Making Sense of Mania and Depression

Written by Peter C. Whybrow

We all feel moments of gloom or exhilaration on occasion. But few of us truly understand how far off-key the melodies of mood can drift. Here, a leading psychiatrist eloquently recounts two real-life tales of mania and depression--and shows how these disorders are indeed moods apart from our everyday experience.

TRY FOR A MOMENT TO IMAGINE a personal world drained of emotion, a world where perspective disappears. Where strangers, friends, and lovers are all held in similar affection, where the events of the day have no obvious priority. There is no guide to deciding which task is most important, which dress to wear, what food to eat. Life is without meaning or motivation.

This colorless state of being is exactly what happens to some victims of melancholic depression, one of the most severe mood disorders. Depression--and its polar opposite, mania--are more than illnesses in the everyday sense of the term. They cannot be understood merely as an aberrant biology that has invaded the brain; for by disturbing the brain the illnesses, enter and disturb the person--the feelings, behaviors, and beliefs that uniquely identify the individual self. These afflictions invade and change the very core of our being. And the chances are overwhelming that most of us, during our lifetime, will come face to face with mania or depression, seeing them in ourselves or in somebody close to us. It's estimated that in the United States 12 to 15 percent of women and eight to 10 percent of men will struggle with a serious mood disorder during their lifetime.

While in everyday speech the words mood and emotion are often used interchangeably, it is important to distinguish them. Emotions are usually transient--they constantly respond to our thoughts, activities, and social situations throughout the day. Moods, in contrast, are consistent extensions of emotion over time, sometimes lasting for hours, days, or even months in the case of some forms of depression. Our moods color our experiences and powerfully influence the way we interact. But moods can go wrong. And when they do, they significantly alter our normal behavior, changing the way we relate to the world and even our perception of who we are.

CLAIRE'S STORY. Claire Dubois was such a victim. It was the 1970s, when I was professor of psychiatry at Dartmouth Medical School. Elliot Parker, Claire's husband, had telephoned the hospital desperately worried about his wife, who he suspected had tried to kill herself with an overdose of sleeping pills. The family lived in Montreal, but were in Maine for the Christmas holidays. I agreed to see them that afternoon.

Before me was a handsome woman approaching 50 years of age. She sat mute, eyes cast down, holding her husband's hand without apparent anxiety or even interest in what was going on. In response to my questioning she said very quietly that it was not her intention to kill herself but merely to sleep. She could not cope with daily existence. There was nothing to look forward to and she felt of no value to her family. And she could no longer concentrate sufficiently to read, which had been her greatest passion.

Claire was describing what psychiatrists call anhedonia. The word literally means "the absence of pleasure," but in its most severe form anhedonia becomes an absence of feeling, a blunting of emotion so profound that life itself loses meaning. This lack of feeling is most frequently present in melancholia, which lies on a continuum with depression, extending the illness to its most disabling and frightening form. It is a depression that has taken root and grown independent, distorting and choking the feeling of being alive.

SLIP SLIDING AWAY. In Claire's mind and in Elliot's, the whole thing began after an automobile accident the winter before. On a snowy evening, while on her way to pick up her children from choir practice, Claire's car had slid off the road and down an embankment. The injuries she sustained were miraculously few but included a concussion from her head hitting the windshield. Despite this good fortune, she began to experience headaches in the weeks following the accident. Her sleep became fragmented, and with this insomnia came increasing fatigue. Eating held little attraction. She was irritable and inattentive, even to her children. By the spring, Claire was complaining of dizzy spells. She was seen by the best specialists in Montreal, but no explanation could be found. In the words of the family doctor, Claire was "a diagnostic puzzle."

The summer months, when she was alone in Maine with her children, brought minor improvement, but with the onset of winter the disabling fatigue and insomnia returned. Claire withdrew to the world of books, turning to Virginia Woolf's novel The Wave, for which she had a particular affection. But as the shroud of melancholy fell upon her, she found sustaining her attention increasingly difficult, and a critical moment arrived when Woolf's woven prose could no longer occupy Claire's befuddled mind. Deprived of her last refuge, Claire had only one thought, drawn possibly from her identification with Woolf's own suicide: that the next chapter in Claire's life should be to fall asleep forever. This stream of thought, almost incomprehensible to those who have never experienced the dark vortex of melancholy, is what preoccupied Claire in the hours before she took the sleeping pills that brought her to my attention.

Why should sliding off an icy road have precipitated Claire into this black void of despair? Many things can trigger depression. In a sense it is the common cold of emotional life. In fact, depression can literally follow in the wake of the flu. Just about any trauma or debilitating illness, especially if it lasts a long time and limits physical activity and social interaction, increases our vulnerability to depression. But the roots of serious depression grow slowly over many years and are usually shaped by numerous separate events, which combine in a way unique to the individual. In some, a predisposing shyness is amplified and shaped by adverse circumstance, such as childhood neglect, trauma, or physical illness. In those who experience manic depression, there are also genetic factors that determine the shape and course of the mood disturbance. But even there the environment plays a major role in determining the timing and frequency of illness. So the only way to understand what kindles depression is to know the life story behind it.

THE TRIP THAT WASN'T. Claire Dubois was born in Paris. Her father was much older than her mother and died of a heart attack shortly after Claire's birth. Her mother remarried when Claire was eight, but drank heavily and was in and out of hospital with various ailments until she died in her late forties. By necessity a solitary child, Claire discovered literature at an early age. Books offered a fairy-tale adaptation to the reality of daily life. Indeed, one of her fondest memories of adolescence was of lying on the floor of her stepfather's study, sipping wine and reading Madame Bovary. The other good thing about adolescence was Paris. Within walking distance were all the bookstores and cafes an aspiring young woman of letters could desire. These few blocks of the city became Claire's personal world.