Bipolar Expeditions (12 page)

Because the patient's behavior is meant to follow the DSM description exactly, this drama has a circular form. Point after point in the checklist of DSM symptoms is illustrated in the patient's behavior: in the segment above we see grandiosity, distractibility, pressure to talk, and racing thoughts. Whereas the patient dramatizations we saw earlier disturb the neat order of assumptions behind categories like these, here the circle of discourse is closed: present and future members of the profession of psychiatry are listening to themselves but not monitoring what is being said. The category of manic depression is meant to be translated directly from the DSM into the actor's depiction, and from there into students' concepts and practices. There is only
one
set of books in this accounting, not two.
¹⁰

We might guess that in practice things are not so simple. Given that method actors are sought for this dramatic performance, it is safe to say that the actors are doing far more than mechanically translating a set of descriptions into behavior. Method actors report drawing on their own personal experience of related if not identical emotional states in making such a character sketch. Nor are the psychiatrists coaching the actors simply doing a mechanical translation. They are trying to reveal the main features singled out by the DSM but also get what they call “the feel” of the patient right. In spite of these complexities, the main goal of such teaching materials is to pass on an intact set of clear working categories to the next cohort of students, not to perturb and question them. This is an important aspect of the quality of scientific rationality, which assumes students need to learn, as a solid foundation, the current state of knowledge. To this end, multiple meanings and ambiguous interpretations are excised as much as possible.

Despite the desire to excise ambiguity, it sneaks through anyway. Right in the midst of his pressured speech, the patient-actor sees the camera and protests. The psychiatrist-actor tells him the camera isn't on, and the patient-actor remarks, in the subjunctive, “if it were.” What is being modeled here is quite outside the DSM: the patient accurately perceives something in his environment (the camera) and reasonably worries about his private affairs being exposed. The psychiatrist then models denying the patient's perceptions and allowing him to be filmed without his knowledge. The teaching video has thoroughly exceeded the description of mania in the DSM and has introduced layers of ambiguity: can people be perceptive even when floridly manic? Should psychiatrists deny patients' perceptions even when doing so would serve the ends of scientific rationality? What is being modeled is a psychiatrist who deceives his patient about taking a visual record of the session and a patient who is left to remark (perhaps sarcastically), “because if [the camera] were [on], I'd comb my hair.” All the while, he does comb his hair! A lot like Kevin's multiple takes, this patient (as enacted) knew that the psychiatrist knew that he knew the camera was on. In short, although for pedagogical reasons, the video is meant to have only one set of books, a second set of books slips through like a shadow.

The Bipolar Experience: Multiplicity

In the series of manic performances I consider next, meanings are multiplied rather than excised; multiple beings seem to coexist in the same person to such an extent that they cause interruptions in the person's sense of self. I begin with a kind of comedic performance that is often described as “manic,” in a dramatic rather than a pathological sense, to draw out the characteristic features of multiplicity in mania. Here is a glimpse of Robin Williams in a very fast-paced, improvisational comedy routine that took place in a San Francisco nightclub in the 1980s, done to the accompaniment of continuous peals of laughter from the audience.

Williams:
[takes sip of wine] My god, woman! [Williams moves quickly toward the audience and steps off the stage to admire the fur coat of a patron seated at a table.] Where did you get this coat? My god, Nanook of Marin! [audience is laughing] My god! [Williams takes the coat and steps back onstage.] This is lovely—look at this thing, right now there's a whole lot of animals going, “Shit is it cold…. Jeezus!” [Williams makes a gesture of protecting himself from the cold—arms around himself—audience cheers and laughs. He looks at the garment label and feels the texture of the fur.] Made from kittens around the world … let me try this on. [Williams begins putting the coat on through his arm.] I won't get the smell in there—you take it home tonight and the animals'll be goin' [makes a noise to indicate animal sounds]—hee hee hoo hoo oh! [As he notices that the underneath of the arms is another color,] I guess you couldn't afford the bottom part. [Williams puts the coat around his shoulders.] I feel like Liberace right now—”Oh, just leave me the candelabra, Samuel, just leave me the candelabra.” Wonderful. [He sighs.] Williams's wearing the lovely pants from Hefty Bag. [Williams parades around the stage holding the sides of his pants, which are made of a shiny, thin, latex-like, black material.] La da dee dah. [Williams hums.] … I love this—this is the type of coat you can go [Williams allows the coat to slide off his shoulders onto the floor as he puts his head up in a stuck-up fashion to imitate a high-society woman], “Andre, park the car.” Or I could play Elephant Man [Williams puts the coat over his face with the arm sticking out in front] going, “I'm not an animal … I'm a comedian!”
¹¹

If we compare these two performances—the actor's simulation of the grad student's mania as described in the DSM and Robin Williams's manic performance—what we notice is that Robin Williams and the actor both appear to be persons with a crowd of people inside them, all jostling for control at once. Aggressive, mocking, conciliatory, humorous, challenging, bragging, suspicious, hostile, expansive, open, belligerent, rejecting, fearful—what stance is not enacted? Although Williams controls his display of multiplicity for comedic reasons, and the actor for pedagogical reasons, they both capture the forms of linguistic expression common among people living under the description of manic depression: ideas are “excessively and immoderately combined and elaborated,” with a “playful, mirthful, and breezy quality” that leads them to intrude incongruous ideas into conversation.
¹²

Such internal multiplicity has long been considered central to the manic condition. As Kraepelin describes it in his classic account of mania,

Impulses crowd one upon the other and the coherence of activity is gradually lost…. [H]is pressure of activity may finally resolve itself into a variegated sequence of volitional actions ever new and quickly changing, in which no common aim can be recognised any longer, but they come and go as they are born of the moment. The patient sings, chatters, dances, romps about, does gymnastics, beats time, claps his hands, scolds, threatens, and makes a disturbance, throws everything down on the floor, undresses, decorates himself in a wonderful way, screams and screeches, laughs or cries ungovernably, makes faces, assumes theatrical attitudes, recites with wild passionate gestures. But, however abrupt and disconnected this curious behaviour is, it is still always made up of fractional parts of actions, which stand in some sort of relation to purposeful ideas or to emotions; it is a case of movements of expression, unrestrained jokes, attacks on people, amusement, courtship, and the like.
¹³

Internal multiplicity may be central to what makes manic depression belong to the irrational, because behavior that seems to indicate there is a crowd of different people inside one person disturbs some common assumptions about normality. Historians have shown that by the early nineteenth century, the prevailing opinion in the United States was that a person should have a certain unity, as if some central organizing force—one's self, one's identity—were in charge. This idea depended on a concept of self-control possessed by the individual. Each individual possessed a rational mental apparatus located inside the brain and this apparatus was a battleground on which the mind's rationality and will fought to control the “uncivilized” animal impulses of the body.
¹⁴
Without a central organizing principle, the person became a bundle of frighteningly unpredictable impulses. Instead of following a coherent plan of action, the person went in many directions at once; instead of subordinating the passions to the governing intellect and will, the person gave them uncontrolled reign.

Persons without a controlling principle were fearsome, as were uncontrolled groups of persons. When the order and control conferred on groups of people by the structure of a school, an army, or a factory was absent, a “crowd” was the result. At the turn of the twentieth century the French writer Le Bon described the fear of crowds graphically: “Isolated, he may be a cultivated individual; in a crowd, he is a barbarian—that is, a creature acting by instinct. He possesses the spontaneity, the violence, the ferocity, and also the enthusiasm and heroism of primitive beings.”
¹⁵
Le Bon participated in the Eurocentrism and racism of his day in likening crowd behavior to “primitive” behavior. But he was also pointing to what apparently can happen when the borders of the controlled, rational, cultivated individual break down: caught up in a crowd, individuals become highly suggestible and lose their ability to reason.
¹⁶
In a crowd, many people meld into one “person,” the crowd, and the crowd goes out of control. In manic depression, the elements are different but the result is similar: one person becomes a “crowd,” and each of the different persons in the “crowd” can go out of control in turn. I stress that the kind of “crowd” at issue in manic depression is not the same as the technically defined condition multiple personality disorder. It is something more like a style of self-presentation or manner of engaging with the world that covers such a wide range of emotions and energy levels over time that it evokes the idea of more than one person at the ready. More often than not, in this kind of multiplicity, the person is all too aware of the other guises at hand. In fact, people report that sometimes they almost deliberately stoke manic energy out of fear of an encroaching depression or out of a desire to “ride the tiger” of an energy-filled mania.
¹⁷
Teddy Roosevelt, said to be “haunted, if not ruled, by melancholy,” observed in a letter to a friend, “depression rarely sits behind a rider whose pace is fast enough.”
¹⁸

In my fieldwork, I observed many contexts in which medical students, learning to identify various forms of mental illness, encountered multiplicity in manic-depressive patients. For example, in this incident from clinical rounds, a resident described a patient as having become a different person. Dr. Dean chaired as a resident presented Mr. Nielson's case, summarizing information from the patient's medical records and from interviews with him and others. After a childhood full of family conflict,

Mr. Nielson graduated high school, went into the army, and left with an honorable discharge. He belongs to an evangelical church, and now lives with a family from the church in Baltimore. His work is waterproofing basements, which involves heavy labor, carrying many bags of cement.

Last fall, he became a different person:
he started feeling sad and withdrawn and thinking of suicide. One time, he put his belongings in the trash, wrote a suicide note, put a noose around his neck, but then ran out of steam. He sleeps twelve or more hours at night and then a couple more during the day. He feels a weight on his head, like a stone. He has difficulty concentrating. He feels he doesn't know what is real. He also has anhedonia [the absence of pleasure from acts that would normally be pleasurable] and doesn't do things he enjoys, like drawing, playing golf, or ringing doors [proselytizing] for the church. He says his stinking brain has gone downhill. He shows compulsive traits such as checking doors over and over, apologizing over and over, and he has been experiencing panic attacks. He got 27 out of 30 on his mini mental [a standard test of mental acuity]. He is hearing voices, and they say, “You should kill yourself, you are a bad person, you are so stupid.”

He has been on the ward since yesterday; the current plan is to try ECT [electroconvulsive therapy].

Stooped over, Mr. Nielson walked into the room slowly, head hanging down with a dejected expression. He was very thin, and his longish hair looked unwashed and uncombed.

Dr. Dean:
How are you feeling today?

Mr. Nielson:
I don't want to live, I don't know how to get out of this.

Dr. Dean:
Is it sad?

Mr. Nielson:
It is like a weight on my head, in my brain.

Dr. Dean:
Do you think something is wrong with your health?

Mr. Nielson:
Yes.

Dr. Dean:
Like what? Like HIV?

Mr. Nielson:
Yes. I have lost thirty pounds. I have panic attacks where I am sure the basement I am working in will be caving in. My heart races, I have sweats, it feels like I will die.

For all of Dr. Dean's gentle efforts to draw him out, Mr. Nielson was silent or monosyllabic during most of the interview. In this case, we only know that Mr. Nielson “became a different person” because of the medical history. Although Mr. Nielson's behavior in rounds belonged only to the depressed end of the mood spectrum, the resident's case history clearly revealed that in the past he had been a dramatically different person.

In a second example from rounds, the patient articulated her own multiplicity, which began after she accidentally fell and hit the back of her head.

It is like I have an extra sister,
I watch myself being eaten by the disease. I am getting barely Bs and Cs while
the real me
knows I could get As. I am bad, no, worse, I am better than bad, but I am never good. There is a window of productivity—there are some hours when I can do errands, even though when I do them I am still crying. Then I have to drop into bed again.
I want my life back.
Everything feels heavy. Everyone gets better but me. Others have lost parents or were abused and so they have a reason to be depressed. But I don't. I had a very happy childhood, a great family.