, chalk the experience up to a dark night of the soul—a process of inner transformation.

People who believe that all emotional problems are caused by toxins in our systems brought on by self-destructive lifestyles and poisonous diets, might suggest I'd been asking for trouble … and was continuing to ask for it.

Fire and brimstone aficionados would undoubtedly see me as someone with a demon that needed to be cast out (especially if they found out I gave credence to tarot readings). Sometimes, it did feel like being possessed. Although, ultimately, I was able to make this friend of the devil a friend of mine.

I don't try to diagnose other people, but usually I can see it in their eyes. At first, it's just the way they look in more than out. As the depression goes on longer or gets more serious, it invades the edges: drawing squint lines that resemble the “crinkles” of a smile and expose hints of skeletal structure. Eventually, you can gauge its severity just by standing near them.

One time I was at a workshop with a bunch of people, all of
whom were very supportive of this haunted figure walking among them. There was a similarly afflicted woman there whom I'd known for years. I saw it in her eyes. She saw it in mine. There was nothing to say. But it made us both feel a little better. Like, if she can take it, I can take it. If I can take it, she can take it.

Then, there's a picture I took of myself alone, in the middle of an Arizona canyon. In the middle of nowhere. All I see are the eyes. Looking through them, I can still hear my thoughts as they raced back and forth from “I'm still here” to “I'm okay” to “Oh, God, when will this end?”

But, of all the non-traditional diagnoses I received, the most accurate was, of all things, astrological.

The “fault,” dear Dave lies not in you, but in the stars. By July, 2006, “How long is this going to last, oh Lord?” had tied, “What's should I try next, oh Lord?” and was threatening to overtake, “If you got something to say, why don't you say it, oh Lord?” on my list of top 10 existential questions.

Which, from a theological point of view, represented at least some kind of progress for a lapsed Jew. So, when someone suggested I visit her favorite astrologer, I was more than happy to do so.

I like serious astrologers. As much for their descriptive as predictive powers—both of which have little relation to the mass-produced newspaper, magazine, and short-form web variety.

In other words, I'm not talking about the, “your partner has different ideas how to spend money,” kind of description. (Wendy and I both know that.) I'm talking: “Pluto is coming opposite your ascendant, and will soon start moving toward your descendant … it's kind of like a death and rebirth. And all you can do is surrender and align with the meaning.”

Even in a therapeutic context, I'll take that kind of talk any day over: “What I hear you saying …” I
know
what you heard me saying. I just heard me saying it. But I never heard me saying that my problems were caused by Pluto. Besides, the experience
did
feel a whole lot like a death and, hopefully, rebirth.

She went on to explain that the purpose of this time in my life
wouldn't, “always be clear at the moment. So,” she continued ominously, “all your knowing is not useful here.”

That's tough love for someone who prides himself on being able to scale tall cognitive dissonances in a single leap of logic. Still, in some small way, it put my mind at ease. At least
it
wasn't going to have to take
all
the heat for this thing.

But, at the time, what mattered most to me was that she gave me a chronological timeline to cling to:

Gobbledy-gook, you say? Well, in March 2007 I indeed went through my final major crisis. And, by June 2007, the storm was, indeed, well on its way out to sea. Power of suggestion? Mental placebo? Fine. Bring it on.