Medication review: Abilify (aripiprazole)

Do you remember the TV commercials for Abilify? At the time, it was being marketed in such a way that a lot of people thought it was an antidepressant. It’s not, though. Abilify is most definitely an antipsychotic, primarily indicated for schizophrenia and bipolar disorder, and it comes with the full list of potential side effects that another antipsychotic might come with. When Abilify was first released, its manufacturer pushed a lot of half-truths (or null-truths) like “Abilify is weight neutral” (26% of patients experience clinically significant weight gain, albeit not as much as Zyprexa) and “Abilify doesn’t cause movement disorders” (it can cause tardive dyskinesia (TD), and 9% of patients experience akathisia — a profound inner restlessness that patients often describe as wanting to “crawl out of [their] skin”). Overall, 15% of patients experience a serious adverse drug reaction.

All of that said… Abilify isn’t a bad drug.

I took Abilify for four years before developing a TD-like movement disorder that ultimately led me to discontinue it. (The same movement disorder worsened on Vraylar, which is a very close relative of Abilify.)

It might be fair to say that Abilify is misunderstood. I don’t think it should have been marketed the way it was. But when we’re talking about schizophrenia and bipolar disorder, well, it’s not the worst of the options. Clozapine and Zyprexa are worse for weight gain. Haldol is worse for movement disorders, like TD and akathisia. But is it effective?

Actually, Abilify was pretty effective for me. When I first started taking it, I would sleep all day. I’d fall asleep in my classes, like, head-on-desk, passed out. (This was particularly troublesome in my class on child abuse.) Then I started taking a stimulant for my ADHD, and everything seemed to be in harmony. Until a new psychiatrist took me off of Abilify to try a newer drug (Latuda — which did nothing for me). When I eventually went back on, I had all kinds of weird side effects. I couldn’t sit, or even stand still — a condition that my psychiatrist would later describe as akathisia. And my head started to shake involuntarily.

So how effective is it, really? The maximum dose of Abilify is 30mg, but benefit at doses higher than 15mg has not been established. A concept that is sometimes floated around in psychiatry is that of equivalent doses, usually CPZ (chlorpromazine) or OLA (olanzapine) equivalents. In this case, we’ll use haloperidol equivalents. 15mg Abilify is equivalent to 7.5 mg of Haldol which is also equivalent to a whopping 750mg quetiapine (Seroquel) — very close to the maximum dose of 800mg. We can see here that Haldol is stronger than Abilify, and Seroquel is weaker. We can tell based on the maximum dose of each and where the others stand in comparison.

Think of it like this: the maximum daily dose of Haldol is 30mg. The equivalent dose of Abilify is 35 mg — above the maximum. So it’s a bit weaker than Haldol. Meanwhile, Seroquel is much weaker. (In fact, Seroquel is the lowest potency antipsychotic, and usually isn’t used to treat psychosis.)

The moral of the story is not to trust the commercials put out by drug companies. I won’t be taking Abilify again, and unfortunately my movement disorder has never completely gone away. For some people, though, it’s a great medication.


Medication review: Lithium

To kick off my series of medication reviews, I have to start with lithium. It has a certain symmetry that is almost beautiful: it saves my life every day by reducing the amplitude of my bipolar symptoms, yet in excess, it almost took my life. I couldn’t get the metallic taste out of my mouth for weeks. Here’s the thing: if you’re bipolar 1, there’s a good chance that it’s the single most effective medication out there. It is for me. That’s why 6 weeks after the overdose in 2018 I was put back on it. At one point, the pharmacy was dispensing it to me weekly.

Lithium is so effective for some people, and not for others — so, researchers talk about “lithium responders” and “nonresponders”. There are certain subgroups of people who tend to be responders. For some reason that is not entirely clear, people who have manias before depression are more likely to be responders than people who have depressions before mania (and most people are consistently one or the other).

Lithium is all-natural. It comes from the earth; it is mined for use in batteries. Discovery of lithium’s mood stabilizing properties in 1949 (though I’ve heard that indigenous Americans once soaked their mentally ill in lithium-rich hot springs) was a happy accident. Yet it has nearly as long been known to cause kidney damage, thyroid damage, diabetes, and more. I have a skin condition called hidradenitis suppurativa that was likely caused by lithium. It causes my inner thighs to develop painful lumps that turn into bleeding lesions, and occasionally develop a secondary infection of the skin and soft tissue.

As terrible as all of that is, I don’t feel I could be living the life I live today without being on lithium. I take 1200mg daily, though the dose is measured by blood level, so one person’s 1200 could be another person’s 1000, or something like that. It has enabled me to recover from the state I was in around 2018, to stay out of the hospital and out of trouble.

Lithium’s mechanism of action is quite complex. It alters the activity of voltage-gated channels throughout the brain. There are no other drugs closely related to lithium, or that share its mechanism of action. Pharmaceutical companies haven’t been able to improve upon it. It remains unique in its treatment of bipolar disorder. One of its more notable clinical features is that it reduces suicidality. It’s ironic to note lithium’s high potential for toxicity.

A common side effect of lithium is tremor. I notice it mostly in my hands; they shake and it’s difficult to eat with a spoon. Interestingly, in toxic situations, the tremor can get much worse. Lithium toxicity also causes profound nausea and vomiting. Toxicity can result from dehydration, or even from travel from a low elevation to a higher elevation. But it’s not just the narrow band between therapeutic and toxic doses that makes lithium deadly — it’s the fact that there is no antidote to lithium toxicity, and lithium doesn’t bind to activated charcoal like most other drugs. Only with hemodialysis can lithium be removed from the body.

What to do if you’ve been prescribed lithium? Drink a lot of water, and wait 1-2 weeks to really feel the difference. Lithium has been absolutely lifesaving for many people. Maybe it will be for you.


If Autism Isn’t a Mental Illness, What Is?

My name is Elliot. I’m an autistic psychologist with bipolar 1 disorder (and ADHD). I’ve been mentioned in passing [1] [2] in news articles about autistic autism researchers, but I prefer to keep on the science side of things. I usually only use Twitter for personal entertainment, sometimes biting my tongue as I weigh the pros and cons of engaging in autism discourse. I don’t entangle myself too deeply in advocacy work. For the most part, I keep my opinions on controversial things low-key no matter which side I am on. This post is a divergence from that tendency.

I have not uncommonly heard people object to classifying autism as a mental illness. It’s almost taken for granted that autism doesn’t fall under that umbrella. You may be surprised to know how people try to justify it if you actually ask them “Why isn’t it a mental illness?” Indeed, when pressed the most common responses are along the lines of:

  • “Autism is a neurodevelopmental disability” / “You’re born with autism”
  • “Autism isn’t an illness” / “Autism doesn’t need to be treated”
  • “Autistic people aren’t like *those* people”

The common element in all of these responses is a lack of understanding of what mental illness is and what mentally ill people experience. The question I want to ask back is this: If autism isn’t a mental illness, what is?

I’m not unsympathetic to the cause of not labeling people as having an “illness” because they’re neurodivergent, but why is it okay to do it to schizophrenic folks and not to autistic folks? There are plenty of mad people who don’t exactly view their diagnosis as an illness, although opinions in the psychiatric community are varied on this topic. Some consider diagnostic labels to be a prison, and others a gift. We sure live with plenty of labels.

Pharmaceutical drug labels.

Mental illness takes many forms. Some of them are quite properly classified as “neurodevelopmental disabilities” (including schizo spec, bipolar disorder, and ADHD — among possibly many others). The disorders I just mentioned are predominantly caused by genetics, and are therefore present at birth. The expression does change over time — but don’t autistic people have qualities that change as they grow and learn?

People refuse to acknowledge the close similarities between autism and schizophrenia (and other severe mental illness).

I’m going to flat-out recognize this: I think a lot of our community is biased. There are a lot of autistic people that are sanist, and they’ve been permitted to perpetuate misunderstanding.

My own therapist once tried to convince me after I admitted to experiencing delusions earlier in the week that I was merely referencing thoughts that were “overly rigid” as a result of my autism. My psychotic symptoms were being falsely attributed to my autism, and a lack of care was being given where care was needed.

And in the real world autistic people are at high risk of being mistaken for schizophrenic and taken to an ER for psych evaluation when they’re in distress. People can be treated horribly. But instead of stepping back and saying “Why do we treat mentally ill people horribly?” we’ve decided that allyship is not for us and we double down on “Autism isn’t a mental illness.” We cast non-autistic (and some autistic!) neurodivergent people as the Other.

To be quite honest, I think some autistic people are scared of crazy.

Perhaps they’re scared of people who may be erratic, hard to predict, or have dramatic emotional reactions.

A person wearing black Converse and a blue hoodie.

Are there reasons to set autism apart from conditions we consider “mental illness”? I just don’t see the justification for viewing autism as so singularly unique from other conditions. It’s possible that, in the future, we could redefine and do away with the label of “mental illness” altogether. I’ll be interested to see how language evolves for neurodivergent folks. I hope even moreso that people in the autistic community approach the psychiatric community with an open mind, and not with fear or prejudice. I see hope for a future of cross-disability solidarity.


1. Does loneliness warp the mind?

I’ve often experienced loneliness
as a toxin. A chemical that corrodes, gnaws through my bones a chasm, a gaping wound in the depths of my ribcage. This characteristic feeling alerts me to the river tide drawing me in, the cosmic forces of mania & depression.
It is a fundamental emptiness;
it destroys everything, it leaves nothing
& nobody untouched.

Mold creeps through a sheet of paper, drifts gently down like a leaf, thin & translucent.
When did I start feeling this way? It had to be — but what changed?
Risperdal & lithium was my lucky combo, wasn’t it? I almost thought I had outrun you, my friend. What do other people see when their eyes are laid to rest? Stay awhile.
Stay & consume me.
I’d rather die a star-crossed lover than a miserable fool. To long for sorrow is as natural as breathing.
Bad Thoughts reverberate in the canyon between my ears.
I imagine a room painted with red. It’s my bathroom — but I am not there now. This isn’t my couch.
A speck of dust floats by, idly drifting in an infinite universe–


Bipolar Disorder vs. Manic Depression

If you’ve heard anything about the term “manic depression”, you might know that it is an older term for bipolar disorder. Here’s my unpopular opinion: “bipolar disorder” is a less accurate and more dehumanizing term than “manic depression”. 

Why? There are several reasons.

  1. The new name “bipolar disorder” was coined for the wrong reasons, and decided by the DSM committee without real input from people who live with the disorder. Officially, the reason was to reduce the stigma associated with inappropriate use of the existing term… but that clearly has not worked, because “bipolar” is now used in the same ways or worse. The real reasons for the change in terminology, despite little to no change in the diagnostic features associated with the disorder, were most likely generated by political division within the APA and not really out of concern for the people who live with it every day. At the time of the change, there was a vocal group of people with bipolar/manic depression that advocated for the original name, including Kay Redfield Jamison (author of An Unquiet Mind).
  2. As far as I know, bipolar people have seen little to no real-life benefit from the change. In fact, “bipolar” conjures a lot of misconceptions about what the condition really looks and feels like. Mania and depression are not really opposites — they feed into each other (by definition), and they can even occur simultaneously. People with bipolar/manic depression typically do not fly from one mood to another within minutes or hours, but “bipolar” seems to encourage that misconception while “manic depression” gives the idea that the disorder is a particular kind of depression, and doesn’t just come and go at the drop of a hat. Rather, much like non-bipolar depression, bipolar moods come in episodes that usually last for weeks to months. “Depression” is something people have more understanding of, even if “manic depression” is a different kind of it; “bipolar” sounds like something else altogether, and it sounds like something scary.

What do you think? Which term is more stigmatized? Is one term more accurate than the other?


Communication Styles in Neurodivergent People

About two weeks ago, my cousin’s husband died from SUDEP (Sudden Unexpected Death in Epilepsy). He showed no signs of having experienced a seizure (no biting his tongue, for example); he simply went to bed one night and never woke up. He is bereaved by his daughter, who turned 7 years old a few days ago, and my cousin.

My cousin turned to me to talk about SUDEP. I warned her that while I knew this would be a difficult topic to discuss, I had a tendency to be very blunt about these things. But it turns out that’s exactly what she was looking for. She wanted to know the truth: Was there anything she could have done differently? And almost everyone on the planet would have told her no, because it’s the “right” answer. But she wasn’t looking for the “right” answer. She was looking for the “true” answer.

I explained that SUDEP doesn’t always follow a major seizure (it’s different than dying from status epilepticus). If the brain is like a computer, then a seizure is like a glitch, and SUDEP is like a system failure. Sometimes your screen glitches up and recovers. Sometimes it glitches and shuts down. But sometimes a broken computer just shuts down with no warning at all. In the latter case, there is nothing that could be done.

Neurodivergent people are often told that we need to be softer in our social approach — less honest, direct, blunt, or whatever you want to call it. But I’m a big believer in playing to our strengths. People with autism, ADHD, bipolar disorder, and other conditions have unique ways of communicating that have value. My cousin later told me that she understood my computer metaphor and it helped her, just a little bit, to begin the process of moving on with the rest of her life.

There’s nothing wrong with being a “blunt” communicator. Sometimes, that’s exactly what is needed. There are a lot of autistic people who won’t lie to you just to make you feel better, and that in itself is actually a virtue.

As for bipolar disorder, I think a lot of us have highly emotional communication styles. There are always going to be situations where this comes in handy, even if some people consider it a downside. People have always been open with me about their suicidal ideation or urges to self-harm because they knew I could take it and I would be there for them without freaking out or telling them they needed to go to the hospital if they didn’t really.

All neurodiverse people have their own styles of communicating, and they all come with benefits in the right situation. What do you think?


Akathisia: an inability to rest caused by antipsychotics

Akathisia is a clinical term for extreme inner restlessness. People who are experiencing akathisia have great difficulty sitting still, or maybe even sitting at all. I first experienced akathisia on Abilify (which I ultimately discontinued because it gave me a facial dyskinesia), and it continued to plague me as I tried different antipsychotics, such as Haldol. I found myself unable to do anything except to go outside, pacing back and forth and smoking cigarettes. Propranolol offered me some relief from the worst of it, but the effect eventually faded.

The medications that are most likely to cause extrapyramidal side effects (EPS) — including tardive dyskinesia — are also the most likely suspects for akathisia. In fact, you might even say akathisia is a type of EPS, even though it does not cause per se involuntary movements. Common suspects would include Haldol and probably also Abilify, which has much greater risk of EPS than we once believed.

It’s excruciating to live with akathisia, and yet most people have never even heard the term. A common descriptor is the feeling of “wanting to crawl out of your skin”.

I’ve had some trouble over the years differentiating between akathisia and hyperactivity associated with my ADHD. The main difference between these two scenarios is the cause, but when you’re on a regimen of multiple antipsychotics plus lithium plus stimulants plus benzodiazepines it becomes difficult to discern cause and effect. No doubt in my mind, at its worst akathisia feels worse and even more frustrating than ADHD — but what about those days where it’s just kind of there?

I’ve also experienced restless leg syndrome. Some scholars believe there is a link between RLS and akathisia — essentially, that akathisia is like RLS experienced during the day (as well as at night — akathisia has kept me awake many nights). I would say this is a pretty apt comparison.

RLS and akathisia may be related.

When I first started propranolol, and was able to sit and rest for a few minutes for the first time in weeks. It was like getting your first pair of glasses, and realizing you can see clearly now. The relief was nearly immediate. Unfortunately, it faded somewhat over time. But I’ll remember that instant where it hit me, the moment I put on the glasses, forever. I hadn’t even realized how bad it was until then.


Pediatric-onset bipolar disorder

Traditionally, it has been thought that bipolar disorder emerges most typically in the early to mid 20s of a person’s life. It has been known since the time of Emil Kraepelin (circa 1921), however, that children can be affected by this illness. While adolescent onset (mid-to-late teens) is now recognized as common and similar to the presentation of adult bipolar disorder, pediatric onset bipolar disorder remains the subject of debate, and its presentation is somewhat different than adult bipolar disorder.

Why do some children get bipolar disorder?

We do have some idea why some people get bipolar disorder as adults, and others get it much younger. The effect is known as genetic anticipation, which occurs when certain genes accumulate in later generations. We know that bipolar youth are highly likely to have members of their family belonging to previous generations (parents, grandparents, aunts, uncles) with bipolar disorder. When those genes add up over successive generations, and the person has a LOT of the polymorphisms that cause bipolar disorder, they tend to get it a) younger and b) more severely. This also helps to explain why pediatric onset bipolar tends to be a clinically severe manifestation.

While adolescent-onset bipolar is not uncommon, bipolar disorder in children under the age of 12 remains rare. Nonetheless, it is important to diagnose. Studies have found that for every year of untreated illness, a child is 10% less likely to experience a resolution of symptoms for 2 months or longer — yet, an average of 10 years passes between symptom onset and treatment.

There is often a long delay between onset of symptoms and treatment. For me, it was 8 years (possibly more).

How does pediatric-onset differ from adult bipolar disorder?

Pediatric onset bipolar is commonly characterized by very rapid cycling. This is an uncommon phenotype (what the disorder “looks like”) in adults, but the majority of children with bipolar disorder are rapid cyclers. Chronic irritability is also common and is part of the reason pediatric bipolar disorder is so controversial. An episodic pattern of moods — whether the manias are dysphoric or euphoric — is arguably the hallmark of bipolar disorder; chronic irritability doesn’t seem to fit the bill, and in children who do not experience depression, an alternative diagnosis may be more appropriate. Nonetheless, irritability is a common symptom even among those children who seem to clearly meet the criteria for bipolar disorder.

Rapid cycling is the rule rather than the exception in children.

What happens to children with bipolar disorder?

Barring tragedy, children with bipolar disorder grow up to be adults with bipolar disorder. They need to be maintained on medication for the rest of their lives, or they are prone to relapse, just like any bipolar patient.

In my anecdotal experience (my symptoms started before the age of 10) I still have rapid cycling and dysphoric mixed manias as an adult. I urge those who are doubtful that rapid cycling bipolar is “real” or that it is somehow less valid to consider that many adults with this phenotype first experienced bipolar symptoms as children.

Recommended reading about bipolar in children

If you want to learn more about bipolar disorder in kids, I recommend the book The Bipolar Child by Demitri Papolos. It is really informative and helped me to better understand myself, as someone who had pediatric onset. I sat down in a library and read it all within a couple of hours.


5 tips to living your best life with bipolar disorder

I’m medication resistant, meaning that meds don’t fully stabilize my cycling. I’ll never be the person who can say “nobody even knows I am bipolar”. In fact, I have to disclose my bipolar disorder to most of the people I work with, due to how it impacts my working hours.

I’ve tried every atypical antipsychotic approved for use in psychiatric patients in the United States except for clozapine (although that has been on the table) plus two typical antipsychotics, three anticonvulsant mood stabilizers, and many other drugs including benzodiazepines, antidepressants, hypnotics, lithium, and so on. I’ve taken the tour.

Currently, this is my regimen: olanzapine, risperidone, lithium, diazepam, and amphetamine salts. I continue to experience symptoms, even with all of that on board. So how do I live and continue to work? The answer is not one-size-fits-all, but for me there are a few key components.

1. Consistent sleep times

I try to go to sleep at the same time every night, and wake up at the same time every morning. Of course it doesn’t always work out that way, but I try. I also make sure not to schedule any meetings that are too late at night, and not to stay out too far into the evening, as both of these things will keep me awake. Each person’s natural bedtime is different, so I can’t tell you what time is correct for you, but for me it’s usually between 10 PM and 12 AM (a fairly wide window, I know).

Sleep is super important in managing bipolar disorder.

2. Structure during the day

It helps me if I am able to maintain some regularity and consistency throughout my days. Since I’m an academic and my work schedule is flexible, this is something I largely have to impose on myself. When I’m really struggling I’ll schedule events in my Google Calendar, even for things I don’t “have” to do — recreational activities, like video games or watching anime. The point is to stay busy, but not too busy. Make sure to build in plenty of breaks. This also helps me get the things on my to-do list for work done efficiently.

I use Google Calendar for this.

3. Take meds religiously

This one doesn’t need a whole lot of explanation, but it’s an important point. Don’t stop taking your meds. At least for me, it always ends in hospitalization, and that’s a huge disruption to my life even though I’m quite used to it by now. Don’t get me wrong — sometimes hospitalization is necessary. However, it’s best to avoid it as much as possible, so that I can stay in contact with my friends and family.

Medication is the primary treatment for bipolar disorder, and it must be taken regularly.

4. Light and darkness

Research has shown that light/dark cycles have a dramatic impact on bipolar moods. I use a light box (or “sun lamp”) for a couple hours daily in the winter. You can buy a clinical strength sun lamp on Amazon (I am not affiliated, and do not gain anything from this) but be aware that the market is flooded with lamps that are not full clinical strength. The recommended protocol for bipolar disorder is to start at noon for 10 minutes, then add 10 minutes every day until you reach 1 hour. This is because the sun lamp does run some risk of triggering mania. At the same time, when you go to sleep (or ideally, when it’s naturally dark outside) there is an equivalent if not more important factor: darkness. Total darkness at night has been shown to dramatically stabilize patients who did not respond to conventional treatments.

Sun lamps can help with low mood and low energy.

5. Mindfulness and psychoeducation

The point of mindfulness in this context is to be able to recognize what mood state you’re in. Likewise, it helps me to be as educated as possible. I read tons of papers, but these are not super accessible to everyone; if you trust your psychiatrist, I recommend asking lots and lots of questions so that you can understand as much as possible. I also compiled a list of some of my favorite bipolar books. The insight into what you’re going through can save your life, even if it doesn’t change what you’re going through.

Keeping track of your mood takes time and practice, but it can be a huge advantage in managing bipolar disorder.

Everything Else

by Elliot Gavin Keenan, 11/29/16

Originally published in gravel magazine in 2017; as of 9/24/21, no longer available on their website.

Mozart was crazy. Flat fucking crazy. Batshit, I hear. But his music’s not crazy; it’s balanced, it’s nimble, it’s crystalline clear. There’s harmony, logic. You listen to these, you don’t hear his doubts or his debts or disease. You scan through the score and put fingers on keys and you play. And everything else goes away. Everything else goes away…

— “Everything Else”, Next to Normal

My favorite confessional poet is Anne Sexton, who committed suicide by carbon monoxide poisoning at age 45. A book of her poetry, published posthumously, featured her therapist: 

I have words for you, Dr. Y., / words for sale. / Words that have been hoarded up, / waiting for the pleasure act of coming out, / hugger-mugger, higgiliy-piggily / onto the stage.

When I was in kindergarten, a boy hit me in the forehead with a toy truck during playtime because I asked to play with him. I sat in the corner and cried. Eventually, the teacher called me over. What’s wrong? she asked me. I don’t have any friends, I replied, sniffling. The teacher called all of the kids to the front of the classroom and asked them to raise their hands if they were my friend. Everybody raised their hands. I don’t know why, but this was probably the moment that I became crazy. 

Or maybe I was crazy all along.

She laughed when I told her this story. She said it was incredibly sad and funny. I’m glad she saw how funny it was. Then she asked me, have you ever written about this?

Eunoia is a dated term for mental health. Literally, it means beautiful thinking. However, some of the most beautiful thinking has been done by people with mental illness. Consider the incredible artistic achievements of people like Vincent van Gogh, Virginia Woolf, and Sylvia Plath. And if you look for mental illness in artists, writers, poets, musicians; the list goes on.

We were running about Whole Foods. I say running because she kept forgetting things on her list and going back. We probably circled around the store three or four times, picking up various items along the way. She was in constant motion. Couldn’t stand in one place. Got excited over a jug of coffee. Perhaps she didn’t even notice, but I did: a slight fidget, balancing on one foot at the cash register. We looked at the things she’d ended up buying and laughed. Talking constantly. I am attuned to these kinds of things. She had told me, though, that she felt manic. I wished I felt as manic as she did, but I was not; rather, I was plagued by a familiar moroseness, a heaviness.

Asked about JS, I mused well, I think you’d win a fight with her.

A few months after the breakup with JS, I fucked a fashion designer from the city. He was kind of cute, dyed hair and a stutter. He slept in my bed with his arm around my waist. I slept uneasily. In my dream, I saw JS. It was the first time in a while I’d seen her face in my dreams. I don’t remember what she said, but I woke up all at once warm and shivering, cold sweat dripping down my forehead. I snuck out from the boy’s grasp and went into the bathroom and splashed cold water on my face. Looking into the mirror, I thought how strange it was. I started to cry. He gave me his shirt afterwards.

I don’t usually see people’s faces in my dreams. I rarely ever learn a person’s face. This is a condition known as congenital prosopagnosia. In fact, I only come to individualize the faces of people I’m in love with. When I told her this, she said it was very romantic. I did not tell her that I had come to know her face.

There is a thing known as a flow state: when words come out of your brain like blood seeping from a tapped vein, an insatiable passion for the task at hand. Manics often get into flow states. The world is poetry, you breathe it like air. Maybe this is part of why we are so successful in art. Love is also like a flow state.

She’s a doctoral student in the psychology department. But she told me that she used to write as if seized by a certain fervor for it, for the language, for poetry. I imagined Van Gogh and his passion for painting, his insatiable hunger. I thought I wanted to kiss those lips stained with yellow paint. Yellow, the color of the edges of a street, the boundaries of a self crossed like two neurons, the actualization of a synesthetic dream. To imbibe it is to take all of that in, the passion, life thrust under your tongue. I wanted that. 

When I was a child, I sat by myself at recess. The teachers saw that I was always alone; they gave me chalk to draw on the sidewalk. My hands dusted with pastel yellow, I would watch the other kids play. It’s not easy for me to admit, but I hated them. I truly hated them. My heart was so full of hate that I couldn’t bear to watch them anymore, and I would go to the bathroom and cry. I’ve never been a good person.

Sadness is part of the human condition, said one of my writing professors, a woman who seemed perpetually rather flummoxed by the world. Without it, you’d be a monster. I wanted to ask, with sadness, am I not a monster?

For me it was different. I, too, was seized by passions; but they occurred for me in successions, a pattern sometimes disapprovingly called serial monogamy. I was like that with my writing, too. But when I was engrossed in the page, or lost in her eyes, everything but the space between my canvas and I disappeared. Everything else goes away

I wrote constantly when I was in love with JS. Everything I felt was transferred to the page. She was my muse; she was the gasoline to the fire behind my eyes. 

Kay Redfield Jamison wrote an entire book about the connections between mental illness, particularly bipolar disorder, and artistic talent. It’s called Touched with Fire.

My heart has holes in it. They’ve been there for a long time; before JS, I’m sure. But maybe I could have ignored them before that. Not anymore. I wanted to patch them up, fill them with cement, or gorilla glue the pieces back together and pretend that it was the same as it was before. A clean canvas, a blank page, a fresh start. But it’s never been the same. I’ve always been different from other people. Maybe that is why I write. To escape the sadness of being alone. The desolation, the emptiness, the misery of a life condemned to this certain loneliness.

Sometimes I try to fill the holes with other people’s loneliness. It never works. I knew right away that she wouldn’t be a suitable shape to fit there, like a square peg in the round hole of what I really needed. I was filled with this dread of knowing. But when I looked at her I would forget. 

Everything else goes away.

I was ten years old when I first decided I was going to kill myself. I wanted to slice off my arm with an old circular saw, patched with rust, and die in a pool of blood on the hard cement floor of my garage. I daydreamed about it, wondered endlessly what it would be like to die there, cold and alone and smeared with bright red, a baptism in blood.

It was Anne Sexton’s therapist, Dr. Martin Orne, who encouraged her to write poetry. Perhaps he thought that poetry would be a form of healing, a way to expel her demons through the pen, exorcism in the act of creation. Put your ear down close to your soul and listen hard, she said. I am a collection of dismantled almosts, she said. Suicide is, after all, the opposite of the poem.

But suicides have a special language.
Like carpenters they want to know which tools.
They never ask why build.

Lithium is like an emotional straightjacket, or at least like wearing a shirt that’s too tight. You can’t breathe. You can’t feel the way you felt before, not manic or depressed or happy or sad or anything. You wonder if you can even write. I didn’t write for months after I started taking it.

She told me she feels sadness only fleetingly. We’re opposites, I guess; two sides of the same coin. I live in a state of melancholy permeated briefly by manic interludes. But I wonder if mania is really like happiness. Or is it like a saccharine substitute for happiness, itself almost a deeper form of sadness?

I remember hanging upside-down on one of the hospital couches and pacing up and down the long hallway, smiling cheerfully at anybody I passed along the way. The doctor informed me point-blank that I was manic. I’m happy, I said. There’s nothing to be happy about, she told me. 

Although the official diagnostic term was changed to bipolar disorder in the DSM-IV, maybe this is why some people identify more with the older term manic depression.

Vincent Van Gogh’s stay at the little yellow house in Arles, France, from February 1888 until he was committed at the St. Remy asylum in 1889, was arguably the most prolific period of his entire career as a painter. He believed that the growing disruption of his inner chaos stirred within him this compulsive creativity: The more I am spent, ill, a broken pitcher, by so much more I am an artist… a kind of melancholy remains within us when we think that one could have created life at less cost than creating art. His time in Arles culminated in an episode wherein he cut off a portion of his left ear and attempted to give it as a gift to a prostitute, requesting she keep this object like a treasure

Perhaps, in the end, this is the ultimate display of love: to give a piece of oneself to the other. To be something more than a memory, something tangible, something real. It’s a distinctly human error, this drive to be treasured.

I was sitting across my kitchen table from her. She was wearing my pajama pants and my sweatshirt, an oversized blue one that falls in folds around her thin wrists. I thought it looked better on her than it did on me. She had a look of deep consternation as she studied. I was quiet. I was watching her mannerisms, an absent-minded gesture of her fingers as she stared into the screen. The harshly azureous light of her laptop illuminated a sharpness in her almost perfectly symmetrical face, a ubiquitously beautiful face.

Perhaps it is not simply that the artistic temperament comes in tandem with emotional pitfalls, but that inner turmoil fuels the creation of art. If Van Gogh had not been crazy, would he have painted at all? Perhaps, like his brother Theo, he would have settled to be an art dealer, and never dirtied his hands with the business of creation.

Do you ever feel like I do, that you know a lot of people, but you’re still very lonely? But sometimes, maybe just when the stars align quite right, I meet someone that sees me. That looks at me like I’m not invisible.

She came up to me in the courtyard one day, a small green space in between the psychology buildings that’s mostly overgrown with ivy and shrubs. I was pacing back and forth, taking long drags and blowing smoke into the October sky. She asked me to bum a cigarette and smiled and said, I’ve seen you out here. You have a very thoughtful walk. 

You always say the right thing, Elliot. You toss out aphorisms like you’re handing out daisies, she said. (Aphorism: either a pithy observation that contains a general truth; or, a concise statement of a scientific principle.)

And you know it’s just a sonata away. And you play, and you play. And everything else goes away. Everything else goes away. Everything else goes away…

She says she finds solace in her loneliness. I wonder if I could ever come to view things the same way. I’ve been alone for a long time, since my childhood. It wasn’t a tragic childhood. But it was solitary. For my whole life, I’ve wanted to find whatever it is that breaks down this invisible wall that divides us, that brings the fragments of people together into one, into a mosaic of shared humanity that I’ve never quite fit into.

I feel like I can tell you anything, she said. You’re very understanding. I feel like you understand me. I smiled sadly.

Is talking easily about something the same thing as healing a wound? About her family, about foster care, about the scar on her thigh? She gave a small laugh, like it wasn’t really a big deal. It’s not my place to say something like are you really okay? No. I couldn’t heal her. She couldn’t heal me. I just wanted to listen, to understand you in the way I have never been understood. That’s why I write.

Balanced there, suicides sometimes meet,
raging at the fruit, a pumped-up moon,
leaving the bread they mistook for a kiss,

I thought to call JS. It rang only twice; I knew she’d blocked my number months ago. I wanted to say, but I was always there for you. I wanted to say, but I loved you. I wanted to say, but I need you, I need you, I need you. Please. Two rings. Silence.

leaving the page of the book carelessly open,
something unsaid, the phone off the hook
and the love, whatever it was, an infection.

She told me about enneagrams, a theoretical model of personality. She told me that I was a type four, the individualist, which she qualified as the suffering artist: expressive, dramatic, self-absorbed, temperamental. In love chiefly with my sadness. I wanted to say, and you are not?

I’ve changed, she says.

But why are you still here?

We read Maggie Nelson’s Bluets. Her voice grew incredibly impassioned as she read aloud: I say something about how clinical psychology forces everything we love into the pathological or the delusional or the biologically inexplicable, that if what I was feeling wasn’t love then I am forced to admit that I don’t know what love is, or, more simply, that I loved a bad man.

Sometimes I would wait in the spot where JS and I would always meet together before class, as if she’d appear there again if I waited long enough. She never did. I found myself there, cold, alone, staring at the sky in its seemingly infinite vastness. Eventually I stopped waiting.

I want to write again, she told me one day, sitting outside the front of her house, smoking a cigarette. The smoke drifted into the gray sky and faded like the unintelligible, inexplicable fragments of a dream upon waking. You should, I said. It was the best healing I knew of.