Why Are We So “Ill?”: A Review of Sarah Fay’s “Pathological: The True Story of Six Misdiagnoses”

From the iridescence of the Loop to the infamous two-flats of Chicago’s neighborhoods, Sarah Fay’s nonfiction debut is just as much about place as it is about mental illness and misdiagnosis. Spanning twenty-five years, “Pathological: The True Story of Six Misdiagnoses” recounts her personal struggles suffering from “serious mental illness” (not to be confused with “any mental illness”) with Chicago playing a role in the care she received—or didn’t. As a memoir, the book places us right there with her as she experiences SSRI withdrawal symptoms underneath the Wabash El station; wanders Northwestern Memorial Hospital for a psych unit that’s not there; and gets mansplained to by a Freudian whose office overlooks He-Who-Must-Not-Be-Named Tower.

Yet the book isn’t a “classic mental-illness memoir [or] quest story” as Fay specifies in the Prologue. The “I” does more than reflect, recall and reconfigure the messiness of mental illness into a neat narrative arc. Instead, it also investigates, complicates and critiques the systems that enable the chronic misdiagnoses or overdiagnoses of mental health patients. Joining the intimacy of memoir with the precision of research, Fay’s book demonstrates that while mental illness is real, the diagnoses are theoretical; that is, in her pages we discover there’s no biological or objective test that mental health professionals can use to assess with certainty whether a patient may have Bipolar I versus Bipolar II versus something else. An obvious conclusion when you first read it, but one that’s obscured by the “mental health industrial complex.”

Fay’s book not only crisscrosses through the Windy City with stints in Iowa and New York but also covers the discursive terrain of Big Pharma’s marketing campaigns, the media’s predilection to promote “false epidemics,” and the pathology of pop culture (think TikTok therapists, Buzzfeed listicles on ADHD, Khloe Kardashian as the face of Nurtec…) to ultimately identify the crux of these issues: “The Diagnostic and Statistical Manual of Mental Disorders (DSM).” Because it’s positioned as “psychiatry’s Bible,” its stakeholders willfully or naively tout the DSM’s mental health diagnoses as one-hundred-percent valid and one-hundred-percent reliable. They aren’t. To be clear, Fay does not want us to throw out the DSM entirely; instead, she’s made it her mission—check out her activism at Pathological: The Movement—to raise awareness that our diagnoses (barring a few exceptions) are subjective. It’s okay to question them and, in some cases, refuse them.

Sarah Fay/Photo: Maria Rosenfeld

The place Fay feels most at home is the classroom. (I took a class in creative writing from her a while back.) In the chapter “On Suicidal Ideation,” Fay writes about pushing through dissociative symptoms to continue teaching college courses in Chicago. We all receive a dose of this teaching ethic because “Pathological” is also about punctuation. Literally. Each of the fourteen chapters focuses on one punctuation mark in the English language and discusses its origins, evolution and even common usage errors. It’s the best part of nonfiction: discovering the prose that stands on its own, resisting a black-and-white characterization on what fits in a memoir or investigative text. Other goodies include mini-allusions to “Jane Eyre,” M.F.K. Fisher and Kurt Cobain. Yet for this review, I’ll end on a quote from another Byronic rocker (sorry Kurt!) that encapsulates the spirit of Fay’s book: “Words got me the wound but will get me well.”

Pathological: The True Story of Six Misdiagnoses
By Sarah Fay
HarperOne, 320 pages