On Psychiatric Cool

At Somatosphere, "Liz Oloft" (heh) writes about the dilemmas of "coming out" as a user of psychiatric meds while being an academic who researches them: Prozac In The Closet.

Liz is a social scientist, while I'm a card-carrying neuroscientist, but like her I also take antidepressants while studying them, and I identify strongly with her thoughts.

One sentence in particular struck a chord -

Depending on who you ask ... to engage in Lacanian psychoanalysis for neurotic problems of living might be cool, to take an antidepressant for depression without psychotherapy is less cool, and to take a cocktail for bipolar might be even less so (although bipolar disorder may be more legitimate than depression because it seems to be more widely accepted as a “real biological disease”).

This is something which isn't much talked about, but it's absolutely true. Some mental illnesses are just cooler than others. Cool is a famously elusive concept, maybe undefinable. Either you got it or you don't. But some diagnoses certainly have more of it than others. From most cool to least the pecking-order seems to be:

1. "Issues" – problems of living and/or "stress", rather than illness
2. "Physical" conditions with psychiatric symptoms, such as thyroid problems and PMT
3. Anxiety, phobias, panic attacks
4. Substance abuse & addiction
5. Bipolar disorder (manic-depression)
6. Eating disorders
7. Unipolar depression
8. "Personality Disorders"
9. Schizophrenia

This list is, of course, subjective - "cool" inherently is – and it goes without saying that I’m not endorsing this hierarchy, just reporting it as I perceive it. I’m no slave to cool as a glance at my iTunes library would verify.

What does it mean for one thing to be higher on the list than other? Amongst much else it means - that people are more comfortable talking about it and being in the presence of it; that people will tend to prefer it as a diagnosis for themself or a loved-one; and that it's easier to think of "cool" people who have it. And, simply, it means it that it’s easier to “come out” as having it.

Some of the rankings may surprise at first glance. If you read the textbooks, you'd think that bipolar disorder is generally speaking "worse" than unipolar depression. And in many ways it is. But it's still cooler, I think. Cobain sang about "Lithium", the quintessential treatment for mania, not "Imipramine". Hendrix sang "Manic-Depression", not "Depression". Lots of cool, or at any rate famous, people, are bipolar, or are widely believed to be. By contrast, try to think of a famous unipolar depressive, and you'll come up with Winston Churchill with his Black Dog and... who else?

The key factor behind psychiatric coolness seems to be the degree to which a problem is seen as internal to the self. There's little shame in being "stressed" due to things that happen to you, because then the problem is external. You're "normal", it's the situation that's screwed up.

Likewise, as Liz says, bipolar disorder is in an important way cooler than depression, because it's seen a closer to being a "physical” illness that happens to you, like a thyroid problem. That’s as opposed to a weakness or failure of you as a person, which is the most damaging and most persistent stigma of unipolar depression.

The one apparent exception is schizophrenia, which is profoundly stigmatized despite being widely viewed as a biological disease. But isn't this because schizophrenia is seen as a disease that disturbs the self, leaving someone merely "mad" or "insane", no longer responsible for their actions and therefore no longer really a person?