When we are stressed, our sympathetic nervous system prepares our body for one of two possible responses: fight or flight. It does this by channelling most of its resources to our vital organs and muscles. The unknown, along with the absence of the familiar, is a major source of stress.
The first time Alin came face to face with the darkness was in his second year of medical school. The shock of his first exam period was long over, and he was described by his lecturers and marks as an above-average student who was attentive to detail and had a varied vocabulary, honed by the long nights he spent poring over books. Moreover, his fellow students described him as sociable, cheerful, cultured, considerate, trustworthy, and versatile. Alongside the lengthy anatomy and physiology texts, Alin found time for tennis and a smile.
However, before that year’s winter exam period, the post-school life he had imagined took a turn that was completely off-script. Out of nowhere, the fullness of his normal, beautiful life began to drain away, as he later described it, beyond any possibility of control, against his will, and perhaps most frustratingly of all, without any specific cause. The sentences which had flowed so easily just a few months earlier were now the pitiful result of an all-too-intense effort. Aware of this phenomenon, Alin had come to prefer isolation for fear of ridicule. Ideas flashed haphazardly before his eyes, settling for fractions of a second into coherent order then vanishing before they could take a form that could be communicated or analysed. And the darkness . . . a dense, isolating darkness of terrifying stillness was gradually consuming every defining fragment of his personality, day by day.
He ceased to be present — first verbally, then mentally, then physically. After just a few weeks, sleeping tablets were the only way he could get any rest because, every time the clamour of the day and external stimuli subsided, he was left alone with his own mind. This mind, once a trusted ally, alternated between absolute nothingness and messages of helplessness, worthlessness, and nonsense. As he turned his thoughts inwards, asking himself relevant questions about his state – “What’s happening to me? Why am I going through all this?” and “What do I need to do to ‘fix’ myself?” – he discovered perhaps the most grotesquely ugly aspect of depression: the lack of an answer. An oppressive silence. After several dozen desperate attempts yielding the same result, Alin tipped the entire contents of his pill bottle into his palm and swallowed them methodically and with a sense of finality. He went to bed, hoping his parents wouldn’t cry too much.
Fight
What is the appropriate reaction to this story? If we were part of Alin’s life and already emotionally involved, what would we say to him? Would we have the answers that he cannot find himself? How would we perceive him? How much patience would we offer him? How long would it take before we became frustrated by these new “quirks”? When would we first be tempted to tell him bluntly, “Pull yourself together! Wake up! Come to your senses!”? Would we take him to see a doctor? Or a priest? Or perhaps, we would explain the bigger picture to him at length, presenting a persuasive account of life’s real tragedies and the plight of many others which are demonstrably in a more deplorable state and worthy of pity.
Should we criticise his way of thinking? Can we say that a patient suffering from depression has a flawed way of thinking?
In part, yes, because of the errors that insidiously creep into the mind before depression takes hold, in the form of cognitive distortions, as defined in cognitive behavioural therapy. One such distortion is maximisation, or the tendency to “make a mountain out of a molehill”, whereby negative, easily surmountable events are exaggerated and polarising language and hyperbole are frequently used. A low mark becomes “the end of the world”, a fruit salad that doesn’t suit one’s tastes is “horrible”, and the little joys of the day are “amazing”. In the world of maximisation, people are categorised as either successful or failures. This view of life, caused by a distorted perception, leads the person in question to believe that life’s events and situations directly control their emotions and behaviour. It also makes them feel incapable of influencing their own emotional state. Just as excessive consumption of saturated fats promotes the development of atherosclerosis, these distortions pave the way for mental disorder. Therefore, qualitative thought disorders represent a predisposing or causal factor, rather than a defining characteristic, for those suffering from depression.
On the other hand, the answer to the above question is no. Alin’s professor from his psychiatry residency insisted — and then demonstrated through clinical examples — that psychiatric patients are usually people of surprising intelligence. In his own words, “in the case of a mental disorder, it means you have something to cause the disorder to”. Beyond the wordplay, one can intuit that a complex mechanism will exhibit more complex faults – this is a worrying thought. Based on this reasoning, a brilliant mind does not necessarily constitute a protective factor.
In addition to the anxiety caused by being aware of their own degree of abnormality, people with neurotic disorders[1][2] face the unfriendly stares of those around them, who may react superficially or with sarcasm, particularly in a less informed environment. It is as though the word describing their problem, “depression”, should not be taken seriously. William Styron wrote in a clearly personal account that “melancholy”, the historical term for depression, “might be a far more apt and evocative word for the blacker forms of the disorder, but it was usurped by a noun with a bland tonality and lacking any magisterial presence, used indifferently to describe an economic decline. . . a true wimp of a word for such a major illness.”[3]
If we allow ourselves to make a definitive diagnosis, are we aware of the identity we attribute to the person experiencing the suffering? The historical definition of the verb “to stigmatise” means to mark with a brand (to set a literal mark of disgrace upon someone, by burning a mark into the skin) while the current definition is similar to the analysis in the Oxford Handbook of Psychiatry, which states that, in a modern sense, it refers to “a sense of collective disapproval and a group of negative perceptions attached to a particular people, trait, condition, or lifestyle”.[4]
The stigmatisation of people with mental health conditions can be described as a three-act play. First, an individual is singled out as different due to their actions or appearance. Then, society forms opinions about that person. Finally, society changes its behaviour towards the “mad person”, usually for the worse. This is essentially the mechanism of fear of the unknown. It is a shortcoming that implies collective guilt, demonstrated by the current pejorative and offensive use of terms that were once part of medical vocabulary.[5]
Flight
The second physiological reaction to the unexpected is to flee. We might take refuge behind ignorance or a lack of information as an excuse. We might simply leave him alone and give him space. Even if we are unfamiliar with the concept of countertransference[6], we may convince ourselves that flight is healthy and protects us from contagion. We might convince ourselves that “where ignorance is bliss, ‘‘tis folly to be wise”.[7] He will certainly be understood and supported by his family, close friends, church, and, of course, the medical system, who will treat him in an informed, academic, and responsible manner. They will analyse him in a cosy armchair-and-sofa setting using random inkblots on paper (the Rorschach test), he will spend some time with people like him, and he will be given a precise cocktail of expensive medication. They will repackage him and return him as a 2.0 version: capable and serene, just as we knew him. This unbearable darkness that brought him to the brink of death will remain for him merely a file in an unfortunate archive.
Epilogue
The next day, Alin woke up feeling clearer-headed than he might have wished. He The next day, Alin woke up feeling clearer-headed than he would have liked. Realising the gravity of his actions the previous evening, he voluntarily admitted himself to the nearest psychiatric hospital. With the attentive care of the staff and his own determination to get better, he managed to return to his classmates and retake the exams he had failed without making any mistakes. In addition to the prescribed treatment, he bought a bicycle and lost 15 kilograms over five months. He resolved to follow a strict rest schedule and an exemplary diet. Less than a year after the first signs of trouble emerged, he said he was “himself” again. However, the story is not yet over, accompanied by an emotionally shifting soundtrack – reminiscent of Tchaikovsky’s music, in which he detailed his recurring bouts of depression.[8] At present, Alin is on the verge of graduating from the Faculty of General Medicine, while he has now experienced four depressive episodes. He has come to identify with this disorder and solutions are slow to emerge, for him and those around him alike. He had hoped it might be due to an organic cause, successively blaming hormones, possible areas of demyelination, or an autoimmune disease. Yet, the results remain painfully frustrating and inconclusive each time.
Alin’s pressing need is to receive coherent answers and explanations within his own paradigms of life, the scientific one – materialistic by definition – dominating the landscape. Given that depression is the leading cause of disability worldwide, you would expect to see a wealth of information and treatments vying for effectiveness, offering a coherent path towards the light. From placebo pills to electroconvulsive therapy, very few solutions have been left unexplored, and a few seem to offer hope despite the relentless statistical trend continuing to rise unchecked.
Could this be the long-overdue moment for an open, sensitive yet serious discussion? If all tangible solutions have been considered and found inadequate, is there room for a plan in which every individual, however overwhelmed by feelings of helplessness, has a purpose, a future, and hope? The 13th-century Persian poet Rumi said that “the wound is the place through which the Light enters you”.
Let there be Light? Could it be that simple?
