Bordering on Crazy

The most disturbing thing about being in a mental ward is the idea that someone else thinks you're crazy. Carolyn* struggled a lot with that during the four days she spent there. The first time I walked in to see her--after I had checked my schoolbag, sweater, purse, cell phone and the contents of my pockets at the door--she took me down the hall to her room, closed the door and whispered to me, "Kelly, Kelly, Kelly, the people here, they're crazy! Like really crazy!" Not crazy in the take-23-Tylenol-with-a-few-glasses-of-vodka way like she was, but in the schizophrenic, multiple personality, have-conversations-with-the-wall kind of way. Carolyn was just depressed. She says she knew from the moment she took the last pill, that life was now going to work itself out somehow and she was, at least for the moment, not responsible for how. But here she was, surrounded by really crazy people. When I sat on her bed that first day, she leaned in to me and whispered, "You know I'm not crazy, right?"

Carolyn lived in my dorm freshman year of college. She sat at her desk wearing T-shirts with Big Ten sports teams on them and played solitaire. Even when she was doing physics problem sets, her 13-inch television blared reality shows and SportsCenter. If you got her talking about cars, she'd never stop. Actually, she never stopped talking at all. By the end of orientation, I knew her life story. She would come into my room, sit down on the plaid futon and wait for Amy and me to notice her. Then she would talk, detailing her high school social world, her lack of boyfriends, her weekend exploits, her philosophy on life. Carolyn was never without advice and never without an opinion. "Let me just tell you..."

But she is just a girl from Indiana, who never ventured beyond the borders and family values of the Midwest. When you talk to her, you can't help but realize that. She calls everyone "hun" and repeats it in threes: "Hun, hun, hun, I know what you mean." She spells the word with a "u." She uses phrases, like "pop a squat," that betray her parents' background in the automobile industry of Detroit. Carolyn listened with boredom when the girls in the dorm talked about their voyages to Europe and Africa. She sighed and tossed her hair while the southern girls debated philosophy and foreign policy into the early hours of Tuesday mornings. Then she ran and shrieked down the hall on Thursday nights, swapping clothes and make-up with the rest of the girls on our hall.

Carolyn had never been away from home and cried every night that first week of school. All day, she was fine. Then in the evenings she alternated calling her mother and sitting on our futon, talking about how much she missed her house and her car and her friends and high school. At her best she is one of the popular girls: boys like her, she wears a size eight, she seems to know everyone. Yet Carolyn's level of coolness always seemed bland and attainable. She's pretty, but not much more than that. Duke and its southern belle demands didn't quite fit her mannerisms. She carries herself like a 12-year-old who has just completed a substantial growth spurt and doesn't yet know exactly where her newly-long limbs go.

"Crazy Carolyn!" Jill yells. "It's time to talk to Kelly about Crazy Carolyn!"

Carolyn has become a punch line. Not because she left school, but because she came back to visit several weeks later and was on some kind of anti-depressant--neither Carolyn nor anyone else remembers which one--and she was drunk. She loudly announced to the hall she had been drinking during the trip from the airport. When Beth asked her if she had been drinking alone, Carolyn said without a hint of irony, "No. The taxi driver was there."

So now the collective dominant memory of Carolyn is a photograph of her straight from the shower, wearing a bathrobe, taking a tequila shot.

"Carolyn drank a lot," says Beth, sipping from a mini-keg can of Heineken. "She used to have mixed drinks and do homework and write papers."

"And Crazy Carolyn hooked up a lot," adds Jill.

"I just remember that her bid day shirt said "Douchemama" on the back," says Ashley. "She was the only girl on our hall who went to every bid night."

Going to every bid night meant six straight days of eating pizza in the hall and washing it down with tequila. Dancing and schmoozing with the newly minted crop of Duke's partying elite. Pounding down furtive shots in between turns on the Shooter's bull. Then finally stumbling home at 3 in the morning, falling into bed still clothed and sleeping through the alarm for a 9:10 class. All this, only a week before the sudden wave of midterms crashes into the social life.

"She used to talk about getting shitfaced with her parents on tequila shots," Beth says.

When I ask Jill why she keeps calling her "Crazy Carolyn," she dropped her smile for the first time. "I'm not," she says, "making fun of the fact that she had a legit mental issue; it was that she reacted so insanely when she came back to visit."

Looking back, Carolyn's life had always seemed a little beyond her control. Maybe if we had known that she was all torn up inside, we could have done something, but Carolyn never let on. Instead of asking for help, she pushed back at us, trying our patience and demanding more from our friendships than most of us could give. By the time she left Duke, she had alienated a lot of us with demands on our time and attention. She was always testing us. Maybe if we had known that it wasn't her fault, we could have helped her before she hit the point of desperation.

The week that midterms started during spring semester, Carolyn felt like she was treading water. She had spent two weeks rushing sororities and the next primping and pretending in order to impress her new sisters. With so much mandatory social activity Carolyn, like many freshmen, had pushed academics aside for the first few weeks. There were chemistry problem sets to do and physics to study. Humanities had never been Carolyn's strong suit, so she felt uniquely stressed by the demands of reading two books and writing a five-page paper for a history class. At some point, when she was sitting alone in her room, she decided it was too much to handle and she wanted to be done.

Carolyn opened up an economy-size bottle of Tylenol she kept in her desk drawer and took 23. She says she lined them up first and counted them twice. Then she washed them down two at a time with a vodka cranberry drink she had mixed together from the liquor bottles that never seemed to stay full. "At the time, I wasn't sure if 23 pills would hurt me or not," Carolyn says. "I just knew I wasn't happy and that 23 pills would do something."

Her roommate, Laura, came home and Carolyn was sitting at her desk sipping on her third vodka cranberry. As Laura flopped on her bed, Carolyn turned to her and said, "I took a bunch of pills." Laura freaked out. She freaks out a lot--about classes, weekend plans, semiformal dates--but this was different. She only flipped out inside; to Carolyn, Laura seemed more in control than she had ever been. After a short negotiation, she convinced Carolyn to call Counseling and Psychological Services. It was Sunday and the office was closed. "I have never been that scared," Laura says. "I didn't really know what happened or anything. I didn't even know she had been unstable. And I didn't know what to do.

"Carolyn said her head felt funny," Laura says. So, since she didn't know how many pills or what kind her roommate had taken and she didn't know about the first two stiff drinks Carolyn had consumed, Laura called the after-hours emergency number from the CAPS answering machine. An hour later Carolyn was locked in one of Duke University Hospital's secure wards.

Most professionals now believe mental health crises and suicide attempts result from a combination of environmental and biological conditions. No single factor dictates the onset of mental illness; instead a conglomeration of causes leads to discernible mental problems. According to a 1999 Surgeon General report on mental health, one in five Americans will experience some kind of mental disorder each year. Although at one time doctors believed that troubling emotions and thoughts caused these episodes, now most researchers believe that there is a genetic predilection for mental disorders.

"It now is recognized that factors that influence brain development prenatally may set the stage for a vulnerability to illness that may lie dormant," reads the same report. "It is now recognized that socioeconomic factors affect individuals' vulnerability to mental illness and mental health problems. Vulnerability alone may not be sufficient to cause a mental disorder; rather, the causes of most mental disorders lie in some combination of genetic and environmental factors, which may be biological or psychosocial."

Starting college inspires a lot of different mental disorders to surface. And coming to a top school like Duke adds to the conflux of factors. There's a brand new social environment that students feel they just can't live up to.

"A lot of students go from being the biggest frog in the pond to one of the tadpoles. Competition to be at the top is really severe and it's difficult for some people to adapt to," says James Clack, director of Counseling and Psychological Services at Duke. "Many, many students feel they're expected to be king of the hill, top of the heap--a number one without showing any effort. And they feel like they're failures if they don't do that."

Every year CAPS says it sees about 14 percent of the student body. Most of those people come for temporary difficulties or depression and anxiety, and twice as many women as men come through CAPS' doors. Clack says women are not more likely to need help for mental issues; they are just more likely to seek it. The students who don't get counseling are the ones who might put themselves in danger.

Carolyn didn't want to ask for help. Even at Duke, a place where most students are well versed in mental health issues, she was afraid of what people might say. "There are students who don't understand and they stigmatize the students and have all kinds of names they use about them. 'They're nuts. They're wacko,'" Clack says. "We wouldn't turn our backs like that on a person who had pneumonia."

But it's harder to explain mental conflicts than fluid in the lungs, and no one can physically see that anything is wrong. It took several months before Carolyn finally found a doctor who could name what was wrong with her. After a series of rather bizarre and scattered diagnoses (social anxiety disorder, manic depressive, bipolar), a psychologist finally found a label that seemed to fit Carolyn's patterns: borderline personality disorder. Most people know it as the disorder that Wynona Ryder's character had in Girl Interrupted, but it's a far more legitimate and complex disease than the movie indicates.

The primary marker of the disease is unpredictable behavior, including spending money, promiscuity, alcohol abuse and self-damaging actions such as suicide. People with borderline personality disorder have difficulty feeling consistently about anything; one minute their roommate is the best person in the world and the next she is a traitor who is just waiting for a chance to betray them. Thus they have problems maintaining close connections and feel emotionally unstable, constantly shifting between hollow anxiety and depression and intense rage and feelings of deprivation. And since all their emotions are strongly polarized, they often don't know what they think of themselves. Otto Kernberg, who defined the disorder in the 1960s, wrote: "Borderlines can describe themselves for five hours without your getting a realistic picture of what they're like."

The mental ward of Duke Hospital is not designed to help anyone get better, especially if the definition of better is saner. The walls are covered with wood-façade Formica and eggshell white paint. It reeks of sterility. The whole experience is vaguely reminiscent of a bad airplane trip. There is only plastic silverware and no one is allowed to have cell phones. You spend a lot of time standing in lines and people in uniform bring you microwave-heated food in compartmentalized trays. There's an emergency call button within reach at all times and you can summon the nurse the same way you do a flight attendant. In both cases, they're supposed to be reserved for emergencies but the only time I ever saw anyone use it in the psych ward was to ask for an extra pillow. At certain times of day, a tone sounds. Sometimes it means mealtime; other times it means room checks--the hospital equivalent of the "fasten seat belt" sign. And of course, when you are really in the psych ward, you can't leave. Even if you check yourself in, like Carolyn did, several doctors have to sign off before you are allowed to escape.

Carolyn lived in the in-patient psych ward for four days before the doctors finally released her. Carolyn had called me with her first phone call and asked me to come see her at the hospital right away. I had been her constant and only visitor since the night when Laura walked her over to the emergency room. And sometime during those endless four days, she made the difficult decision to put college on hold for a while, withdraw from classes, move back home and concentrate on her mental health.

The reason to leave college and go home is at least twofold. First, it's to get away from all the pressure of school. Classes are hard. Constantly impending deadlines create stress. Living with all your friends and letting them see every mistake you make is intimidating. A recent study at the University of California found that more than 30 percent of college students "felt overwhelmed" regularly while at school. It's good to get away. The second, and perhaps the more crucial reason to go home, is to have the support of family during recovery. You need people who care and who offer guidance that friends simply cannot give. The network of people at home is supposed to be the real driving force behind learning to cope with life again.

From the beginning, Carolyn's parents failed to acknowledge the underlying reasons that caused her to leave Duke. And even though both her mother and her father love her, they failed to force her to take certain critical steps. When Carolyn came home, her mother thought it was best to let her do whatever she wanted. Now her mom talks about loving Carolyn and how the most important thing she could do was to let her daughter make all her own decisions. After a few weeks of just lounging around the house and watching television, Carolyn finally made a doctor's appointment and received a prescription for drugs to help balance her brain chemistry.

Most experts agree that psychopharmaceuticals diminish the effects of borderline personality disorder, but other forms of therapy are necessary too. Borderlines need to learn to set limits and solve problems with reality-based solutions. Carolyn decided that her way of dealing with life would be to surround herself socially and drink. Heavily. After she left Duke, she started sleeping around. She found a boyfriend, then cheated on him repeatedly. Tim cheated on her too. She would yell at him and he would insult her. They spent a lot of time at bars and dance clubs. Then after a few months, Carolyn overdosed on whatever pill she was taking for her borderline personality and Tim couldn't handle it anymore. They broke up.

She started drinking more regularly and more frequently with her parents. She slept with more people. And as she fell short of her perfectionist expectations, she started to give up, falling deeper into the mental constructs of the personality disease that told her she could never be good enough. Faced with failure, she stopped seeing her psychologist. "I was popping Xanax like it was my job," she said.

By the end of October 2003, Carolyn and I stopped talking. She got sick of me telling her she needed to see a psychiatrist for a while and deal with her issues before she could return to college. I couldn't handle her bragging about sleeping with men she barely knew anymore. I heard from Laura that Carolyn enrolled in a new university last January.

Carolyn says she's better. We talked on the phone a few months ago. Actually, she talked. It's still hard to get a word in with Carolyn; and even after all the perspective she claims to have gained during the past year, she has yet to inquire how I am.

"Well, the biggest change in my life since this summer is that I'm totally, completely in love. I'm absolutely in love," she gushes.

Carolyn is in love with Tim. Again. This is the same guy she fell in love with at the beginning of the summer. Who was still dating his "ex"-girlfriend throughout their whole relationship. Who said things to her in bed that were so horrible she cried as she recounted them to me last August. The same Tim she was in love with when she flew to Miami for a weekend to sleep with a 30-year-old man she had met on a cruise.

"Things back then were so different than now," Carolyn says. "I was still all screwed up and on pills and confused, and he had yet to figure out what he wanted."

Carolyn is not screwed up anymore, she says. She is enrolled full time in school as an engineering student. She lives in an apartment with one of her close friends from high school and another girl from college. "I still have yet to figure out who I am friends with," she says, "where I fit in, what I am planning on doing as a career, etc. That is pressure and very confusing, but I am happy in the classes that I am taking. They're a lot easier this time. I think I can just handle it better. And when I am with Tim, I'm just happy."

Carolyn tells about going to parties three or four nights a week, smoking pot once or twice a week and still being able to get her schoolwork completed.

She has decided not to seek any more professional help for her mental issues because she does not believe any doctor knows more about how she should deal with her life than she does. "Hun, hun, hun," she tells me over the phone, "why should I let someone mess with who I am?"

I ask her if she actually thinks she has life under control. What happens if she feels like taking 23 Tylenols again?

"Basically," she says, "I still have a ways to go in order to figure things out and be genuinely happy, but now I feel like I am capable and one day I will reach that goal and whatever goals I set. I do not doubt myself anymore; I know can do it."

I want to believe Carolyn. I really would like to take her analysis of her life at face value. Everything she says about her long term goals sound so sensible. But even as she acknowledges sheepishly that she "probably does" have some kind of chemical imbalance, she refuses to recognize that she might need professional help.

And the more she talks, the more a characteristic of borderline personality disorder echoes through my head: Borderlines can describe themselves for five hours without your getting a realistic picture of what they're like.