The Problem With Comparing Mental Health To Physical Health

Not long ago, I tried to explain to my husband what happened in my head when I had a panic attack. The night before, I’d woken him up, crying and shaking over a problem that did not exist.

I compared my anxiety and depression to something that spins, like a hurricane or a planet. When it’s smaller, it’s easier to resist its gravity. But as it gets bigger, it gains speed and power, and pulls in everything in my life.

I mixed metaphors. I knew they were inadequate — truthfully, I don’t always understand my panic either — but they were the closest I could get to clarity. Metaphors have always been how mental illness was explained to me, most often as an analog to physical health. Most Americans, in fact, are now likely familiar with thinking of mental illness as a “chemical imbalance,” even though researchers have long challenged that theory.

Still, the parallel gives people who haven’t experienced mental illness a basis for comparison (“You wouldn’t get mad at someone for breaking their leg!”) and encourages treatment (“If you broke your leg, you would get help!”). For me, anyway, it was helpful. Until it wasn’t.

When my physician first told me she wanted me to try medication, for example, she explained those feelings as a chemical imbalance that could be fixed, the same way any other levels in my brain or body could be “off.” People often have a resistance to medication for mental health, she told me, because they didn’t think they were sick enough to justify its use. “But you’d never say that about a sinus infection,” she said.

Metaphors have always been how mental illness was explained to me, most often as an analog to physical health.

I embraced this mindset and latched onto the hope promised by yet another metaphor: Medication couldn’t get you out of the hole, but it could act as a shovel so you could dig yourself out. I gave the Lexapro a try.

For about two weeks, I was sick to my stomach; after that came deep, almost existential fatigue. For the first time in my life, I was falling asleep easily and sleeping through the night. No matter how much I slept, I was still exhausted. Perhaps foolishly, I took this as an encouraging sign. An overcorrection, maybe, but still — a lifelong problem solved, just like that.

What came next, however, were intrusive thoughts beyond anything I’d ever experienced before. I became scared of everything: leaving my house, talking to friends, making any choices. What can you trust if not your own thoughts? Even though I wasn’t actively suicidal, not being about to stop fixating on killing myself was Not Good. I went off the Lexapro cold turkey, which was awful, a low I hadn’t experienced any time before or since.

In that case, the shovel metaphor did work: You can’t dig yourself out of a hole, only tunnel deeper.

My doctor’s office enrolled me in a collaborative care program where I had three physicians figuring out what to do with me. At first, I didn’t see the point of trying. I took my new diagnosis of “treatment resistant” to mean fundamentally broken, perhaps unfixable. A treatment-resistant infection can be fatal. How was this any different?

The framing of my mental illness as equal to a physical one was one of the first things my therapist told me to abandon. Yes, thinking about depression like a physical illness was helpful so people would take both their mental health and the health of others more seriously. But simple language belies simple concepts, in this case implying that we know how things work when we don’t.

At a biological level, our understanding of mental health disorders is vastly immature compared to physical health. For physical injuries and diseases, we can take X-rays or MRIs or run blood tests to understand what’s going on “under the hood.” We don’t really know what depression is beyond a set of symptoms, nevermind how the medication addresses it or even how to measure it beyond feeling well enough that the side effects are worth it. Each brain is a black box.

Instead of trying to wrap my arms around a concept even scientists don’t yet understand, my therapist suggested I take smaller, more practical steps to feeling better. For me, this meant sleeping whenever I could, focusing less on sticking to a schedule and more on resting when I was tired, running in the middle of the afternoon instead of trying to fit it in after my inevitably ballooning workday, turning off literally all notifications on my phone, and a hundred other little things that made my life maybe 1% better.

None of these choices cured me, but focusing on how I felt instead of the concrete terms of “well” or “unwell” at least made me feel like I wasn’t failing all the time. For the first time, I understood what it meant to manage my illness. I’d reconstructed a life that felt like it was made for my needs — because it was. And for about a year, I was mostly OK.

Maybe I got complacent, or it was exacerbated by the winter darkness, or it was simply just time. I don’t know. I can’t know. But I didn’t just backslide into depression. I was leveled by it. My thoughts wouldn’t connect to each other unless they were amplified by hyperfixation. I couldn’t focus on conversations or remember to do anything. It was, in the words of the final question on the mental health survey, “impacting my ability to function in daily life.”

Sometimes I think I use the metaphors as much for distance as I do for understanding.

In an attempt to wrangle my life back, I tried the “small practical things” approach again. I wrote down list after list: things I needed to do for work, things that made me happy, even the tasks I normally do automatically like brushing my hair that were falling out of habit. I went on my runs, bought my lattes, took my dog to the beach, and asked for extensions on deadlines. This time, though, none of it worked.

My therapist was concerned. When she probed to see what had triggered this episode, I cried and showed her my lists, page after page of the only proof I had that I was trying so, so hard. I recited what we’d been practicing for a year: that I knew I didn’t actually hate myself, and that I deserved care and love and rest.

“But,” I said, “I still do.”

By the end of the week, I had two more doctors’ appointments and a prescription for Wellbutrin, with a supplementary sleep aid if it kept me up. I kept the bottle on our coffee bar — where it still is now, full, many months later.

Time heals all wounds: another imperfect aphorism because it’s also what kills us. But it was the only way I could explain to my friends how I could be feeling as awful as I did and not immediately take the medical lifeline offered: I wanted to wait. The Lexapro experience and subsequent fallout had disrupted nearly every facet of my life, and it had taken me about a year to feel like myself again. I felt like I needed breathing room so if things went as badly as they did with Lexapro, I could fully retreat from the world and ride it out without bailing on my friends and family and blowing up my professional life. By the time I had the space, the tides had changed as they always do.

It turns out waiting was probably the right decision. Since I haven’t had panic attacks consistently like I have this month for almost a decade, I would have blamed the pills for something that would have happened anyway. Or maybe I would have felt better and not had panic attacks at all. I don’t know. I can’t know.

Sometimes I think I use the metaphors as much for distance as I do for understanding. By having my mental illness be a planet or weather or the tides, it can live outside of me. The metaphor lets me accept my illness as this massive thing I have no control over yet must find a way to live with, without making me feel like I’ve given up. It’s not surrendering to board your windows or put chains on your car or find safer ground. It’s what you do to stay alive.