Experiencing a psychotic break is like looking at your whole life but in a kaleidoscope. Whatever coherence there is in your world departs, leaving pieces of what you understand as reality to fold and blend together into new and unrecognizable shapes.
I felt the terror of just such an episode for the first time recently. This harsh storm lasted several days, during which I washed up among other psychic flotsam of decades of industrialized warfare. To put it another way, I admitted myself to the psych ward of the VA hospital in Pittsburgh.
A psychotic break is a difficult thing to explain in plain language. “What is madness?” Naguib Mahfouz, the wonderful Egyptian writer, says at the beginning of the novel The Whisper of Madness. “It seems to be an obscure condition, like life and death. You can know the main thing about it if you look at it either from the exterior, or the inside, or the essence, and find a closed mystery.”
Using clinical language, meanwhile, is akin to describing fire as an expression of the properties of oxygen molecules. It’s not wrong, but it doesn’t get you very far. My sister, a psychiatrist, calls what happened to me a “mixed episode.” That sounds more or less correct.
For several days before and after I arrived on the ward, I believed that I could see evil. I had the notion that everyone on the ward was a ghost or analog (even in the moment, I wasn’t really sure about the contours of this particular delusion) of someone I knew outside of there. I came to believe that I had died and was in Purgatory, so that even routine things, like which staff member gave me my meds, became events of metaphysical importance, even if I guarded my secret initiation into this mystery by keeping it to myself. I recalled myriad events when I plausibly could have died and concluded I did die without realizing it at the time. A couple examples:
Years ago I was detained by the Kenyan military on a bogus suspicion of terrorism. I was released after less than a day in jail but probably could have been shot during my arrest, had I been unlucky. Last December, I fell through the ice into a pond in the woods near my parents’ house in Downeast Maine. I was traveling on a bike, so I had to pedal the eight or so miles home in freezing clothes, warming one hand against my skin at a time while steering with the other.
An even more bizarre idea I got into my head was that one of my fellow patients, a quiet older gentleman named Bob, was in fact the writer Gary Indiana. (Fortunately, Bob was a pretty good sport about the whole thing.) Fittingly, it was Indiana who once wrote that “any psychotic tends to utter something true in the process of saying something crazy.”
There were at least a few kernels of truth at the core of my private nightmare. When I’m more clear-headed, I would never claim to be able to “see evil,” but I do get senses about people. In the beginning months of the Covid-19 crisis, my five-year career as a reporter for local newspapers outside Pittsburgh ended in a layoff. Back when I was a beat reporter, the impressions from some people that something was “off”—even from pillars of the community—were often a decent guide for which rocks to look under.
The hours were bad and the assignments were often boring, but losing my job as a reporter amounted to knocking down the last block that was holding up the shaky Jenga tower of my sanity. While some part-time work and unemployment compensation kept me financially secure if not wealthy. Because of additional money from the CARES ACT, there was a period of time when I made substantially more from unemployment that I had as a working journalist. Still, losing the structure afforded even by a job with bad hours was not something I was prepared for.
For some time before I lost my most recent job, I’d been treated by the VA for what we took at the time to be depression. Because of my interest in medication, I wound up enrolling in a pharmacogenetic study. Based on its supposed compatibility with my metabolism as revealed by genetic testing, I was prescribed the antidepressant venlafaxine, which is marketed under the brand name Effexor.
While I was working, ‘faxine helped elevate my mood and energy so that the bouts of despair I’ve lived with pretty much since I was a child became manageable enough not to get in the way of my work. To this day I credit the drug, which felt the same way I imagine small doses of speed at regular intervals would feel, with some of the work I still remember with the most pride from my reporting days. On the downside, the medication didn’t cause the long-simmering drinking problem that had me averaging a six pack or more a day, but it gave me the stamina to keep at it.
Another problem was that when I finally went to the hospital I was diagnosed with bipolar disorder, meaning I fluctuate from spells of depression into periods of elation, even euphoria. Drugs like venlafaxine can make mania worse. When I first started taking it, it was so effective at lifting my spirits that I would sprint up the hills overlooking the North Side of Pittsburgh just to burn off excess energy. I halved the dosage from 150 mg to 75 mg. I kept taking the drug even after I was laid off in May, meaning I had plenty of ideas and energy but not much to do with either.
By the end of October, my condition had deteriorated into paranoia. I saw political events as a kind of conspiracy involving nonprofits, the ever-innovative political class, and the elite leadership of the military. (To be fair, I was able to find plenty of basis for this hypothesis, but I don’t really think the central planning required for a true conspiracy is there. Plus, my idea that there was, just maybe, something I could do about it was clearly delusional.) From there, I descended even further into psychosis, coming to believe that God and the Devil were speaking to me through people I knew.
It was in this state that I went into the VA hospital for what became a 12-day stay, the first several days of which blur together in my memory. Early on I thought I was actually dead and could soon wake up in Hell if I played my cards wrong. I was so convinced that I was there to atone for a lifetime of being curious about—rather than repelled by—human badness or evil, so I took it upon myself to prove I could follow the rules of the institution. I briefly became so committed to this path that I nearly started a fight with a fellow veteran and patient who was trying to make a phone call (which, regardless, he was allowed to do) to prove I was finally ready to follow rules.
A different time while sitting with some of the guys who were playing cards I began to laugh uncontrollably as I thought of something the novelist Rachel Kushner said in praise of the great Curzio Malaparte: “moral ambiguity is only for those who get the joke.” I’d been reading Malaparte’s The Skin, which depicts widespread prostitution and corruption in Naples immediately after the Allies liberated the city, on and off for some time.
I began to see Malaparte’s position as a close observer of widespread moral decay as a kind of summation of my own—to be astute enough to acknowledge that something was wrong, but too indifferent to do anything about it. “Moral ambiguity is only for those who get the joke!” I cackled. Only one other patient, a guy with wispy blond curls and tattoo sleeves that extended over his hands, found my outburst funny.
Religion was my only comfort in that pit. I prayed with a priest the morning after I was admitted. While I still thought I was dead, I ruminated at length on the simplicity and mystery of Christ’s death and resurrection—God’s son had to willingly lose his life to save all of ours—because I couldn’t think of anything else that would reconcile my desire not to harm people and my fascination with what I would charitably call moral nuance.
It took a drastic change in medication—a cocktail of lithium and the antipsychotic risperidone—to finally stabilize my mood.
There are plenty of things to criticize the VA for, but I’m lucky that I qualify for care through the system. Nationwide, a period of residential treatment for mental health costs, on average, $5,700, according to the healthcare blog Piper Report. I paid nothing for my stay or for the multi-week outpatient program I’ll complete or for the drugs, supplements, and vitamins I received at the end of my stay. Without the VA, I’d have insurance coverage that was tied to my now-ended job. I suppose that in that scenario I’d be eligible for COBRA, but that program is a massive SCAM.
I spent my last week and a half or so in the cuckoo’s nest piecing my sense of reality back together. I played spades and gin rummy with a proud Army veteran who spoke of the grim fighting he saw in Sadr City and who was determined to go on living in the world for his young daughters. We were sometimes joined by a Marine infantryman who was in his 40s but used a wheelchair because of what the grunt’s life had done to his body. I ate meals with a former Air Force lieutenant colonel who’d fallen on hard times. She told stories of Desert Storm and spoke wistfully of the influence and prestige her rank used to bestow on her. I met an Air Force veteran a few years younger than I (I’m 34) whose experiences of mania were quite similar to mine.
Since the only book I had for most of that time was the King James Bible, I read the Book of Job straight through for the first time in my life. In it, God allows the Devil to test Job, a righteous man. Despite the loss of his worldly possessions, Job refuses to denounce God, who blesses Job in the end. I nearly cried while reading the flowery text. It was a reminder that no matter how much I filled my belly with the east wind, God could still love me enough to allow me to be stripped of my pride.