Bipolar Expeditions (4 page)

Although the term “mental illness” implies that Alice Faye Redd could be cured of what is wrong with her, and although new therapies are available that might cure her, the fear of madness still haunts those diagnosed with mental illness. Madness is a strange and horrible thing: who has not felt this? One of the classics of Western literature,
Heart of Darkness,
gave us the image of Colonel Kurtz, a mad soul wandering in a wilderness inhabited by beings he considers barely human, consumed by desire without restraint, operating outside reason.
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A contemporary anthropological study describes the fear of madness as the terror of looking into the eyes of a mentally ill person and seeing no answering comprehension.
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A contemporary memoir describes the madness of depression as a descent into darkness with a terrifying loss of lucidity.
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In the face of such deep terror, my strategy in this book is to open up the terrain between the comfortable rational and the terrifying irrational, allowing more complex kinds of description to emerge. Most of the tidy dichotomies that float in the wake of the separation between rational and irrational (sane/insane, controlled/uncontrolled, responsible/irresponsible, reasonable/unreasonable) are inadequate to the task of capturing complex experiences like living under the description of manic depression.
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My focus will be on mania for two reasons. First, far less has been written about mania than depression, perhaps because depressive disor ders are more common in the United States than manic depression (depressive disorders are commonly estimated to be found in 9.5 percent of the population over a twelve-month period, compared to 1.2 percent for manic depression).
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Second, mania is the part of manic depression that we will see emerges onto the political economic stage as an object of desire. My argument is that we need to understand the meaning of manic behavior by describing what people do with “mania” and why they do it. In the same way we might try to understand the meaning of a word in a foreign language by noticing all the ways native speakers use the word, I have tried to notice all the ways that “mania” and related concepts and practices are used and interpreted in the different contexts of my fieldwork. The task is complicated because people cannot be aware of all aspects of their behavior. A great deal of what people communicate in their words and behavior is inchoate, beyond articulation in words. For this reason I have taken care to notice aspects of behavior—sometimes fleeting ones—that involve performance and style. On the importance of her own performance and style as a dancer, Isadora Duncan said, “[I]f I could tell you what it meant, there would be no point in dancing it.” The anthropologist Gregory Bateson understood Duncan's remark to mean that communicating her message in words would falsify it: the use of words would imply that her message was fully voluntary and consciously understood when it was not.
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Fully conscious or not, how another person understands one's actions on a certain occasion may well hinge on such things as the effectiveness of one's performance or one's success in carrying off a style. These concepts will be central in my accounts of mania because they allow me to capture nonverbal aspects of meaning and to capture meaning in the moment people are making it.
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Given the importance of language in forming our concepts of mental illness—medical diagnosis and the like—it will be especially important for me to focus on people's actions as well as their words. Habitual actions, outside discourse, can persist in social life because they are relatively immune from being completely overtaken by the terms of discourse. Habitual practices could be said “to haunt objects and the material world.”
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Hence both observing everyday actions and tracking the movement of ordinary ob jects are ways to glimpse forms of agency that are not entirely captured by the terms of discourse.

These tasks complement the task my students took on: although they were defined as psychologically normal, they were able to produce reams of material about “irrational” experiences in their lives. In this book, I describe the behavior of people living under the description of manic depression, showing that their range of meaning-making, inflected by style, achieved through performance, is easily as complex as it is for those described as psychologically normal. Just what people take manic behavior to be—whether it is rational, irrational, or somewhere in between—is not a given. It is a matter determined by people actively trying to place behavior, words, performance, and style in a field of meanings. To keep this issue foremost, I deliberately use the phrase “living under the description of manic depression (or bipolar disorder)” to refer to people who have received this medical diagnosis. The phrase is meant to reflect the social fact that they have been given a diagnosis. At the same time, it calls attention to another social fact: the diagnosis is only one description of a person among many.

Mania is a concept that is used so differently by people in the same setting that it is almost as if the same word is being used in the sentences of different languages. This makes it a fruitful place to see contemporary changes in the significance that is given to manic behavior. What is happening is not completely new—mania has enduring significance that draws on its early twentieth-century formulation—but the concept is being applied in new domains and used to solve new problems, problems that are specific to the present time and place. While I have just written of “new” problems and domains, I do not pretend that what I will describe in this book is altogether new. It would be more accurate to describe what is happening as a shift of emphasis, a refocusing of the lenses through which we look. Broad notions of self-improvement, cyclic emotion, brain-based mind, and creative insanity have long been abroad in American society. But, as usual, the devil is in the details: my goal is to describe not a completely new set of concepts but rather an intensification of many old concepts that has made it possible for Americans to think about social life and about their psychic lives in new ways.

Brains and Genes

Cultural aspects of knowledge from the brain sciences are not a major focus of this book, largely because this knowledge, though central, did not play a dynamic role in the main settings of my fieldwork. The belief that the brain and its genetic determinants lie behind mental disorders like manic depression was simply assumed by most of the people in my fieldwork, inside and outside medical settings.
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In the course I took on neuropsychology during my fieldwork, we students dissected our way, week by week, through a sheep's brain. To understand psychological phenomena like attention or perception, we would have to understand the physical workings of the brain. This meant not only knowing the names and locations of brain structures, but also learning how to see them, and to separate them with a knife from the gray, gelatinous mass of brain tissue. In California, where research on brain imaging is a particular focus of university neuroscientists, many scientists I met were involved in ongoing efforts to correlate specific images of brain activity with specific disorders. More generally, there were increasing numbers of media articles picturing the activity of the brain (through PET scans and MRIs) and claiming to correlate brain states and conditions like emotion, addiction, schizophrenia, or criminality.
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Lately these claims have begun to reach an astonishing degree of specificity. One group reported that Democrats and Republicans had different brain states when they watched campaign commercials.
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Reflecting an awareness of these news items, people in support groups I attended would quite commonly remark that they had volunteered as subjects in local university or hospital research on brain imaging and bipolar disorder. In group discussions, people often made remarks about having disordered or unbalanced “brain chemistry,” which they hoped the drugs they were taking would fix. Since having a physical malady has far more validity in Western culture than having a mental one, people usually greeted new evidence that bipolar disorder is a “brain disease” as welcome news because of the generally accepted belief that physical ailments can be cured and, in the meantime, would be covered by health insurance, disability payments, or compensation claims.

As for the genes that we may regard as responsible for the shape of our particular brains, people in support groups would often bring in newspaper clippings of scientific researchers' efforts to identify genetic and anatomic locations for manic depression. This was invariably done in the hopeful spirit, identical to the spirit in which most such articles are written, that locating the right gene or genes would lead to a specific treatment for the root cause of the problem. Perhaps because genetic research into the causes of manic depression has not yet reached a plausible conclusion, let alone developed therapeutic interventions, concern with this level of understanding among people in my fieldwork, outside research labs, was at a fairly general, taken-for-granted level. Most people hoped and believed that in time more effective treatments for psychic disorders would come along, and they would act directly, somehow, on genes, the brain, or both.

Although the topic of brains and genes was not often the subject of dispute during the years of my fieldwork, it could still give rise to drama. Some of my interlocutors living under the diagnosis of manic depression told me that given the presumption that the condition has a genetic component, they wondered about having children. The condition might be—whatever its value for creativity and productivity—too painful to risk bringing on one's own. Some knew of the brutal way Kay Jamison (a psychiatrist who has written about her own manicdepressive illness) was advised by her doctor not to have children.
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Others knew of a scene in Stephen Hinshaw's book about his bipolar father, Virgil Hinshaw: Kay Jamison visited Stephen's medical school class and proposed a hypothetical question. If in the future, a prenatal test were available that could detect a gene that was strongly linked to bipolar disorder, how many would elect to abort if their fetus received a positive diagnosis? Almost all of the twenty-odd medical students, interns, and staff in the room raised their hands.
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In these cases, fear of mental illness is enough to make manic depression seem incompatible with life.

Many people in my research believed that neurons and neurotransmitters in the brain affected their mental states.
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In support groups, I frequently heard people discuss their ideas about how low serotonin levels cause depression and how medication can raise the level of sero tonin. Although most people treated the brain and its neurotransmitters as stable givens determined by their genetic makeup, they also assumed that drugs could modify the brain and its neurotransmitters.
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In this book I do not deal extensively with the brain or genes, but I do not mean to imply that brain chemistry is unrelated to a scientific understanding of manic depression or to patients' experience of manic depression. I often heard from my psychiatrist that my problems were related to my neurotransmitters, and I always found this comforting. I took this to mean that my problems were not entirely within my control.

The Drug Factor

It is difficult to estimate with certainty whether the prevalence of mood disorders is increasing, but there is widespread public belief that it is.
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For those who have access to information and health care, enhancement and modulation of moods through drugs has become as matterof-fact as driving a sportutility vehicle down the highway.

The one glimpse I had of the kinds of databases that the pharmaceutical industry has access to showed me that the rates of prescriptions for antidepressants and antipsychotics (increasingly used for mood disorders) had recently increased about two and a half times, from 51,003,000 in 1991 to 133,782,000 in 1998.
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In 2006, a national survey reported in the
New York Times
found that prescriptions of “potent” antipsychotics for children and adolescents had risen fivefold from 1993 to 2003.
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To understand the ways in which drugs become available, we will have to confront some forces that seem driven by the profit motive. For example, the Republican administration made determined efforts in 2004 to prevent the lowering of domestic prices for drugs by blocking European countries from exporting cheaper drugs to the United States and by delaying competition from generic drugs.
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When I was lecturing in Iceland in 2003, I visited a medical conference that had attracted numerous sales representatives from the major pharmaceutical companies. I asked the representatives at one booth why they had come to Iceland, with its small population and lack of direct-to-consumer (DTC) advertising. The reps explained that they expected Iceland to be the first European country to permit DTC advertising. They were there to make connections with fledgling patient support organizations for depression and other conditions, and to support them financially as they have done in the United States. Presumably, people suffering from depression, manic depression, anxiety, panic, and other harrowing conditions will benefit from strengthened organizations that work on their behalf, not to mention from greater access to and information about drugs that can lift the spirit, smooth the brow, and ease despair.