Bipolar Expeditions (29 page)

7.1. Benjamin Rush's 1833 “Moral Thermometer” showing a range of mental states as hot and cold temperatures. © Benjamin Rush, “Moral Thermometer.”
Journal of Health and Recreation
4, no. 1 (1833): 5. Courtesy of National Library of Medicine.

Mood charts such as Amy's encourage people to manage their psychological states rationally so they can work productively. The conviction that psychological management is rational came out of the early history of the disciplines of psychiatry, psychology, and psychoanalysis. These disciplines came to think that persons, as individuals, could achieve desirable goals such as authority, tranquility, sanity, virtue, or efficiency by governing their own subjectivity. To govern themselves, individuals would need to collect information about their subjectivity in any number of forms, from written reports to drawings, from charts to statistics.
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As the person scrutinized and recorded his inner states, he would become more aware that he was a separate individual who bore the responsibility for self-government.
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Today, a person who keeps a mood chart is translating inside, subjective experience into outside, socially visible forms.
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The practices of introspection and record keeping we have come to take for granted build a strong identity at the individual level, both general (I am a self-regulating calculating, rational person) and specific (these are my mood patterns, and this is how I respond to my specific medications).

Once a person writes her subjective information down in some form, she can manage it in new ways. If she collects her information on a chart whose categories are widely used, she can compare her inner states to another person's. The chart creates a sense that everyone experiences the same kinds of moods, though they may experience them in different combinations and intensities. Comparisons on a common scale are not only invited; they rush to the forefront as charts proliferate. It is as if moods have been thrown into what Marx called the “great social retort.”
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The “retort” boils out particular flavors and leaves only measurable abstract qualities, such as degrees of sanity, modernity, or rationality.

If a person collects her information on a chart that has a numerical scale, still more elaborate forms of management open up. She can now track her moods numerically over time and ascertain whether, by the year, month, or day, her moods are averaging higher or lower. As her moods become represented by a numerical value, they become commensurable with the moods of others.
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If she provides numerical information about her moods to her doctor or a public health specialist, she may contribute to statistical measures of the national or global mood. These forms of record keeping create standardized measures for private, interior states, standardized measures that enable new kinds of measurement of populations.
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To gain greater historical perspective on contemporary mood charts, I turn to Emil Kraepelin's charts of moods in
Manic-Depressive Insanity and Paranoia,
originally published in 1921 and reprinted in color in 2002. For Kraepelin, there were a limited number of types of mood states within the general category manic depression. Each was marked with a special graphic or shade of color: mania, hypomania, raving mania, and manic stupor (all in shades of red), light depression, heavy depression, depression with flight of ideas, and depressive excitement (all in shades of blue).
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But the many charts he included in the book demonstrate that Kraepelin recognized the immense variety of ways individuals with manic depression cycled through mood states. He argued that others' efforts to lump groups of individuals into subtypes of the illness were futile: “[T]he multiplicity of the courses taken by manic-depressive insanity … is absolutely inexhaustible. The cases reported only show that there can be no talk of even an approximate regularity in the course, as has formerly been frequently assumed on the ground of certain isolated observations.”
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For Kraepelin, the time scale was in years (numbered on the left side of the chart), subdivided only into months and portions of months (labeled across the top of the chart). So compact was the chart that the entire lifetime of a person could be contained on one single page.

Doctors familiar with patients in a clinical setting compiled the condensed information in Kraepelin's charts over many years. Patients themselves had no role in writing down their symptoms: rather, doctors kept careful records of patients' health, from how much they weighed to how neatly they could write.

Kraepelin saw manic-depressive insanity as a disease that had a natural, inevitable progression. He regarded it as a “natural disease entity”
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whose characteristics he and his associates discovered through clinical record keeping of “countless” patients.
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He devised a special form called the “Zählkarten”
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to categorize information on each patient. Although masses of data were collected and studied, there is no evidence that Kraepelin quantified this data to present it in the form of graphs or charts summarizing many patients. Nor did he use mathematical forms of representation to show, say, the rise and fall of mood in individual patients over time. His charts only showed the many ways subtypes of moods succeeded one another in different individuals.

According to Kraepelin, although the progression of manicdepressive insanity could be charted, ordinarily no cure would be possible for patients admitted to institutions: he said most were “forever lost.”
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The only hope would come from prevention: in Kraepelin's view, at least one-third of all mental illnesses had causes he regarded as preventable, such as alcoholism, syphilis, traumatic injury, or addiction to morphine and cocaine.
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In spite of the gloomy prospects for his patients, Kraepelin's charts, as well as his descriptions, showed the possibility for patients to enjoy prolonged and frequent disease-free periods. Kraepelin called these remissions “long lucid intervals”
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when patients were “able to reenter the family, to employ themselves profitably, and to return to their profession.”
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On his charts, these intervals are shown as white spaces.

7.2. A 1921 mood chart representing a patient's mood changes month by month over more than three decades. Reprinted with permission. E. Kraepelin,
Manic-Depressive Insanity and Paranoia.
1921. Bristol, England: Thoemmes Press, 2002. © 2002 (1921) Emil Kraepelin.

Today, in contrast to Kraepelin's time, individuals keep their own mood charts. The charts appear in popular books, magazines, doctors' offices, and on the Web. Many groups interested in manic depression explicitly encourage their use. For example, the Web site for the Harvard Bipolar Research group provides a sample chart already filled in and a blank chart you can download and print out for your own use.

The Web site for the patient advocacy group, the Depression and Bipolar Support Alliance, provides a sample chart, a chart for downloading, and a page of detailed instructions. The pharmaceutical company Lilly gives consumers a Web page with a slider to register where one is in the range of moods, and a button to click if one wants to see one's moods over time as a graph. The federally funded NIMH Web site presents visitors with a complex chart accompanied by extensive instructions.
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In addition, various kinds of charts have been developed for parents to use at home and for teachers to use in the classroom. With one device, children use markers to color in which cartoon face best represents their moods, from sad to frantic; with another device, children place plastic stickers on a “Mood Tree.” The designer of the Mood Tree, Rosalyn Newport-Olsen, LCSW, explained to me that children (or in other versions adolescents or adults) place plastic stickers on the Mood Tree to “illustrate their symptoms when they are occurring and to what degree.” She designed the device to be nonthreatening to the patient and to facilitate communication between therapist and patient: “[T]he Mood Tree's visible and tactile appeal makes it useful [for] those unable or unwilling to stay with graphics charting.”
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These techniques are marketed to the parents of children who display behavior problems in the home or classroom. Most recently, a diary is being marketed directly to children who have no particular behavior problems.
The Judy Moody Mood Journal,
a spin-off from a series of popular books about a temperamental third grade girl, encourages children to keep track of their moods, following the character, Judy Moody, who is “always in a mood.” The diary has a “Dial-a-Mood-Meter” built into the cover: you can spin the pointer to see which of ten moods (from “moody blues” to “mischievous”) it will come to rest upon.
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As children are taught to keep records of their interior states, they are being taught to take individual responsibility for managing those states. The record keeping of moods thus extends from children whose moods cause problems at school or home to (potentially) all children.

As in Kraepelin's charts, contemporary charts record a range of psychological states. But in contemporary charts, only simple, everyday feelings and behaviors are listed (anger, sadness, irritability, tiredness, hunger, and so forth), rather than technically defined complexes of traits (Kraepelin's “manic stupor”). The traits charted, itis assumed, are knowable by the individual directly. Do I feel sadness? Elation? Do I experience energy? Fatigue? The charts do not require trained observers of the sort Kraepelin needed.

7.3. Children or adults can indicate the state of their moods by moving plastic stickers around the Mood Tree. Reprinted with permission. The Mood Tree, designed by Rosalyn Newport-Olsen, MSW, LCSW.
http://www.moodtree.com
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7.4. Cover of
The Judy Moody Mood Journal
with an arrow on a dial that points to different moods when it is spun. Text copyright © 2003 by Megan McDonald. Illustrations copyright © 2003 by Peter H. Reynolds. Judy Moody font copyright © 2003 by Peter H. Reynolds. Reproduced by permission of the publisher, Candlewick Press, Inc.

Compared to Kraepelin's charts, the contemporary mood chart has undergone a certain elaboration. In Kraepelin's case, an individual's entire life span could be described on one page; today, one page usually contains the details of only a single day. Each day, in turn, can be divided into periods of hours and minutes and each quality or activity can be registered practically by the minute. Self-scrutiny can thus be carried out at a finer level of detail. I can record, and worry about, my mood variations minute by minute. From details
by the year
to details
by the hour
is a speedup of more than 10,000–fold.

The biggest difference between then and now is that contemporary charts invariably contain a place to record the means of ameliorating mood disorders. All charts I have seen have a section, often occupying nearly half of the chart, for recording what medicines the person takes as well as how much and when they take them throughout the day. Medications are carefully plotted in relation to symptoms so that the mood pattern can be adjusted up or down. A software company has devised a program, Mood Monitor, which allows patients to fill out charts on their home computers while the doctor keeps tabs on their condition remotely. The program calculates summary data from moods juxtaposed to medications, and doctors adjust medications as necessary. On the company's Web site, a doctor writes, “I have used Mood Monitor® in my clinical practice and am very impressed. I have long found that bipolar patients are unable to accurately measure their moods and other parameters between sessions. With Mood Monitor, I can see at a glance how their moods are varying as well as how the patient is sleeping. This allows me to make adjustments in medications with more confidence.” Even without a doctor's involvement, people in support groups frequently said that representing their moods on a chart over time allowed them to see more clearly exactly what differences medications make. A Web author who makes his mood chart available on line agrees: “I've found thatminor changes in medication can make big changes in how I felt, so tracking dosages was useful. And, embarrassing as it was, tracking when I didn't take medicines was useful, too.”
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