Why did our minds evolve with the capacity to go mad? Why are our emotions capable of disabling us? Why did we end up with feelings at all?

Let’s start with the last question. When evolutionary biologists study emotion, they usually ask about its survival value. What is it that makes feelings useful to a creature’s reproductive success?

This approach troubles me, because it suggests (implicitly) that animals might just as well have evolved as heartless robots, devoid of any true investment in life. The only reason for feelings in this style of evolutionary logic is that they increased mammalian ability to foster viable offspring. And note that the word mammalian is not arbitrary. Such hypotheses generally go on to assert that reptiles, amphibians, fish, and invertebrates are devoid of meaningful emotion. Which, if you think about it, is another way of saying they don’t care about their lives.

But as I’ve pointed out in another post, even spiders seem pretty insistent on their preference for living over dying. So-called lower animals don’t appear robotic and unaffected. They behave quite passionately when their survival is threatened. Could it be that feelings aren’t just utilitarian, but fundamental to life?

Consider next how this reductionist style of evolutionary reasoning gets applied to psychiatric conditions. How does this rubric explain the persistence of mental afflictions in human populations? After all, psychiatric conditions strike during reproductive years and carry a significant mortality rate (possibly as high as 20% for bipolar conditions). If we argue by selection, we must conclude that the reproductive benefits outweigh the risks.

What are the positive qualities that accompany mental instability? Here we start by considering that intellectual and artistic abilities might have evolved because they increase a mate’s desirability. The idea is that the cavemen who could paint evocative bisons had more success with the cave-ladies. Those who created also procreated.

Then remember that mental health conditions occur more commonly among artists and visionaries. Could the persistence of madness result from its tendency to increase creative output, not to mention reproductive drive?

It’s a reasonable argument, and probably one with some underlying truth. But to me it seems a surprisingly uninspired view of inspired lunacy. It sounds like something a bureaucrat would think up.

And in fact, one criticism of Darwinian theory has always been that it suits capitalists. Bean-counters like “survival of the fittest,” because it justifies the hoarding of beans. To say that passion, creative drive, and wild thinking evolved through better baby-making may not be wrong, but it may leave out mysterious and vital undercurrents in human life.

Let’s imagine, momentarily, that there is more to the cosmos than the material realm. It could be, after all, that mystical forces affect our lives. In which case we might expect that some of our qualities result from influences other than competitive insemination and over-protective child-rearing. We might have lessons to learn, for instance. Maybe some human qualities arose to help us evolve in the spiritual rather than biological sense.

So could it be that mental health problems are serving a higher purpose? Just possibly, the pain of psychiatric distress serves to break down egos and open minds to realms beyond the physical. Maybe “mental illnesses” are not as disastrous as many believe. Maybe they are Grace in formation.

If that were true, and I admit to wild (creative?) speculation here, we would be completely misguided in trying to suppress such conditions. By doing so, we would be robbing people of their chances for growth. We’d be better advised to help the potent energies of psychiatric distress play out in safe and instructive ways.

Unfortunately, the choice in current society is all-too-often between medication and alienation. Or between hospitalization and jail. Inner turmoil no longer has any chance of creating shamans or prophets, because we drug down or lock up anyone who deviates too far from the claustrophobic modern mold.

This is the danger of accepted wisdom. Everyone assumes that natural selection is the sole element at play in evolution only because that’s what everyone assumes. While selection is no doubt a potent force, it has not been proven to be the only influence on evolution, and many scientific facts suggest that we need a more encompassing theory. Postulating purposeful nudges that supervene among the changes sculpted by selection would resolve the evidentiary problems in conventional evolutionary theory. (These nudges wouldn’t necessarily require an omnipotent deity, but could arise as part of the natural self-organization of the cosmos—but this is a topic for another essay.)

Yes, it may be that feelings, madness, artistry, and the like can all be explained in terms of robotic animals competing for resources and mates. But let’s at least admit that richer and more interesting possibilities remain. Until they have been ruled out, we are neither scientific nor inspired if we dismiss them from consideration. And if other explanations deserve attention, then so do other treatment models. If mental conditions are meant to teach us, our society should honor rather than abhor them, and our psychiatric care should promote rather than hinder their flowering.

The years 1999 and 2000 were the worst of my adult life. Work-related spinal injury ended my career as a surgeon. I found out the damage in my neck foreshadowed lifelong pain with the possibility of paralysis. In 1999 my wife and I abandoned the city we called home, and a house we’d lovingly renovated, in order to move closer to my work and spare my neck the long commute. But even so, within a year I could no longer operate. My colleagues reacted negatively to what they perceived as my abandonment of responsibilities. As an added blow, a long-running lawsuit settled against me. I felt very alone and very lost.

Soon after, I found out how badly my mind could go awry. Depression had been an intermittent companion for twenty years, but I sank to depths that exceeded anything previously experienced or imagined. I ended up in a psychiatric ward on a suicide watch. Discharged after twelve days but not feeling much better, I left the hospital on a powerful new antidepressant.

Five days later I landed in another psychiatric unit, only this time in a state of extreme mania and florid psychosis. The new medications may have triggered it. Never having experienced such insanity in myself, I feared my mind had permanently snapped. Those were my lucid moments. More often, I drifted in a novel world where God spoke to me and magic was everywhere.

The intense mania resolved quickly, but full recovery has been slow and painful. My psychiatrist convinced me that my mind now had a terrible illness. Depression that hitherto had been unpleasant, but never disabling, had morphed into a dangerous brain disease. My moods needed potent medications and lots of coddling. Slips into hypomania threatened my sanity in ways my doctor assured me were dreadful, but never really explained. Rather than encouraging me to regain strength and reenter the world, she cautioned against ‘taking on too much’.

I became hesitant and fearful. I abandoned career opportunities when confronted with difficulty and conflict, because of my psychiatrist’s ceaseless admonition that I now had ‘poor stress tolerance’. Better to live a boring and disabled life than risk jostling my fragile brain.

That message led me into a trap that is proving difficult to escape. I’ve weaned off most of the drugs, and feel eager to work. But after ten years of minimal productivity, potential employers no longer take me seriously. My future probably depends on developing a freelance career, but the long running discouragement eroded my confidence. And years of inactivity have sapped my endurance.

I write this as a warning to others. Be very cautious about allowing your doctors to set limits on your potential. It is safer for them if you stay at home in a medicated daze than if you take risks. But it’s worse for you. Our minds may be different, but they remain vital and capable. Be your own best friend, and don’t let the concept of mental ‘illness’ limit your dreams.

The thrill is gone. Yesterday evening I returned from my 44 hour retreat at a Jesuit center ninety minutes south of here. Not always, but sometimes retreats turn magical as participants attend sessions, meditate, get to know one another, and relax. It happened this time, at least for me. I felt so very elated last night. Unable to sleep, I wrote the poem of the last post in the early hours of my birthday. For the first time I articulated my sense of mission, a conviction that has been growing inside me for about a year.

I am not surprised that today has been a letdown. I feel embarrassed by my enthusiasm, both internal and exhibited. I reached out with love for all, and now recognize I have no clue how normal people behave. I am emotionally immature. Not in the sense of acting out and throwing tantrums, but in the sense of not keeping a lid on it all.

The odd thing is, that has been exactly my goal. To remove the lid. I’ve wanted to feel my emotions flow freely, and now I have. The consequence, of course, is that others have seen it too. I forget that our society prohibits emotional freedom. In my strongest moments I don’t care, but this is not my strongest moment.

It is time for rest. I slept little last night, my mind was so amped up. Hypomania would be the clinical diagnosis. Now I suffer the follow-on depression. Maybe I’m bipolar. Maybe I’m passionate. Maybe I’m a mess.

It’s strange how strong feelings power my most heartfelt writing, and give me the best sense of connection with higher powers, and yet leave me with such a low opinion of myself. I won’t try to figure it out, at least not tonight. I foresee a future of writing in isolation, because the forceful connection with my heart that I use as a creative engine makes me a social misfit. Given the choice between art and society, I can only choose the former. Besides, no matter how hard I try, I will never fit in. Might as well go with the river that keeps hugging me into its depths, write for my own purpose, speak when called on, and let my words find who they will.

Rest. Rest. Rest.

I have a few minutes to write about black and white. One of the pillars of a successful CBT (cognitive behavioral therapy) program is to avoid ‘black and white thinking,’ and it is a perennial trial for me.

The ease with which people cling to extremes, and the trouble they have dealing with ambiguity, seem to be root explanations for much human dysphoria, not to mention disagreements and war. As I make a decision about the next step in my life, I have to work hard not to search for a single ‘perfect’ answer, and to remember that most outcomes are neither all-good nor all-bad. Even more important, when I assess my past, it is vital that I not label my choices ‘mistakes,’ just because I believe I would choose differently if given another chance.

If I decry the ten years I spent becoming a surgeon as wasted time, it immediately demoralizes me. Yes, the end result was bad arthritis and an early medically-compelled retirement. Not the best outcome, perhaps, but not an utter catastrophe. I was fortunate to have bought a pretty good disability policy, which has permitted me to explore a number of different interesting directions, and grants me the luxury of pursuing graduate study in creative writing. I would not have this freedom if I had gone a different way. Learning the anatomy, physiology, pathology, and skill sets needed by an ophthalmic reconstructive surgeon was one of the most interesting experiences of my life. My clinical work left me with a trove of stories to write about that I could only have built up by going through medical training. Yet there have been times when I’ve believed that entering medicine ruined my life. It has been a real challenge to say: “OK, becoming a surgeon was stressful and led to a career that damaged my body, and that I couldn’t sustain. One that did not suit a person of high anxiety, familial arthritis, and attention deficit disorder. Yet many benefits accrued.”

My wife and I sold a house in San Francisco at the same time that my career was collapsing. We moved 30 minutes north to a suburb I have never liked. Often this, too, has felt like a catastrophic choice. However, if I assess the results objectively, I recognize that I have made good friends here, and found a psychiatry clinic that guided me to better mental health than I’ve ever previously enjoyed (even if my psychiatric condition is far from perfect.) We also ended up building a retreat in the mountains, which we would never have done if we had kept the old place. The experience of designing and building was enriching, and the opportunity to spend time in the gorgeous area I remember fondly from my teenage days has been a Godsend. Despite these benefits, I remain certain that I would never have sold that San Francisco house if I had foreseen how things were going to play out. Yet it was not an complete rout.

As I plan my next move in this game of life, it helps me to keep this perspective. I need to remember that even if deciding to spend time and money improving my writing does not lead to the income I will eventually need, going back to school is unlikely to turn into a complete waste of effort and resources. If I can avoid thinking that things must either be ideal or they will destroy me, I feel less paralyzed and more able to choose.

Shades of gray are hard for people with intense and fluctuating moods. Whether you call this mental tendency ‘bipolar disorder,’ or just accept it as a human variation, it still requires one to take special care in evaluating and choosing. Given that I’ve spent my life feeling either pretty excited or (much more often) crushed by depression, I tend to view everything as if there are only two levels of quality: ‘perfect’ or ‘satanic.’ Other people, who live with less extreme emotions, must have an easier time recognizing that life is usually neither.

That’s my little meditation for today, a memo to myself as I try to make a choice without putting too much pressure on my psyche to find nirvana. I always appreciate the comments others leave when I mull these kinds of things, as your perspectives broaden my own. Best wishes to all.

Wow! There are so many mental health blogs to read. It’s enough to make an insecure manic-depressive jump off a cliff. How can I possibly stand out in such a throng?

Oh well. I’m used to being put in my place. If this past decade had a purpose, it was to teach me humility.  Where once I could tell people I was an oculoplastic surgeon, all I can say now is that I have started a blog. Well, who hasn’t? I’m trying to show up in mental health circles on the internet. I read the successful blogs about the subject (I’d read less successful ones, but how do I find them?). Since I always think I have something to add, I post lots of comments. I keep plotting a direction for my own work.

As I write my comments, It seems inevitable that one of my insightful observations will attract attention, bringing readers back to my own site, but no luck so far. Maybe the comments aren’t all that insightful after all. Inevitability inevitably fails.

It’s not easy being a psychiatrically ill former physician (is it easy to be any kind of human?); I feel like people should take me seriously, just because I was once successful and my history is fairly unique (you’d probably agree if you knew even half of it). But in this society the question often is simply, “what have you done lately?” Watching my past glory fade into my current obscurity hurt for a long time, but not anymore. I now feel happy to be free of the pressure to compete. It is a pleasure to be an ordinary human, and not worry about trying to be better than others.

On the other hand, I would like my message(s) to get out. If I could get someone to listen, I think I have important stuff to say about mental illness and psychiatric care. Maybe my experiences would help others. Maybe they could avoid my mistakes, and reach happiness sooner. Nothing would please me more than having someone struggling with mental illness derive benefit from my history.

Believe it or not, I used to think it would be kind of cool to have a bipolar I diagnosis. So much more interesting than ‘mere’ depression. It pleased me when I started to come out of my manic psychosis/religious ecstasy and I realized that I was now officially manic-depressive. I had always read about bipolar artists and writers, and I was happy to join the club. Pretty naive, don’t you think? I now realize that many people are frightened and turned off by mental illness. I understand that it looks like weakness to others (even though I know it takes strength to survive the storms of emotion that come with bipolar disorder). I see now that it might have been better to hide my psychiatric problems. But I already  told everyone who would even half listen about my religious ‘delusions’, my hospitalizations, medications, and so on.

Since everyone around me knows the story, whether they wanted to or not, I figured I had nothing to lose by starting a blog. So what if the whole world knew my story?

It is now obvious that the whole world could not care less. There are so many bigger problems, more famous people, and better writers. Not to mention more than a hundred million blogs! (Or is it two hundred million?) What’s a poor former surgeon to do?

Keep writing. Keep hoping. Keep living.

I am prepared to fulfill my mission–to bring light to others with mental illness. But will anyone ever hear me? What can I do to make it happen?

Keep writing. Keep hoping. Keep living. My new motto.

Anyone who spends time in a psychiatric ward as clinician or observer rather than a patient (I’ve been on the ward in all three capacities at different times), can see that medications really are necessary in some cases. There is a perception that the meds are just to control behavior, and they do get used that way; more often, however, there is genuine suffering going on, and the drugs help.

The same is true in outpatient settings. Sometimes people are in such pain that more conservative measures have no chance of success. Medications are needed to bring the symptoms down to a level where a person can engage his or her recovery. The problems come up when too much medication is prescribed for too long a time. In particular, I suspect that many people could eventually be weaned off most (not necessarily all) medications over time. However, there is little incentive to try. The drug companies discourage the loss of sales; the doctors don’t want the extra work of handling patients who might decompensate, and often the patient (or family) is frightened of setbacks. It takes time, work and commitment to get someone off medications. It is so much easier to just leave them as-is: heavily medicated.

So my message is not that drugs are bad. Just that new ones should be used cautiously, and all drugs should be used in the lowest dose for the shortest time possible.

Years later, we now know that the SSRIs do not exceed the older drugs in effectiveness. Compared with ‘tricyclics’ (the older antidepressants), drugs like Prozac have different side effects, but not fewer. Perhaps the only real advantage of SSRIs in treating depression is that they don’t kill you if you take too many. Tricyclics are notoriously lethal in overdose.

So the dust has settled, and SSRIs no longer look like wonder drugs. Worse (from the standpoint of the drug companies) most of the patents of the native SSRIs have expired (long acting preparations and other alterations may still be available only in branded forms). So the pharmaceutical industry needed to move on to something new.

Enter the ‘atypical antipsychotics’. They are ‘atypical’ because they work differently from the old antipsychotics. The old drugs were essentially dopamine blockers. The class had been discovered because of an herbal folk remedy for insanity, from which a very effective anti psychosis drug was isolated. It turned out that it worked by blocking the effects of dopamine in the body. This led to the ‘dopamine hypothesis’, where schizophrenia was postulated to be the result of excess dopamine. That idea turned out to be far too simplistic, but there is little doubt that dopamine is one of the neurotransmitters that goes awry in psychotic illnesses.

Atypicals, however, have less effect on dopamine than the older drugs, and more effect on serotonin and other neurotransmitters. (They also may be more discriminating in which of the body’s several types of dopamine receptors they target.) The prototype was clozapine (Clozaril), which had tremendous antipsychotic activity, but life-threatening side effects. Working from the structure of clozapine, researchers created the other atypical agents. These include: olanzapine (Zyprexa), quetiapine (Seroquel), ziprasidone (Geodon), aripiprazole (Abilify), and risperidone (Risperdal).

Unfortunately, I have taken all of them at one time or another. Oddly, although I have had one episode of psychosis, my psychiatrist at the time prescribed atypical antipsychotics long after the psychosis had resolved. That’s because the drug companies started promoting these agents for mood disorders. First they were proposed for manic symptoms, but eventually some of them were touted as effective agents for severe depression. They are being used more and more for such reasons.

When I took them, they mainly felt like strong sedatives. Sure, they helped with agitation. They made me feel like I’d been hit with a hammer.

Problem was, they had terrible side effects. Well-known problems include incredible weight gain, increased cholesterol, and diabetes. I got the first two, and was well on my way to the third by the time I finally quit the drugs. There are other side effects, it turns out, when these drugs are used in combination with different classes of psychiatric medications. I won’t go into detail right now, because I am still getting up the nerve to talk about how these drugs have harmed me: it is a very sensitive subject for me.

My point right now, however, is that these are toxic drugs. Their side effects are far more dangerous than, say, those of the SSRIs. Given the epidemic of obesity and ‘metabolic syndrome’ in this country, we really should question whether these drugs are being overused. Especially since the evidence for their effectiveness in many conditions is not all that convincing.

Addendum:
Here is a link to a good site to check out if you want to know more about the controversies surrounding atypical antipsychotics. I also just came across an article about the problems with big Pharma and atypicals (with reference to a recent major legal settlement involving Zyprexa) on HuffPost by Dr. LLoyd I. Sederer. My thanks to Liz Spikol for her The Trouble With Spikol blog post summarizing the article.