Bipolar Expeditions (5 page)

Intro. 2. Refrigerator magnet showing antidepressant and anti-anxiety drugs as highway signs. Courtesy of Ephemera-Inc. © Amy Hill.

A reader might judge these benefits to be sullied by the commercial motives that propelled the development and promotion of psychotropic drugs in the first place, but even the most aggressive commercial campaign can have intriguing multiple effects. Pharmaceutical marketers are no strangers to the kinds of cultural nuances that surround how mental life is imagined. They are studying these nuances, often with the help of ethnographers on staff in their companies. But they have different aims in mind. For example, there is a sophisticated effort in play to introduce drugs for depression in Japan. This effort began when Solvay Pharmaceuticals and the two Japanese companies that shared rights to sell an antidepressant called Luvox decided it would be necessary to change the language Japanese people used to describe depression. Since the original word, “utso-byo,” was associated with severe psychiatric illness, they began to substitute “kokoro no kaze,” which loosely means “the soul catching a cold.” This phrase, meant to imply that depression is a simple malady whose symptoms can be treated, contributed to sales of Luvox and to efforts to introduce similar drugs, among them Paxil and Zoloft.
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One effect of the companies' efforts might be to increase the social acceptability of mental disorders, but it is disquieting that the drug comes first and the disorder it is said to cure comes second.

Mania is like a new continent with a distant frontier, whose receding horizon invites exploration and development, promising profits to pioneers. To extend the metaphor, many “developers” have been attracted to the riches of this land, where they have begun to exploit manic behavior as a promising source. Specialized companies actually help corporate work teams learn
how to be
manic. In no case is the development of methods of managing mania a simple matter of exploiting or manipulating people. In order for such management methods to capture public attention and compel action, a cultural proposition about the necessity of continually improving the person must already exist. This proposition builds on the longstanding American tradition of self-help through psychological knowledge,
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but now greatly intensifies it. No person has an option about pursuing his or her development and the task is never done: the horizon of development is ever receding and the landscape that affects
how
one should develop is continuously changing.

The development of a large new array of drugs to alter and enhance psychological states has changed the psychological environment for everyone, inside and outside the categories of mental illness, although not, of course, for everyone in the same way. The familiar debate over whether a person with mental illness is capable of rationality is changed beyond recognition when people in every corner of society are thinking about enhancing their mental processes and when domains like mania that were formerly categorized as irrational have become a new continent waiting to be tapped for the sake of greater creativity and innovation, and, ultimately, greater productivity and profit.

A Short History of Manic Depression

Where did the category of “manic depression” come from? Its history goes back to the ancient Greeks, who thought that the health of the body was related to the four body humors: blood, phlegm, choler (yellow bile), and black bile. Because one's character and health reflected whichever of these fluids was preponderant, a person could be sanguine, phlegmatic, choleric (bilious), or melancholic. Some traits that would look like depression today belonged to the melancholic humor and some that would look like mania today belonged to the choleric humor. The Greeks believed that mental derangement could involve imbalance among the humors, as when melancholy, heated by the fluxes of the blood, became its opposite, mania. Faced with such an organic cause, they might attempt to restore humoral balance by bleeding or purging.
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In classical thought, the causes of madness were thought to be much broader than physical imbalance. In Plato's account in the
Phaedrus,
manias could be caused by inspiration—from God, from poetry, or from love. A much later text greatly influenced by classical thought, Robert Burton's
Anatomy of Melancholy
(published in 1621 and still in print), listed a wide range of causes for melancholy, including faulty education, stress (he cites too much studying), childhood influences, heredity, supernatural elements, Satan, the stars, God, a bad nurse, poverty, and much else.
⁴⁵
Nor were these causes easy to classify as divine or demonic: in Christendom, especially, there was a heated debate about how to tell whether madness in the form of mania was divinely inspired, a form of spiritual rapture, or demonic, a form of frenzied lunacy.
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In mania, because the soul had partly or wholly escaped the restraint of the body, the result could be sublime (one could be lifted into a transcendent state) or frightening (one could descend into a bestial, obscene condition).
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In later antiquity, some writers began to identify states other than the humors, which contributed to health. Galen wrote about the “nonnaturals,” which included the passions, and set them alongside the humors. For Galen and other later medieval scholars, keeping the passions in balance was as important for mental and physical health as keeping the humors balanced.
⁴⁸
However, they still believed that the primary cause of insanity lay within the intellect rather than within the passions. Melancholia, for example, involved loss of acuity of an intellectual sort (a mixture of irrationality and impaired behavior) rather than disordered emotions. A specific emotional state such as sadness or fear was neither a necessary nor a sufficient condition for insanity.
⁴⁹
The emphasis on the intellect as the domain of sanity—a sound mind as the basis of rationality—reached its apex in the philosophy of Descartes and other seventeenth-century thinkers. In this period, theories of insanity moved away from emphasis on the demons and humors of classical thinking. Enlightenment theorists provided no detailed account of insanity, but left it by default to a defect in the body or to a defective connection between mind and body.
⁵⁰

The idea that disorders of the emotions could be responsible for insanity emerged in a halting way. After 1800, adherents of “faculty psychology” began to regard emotions as one of the separate powers of the mind, alongside others such as the will and the intellect.
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Faculty psychologists acknowledged that there might be disorders of the emotions, or affect, and in line with this, they proposed emotional forms of insanity.
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But even those most interested in including the emotions as a cause of insanity failed to develop a systematic account of what different forms of emotion meant to those experiencing them.
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Darwin hindered the chance of developing a more sophisticated understanding of affect because he believed that the emotions were registered so deeply in the organism that no individual experience could account for them. According to Darwin, the emotions were the result of our evolutionary past and revealed our animal origins. Hence, individuals' subjective experiences would not shed much light on their emotions, a view that left by the wayside doctors who tried to understand patients in terms of their individual lives.
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In spite of Darwin's impact, under the influence of faculty psychology in the second half of the nineteenth century, mania and melancholia were narrowed down and redefined as “primary disorder[s] of affect and action.”
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These new forms were “combined into the new concept of alternating, periodic, circular or double-form insanity.”
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This process culminated in Emil Kraepelin's concept of “manic-depressive insanity,” which included most forms of affective disorders under the same diagnostic umbrella.
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Drawing on thousands of clinical cases in Germany, Kraepelin reclassified all known mental illnesses into two major categories: dementia praecox (later renamed schizophrenia) and manic depression. In this bold reorganization, referred to as Kraepelin's synthesis, one major category (dementia praecox) was a malady of the intellect; the other (manic depression) a malady of the emotions.
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He distinguished emotional maladies from intellectual maladies: emotional maladies were periodic, more benign in prognosis, and common in family histories.
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Since Kraepelin thought of manic depression as a disease, he assumed that eventually a specific cause would be discovered and the invariant course of the disease would be described, just as the specific natural history and pathophysiology of pellagra (vitamin deficiency) and syphilis, both of which were believed to affect the central nervous system, already had been.
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Kraepelin's synthesis continues to operate with force in contemporary psychiatric taxonomies, shaping the division between cognitive and affective disorders.

The other psychiatric school of thought that developed ideas about the etiology of mania and depression in the early twentieth century was psychoanalysis. In his early writings (1917), Sigmund Freud saw melancholia, an “open wound” that drains the ego until it is “utterly depleted,” as a loss or disappointment that was turned inward against the ego. He recognized that some patients alternated between melancholia and mania but could not at that time devise an explanation that satisfied him.
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By 1923, Freud saw that when melancholia takes hold, it is a result of the person's “excessively strong super-ego,” which rages sadistically against the ego and can drive the ego into death, if the ego “does not fend off its tyrant in time by the change round into mania.”
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Mania, therefore, is the ego's defense against the destructive impulses of the super-ego. More influential in England than in Europe or the United States, Melanie Klein developed the notion of the “depressive position,” something the healthy psyche achieves in the first year of life. The depressive position, in which the person recognizes herself as separate from others and as a result has to contend with feelings of loss, mourning, and sadness, can give rise to the “manic defense.” Out of a wish to avoid the pain of the depressive position, the person uses a sense of omnipotence (manic activity) to master and control the threat. Hence, for Klein, depression and mania could both be part of normal development, though ideally the manic defense would eventually give way to other forms of accommodation to the depressive position.
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Alongside these developments in psychiatry, popular representations of mania and manic depression took many turns from the beginning of the twentieth century to the present. From the start of the century until the 1940s, judging from my reading of popular magazines and newspapers in the United States, neither mania nor manic depression was mentioned with any frequency except in relation to a frightening kind of insanity.
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News stories about people with manic depression described uncontrollable impulses that led to violence or self-destruction. These headlines illustrate the tone: “Maniac Kills Man by Push on Elevated [railway]; Says He Acted on Irresistible Impulse in Causing Death at First Attributed to Fall” (1929)
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; “Mrs. Fosdick Kills 2 Children and Self; Lawyer's Wife, Deranged for Years, Shoots Daughter, 16, and Son, 10, as They Sleep” (1932).
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Closer to the 1940s, articles with sensational headlines about deranged maniacs become hard to find. The appearance of the first reports of chemical means to treat mental illness could have been responsible for a reduction in fear of the out-of-control “mentally ill.” “Chemistry of Insanity” (1938) describes new therapies using insulin and Metrazol shock therapy and new technology, such as the electroencephalograph, that could reveal different brain electric waves in different forms of mental illness.
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“New Vistas Opened for Chemical Approach to the Treatment of Mental Illnesses” (1947) and “Chemical's Cure of Insane Is Seen” (1947) describes continuing technological advances in visualizing brain function and evidence of physical differences between normal and “mentally ill” patients' brains.
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From the 1940s to the 1960s, the tone in descriptions of manic depression is tinged with sorrow. An episode of the television show
Manhattan
(1960) featured a heroine who was driven to manic depression by her villainous husband.
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The victim in this episode was seen as helpless, but in other cases, the manic-depressive person was exhorted to improve. In lectures given in New York to Red Cross home nurses to prepare them to care for returning war veterans, manic-depressive patients were described thus: “They don't deviate too much from normal people—except they go too far. They are over-elated. They overtalk, over-act. They cannot settle down to things that are part of daily routine.” The cause of this is that these individuals have denied themselves simple pleasures over the years, in favor of working too much. As a result, there is “an accumulation of tension and a final blowing off into a manic-depressive stage.” These people need to be shown “how vitally important it is for them to tone down their excessive energy and to give some of it to the enjoyment of simple human pleasures.”
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I have been able to find only a handful of book-length biographies or autobiographies from the turn of the century to the end of the 1960s that mention the subject's manic depression. By and large, reviews of these books only obliquely, if at all, associate manic depression with talent or virtue. A minor character in a biography of the Robert Pearsall Smith family suffers from manic depression in old age and becomes an “intolerable old man.”
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Lawrence Jayson, the author of an autobiography from 1937 titled
Mania
does not spare the reader accounts of his suffering and subsequent suicide attempts. In this book, unusual for its time, the author juxtaposes the states of mania and depression with his experiences at work, for good or ill. On the one hand, his coworkers try to draw on his “high powered salesmanship” to save an account; on the other, he fears that if he fails, this will precipitate another cycle of depression.