Bipolar Expeditions (28 page)

Another doctor asks for information regarding menstrual irregularities in her thirty-three-year-old patient taking Drug R, which has eased her depression. In addition the doctor wonders how to handle the side effect of insomnia, which occurred when he increased the dose of Drug R to a level adequate to handle the depression. The doctor had used Ambien, to induce sleep on a temporary basis, but worries about harm from adding an atypical antidepressant with sedative properties such as trazodone to Drug R. The expert suggests several possibilities: split the total dose of Drug R with a lower dose at night; combine Drug R with trazodone, which has had no complications in his experience; even better, combine Drug R with an over-the-counter antihistamine such as Benadryl; or combine Drug R with a low dose of Zyprexa at night.

As a patient I have experienced how strategies like these are translated into written instructions. At the onset of a rapid descent into depression, with insomnia and anxiety (I had been taking lithium [450 mg] and Celexa [10 mg] at the time), my doctor wrote the additional measures I should take on a prescription pad.

1. bed at 10 p.m.

2. take Ambien at bedtime

3. try Dexedrine 5 mg in a.m.; can go to 20 mg by 5 mg increments

4. Ativan, try .25 mg in afternoon before anxiety sets in and in middle of night try .25 or .5 mg.

One week later, with not much improvement, I got another set of written instructions to
add
to the previous ones.

1. take Ativan, .5 mg 4 times a day, a.m., noon, early p.m., and late p.m.

2. take Ativan again .5 mg during middle of night

3. increase Celexa to 20 mg

Doctors and patients develop more and more elaborate combinations of drugs as they try to solve the side effects or symptoms of one by the action of another.
¹⁸
The need to take so many drugs, and to monitor their relational effects, might have the effect of diluting any sense that each drug has a particular personality. Each drug is more like a precise instrument than a living being. Gone from this picture are the complex associations possessed by old drugs like lithium. Marcy prefers “the magical specificity property” of Depakote, but she may have to give up the “yellow light” of Sting's “Lithium Sunset.”

When I started this research, perhaps seduced by the marketing literature I had read, I imagined that people would invest their drugs with personalities and form some kind of relationship with them, perhaps seeing them as encouraging companions, calming presences, or strong protectors. My expectations led me to look hard for such relationships. What I actually found was that patients personify new, high-tech drugs only weakly, and do not usually invest them with elaborate symbolic value of a person-like sort. Both doctors and patients see drugs as precision instruments that would excise suffering if they could only find the right combination. It is as if there is a dearth of appealing metaphors to capture what it is like to live with a drug inside you. Let me suggest one: when drugs lift depression or calm mania they could be seen as teachers, modeling new habits. Medications need not be seen as a management tool, a view that inevitably raises the question whether the patient or the doctor is in charge of the medication, but as something we might call “co-performers.” This terminology casts them as something like agents inside the person who enable the performance of calm, of energy, of organization, or, if needed, of stability. Medications could be regarded as teachers who enable the person to experience such states. Can a precision instrument that is only slightly personified perform or teach? I think the answer is yes. A training board for a windsurfer, a walker for a stroke patient: these are among the simple but precisely engineered devices that guide and steer people as they learn new skills. Could not drugs be regarded in this light?

The accounts above are permeated with ambivalence—simultaneous and contradictory feelings of attraction and repulsion. The drugs help me, they hurt me; they ease one kind of pain and intensify another; and they take away one painful symptom but add a new one. It was to my astonishment, then, that I witnessed a display at the 2000 APA, which depicted the worry patients feel (some of which is surely legitimate) as a literal form of paranoia. This display, liberally branded with the logo of Risperdal, a major prescription antipsychotic from Janssen Pharmaceutica, was a virtual reality set-up called “Virtual Hallucinations.” People stood in line reading an information card explaining what was to come. Meanwhile, overhead, a video on continuous loop featured a man diagnosed with schizophrenia telling us that the experience we were about to have was true to life. Eventually I reached the head of the line, went to my assigned station, and put on my headphones and helmet. This gear would provide the sight and sound for me to experience a virtual world. The attendant instructed me, “When you enter the pharmacy, look around, and keep looking around to find the pharmacist.” As the virtual scene unfolded, I understood that I was a patient who needed her antipsychotic medication, but my prescription had run out. So my friend, a woman, had brought me to the pharmacy to get a refill. My friend and I entered the pharmacy door. Just inside, the friend turned around and said, “I'll be back soon; you will be all right, won't you?” She then vanished rapidly out of sight into the back of the store. The virtual reality narrator directed me to look around for the pharmacist. I saw people in the aisles who seemed to be there one minute and gone the next. The sound was echoing and distorted. Objects and people sped through space in a blur. Voices came from everywhere, and sometimes specifically from the people I saw. A woman in the aisle looked at me suspiciously with a hateful expression. As I made my way to the back of the line to wait for my prescription, the virtual reality narrator provided the script of my thoughts: “The pharmacist does not want me to have the pills; he is going to do something terrible; he is going to call the insurance company and this will put me in danger. Who can tell what the consequence might be?” I felt frightened and wanted to flee. As I watched him prepare my medication, the pill bottle turned into a bottle of poison with a skull and crossbones on it. The dissonant music and disturbing special effects made this terrifying prospect the dramatic culmination of the experience.

The intended message of the display was that paranoia is a wellknown symptom of some psychotic conditions and that the drugs that the virtual pharmacist was preparing can alleviate this symptom. The patient, however, could have been frightened by any number of strange things that happened in the virtual scene. What the patient feared most intensely was the pharmacist and the drugs he was preparing. This startling development echoes back to Mr. Burton's rounds, where social knowledge—repressed in rounds but erupting from a hidden place—pushes through. The obvious message is that the patient has irrational, paranoid fears of the pharmacist. But the obvious message overlays another darker one: the reason the patient fears the pharmacist and his drugs is because the drugs are poison! The association between feelings of paranoia and schizophrenia comes right out of the DSM: what is extraordinary is that Janssen Pharmaceutica, surely despite its own interests, portrayed a prescription antipsychotic (a product they manufacture) as a bottle of poison. When even powerful pharmaceutical corporations cannot stop themselves from imagining that the psychotropic drugs they produce are poisons, we can better understand why the people in this chapter who decide to consume such drugs also regard them with ambivalence.

PART
TWO

 

 

Mania as a Resource

The purpose of part 2 is to consider how psychotropic drugs and manic depression are imagined on an almost mythical scale. This giant landscape will be replete with larger-than-life images in advertisements and media, and with the activities of powerful institutions like corporations and markets. Although we leave behind the close-up views of pharmaceutical employees, physicians, and patients living under the description of manic depression, we need to remember the uncertainty and ambivalence revealed in part 1. Even international markets and global corporations have come into being through the activities of employees, practitioners, and patients whose actions and notions are imbued with uncertainty.

In the U.S. economic system, there is a premium on measuring and tracking any valuable resource, and that includes moods. The activities of charting and recording moods make moods and their potential benefits or detriments visible and quantifiable. Norms for moods have gone up the scale from “moderate” toward “hot.” Anyone living under the description of manic depression—as well as anyone who partakes in the powerful aura of a manic style—learns they have the capacity to be “hot” and the potential to parlay this capacity into a valuable commodity in the market. But being “hot” means walking high up on an “edge.” Walking high up on an “edge” means fearing the inevitability of a fall into the abyss of “cold” depression.

CHAPTER SEVEN

 

Taking the Measure of Moods and Motivations

Numbers
are the product of counting.
Quantities
are the product of measurement. This means that numbers can conceivably be accurate because there is a discontinuity between each integer and the next. Between
two
and
three,
there is a jump. In the case of quantity, there is no such jump; and because jump is missing in the world of quantity, it is impossible for any quantity to be exact. You can have exactly three tomatoes. You can never have exactly three gallons of water. Always quantity is approximate.

—Gregory Bateson,
Mind and Nature: A Necessary Unity

A
s we move from the small-scale daily experiences of people to the larger-scale phenomena of markets and popular media, a bridging concept is Raymond Williams's “structures of feeling.”
¹
Structures of feeling are actively felt sensibilities that can be vague rather than explicit, informally sensed rather than formally codified. Comedians who use manic energy to draw audiences into hilarious laughter, support groups who turn to an enactment of mania to demonstrate the volitional aspects of going manic, a doctor who uneasily relies on a group of manic depressives to care for a schizophrenic man—all these fleeting events draw on a sense that mania is linked to something powerful, not just to something disordered. Small scale and amorphous they may be, structures of feeling can still play a important part in producing larger-scale phenomena. For example, as we saw in the last chapter, the sensibilities of pharmaceutical advertisers about creativity and manic depression play a role in developing ads that end up as part of mass media. In turn, as we will see in the second half of the book, larger institutional forces flowing from markets and media act back on the everyday sensibilities of the people we met in the first half.

Americans living under the description of manic depression today are often encouraged to keep a “mood chart” in order to manage their manias and depressions. Filling out a mood chart—a small act of individual discipline—can have dramatic effects. When many people fill out the same charts or register their moods on a numerical scale, they make their distinct experiences comparable. When people assign a number to a mood, they are paving the way for statistics that describe the moods of a population and their changes over time. Through the social technology of the mood chart, manic depression emerges from the psychology of individuals onto the scene of national and global concerns with the rationality and productivity of populations.

The practice of mood charting is part of a long tradition dating back to the eighteenth century, when charts were used to manage the daily ups and downs of moods. The Philadelphia physician Benjamin Rush devised a “moral thermometer,” published in a popular health magazine in 1833, that enabled people to register changes from “unfeeling,” “cold,” or “sullen” on the low end to “hot,” “passionate,” or “ungovernable” on the high end. Rush intended the moral thermometer to regulate people's “tempers” in accord with the dictates of the temperance movement of that time.

At the end of this chapter, I will return to Rush's chart for comparison with the multitude of contemporary charts I came across in my fieldwork. One example is “Amy's self-rated mood chart,” found in a popular contemporary handbook on managing bipolar disorder.
²
This chart is a grid that fits on one page of the book, with a row for each day of the month. The left part of the chart is devoted to records of medication and the right part to mood. There are columns for daily notes such as “friend's wedding” or “dog got sick; went to hospital,” and columns to indicate “irritability,” “anxiety,” and hours of sleep. The range of moods is from “elevated” to “depressed,” and, strikingly, times when one is “able to work” or “not able to work” are distinguished for both elevated and depressed moods. This chart connects working and not working, productivity and unproductivity, with the individual's moods. This connection reiterates in another form the link we have seen several times before between moods and motivation.