Bipolar and psychosis

Darian Leader has recently written a book on bipolar1, which is the new name for an old form of psychosis, namely manic-depressive insanity (to use the term adopted by Emil Kraepelin).

Leader’s central argument is that manic depression (bipolar) is an attempt to avoid contradiction, because the individual is unable to bear conflicting ideas, e.g. loving and hating the same person. He links this with problems in the early childhood relations that the individual had with its parents, which were often plagued with ambivalence and ambiguity.

Manic-depression is the effort to separate, to maintain an elementary differentiation in the place of a more confusing and more painful set of contradictions. And this is perhaps the real sense of bipolar: not the alternation of moods that much contemporary psychiatry is so eager to pathologize but the search for a primary bipolarity, a baseline splitting of traits. (p.32)

Leader also raises a number of interesting points about bipolar in relation to its (apparent) growing prevalence and the fact that it almost seems to have taken on some kind of ‘celebrity status’ – not least, perhaps, because so many celebrities have been quite open in admitting a diagnosis of bipolar.   Leader cites celebrities such as Catherine Zeta-Jones, Stephen Fry (whom he refers to a great deal in the book), Jean-Claude Van Damme and even people like Adam Ant, who all publicly speak about their bipolar condition. He also refers to fictional celebrities such as the CIA agent Carrie Mathison in Homeland.  Stephen Fry himself has since made the news with his admission of a suicide attempt, which appears to be closely linked to his illness.2

With regards to prevalence, Leader points out that:

A diagnosis that once applied to less than 1% of the population has risen dramatically, with almost 25% of Americans estimated to suffer from some form of bipolarity. Mood-stabilizing medication is routinely prescribed to adults and children alike, with child prescriptions increasing by 400% and the overall diagnosis by 4,000% since the mid-?90s. (p.4)

As for the reason for this massive increase in diagnosis, Leader, referring to the work of historians of psychiatry, points out that:

It was precisely when the patents began to run out on the biggest-selling mainstream antidepressants in the mid-?90s that bipolar suddenly became the recipient of the vast marketing budgets of the pharmaceutical industry. (p.5)

Essentially, according to the psychiatrists making the diagnosis of bipolar,  those people who had previously being diagnosed with depression and prescribed anti-depressions, had, in fact, been misdiagnosed, and had actually been suffering from bipolar all along:

The patients were actually bipolar, yet the subtle mood changes had been missed by the prescribing physician. Between 20% and 35% of those diagnosed with depression in primary care have now been deemed to suffer from bipolar disorder. As the psychiatrist David Healy points out, rather than trying to make more effective antidepressants, the industry opted to market a new brand: a new set of disorders called ‘bipolar’ rather than a new medication. (p.5)

However, be that as it may, what does it actually mean to be bipolar?

Bipolar individuals are characterised by extreme mood swings – from mania to extreme depression (or to use a term which tends to be less popular nowadays, melancholia).  Or to put it more simply, such individuals swing from ‘highs’ to ‘lows’ – hence the term ‘bipolar’.

However, in many ways this is a bit too simplistic, and it could be argued that the term ‘bipolar’ itself is a way of ‘sanitising’ the reality, the lived experience, of manic-depression. Ironically, perhaps, when it comes to the ‘celebrity status’ of bipolar, it is a very ‘unipolar’ view that gets presented. This refers to the dynamism, the enthusiasm, the hyper-energy of bipolar individuals when they are in full ‘flight’, i.e. in their manic phase.

As Leader points out, this ‘manic’ attitude chimes very well with the demands of modern society, and in many ways can be necessary for any new idea to get off the ground, and as a way of motivating people who are perhaps not as enthusiastic about things as the ‘movers and shakers’ in a particular enterprise might be.  This is not to say that all leaders and other people charged with motivating others are necessarily bipolar.  However, this might explain the high degree of psychopathology that seems prevalent in the higher echelons of some businesses, e.g. the financial sector.

One of the common characteristics or ‘symptoms’ of the manic ‘pole’ of bipolar is what psychiatrists call the ‘flight of ideas’. This links very closely to what Leader identifies as the ability for bipolar individuals to make (linguistic) connections; in other words, the individual is able to continually make one connection after another between different ideas, and to sustain this to the point of exhaustion – both for the individual him or herself, and the person he or she is talking to.

An example of such manic behaviour, which as it turns out, is (potentially) very beneficial to the CIA, comes from episode 11, series one of Homeland, and centres around Carrie Mathison, a CIA agent who is bipolar; and Saul Berenson, who is Carrie’s mentor and the CIA’s Middle-East Division Chief.

Saul goes to the hospital to pick up Carrie who has been there for a week recuperating from her injuries incurred through a bomb explosion. He finds Carrie acting like a totally different person, talking frantically, and ranting and raving about the terrorist Abu Nazir. Saul and Maggie (Carrie’s sister) take Carrie home and it is only at this point that Saul discovers that Carrie is bipolar.

However, instead of resting and waiting for her medication to take effect, Carrie is up all night wading through reams of classified information relating to Abu Nazir, and carefully colour coding it. The episode portrays her carrying out this task in a very frantic and ‘manic’ way, and in the end she collapses from exhaustion. It is left for Saul to arrive at the house the next morning and find all this material strewn everyway, and to then arrange it into a ‘timeline’ which starts to reveal Nazir’s whereabouts during critical periods. However, although it is Saul who actually constructs the timeline, it is clear from the episode that it is Carrie who, in her ‘mania’, is making the connections between the various bits of information, and using her colour coding system to facilitate this process. In other words, it is her frantic/manic efforts that make such a timeline possible in the first place.

At some point, though, every flight has to end, and for the bipolar subject this end is invariably a crash landing. However, Leader cautions against comparing the depression of a bipolar subject to that of ‘unipolar’ depression or, to use the more classical term, melancholia.  Whereas melancholia is characterised by self loathing, guilt, and sense of completed unworthiness and of having destroyed the Other, in the depressive stage of manic-depression there is much more of an oscillation between self-reproach and guilt on the one hand, and blaming the Other, the world, on the other hand.

Furthermore, Leader talks about a sense of paralysis, and a loss of a sense of self, and also a feeling of impending catastrophe, rather than guilt about what one has done in the past. Often the individual will resort to paranoid thinking as a way to defend him or herself against reaching such depths of despair, which can last for months. At this point, the danger of suicide is very real.

As mentioned in the introduction, bipolar can be seen as an attempt to avoid contradiction, ambiguity, ambivalence.  And this is linked closely to early childhood experiences of contradiction, ambiguity and ambivalence.  In other words, the young child never quite knew what to expect of his or her parents, and was never quite sure whether their parents really loved or cared about them.  However, at this point we should note that this problem with contradiction, double meanings, loving and hating the same person, is characteristic of many psychotic individuals, not just those with a diagnosis of bipolar.

So it seems a pertinent question to ask where we might situate bipolar within the wider context of psychotic illnesses.  From a psychiatric position this is a somewhat irrelevant question, because modern psychiatry does not view specific ‘disorders’ such as bipolar in terms of an underlying clinical structure.  Instead it is viewed as a cluster of symptoms (see for example the DSM-IV-TR classification for bipolar disorder3).

The Lacanian position, on the other hand, is that psychosis is a clinical structure; more precisely, a clinical structure based on the subject’s relation to language, meaning and jouissance (enjoyment).  In ‘classical’ Lacanian theory, psychosis is defined in terms of the foreclosure of the signifier of the Name-of-the-Father.  Most of Lacan’s early writings and teachings on psychosis focused on paranoia, and the whole of his third seminar is a close re-reading of the Schreber case, with particular reference to Freud’s interpretation of this case.4 Lacan’s focus here was on Schreber’s relationship to language and meaning, and particularly the way Schreber constructed a delusory universe as an attempt to restore his shattered subjectivity.

In what might be loosely described as ‘revisionist’ or ‘later’ Lacanian theory, the Name-of-the-Father is viewed as simply one instance of the sinthome, which is a knotting together of the registers of the Real, Symbolic and Imaginary.   So, for example, in his seminar on James Joyce, Lacan explores the way Joyce’s writings could be construed as a form of sinthome through which Joyce avoided a complete psychotic breakdown.  At the same time, the emphasis moved away from language in terms of meaning and focused more on the letter, the materiality of language, and the jouissance (enjoyment) of language.

In his paper Three Enigmas: Meaning, Signification, Jouissance, Eric Laurent traces the development of Lacan’s work on psychosis – and their subsequent reworking by Jacques-Alain Miller.5 And he highlights the important distinction between paranoia and schizophrenia in terms of what he calls ‘the diverse destinies of jouissance’.

In paranoia, one of the key enigmas for the subject is the jouissance of the Other; more precisely,  the subject locates jouissance in the Other, whilst he becomes the repository of the Other’s jouissance.

What is enigmatic for Schreber is that God or the Other should enjoy his (Schreber’s) passive being and that he should support this. (p.124)

For Schreber, and for other paranoid subjects, there is method in this apparent madness.  By situating jouissance in the Other – and therefore situating themselves in relation to the Other’s jouissance, the subject is able to create a form of stability, a sense of identity, and is able to construct what can often be very elaborate systems of meaning, which all centre around themselves.  For the paranoid subject, the Other is not only the locus of jouissance, but is also the enemy, the persecutor, the one who is responsible for all the badness in the (subject’s) world.

But at least in this set-up there is a subject (of sorts) who is being persecuted.  With schizophrenia, on the other hand, the enigma for the subject is the jouissance of his or her own body, and, consequently,  his or her very identity is under threat.  The schizophrenic’s body is ‘invaded’ by jouissance, which explains the high degree of somatisation and hypochondria amongst many schizophrenic subjects.  Furthermore, some schizophrenic patients that I’ve worked with appeared to be in a state of bodily rapture, even as they described how their bodies were racked with pain.  Schizophrenic subjects have a very fragile sense of self, and often the boundaries between self and other are extremely fluid.  Unlike the paranoid subject, schizophrenic subjects find it difficult to construct a stable, albeit delusory, network of meanings.

When it comes to biploar/manic depression, there appear to be very few references in the Lacanian literature, which is what makes Leader’s book all the more interesting.   However, what Leader does not do in the book, and perhaps this is because he is trying to reach a wider audience, is to theorise bipolar in the wider context of the other psychoses, and especially paranoia and schizophrenia.

But perhaps paranoia and schizophrenia themselves already offer us a clue as to where to situate manic-depression. If we think of schizophrenia as a collapse of the subject, and an ‘invasion’ of the body by jouissance; and if we then think of paranoia as an attempt at the  ‘restoration’ of the subject through delusion; then perhaps we could think about manic depression as being somewhere ‘between’ these two ‘destinies of jouissance’.

If we start from the position that there is a single mechanism, foreclosure, operating in psychosis (and, some Lacanians would argue, in all subjects), then it seems quite feasible to think about how there might be a shift in a particular psychotic subject in terms of their relationship to meaning, language and jouissance.   In fact, we could take this further and think about psychosis in relation to the enjoy-meant of language, the jouissance of the letter (Russell Grigg has written an interesting paper on this very subject6).

In other words, although paranoia, schizophrenia and manic-depression are not separate clinical structures, they can be seen as different relationships to jouissance, to enjoy-meant.

However, we still haven’t situated bipolar/manic-depression in this set of relationships.  If we look at the way bipolar subjects behave, both in their ‘manic’ phase and in their depressed phase, then what strikes me is that we could be looking some form of ‘oscillation’  between schizophrenia and paranoia.   On the one hand, the connections that bipolar subjects are adept at making, in which everything appears to relate to everything else (Leader describes this is some detail in his book) have strong resonances with the systems of meaning that paranoid subjects are so good at constructing.  And yet, unlike the often torturously rational and elaborate (and not to say sometimes bizarre) networks of meaning that characterise the paranoid subject, the connections made by bipolar individuals are often superficial and tenuous to say the least, and would be unlikely to stand up to much scrutiny – which is one of the reasons that bipolar subjects won’t allow the person they are elaborating their connections to to get a  word in edgeways.

Leader gives the amusing example of Norma Farnes visiting Spike Milligan for the first time to apply for the job as his personal assistant (Milligan was a well known manic-depressive British comedian).  When she remarked that the room was freezing, Milligan responded by saying: ‘Yes, I hate the Americans’.    Leader explains that Milligan was making a connection between the room temperature and his (erroneous) belief that the Americans had invented central heating, which was failing to work in this case.  As Leader points out, it was probably prudent of Farnes not to point out that it was the Romans who had invented central heating, not the Americans.  However, I suspect if she had Milligan would had really struggled to respond, whereas a paranoid person would have, if necessary,  produced a twenty page proof explaining in elaborate detail the connection between central heating, the fact it wasn’t working properly, the Americans, the Romans, the CIA, the KGB, the Knights Templars…

There is also something in the bipolar’s use of language which resonates with the idea of the jouissance of the letter.  In other words, there is a playfulness with words, without any particular regard for meaning.   Words are treated as objects, as things.  As Leader points out:

Language can be turned inside out, dazzling analogies and juxtapositions invented and discovered.  to be able to do this, there has to be an ability to move around language, to not be weighed down by significations. (p.29)

At this point, where is the jouissance?  It is certainly not in the body, but neither is it in the Other.  Rather, it is in the language itself.  And where, for that matter, is the subject?  Interestingly, Leader notes that unlike schizophrenic or paranoid subjects, bipolar individuals desperately need an other, an addressee, to explain their ideas to.  Could this be because they have no sense of self, so they have to find it in another person, a specular other, who acts not so much as a reflection of their ego, but as a surrogate ego or self?   And this might also explain, as Leader also notes, that once the bipolar individual comes crashing down to earth, they experience a void of the self, a complete loss of who they are.  This sounds remarkably like the experience of schizophrenia.

And, finally, as Leader points out, when the crash comes, the bipolar subject may well adopt a paranoid position in order to ward off the engulfment of depression and the sense of void that comes with it.

  1. Leader, D. (2013) Strictly Bipolar. London, Penguin (e-book version). []
  2. http://www.guardian.co.uk/culture/2013/jun/05/stephen-fry-attempted-suicide-bipolar []
  3. http://wps.prenhall.com/wps/media/objects/5097/5219346/tools/diag_crit_bipolar_disorders.pdf []
  4. Lacan, J. (1993) The Seminar of Jacques Lacan: Book III 1955-1956 The Psychoses. London, Routledge. []
  5. Laurent, E. (2007) Three Enigmas: Meaning, Signification, Jouissance. In: V. Voruz & B. Wolf eds. The Later Lacan: An Introduction. New York, Sunny Press, pp.116-127. []
  6. Grigg, R. (2002) Enjoy-meant of language and jouissance of the letter. Psychoanalytical Notebooks, (8), p.pp.57-65. []

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