Source: New York Review of Books
Date: Volume 55, Number 14 · September 25, 2008

A Summer of Madness

By Oliver Sacks

Hurry Down Sunshine
by Michael Greenberg
Other Press, 234 pp., $22.00


Wisdom, Madness and Folly: The Philosophy of a Lunatic
by John Custance
Pellegrini and Cudahy, 254 pp. (1952)

Manic-Depressive Illness: Bipolar Disorders and Recurrent Depression
by Frederick K. Goodwin and Kay Redfield Jamison
Oxford University Press, second edition, 1,288 pp., $110.00

An Unquiet Mind: A Memoir of Moods and Madness
by Kay Redfield Jamison
Vintage, 224 pp.,$13.95 (paper)

Touched with Fire: Manic-Depressive Illness and the Artistic Temperament
by Kay Redfield Jamison
Free Press, 384 pp., $15.00 (paper)

The Seduction of Madness: Revolutionary Insights into the World of Psychosis and a Compassionate Approach to Recovery at Home
by Edward M. Podvoll
HarperCollins, 342 pp. (1990)

Lectures on Clinical Psychiatry
by Emil Kraepelin
William Wood, 308 pp. (1904)

Manic-Depressive Insanity and Paranoia
by Emil Kraepelin
Edinburgh: Livingstone, 280 pp. (1921)

"On July 5, 1996," Michael Greenberg starts, "my daughter was struck mad." No time is wasted on preliminaries, and Hurry Down Sunshine moves swiftly, almost torrentially, from this opening sentence, in tandem with the events that it tells of. The onset of mania is sudden and explosive: Sally, the fifteen-year-old daughter, has been in a heightened state for some weeks, listening to Glenn Gould's Goldberg Variations on her Walkman, poring over a volume of Shakespeare's sonnets till the early hours. Greenberg writes:

Flipping open the book at random I find a blinding crisscross of arrows, definitions, circled words. Sonnet 13 looks like a page from the Talmud, the margins crowded with so much commentary the original text is little more than a speck at the center.

Sally has also been writing singular, Sylvia Plath–like poems. Her father surreptitiously glances at these, finds them strange, but it does not occur to him that her mood or activity is in any way pathological. She has had learning difficulties from an early age, but she is now triumphing over these, finding her intellectual powers for the first time. Such exaltation is normal in a highly gifted fifteen-year-old. Or so it seems. But, on that hot July day, she breaks—haranguing strangers in the street, demanding their attention, shaking them, and then suddenly running full tilt into a stream of traffic, convinced she can bring it to a halt by sheer willpower (with quick reflexes, a friend yanks her out of the way just in time).

Robert Lowell described something very similar in an attack of "pathological enthusiasm":

The night before I was locked up I ran about the streets of Bloomington Indiana.... I believed I could stop cars and paralyze their forces by merely standing in the middle of the highway with my arms outspread. Such sudden, dangerous exaltations and actions are not uncommon at the start of a manic attack.

Lowell had a vision of Evil in the world, and of himself, in his "enthusiasm," as the Holy Ghost. Sally had, in some ways, an analogous vision of moral collapse, seeing all around her the loss or suppression of God-given "genius," and of her own mission to help everyone reclaim that lost birthright. That it was such a vision which led to her passionate confrontation with strangers, her bizarre behavior imbued with a sense of her own special powers, her parents learn when they quiz her the next day:

She has had a vision. It came to her a few days ago, in the Bleecker Street playground, while she was watching two little girls play on the wooden footbridge near the slide. In a surge of insight she saw their genius, their limitless native little-girl genius, and simultaneously realized that we are all geniuses, that the very idea the word stands for has been distorted. Genius is not the fluke they want us to believe it is, no, it's as basic to who we are as our sense of love, of God. Genius is childhood. The Creator gives it to us with life, and society drums it out of us before we have the chance to follow the impulses of our naturally creative souls....

Sally related her vision to the little girls in the playground. Apparently they understood her perfectly. Then she walked out onto Bleecker Street and discovered her life had changed. The flowers in front of the Korean deli in their green plastic vases, the magazine covers in the news shop window, the buildings, cars—all took on a sharpness beyond anything she had imagined. The sharpness, she said, "of present time." A wavelet of energy swelled through the center of her being. She could see the hidden life in things, their detailed brilliance, the funneled genius that went into making them what they are.

Sharpest of all was the misery on the faces of the people she passed. She tried to explain her vision to them but they just kept rushing by. Then it hit her: they already know about their genius, it isn't a secret, but much worse: genius has been suppressed in them, as it had been suppressed in her. And the enormous effort required to keep it from percolating to the surface and reasserting its glorious hold on our lives is the cause of all human suffering. Suffering that Sally, with this epiphany, has been chosen among all people to cure.

As startling as Sally's passionate new beliefs are, her father and stepmother are even more struck by her manner of speaking:

Pat and I are dumbstruck, less by what she is saying than how she is saying it. No sooner does one thought come galloping out of her mouth than another overtakes it, producing a pile-up of words without sequence, each sentence canceling out the previous one before it's had a chance to emerge. Our pulses racing, we strain to absorb the sheer volume of energy pouring from her tiny body. She jabs at the air, thrusts out her chin...her drive to communicate is so powerful it's tormenting her. Each individual word is like a toxin she must expel from her body.

The longer she speaks, the more incoherent she becomes, and the more incoherent she becomes, the more urgent is her need to make us understand her! I feel helpless watching her. And yet I am galvanized by her sheer aliveness.

One may call it mania, madness, or psychosis—a chemical imbalance in the brain—but it presents itself as energy of a primordial sort. Greenberg likens it to "being in the presence of a rare force of nature, such as a great blizzard or flood: destructive, but in its way astounding too." Such unbridled energy can resemble that of creativity or inspiration or genius—this, indeed, is what Sally feels is rushing through her—not an illness, but the apotheosis of health, the release of a deep, previously suppressed self.

These are the paradoxes that surround what Hughlings Jackson, the nineteenth-century neurologist, called "super-positive" states: they betoken disorder, imbalance in the nervous system, but their energy, their euphoria, makes them feel like supreme health. Some patients may achieve a startled insight into this, as did one patient of mine, a very old lady with neurosyphilis. Becoming more and more vivacious in her early nineties, she said to herself, "You're feeling too well, you must be ill." George Eliot, similarly, spoke of herself as feeling "dangerously well" before the onset of her migraine attacks.

Mania is a biological condition that feels like a psychological one—a state of mind. In this way it resembles the effects of various intoxications. I saw this very dramatically with some of my Awakenings patients when they began taking L-dopa, a drug which is converted in the brain to the neuro-transmitter dopamine. Leonard L., in particular, became quite manic on this: "With L-dopa in my blood," he wrote at the time, "there's nothing in the world I can't do if I want." He called dopamine "resurrectamine" and started to see himself as a messiah—he felt that the world was polluted with sin and that he had been called upon to save it. And in nineteen nonstop, almost sleepless days and nights, he typed an entire autobiography of 50,000 words. "Is it the medicine I am taking," wrote another patient, "or just my new state of mind?"

If there is uncertainty in a patient's mind about what is "physical" and what is "mental," there may be a still deeper uncertainty as to what is self or not-self—as with my patient Frances D., who, as she grew more excited on L-dopa, was taken over by strange passions and images which she could not dismiss as entirely alien to her "real self." Did they, she wondered, come from very deep but previously suppressed parts of herself? But these patients, unlike Sally, knew that they were on a drug, and could see, all around them, similar effects taking hold on the others.

For Sally there was no precedent, no guide. Her parents were as bewildered as she was—more so, because they did not have her mad assurance. Was it, they wondered, something she had been taking—had she dropped acid, or something worse? And if not, was it something that they had bequeathed her in their genes, or something awful they had "done" at a critical stage in her development? Was it something she had always had in her, even though it was triggered so suddenly?

These were the questions my own parents asked themselves when, in 1943, my fifteen-year-old brother Michael became acutely psychotic. My brother saw "messages" everywhere, felt his thoughts were being read or broadcast, had explosions of strange giggling, and felt he had been translocated to another "realm." Hallucinatory drugs were rare in the 1940s, so my parents, who were both doctors, wondered whether Michael might have some psychosis-producing illness—perhaps a thyroid condition or a brain tumor. It ultimately became clear, though, that my brother suffered from a schizophrenic psychosis. In Sally's case, blood tests and physical exams ruled out any problems with thyroid levels, intoxicants, or tumors. Her psychosis, though acute and dangerous (all psychoses are potentially dangerous, at least to the patient), was "merely" manic.

One can become manic—or depressed—without becoming psychotic: having delusions or hallucinations, losing sight of reality. Sally, though, did go over the top, and on that hot July day, something happened, something snapped. All of a sudden, she was a different person—she looked different, sounded different. "Suddenly every point of connection between us had vanished," her father writes. She calls him "Father" (he was "Dad" before), and speaks in a "pressured, phony voice, as if delivering stage lines she has learned"; "her normally warm chestnut eyes are shell-like and dark, as if they've been brushed over with lacquer."

Greenberg tries to speak to her of ordinary matters, asking her if she is hungry or wants to lie down:

Each time, however, her otherness is reaffirmed. It is as if the real Sally has been kidnapped, and here in her place is a demon, like Solomon's, who has appropriated her body. The ancient superstition of possession! How else to come to grips with this grotesque transformation?

...In the most profound sense Sally and I are strangers: we have no common language.

The special qualities of mania have been recognized and distinguished from other forms of madness since the great physicians of antiquity wrote on the subject. Aretaeus, in the second century, gave a clear description of how excited and depressed states might alternate in an individual, but the distinction between different forms of madness was not formalized until the rise of psychiatry in nineteenth-century France. It was then that "circular insanity" (folie circulaire or folie à double forme)—what Emil Kraepelin later called manic-depressive insanity and what we would now call bipolar disorder—was distinguished from the much graver disorder of "dementia praecox" or schizophrenia. But medical accounts, accounts from the outside, can never do justice to what is actually experienced in the course of such psychoses; there is no substitute here for firsthand accounts.

There have been several such personal accounts over the years, and one of the best, to my mind, is Wisdom, Madness and Folly: The Philosophy of a Lunatic by John Custance, published in 1952. He writes:

The mental disease to which I am subject is...known as manic depression, or, more accurately, as Manic depressive Psychosis.... The manic state is one of elation, of pleasurable excitement sometimes attaining to an extreme pitch of ecstasy; the depressive state is its precise opposite, one of misery, dejection, and at times of appalling horror.

Custance had his first manic attack at the age of thirty-five, and would continue to have periodic episodes of mania or depression for the next twenty years:

When the nervous system is thoroughly deranged, the two contrasting states of mind can be almost infinitely intensified. It sometimes seems to me as though my condition had been specially devised by Providence to illustrate the Christian concepts of Heaven and Hell. Certainly it has shown me that within my own soul there are possibilities of an inner peace and happiness beyond description, as well as of inconceivable depths of terror and despair.

Normal life and consciousness of "reality" appear to me rather like motion along a narrow strip of table-land at the top of a Great Divide separating two distinct universes from each other. On the one hand the slope is green and fertile, leading to a lovely landscape where love, joy and the infinite beauties of nature and of dreams await the traveller; on the other a barren, rocky declivity, where lurk endless horrors of distorted imagination, descends to the bottomless pit.

In the condition of manic- depression, this table-land is so narrow that it is exceedingly difficult to keep on it. One begins to slip; the world about one changes imperceptibly. For a time it is possible to keep some sort of grip on reality. But once one is really over the edge, once the grip of reality is lost, the forces of the Unconscious take charge, and then begins what appears to be an unending voyage into the universe of bliss or the universe of horror as the case may be, a voyage over which one has oneself no control whatever.

In our own time, Kay Redfield Jamison, a brilliant and courageous psychiatrist who has manic-depressive illness herself, has written both the definitive medical monograph on this subject (Manic-Depressive Illness, with Frederick K. Goodwin, 1990; second edition, 2007) and a personal memoir (An Unquiet Mind, 1995). In the latter, she writes:

I was a senior in high school when I had my first attack of manic-depressive illness; once the siege began, I lost my mind rather rapidly. At first, everything seemed so easy. I raced about like a crazed weasel, bubbling with plans and enthusiasms, immersed in sports, and staying up all night, night after night, out with friends, reading everything that wasn't nailed down, filling manuscript books with poems and fragments of plays, and making expansive, completely unrealistic, plans for my future. The world was filled with pleasure and promise; I felt great. Not just great, I felt really great. I felt I could do anything, that no task was too difficult. My mind seemed clear, fabulously focused, and able to make intuitive mathematical leaps that had up to that point entirely eluded me. Indeed, they elude me still.

At that time, however, not only did everything make perfect sense, but it all began to fit into a marvelous kind of cosmic relatedness. My sense of enchantment with the laws of the natural world caused me to fizz over, and I found myself buttonholing my friends to tell them how beautiful it all was. They were less than transfixed by my insights into the webbings and beauties of the universe, although considerably impressed by how exhausting it was to be around my enthusiastic ramblings.... Slow down, Kay.... For God's sake, Kay, slow down.

I did, finally, slow down. In fact, I came to a grinding halt.

Jamison contrasts this experience with the episodes that came later:

Unlike the very severe manic episodes that came a few years later and escalated wildly and psychotically out of control, this first sustained wave of mild mania was a light, lovely tincture of true mania.... It was short-lived and quickly burned itself out: tiresome to my friends, perhaps; exhausting and exhilarating to me, definitely; but not disturbingly over the top.

Both Jamison and Custance describe how mania alters not just thought and feeling, but even their sensory perceptions. Custance carefully itemizes these changes in his memoir. Sometimes the electric lights in the ward have "a bright starlike phenomenon emanat[ing]...ultimately forming a maze of iridescent patterns." Faces seem to "glow with a sort of inner light which shows up the characteristic lines extremely vividly." Though normally "a hopeless draughtsman," Custance is able to draw quite well while manic (I was reminded here of my own ability to do this, many years ago, during a period of amphetamine-induced hypomania); all of his senses seem intensified:

My fingers are much more sensitive and neat. Although generally a clumsy person with an execrable handwriting I can write much more neatly than usual; I can print, draw, embellish and carry out all sorts of little manual operations, such as pasting up scrapbooks and the like, which would normally drive me to distraction. I also note a particular tingling in my fingertips.

My hearing appears to be more sensitive, and I am able to take in...many different sound-impressions at the same time.... From the cries of gulls outside to the laughter and chatter of my fellow-patients, I am fully alive to what is going on and yet find no difficulty in concentrating on my work.

...If I were to be allowed to walk about freely in a flower garden I should appreciate the scents far more than usual.... Even common grass tastes excellent, while real delicacies like strawberries or raspberries give ecstatic sensations appropriate to a veritable food of the gods.

At first, Sally's parents struggle to believe (as Sally herself believes) that her excited state is something positive, something other than illness. Her mother puts a somewhat New Agey spin on it:

Sally is having an experience, Michael, I'm sure of it, this isn't a sickness. She's a highly spiritual girl.... What's happening right now is a necessary phase in Sally's evolution, her journey toward a higher realm.

And this interpretation finds echoes of a more classical kind in Greenberg himself:

I wanted to believe this too, believe in her breakthrough, her victory, the delayed efflorescence of her mind. But how does one tell the difference between Plato's "divine madness" and gibberish? between [enthusiasm] and lunacy? between the prophet and the "medically mad"?

(It was similar, Greenberg points out, with James Joyce and his schizophrenic daughter, Lucia. "Her intuitions are amazing," Joyce remarked. "Whatever spark of gift I possess has been transmitted to her and has kindled a fire in her brain." Later, he told Beckett, "She's not a raving lunatic, just a poor child who tried to do too much, to understand too much.")

But it becomes clear within hours that Sally is indeed psychotic and out of control, and her parents take her to a psychiatric hospital. At first, she welcomes this, seeing the nurses, the attendants, and the psychiatrists as specially tuned to understand her insight, her message. The reality is brutally different: she is stupefied with tranquilizers and put in a locked ward.

Greenberg's description of the ward takes on the richness and density of a novel, embracing a Chekhovian cast of characters—the staff, the other patients on the ward. He sees a highly disturbed, obviously psychotic young Hasidic man, whose family will not accept that he is ill: "He has achieved devaykah ," says his brother, "the state of constant communion with God."

There is relatively little attempt to understand Sally in the hospital—her mania is treated first of all as a medical condition, a disturbance of brain chemistry, to be dealt with on a neurochemical basis. Medication is crucial, even life-saving, in acute mania, which untreated can lead to exhaustion and death. Unfortunately, though, Sally does not respond to lithium, which has been invaluable for many patients with manic-depressive illness, and so her physicians have to resort to heavy tranquilizers—which damp down her exuberance and wildness but leave her stupefied and apathetic and parkinsonian for a time. Seeing his teenage daughter in this zombie-like state is almost as shocking for her father as her mania has been.

After twenty-four days of this, Sally is released—still somewhat delusional and still on strong tranquilizers—to go home, under careful and at first continuous surveillance. Outside the hospital, she establishes a crucial relationship with an exceptional therapist, who is able to approach Sally as a human being, trying to understand her thoughts and feelings. Dr. Lensing shows a disarming directness: "I bet you feel as if there's a lion inside you" are her first words to Sally.

"How did you know?" Sally is amazed, her suspicion instantly melting away. Lensing goes on to talk of mania, Sally's mania, as if it were a sort of creature, another being, inside her:

Lensing nimbly lowers herself into the waiting area chair next to Sally's and tells her in a tone of woman-to-woman straight talk that mania—and she refers to it as if it is a separate entity, a mutual acquaintance of theirs—mania is a glutton for attention. It craves thrills, action, it wants to keep thriving, it will do anything to live on. "Did you ever have a friend who's so exciting you want to be around her, but she leads you into disaster and in the end you wish you never met? You know the sort of person I mean: the girl who wants to go faster, who always wants more. The girl who serves herself first and screw the rest.... I'm just giving an example of what mania is: a greedy, charismatic person who pretends to be your friend."

Lensing tries to get Sally to distinguish her psychosis from her true identity, to stand outside the psychosis and to see the complex, ambiguous relationship between it and her. (Psychosis is "not an identity," she says sharply.) She speaks of this to Sally's father, too—for his understanding is also necessary if Sally is to get better. She emphasizes the seductive power of psychosis:

Sally...doesn't want to be isolated, her impulse is outward, which I can tell you is extremely good news. Her desire is to be understood, and not only by us, she wants to understand herself as well. She's still attached to her mania, of course. She's remembering the intensity of her experience, and she's doing her damnedest to keep that intensity alive. She thinks that if she gives it up, she'll lose the great abilities she believes she's acquired. It's a terrible paradox really: the mind falls in love with psychosis. The evil seduction, I call it.

"Seduction" is the crucial word here (it is also the key word in the title of Edward Podvoll's marvelous book The Seduction of Madness, on the nature and treatment of mental illness). Why should psychosis, and mania in particular, be seductive? Freud spoke of all psychoses as narcissistic disorders: one becomes the most important person in the world, chosen for a unique role, whether it is to be a messiah, a redeemer of souls, or (as happens in depressive or paranoid psychoses) to be the focus of universal persecution and accusation, or derision and degradation.

But even short of such messianic feelings, mania can fill one with a sense of enormous pleasure, even ecstasy—and the sheer intensity of this may make it difficult to "give up." It is what prompts Custance, despite his knowledge of how dangerous such a course is, to avoid medication and hospitalization in one attack of mania, and instead embrace it, undertaking a risky and rather James Bond–like adventure in East Berlin. Perhaps a similar intensity of feeling is sought by drug addicts, especially those addicted to stimulants like cocaine or amphetamines; and here, too, a high is likely to be followed by a crash, just as a mania is usually followed by a depression—both, perhaps, due to the exhaustion caused by neurotransmitters like dopamine in the overstimulated reward systems in the brain.

Mania, though, is by no means all pleasure, as Greenberg continually observes. He speaks of Sally's "pitiless ball of fire," her "terrified grandiosity," of how anxious and fragile she is inside the "hollow exuberance" of her mania. When one ascends to the exorbitant heights of mania, one becomes very isolated from ordinary human relationships, human scale—even though this isolation may be covered over by a defensive imperiousness or grandiosity. This is why Lensing sees Sally's returning desire to make genuine contact with others, to understand and be understood, as a propitious sign of her returning to health, her coming back to earth.

Psychosis, as Lensing says, is not an identity, but a temporary aberration or departure from identity. And yet having a chronic or recurring mind-altering condition like manic-depressive illness is bound to influence one's identity, to become part of one's attitudes and ways of thinking. As Jamison writes,

It is, after all, not just an illness, but something that affects every aspect of my life: my moods, my temperament, my work, and my reactions to almost everything that comes my way.

Nor is it just a piece of biological bad luck for which there is nothing to be said. Although Jamison says there is nothing good to be said for depression, she does feel that her manias and hypomanias, when not too out of control, have played a crucial and sometimes positive part in her life. Indeed, in her book Touched with Fire: Manic-Depressive Illness and the Artistic Temperament (1993), she has provided much evidence to suggest a possible relationship between mania and creativity, citing the many great artists—Schumann, Coleridge, Byron, and Van Gogh among them—who seem to have lived with manic-depressive illness.

When Sally is hospitalized, her father asks the psychiatric resident about her diagnosis. "Sally's condition," the resident says, "has probably been building for a while, gathering strength until it just overwhelmed her." Greenberg asks what her "condition" is:

What we call [it] is not what's important right now. Certainly many of the criteria for bipolar I are here. But fifteen is relatively early for fulminating mania to present itself.

In the last couple of decades, the term "bipolar disorder" has come into use, in part, Jamison suggests, because it is felt to be less stigmatizing than "manic-depressive illness." But, she cautions,

Splitting mood disorders into bipolar and unipolar categories presupposes a distinction between depression and manic-depressive illness...that is not always clear, nor supported by science. Likewise, it perpetuates the notion that depression exists rather tidily segregated on its own pole, while mania clusters off neatly and discreetly on another. This polarization...flies in the face of everything that we know about the cauldron-ous, fluctuating nature of manic- depressive illness.

Moreover, "bipolarity" is characteristic of many disorders of control—like catatonia or parkinsonism—where patients lose the middle ground of normality and alternate between hyperkinetic and akinetic states. Even in a metabolic disease such as diabetes, there may be dramatic alternations between (for instance) very high blood sugar and very low blood sugar, as the complex homeostatic mechanisms are compromised.

There is another reason why the notion of manic-depressive illness as a bipolar illness, swinging from one pole to the other, can be misleading. This was brought out by Kraepelin more than a century ago, when he wrote of "mixed states," states in which there are elements of both mania and depression, inseparably intertwined. He wrote of "the deep inward relationship of such apparently contradictory states."

We speak of "poles apart," but the poles of mania and depression are so close to each other that one wonders if depression may be a form of mania, or vice versa. (Such a dynamic notion of mania and depression—their "clinical unity," as Kraepelin put it—is underlined by the fact that lithium, for those patients in whom it works, works equally well on both states.) This paradoxical situation is described by Greenberg with often astonishing oxymorons, as when he speaks of the "abysmal elation" Sally sometimes feels "in the throes of [her] dystopic mania."

Sally's final return from the mad heights of her mania is almost as sudden as her taking off into it seven weeks earlier, as Greenberg recounts:

Sally and I are standing in the kitchen. I have spent the day at home with her, working on my script for Jean-Paul. "Would you like a cup of tea?" I ask.

"That would be nice. Yes. Thank you."

"With milk?"

"Please. And honey."

"Two spoonfuls?"

"Right. I'll put the honey in. I like watching it drip off the spoon."

Something about her tone has caught my attention: the modulation of her voice, its unpressured directness—measured, and with a warmth I have not heard in her in months. Her eyes have softened. I caution myself not to be fooled. Yet the change in her is unmistakable.

...It's as if a miracle has occurred. The miracle of normalcy, of ordinary existence....

It feels as if we have been living all summer inside a fable. A beautiful girl is turned into a comatose stone or a demon. She is separated from her loved ones, from language, from everything that had been hers to master. Then the spell is broken and she is awake again....

After her summer of madness, Sally is able to return to school—anxious, but determined to reclaim her life. At first, she keeps her illness to herself, and enjoys the company of three close friends from her class. "Often," her father writes, "I listen to her on the phone with them, intimate, biting, gossipy—the buoyant sound of health." A few weeks into the school year, after much discussion with her parents, Sally tells her friends about her psychosis:

They readily accept the news. Being an alumna of the psych ward confers social status on Sally. It's a kind of credential. She has been where they have not been. It becomes their secret.

Sally's madness resolves, and this, one might hope, would be the end of the story. But the very defining feature of manic-depressive illness is its cyclical nature, and in a postscript to his book, Greenberg indicates that Sally did have two further attacks: four years later, when she was in college, and six years after that (when her medication was discontinued). There is no "cure" for manic-depressive illness, but living with manic-depressive illness may be greatly helped by medication, by insight and understanding (in particular, by minimizing stressors like sleep loss, and being alert to the earliest signs of mania or depression), and, not least, by counseling and psychotherapy.

In its detail, depth, richness, and sheer intelligence, Hurry Down Sunshine will be recognized as a classic of its kind, along with the memoirs of Kay Redfield Jamison and John Custance. But what makes it unique is the fact that so much here is seen through the eyes of an extraordinarily open and sensitive parent—a father who, while never descending into sentimentality, has remarkable insight into his daughter's thoughts and feelings, and a rare power to find images or metaphors for almost unimaginable states of mind.

The question of "telling," of publishing detailed accounts of patients' lives, their vulnerabilities, their illness, is a matter of great moral delicacy, fraught with pitfalls and perils of every sort. Is Sally's struggle with psychosis not a private and personal matter, no one's business but her own (and that of her family and physicians)? Why would her father consider exposing his daughter's travails, and his family's pain, to the world? And how would Sally feel about a public disclosure of her teenage torments and exaltations?

This was not a quick or easy decision for either Sally or her father. Greenberg did not grab a pen and start writing during his daughter's psychosis in 1996—he waited, he pondered, he let the experience sink deep into him. He had long, searching discussions with Sally, and only more than a decade later did he feel that he might have the balance, the perspective, the tone that Hurry Down Sunshine would need. Sally, too, had come to feel this, and urged him not only to write her story, but to use her real name, without camouflage. It was a courageous decision, given the stigma and misunderstanding that still surround mental illness of any kind.

It is a stigma that affects many, for manic-depressive illness occurs in all cultures, and affects at least one person in a hundred—there are, at any time, millions of people, some even younger than Sally, who may have to face what she did. Lucid, realistic, compassionate, illuminating, Hurry Down Sunshine may provide a sort of guide for those who have to negotiate the dark regions of the soul—a guide, too, for their families and friends, for all those who want to understand what their loved ones are going through. Perhaps, too, it will remind us of what a narrow ridge of normality we all inhabit, with the abysses of mania and depression yawning to either side.

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