NOVEMBER 22, 2017
A SHOW OF HANDS: If you knew the baby in your womb would become manic depressive, would you abort? A psychiatry professor polled her class in 1981. Many of her students had only just encountered bipolar disorder for the first time, at UCLA’s mood disorders clinic. They saw patients hospitalized at their worst: suicidal, psychotic, agitated. Most of the young therapists raised their hands. Why not spare this suffering? But one held his firmly on the table, and thought of his father. He didn’t know his professor also had a secret.
The student was Stephen Hinshaw, now a professor of psychology himself, at UC Berkeley. If bipolar babies were systemically aborted, he wouldn’t be alive. As for his professor, she was Kay Redfield Jamison, a leader in bipolar research. Years later, in 1995, Jamison published her memoir, An Unquiet Mind, about her life with manic depression. Six other books met great acclaim, including the medical textbook Manic-Depressive Illness. If doctors screened out people with genes for bipolar disorder, creative people like her would have been aborted: Edgar Allan Poe, Hemingway, and Robin Williams; Charlie Parker, Amy Winehouse, and Kurt Cobain; Walt Whitman and Robert Lowell. Hinshaw’s father likewise would have been aborted. So would I.
Stephen Hinshaw has penned a new memoir about how mental illness affects his gifted family. While not bipolar himself, he is heir to moody genes. This legacy, he argues, can be like family silver or inherited fame: at once a burden and a bounty. All families face the same struggle — to get along despite difference, and to forgive their kin for sins they can’t help: the nagging, the flighty carelessness, the drinking problem, the workaholism, the diatribes at Thanksgiving, the tacky gifts. But moody genes raise the stakes. They intensify the turbulence. Add the secrecy and stigma that mental illness brings — everyone embarrassed, together — and you have a recipe for alienation. Or for closeness.
“The story of the Negro in America is the story of America,” wrote James Baldwin, who also coined the title Hinshaw chose for his book: Another Kind of Madness. Racism, Baldwin meant, is America’s dark secret — an open secret. Something similar is true of mental illness: it’s a glaring but often unspoken shame embedded within the human family at large.
Another Kind of Madness is not so dark, though. It’s a relatable tale of a Midwestern boy’s coming of age and his bond with his father — sometimes mad, but mostly kind, energetic, and smart. Virgil, the father, is a philosophy professor at Ohio State University when we meet him, with degrees from Stanford and Princeton. His son recounts how, when he was a child, his father periodically disappeared for months, without explanation. Then he’d reappear, also without explanation — making coffee at the kitchen sink, preparing lectures as if there had been no absence. Once Steve reached college, his dad opened up about his schizophrenia and the mental hospitals where he’d been treated during those absences, often brutally, since the 1930s. Later, between Harvard and grad school, Steve realized his father had been misdiagnosed for 40 years: his episodic manias were not typical of schizophrenia. Virgil then started taking lithium, a drug newly approved in 1974. The same salt has kept me sane for over five years.
Another Kind of Madness toggles between registers. By inhabiting two selves — Stephen Hinshaw, PhD, expert on mental illness; and little Steve, a boy with a troubled father — Hinshaw writes with immediacy and authority, in both personal and analytic modes. In what follows, I will toggle, too, between registers. I’ll discuss what mania feels like from the inside and out. Then I’ll turn to families, Steve’s and mine, to address those who partner with the mad, and their children, imbued often with a dose of moody genes.
What Mania Feels Like: The Imp of the Perverse
Words flow, even silent, from the infinite tap of talk. If ever I forget the pills, I don’t sleep right: my body’s hot, heart’s a rabbit. Ideas metastasize. The voices say dumb stuff like, “Go buy the pants from the whumple-dumpskin,” as I’m nodding off, or they repeat hip-hop lyrics, and wake me with a start. Sometimes they recite poetry lines I’ve read and loved. “Let us go then, you and I, while the evening is spread out against the sky”; “Had we but world enough and time, this coyness, lady, were no crime”; “Ale, man, ale’s the stuff to drink, for fellows whom it hurts to think!”; “Thus, though we cannot make our sun stand still, yet we will make him run.”; “Till human voices wake us, and we drown.”
The voices aren’t real, I know. But so knew the guy, at first, in “The Tell-Tale Heart” by Edgar Allan Poe, who heard the voice telling him to go dig up the dead fella under the floor. Sometimes, with tears on my face, I pace at 7:00 a.m., giggling at lines like, “God becomes man becomes fish becomes barnacle goose becomes featherbed mountain.” On four hours of sleep, I laugh at our lovely loneliness. The forever feeling surges again, a sense of what we share. It’s that old drive, defiant and in vain — our messy human hope.
When the voices intrude in this way, I make sure not to miss any more pills. Soon I’m sleeping normally again. Lithium gives my hands their tiny, telltale tremor — shaking a coffee cup, making handwriting jagged. But it prevents mania, as it has since 1949, letting folks like Virgil and me channel our energy productively. Lithium carbonate, a salt dug from the ground, is psychiatry’s most successful drug. In a third of cases, the metallic ion, the third element, wards off mania for 10 years or more.
In his book, Hinshaw describes what it’s like to witness mania as a small boy. One Sunday in Church, he remembers, when his father Virgil interrupted the sermon to yell, “He’s jerking us off!” Another time, driving his family to his mother-in-law’s after church, Virgil “half-yell[s] […] ‘It’s absurd to think that any self-respecting philosopher would dream of making such a statement.’” “Although I didn’t know exactly what he meant,” his son writes, “it was absolutely clear that he was right and everyone else was wrong.” “[B]ut who was his audience? Why was he shouting?” Virgil ruins dinner with grandma at the Willard Restaurant on Main Street, their usual place, “nearly gloating with perverse joy,” by calling it off when young Steve complains about waiting. Virgil “roars,” to his mother-in-law, “his face beet red, ‘if you didn’t spoil him so badly […] this would never have happened!’” Steve tells us, “I had the strange feeling that he’d wanted to tell her off like this for a long time but never before had the nerve.” As the son, now an expert, recalls years later, his dad was “fast escalating.” That day was their last at the Willard.
“The Imp of the Perverse,” the best phrase I’ve heard for this impulse, is the title of another story by Poe. In manic modes and even when we’re not manic, people like Virgil and me are often driven to think, say, and do what we know we’re not supposed to do. Poe’s story, written in 1845, universalizes this kind of “folly,” as he calls it.
Long before I’d heard of mania, let alone felt its spell, I recognized the compulsion Poe described in his story for what is now called breathless talk, or pressured speech: “There lives no man who at some period has not been tormented by an earnest desire to tantalize a listener by circumlocution,” his narrator says. “The impulse increases to a wish, the wish to a desire, the desire to an uncontrollable longing, and the longing (to the deep regret and mortification of the speaker, and in defiance of all consequences), is indulged.”
We can’t control our tongues — but that’s not all.
In the next breath, Poe takes us to a cliff: “We stand upon the brink of a precipice,” he writes, “We peer into the abyss — we grow sick and dizzy. Our first impulse is to shrink from the danger. Unaccountably we remain.” Like a genie from a bottle, a thought comes to mind, which chills us “with the fierceness of the delight of its horror.” What chills us, notice, is not the horror, but the giddy delight — our delight, in horror.
Who among us has not at some point wondered what it would feel like to fall?, asks Poe’s narrator. “[B]ecause our reason violently deters us from the brink, therefore, do we the more impetuously approach it. There is no passion in nature so demoniacally impatient, as that of him who, shuddering upon the edge of a precipice, thus meditates a plunge.”
To be bipolar is to stand on the brink — of a debate, a family feud, a sermon, an affair — and delightedly to contemplate a plunge. Then to find another cliff. Again, forever.
The plunge for Poe’s narrator, a killer, is to blurt out his confession. How the guilty man describes this urge, if you’re wired similarly, is chilling. Poe animates, from the inside, the same escalating sensations that Hinshaw describes from the outside: first as a boy watching his father, then as an expert. When I think of the ramp-up to mania in my life, I picture a falafel dinner with friends in Brooklyn, cozy and benign until someone brings up identity politics. I can’t help taking a stance I know will provoke, and won’t stop fighting until a person I care for is in tears and I am cursing. Poe nails the heedless gallop of speech — the feeling when, sitting across from someone in tears because of you, you won’t — can’t — stop talking.
“They say that I spoke with a distinct enunciation, but with marked emphasis, and passionate hurry, as if in dread of interruption,” says Poe’s doomed narrator, “before concluding the brief but pregnant sentences that consigned me to the hangman, and to hell.”
One misconception about manic depression that persists in TV and movie accounts is that the condition is a wild, constant pendulum swing between moods. This is true of some atypical forms — the types that don’t respond to lithium. But classic “manic-depressive insanity,” as first defined by Emil Kraepelin in the 1890s, is episodic: the illness comes and goes with long stretches of stability and high function between manias. You would not know, most of the time, that a person like Virgil has anything wrong with his brain. Virgil held a job as a professor at Ohio State for decades. In my case, I’m a writer with degrees in neuroscience and journalism. Virgil was sociable, as am I. He was married with kids. I was 27 before I was hospitalized and started taking lithium; and, even before being treated, I was more often upbeat than unstable. Virgil was misdiagnosed until mid-adulthood and yet still thrived for the most part. This said, if our neurons aren’t stabilized, we can act out in ways that make for good TV.
“What’s poorly understood — even now,” Hinshaw writes of his father, “is that when full-blown mania hits, irritability and anger are part of the picture just as much as euphoria and expansiveness.” This is the bipolar trait that most strains relationships, makes a person snappy with a loved one, or excitedly unable to pay attention. Impatience is a trait that Steve Hinshaw recognizes in himself, too: “[W]hen impatient, pushed too far, or overheated, I would sometimes burst in a split second of pure heat. Sometimes I still do.”
A suite of other traits also characterizes the bipolar temperament — for instance, treating argument like sport. We are drawn to surprise, change, provocation, which can make us a pain in the ass. Easily bored by agreement, we want people to argue or joke or teach — forever. At the family dinner table, at any table, we often won’t shut up. We may change sides from day to day, moment to moment, especially if we can ignite conflict or novelty. The smug assurance that many have about their views — especially liberal people, like me — easily sends us into a playful fury. So, in my case, I find myself arguing against things I believe, often. I attack progressive sacred cows — say, over drinks with friends on a Friday night, or with an in-law — not because I disagree, but because I find stability tedious and moral superiority insufferable. I’ve seen such arrogance in myself plenty of times, and I hate it.
There are upsides: Hinshaw recounts how Virgil’s urge to connect and debate led him to engage with luminaries like Einstein and Bertrand Russell as a PhD student at Princeton, and to start the frank discussions with his 18-year-old son that led to this book. When the renegade Scottish psychiatrist R. D. Laing visits Columbus, Virgil invites him for drinks and the two then talk for hours. When he meets people with experience in a mental hospital, Virgil often engages them, fearless of awkwardness, even though his own stays in mental hospitals were still a family secret.
But the upsides are precarious. If Virgil’s intensity pushes him to engage with others, when taken too far, that intensity devolves — beyond debate, beyond two-way talk of any kind — into mania. Out there, Virgil is faraway in a glittery cosmos, shimmery to him and remote to others, deep inside his head. “[T]he glint in his gaze, the inevitable sign of an episode ready to emerge” is what Steve’s mother recalls seeing when she met her husband at the airport after a conference. “It was a particular sparkle, giddy yet menacing, which only she understood.” “From past experience, [Steve’s mother] knew all too clearly what would soon take place: exuberance, wild energy, suspicion, sexual fervor, quick bouts of rage. She knew, too, that there was nothing to stop the runaway train once it had left the station.” The train, the tantrum, the thrill.
Hinshaw also gained insight about Virgil’s mind, and in particular about his first break, by reading the “frenetic” notebooks Virgil kept as a youth. Peering into this old writing one summer afternoon, the son writes, “I felt like an astronomer with a more powerful telescope.” After having jumped naked off the roof of his family’s house to save the world from fascism, the 16-year-old Virgil wrote from the mental hospital in 1936: “At one with the world — ‘in, but not of, this world.’” The aspiring philosopher added, “Celestial music of the spheres, all night long, since I slept so little.” Then he wonders if he is a Roman poet reborn. “Are many of the Latin words echoic in origin, and related to the breathing patterns of a baby? Was I, in some respects, the Vergil of the Aeneid? Is there metempsychosis? Reincarnation?” Decades later, giving a lecture while manic with the same grandiose overtones, Virgil looks over his students’ heads with “a far-off look in his eye. Haughty and self-assured,” he speaks in a “strange and commanding” voice, much like Poe’s narrator bound for the gallows. He “wove a tale of the beginnings of modern humans […] with man and woman in eternal rapture […] Primitive lust transformed into sensual, deep love! The human species rose to new heights.”
No discussion of mania is complete that doesn’t include the Icarian fall. On the heels of his manias, Virgil invariably falls earthward. Bipolar depression, less salient than mania, gets comparatively less attention in Hinshaw’s book, but he’s evocative when he does touch on the crash after the psychedelic high. Confidence shrivels to doubt. What the two states have in common is interiority — a yawning sink of self that eats everything. “Distance,” Hinshaw’s word for the mode when “all emotion [seems] leached from the body” is a far more apt term than sadness for this mode. Depression here is not really melancholy. Manic depressives who tend toward excitement — of the sleepless, agitated, exhausting kind — literally get worn out. We accrue a debt while manic that we must pay back. In the wake of a manic high, we feel not just sad but adrift in space. Indifferent, without will, we’re certain that human contact is futile. Our thoughts are disorganized, like a clutter of papers on a messy desk.
Who Couples with the Mad?
Much of Hinshaw’s book is about the family members who weather the storm and enable bipolar people to persist, sometimes to thrive. Virgil Hinshaw’s wife is one such rock, who had no idea what she was signing up for when she married Virgil. “Mom,” as Steve calls her in the book, is patient, independent, and grossly unprepared. But she almost seems, from the perspective of their son, to complement Virgil, to cool him. “Compared to Mom’s more deliberate style,” writes Hinshaw, “Dad’s hurried gestures were jarring, but their familiarity was reassuring all the same.” When Virgil is foggy, fresh from a stint in the mental hospital, doped on Thorazine, his wife re-teaches him the neighbors’ names. “During these years” in the ’50s, writes Hinshaw, “he was the apple of the Ohio State philosophy department’s eye. At any gathering, [Virgil] held court about the world’s big ideas. In a few hours, the couple’s charm and erudition would be on full display, the picture of grace and accomplishment.” Virgil’s wife shared his passion for learning and his ambition: she taught English at OSU when few professors were women.
She bore witness to at least six of Virgil’s episodes in their first 10 years of marriage. At one point, she went to see a lawyer about the possibility of divorce — but was too embarrassed to tell him why she was there. The house the couple bought together, in the late ’50s, was, writes Steve, “a vote, made from blind faith, for the family’s continuation.”
One night, as a dinner party hosted by the Hinshaws winds down, Steve’s mother stands in the door with a “brave smile.” Worrying about when “the tell-tale signs [might] return, the signs of incipient madness,” writes her son, “she’d already made the crucial decision in her life. To survive, she would need to concentrate on the good times, like tonight.” “Wait,” the author imagines his mother thinking as the guests depart, “Don’t leave! If only the party could continue just a while longer. If only the magic could last.”
It can’t. “So dawn goes down to day. Nothing gold can stay,” the poet Robert Frost wrote. It’s the stubborn faith in cycles, I believe, that makes spouses like Steve’s mother stay.
My ex and I used to call her worries bubbles: persistent but small, easy (for me) to pop. Mine were cosmic, delusional, but rare: flights into fantasy or terror. Hinshaw’s parents seem similar. His mom was agreeable and thoughtful, and Virgil more self-involved, perhaps careless like me. On one birthday my ex bought me a stack of novels I’d mentioned, and the butterfly, framed, that she saw me ogle once in an antique store. She’d kept a list, as I’d never think to do. Her slight neuroticism made her endearing, reliable, punctual, always there for friends. I kept things talkative, edgy, interactive.
Yet unchecked mania takes a bodily toll on romantic partners. When Steve Hinshaw’s mother develops rheumatoid arthritis at an early age, Steve chalks it up to a lifetime of hiding her husband’s disappearances. Fearing for his health and her family’s stability, she’d been anxious her whole adult life. The blame for her suffering, Hinshaw is quick to point out, rests not solely on her husband’s condition, but on stigma: “Her entire nervous system and immune system had been on alert as long as she’d been married,” Steve writes, “handling impossible situations without communication or support.” Our ignorance and taboos around mental illness, in other words, inflict real medical harm.
The question of coupling has been approached by scientists, too. One 2016 study by Swedish researchers found that pairing for the mentally ill is not random: certain types seem to complement one another. People with mental illnesses, in particular, mate with one another “within and across disorders,” at rates much higher than expected. Diseases that emerge early in life, like schizophrenia, ADHD, and autism spectrum disorder, showed the strongest pattern of mating within type. The association was four times as high as those reported between personality traits of partners in other studies, and twice as high as typical correlations between partners by height or weight. Bipolar people were most likely to match with someone on the autism spectrum, followed by someone with social phobia, ADHD, or bipolar disorder. While Virgil’s wife and my exes were not autistic or otherwise mentally ill, the study, published in the journal JAMA Psychiatry, suggests certain traits might cool the intensity that characterizes bipolar ones.
Stigmatized, isolated people might be expected to pair with one another. But there’s a less cynical explanation, too: personality traits tied to manic depression and autism each exist on a spectrum. We each have a bit of schizophrenia, autism, and ADHD within our genes. To the extent that people with autism-like or anxious personalities are complementary to those associated with psychotic illness, they may be drawn to each other, the way opposite personalities are said to attract. Bipolar and autistic weaknesses are complementary, to a degree: autism is a social disorder that includes eye contact difficulties; compulsions; perseverative interests, often in physical things like trains; sometimes mathematical talent. Bipolar people, chatty and energetic, are often charismatic and persuasive, and have no trouble making eye contact. On the contrary, you can identify us by our intensity. We have no trouble being expressive, but can be disorganized in our emotions and confusingly nonlinear in our thinking. Such “complementarity” in couples is inconclusively supported by the psychology literature. But when it comes to extremes of personality, the JAMA study is certainly comprehensive: using the Swedish National Register, including every birth since 1943 and psychiatric data since 1973, it tracked every pairing in the country for over 30 years.
A Partial Dose: Kin and Ken
When I met Steve Hinshaw, in Berkeley, I noticed he talks like I do: intensely. Full of grand, positive plans, he is excited by ideas, quick to encourage others. His expressive eyes shine mostly sunny optimism, with occasional clouds of self-doubt. Eager to be liked, he comes off as warm, intelligent, and endearing. If he has a touch of ego, he’s self-aware about it — a limbic cocktail I know well. His memoir shows him to be a gifted storyteller and an articulate teacher. To be sure, parts of the book read like a résumé: his occasional tendency to list details of his trajectory, like a tour of a trophy shelf, and to tidy up each experience with a pat moral can feel cloying, even digressive. (Not that this reviewer has any business calling anyone digressive.) But such moments are rare. He is mostly driven to feel for those who suffer. Thanks to books like his, readers may come to understand what mental illness is to our species: not a bug, but a feature.
As I suggested earlier, Another Kind of Madness underscores the father and son’s similarities: garrulousness and intensity, curiosity and ambition. The intensity pushing a father to mania propels his son to achievement. “Small bursts of energy aided my efforts,” Hinshaw writes of his own career. But if he gained from having bipolar genes, he also suffered. As a young man, he forced himself to vomit at night to deal with anxiety related to family problems. Purging in the bathroom at Harvard, and in thin-walled cabins where he worked as a counselor for children with mental problems, the perfectionist tried to hide his embarrassing urge. His secret caused him social trouble like his dad’s. “My drive for connection was a blind hunger,” he recalls of his efforts to date, “but how real could it be if I wasn’t all there myself?”
“Rejection of some sort is usually the trigger,” Hinshaw writes of his mood swings. What Hinshaw describes as the sense that “somewhere deep inside me, fundamental parts are still missing” is a shade of what we call mood disorder. The gift of Hinshaw’s book, a memoir by someone acquainted with mania but not mentally ill, is a portrait of an everyday insanity that most readers likely share to some degree.
Steve’s “far-off look” can, like his dad’s, signal both inspired focus and, at times, cold detachment from loved ones — though both Steve and his father were known as generous mentors and family men when mentally present. One questionnaire for people with bipolar disorder includes the statement: “I am driven by an uncomfortable restlessness that I do not understand.” This mood is of course not unique to people with manic depression, but recognizable to ambitious healthy people, too — especially those, like Steve, with bipolar relatives. At its most extreme, the frantic drive spurs bipolar people, “intolerant of boredom” as psychologists coolly say, to chase thrills or challenge.
Not only is Hinshaw a tenured professor at the Universities of California, Berkeley and San Francisco, he is the author of hundreds of papers, book chapters, and books, a holder of three international research awards, and a tireless advocate and leader in the crusade against stigma. It may be no accident that his relatives include luminaries like Corwin Hinshaw, a member of the physician team that tested antibiotics on tuberculosis, a competitor for the Nobel Prize; and one of the first female doctors in the West. It may likewise be no accident that his cousins include alcoholics, a woman with an eating disorder who died young, perhaps by suicide, and others who were hospitalized. One of Steve’s cousins killed himself at age 30. “The more I learned,” Hinshaw writes, “the clearer the divide became: in Dad’s family, people either did great things or collapsed.”
This is also true of my Alabama family. I have cousins with psychotic illness, in various states of health. Our family ran a lumber company for 65 years, and included an inventor who earned over 100 patents before killing himself in a mental hospital, at age 37. Many of our family members went to schools like Yale, Princeton, and Stanford, and became successful doctors, lawyers, or ran businesses. Reading Hinshaw’s story, I nodded along.
Bipolar genes can thrive if family members choose to tolerate intensity. I have been lucky, like Virgil, to grow up with fireproof kin. My mother, chatty, literary, and passionate about learning, gave me my manic buzz. In a Freudian twist, I tend to date women who are more like my father. An even-tempered industrial engineer with a gift for drawing, and a touch of neurosis in his blood, he makes the world seem saner, like a clean garage. Capable as he is at home repair, sports, and running factories, dad can be bewildered by irrational moods. My brother, a fun-loving tree scientist, has our dad’s pragmatism, but befriends people who are as restless and rambling as I am. Our sister is the most successful sibling in conventional terms — a pediatrician married to a surgeon, with two kids, a dog, and a house. She’s more conscientious than I am, remembering birthdays, sharing photos of her kids with the family, and far less self-involved. She’s more “agreeable,” as psychologists say. This means not just that she’s easy to get along with — she’s not always — but rather that she avoids conflict, preferring that people get along.
I believe our family works not despite differences, but because of them. We’re used to bridging differences: my longtime Republican dad from Mississippi started reading The New Yorker when I was in high school. Years later, he voted for Obama — “damned if this gay thing didn’t turn me into a liberal,” he joked about my brother and cousin, who had recently come out. Now he argues at Alabama family gatherings for marriage equality, taxing the rich, and legalizing marijuana. And, of course, for mental healthcare.
“Risk” Genes and the Cost of Stigma
Temperament grows from genes embedded in experience. Hinshaw points out that losing a parent between age three and five raises the risk of having a mood disorder later. Being born more than two months premature, as I was, increases the risk of developing manic depression by seven times. Abuse or neglect in childhood impact brain development in ways that last into adulthood. On the other hand, being raised in a stable family is protective — and may be why my mania did not emerge until I was 27 years old, in 2012, 10 years older than Virgil was in 1936.
Genetics nonetheless account for most of the risk for psychotic illness. “Risk genes” predisposing a person to a mood disorder are present in healthy relatives, too. Their telltale traces appear in Steve Hinshaw. They appear in my mother’s chatty hyperactivity, my sister’s breathless phone calls and countless marathon races, and in my brother’s restless gallivanting about the globe, from Panama to Nicaragua to Oslo.
A 2017 paper argues that the genetic variants tied to “externalizing” personality traits, like outgoingness and openness, overlap with risk genes for bipolar and schizophrenia. Thrilled by reward, bipolar people are relatively fearless of risk, which is likely why so many of us are explorers and entrepreneurs. These traits seem to follow an “inverted U,” as UC San Diego psychologist Tiffany Greenwood has written: bipolar personality traits are useful up to a point, beyond which they interfere with function.
Teddy Roosevelt famously wrote “black care rarely sits behind a rider whose pace is fast enough.” Both his mother and brother were felled by mental illness. The fact that Elliott Roosevelt, Teddy’s brother, was likely bipolar seems no coincidence. In one genetic node, Elliott connects America’s first great progressive president to the most influential first lady in American history: his brother and his daughter, Eleanor. Both were assertive strivers. Motivated by grand causes, empathetic to the weak, they were fierce to their foes. Their temperaments, like Hinshaw’s, had a dash of mania.
Since the 1930s, when Virgil first met the imp of the perverse, knowledge about mental illness has improved, but prejudice has not. “Facts,” as Steve Hinshaw calls them, about the biology of mental illness often re-enforce stigma. People reason (wrongly) that violence and mental illness are linked, or they avoid the mentally ill because they fear their imagined instability, unreliability, or temper. Or just the awkwardness of difference.
We know today that the heredity of bipolar and schizophrenia are connected. But bipolar disorder is far more common: if you include the whole spectrum, it affects up to four percent of Americans. Schizophrenia, a chronic degenerative condition from which people don’t often “wake” into sanity, is three times less common. That said, “manic-depressive insanity,” as it was first called — the pure episodic form described by Kraepelin in the 1890s, which is Virgil’s form and mine — is just about as rare as schizophrenia. Responsive to lithium, with healthy gaps between episodes, it is mostly mania. Luckily for some, it is the form with the best prognosis.
Sadly, though, just one third of all bipolar patients respond to lithium. Many consider the “pure” form a distinct condition, not a flavor of the broad category of mood swings — “rapid cycling,” bipolar II, et cetera — now grouped together. Lithium only treats mania, not depression. A person with classic bipolar disorder needs to rein in only one pole. Kay Jamison objects to the new name “bipolar disorder” because it is misleading. True manic depression, as I’ve suggested, is not a swinging between two poles — conceptualized as a pendulum, perpetually unstable — but, rather, a propensity for “psychotic excitement.”
All families are likely to have some madness tucked away somewhere. The risk, after all, rides on positive traits: the itch to explore and engage, the desire to be changed. More often than not, discoveries emerge not from manic obsession per se, but from what one writer calls “majestically misguided voyages.” Questing after the Orient, the explorer Henry Hudson found New York. Like Ahab sailing the globe in search of one white whale, Hudson’s intensity brought unexpected treasure. His city still crackles with an energy like mania. Mental illness is so interwoven with ambition and imagination, with the buzz that drives bravery and the neuroticism that dots every i and crosses every t, that “disorder” is a lame term. Debilitating moods need treatment, yes. But even more, we need relief from the other madness — the prejudiced insanity of those we call “sane.”
Read more LARB pieces related to mental health and illness here.