Functionality - Not Exactly Clear-Cut

John McManamy Health Guide
  • Two weeks ago, in my piece, Mania vs Hypomania and the DSM, I observed that the key distinguishing feature is severity, which translates to the issue of functionality vs non-functionality. According to the DSM-IV, for mania:


    The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.


    And for hypomania: 


    The mood disturbance is not severe enough ...


    For a change, the DSM and I are in general agreement, but Peachy, in a comment, took issue. Don’t worry, Peachy, I totally validate where you are coming from. You have opened up a very pertinent discussion. So let’s begin with your challenge:

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    One of my big beefs with the approach taken by DSM and by you is that you are worshiping at the altar of functionality. I can (and have) been manic and still "functional" as far as some folks could tell.


    Peachy goes on to describe how she had to argue to get admitted because she was entirely too articulate and well-dressed to be manic. As she observes:


    This was apparently a strike against me because, as we all know, anyone who is manic will continue to drive their car despite the fact that for several days they have been wanting to drive it off the road into tree or run down anyone in their path. Because I had realized that I wasn't safe and had stopped driving 3 days earlier I was by definition not manic.


    She goes on to say:


    The poor delusional men who have killed people were perfectly functional. They had no problem walking into a gun store and buying a gun or ammo or whatever they needed so they could go kill. I bet if you asked the people they did business with those folks would say "yep, functional. maybe a little odd but hey, everybody's odd sometimes.”


    Sylvia Nasar, in her book “A Beautiful Mind,” delved into the same issue. The book, you may recall, recounts the life of John Nash, the brilliant mathematician whose career was sidetracked by schizophrenia. In 1994, he was awarded the Nobel Prize in Economics for work he had done in 1949, at age 21, seven or eight years before a psychotic break that would result in nearly three lost decades of his life.


    Nash ran the full gamut of delusional thinking and behavior. Part of this included his belief that the US government was persecuting him. As a result, he sought refuge in Europe, visiting embassies in various capitals attempting to turn in his citizenship. Neverthess, Nasar points out, despite clear evidence of a brain that was clearly not working right, he was able to book his tickets, make his own travel arrangements, and somehow not wind up on the street.


    What gives?


    Nasar also looks at the issue another way. Prior to his break, Nash was very much eccentric in his behavior, even by the oddball standards of academic math whizzes. What we see, in effect, is a brain operating on the very edge - a stellar display of logic and order and inspiration on one hand, signs of not quite being able to hold it together on the other.


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    Then the wheels all came flying off. Or, rather, most of them. He could still make his own travel arrangements, remember?


    Then, in the 1980s, gradually his brain started to return to him. He didn’t return to a paid academic post, but he was able to work on mathematical problems that made sense and carry on learned discussions with his peers. Plus, he was able to learn new stuff, such as using computers in his research. In 1994, came the phone call from Sweden.


    Obviously, functionality is not as clear-cut as psychiatry makes it out to be, and this is the point I think Peachy is making. There are no easy answers, here, but as an exercise I ask you to look at the life of John Nash as I described it here and hopefully read Ms Nasar’s book if you haven’t read it already. I can think of no better case study of the supremely high-functioning blending with the abysmally low functioning, often at the same time, over the course of a lifetime.


    It’s one hell of a riddle wrapped in a mystery inside an enigma.  You tell me - what gives? 

Published On: February 17, 2013