Ups and Downs

I had some trouble sleeping last night, so I took the advice I usually give to others and got out of bed.   That is why I am writing these words at 5:30 in the morning, after waking at 4– a cruel hour if there ever was one.   Sleep may be one of the only occasions this life offers in which—finding oneself unable to get down, one should just get up.

It happens sometimes in aviation, when an airplane’s wings begin to collect ice, and warmer air might be found at higher altitudes.   Then, going down might be more hazardous than climbing, so sometimes you have to temporarily go up in order to eventually land safely. Usually, however, what goes up must come down, and what comes down need never go up.

One of my day jobs is to teach a class at UCLA Medical School (now sadly named after David Geffen), where each week a new “case”– as physicians are trained to refer to humans in order to see them as less human– is presented and discussed.   The other week we presented the case of someone who was ultimately diagnosed with bipolar disorder, a mood disorder in which a person swings between periods of mania and depression (hence the outmoded term “manic-depression”).

Bipolar disorder is fairly common, affecting about 6 million Americans a year, but when I was seeing 30 clients a week I found it one of the easiest diagnoses to miss.   That is because when a person shows up in front of you who might be suffering from a bipolar disorder and isn’t in the midst of either a manic or depressive episode, there is nothing in their manner that would lead one to believe there is anything to diagnose. The diagnosis resides in the history (or herstory).

The psychiatric nomenclature (as codified in its “bible,” the DSM) reflects Newton’s law in that what goes up must come down, while the opposite doesn’t apply. One can be diagnosed with either a bipolar disorder or severe depression, but if you are severely manic then you must also be bipolar.   You just can’t stay manic forever. (You can, however, according to DSM, be “hypomanic,” which means you can go on a shopping spree and charge up all your credit cards as long as you don’t go over the credit limit.)

Mania, though, has been around a long time, although I suspect it has generally been viewed as less pathological than depression. Emil Kraepelin, the prolific German psychiatrist often cited as the founder of scientific (as opposed to Freudian, which seemed to emanate more from Freud’s imagination than empirical data) psychiatry, described mania this way over a hundred years ago:

The patient feels the need to get out of himself, to be on more intimate terms with his surroundings, to play a part. As he is a stranger to fatigue, his activity goes on day and night; work becomes very easy to him; ideas flow to him. He cannot stay long in bed; early in the morning, even at four o’clock he gets up, he clears out lumber rooms, discharges business that was in arrears, undertakes morning walks, excursions. He begins to take part in social entertainments, to write many long letters, to keep a diary, to go in a great deal for music and authorship. Especially the tendency of rhyming … is usually very conspicuous. … His pressure of activity causes the patient to change about his furniture, to visit distant acquaintances, to take himself up with all possible things and circumstances, which formerly he never thought about.

One of the first things I did when I awoke at 4 was try to rhyme some words (it’s a song lyric, and it’s not bad but needs a lot of work). On the other hand, I like my furniture exactly where it is and although I love many of my acquaintances, I will be happy today to stay home and clear out my lumber room. And not only am I no stranger to fatigue, she is my constant companion.   No, this is just simple anxiety-driven insomnia, probably about a scan I have coming up.   No mania for me.

It could be that one of the reasons I tend to miss the diagnosis of bipolar disorder is that it is one of those labels I have never applied to myself.   Surely I have had my bouts of depression, a few of which have immured me, but the idea of having boundless energy is as foreign to my nature as waking up one day being able to speak Russian.   Not likely in this lifetime.

The idea that what goes up must come down is echoed in the notion that one can go through life getting stronger or weaker.   Freud (who happened to be born a couple of months apart from Kraepelin but outlived him by 13 years) had a rather bleak view, and having been a military man saw life as a battlefield in which each battle leaves fewer troops surviving to fight the next.   Nietsche, from whom Freud undoubtedly stole the notion of an unconscious (and who, by the way, may have known Kraepelin as they both spent time in Leipzig) is famously quoted as having said that “Whatever you don’t die from makes you stronger.”   I don’t know if he ever really said that, but a friend once tried to console me by telling me that Nietsche said that.   No good friend should waste precious breath with consolation when confrontation could suffice.   There are just too many examples of things that happen, from divorces to lawsuits to car wrecks to marriages to chronic, debilitating illnesses that wear us down and from which recovery just doesn’t happen. Surely, what comes down often just keeps coming down.

On the bright side, however, I am reminded that in order to safely return to earth, one must safely leave it.   And I am convinced that home is made more soothing after having flown far from it and fought a few dragons along the way.   It is simply a matter of fact that one’s wings can collect ice at just about any altitude, and it is never entirely clear whether warmer air can be found above or below you. And in that sense, it may matter less whether one is going up or down than whether one is going at all.