Bipolar Expeditions (36 page)

What forces are pushing this expansion? Judging from the Celexa posters at the APA, the marketers and advertisers hired by the drug companies were aiming for an increasingly general understanding of depression so that anyone could imagine being in Celexa's picture frame. But there is also another force in play, which is the desire (by marketers, advertisers, and manufacturers) to make consumers aware that particular drugs target specific conditions. For example, more and more drugs, formerly used as antiseizure medications (Lamictal and Depakote) or antipsychotic medications (Zyprexa), have gained FDA approval to claim that they are effective for bipolar disorder. Bipolar disorder then becomes the focus of advertisements designed to send consumers to doctors in search of a particular drug. In Zyprexa's case, the occasion inspired a television ad featuring a woman who shopped and worked frenetically all day long, and then exuberantly splashed her living room wall with red paint in the evening. The voice-over encouraged the viewer to “tell your doctor about your ups as well as your downs,” so that you can be medicated with Zyprexa for bipolar disorder instead of with an antidepressant. In the fall of 2005 a new drug for bipolar disorder hit the market. Abilify, from Bristol-Myers Squibb, was ushered into public awareness by means of full-page, full-color ads that ran in the front section of the
New York Times
over several weeks. The ad was directed to the consumer: “You've been up and down, with mood swings and relapses. You may have also been misunderstood or misdiagnosed for years before being properly treated…. Abilify may be able to help…. Askyour doctor or healthcare professional if ABI-LIFY is right for you.”
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As a capstone of all these developments, psychiatrists have been publishing books that connect not only New Yorkers but all Americans with hypomania.
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In
Exuberance,
Kay Jamison sets the tone. The first European immigrants to the New World brought with them an “improbable optimism,” as well as ingenuity and vigor. Of these immigrants, only those with the most enthusiasm, possessing “a stupendous energy” and will, undertook to cross the mountains and prairies of the continent. In the westward crossing, “exuberance came into its own—needed and selected for—as a vital feature in the American character.”
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In
The Hypomanic Edge: The Link between (a Little) Craziness and (a Lot of) Success in America,
the psychologist John Gartner surmises with Jamison that the ancestors of contemporary Americans tended to be hypomanic—energetic and optimistic. Because of its strong genetic component, hypomania has come to make up a significant part not just of American character but also of the “American temperament.”
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In his
American Mania: When More Is Not Enough,
Peter Whybrow sees a darker side of American mania. He thinks the biologically wired drive for pleasure and success that fuels mania makes people neglect more satisfying relationships with other people.
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These three books manage to make mania seem more like a thing in two ways. They see exuberance, hypomania, and mania as states that existed in the same form and manifested the same behaviors in earlier historical periods as they do today. They make this claim plausible by attaching exuberance, hypomania, and mania to material processes that would be unchanged over time: the forces of selection (Jamison), the operation of genes (Gartner), or the wiring of the brain (Whybrow). These claims might seem like the essence of contemporary scientific practice. Scientists trace a mental illness to its cause in the brain (opening the hope for a cure, or at least improvement) and describe the social consequences of the illness, sometimes good and sometimes bad. I want to raise questions about what this practice leaves out: if the experiences that sent immigrants to the New World included poverty, famine, religious persecution, and much more besides, did their “energies” have the same meaning as the “energies” of those who later explored the continent or speculated on Wall Street? I suggest it would be misleading to even describe these “energies” with the same term.

Finding grounds for resisting the thing-ness of mania takes us back to John. He told us, “we have seen some vistas” and they should be neither “exalted nor put down.” Peter Whybrow insists that “there is no difference except the context” between genius and derangement. Both statements are different ways of saying that the way manic states are experienced and the effects they have in the world are not fixed. There is no “thing” called mania that is, apart from its context, invariably on the side of heaven or hell, exaltation or despair. The import of manic experiences depends on when they happen, to whom, in juxtaposition to what events and the presence of what persons. In these respects, mania is no different from any other state of mind that exists only through being experienced. Whatever the physical substrate underneath mania, whether it is in the genes or the brain or both, mania is also an experience, constituted, as are all human experiences, by its context and by social imagination that is historically specific.
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Understanding Mania and Manic Depression in Their Contexts

Ironically, the contemporary fashion of identifying famous people from the past as manic depressive may also contribute to making mania appear to be a stable thing. One motive for reinterpreting the past as Jamison does is to shed a salutary light over a diagnosis that shadows many people with stigma. But describing what people experienced in past eras using contemporaryterms can be problematic. Can the behavior of people in a time before the category “manic depression” existed be used as evidence that the condition existed then? In
Rewriting the Soul,
Ian Hacking explores this question for the case of multiple personality disorder (MPD). Hacking builds his case using Elizabeth Anscombe's account of intentional actions, which I introduced in
chapter 5
. Anscombe was arguing against the commonsense view of an intention as composed of an action plus an interior mental state. Looking at the ways we speak of an action as done “intentionally,” she concluded that “intention” in everyday language means something done as an action of a whole person, a moral agent, “under a description.”
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The relevant description would include the past and present social contexts relevant to the person as much as his or her interior states.

To turn to Hacking's study, in descriptions of MPD until the 1980s, there was more than one person inside the individual, and these persons were so independent that they might actively struggle for control. Under these older descriptions, it would be appropriate to speak of intentional action on the part of each person who made up the multiple because each had enough integrity and wholeness to have intentions.
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But in some more recent accounts of multiplicity, under the rubric of disassociative identity disorder, the switch among personalities is involuntary, and hence the criteria for speaking of intentionality are not present in the same way. Hacking suggests that new forms of description made new kinds of intentional action possible. Since the kinds of intentional action that are possible at a given time depend on the particular cultural assumptions that are contained in the languages available for describing action, these new kinds of intentional actions would not have been open to a person lacking those descriptions.
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To elide the difference between the kind of intentionality in the older “aware” multiple and the new “unconscious” multiple would be as absurd as saying two distinct languages are just the same.
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Instead of one unitary condition, MPD, there are minimally two, one organized around an older notion of intentionality, and one introducing new, and not fully realized, forms of intentionality.

Hacking might find Jamison's historical work troubling. When Jamison redescribes artists and musicians who lived in earlier centuries as “manic depressive,” she means that something in their physical bodies, their particular genetic makeup, the formation of their brains, or all of these, conspired to cause their singular behavior: their mood swings, as well as their periods of creativity and fallowness. However, on the phenomenal level, Jamison might agree that Schumann, Van Gogh, and the other nineteenth-century artists she identifies could not have
experienced
their lives as manic depressives because the cultural work that eventually created the linguistic and social category of manic depression had not yet come into being. Whether or not genes or brains could determine Schumann's or Van Gogh's behavior, what their behavior meant to them would have to lie in the structures of meaning contemporary with them, and manic depression was not yet an available category of thought.
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Nonetheless, there were certainly similar ways of thinking in the nineteenth century that did link artistic creativity with some kind of madness, often called melancholia. My point is that the contemporary conception of manic depression was not available then, with the specific features of mania that I have been outlining: its celebration in a wide variety of cultural contexts, its ability to be optimized by means of drugs, and its association with motivation and productivity.

I must stress that the wish to find manic depression as a thing-like entity in the distant past extends far beyond Jamison's work. Ron Chernow, the author of the recent biography of Alexander Hamilton, appearing on
Washington Journal
on CSPAN, responded to a caller from Winter Haven, Florida, who had asked, “The way you describe Hamilton, it sounds as though he had great energy, he was very charismatic, he was smart, he wrote the
Federalist Papers
at the same time as he practiced law, he had a real quick mind and was probably a good lawyer—could he have been bipolar?” Chernow replied,

It's funny you ask that. The very first speech I gave on the book was to a group of doctors in New York and I was talking about these extreme mood swings…. Hamilton who had absolutely superb judgment 90 percent of the time, had absolutely atrocious judgment the remaining 10 percent of the time. As I finished the speech, of the doctors in the audience there was a contingent of psychiatrists who rushed up to the podium and in one voice they said, “Narcissistic or bipolar disorder! We've seen many Manhattan types like this in a clinical setting.” I deliberately refrained (as somebody doing an eighteenth-century biography) from introducing modern psychoanalytic jargon into an eighteenth-century narrative where I think it would be very, very jarring and intrusive but it has struck me since the book has come out from people who are trained in psychology or psychiatry how frequently the terms “narcissism” and “bipolar” come up so maybe there is some truth to it.
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The “truth” to it is how easy it is to see Hamilton's style of acting and being in the world as another form of the “thing” that is contemporary bipolar disorder.

The importance of Hacking's analysis goes beyond correcting anachronisms. What is at stake is whether we understand intentional human action as gaining its meaning in an interior, hidden, and thus socially inaccessible space, or out in the light of social experience. Anscombe worked in a Wittgensteinian mode to move intentionality out from the private interiority of the mind into the space of social interaction, where meaning in language is constituted.
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Wittgenstein conveyed this message through many homely examples.

I tell someone: “I'm going to whistle you the theme,” … it is my intention to whistle it, and I already know what I am going to whistle.

It is my intention to whistle this theme: have I then already, in some sense, whistled it in thought?”
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One would like to ask: “Would someone who could look into your mind have been able to see that you
meant
to say
that?”

Suppose I had written my intention down on a slip of paper, then someone else could have read it there. And can I imagine that he might in some way have found it out
more surely
than that? Certainly not.
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The point is that intentionality resides in the whole complex of events, from the inception of the notion to the execution of the action. We decide whether someone had a certain intention, not by referring to some event or template in the mind, but by whether his or her gestures, postures, words, and actions fit with a socially defined notion of being about to whistle a tune or meaning to say something. Sometimes a mental event (whistling the tune or saying the words in one's head) might precede the action, and sometimes not, but in any case, that interior event could not constitute a final criterion for whether someone was intending to whistle or meaning to speak.

Seeing that manic or depressed behavior gets its meaning from the social context in which it is done is important. People living under the description of manic depression or any other mental illness are automatically demoted to less than fully human personhood by virtue of their putative “irrationality.” Encouraging a sense that their actions, like anyone's, gain their sense from the entire social context, instead of by reference to an internal process, mental or physical, is my goal. This is one way even those who come to think of their serotonin as out of balance can feel they are (and can be taken for) worthy persons and moral agents. Writing down one's intention to whistle is as sure a way to communicate one's intention as anything one might think! Of course not every action can be understood as having sense, no matter how broad the social context we consider. But I think far more actions of the “irrational” sort can be understood—can be recognized as familiar—than we have realized. In the absence of a robust sense of how actions take their meaning from the social context, no amount of positive revaluing of mania will restore full personhood to those living under the description of manic depression.