Making Sense of Mania and Depression

We all feel moments of gloom or exhilaration on occasion. But few of us truly understand how far off-key the melodies of mood can drift. Here, a leading psychiatrist eloquently recounts two real-life tales of mania and depression--and shows how these disorders are indeed moods apart from our everyday experience.

TRY FOR A MOMENT TO IMAGINE a personal world drained of emotion, a world where perspective disappears. Where strangers, friends, and lovers are all held in similar affection, where the events of the day have no obvious priority. There is no guide to deciding which task is most important, which dress to wear, what food to eat. Life is without meaning or motivation.

This colorless state of being is exactly what happens to some victims of melancholic depression, one of the most severe mood disorders. Depression--and its polar opposite, mania--are more than illnesses in the everyday sense of the term. They cannot be understood merely as an aberrant biology that has invaded the brain; for by disturbing the brain the illnesses, enter and disturb the person--the feelings, behaviors, and beliefs that uniquely identify the individual self. These afflictions invade and change the very core of our being. And the chances are overwhelming that most of us, during our lifetime, will come face to face with mania or depression, seeing them in ourselves or in somebody close to us. It's estimated that in the United States 12 to 15 percent of women and eight to 10 percent of men will struggle with a serious mood disorder during their lifetime.

While in everyday speech the words mood and emotion are often used interchangeably, it is important to distinguish them. Emotions are usually transient--they constantly respond to our thoughts, activities, and social situations throughout the day. Moods, in contrast, are consistent extensions of emotion over time, sometimes lasting for hours, days, or even months in the case of some forms of depression. Our moods color our experiences and powerfully influence the way we interact. But moods can go wrong. And when they do, they significantly alter our normal behavior, changing the way we relate to the world and even our perception of who we are.

CLAIRE'S STORY. Claire Dubois was such a victim. It was the 1970s, when I was professor of psychiatry at Dartmouth Medical School. Elliot Parker, Claire's husband, had telephoned the hospital desperately worried about his wife, who he suspected had tried to kill herself with an overdose of sleeping pills. The family lived in Montreal, but were in Maine for the Christmas holidays. I agreed to see them that afternoon.

Before me was a handsome woman approaching 50 years of age. She sat mute, eyes cast down, holding her husband's hand without apparent anxiety or even interest in what was going on. In response to my questioning she said very quietly that it was not her intention to kill herself but merely to sleep. She could not cope with daily existence. There was nothing to look forward to and she felt of no value to her family. And she could no longer concentrate sufficiently to read, which had been her greatest passion.

Claire was describing what psychiatrists call anhedonia. The word literally means "the absence of pleasure," but in its most severe form anhedonia becomes an absence of feeling, a blunting of emotion so profound that life itself loses meaning. This lack of feeling is most frequently present in melancholia, which lies on a continuum with depression, extending the illness to its most disabling and frightening form. It is a depression that has taken root and grown independent, distorting and choking the feeling of being alive.

SLIP SLIDING AWAY. In Claire's mind and in Elliot's, the whole thing began after an automobile accident the winter before. On a snowy evening, while on her way to pick up her children from choir practice, Claire's car had slid off the road and down an embankment. The injuries she sustained were miraculously few but included a concussion from her head hitting the windshield. Despite this good fortune, she began to experience headaches in the weeks following the accident. Her sleep became fragmented, and with this insomnia came increasing fatigue. Eating held little attraction. She was irritable and inattentive, even to her children. By the spring, Claire was complaining of dizzy spells. She was seen by the best specialists in Montreal, but no explanation could be found. In the words of the family doctor, Claire was "a diagnostic puzzle."

The summer months, when she was alone in Maine with her children, brought minor improvement, but with the onset of winter the disabling fatigue and insomnia returned. Claire withdrew to the world of books, turning to Virginia Woolf's novel The Wave, for which she had a particular affection. But as the shroud of melancholy fell upon her, she found sustaining her attention increasingly difficult, and a critical moment arrived when Woolf's woven prose could no longer occupy Claire's befuddled mind. Deprived of her last refuge, Claire had only one thought, drawn possibly from her identification with Woolf's own suicide: that the next chapter in Claire's life should be to fall asleep forever. This stream of thought, almost incomprehensible to those who have never experienced the dark vortex of melancholy, is what preoccupied Claire in the hours before she took the sleeping pills that brought her to my attention.

Why should sliding off an icy road have precipitated Claire into this black void of despair? Many things can trigger depression. In a sense it is the common cold of emotional life. In fact, depression can literally follow in the wake of the flu. Just about any trauma or debilitating illness, especially if it lasts a long time and limits physical activity and social interaction, increases our vulnerability to depression. But the roots of serious depression grow slowly over many years and are usually shaped by numerous separate events, which combine in a way unique to the individual. In some, a predisposing shyness is amplified and shaped by adverse circumstance, such as childhood neglect, trauma, or physical illness. In those who experience manic depression, there are also genetic factors that determine the shape and course of the mood disturbance. But even there the environment plays a major role in determining the timing and frequency of illness. So the only way to understand what kindles depression is to know the life story behind it.

THE TRIP THAT WASN'T. Claire Dubois was born in Paris. Her father was much older than her mother and died of a heart attack shortly after Claire's birth. Her mother remarried when Claire was eight, but drank heavily and was in and out of hospital with various ailments until she died in her late forties. By necessity a solitary child, Claire discovered literature at an early age. Books offered a fairy-tale adaptation to the reality of daily life. Indeed, one of her fondest memories of adolescence was of lying on the floor of her stepfather's study, sipping wine and reading Madame Bovary. The other good thing about adolescence was Paris. Within walking distance were all the bookstores and cafes an aspiring young woman of letters could desire. These few blocks of the city became Claire's personal world.

Just before the second World War, Claire left Paris to attend McGill University in Montreal. There, she spent the war years consuming every book she could lay her hands on, and after college she became a freelance editor. When the war ended, she returned to Paris at the invitation of a young man she had met in Canada. He proposed marriage, and Claire accepted. Her new husband offered her a sophisticated life among the city's intellectual elite, but after only 10 months he declared that he wanted a separation. Claire never fathomed the reason for his decision; she assumed he had discovered some deep flaw in her that he would not reveal. After months of turmoil she agreed to a divorce and resumed to Montreal to live with her stepsister.

Much saddened by her experience and considering herself a failure, she entered psychoanalysis and her life stabilized. Then, at age 33, Claire married Elliot Parker, a wealthy business associate of her brother-in-law's, and soon the couple had two daughters.

Claire initially valued the marriage. The sadness of her earlier years did not return, although at times she drank rather heavily. With her daughters now growing rapidly, Claire proposed that the family live in Paris for a year. She eagerly planned the year in every detail. "The children were signed up for school. I had rented houses and cars; we had paid deposits," she recalled. "Then, one month before it was to begin, Elliot came home to say that money was tight and it couldn't be done.

"I remember crying for three days. I felt angry but totally impotent. I had no allowance, no money of my own, and absolutely no flexibility." Four months later, Claire slid off the road and into the snowbank.

As Claire and Elliot and I explored her life story together, it was clear to all that the event that kindled her melancholia was not her automobile accident but the devastating disappointment of the canceled return to France. That was where her energy and emotional investment had been placed. She was grieving the loss of the dream of introducing her adolescent daughters to what she herself had loved as an adolescent: the streets and bookshops of Paris, where she had crafted a life for herself out of her lonely childhood.

Elliot Parker loved his wife, but he had not truly understood the emotional trauma of canceling the year in Paris. And it was not Claire's nature to explain how important it was to her or to request an explanation of Elliot's decision. After all, she had never received one from her first husband when he left her. The accident itself further obscured the true nature of her disability: Her restlessness and fatigue were taken as the residue of a nasty physical encounter.

THE LONG ROAD TO RECOVERY. Those bleak midwinter days marked the nadir of Claire's melancholia. Recovery required a hospital stay, which Claire welcomed, and she soon missed her daughters--a reassuring sign that the anhedonia was cracking. What she found difficult was our insistence that she follow a routine--getting out of bed, showering, eating breakfast with others. These simple things we do everyday were for Claire giant steps, comparable to walking on the moon. But a regular routine and social interaction are essential emotional exercises in any recovery program--calisthenics for the emotional brain. Toward the third week of her hospital stay, as the combination of behavioral treatment and antidepressant drugs took hold, Claire's emotional self showed signs of reawakening.

It was not difficult to imagine how her mother's whirlwind social life and repeated illnesses, plus the early death of her father, had made Claire's young life a chaotic experience, depriving her of the stable attachments from which most of us securely explore the world. She longed for intimacy and considered her isolation a mark of her unworthiness. Such patterns of thinking, common in those who suffer depression, can be shed through psychotherapy, an essential part of the recovery from any depression. Claire and I worked on reorganizing her thinking while she was still in the hospital, and we continued after she returned to Montreal. She was committed to change; each week she employed her commuting time to review the tape of our therapy session. All together, Claire and I worked intensively together for almost two years. It was not all smooth sailing. On more than one occasion, in the face of uncertainty, hopelessness returned, and sometimes Claire succumbed to the anesthetic beckoning of too much wine. But slowly she was able to put aside old patterns of behavior. While it is not the case for all, for Claire Dubois the experience of depression was ultimately one of renewal.

One reason that we do not diagnose depression earlier is that--as in Claire's case--the right questions are not asked. Unfortunately, this state of ignorance is often present as well in the lives of those who experience mania, the colorful and deadly cousin of melancholia.

STEPHAN'S TALE. "In the early stages of mania I feel good--about the world and everybody in it. There's a sense that my life will be full and exciting." Stephan Szabo, elbows on the bar, leaned closer as voices rose from the crush of people around us. We had met years earlier in medical school, and on one of my visits to London he agreed to a few beers at the Lamb and Flag, an old pub in the Covent Garden district. Despite the jostle of the evening crowd, Stephan seemed unperturbed. He was warming to his topic, one he knew well: his experience with manic depression.

"It's a very infectious thing. We all appreciate somebody who's positive and upbeat. Others respond to the energy. People I don't know very well--even people I don't know at all--seem happy around me.

"But the most extraordinary thing is how my thinking changes. Usually I think about what I'm doing with the future in mind; I'm almost a worrier. But in the early manic periods everything focuses upon the present. Suddenly I have the confidence that I can do what I had set out to do. People give me compliments about my insight, my vision. I fit the stereotype of the successful, intelligent male. It's a feeling that can last for days, sometimes weeks, and it's wonderful."

A TERRIBLE TORNADO. I felt fortunate Stephan was willing to talk openly about his experience. A Hungarian refugee, Stephan had begun his medical studies in Budapest before the Russian occupation of 1956, and in London we had studied anatomy together. He was a wry political commentator, an extraordinary chess player, an avowed optimist, and a good friend to all. Everything Stephan did was energetic and purposeful.

Then two years after graduation came his first episode of mania, and during the depression that followed he tried to hang himself. In recovery, Stephan had been quick to blame two unfortunate circumstances: He had been denied entry to the Oxford University graduate program and, worse, his father had committed suicide. Insisting that he was not ill, Stephan refused any long-term treatment and over the next decade suffered several further bouts of illness. When it came to describing mania from the inside, Stephan knew what he was talking about.

He lowered his voice. "As time rolls on, my head speeds up; ideas move so fast they stumble over each other. I begin to think of myself as having special insight, understanding things that others do not. I recognize now that these are warning signs. But typically, at this stage people still seem to enjoy listening to me, as if I have some special wisdom.

"Then at some point I start to believe that because I feel special, maybe I am special. I have never actually thought I was God, but a prophet, yes, that has occurred to me. Later--probably as I cross into psychosis--I sense that I am losing my own will, that others are trying to control me. It's at this stage that I first feel twinges of fear. I become suspicious; there's a vague feeling that I am the victim of some outside force. After that everything becomes a terrifying, confusing slide that is impossible to describe. It's a crescendo--a terrible tornado--that I wish never to experience again."

I asked at what point in the process he considered himself ill.

Stephan smiled. "It's a tough question to answer. I think the `illness' is there, in muted form, in some of the most successful among us--those leaders and captains of industry who sleep only four hours a night. My father was like that, and so was I in medical school. It's a feeling that you have the ability to live life fully in the present. What's different about mania is that it goes higher until it blows away your judgment. So it is not simple to determine when I go from being normal to being abnormal. Indeed, I'm not sure I know what a `normal' mood is."

EXHILARATION AND DANGER

I believe there is much truth in Stephan's musing. The experience of hypomania--of early mania--is described by many as comparable to the exhilaration of falling in love. When the extraordinary energy and self-confidence of the condition are harnessed with a natural talent--for leadership or the arts--such states can become the engine of achievement. Cromwell, Napoleon, Lincoln, and Churchill, to name a few, appear to have experienced periods of hypomania and discovered the ability to lead in times when lesser mortals failed. And many artists--Poe, Byron, Van Gogh, Schumann--had periods of hypomania in which they were extraordinarily productive. Handel, for example, is said to have written The Messiah in just three weeks, during an episode of exhilaration and inspiration.

But where early mania may be exciting, mania in full flower is confusing and dangerous, seeding violence and even self-destruction. In the United States, a suicide occurs every 20 minutes--some 30,000 people a year. Probably two-thirds are depressed at the time, and of those half will have suffered manic-depression. Indeed, it's been estimated that of every 100 people who suffer manic-depressive illness, at least 15 will eventually take their own lives--a sobering reminder that mood disorders are comparable to many other serious diseases in shortening the life span.

The crush of revelers in the Lamb and Flag had diminished. Stephan had changed little with the years. True, he had less hair, but there before me was the same nodding head, the long neck and square shoulders, the dissecting intellect. Stephan had been lucky. Over the past decade, since he had decided to accept his manic depression as an illness--something he had to control lest it control him--he had done well. Lithium Carbonate, a mood stabilizer, had smoothed his path, reducing the malignant manias to manageable form. The rest he had achieved for himself.

While we may aspire to the vivacity of early mania, at the other end of the continuum depression is still commonly considered evidence of failure and a lack of moral fiber. This will not change until we can speak openly about these illnesses and recognize them for what they are: human suffering driven by dysregulation of the emotional brain.

I reflected this to Stephan. He readily agreed. "Look at it this way," he said as we got up from the bar, "things are improving. Twenty years ago neither of us would have dreamed about meeting in a public place to discuss these things. People are interested now because they recognize that mood swings, in one form or another, touch everybody every day. Times really are changing."

I smiled to myself. Here was the Stephan I remembered. He was still in the saddle, still playing chess, and still optimistic. It was a good feeling.

THE MEANING OF MOODS

During a recent interview, I was asked what hope I could give those who suffer the "blues." "In the future," my interviewer asked, "will antidepressants eliminate sadness, just as fluoride has eradicated cavities in our teeth?" The answer is no--antidepressants are not mood elevators in those without depression--but the question is provocative for its cultural framing. In many countries, the pursuit of pleasure has become the socially accepted norm.

Behavioral evolutionists would argue that our increasing intolerance of negative moods perverts the function of emotion. Transient episodes of anxiety, sadness, or elation are part of normal experience, barometers of experience that have been essential to our successful evolution. Emotion is an instrument of social self-correction--when we are happy or sad, it has meaning. Seeking ways to blot out variation in mood is equivalent to the airline pilot ignoring his navigational devices.

Perhaps mania and melancholia endure because they have had survival value. The generative energy of hypomania, it can be argued, is good for the individual and social groups. And perhaps depression is the built-in braking system required to return the behavioral pendulum to its set point after a period of acceleration. Evolutionists have also suggested that depression helps maintain a stable social hierarchy. After the fight for dominance is over, the vanquished withdraws, no longer challenging the leader's authority. Such withdrawal provides a respite for recovery and an opportunity to consider alternatives to further bruising battles.

Thus the swings that mark mania and melancholia are musical variations upon a winning theme, variations that play easily but with a tendency to become progressively off-key. For a vulnerable few the adaptive behaviors of social engagement and withdrawal unravel under stress into mania and melancholic depression. These disorders are maladaptive for the individuals who suffer them, but their roots draw upon the same genetic reservoir that has enabled us to be successful social animals.

Several research groups are now searching for genes that increase vulnerability to manic depression or recurrent depression. Will neuroscience and genetics bring wisdom to our understanding of the disorders of mood and spur new treatments for those who suffer these painful afflictions? Or will some members of our society harness genetic insights to sharpen discrimination and drain compassion, to deprive and stigmatize? We must remain vigilant, but I am confident that humanity will prevail, for all of us have been touched by these disorders of the emotional self. Mania and melancholia are illnesses with a uniquely human face.

From A Mood Apart by Peter C. Whybrow, M.D. Copyright 1997 by Peter C. Whybrow. Reprinted by permission of BasicBooks, a division of HarperCollins Publishers, Inc.

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