A First-Rate Madness (3 page)

The most popular psychological theory about depression these days is the
cognitive-behavioral model,
which views depression as distorting our perception of reality, making our thoughts abnormally negative. This model, the basis for cognitive-behavioral therapy, is contradicted by another theory that has a growing amount of clinical evidence behind it: the
depressive realism hypothesis
. This theory argues that depressed people aren't depressed because they distort reality; they're depressed because they see reality more clearly than other people do.

The notion of depressive realism implies that the disease has an upside, but I don't want to misrepresent how deeply dangerous and painful depression is. If untreated, it becomes a game of Russian roulette, with nature pulling the trigger when she decides, and with suicide the outcome. “Depression is a terrifying experience,” said one of my patients, “knowing that somebody is going to kill you, and that person is
you
.” Suicidal thoughts occur in about half of clinical depressive episodes.

The anger and despondency of depression (as well as the impulsivity of mania) can also cut a person off from the people he loves most. Divorce and broken relationships are the rule. Said one patient, “The illness is a kind of robbery; it robs you of those you love. I don't want money or power or fame. I just want to keep those I love. And this illness robs them from me. They wake up one day, and I am not the same person, and they say, ‘Who is this?' And they leave.” The benefits of depression come at a painful, if not deadly, price.

 

 

IF THE NUANCES of depression are confusing, mania seems even more complicated. Here mood is generally elated, even sometimes giddy, often alternating with anger. One doesn't need to sleep much; four hours can do it. While the rest of the world is sleeping, one's energy level is as high as it might be at 11 a.m. Why not clean the entire house at 3 a.m.? Things need to get done, even if they don't. Redecorate the house; do it again; buy a third car. Work two or three extra hours every day: the boss loves it. One's thoughts pour forth; the brain seems to be much faster than the mouth. Trying to keep up with those rapid thoughts, one talks fast, interrupting others. Friends and coworkers become annoyed; they can't get a word in edgewise. This may make one more irritable; why can't everyone else get up to speed? “Mania is extremity for one's friends,” Robert Lowell remarked, “depression for oneself.”

Self-esteem rises. Sometimes it leads to great successes, where one's skills are up to the task at hand. But often it leads to equally grand failures, where one oversteps one's bounds. But for someone in a manic state, there is no past; there is hardly today; only the future counts, and there, anything is possible. Decisions seem easy; no guilt, no doubt, just do it. The trouble is not in starting things, but in finishing them; with so much to do and little time, it's easy to get distracted.

Mania often impairs one's judgment, and bad decisions typically fall into four categories: sexual indiscretions, spending sprees, reckless driving, and impulsive traveling. Sex becomes even more appealing; one's spouse may like it, or tire of it. The urge is so strong that one might look to satisfy it elsewhere; affairs are common; divorce is the norm; HIV rates are high. Divorce, debt, sexually transmitted diseases, occupational instability: mania is the perfect antidote to the cherished goals of most people—a family, a home, a job, a stable life. The depressed person is mired in the past; the manic person is obsessed with the future. Both destroy the present in the process. In the worst-case scenario, the depressed person takes her life, the manic ruins hers. In manic-depressive illness, one suffers from both tragic risks.

Yet for all its dangers, mania can confer benefits that psychiatrists and patients both recognize. A key aspect of mania is the liberation of one's thought processes. My patients are sometimes eloquent when describing this freedom of thought (which psychiatrists label “flight of ideas”):

“Everything was swirling like a whirlwind; you just had to reach up to grab a word. You could see it, but you couldn't say it, like the word ‘flower.' But when it got faster, you couldn't even see it.”

Or: “My thoughts were like fireworks, going up and then exploding in all directions.”

This emancipation of the intellect makes normal thinking seem pedestrian: “It felt like my mind was a fast computer,” said one patient.

This produces the swell of creativity that only great poets who have themselves been manic can describe. Like William Blake:

Or Robert Lowell:

THEORIES OF MANIA do not abound. It's as if traditional psychiatry saw the condition as too superficial to merit explanation.

The psychoanalytic view, which sees mania as a defense against depression, is the most coherent but probably the most wrongheaded. Some of my own patients offer a version of this explanation. “Sometimes I think I make myself become manic to ward off a depression,” one patient told me. “I make myself be happy about everything and I do a lot of things and I stop sleeping because I know if I don't do this, I'll become depressed.” Such rationales seem logical, but I'm skeptical about them. Mania often occurs without any preceding depression, and in fact more commonly, depression follows mania, suggesting that mania causes depression, rather than the reverse.

For psychoanalysts, depression was respectable; mania was not. Freud at least was honest about this: he wrote practically nothing about mania, and he admitted that psychoanalysis had no role in understanding or treating manic-depressive illness. His followers spoke where he was silent, blaming manic patients for being too childish to face their depressions. Mania does seem to hamper self-awareness, perhaps another reason why psychoanalysts looked askance at it. In my practice, I often see patients who are manic but don't realize it. Some others only see the benefits of mania: enhanced creativity, energy, sociability. Mania becomes a kind of temporary “personality transplant” where people take on the kind of charisma that our society rewards. But they don't fully realize the negative aspects of the disease, which are usually even more pronounced than its benefits: irritability, promiscuous sexuality, and lavish spending.

Mania is like a galloping horse: you win the race if you can hang on, or you fall off and never even finish. In Freudian terms, one might say that mania enhances the id, for better or worse. All energies, sexual and otherwise, overwhelm the usual controls that we learn to impose over a lifetime. The core of mania is
impulsivity with heightened energy
. If to be manic means to be impulsive, then perhaps the expression of mania depends on how far the civilized veneer that holds our lives together is stretched. If it is stretched only a little, manic-depressive persons may function fine and actually be rewarded for their creativity and extraversion. If it is stretched too much, society disapproves, and tragedy may ensue.

 

 

SOME PEOPLE ARE neither depressed nor manic, but they aren't mentally healthy either. They have
abnormal personalities or temperaments
. Personality or temperament is just as biological as mental illness, though most of us think otherwise. Our basic temperaments are set by the time we reach kindergarten; studies show that those basic temperaments measured at age three persist and predict adult personality at age eighteen. From then onward as well, despite what many intuitively believe, our basic personality traits change little throughout adulthood and into old age. We may get wiser as we get older, but we do not become less introverted, or more open to experience, or less neurotic (to mention three basic personality traits).

Usually we don't think about personality in relation to mental illness. Indeed, my main focus in this book will be to apply the psychiatric concepts of depression and mania to history. But many leaders, though not manic-depressive, have abnormal temperaments that are mild versions of manic-depressive illness.

Personality traits are like height and weight—variables that describe the shape of our minds, just as height and weight describe the shape of our bodies. A century of research on personality has produced some consensus. Most studies on personality identify at least three basic traits common to all people: neuroticism, extraversion, and openness to experience. One of these traits is anxiety—we're all more or less anxious (neuroticism). Another is sociability—some of us are more extraverted, some more introverted (extraversion). Another is experience seeking—some of us are curious and take risks, others are more cautious (openness to experience). We each have more or less of these traits, and, with well-designed psychological tests, one can establish how they're distributed among thousands of normal people. One can then know where any single person stands on each trait, near the middle of a normal curve—and thus near the average—or toward the extremes.

These traits can combine to form specific personality types. Some people are always a little depressed, low in energy, need more than eight hours' sleep a night, and introverted. This personality type is called
dysthymia
. Other people are the opposite: always upbeat, outgoing, high in energy. They need less than eight hours' sleep a night and have more libido than most of us. This type is called
hyperthymia,
and it occurs often in great leaders, like Franklin Roosevelt and John F. Kennedy. And some people are a little of both, alternating between lows and highs in mood and energy. This type is called
cyclothymia.

These abnormal temperaments are mild versions of depression, mania, and bipolar disorder; as such, they're abnormal personality traits, which a person has all the time, not mood episodes that come and go. They can occur by themselves, without any episodes of mania or depression, or they can occur alongside bipolar disorder or severe depression (for instance, someone might have episodes of mania or depression every other year, and in between those episodes have a dysthymic personality). In fact, these abnormal personalities occur more often in those with bipolar disorder or severe depression than they do in people without mental illness. They also occur much more frequently in relatives of people with severe depression and mania than in the normal population.

These temperaments were described by the early-twentieth-century German psychiatrist Ernst Kretschmer, the first modern researcher on abnormal personality, who also noted the link between insanity and genius. He recognized the benefit of a little mental abnormality, either in “the initial stages” of severe mental illness, or in “mild, borderline states of mental disease,” which is what I mean by abnormal personalities or temperaments. If we removed the insanity from these people, Kretschmer said, we would convert their genius into merely ordinary talent. Insanity is not a “regrettable . . . accident” but the “indispensable catalyst” of genius.

 

 

SURPRISINGLY, MENTAL HEALTH can be as challenging to define as mental illness, because our sense of one is informed by our sense of the other. To keep it simple, I define mental health as
the absence of mental disease, plus being near the statistical average of personality traits.
Thus,
mental illness
means the presence of disease, like manic-depressive illness; and
mental abnormality
means being at the extremes, not near the average, of personality traits. Mental abnormality means having abnormal temperaments—like dysthymia, cyclothymia, hyperthymia—that don't occur in the vast majority of normal people. Therefore, these conditions aren't part of mental health; they are essentially milder versions of mental illness.

With these definitions, the theme of this book can be stated this way:
The best crisis leaders are either mentally ill or mentally abnormal; the worst crisis leaders are mentally healthy.

In times of peace, mental health is useful. One meets the expectations of one's community, and one is rewarded for doing so. In times of war or crisis, it is the misfits who fill the bill. Kretschmer noticed this pattern and explained it using the metaphor of bacteria, which replicate and survive only in times of crisis. “The brilliant enthusiast, the radical fanatic and the prophet are always there, just as the tricksters and criminals are—the air is full of them,” but they flourish only during crisis. In peacetime, they are our patients, he famously wrote; we rule them. In crisis periods, they rule us.

Great crisis leaders are not like the rest of us; nor are they like mentally healthy leaders. They're often intelligent, prone to poor physical health, the products of privileged backgrounds, raised by parents in conflict, frequently nonreligious, and ambitious. All these personality traits and experiences are also associated with mental illness, like mania and depression, or with abnormal temperaments, like hyperthymia. Much of what passes for normal is not found in the highly successful political and military leader, especially in times of crisis. If normal, mentally healthy people—what I will later define scientifically as “homoclites”—run for president, they tend not to become great ones.

 

 

A FINAL DISCLAIMER: the true mark of science (as opposed to its many masquerades) is an attempt to refute one's hypothesis, to be self-critical, to examine one's assumptions, and to point out ways to further test one's theory. I will strive to do all of these things throughout this book. Science makes probabilistic claims; it is not usually about proving that something is
always
the case, or
never
the case. Almost all science is about showing a greater probability that something is
usually
the case. On most scientific matters, especially in medicine and on the topic of disease, no single exception is a disproof. The preponderance of the evidence represents scientific knowledge.