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About Face Illustration by Chris Kuzma.

About Face

Shane Neilson always thought that bipolar disorder had permanently distorted his facial expressions. But the truth ran much deeper.

THE FIRST THING MOST INFANTS learn about faces is which one belongs to mommy. Coming on the heels of that is the ability to interpret and express basic emotions—happiness, sadness, anger. By age three or four, many start to understand their face and what it represents. We hear relatives and family friends remarking, “Little Ahmed looks so much like his father!” Parents tend to love those kinds of comments. Kids, not so much.

My daughter Zee doesn’t look like me. She takes after her mother: beautiful, with the dark hair and eyes of her Japanese background. I never thought I would see my own face in her. And that would have been a good thing.

At ten, though, Zee fell ill with depression. Her face took on a slack expression. She slept more, ate less and stopped playing with her friends. Zee only got up to go to school and went straight to bed upon arriving home. She didn’t receive a single birthday party invitation that year, a stark contrast to the dozen she was given twelve months prior. At odd hours of the night, she would come into our master bedroom and stare, quietly, out the window. Watching her in those moments, seeing her long-distance gaze and the dim reflection of her blank visage, she looked different—I could see little resemblance to her mother. In that glass, backlit by Guelph streetlights, all I could see was myself.

THE PROBLEM WITH MY FACE started when I was eight. I began going to bed at six in the evening and waking up just in time for school the next morning. I stopped playing street hockey with my friends and kept to my room, counting the cracks in my bedroom ceiling, hiding from my father. One morning, awake before anyone else, I took down his pump-action shotgun from its perch over the stairs and tried to shove an old bullet in one of the barrels. It wouldn’t fit, so I went back to bed.

A school picture of me from this period is still displayed on my parent’s living room wall. In it a blue shirt stretches tight over my chest. My hair is flat, oily. My face looks as though I carry all the pain in the world and yet have the capacity to bear more. Back then, I’d often hear women whisper to my poor mother, He really should smile more!

My smile did eventually come back. By the next summer, I once again took pleasure playing with friends. More time passed. I landed my first girlfriend, a blonde gymnast. I attended the University of New Brunswick and was the top student in my science faculty. I entered medical school after completing three years of an undergraduate degree. The smile I readily showed to the world became a signal of my well-being, my success, my happiness.

It didn’t last, though. When I was twenty-one—around the classic age when bipolar disease becomes florid—my smile vanished completely. During my second year of medical school at Dalhousie, I started staying in to count the stucco puffs on my ceiling, listening to the rain strike the balcony’s sliding glass doors. My new girlfriend, also a medical student, began to notice the changes. You seem so tired and so angry, she said, a few months before fleeing. Are you okay? 

I started hearing that question regularly. Are you okay? It even came from the patients for whom I was supposed to be caring. I know now what my girlfriend and everyone else was witnessing in my face, posture and tone. Rather than the discontented, vaguely disdainful expression that many inadvertently express, my face defaulted to a roiling, chaotic anger. I was polite and had a genuine wish to do good, but I wore—and wear now—a disordered face, one that acts as an amplifier for the negative emotions I only dimly perceive in myself. Getting started on lithium helped mitigate the issue, yet the problem endured beyond medication. Eventually, I chalked it up to some stickiness inherent to bipolar disorder: I figured that the disease had permanently scrambled my expression, that I’d lost the ability to regulate the surface play of feelings. Though I was treated and felt well for the first time in what felt like a lifetime, my face still reverted to furrowed brows and a slightly clenched jaw. Even now, when I smile, it shines through a baseline of frustration, anger and fear. Or so I’m told by others, since I feel perfectly fine.

But I didn’t feel fine when I saw Zee’s reflection in the glass that winter night when she was ten. Lying in bed afterwards, unable to sleep, my mind returned to that morning I picked up my father’s shotgun at age eight. Extrapolating, I thought that Zee might die. I got up and stood in front of the bathroom mirror. I finally understood what people meant when they commented on my face. Look what happened to me, I thought. Am I to blame? I began to think that my face held a prophecy for my children.

I looked closer. I radiated anger. Why is my daughter sick? I asked my reflection. In response, I was met with an unruly loop of grief, anger and sadness—hatred of the question, hatred of the circumstances, hatred of the self. I knew then that I needed to fix my face—that figuring out what was wrong with it might change the affective weather in the house and also show Zee that it is possible to get better. If my outward appearance settled, my reasoning went, perhaps she would get better too.

I STARTED WITH THE PHILOSOPHERS. Titans such as Plato, Aristotle and Hume had their theories on where emotions come from. Yet the problem was that “emotion” meant different things to each of them. Plato and Aristotle’s Greek did not have a word for “emotion” as we understand it. Hume describes interchangeable things like “passion,” “sentiment” and “taste” in his writings. In his A Treatise of Human Nature, he writes, “Reason is, and ought only to be the slave of the passions, and can never pretend to any other office than to serve and obey them.”

Getting nowhere, I moved on to the poets. We don’t expect anything other than idiosyncratic genius from them. Here’s Robert Frost: “Poetry is when an emotion has found its thought and the thought has found words.” Not bad. Ezra Pound’s good too: “Only emotion endures.” Left with beautiful, conflicting aphorisms but no real explanations, I turned my research to the domain of affective neuroscience—the study of the neural basis of emotion.

I read up on functional magnetic resonance imaging (fMRI), a technology that detects the difference in magnetic signature between oxygenated and deoxygenated blood in the brain. Neurons that fire need more oxygen, and fMRI is able to tell where areas of increased oxygen uptake are occurring. In other words, it is a fancy machine that allows doctors and researchers to create a picture of a rainbow brain—an explosion of colour showing the different areas that are being used when faced with certain tasks: problem solving, memory and feeling emotions. Thanks to fMRI, we now know the anatomical structures that form the emotional brain but we don’t yet know how they allow us to feel emotions. It’s like knowing the address of a shopping mall that you’ve never visited: you know where it is and that you can shop there, but you have no idea what stores are actually inside.

After knocking down three textbooks and over a hundred fMRI journal articles, I was still in the dark about my specific—and seemingly unique—problem with controlling my expressions, so I made some consultations. I called Benicio Frey, head of the mood disorders program at McMaster University. We don’t know at present if bipolars even have a problem with facial expression, he said. But it’s worth studying.

This was just one opinion, right? I reached out to Dr. David Miklowitz, professor of psychology and psychiatry at UCLA who specializes in bipolar disorder, to see if he knew of any links between the condition and facial expression. Well, no, was his reply. Not to my knowledge, not in anything I’ve read.

After months of studying and a flurry of emails and conversations with medical researchers, I concluded that, at least in the present, the problem with my face could not be definitively answered with science. The pretty coloured pictures from fMRIs are, so far, just another artistic representation of anger, sadness and joy—they don’t and can’t represent any of the emotions in their totality. My long-held theory that my inability to regulate or control the emotions on my face was directly connected with bipolar disorder was just that—a theory. It seems that, when it comes to understanding emotions, science is still no better than the poets or philosophers.

LATE IN THE AFTERNOON one Friday last December, my patient list worked through, I walked down my clinic’s main hallway at the University of Guelph. Despite spending months reading and conversing with experts, I felt no closer to understanding my uncontrollable face. I believed myself condemned to display anger to my daughter when I felt none. In that moment, I did feel angry—it wasn’t just a detached expression. At the very end of the hall was the office of Dr. Briar Long, the local psychiatrist.

As expected, the doctor was in. A petite woman with a mischievous smile, Briar is the hardest working person in my clinic. I sometimes feel guilty writing out referrals to her because I know, at the end of the day, I’ll pass her office on my way out of the building and see the light on and the door open in case any of the family physicians wish to discuss a case. That day I felt guilty because I was stopping to talk about myself. I have this problem with my face, I said as Briar looked up from her files. I told her in brief about my career as a bipolar patient, about how my daughter fell ill and how I thought my facial expressions were somehow influencing what was happening in her life.

After pausing for a moment, Briar asked if my parents had a history of mental illness. Did it hit me then? I don’t think so; I’ve always remembered the image of my father’s face, contorting, angry, perhaps the most frightening thing I have ever seen. A violent and mentally ill alcoholic, my father’s face was a signal that I’d interpreted as a child in order to stay alive. I remember watching for his arrival home after work by looking out the living room window. If his face looked a certain way as he parked the car and entered the house, I ran out the back door and stayed away that night. Yes. My father, I said. But I think I’m over all that. It happened a long time ago. I forgave him a long time ago.

Briar befriends people so that they spill their guts. There’s a warmth in her smile, but more than that, it’s the patience and bemusement underneath it that encourages confession. Wearing that same expression, Briar told me a story. A patient was referred to her because of the great distress she felt in social situations. This young woman, when called upon in class or when her name was announced in airports or in any moment in which attention was placed on her, underwent a visible transformation: her face took on an appearance of disgust. But the young woman didn’t feel sick, just scared. Acquaintances called her haughty. And even Briar, when she called the woman’s name in the waiting room, saw the disgusted-disdainful face herself and wondered, Did I say something wrong?

I thought for a moment. Sure, it could be fear. But what does that have to do with me? I really don’t feel like that inside. What would I be afraid of, anyway? My face is always like this.

Sensing my confusion, Briar told me a second story about how she went to the American Psychiatric Association’s annual meeting in Philadelphia in 2012. She signed up for a workshop that was led by a husband-and-wife team that specialized in treating trauma through Qigong breathing—an old technique in Chinese medicine that involves using the abdominal muscles preferentially in order to connect the mind and body. The trainers paired people off and Briar was partnered with a psychiatrist from Argentina. Before Briar and her partner started doing the exercise, the workshop leaders mentioned that, sometimes, people get overwhelmed and need to take a break or stop altogether. It’s normal for those who experienced past trauma to reconnect with that trauma through the breathing process, they explained. Briar thought she would be fine; after all, she only wanted to learn how to do the exercise so that she could teach it to her patients. At that point in the story Briar paused, the bemused expression brightening into merriment.

What happened? I asked.

As Briar worked on the exercise, she began to cry—to weep. And she couldn’t stop. Even though she found it embarrassing, she couldn’t stop. Her poor partner became concerned and tried to help, but once the crying started, it followed its own agenda. Briar then explained something that I must have told my own patients a thousand times: there are things that have happened to us that we might feel are settled, but they aren’t. And our bodies tell us this in different ways. She told me that my signal might be in my face.

I thought about what she said. I felt fine. Was my face showing anger right then? Or perhaps sheepishness? I thought I’d gotten the problems I encountered during my childhood under control a long time ago, that that part of me was at peace. How much time had I spent chasing fMRI studies and international researchers, thinking that the problem with my face existed within me but apart from me—a symptom of a medical condition? What Briar said clicked, and it seemed that my answer had been right in front of me all along: I remain frightened of things that occurred deep in my past and need to do trauma work in order to let go of the angry mask my muscles have formed into since I was young. I need outside help integrating the old story of pain with the old painful feelings, the words and emotions connecting together so that, once assembled into a narrative, I can speak and feel its end. If I don’t, I might pass the mask on to my daughter for good. I don’t want Zee to have to look like me. I don’t even want to look like me. I want the me underneath the surface.

Briar, I asked, do you know any good local therapists for PTSD?