Alexa is a Caucasian woman of Eastern European descent in her late sixties. She was born abroad, and her family was forced to emigrate from their home to the United States in order to escape political persecution from a harsh dictator. Many of Alexa’s family members suffered from various psychiatric difficulties, and they were given diagnoses including schizophrenia and bipolar disorder. She herself had been diagnosed as having bipolar disorder with schizoaffective features. Although much of her distress seemed to stem from the consequences of paranoid psychosis and the rupture it created in her capacity to make meaning of reality, Alexa felt that at its core, she suffered from severe and chronic depression. All of these conditions are symptoms that serve as potential solutions when a person is faced with unbearable pain. Alexa had individual vulnerabilities—such as the consequences of emigration, painful early childhood events, and numerous losses—that made coping with traumatic events exceptionally difficult. It is also possible that through a combination of genetics, environmental factors, and characterological qualities, Alexa had a predisposition to becoming overwhelmed by emotional stimuli. It is tempting to search for the origins of her suffering within the symptoms themselves; one might wonder whether Alexa’s depression triggered periodic psychotic episodes or whether it was the psychosis that led her to feel overwhelmingly depressed by the losses she incurred in that state. However, this type of diagnostically bound speculation runs the risk of splitting off experience into dualistic categories. It oversimplifies and disregards the nuances of individual subjectivity. It is therefore much more appropriate to think of Alexa’s experience in terms of an overarching pain that manifested itself along a continuum of symptoms in response to existential suffering.
Alexa believed that her symptoms could have been the result of a genetic predisposition toward mental illness that was potentially triggered by a brain injury. She said, “Ah I definitely believe ah that it is in the genes” and then she described several different family members who had experienced one form or another of psychiatric difficulty. In addition, in her early twenties Alexa had been in a severe car accident and sustained a head injury as a result. She wondered whether her difficulties could be attributed to this:
I read and I was told that if anybody has any kind of propensity to have mental
illness- like you know some people are more likely to have it, that if you have . . .
quite an impact or or or or uh shock to your head, that it can bring it on.
Although these theories provided a framework for Alexa to conceptualize her psychiatric difficulties within the broader context of her life narrative, it is impossible to determine causation. It is the subjective quality of her experiences that take precedence over unknowable explanations, and that will be the focal point within this chapter.
Alexa’s presentation of her life narrative was filled with loose associations. Her speech had a voluminous quality that resembled more a flight from affect than a capacity to remain with it. As a result, it became difficult at times to follow her train of thought, as she would often deviate from one anecdote in order to inject the details of another, only to return many moments later to the original idea. This also made it difficult to obtain a linear account of significant formative events in her life. Nonetheless, Alexa was able to articulate quite clearly the devastating effects of suffering from a chronic condition. Her account is punctuated with descriptors like “torture,” “anguish,” and “suffering,” which can be directly linked to an overwhelming sense of loss incurred in multiple arenas of her life.
During moments when she was not well, Alexa became unable to trust in a basic sense of reality. She could no longer verify with any certainty whether she existed or who she was, and this made it impossible to trust not only her own perceptions but also any of the people around her. She lost connections with family members and friends not only objectively speaking but also psychologically so, which was even more terrifying to her, because she could not trust the intentions or professed affections of those around her. This manifested itself in what Alexa referred to as “paranoia,” in which she felt an overwhelming sense that she was going to be abducted, killed, or otherwise harmed. She likewise feared that she would lose control and that her badness would overwhelm her and cause her to be destructive toward others. The extreme confusion she felt during these states was incredibly frightening, and it led her on many occasions to fixate on suicide as a solution to the agony she felt.
Alexa experienced a rupture with reality and the capacity to make meaning. She felt a schism between herself and all others with whom she had relationships, including her closest family members. During these times, she was unable to maintain her professional identity, which served as another blow. She had established for many years a very successful career that provided her with a sense of autonomy, accomplishment, and purpose. Through her work, she was able to travel and live extremely independently. Alexa took pride in the fact that she was a “capable person,” and this made the pain that resulted from her diminished ability to work during episodes of psychosis all the more palpable. She had been hospitalized several times throughout the course of her lifetime, and she had been given a variety of medications with varying levels of efficacy. However, suffering from a chronic condition meant that these periods of disintegration had cumulative effects. All of the losses incurred ultimately culminated in a loss of the potential for a secure sense of self, and it was an ongoing struggle for Alexa to regain and maintain her positive self-identity. It is possible that Alexa never quite fully developed a stable sense of self. If we view identity as a developmental capacity that is formed across many stages of life, it is possible that this potential was never fully actualized, thus making Alexa more vulnerable to psychic assaults.
Alexa’s case is significant because it defies the expectations that accompany “depression” and “psychosis” as reified entities. It can serve as a grounding and organizing function to conceptualize complicated experiences in terms of categorical diagnoses. Using that language, Alexa’s case is not representative of a “typical” account of depression in the sense that there were predominantly psychotic features that were transposed over a depressive backdrop. However, the nuance and overlapping of symptoms speaks to the reality that emotional experience falls along a continuous spectrum. In this way, thinking about Alexa’s subjective experience allows us to expand our thinking about the human condition to a more inclusive space, in which we can better appreciate the exquisite difficulties that many individuals face.