The benefits of mental illness

This article was originally published in Aug., 2011

NASSIR GHAEMI is a physician and professor of psychiatry at Tufts University School of Medicine in Boston. In A First-Rate Madness: Uncovering the Links Between Leadership and Mental Health, he argues that in times of crisis, a lifetime of sanity can be a serious liability for political and military leaders, while the lessons and legacy of madness have proven invaluable.

Q: To put your counterintuitive thesis in a nutshell, would it be that too much of anything, including normality, is a bad thing?

A: You could put it that way. I would add that mentally normal leaders, who often have enormous success in normal times, often do not have the personal resources to cope with crisis change. But those who have struggled with mental illness—not outright psychosis or delusions, but the common mental illnesses of bipolarism or depression—have often developed just the traits that crisis leaders need and demonstrate: realism, resilience, creativity and empathy.

Q: Why do the mentally ill experience those benefits?

A: The connection between mania—the up side of bipolar disease—and creativity is well-known; resilience also accompanies mania. Studies show depressed people consistently see the world around them more realistically than mentally healthy people who are biased toward optimism. Depression makes leaders more realistic and empathetic, and mania makes them more creative and realistic. The same, to a lesser but important degree, goes for people who are neither depressed nor manic, but not mentally healthy either—those with abnormal personalities. Examples are dysthymic people—a little depressed, low in energy, needing sleep—and the hyperthymic—always upbeat, sleep little, high libido.

Q: You make your case by comparing mentally unbalanced leaders who rose to the occasion during grave situations and “normal” leaders who failed during those moments. You don’t believe the mentally ill seek leadership more than sane people, but do you think hyperthymic personality types are disproportionate?

A: I would say so. They’re disproportionate among successful people of all kinds–businessmen, politicians, academics, doctors, lawyers. Their personalities basically mean having mild manic symptoms most of the time. It’s more common in families of people with bipolar disorder and probably reflects having a mild version of that illness, but reflected in one’s usual personality rather than as a disease that comes and goes. That means having a high amount of energy, being very talkative, very sociable, charismatic, extroverted, very productive, even workaholic, frequently with a high sexual drive.

Q: That’s why some speculate there’s evolutionary selection going on for this personality?

A: Bipolar disorder is the most genetic psychiatric illness we have: twin studies show that the likelihood of having bipolar disorder is about 80 per cent genetic. So it may be there’s an evolutionary aspect, because this kind of temperament fits the work structure of most human societies, and it’s something that we praise and reward. As well, this hyperthymic temperament is associated with resilience to trauma. When people have traumatic experiences—war or terrorism—hyperthymics recover from the traumas without as much anxiety and depression or post-traumatic stress symptoms as others. Some leaders, like Franklin Roosevelt and John Kennedy, who I think were hyperthymic, recovered from serious physical illnesses—polio in one case, Addison’s disease in the other—and became more resilient individuals, and that translated, I think, to their political success and the resilience that they showed facing political crises.

Q: On the other side, you conclude somebody like the perfectly normal Tony Blair, who worked standard politics brilliantly, couldn’t cope when things changed?

A: Right, and Neville Chamberlain would be the other classic example. You have people who are very successful because they’ve never been tested. They are able to do well in college, they’re able to do well as mayors, as parliamentarians, they have lots of friends, they work the political ladder quite well, and they reach the top. And then when the crisis comes, none of those skills count for anything and they don’t know what to do.

Q: How can you form a diagnoses of historical people? Isn’t it difficult, if not impossible?

A: In psychiatry, as in history, it’s standard to have four separate lines of evidence: symptoms, genetics, course of illness and treatment. There are symptoms specific to depression and mania, like extreme sadness or euphoria. The genetics are very important—if there’s a family history of bipolar disorder, it’s very likely that someone else will have it as well. Course of illness is important because there is a certain pattern. They begin in young adulthood and they happen many times over the course of a lifetime. If someone has one of these illnesses then he would match that pattern. Treatment is relevant because frequently when someone is ill, others will try to get them treated, and this is evidence for an illness. My work is not psychohistory in the traditional Freudian sense: I’m not speculating about how someone’s relationship with their mother might have affected them.

Q: Your comparison of John Kennedy and Richard Nixon comes out exactly opposite to prevailing public opinion.

A: You mean Kennedy as mentally ill and Nixon as normal? I define mental health as the absence of mental illness and being within the normal range of personality traits, and I think an objective analysis of Nixon’s biography, looking for those four markers, would support that conclusion. I think the main reason people ascribe so much mental abnormality to Nixon has been because they haven’t liked his behaviours, and that’s a reflection of psychological stigma, of stigma against mental illness, which is really very deep-rooted in our society.

Q: You see Nixon and Blair as a perfect pair, two men stubbornly digging in their heels—over Watergate and the Iraq invasion—and refusing to change course?

A: Research on normal psychology and normal thinking patterns shows that most people react to mistakes the way they did, by refusing to accept them. Most of us have some irrational thinking patterns—that’s normal—and I think that what happens when you take an average, healthy person and put that person in a position of great power and limit their access to contravening information—they develop hubris. Then they become leaders like Blair, like George W. Bush, like Nixon, like Chamberlain: increasingly out of touch with what the facts are.

Q: Kennedy’s other pairing is with Hitler, which you portray as a study in competing drug therapies. You note that Kennedy was, in his early time as president when he lurched from one unsuccessful crisis to another, on a dangerous drug regimen, and a far better one in his later months when he made better decisions. Have historians paid sufficient attention to this?

A: They haven’t and I think they need to. I mean, the truths of biology apply to everybody, and it doesn’t matter if you’re a president or a janitor. Now, people on steroids, like Kennedy was, if they have bipolar disorder or even hyperthymic temperament—which is the least Kennedy had—they have a notable risk of getting manic. Full-blown mania, in fact; at the very least, there’s a much higher rate of manic symptoms like hypersexuality, irritability, aggressiveness—all of which he had. Previous historians also noted that Kennedy was on amphetamines, but they concluded these drugs had no effect on him!

Q: Hitler’s drug therapy, you believe, was even more likely to have affected his decisions?

A: Intravenous amphetamine use is much worse than oral, because it goes more directly and more quickly to your brain, and has much more impact. In the case of Hitler, it was daily, from 1937 until the day he died. If you take someone who has bipolar disorder, as the evidence suggests he did, and you give him intravenous amphetamines every day for years, one is guaranteed to have a very bad outcome, with much worsening frequency of manic and depressive episodes—more often and deeper—and probably psychosis as likely happened with Hitler.

Q: Is your purpose to reduce the stigma of mental illness by showing that we all have the virtues of our vices, and that mental illness is more common and milder than we realize?

A: This distinction between mental health and mental illness is not all or nothing. We all have—even the most mentally healthy—some irrational thinking habits, and even the most mentally ill people have some aspects of their personality that are still healthy, in touch with reality. Mild to moderate mental illness can actually be helpful in circumstances like crisis leadership. Even severe mental illness can have benefits, even if those benefits are not present when the person is actively severely depressed or manic. But maybe after they recover and they look back, there might be aspects of what happened that later prove helpful, such as resilience and increased empathy and realism with depression, increased creativity with mania.

Q: A mentally ill leader is still mentally ill, even if he has learned a few things, but you do not think he is untrustworthy for that alone?

A: Absolutely not. In fact, the message partly is that he’s more trustworthy because of that characteristic, certainly in crisis situations.