- The Oxonian Review - http://www.oxonianreview.org/wp -

What Is It Like to Be Manic?

Paul Lodge

[1]

My memories of the months preceding the episode are hazy. It started in the spring of 1993 and crescendoed. I was twenty-five and in love, writing songs again for the first time in several years, and beginning to find my vocation as I ploughed through Leibniz with furious abandon. By autumn, love had failed, and I was struggling to teach a university class for the first time, on a subject that I knew nothing about. Seemingly overnight, euphoria became crippling depression. I was never suicidal, but it was the greyest of times, as I lived alone in a basement apartment and struggled every day to lift myself off the futon mattress that served as a bed. Nevertheless, after a month or so taking the anti-depressant Zoloft, I was off again. I surrounded myself with books of all kinds, as I tried, with euphoric fervor, to trace the myriad connections that were opening up.

I can state with considerably more precision the date on which my life changed irrevocably: January 28, 1994. A combination of warm temperatures, frozen ground, and heavy rain had caused flooding throughout Southern New Jersey. I remember the following: walking barefoot in the rain and melting snow across the Raritan bridge to an appointment to see my counsellor at Rutgers University; being shepherded into a room where electrodes were placed on my chest to measure my heart rate; being given an oral dose of the anti-psychotic Haldol and sent home; finding several inches of water in my basement apartment, but with damage done to only one of my precious books (a copy of Wittgenstein’s Philosophical Investigations); being led upstairs to a bedroom in my landlord’s house; and sleeping fitfully for twenty-four hours.

I have no recollection of the subsequent meeting with my psychiatrist. But I emerged in the knowledge that I had had a ‘manic episode’—it has turned out to be my only one—and that I was suffering from ‘bipolar disorder’. Since recovering from the manic episode, I have experienced periodic mild elevations of mood, accompanied by the occasional transition to ‘hypomania’, the experience of which resembles a manic episode, but for being more attenuated. I am lucky, in that my symptoms have been manageable. Still, the manic episode of 1994 permanently altered my relationship to all of my experiences—just as much those experiences that occurred before the episode as those experiences following it. It also left me with the task of attempting to make sense of that transformation.

**

Mania is a strange and disconcerting mode of being. The task of making sense of it presupposes some grasp on what a manic episode is. This, in turn, raises the question of which criteria should be used to determine whether someone has undergone such an episode. And there is an important distinction here between criteria that are behavioural and those that are phenomenological—roughly, between those that capture how manic episodes seem to observers from a third-personal perspective, and those that capture how they seem from the first-personal perspective which is accessible only to the subjects who are having them. While psychiatrists are aware of the distinction between the behavioural and phenomenological, behavioural criteria are often emphasised to the neglect of phenomenological ones; more subtly, behavioural criteria have sometimes been confusedly categorised as phenomenological. The lack of clarity concerning this distinction has thus hindered the development of an adequate phenomenological account of mania.

As both context for, and an example of, this lack of clarity, consider the widely accepted account of manic episodes that one finds in The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V). According to the DSM-V definition, a subject has had a manic episode if their life contains an extended “period of mood disturbance and increased energy or activity”, during which they exhibit several of the following symptoms: “increased self-esteem or grandiosity”, “decreased need for sleep”, “more talkative than usual or pressure to keep talking”, “flight of ideas or subjective experience that thoughts are racing”, “distractibility (i.e. attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed”, “increase in activity…or psychomotor agitation”, and “excessive involvement in activities that have a high potential for painful consequences”. DSM-V also requires either that the mood disturbance is severe enough to cause “marked impairment in social or occupational functioning”, that it require hospitalization, or that it includes “psychotic features”. The related category which I employed in my autobiographical sketch above, ‘hypomania’, is differentiated from mania insofar, and only insofar, as the episode fails to meet any of these last three criteria.

DSM-V allows that different collections of symptoms suffice for being manic. And several of its stated criteria for manic episodes include features that are plausibly accessible only from a first-personal perspective. This is clearly acknowledged in the DSM-V criterion concerning flight of ideas, for instance, and seems implicit in criteria such as mood elevation and increased pressure to speech. But the majority of the DSM-V’s criteria are behavioural. Correspondingly, testimonial evidence suggests that the definition misses much of what it can feel like to be manic. Thus, if we want an adequate account of the phenomenology of mania, the DSM-V definition has to be understood, at best, as a starting point.

The clinical psychologists Louis Sass and Elizabeth Pienkos have done the best—though self-confessedly preliminary—work to date in developing systematic accounts of the subjective experience of manic episodes. In a series of four papers published in 2014 and 2015, they draw on sources that range from published clinical studies to work in phenomenological psychiatry to first-personal accounts taken from memoirs. Sass and Pienkos explore differences between the experiences of schizophrenic, manic and melancholic (i.e., depressed) subjects across four domains of experience: “varieties of self-experience”, “space, time, and atmosphere”, “interpersonal experience” and “linguistic experience”. But while this work is both fascinating and helps to answer the question of what it is like to be manic, it still confuses behavioural and phenomenological criteria. I will illustrate this by offering a critical discussion of their accounts of the experiences that manic subjects have of thinking and of using language. A caveat is in order throughout: My critical remarks will be derived from my own recollections of my manic episode and subsequent periods of hypomania. It is clearly possible that some of these will be idiosyncratic in ways that further investigation might reveal.

Saas and Pienkos’ account of ‘manic thinking’ forms part of their paper addressing self-experience. The phenomena they are concerned with are naturally associated with Ludwig Binswanger’s description of manic thought as involving a ‘flight of ideas’, an expression which has become so canonical that it is included in the DSM-V criteria with the gloss “subjective experience that thoughts are racing”. But Sass and Pienkos argue that this description is far too simplistic. Indeed, they suggest that Binswanger himself intended the expression to indicate “not merely a simple increase in thought quantity or speed” but also thought that is “frequently disordered and confused, jumping from one idea to the next with little goal-directedness or respect for the rules of grammar or logic”. Sass and Pienkos support this claim with reference to a study by Holzman, Shenton, and Solovay. Using the Rorschach Thought Disorder Index, Holzman, Shenton, and Solovay conclude that non-psychotic manic subjects exhibit a complex pattern of thought disorder with four central features: vagueness; rule violations; inappropriate distance (i.e., offering hyper-literal or hyper-abstract conceptions of sensory experience); and incongruous ideas.

Yet it is odd to find Sass and Pienkos relying on a study that employs the Rorschach Thought Disorder Index, given that this involves third-personal observation of linguistic behaviour. For it is clear that the inference from language use to subjective experience of thought patterns can be questioned. Indeed, Sass and Pienkos seem to be confusing what it is like to think manically with something very different, namely, what it is like to perceive what one takes to be expressions of the thought processes of manic subjects. Testimony of others, as well as evidence from my own writing on occasions when I was manic or hypomanic, suggest that the factors that Shenton and Solovay identified were present during these episodes. However, my recollections are not of states of mind in which it seemed to me that my thoughts were disordered. To the extent that there was an experience of myself thinking, my thinking felt more appropriate and adequate to its task than normal. The identified factors did not seem problematic; in fact, quite the contrary.

Sass and Pienkos also observe that it is useful to think of manic thought in terms of “mattering … or rather of how things matter”. They suggest this partly involves “a form of distraction—an inability to ignore environmental stimuli that are capable of arousing lively but ephemeral interest in the patient, but that, in a normal individual, would remain on the margin of awareness, outside the focus of attention”; or, more prosaically, “there being too many things that matter, and that come to matter too quickly and fleetingly, for the individual”. Here Sass and Pienkos point to another phenomenon that is criterial in DSM-V (“distractibility”). And while they again seem to switch between attempting to describe what it is like for the subject and attempting to describe what the subject is doing (i.e., thinking in a distracted way), Sass and Pienkos do make an observation that I believe is crucial: namely, that mania involves a sense of there being many more things that demand attention than usual.

My own experience concurs with the main features of Sass and Pienkos’ account. But their suggestion that this is all somehow too much for the subject needs qualification. For a proper understanding of these phenomena, it is important to recognize that during at least some manic and hypomanic episodes, there is a sense of an exponential increase in objects of attention. And this brings with it an exhilarating sense of being exposed to an unlimited number of objects and their interconnections all at once, and a sense that one is being offered a window into the true nature of reality. This is not to say that there is never a feeling that this is all too much. Indeed, this feeling is usually a component of the way in which mania and hypomania come to an end, if allowed to run their course without external intervention. And a sense of being overwhelmed may also arise if one feels unable to communicate what one is experiencing to those around one. But for the manic subject, at the heart of the experience is the feeling of successful insight.

Disturbances in the “experience of language” provide another case in which Sass and Pienkos’s work mixes phenomenological and behavioral descriptions. First, they discuss the symptom of “pressure of speech, with increased rapidity of speech and ideational flow”. This is illustrated by a quote from Kay Redfield Jamison’s autobiography An Unquiet Mind, where Jamison reports a manic episode during which she remembers “talking to scads of people” and being “irresistibly charming”, even though a third person report said that she was “frenetic and far too talkative”.

Being “more talkative than usual”—also one of the DSM-V criteria—is indeed a central feature of manic and hypomanic behaviour. But being more talkative than usual is not the same as its seeming to one that one is being more talkative than usual. While the quote from Jamison suggests that there are occasions on which this might be the case, it is notable that she draws a contrast between this and being perceived to be too talkative. A corollary of the fact that more objects seem to be available during mania and hypomania is that that there seem to be more things to talk about. In the absence of an audience, this generally remains at the level of internal speech. Of course, with an audience available, the desire to bring such thought to speech is extremely strong, and, absent significant resistance from those around one, this is likely to result in more talking. But it still need not be the case that it seems as though one is talking more or too much. Indeed, the sense of excess arises largely in relation to how those around one are perceived to react. And other features of mania and hypomania tend to leave one insensitive to the cues that would lead one to stop.

Second, drawing on work by Andreasen and Lake, Sass and Pienkos present a related group of linguistic phenomena, namely “derailment”, “incoherence”, “illogicality”, and “blocking, loose association [and] disorganization”. They illustrate these factors by reference to a patient who reported that “a dropped key chain had caused him to think of the ‘key of life’, then of life beginning in Egypt’s Nile River valley, then of the pyramids, then of the desert, then of feeling hot and thirsty, then of desiring a glass of water”. Manic subjects are also said to be “frequently observed” to make “clang associations”. ‘Clanging’, or ‘glossomania’ is speech which involves association by sound rather than by meaning. Here, Saas and Pienkos cite several striking examples from Cutting’s Principles of Psychopathology: “Dr. Malmberg you are an ice woman an iceberg a lettuce”, “mystery history”; “I’ll never be sick like a tailor even though my dad was a tailor even though my dad was a sailor”.

I see no reason to deny the existence of the patterns of language use described. But with these phenomena, Sass and Pienkos again appear to have drawn on third-personal reports. And, as before, absent correction due to social context, manic and hypomanic speech may well exhibit such features without one’s having any sense that one is violating norms of speech that one should be obeying. Indeed, it might even seem that one is speaking in a more authoritative way. My own experience suggests that a crucial feature of the manic and hypomanic experience of language use is a breaking down of the sense that the language is a vehicle for communicating mutually intelligible content. Even where one is trying to achieve this, one does not always expect to be understood, or care whether one is. And there are occasions, too, where radically idiosyncratic use of language without the desire to be understood seems wholly appropriate.

So far, I have been concerned with phenomena that Sass and Pienkos regard as features of manic episodes. However, they also mention experiences that they attribute only to those with melancholia, and schizophrenia, during which subjects

become preoccupied with something too general or all-inclusive to be put into words, as for instance with the all-pervasive feeling of Being, of sheer existence itself… [where] they may attempt to capture some mystical feeling or insight of an all-encompassing nature that resists all normal or readily comprehensible forms of description, leading at times to a kind of hyper-abstract or hyper-philosophical style that may be, or may seem, but “empty abstractions”.

This description also seems to me to capture what it is like to be in a manic and hypomanic states, at least some of the time. Mania and hypomania do not bring with them the sense of a loss of self or of the complete disappearance of otherness which are found in schizophrenia. Nonetheless, the strangeness of the experiences may also be accompanied by a heightening of something that one might try to capture as an awareness of the pervasive sheer fact that things are. And where this does happen, the sense of having access to something beyond words is a crucial component. Insofar as this is accompanied by a sense of anything like an awareness of the everyday world of social interaction, it brings with it a profound sense of alienation. But this need not be experienced as unpleasant. Indeed, it may be experienced as just the opposite—for instance, as an ecstatic sense of the meaningfulness of existence, accompanied by the sense of an encounter with (though ‘encounter’ does not seem quite the right word) something ‘sacred’. Furthermore, this compelling sense of ineffability can lead to seeing the relationship between language and reality in a radically different way. When it comes to seem that nothing can really speak to the most real of what one is experiencing, to the extent that one continues to employ language, it can only be with a sense that its supposed capacity to articulate the nature of reality is an illusion.

**

The papers by Sass and Pienkos contain discussions of a significant number of features of manic experience. Consideration of all of these would surely provide the basis for a much richer account of what it is like to be manic. But I want now to draw attention again to the significance of Sass and Pienkos’ tendency to conflate the behavioural and the phenomenological aspects of mania and hypomania. Raising this issue was central to the accounts of some of the particular phenomena that I have considered. But it also bears on the more general importance of a proper demarcation of these kinds of criteria. Careful distinction between the behavioural and phenomenological seems to me crucial in at least two respects. As I hope to have shown above, with attention focussed more clearly on the phenomenological aspects of mania and hypomania, space is opened up for reflection on the ways in which these may diverge from the behaviour that accompanies them. But, in addition, the kind of understanding that the subjects themselves seek is not a third-personal one. We do not want people to think they know how we will behave if we become manic or hypomanic. We want proper account to be taken of what it is that motivates us to behave in the ways we do during such periods. Phenomenological descriptions of manic episodes may lead people to think that the manic and hypomanic have very different senses of themselves and the world in which they live. But there is also reason to hope that the further examples of the kinds of accounts that we find in Sass and Pienkos, and in my own testimony, might lead people to see that what it is like to be manic or hypomanic is not completely alien, or at least not alien in a way that warrants fear and avoidance.

Up until now I have been concerned with the phenomenology of manic experiences themselves. But I want to finish with a brief discussion of what it is like to live in the wake of a manic episode. Again, a proper account of this would require attention to phenomena that I have not discussed. But the discussion above should suffice for my current purposes.

As I noted in my brief autobiography, my own manic episode led to an irrevocable transformation in my relationship to all the experiences I had had before and have had since. What I have in mind here can be illustrated by drawing on elements from the phenomenology of manic and hypomanic thinking and language use that I have offered. The crucial feature to which I want to draw attention is the recurrent sense that the radical alterations that occur are ones which are preferable to ordinary subjectivity, and, even more importantly, ones which involve a sense of having been offered a glimpse into a more truthful relationship to existence. Moreover, these changes emerge in such a way that they seem unbidden and completely unexpected.

The seemingly spontaneous nature of mania means that manic experiences involve a high degree of trauma, even though the experiences themselves may seem desirable at the time. And, like other traumas, they take a while to subside, and leave traces that never go away. Indeed, it might not be too much of a conceptual leap to suggest that the majority of people who have had a manic episode should be regarded as suffering from a form of post-traumatic stress. This stress has multiple dimensions. First, there is the ever-present uncertainty about whether the same kind of experience might emerge and what kinds of social consequences it might have. This uncertainty is likely to leave people coping with a constant sense of anxiety. For, although it is possible to come to learn about features which are regularly correlated with the onset of mania and hypomania, such as lack of sleep, there remains the sense that episodes may occur whether these background conditions are present or not. For many, this anxiety is double-edged. It holds out not only the promise of the desirable ecstatic elements, but also the threat of a return which will deposit one in a social world which has been devastated by one’s behaviour.

Yet there is another kind of stress that emerges from having had experiences involving the overwhelming sense that both what one was thinking and the way one was thinking were more appropriate than before—that is, the sense that one had previously been aware of an unlimited number of connected objects, or of different ways in which thoughts might be linked together. How seriously should people who have felt this way take the echoes of what now seems like a distant land? Worse, the echoes of a land that is completely at odds with the one in which those around them seem to live? The dilemma becomes more severe given a social environment in which, if one were to take the manic sense of things seriously, one would run the risk of incomprehension, ridicule, and social alienation.

Likewise, the case of manic speech offers a number of phenomena which may be attended with a compelling sense of appropriateness: voluminous speech emerging from the sense of there being much more that needs to be said than normal; illogical speech that does not conform to normal patterns and which may be playfully governed by such linkages as clang associations, rather than the requirement to communicate; the need to try to speak to the sheer being of things; alienation from language altogether; and the sense that speech could never convey what it is like to be having the experiences one is having. And again, the person who has had these kinds of experiences is faced with difficult choices about how seriously to take them when using language in their wake. What will be remembered is having utterly compelling experiences of there being much more to be said than most people are saying around one, accompanied with the sense that one has had access to that content, so it will be tempting to think that there are more important things to be said than is in fact being said. The recollection of the complete legitimacy of rule-violation, if not the requirement to break rules, will bring with it a sense that language is not functioning at its best when it communicates truths by referring to elements in a common world; that language should be something which we push beyond its ordinary limits in order to try to express the way things ‘really are’. And there will be even more disturbance for those for whom mania brought a sense that it is only with a recognition of the total inadequacy of language that insight begins.

**

Paul Lodge [2] is Professor of Philosophy at the University of Oxford and a Fellow of Mansfield College, Oxford.