Booksology “On paper, I had it all together. Behind my mind’s closed doors, I was completely broken apart.”
Many readers will identify with this painful dislocation in Laura Delano’s wrenching and insightful memoir, Unshrunk: A Story of Psychiatric Treatment Resistance, published tomorrow by Viking Books.
The insights point to a deep-seated, years-long conflict with her parents and family, driven in part by some very high expectations. Add in prestige schooling, debutante balls, and elite universities, and mix in liberally with hyper-competitive peers. There’s also the New England legacy the Delano family shares with an admired former U.S. president, Franklin Delano Roosevelt.
The private academy that guides Laura’s early admission to Harvard University bears the motto, “Be Worthy of Your Heritage.” It’s not just a chapter title in her memoir but a silent commandment that runs throughout, underwriting much of the later turmoil.
Over the course of 13 years, Laura’s various conflicts—over body size, academic performance, fitness for athletics, sexuality, and perfectionism—dramatically worsen, fueled by a type of self-criticism that seems difficult to appease in that it borders on self-hatred. She writes of being “spun out in a self-destructive spiral,” at the mercy of an inner monologue that is quick to condemn her as “defective,” “disgusting,” “a dysfunctional failure,” and a “pathetic waste of oxygen.”
Rather than ask why a dedicated, focused, though nonetheless “ashamed (and) bewildered fourteen-year-old girl overwhelmed by painful emotion” would berate herself so continuously, the various psychiatrists Laura sees diagnose her with bipolar I disorder, a seemingly incurable brain dysfunction, and assure her that “with therapy and proper medications, (she) can live a very good, manageable life.”
With the diagnosis alone, as Delano later observes, she would join a “fortyfold increase in the diagnosis of bipolar disorder” in American children and teens over the 1994–2003 decade, leading her to ask of the broader trend: “How could this have happened on such a massive scale?”
First-line treatment: off-label prescribing
In Delano’s case, the diagnosis leads to the simultaneous prescribing of Depakote off-label, an antipsychotic with a high incidence of adverse events, and Prozac, a selective serotonin reuptake inhibitor (SSRI) whose dosage is routinely increased the more she exhibits physiological signs of difficulty (in her case, excessive sweating, pronounced nausea, chronic vertigo, protracted insomnia, and severe hypothyroidism from extended treatment on lithium).
At the same time, the scattershot prescribing results in more, not less, obsessiveness and suicide ideation: “As my Prozac dose slowly crept up,” she notes, “I simultaneously developed an agitating, compelling urge for control. The compulsion grew so demanding that I began to focus it on the closest available target: my body.”
High scores for compliance
By the time she is a freshman at Harvard, Delano has been diagnosed with bipolar disorder, major depression, social anxiety disorder, eating disorder NOS, binge-eating disorder, substance use disorder, and borderline personality disorder. “Someone had even thrown obsessive-compulsive disorder in there along the way.”
Each diagnosis is presented to her parents, then to her, as accurate, precise, and meticulous in what it captures of her condition and behavior. Initially, she is pleased to reciprocate, converting her perfectionism into hopeful compliance, to be both a model patient and newfound success, with an underlying expectation of still-greater efficiency: “I couldn’t wait to see what the meds would do for me—how they’d settle me down, balance me out, help me feel more productive.”
Contraindications
The prescription cascade that follows is so well-documented, it can be said to involve prescribers with few stated concerns for how the drugs themselves interact—the compounding consequences of Delano’s being prescribed several different kinds of psychiatric drugs, with markedly different known actions.
Over 13 years, Laura is prescribed 21 different psychiatric drugs. Among those taken as prescribed since age 14, “there were the antipsychotics: Seroquel, Geodon, Zyprexa, Risperdal, and Abilify. There were the mood stabilizers: Depakote, Topamax, Lamictal, and lithium. There were the antianxiety drugs: Klonopin and Ativan. The insomnia drug: Ambien. The narcolepsy drug: Provigil. The substance abuse drugs: Antabuse and naltrexone. And the antidepressants, all those antidepressants: Prozac, Effexor, Celexa, Cymbalta, Wellbutrin, Lexapro.”
Delano also catalogs the physical issues that, for her, develop as a result—medical symptoms bearing all the hallmarks of being medically induced: “Hashimoto’s disease, the autoimmune thyroid condition I’d gotten soon after starting lithium. Irritable bowel syndrome. Total loss of sexual function… The seventy-pound weight fluctuation. The chronic headaches and muscle pain. The clumps of hair in the shower. The flaking fingernails. The incessant sweating. The shocking decline in my cognitive capacities.”
Despite her many adverse reactions, which she shares openly with her psychiatrists, Delano’s contraindications are routinely re-diagnosed as an overlooked or previously misidentified psychiatric disorder. Rather than halt the ensuing prescription cascade, those diagnosing her are also prone to tell her, with unmistakable condescension, “You did go to Harvard, is that correct? I have to imagine you didn’t think this was where you’d be in your life by now.”
Unforeseen consequences
Anchored by her medical records, which she is careful to request from those who diagnosed her, Delano’s Unshrunk is invaluable in documenting American selfhood and adolescence on polypharmacy and off, where the differences are stark and painful, and the diagnoses guiding treatment compounded by error and missed signals. For example: “Worries that she is too complicated and ‘pathetic’ for others (esp. men) to handle. Increase Prozac to 60 mg.”
The ensuing prescription cascade pitches Delano ever deeper into polypharmacy. Yet, despite routine assurances from recognized specialists that her problems are largely neurochemical, what she calls her “willful lurch toward self-annihilation” results in an intentional suicide attempt, with four subsequent stays in psychiatric hospitals and a cocktail of drugs that leave her feeling sedated, but also physically and mentally impaired. All the while, her self-criticism is severe and unrelenting. And despite hours of treatment, it appears largely untouched and unexamined as a factor.
“Who would I be off my meds?”
Delano concludes, “My therapists and I operated under the assumption that my emotional and mental difficulties were symptoms of an incurable brain disease for which medication was my first-line treatment.”
Ironically, it’s the ensuing akathisia—Delano’s long list of medically-induced symptoms—that leads to a breakthrough in her “dialogue with herself”: “You’ve been medicated since you were a kid. You’ve never had the chance to really know yourself without pills.… Maybe this is kind of a problem.”
As Unshrunk attests repeatedly, it is a serious problem. One reason why, the book shows clearly, is that treatment is repeatedly failing to engage with root causes on the assumption that those are mostly neurochemical. It is by “tracing the contours of that bigger story through the aperture of (her) own experience” that Delano can fully extrapolate: “What happened to me did not occur in a vacuum; it unfolded within the broader context of the American mental health industry over the past century.”
While Laura Delano finds continued relief via deliberate self-forgiveness—a sustained effort “to show myself grace, at least some of the time,” suggesting that a fair amount of the conflict was interpersonal and intrapsychic, the drug-induced turmoil she endured for 13 years is very much addressed to those whose diagnoses opened the door to so much careless prescribing.
