Over the course of thirty years, writer and teacher Sarah Fay received six different psychiatric diagnoses: anorexia, major depressive disorder, anxiety disorder, attention deficit hyperactivity disorder, obsessive-compulsive disorder, and bipolar disorder. Only twelve when she was diagnosed with anorexia, Fay accepted the diagnosis and came to identify as an anorexic, reading and rereading Steven Levenkron’s The Best Little Girl in the World, even coming to model herself on the book’s heroine. Later, like most young adults, Fay struggled through difficult break-ups and establishing herself in her career. She had moments of despair and what she calls a sense of internal “cracking,” yet she was able to go on, teaching writing in New York City Public Schools, and later enrolling in and completing an English PhD program. Along the way, experiencing increasing symptoms of anxiety, she sought help for her “mental illness.” And that, according to Fay, is when things got really bad.
Pathological: The True Story of Six Misdiagnoses is both a memoir and investigative report into the “mental health industrial complex.” For Fay, the central problem with the American approach to mental health lies squarely with the Diagnostic and Statistical Manual of Mental Disorders (DSM), psychiatry’s so-called Bible. Now in its fifth edition, the DSM, Fay charges, lacks scientific validity—meaning that there is no evidence that any of its disorders actually exist in a biological sense outside of the DSM’s own system of classification. This argument covers somewhat familiar ground for those who’ve followed the debates over antidepressants dating back to Peter Kramer’s Listening to Prozac and Elizabeth Wurtzel’s Prozac Nation. Fay dutifully cites statistics and peer-reviewed studies to bolster her argument, but readers wanting a comprehensive history of the DSM are better off looking elsewhere.
Pathological is strongest when it roots down into the uncertainty and indeterminacy of Fay’s own experience. That experience, while extreme, is likely to contain familiar elements for anyone who has ever ventured to tell a doctor they might be unhappy. Fay finds a primary-care physician eager to prescribe Ritalin for her OCD, a diagnosis that a psychiatrist later overturns. She starts taking SSRIs for her depression, only to be later told that that medication is the wrong one for someone like her, who “is” bipolar. When she tries to wean off the SSRIs, she experiences withdrawal and despair. Perhaps most concerning, she is prescribed antipsychotics for her bipolar disorder that render her unable to function—unable to read, write, or teach, the very activities that previously sustained her in both a financial and spiritual sense. It’s in this condition that she moves back in with her mother and experiences the suicidal ideation that lands her in a partial hospitalization program. Only when a different psychiatrist tries to sort through the “mess” of her medications and she stops taking most of them does she actually begin to recover.
Ultimately, Fay’s story is a disconcertingly familiar one in which a person suffering from mental illness receives care that actually worsens her condition. As a younger person, Fay placed her trust in the expertise of psychiatrists. She is someone who likes lists and clear categories, and her discovery of the rickety science underlying most psychiatric disorders feels like a personal betrayal. She paints a disturbing and moving portrait of the human costs of a system that overdiagnoses and over prescribes.
A devoted student of the English language, each chapter attempts to draw a metaphorical connection to a specific punctuation mark. Commas are about lists and classification; periods signal a complete pause; semicolons are about unexpected connections. If at times the individual examples feel forced, the underlying parallel is illuminating. Punctuation, and writing in general, tries to systematize the unbroken stream of sound that is spoken language, while psychiatry tries to categorize (and in doing so normalizes and pathologizes) the complex and messy range of human experience. Writing, like psychiatry, imposes order on chaos—and there is something both lost and gained in this artificial systematization.
By the end of Pathological, Fay accepts that she has “mental illness” but rejects all of the specific diagnoses that have been offered to her. With a tendency toward what one psychiatrist called “black and white thinking,” she comes to recognize that, “Maybe I didn’t have to embrace or reject the mental health industrial complex entirely. Maybe I could live without clarity or symptoms lists or order or an answer.” Dropping the false clarity of the diagnosis in favor of embracing the messiness of the unknowable, Fay writes, “When I stopped labeling and talking to myself as a sick person, I no longer was one.”
Pathological: The True Story of Six Misdiagnoses
By Sarah Fay
Published March 29, 2022
Editors’ note: A previous version of this review inaccurately stated that Fay taught in prisons. This error has been removed.