Dr. H’s office sat high above Michigan Avenue in Chicago, and on clear days the view took in a long sweep of the city I loved—the lake flat and silver to the east, the grid of streets extending westward. The office itself was full of books and small sculptures, the room of a man who believed the psyche was a thing worth taking seriously. I had found this reassuring once.

By the summer of 2016, sitting in the chair across from his desk, I could no longer feel the city below as something that belonged to me.

When I asked him what he thought was wrong with me, he offered two diagnoses: major depressive disorder and generalized anxiety disorder. Both came from the DSM, psychiatry’s diagnostic manual. Both were delivered with the confidence of a man who had practiced for 40 years.

Neither fit.

For over three decades, I had never experienced depression for any significant stretch of time. I was constitutionally, almost aggressively optimistic—the friend people called when they needed cheering up, not the one who called in distress. Anxiety before a lecture or a deadline, yes, but a clinical disorder? The labels felt like a coat cut for someone else’s body: technically mine, functionally wrong, a daily reminder that the person being treated was not quite the person who had arrived.

What I could not yet see—what no one in that room could see—was that my suffering was real but had been misidentified at its root. I was experiencing the crash side of a bipolar illness that would not be correctly named for another four years. And something else was happening that neither checklist nor clinical interview could reach: a syphilis infection, progressing quietly through my nervous system, mimicking psychiatric illness with eerie precision.

Syphilis is called “the great imitator” for a reason. It can produce anxiety, insomnia, cognitive fog, and mood instability. It can rewrite experience from the inside, molecule by molecule.

Yet no one ordered a blood test. We were speaking serotonin.

The Roulette Wheel

What followed was a high-stakes game of pharmaceutical trial and error. When one medication failed, we tried another. When trazodone brought no relief, we moved to hydroxyzine. When that did nothing, Dr. H prescribed seroquel, a powerful antipsychotic.

Each new prescription carried the implicit promise that relief lay just one adjustment away. Each failure felt less like a data point in an uncertain science and more like evidence that something was fundamentally wrong with the process itself.

The practice has a clinical name—polypharmacy—and it is widespread enough to have raised serious questions about the quality of mental healthcare in America. The wheel keeps spinning because the system is designed to treat symptoms, not to locate causes.

But Dr. H was not the only one spinning it. Over the course of four months in 2016, I was evaluated by four different hospital systems, in addition to my longtime outpatient psychiatrist. Not one of them questioned the original diagnosis. Not one ordered a comprehensive history and physical. Not one, despite my identity as a gay man in a period of high-risk sexual behavior, ordered an STD panel. Each institution accepted the labels it inherited from the last, added its own prescriptions, and passed me along.

A cardiologist who saw a patient with recurring chest pain likely wouldn’t simply prescribe anti-angina medication and move on. She would investigate the cause of the pain. Yet in psychiatry, I felt like I was handed the equivalent of a pain reliever and sent home, again and again, by institution after institution.

My mother kept asking the question that none of these institutions were structured to ask: What was the source of my anxiety? Where was it coming from? She had no more answer than I did. But she was the only one asking.

The psychologist Gary Greenberg, in The Book of Woe, describes the DSM as “an anthology of suffering,” not a map of diseases but a catalog of the ways people commonly hurt. The diagnostician’s job, he writes, is to find the disease that unites scattered symptoms and “makes them manifest in precisely the way they do.” But even in the best cases, “nature gives up its secrets grudgingly.”

Psychiatry Essential Reads

The DSM offers symptom checklists. It does not, in most cases, offer causes. Where every other branch of medicine categorizes illness by both its symptoms and its underlying mechanism, psychiatry can typically offer only the former. There are no blood tests, no biopsies, and no imaging studies that can isolate depression or bipolar disorder. Those diseases cannot be found in tissue.

This made my diagnosis a particular kind of trap. The labels were not “wrong” the way a misread X-ray is wrong. They were incomplete in a more dangerous way: They described what I appeared to be suffering while actively obscuring what was causing it.

And unfortunately, the antidepressants prescribed to treat my supposed unipolar depression were the very class of drugs known to destabilize a bipolar brain. Each prescription, written in good faith, pushed me further into the illness it was supposed to be pulling me out of.

The Question No One Asked

Four months after I left Dr. H’s care, I nearly died. A suicidal overdose left me in a coma for six days. The drugs I swallowed one Monday morning were the very ones that had been prescribed to help me: trazodone, seroquel, lexapro, buspar. The instruments of treatment became the instruments of crisis.

When the blood test was finally drawn in the aftermath, the syphilis diagnosis arrived not as a surprise but as a kind of grim revelation. The body had been keeping score all along.

Even then, the system did not course-correct. The psychiatric team that treated me for three weeks after the overdose conducted no deeper investigation. They did not explore whether earlier manic episodes, which were present in my history, had anyone looked, might point to a different diagnosis. My mother asked to be present during their assessments. They declined. They did not interview her or my father independently. They discharged me with the same diagnostic labels and the same class of medications.

I do not tell this story to indict any single clinician. The historian Anne Harrington has written that biological psychiatry, by the early 21st century, had “overreached, overpromised, overdiagnosed, overmedicated, and compromised its principles.” Every clinician I encountered was working precisely as they had been taught. The failure was architectural, not personal.

But the cost was personal. Years of misdiagnosis fed years of polypharmacy, which fed a destabilization that the correct diagnosis, delivered earlier, might have prevented. The bipolar disorder that no one identified until 2020 had been building throughout the years of wrong prescriptions. The syphilis that no one tested for had been inflaming a brain already vulnerable to mood disorder. The two conditions fed each other in a spiral that the system’s symptom-first architecture was not designed to interrupt.

What my mother was asking—where is this coming from?—was the question that could have interrupted it. Not because she had clinical training in psychiatry, but because she knew me. She held the longitudinal knowledge of who I had been before the illness arrived: optimistic, driven, constitutionally incapable of the depression I was being told I had. That knowledge was a diagnostic instrument the system did not know how to use.

The coat Dr. H handed me was not made for my body. But it was the only coat the system had. And so I wore it, and the wearing of it carried me further from help with every passing month toward a manual that had been stitching coats like mine for decades, and whose seams, as I would come to learn, had never held.