Susanna Kaysen did not read “the charges against [her]” until twenty-five years after her time at McLean. During her hospitalization, all her doctors and nurses had told her was that she had been diagnosed with a “character disorder.”
The fact that Susanna was never informed of her actual diagnosis highlights the webs of isolation and manipulation which structured life on the psych ward.
Susanna had to hire a lawyer who would help her obtain her records from the hospital, and even then locating her exact diagnosis required her to pore over her admission and discharge forms and cross-reference them with the Diagnostic and Statistical Manual of Mental Disorders. She considers her diagnosis a “fairly accurate picture of [herself] at eighteen,” minus a few behaviors such as reckless driving and binge-eating. She is tempted to refute the diagnosis, but notes that resistance and defensiveness are two hallmarks of BPD.
Kaysen has spent years excavating the records of her own personal medical history and parsing them to discover what it was that sent her to the hospital in the first place. In this tongue-in-cheek passage, Susanna admits that certain things she reads about her diagnosis ring true, and other things to this very day seem to mark her as a sufferer of the very diagnoses she wishes to challenge.
Rather than refute it outright—though she clearly is in some disagreement with it—Kaysen begins to annotate her diagnosis for her readers. She makes her way through the DSM entry on the disease, starting at the initial definition. She starts by noting that the “uncertainty about self-image, sexual orientation, goals, [and] types of friends or lovers to have” still manifests in her life sometimes. When meeting new people, she constantly asks herself if the person she’s bringing into her life is the right kind of person to bring into her life.
This section of the novel is marked by a major contradiction. Susanna wants to challenge her diagnosis, but admits that a contrarian nature is a hallmark of the disorder, and further concedes that some of the instabilities and alterations in perception that the disorder causes still infiltrate her life. Susanna wants to get to the bottom of whether her diagnosis was correct all along, or whether doctors were simply sensationalizing her symptoms and attempting to isolate and contain someone who was too “contrary” for their liking.
If the diagnosis had been bipolar illness or schizophrenia, Kaysen says, she would be “blameless” in falling ill, and would be seen as a “real” insane person. She wonders what “borderline personality” even means, and concludes that it seems to be a “way station” between neurosis and psychosis in which the psyche is “fractured but not disassembled.”
Susanna has expressed multiple times throughout the narrative her insecurity about the nature of her disorder—specifically, that it points to a fault in her personality or her character rather than a neurological problem in her brain, which would not be “her fault.” She feels that the nature of the disorder places her, for all of her life, in a constant state of flux between being merely fractured or unstable and being “disassembled” and truly insane.
Kaysen notes that she sees what is diagnosed as “borderline personality disorder” as simply a description of what it is to be an adolescent. The only thing that took her by surprise about her diagnosis was the description of self-mutilation; as a teenager, Susanna would bang her wrist repeatedly on the edge of a metal butterfly chair she had in her childhood bedroom, creating a “cumulative injury.” She’d had an earlier fascination with face-scratching, but found that it was too noticeable. Wrist-banging became the only way that Susanna could communicate or demonstrate her interior pain.
Susanna struggles to reconcile the qualms she has about accepting her diagnosis with the fact that she did, as a teen, exhibit one of the most telltales signs: the desire for self-mutilation. Susanna was in such inner turmoil that she needed a way to try to relieve it, and saw self-harm less as a cry for help than a shout into the void.
Kaysen, as an adult, feels that her misery “has been transformed into common unhappiness,” and so she is classified as “recovered.” She wonders whether her personality has truly crossed back over whatever “border” it had approached during the time of her illness. Susanna argues that her self-image was never unstable: she recalls seeing herself, as a teenager, as “unfit for the educational and social systems” around her. In fact, it was her parents’ and teachers’ image of her which was unstable and out of sync with their wishes for her. Her teachers often told her she was a nihilist, and her parents fretted over how she would make a life for herself out of her only discernable interests: boyfriends and literature.
Both the nature and appropriate measure of recovery are called into question in this passage, as Susanna considers what it means to have “recovered” from a disorder of the personality or “character.” She is still unhappy, she says, but in a more “common,” quotidian way. Her pain still exists, but is manageable, and she has continued forth on a career path which many around her considered untenable, achieving success in her writing and her life. She has, for all intents and purposes, made a recovery and gotten distance from the “border” of insanity, but now wonders what exactly that means.
The result of such constant, overwhelming scrutiny, Kaysen says, was “chronic emptiness and boredom”—yet another major hallmark of BPD. Susanna felt anger at her being “shut out of life,” and while her classmates invested in their futures, Susanna become the first person in the history of her prestigious school not to go to college. Emptiness and boredom, Susanna says, is an understatement concerning the “complete desolation, despair, and depression” she felt as a teenager. Susanna concedes that she probably was crazy, though at the time she constantly belittled herself and told herself that all she needed was to pull herself together.
As Susanna more carefully delves into the memories of the feelings she experienced during her adolescence, she admits that she was probably suffering from a “craziness” which manifested as Borderline Personality Disorder. Susanna, a bright girl who felt squashed by others’ expectations of her, did not want to—and still, seemingly, does not want to—admit that she had a real problem. She has instead spent her life putting effort into pulling herself up by her bootstraps and trying not to get sucked back across the “border.”
Announcing that she has a few more annotations to make, Kaysen considers the following sentence: “the disorder is more commonly diagnosed in women.” The DSM does not state that “the disorder is more common in women,” and Kaysen chastises the writers of the manual for not even bothering to try to “cover their tracks.” Many disorders are more commonly diagnosed in women, Kaysen argues, such as “compulsive promiscuity.” She observes that the gulf between the label of “promiscuous” in men and women is unfair.
Susanna arrives at one of the most groundbreaking points of the whole book as she points to the unfair way in which women’s psychological issues are diagnosed based on a double standard. Men are not as commonly diagnosed with BPD or other“character” disorders of its ilk, and Susanna posits that this is due to the exceptions, allowances, and excuses that society is wiling to make for men that it is not willing to make for women.
Though Susanna avoided “premature death,” one of the major “complications” of her disorder, she admits that she thought about suicide almost constantly in order to make herself feel better about things. Susanna was never seriously suicidal, she maintains, but for someone like Daisy, she wonders if suicide is indeed a “premature” death. She doesn’t believe Daisy should have been made to sit in her “eat-in kitchen with her chicken and her anger for another fifty years.”
Susanna wonders—again playing with societal perceptions—what a “premature death” means in a case like Daisy’s. For someone as trapped in a world of ritual, manipulation, and misery as Daisy was, it is unclear whether suicide was a “complication” of her disease or the only way of finding freedom from it. Susanna does not believe that society’s ideas of the “right” way to treat mental illness are always in line with the reality of what those suffering from mental illness actually want or need, especially when it comes to mentally ill women.
Kaysen wonders if she was just “flirting with madness,” the way she flirted with her teachers and classmates. Though she was often afraid she would become crazy, she was never actually convinced that she was, and she now wonders whether constantly questioning her insanity was and is a veritable mark of her sanity. To this day, Kaysen writes, she finds herself asking herself—and others around her—if she’s insane. She’ll wonder if she’s said something “crazy,” or preface a controversial line of thought by saying “Maybe I’ve gone totally nuts.” Though “crazy” is a common enough phrase, it is evocative and specific to Kaysen—it represents McLean, and it represents the “ever-shifting borderline” that continually beckons to be crossed. Susanna, at last, has no desire to cross it ever again.
After a detailed annotation of her disorder and an investigation of her own memories and recollections of the time just prior to her hospitalization, Susanna Kaysen is still without answers when it comes to the landscape of her mind. She still isn’t sure what constitutes “crazy.” Her perceptions have been so skewed by society’s extreme sensitivity to “insane” behavior, and though she has been qualified as “recovered,” this uncertainty leaves her afraid to re-encounter the feelings and behaviors of her youth which brought her to the “borderline” of her own self in the first place.