by Oliver Sacks
Sharpest of all was the misery on the faces of the people she passed. She tried to explain her vision to them but they just kept rushing by. Then it hit her: they already know about their genius, it isn’t a secret, but much worse: genius has been suppressed in them, as it had been suppressed in her. And the enormous effort required to keep it from percolating to the surface and reasserting its glorious hold on our lives is the cause of all human suffering. Suffering that Sally, with this epiphany, has been chosen among all people to cure.
As startling as Sally’s passionate new beliefs are, her father and stepmother are even more struck by her manner of speaking:
Pat and I are dumbstruck, less by what she is saying than how she is saying it. No sooner does one thought come galloping out of her mouth than another overtakes it, producing a pile-up of words without sequence, each sentence canceling out the previous one before it’s had a chance to emerge. Our pulses racing, we strain to absorb the sheer volume of energy pouring from her tiny body. She jabs at the air, thrusts out her chin…her drive to communicate is so powerful it’s tormenting her. Each individual word is like a toxin she must expel from her body.
The longer she speaks, the more incoherent she becomes, and the more incoherent she becomes, the more urgent is her need to make us understand her! I feel helpless watching her. And yet I am galvanized by her sheer aliveness.
One may call it mania, madness, or psychosis—a chemical imbalance in the brain—but it presents itself as energy of a primordial sort. Greenberg likens it to “being in the presence of a rare force of nature, such as a great blizzard or flood: destructive, but in its way astounding too.” Such unbridled energy can resemble that of creativity or inspiration or genius—this, indeed, is what Sally feels is rushing through her: not an illness, but the apotheosis of health, the release of a deep, previously suppressed self.
These are the paradoxes that surround what Hughlings Jackson, the nineteenth-century neurologist, called “super-positive” states: they betoken disorder, imbalance in the nervous system, but their energy, their euphoria, makes them feel like supreme health. Some patients may achieve a startled insight into this, as did one patient of mine, a very old lady with neurosyphilis. Becoming more and more vivacious in her early nineties, she said to herself, “You’re feeling too well, you must be ill.” George Eliot, similarly, spoke of herself as feeling “dangerously well” before the onset of her migraine attacks.
Mania is a biological condition that feels like a psychological one—a state of mind. In this way it resembles the effects of various intoxications. I saw this very dramatically with some of my Awakenings patients when they began taking L-dopa, a drug that is converted in the brain to the neurotransmitter dopamine. Leonard L., in particular, became quite manic on this: “With L-dopa in my blood,” he wrote at the time, “there’s nothing in the world I can’t do if I want.” He called dopamine “resurrectamine” and started to see himself as a messiah—he felt that the world was polluted with sin and that he had been called upon to save it. And in nineteen nonstop, almost sleepless days and nights, he typed an entire autobiography of fifty thousand words. “Is it the medicine I am taking,” wrote another patient, “or just my new state of mind?”
If there is uncertainty in a patient’s mind about what is “physical” and what is “mental,” there may be a still deeper uncertainty as to what is self or not-self—as with my patient Frances D., who, as she grew more excited on L-dopa, was taken over by strange passions and images that she could not dismiss as entirely alien to her “real self.” Did they, she wondered, come from very deep but previously suppressed parts of herself? But these patients, unlike Sally, knew that they were on a drug, and could see, all around them, similar effects taking hold on the others.
For Sally there was no precedent, no guide. Her parents were as bewildered as she was—more so, because they did not have her mad assurance. Was it, they wondered, something she had been taking—had she dropped acid, or something worse? And if not, was it something they had bequeathed her in their genes or something awful they had “done” at a critical stage in her development? Was it something she had always had in her, even though it triggered so suddenly?
These were the questions my own parents asked themselves when, in 1943, my fifteen-year-old brother Michael became acutely psychotic. My brother saw “messages” everywhere, felt his thoughts were being read or broadcast, had explosions of strange giggling, and believed he had been translocated to another “realm.” Hallucinatory drugs were rare in the 1940s, so my parents, who were both doctors, wondered whether Michael might have some psychosis-producing illness—perhaps a thyroid condition or a brain tumor. It ultimately became clear, though, that my brother suffered from a schizophrenic psychosis. In Sally’s case, blood tests and physical exams ruled out any problems with thyroid levels, intoxicants, or tumors. Her psychosis, though acute and dangerous (all psychoses are potentially dangerous, at least to the patient), was “merely” manic.
One can become manic (or depressed) without becoming psychotic—that is, having delusions or hallucinations, losing sight of reality. Sally, though, did go over the top, and on that hot July day, something happened, something snapped. All of a sudden, she was a different person—she looked different, sounded different. “Suddenly every point of connection between us had vanished,” her father writes. She calls him “Father” (he was “Dad” before) and speaks in a “pressured, phony voice, as if delivering stage lines she has learned”; “her normally warm chestnut eyes are shell-like and dark, as if they’ve been brushed over with lacquer.”
Greenberg tries to talk with her of ordinary matters, asking her if she is hungry or wants to lie down:
Each time, however, her otherness is reaffirmed. It is as if the real Sally has been kidnapped, and here in her place is a demon, like Solomon’s, who has appropriated her body. The ancient superstition of possession! How else to come to grips with this grotesque transformation?…In the most profound sense Sally and I are strangers: we have no common language.
The special qualities of mania have been recognized and distinguished from other forms of madness since the great physicians of antiquity wrote on the subject. The Greek physician Aretaeus, in the second century, gave a clear description of how excited and depressed states might alternate in an individual, but the distinction between different forms of madness was not formalized until the rise of psychiatry in nineteenth-century France. It was then that “circular insanity” (folie circulaire or folie à double forme)—what Emil Kraepelin later called manic-depressive insanity and what we would now call bipolar disorder—was distinguished from the much graver disorder of “dementia praecox,” or schizophrenia. But medical accounts, accounts from the outside, can never do justice to what is actually experienced in the course of such psychoses; there is no substitute here for firsthand accounts.
There have been several such personal narratives over the years, and one of the best, to my mind, is Wisdom, Madness and Folly: The Philosophy of a Lunatic, by John Custance, published in 1952. He writes:
The mental disease to which I am subject is…known as manic depression, or, more accurately, as Manic-depressive Psychosis….The manic state is one of elation, of pleasurable excitement sometimes attaining to an extreme pitch of ecstasy; the depressive state is its precise opposite, one of misery, dejection, and at times of appalling horror.
Custance had his first manic attack at the age of thirty-five and would continue to have periodic episodes of mania or depression for the next twenty years:
When the nervous system is thoroughly deranged, the two contrasting states of mind can be almost infinitely intensified. It sometimes seems to me as though my condition had been specially devised by Providence to illustrate the Christian concepts of Heaven and Hell. Certainly it has shown me that within my own soul there are possibilities of an inner peace and happiness beyond description, as well as of inconceivable depths
of terror and despair.
Normal life and consciousness of “reality” appear to me rather like motion along a narrow strip of table-land at the top of a Great Divide separating two distinct universes from each other. On the one hand the slope is green and fertile, leading to a lovely landscape where love, joy and the infinite beauties of nature and of dreams await the traveller; on the other a barren, rocky declivity, where lurk endless horrors of distorted imagination, descends to the bottomless pit.
In the condition of manic-depression, this table-land is so narrow that it is exceedingly difficult to keep on it. One begins to slip; the world about one changes imperceptibly. For a time it is possible to keep some sort of grip on reality. But once one is really over the edge, once the grip of reality is lost, the forces of the Unconscious take charge, and then begins what appears to be an unending voyage into the universe of bliss or the universe of horror as the case may be, a voyage over which one has oneself no control whatever.
In our own time, Kay Redfield Jamison, a brilliant and courageous psychologist who has manic-depressive illness herself, has written both the definitive medical monograph on this subject (Manic-Depressive Illness, with Frederick K. Goodwin) and a personal memoir, An Unquiet Mind. In the latter, she writes:
I was a senior in high school when I had my first attack of manic-depressive illness; once the siege began, I lost my mind rather rapidly. At first, everything seemed so easy. I raced about like a crazed weasel, bubbling with plans and enthusiasms, immersed in sports, and staying up all night, night after night, out with friends, reading everything that wasn’t nailed down, filling manuscript books with poems and fragments of plays, and making expansive, completely unrealistic, plans for my future. The world was filled with pleasure and promise; I felt great. Not just great, I felt really great. I felt I could do anything, that no task was too difficult. My mind seemed clear, fabulously focused, and able to make intuitive mathematical leaps that had up to that point entirely eluded me. Indeed, they elude me still.
At that time, however, not only did everything make perfect sense, but it all began to fit into a marvelous kind of cosmic relatedness. My sense of enchantment with the laws of the natural world caused me to fizz over, and I found myself buttonholing my friends to tell them how beautiful it all was. They were less than transfixed by my insights into the webbings and beauties of the universe, although considerably impressed by how exhausting it was to be around my enthusiastic ramblings….Slow down, Kay….For God’s sake, Kay, slow down.
I did, finally, slow down. In fact, I came to a grinding halt.
Jamison contrasts this experience with her later bouts:
Unlike the very severe manic episodes that came a few years later and escalated wildly and psychotically out of control, this first sustained wave of mild mania was a light, lovely tincture of true mania….It was short-lived and quickly burned itself out: tiresome to my friends, perhaps; exhausting and exhilarating to me, definitely; but not disturbingly over the top.
Both Jamison and Custance describe how mania alters not just thought and feeling, but even their sensory perceptions. Custance carefully itemizes these changes in his memoir. Sometimes the electric lights in the ward have “a bright starlike phenomenon emanat[ing]…ultimately forming a maze of iridescent patterns.” Faces seem to “glow with a sort of inner light which shows up the characteristic lines extremely vividly.” Though normally “a hopeless draughtsman,” Custance is able to draw quite well while manic (I was reminded here of my own ability to do this, many years ago, during a period of amphetamine-induced hypomania); all of his senses seem intensified:
My fingers are much more sensitive and neat. Although generally a clumsy person with an execrable handwriting I can write much more neatly than usual; I can print, draw, embellish and carry out all sorts of little manual operations, such as pasting up scrapbooks and the like, which would normally drive me to distraction. I also note a particular tingling in my fingertips.
My hearing appears to be more sensitive, and I am able to take in…many different sound-impressions at the same time….From the cries of gulls outside to the laughter and chatter of my fellow-patients, I am fully alive to what is going on and yet find no difficulty in concentrating on my work.
…If I were to be allowed to walk about freely in a flower garden I should appreciate the scents far more than usual….Even common grass tastes excellent, while real delicacies like strawberries or raspberries give ecstatic sensations appropriate to a veritable food of the gods.
At first, Sally’s parents struggle to believe (as Sally herself believes) that her excited state is something positive, something other than illness. Her mother puts a somewhat New Agey spin on it:
Sally is having an experience, Michael, I’m sure of it, this isn’t a sickness. She’s a highly spiritual girl….What’s happening right now is a necessary phase in Sally’s evolution, her journey toward a higher realm.
And this interpretation finds echoes of a more classical kind in Greenberg himself:
I wanted to believe this too…to believe in her breakthrough, her victory, the delayed efflorescence of her mind. But how does one tell the difference between Plato’s “divine madness” and gibberish? between [enthusiasm] and lunacy? between the prophet and the “medically mad”?
(It was similar, Greenberg points out, with James Joyce and his schizophrenic daughter, Lucia. “Her intuitions are amazing,” Joyce remarked. “Whatever spark of gift I possess has been transmitted to her and has kindled a fire in her brain.” Later, he told Beckett, “She’s not a raving lunatic, just a poor child who tried to do too much, to understand too much.”)
But it becomes clear within hours that Sally is indeed psychotic and out of control, and her parents take her to a psychiatric hospital. At first, she welcomes this, seeing the nurses, the attendants, and the psychiatrists as specially tuned to understand her insight, her message. The reality is brutally different: she is stupefied with tranquilizers and put in a locked ward.
Greenberg’s description of the ward takes on the richness and density of a novel, embracing a Chekhovian cast of characters—the staff, the other patients on the ward. He sees a highly disturbed, obviously psychotic young Hasidic man whose family will not accept that he is ill: “He has achieved devaykah,” says his brother, “the state of constant communion with God.”
There is relatively little attempt to understand Sally in the hospital—her mania is treated first of all as a medical condition, a disturbance of brain chemistry, to be dealt with on a neurochemical basis. Medication is crucial, even lifesaving, in acute mania, which untreated can lead to exhaustion and death. Unfortunately, though, Sally does not respond to lithium, which has been invaluable for many patients with manic-depressive illness, and so her physicians have to resort to heavy tranquilizers—which damp down her exuberance and wildness but leave her stupefied and apathetic and parkinsonian for a time. Seeing his teenage daughter in this zombielike state is almost as shocking for her father as her mania has been.
* * *
—
AFTER TWENTY-FOUR DAYS of this, Sally is released—still somewhat delusional and still on strong tranquilizers—to go home, under careful and at first continuous surveillance. Outside the hospital, she establishes a crucial relationship with an exceptional therapist, who is able to approach her as a human being, trying to understand her thoughts and feelings. Dr. Lensing shows a disarming directness: “I bet you feel as if there’s a lion inside you” are her first words to Sally.
“How did you know?” Sally is amazed, her suspicion instantly melting away. Lensing goes on to talk of mania, Sally’s mania, as if it were a sort of creature, another being, inside her:
Lensing nimbly lowers herself into the waiting area chair next to Sally’s and tells her in a tone of woman-to-woman straight talk that mania—and she refers to it as if it is a separate entity, a mutual acquaintance of theirs—mania
is a glutton for attention. It craves thrills, action, it wants to keep thriving, it will do anything to live on. “Did you ever have a friend who’s so exciting you want to be around her, but she leads you into disaster and in the end you wish you never met? You know the sort of person I mean: the girl who wants to go faster, who always wants more. The girl who serves herself first and screw the rest….I’m just giving an example of what mania is: a greedy, charismatic person who pretends to be your friend.”
Lensing tries to get Sally to distinguish her psychosis from her true identity, to stand outside the psychosis and to see the complex, ambiguous relationship between it and her. (Psychosis is “not an identity,” she says sharply.) She speaks of this to Sally’s father, too—for his understanding is also necessary if Sally is to get better. She emphasizes the seductive power of psychosis:
“Sally…doesn’t want to be isolated, her impulse is outward, which I can tell you is extremely good news. Her desire is to be understood, and not only by us, she wants to understand herself as well. She’s still attached to her mania, of course. She’s remembering the intensity of her experience, and she’s doing her damnedest to keep that intensity alive. She thinks that if she gives it up, she’ll lose the great abilities she believes she’s acquired. It’s a terrible paradox really: the mind falls in love with psychosis. The evil seduction, I call it.”
