Linda Logan - The Problem With How We Treat Bipolar Disorder

From the New York Times Magazine, this is an excellent article from a woman, Linda Logan, on her battle with bi-polar disorder and the with the medications that took away her sense of self. It's good to see an article like this in the NYT Magazine - the serious side effects of psychopharmacological interventions need to be more widely publicized.

The Problem With How We Treat Bipolar Disorder

By LINDA LOGAN
Published: April 26, 2013

The last time I saw my old self, I was 27 years old and living in Boston. I was doing well in graduate school, had a tight circle of friends and was a prolific creative writer. Married to my high-school sweetheart, I had just had my first child. Back then, my best times were twirling my baby girl under the gloaming sky on a Florida beach and flopping on the bed with my husband — feet propped against the wall — and talking. The future seemed wide open.

The author in 1980, pregnant with her first child.

I don’t think there is a particular point at which I can say I became depressed. My illness was insidious, gradual and inexorable. I had a preview of depression in high school, when I spent a couple of years wearing all black, rimming my eyes in kohl and sliding against the walls in the hallways, hoping that no one would notice me. But back then I didn’t think it was a very serious problem.

The hormonal chaos of having three children in five years, the pressure of working on a Ph.D. dissertation and a genetic predisposition for a mood disorder took me to a place of darkness I hadn’t experienced before. Of course, I didn’t recognize that right away. Denial is a gauze; willful denial, an opiate. Everyone seemed in league with my delusion. I was just overwhelmed, my family would say. I should get more help with the kids, put off my Ph.D.

When I told other young mothers about my bone-wearying fatigue, they rolled their eyes knowingly and mumbled, “Right.” But what they didn’t realize was that I could scarcely push the stroller to the park, barely summon the breath to ask the store clerk, “Where are the Pampers?” I went from doctor to doctor, looking for the cause. Lab tests for anemia, low blood sugar and hypothyroidism were all negative.

Any joy I derived from my children was now conjoined with grief. I couldn’t breathe the perfume of their freshly shampooed hair without being seized by the realization that they would not always be under my roof. While stroking their backs, I would mentally fast-forward their lives — noses elongating, tongues sharpening — until I came to their leave-taking, until I reached my death and, ultimately, theirs.

I lost my sense of competence. If a colleague remarked on my intelligence, I mentally derided him as being too stupid to know how dumb I was. If someone asked what I did for a living, I would say, “Nothing” — a remarkably effective conversation stopper. I couldn’t bear the thought of socializing; one night I jumped out of the car as my husband and I were driving to a party.

Despite having these feelings in my mid-30s, when my kids were 8, 5 and 3, I was thriving professionally: I had recently completed my Ph.D. in geography, had just finished co-teaching a semester at M.I.T. as a lecturer and was revising my dissertation on spec for a respected university press. Yet several nights a week, I drove to the reservoir near my home, sat under a tree and, as joggers and their dogs ran past, thought about ending it all. There was a gun shop on the way to my poetry group; I knew exactly where to go when the time came.

My day, once broken by naps, gradually turned into lengthy stretches of sleep, punctuated by moments of wakefulness. My husband and I didn’t explain to the kids that I was depressed. “Mommy’s a little tired today,” we would say. A year or so earlier, a therapist told us to tell the children. “But they’re just kids,” we said. “What do they know?” “They know,” she said. When we eventually spoke to them, my oldest daughter came to me and asked: “Why did you keep it a secret? I thought all mothers were like you.”

After a few weeks of stopping at the reservoir, as suicide eclipsed all other thoughts, I finally told my husband about my worsening psychic pain. The next day I was hospitalized. It was June 1989. Even though we were living in Boston, we decided I should go to Chicago to work with the psychopharmacologist who, 15 years earlier, restored the health of my father, who had also been hospitalized for depression. As the cab pulled away from our house, I turned and saw three children’s hands pressed against the screen of an upstairs window. This is the way the world breaks.

The moment the psych-unit doors locked behind me, I was stripped of my identity as wife, mother, teacher and writer and transformed into patient, room number and diagnosis. I couldn’t open a refrigerator without permission. If I were on suicide watch, I had to ask before going to the bathroom. I was told when to sleep and when to wake, when to eat and when to go to group. My routine, which at home had cleaved so closely to my children’s, now revolved around the clattering sounds of the food trays being brought three times each day from the service elevators into our unit. With my husband and children nearly 1,000 miles away, I was severed from my fixed stars. I missed my children’s smells, the way they used to wrap their bodies around my legs when I was on the phone. I brought my son’s comforter to the hospital for my bed. I remembered him with one leg thrown across the covers, a small foot peeking out from his pajamas.

When my children visited, I had to resuscitate my maternal self, if only for an hour. I dragged myself to the shower, pulled on a pair of clean sweat pants and a fresh T-shirt and ran a streak of lipstick across my lips, hoping to look like a reasonable facsimile of a mother.

My doctor used my first hospitalization as a so-called washout, a period during which he planned to take me off the medication I was on and introduce several drugs in several different combinations. The prospect of polypharmacy — taking many drugs at once — seemed foreboding. I read about Prozac’s giving some people entirely new personalities: happier, lighter, even buoyant. “Who are you going to turn me into?” I asked my doctor.

“I’m not turning you into anyone,” he said. “You’ll be yourself, only happier.”

“I don’t think I even have a self anymore.”

“We’ll find your self.”

I was wary. “Just don’t turn me into Sandy Duncan.”

How much insult to the self is done by the symptoms of the disorder and how much by the drugs used to treat it? Paradoxically, psychotropic drugs can induce anxiety, nervousness, impaired judgment, mania, hypomania, hallucinations, feelings of depersonalization, psychosis and suicidal thoughts, while being used to treat the same symptoms. Before getting to the hospital, my daily moods ranged from bad to worse, each state accompanied by a profound depth of feeling. The first drug I was given was amitriptyline (Elavil), which, in the process of reducing my despair, blunted all my other emotions. I no longer felt anything. It was like going from satellite TV to one lousy channel.

While some medications affected my mood, others — especially mood stabilizers — turned my formerly agile mind into mush, leaving me so stupefied that if my brain could have drooled, it would have. Word retrieval was difficult and slow. It was as if the door to whatever part of the brain that housed creativity had locked. Clarity of thought, memory and concentration had all left me. I was slowly fading away.

I would try to talk to my doctors about my vanishing self, but they didn’t have much to say on the subject. Instead they focused on whether I could make eye contact or how much expression I showed in my face. They monitored my lithium and cortisol levels; they took an M.R.I. of my head. I received an EKG, was exposed to full-spectrum lighting and kept awake all night for sleep-deprivation therapy. Nurses jotted down their observations; my scribbled lines in art therapy were inspected. Everything was scrutinized — except the transformation of my self and my experience of its loss.

My current psychiatrist, William Scheftner at Rush University Medical Center, says this is typical when treating patients with acute mental disorders. The primary goal at the height of a mental-health crisis is symptom reduction. That means monitoring patients’ sleep patterns, appetites and responses to medications — not worrying about philosophical questions like who they are and who they will become. “The issue of self just isn’t there,” he told me, “because you’re so preoccupied with whether someone is actually improving or not.”

By August 1989, I was back in Boston with my husband and kids, having been discharged from the hospital almost three months after I was admitted. My children, like many people, mistook “discharge” for “recovery.” “Why did they let you out if you’re not better?” my daughter asked. I didn’t know how to explain the welter of factors that go into discharge: poses no threat to self or others; is functioning at a high-enough level to participate — however minimally — in the tasks of daily living. Recovery was not an end, I told her, but a process.

The trees were starting to change colors. Acorns dropped and exploded like tiny bombs. My car was in the driveway; my clothes were in my closet. But things felt ill fitting and unfamiliar. “Whose kids are these?” I wondered. “And when is their mother coming to pick them up?” Nowhere was my otherness more keenly experienced than at the driveway at the grammar school. Everyone knew that I had been “away,” and why. I tried to imitate the other mothers, their relaxed camaraderie, their confidence, the way they threw their heads back when they laughed.

Around Halloween, as our neighbors made wild-eyed pumpkins with crooked teeth, my children noticed that there were frightening things in our house, too. I had my first hypomanic episode. This was how my doctors confirmed that my depression wasn’t just depression — I had bipolar II disorder, like my father. With bipolar II, unlike bipolar I, the upward swing from depression stops at hypomania, not mania. Mania is having five grand pianos delivered to your house; trying to buy the Sears company; sleeping with the local baseball team. Hypomania is mania with a tether, and, while it might avert some of the financial and interpersonal disasters that unchecked mania may engender, it can still feel like a runaway train.

By that point my vestigial self had grown used to my depressed self, with her somber mood and tenuous hold on life. Now a newcomer arrived. I seemed to have split into three: my shellshocked self, my depressed self and a brazen hypomanic self. We could practically hear the new girl sizing us up, cackling. Under her reign, we slept two hours a night. We ate half a sandwich and two potato chips a day. We packed the children’s lunchboxes at 3 a.m. We began to study for the MCATs (the fact that we had never taken a biology or chem class seemed irrelevant). We telephoned long-lost friends. The hypomanic self’s activities, from relentless lunch dates and impulsive spending sprees, left my tattered and depressed selves saying, “That’s not us” and “We don’t do that.”

I no longer went to bed with my husband. Instead I stayed awake, scribbling in my notebooks. My wakefulness worried my son. “I had a bad dream,” he said. “You were downstairs working in the middle of the night. And while everyone else in the house was sleeping, the whole house fell down on you.”

“Oh,” I said, pulling him close. “That is a bad dream. Did anybody get hurt?”

“No, but the cats almost died.”

Every few weeks, I needed to buy smaller clothes. “What’s happening to you, Mommy?” my daughter asked. “You’re shrinking.”

Hypomania was consuming me. My doctor, in an effort to quash the hypomania, upped my lithium dose and catapulted me back into depression, back to Chicago, back to a locked psych unit, after New Year’s Day in 1990. A few weeks later, my kids came to visit. I met them in the lobby. The chair I was sitting in felt insubstantial; the walls seemed to bend. My son was excited. “I made a scientific discovery!” he said. “There can’t be a shadow in the darkness.” He understood depression better than my doctors, I thought. “Mommy?” he said a few moments later. He sounded miles away. I leaned back and fell asleep. I didn’t see them again for four months.

My medical records show that by the spring, I thought I was in a Canadian train station and that it was 1976. I lugged a suitcase stuffed with towels around the unit, looking for the departure platform. If my self had been assailed by depression, then psychosis was the final blow. My sense of boundedness — where I stopped and other people or the environment began — was sloppy, like a toddler scribbling outside the lines. I didn’t envision myself as human; I pictured myself as black vermicelli on an asphalt driveway. For a brief time, I could neither write nor speak. My journals show a perseverating pencil — a long string of Ts or entries in hypergraphic writing, alternating between conventional and unconventional language: “They will have a stronstrazzly negative reaction to them. I need held . . . In stortingitoat — plus, the idea of [X] a new set of residential pleomorph — exoskeleton weitropstite jejoined to be betters. blep.”

I hallucinated. The world was suddenly up for grabs; reality, an option. Rectangular rainbows streamed through the day-room windows. Nonexistent organ music pealed through the neighborhood on a Sunday morning. Peasants from a Jean-François Millet poster walked out of the frame and marched across the wall.

Some researchers say that in psychosis, the self persists, however tenuously. Sue Estroff, a professor of social medicine at the University of North Carolina, described it as “more of a foreground, background thing. During psychosis, the self recedes.” But, she told me, “you’re still in there.” I don’t think so. If I had been allowed outside, I would have doubted the reality of my shadow.

By early summer, the psychosis had run its course, and I returned to lucidity. The kids came to visit. They dragged me off the sofa and onto the carpet. We were laughing and crying simultaneously. I felt the surge of something primal.

Later that summer, after I became well enough to be discharged once again, we decided to move to the Chicago area so that I could continue working with my father’s doctor, whom I trusted, and be near our families. But seven months after moving into our new house, I was back in the hospital. I would be readmitted and discharged two more times over the next half-year. When I left the hospital for the last time in August 1991, I was 38, and while no longer intent on self-destruction, I was more accurately rescued, not restored.

Taking care of children and running a household seemed like a herculean task. My husband and I realized we needed a full-time housekeeper. We found a wonderful woman who knew just what needed to be done: cook, clean and be a surrogate mother. While appreciative of her help, I felt as if my role had been usurped.

I continued to see my doctor every week as an outpatient. But I was demoralized and failed to see much of a change. I asked him how he healed my father, maintaining him on only three lithium tablets a day, whereas I had experimented with about 100 different combinations and dosages of medications (including antidepressants like monoamine oxidase inhibitors, tricyclics and, later, S.S.R.I.’s). “Because,” he said, “your dad was a Ford. You are a Ferrari.” I didn’t know if this was a compliment or an insult.

The first few years after my last hospitalization, I spent a lot of time on the shore of Lake Michigan, near my home. I collected hundreds of beach stones and organized them by size, color, shape and heft. Soon I had dozens of shoe boxes full of them. Sometimes I talked to the Russian fishermen looking for smelt on the pier; other times I walked alongside older women and helped them look for sea glass. I took three-hour naps every afternoon, trying to remember to set the alarm clock, so I would be awake when the kids came home from school. Many times they met a closed bedroom door.

By 1995, I started to feel small changes. The medications were the same. I was still seeing my father’s doctor. I had the same support from my family and from my husband, who once, when I came home on a day pass, had pansies — my favorite flowers — planted along the path from the driveway to the house. The protective cocoon he made for me, along with time, allowed my self to regrow. I could feel my self filling in.

Gradually, I was able to fulfill more of my maternal role: helping with homework, driving to piano lessons, making the worst Rice Krispies Treats in the school. Our housekeeper, while still a tremendous support, was becoming more of a safety net than a primary caregiver. One of my favorite things was driving in the car with the kids, singing along to oldies, trying to answer their questions: “Is the sun going to fall on the earth?” “Where is the first car?” “Why are some books called a ‘turn-pager’?” I had lunch with family members and the occasional friend. With confidence easing its way back to my self, I volunteered at an anorexia foundation near my house. I lined the edges of my desk with stones. Writing was getting easier, words were unlocking. One day I was on the porch with the two younger kids, who were doodling with crayons, when I wrote down the word “pain.” Without thinking, I picked up a crayon and added the letter T to the end of the word. A half-hour later, we were at an art-supply store, buying brushes, tubes of paint and a canvas. We converted the unused third floor of our house into a cavernous studio. Passion had returned and, along with it, creativity.

One day, about eight years ago, it struck me that bipolar disorder was the hand I was dealt. I remembered what my father said to me when I moved from Boston: “Don’t look at what your disorder has taken away from you, try to find what it has given you.” I began speaking to family-education classes of the local chapter of a mental-health organization. I presented a paper at a conference. The more often I spoke, the less traumatic my experience seemed, the less sad, the less painful and, somehow, the less personal.

Over the years, I’ve talked to clinicians about why the self is rarely mentioned in treating patients who suffer from mental illnesses that damage their sense of who they are. If anything, it seems that psychiatry is moving away from a model in which the self could be discussed. For many psychiatrists, mental disorders are medical problems to be treated with medications, and a patient’s crisis of self is not very likely to come up in a 15-minute session with a psychopharmacologist.

Philip Yanos, an associate professor of psychology at John Jay College of Criminal Justice, in New York, studies the ways that a sense of self is affected by mental illness. He told me that when his work was under grant review, it was initially met with skepticism. Some thought that what he calls “illness identity,” which manifests in some patients as overidentifying with their mental disorder, was a topic of lesser importance in the face of other serious symptoms that patients experience, like cognitive impairment and thoughts of suicide.

Yanos told me that reshaping your identity from “patient” to “person” takes time. For me, going from patient to person wasn’t so arduous. Once I understood I was not vermicelli, part of my personhood was restored. But reconstructing my self took longer.

One reason that may have been the case, as Amy Barnhorst, a psychiatrist at the University of California, Davis, told me, is the unique set of challenges facing people who have experienced mania and hypomania. “The parts of the selves that may come out” in mania and hypomania, which can be horrifying, “are very real,” she said, making it difficult for patients “to reconcile those behaviors with their self as they have come to know it.” In mania and hypomania, the sick self has no accountability; the improved self has a lot of explaining, and often apologizing, to do.

For many people with mental disorders, the transformation of the self is one of the most disturbing things about being ill. And their despair is heightened when doctors don’t engage with the issue, don’t ask about what parts of the self have vanished and don’t help figure out strategies to deal with that loss.

Some in the mental-health field are beginning to recognize this need. Janina Fisher, a psychologist and the assistant director of the Sensorimotor Psychotherapy Institute in Broomfield, Colo., told me that there has been a “sea change” in the role the self plays in the therapeutic dialogue since the decades when I was sick. New therapies and treatment philosophies, founded mostly by clinical psychologists and other practitioners who are not medical doctors, recognize the role of the self in people with mental illness. Patients tell her, “I just want to be that person I used to be.” Fisher encourages her patients to recognize that their mental trauma is a part of their life, but shouldn’t dominate it.

In my own experience with Scheftner, whom I began seeing after my father’s doctor moved away, we talk about the self but only when I bring it up. That’s why I have enjoyed helping to run a support group for people with mental disorders, something I’ve been doing for the last three years. There are usually 8 of us, sometimes 12. We sit in the basement of a local library every Wednesday afternoon. Though we know one another’s innermost thoughts, we are intimate strangers, not friends. Like A.A. and other self-help groups, we’re peer-led: run by and for people with mental disorders. We talk one by one about the past week — small achievements, setbacks, doctor appointments, family conflicts. While the self is not always an explicit topic, the loss of self — or for those doing better, the reconstruction of the self — is a hovering presence in the group.

One day, not long ago, a middle-aged man came to our group. He told us that he spent the past year attending different grief groups, but none of them were right. “Why not?” someone asked. The man said: “Because everyone there was grieving over the loss of another person. I was grieving for myself. For who I used to be before I got sick and who I am now.”

During the 20-odd years since my hospitalizations, many parts of my old self have been straggling home. But not everything made the return trip. While I no longer jump from moving cars on the way to parties, I still find social events uncomfortable. And, although I don’t have to battle to stay awake during the day, I still don’t have full days — I’m only functional mornings to midafternoons. I haven’t been able to return to teaching. How many employers would welcome a request for a cot, a soft pillow and half the day off?

One morning, about five years ago, my husband and I were talking on the family-room sofa. I was still wearing my pajamas and had wool hiking socks on. As he rubbed my feet, he told me he was leaving. It was, at once, a scene of tenderness and savagery. A little later, he threw some clothes into a suitcase and moved out. But my self — devastated, grieving, angry — remained intact.

Today, my mind is nimble. Creative writing has crept back into my life. I’ve made a couple of close friends in Chicago. My greatest pleasure is still my children — they’re starting careers, marrying, on the brinks of their lives. I’m looking forward to grandchildren, to singing the 1950s favorite “Life Is but a Dream” while spinning those babies under the stars of a falling night on a Florida beach. This June, I’m turning 60. I’m having a small party to celebrate my ingathering of selves. My old self was first to R.S.V.P.

World Science Festival - Madness Redefined: Creativity, Intelligence and the Dark Side of the Mind

Here is another interesting panel discussion from the World Science Festival - Madness Redefined: Creativity, Intelligence and the Dark Side of the Mind.

The notion of a “tortured genius” or “mad scientist” may be more than a romantic aberration. Mounting studies have established that bipolar disorder and schizophrenia correlate with high creativity and intelligence. Join leading researchers as they examine the shifting spectrum between brilliance and madness. The panelists: Cynthia McFadden, James Fallon, Kay Redfield Jamison, Susan McKeown, and Elyn Saks.

Video streaming by Ustream

Ethically, diagnosing children with bipolar is way out of bounds. Even so, since the mid-1990s, the number of children diagnosed with bipolar disorder has increased a staggering 4,000 percent. The only problem is the the children do not have the behaviors outlined in the DSM as to how bipolar manifests.

This story from NPR gives a little history of the bipolar diagnosis in children:

The Beginning Of 'Bipolar' Children
The notion that children might suffer from bipolar disorder in large numbers is new, dating back only to the mid-1990s.

Dr. Janet Wozniak, an assistant professor of psychiatry at Harvard Medical School, was one of the people who first popularized this idea.

Wozniak says that when she was starting out, most psychiatrists placed the prevalence of bipolar disorder in children somewhere between "never" and "vanishingly rare."

"Papers about bipolar disorder in children would usually start out with the phrase, 'Here's a disorder that's so rare maybe you'll see one or two in your entire lifetime in practice,' " Wozniak says.

Wozniak herself only started thinking about pediatric bipolar disorder when she got a job as a researcher in the clinic of a famous Harvard child psychiatrist named Dr. Joseph Biederman. Biederman was studying kids with attention deficit hyperactivity disorder and felt that there was a portion of the kids in his clinic whose problems with anger seemed to go way beyond normal ADHD. So he asked Wozniak to look into it.

She did. And what she found were kids who continued to struggle with intense, uncontrollable outbursts of anger — violent hitting and screaming and kicking — even after they passed through the preschool years.

She felt these outbursts were substantively different from the kind of outbursts you saw among ADHD kids, who often had problems regulating their impulses. Then one day, she says she had an insight.

"This child that I was thinking of as having really difficult-to-treat ADHD and a lot of parent-child interaction problems, I really was ignoring the serious mood component of their problem." In other words, it wasn't that the kids just had problems with their impulse control; there was a more serious problem of mood. These kids were bipolar.

Redefining A Defining Characteristic
Wozniak wrote all this up in a now famous paper proposing that some of the kids characterized as having ADHD were actually bipolar.

The paper won awards. Clinicians began to approach Wozniak at meetings saying her insights made intuitive sense. She had helped transformed their practice.

But Shaffer says that to see these children as bipolar, Wozniak and her co-author, Joseph Biederman, had to change one critical component of the traditional definition of bipolar disorder. "The defining feature of manic-depression was that it was episodic," says Shaffer. "You had episodes of depression and episodes of mania and episodes of normal mood, and that was really, its defining characteristic."

But the kids Wozniak described rarely, if ever, had these kind of discrete weeklong or month-long episodes. So to make them fit the traditional concept of bipolar disorder, Shaffer says, she and Biederman made the argument that in children, episodes presented themselves in a radically different way.

"They said maybe in childhood the episodes would be very brief and very frequent," says Shaffer. "These are called 'ultra diem,' you know, 'many times a day.' If you regarded every time children changed their mood, every time they lost their temper or became overexcited, as a mood episode, then they were really being misdiagnosed and were really cases of bipolar disorder."

Critics countered that bipolar should look the same in kids and adults, that there wasn't good evidence that these kids grew up to be bipolar, and that if you looked backward at bipolar adults, they didn't necessarily have these uncontrolled anger issues when they were young, Shaffer says.

Nevertheless, pediatric bipolar disorder took off. Today, it's estimated that at least 1 million children in the United States have been diagnosed with the disease. Wozniak is convinced that she knows why. "The diagnosis took off because it made clinical sense," she says. "Because we opened our eyes."

There is a proposal to add a new listing for the DSM-5, one which removes the lifelong stigma of bipolar diagnoses, and one which more accurately describes the behaviors.

Temper Dysregulation Disorder: This proposed new disorder is seen as a brain or biological dysfunction, but not necessarily a lifelong condition. It can only be diagnosed in children over the age of 6, and onset must begin before a child is 10. 

The disorder is characterized by severe recurrent temper outbursts in response to common stressors. To have the disorder, the person has to have had these symptoms for at least 12 months, and cannot have been free of symptoms for more than three months at a time.

• temper outbursts involving yelling or physical aggression
• overreacting to common stressors
• temper outbursts occurring on average three or more times a week
• nearly everyday the mood between temper outbursts is persistently negative.
• in the past year the patient has not had a period longer than a day of elevated or euphoric mood.

Personally, I think this is a much more complex issue that has a lot to do with parenting (or the lack of it), environmental over-stimulation (video games, electronic education devices, television, etc.), chemical dysregulation of affective systems from environmental toxins and food additives, lack of boundaries and consequences, and a whole host of other issues. But parents and physicians want the quick fix, not the real solution.

Shrink Rap Radio #305 – The Dangers of Diagnosing Children as Bipolar with Stuart Kaplan, MD

According to Stuart L. Kaplan MD, there are six things you should know about him:

• He is a Distinguished Life Fellow of the American Academy of Child and Adolescent Psychiatry.
• He is a Clinical Professor of Psychiatry at Penn State College of Medicine.
• He was awarded the Outstanding Mental Health Professional of the Year by the National Alliance of the Mentally Ill, Saint Louis Chapter, in 1998.
• He has served as the Director of Child and Adolescent Psychiatry at three major institutions, two of which were University medical schools.
• He is Board Certified in Child Psychiatry and Adult Psychiatry and served as an examiner for the American Board of Psychiatry and Neurology 14 times.
• Dr. Kaplan has authored over 100 scientific papers, book chapters, abstracts and national and international scientific presentations.

Check out the following Psychology CE Courses based on listening to Shrink Rap Radio interviews:

• Jungian Psychotherapy Part 1 (6 CEUs)
• Jungian Psychotherapy Part 2 (7 CEUs)
• Jungian Psychotherapy Part 3 (7 CEUs)
• Jungian Psychotherapy Part 4 (6 CEUs)
• Jungian Psychotherapy Package of the Four Above (26 CEUs)
• Wisdom of The Dream (4 CEUs)
• Positive Psychology (6 CEUs)

A psychology podcast by David Van Nuys, Ph.D.

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Stephen Fry: The Secret Life of the Manic Depressive

Interesting . . . I didn't know that Stephen Fry is bipolar. In this two-part series, Fry looks into the disease and speaks with others, including celebrities, who also live with bipolar.

Stephen Fry: The Secret Life of the Manic Depressive

Stephen Fry presents this documentary exploring the disease of manic depression; a little understood but potentially devastating condition affecting an estimated two percent of the population.

Stephen embarks on an emotional journey to meet fellow sufferers, and discuss the literal highs and lows of being bi-polar.

Celebrities such as Carrie Fisher and Richard Dreyfuss invite the comedian into their home to relate their stories.

Plus Stephen looks into the lives of ordinary people trying to deal with the illness at work and home, and of course to the people studying manic depression in an effort to better control it. A fascinating, moving and ultimately very entertaining Emmy Award-winning programme.

Part 1

Part 2

Tags: Stephen Fry, The Secret Life of the Manic Depressive, Top Documentary Films, Psychology, bipolar, mental illness, documentary, Carrie Fisher, Richard Dreyfuss, manic depression, bi-polar, bipolar disorder

Mark Vonnegut - Just Like Someone Without Mental Illness, Only More So

I could have sworn I heard an interview with Mark Vonnegut this morning on NPR, but I can't find it. Still, I did find this review and excerpt from the book he wrote that they were discussing in the interview. Very interesting - I really knew nothing about Kurt's son.

There is an excerpt at the bottom.

'Only More So': Mark Vonnegut's Battle With Bipolar

by Genevieve Wanucha

Just Like Someone Without Mental Illness, Only More So: A Memoir
By Mark Vonnegut
Hardcover, 224 pages
Delacorte Press
List price: $24

October 19, 2010

Recovering from a psychotic break is far from a guarantee. The famed novelist Kurt Vonnegut once wrote, metaphorically, of the challenges of mental illness: "Some people survived going over Niagara Falls in a barrel. Others didn't. The turbulence is really something." But it's his son, Mark Vonnegut, who has written most vividly and personally about surviving bipolar disorder, about returning to a reality that's been snapped. In a phrase, life takes on a new imperative: to be "normal with a vengeance."

Just Like Someone Without Mental Illness, Only More So — Mark Vonnegut's exactingly titled second memoir — is an honest, witty and vivid depiction of "normal" life in between interruptions of mental illness. It's about how much one can accomplish, while a history of insanity follows close behind. "Once you've been talked to by voices, it's not possible to go back to a world where talking voices is not possible," he writes. Instead, he couldn't shake the feeling that he was just trying to pass for normal, as if forgetting to tiptoe around the mental eggshells would let the voices return.

More than anything, Mark's bipolar illness gave him the desire to be useful, to make up for the time he spent feeling so utterly useless while hospitalized in his 20s. And useful he became — after 19 rejections, young Vonnegut earned admission to Harvard Medical School and pursued a long and dedicated Boston-based pediatrics career. To the benefit of his readers, this endows him with a rare prerogative to lament the American medical system, or more accurately, the insurance regulations and cost-efficiency guidelines that make trying to practice medicine today like "long jumping with weights on your ankles."

Enlarge Barb Vonnegut

Mark Vonnegut, pictured above with his son Mark Oliver, is a pediatrician and writer living in Massachusetts. He is also the author of The Eden Express: A Memoir of Insanity. He is the son of novelist Kurt Vonnegut.

Whereas Vonnegut's first memoir, The Eden Express, is a young man's artistic account of spiraling into psychosis amid the social tumult of the 1960s, Just like Someone Without Mental Illness is a vastly more readable, down-to-earth narrative. Wisdom tempers a zeal for political rebellion, and a sense of humor allows brazen self-reflection. He subsumes within these chapters a remarkable amount of his midlife experience, ranging from his around-the clock pediatric residency, alcohol dependence, returning bipolar illness that nearly launched him out a window, remarriage, and a life in the shadow of his father.

The late Kurt Vonnegut is an eccentric background character, and Mark's childhood memories of his not-yet-famous father are worth chasing through the pages for. Far from remembering him as the author of Cat's Cradle, Mark knows Kurt as the man throwing the chessboard across the room upon losing, dancing with his wife and a mop to the tango music in the aisles of Walmart, and adopting four children. It's always amusing to learn that one of the 20th century's most influential writers was once a terrible car salesman who couldn't get hired to teach English at Cape Cod Community College.

Coming from a man who was named Boston Magazine's "No. 1 Pediatrician" just as he was experiencing a fourth psychotic episode, Vonnegut's memoir is ultimately about how bipolar disorder can shape, but not define, a life. Just don't expect it to be normal.

Here is a taste of the book, also courtesy of NPR.

Excerpt: 'Just Like Someone Without Mental Illness, Only More So'

by Mark Vonnegut

Just Like Someone Without Mental Illness, Only More So: A Memoir
By Mark Vonnegut
Hardcover, 224 pages
Delacorte Press
List price: $24

Chapter One

A Brief Family History

It's good to have a sixth gear, but watch out for

the seventh one. If you think too well outside the box,

you might find yourself in a little room without much in it.

The arts are not extracurricular.

One hundred thirty-nine years ago, my great-grandfather Bernard Vonnegut, fifteen years old, described as less physically robust than his two older brothers, probably asthmatic, started crying while doing inventory at the family hardware store. When his parents asked what was wrong, he said he didn't know but he thought he wanted to be an artist.

"I don't want to sell nails," he sobbed.

Maybe his parents should have beaten him for being ungrateful, but they wanted their son to be happy and the business was successful enough that they could hire someone else to do inventory. He became an apprentice stonecutter and then went to Europe to study art and architecture. He designed many buildings in Indianapolis that still stand today. He drew beautifully, made sculptures and furniture. He was also happily married and had three children, one of whom was Kurt senior, my grandfather, who was known as "Doc" and who also became an architect. Doc could also draw and paint and make furniture. He made wonderful chessboards, one of which he gave to me when I was nine.

When he was sixty, Doc was pulled over for not stopping at a stop sign. The cop was astonished to notice that his driver's license had expired twenty years earlier.

"So shoot me," said Doc.

At the end of his life, which had included financial ruin in the Great Depression, his wife's barbiturate addiction and death by overdose, and then his own lung cancer, Doc said, "It was enough to have been a unicorn." What he meant was that he got to do art. It was magic to him that his hands and mind got to make wonderful things, that he didn't have to be just another goat or horse.

When I worked on the Harvard Medical School admissions committee, artistic achievements were referred to as "extras." The arts are not extra.

If my great-grandfather Bernard Vonnegut hadn't started crying while doing inventory at Vonnegut Hardware and hadn't told his parents that he wanted to be an artist instead of selling nails and if his parents hadn't figured out how to help him make that happen, there are many buildings in and around Indianapolis that wouldn't have gotten built. Kurt senior wouldn't have created paintings or furniture or carvings or stained glass. And Kurt junior, if he existed at all, would have been just another guy with PTSD-no stories, no novels, no paintings. And I, if I existed at all, would have been just another broken young man without a clue how to get up off the floor.

Art is lunging forward without certainty about where you are going or how to get there, being open to and dependent on what luck, the paint, the typo, the dissonance, give you. Without art you're stuck with yourself as you are and life as you think life is.

Craziness also runs in the family. I can trace manic depression back several generations. We have episodes of hearing voices, delusions, hyper-religiosity, and periods of not being able to eat or sleep. These episodes are remarkably similar across generations and between individuals. It's like an apocalyptic disintegration sequence that might be useful if the world really is ending, but if the world is not ending, you just end up in a nuthouse. If we're lucky enough to get better, we have to deal with people who seem unaware of our heroism and who treat us as if we are just mentally ill.

My great-grandfather on my mother's side drank to keep the voices away and ended up the town drunk in the middle of Indiana. My maternal grandmother wrote textbooks on teaching Greek and Latin and had several bouts of illness that resulted in long hospitalizations. When my mother, Jane, was in college the family resources were exhausted after my grandmother spent over two years in a private hospital. With great shame and embarrassment her husband transferred her to a state hospital, where she became well enough to go home a few weeks later. She remained mostly well and never had to be hospitalized again, but she had spent roughly seven years of my mother's childhood institutionalized.

There was no acknowledgment of or conversation about my grandmother's illness either between my mother and her father or my mother and her brother, who would also be in and out of hospitals most of his life. He emerged normal enough to marry three times in his fifties and sixties, hold a job as a librarian, and be the Indiana State senior Ping-Pong champion.

This same maternal grandmother warned my mother not to marry my father because she was convinced there was mental instability in the Vonnegut family. My father's mother, a barbiturate addict who didn't come out of her room let alone the house for weeks at a time, told my father to stay away from my mother because there was mental illness in the Cox family. My father's mother famously (some say it was an accident, but does it really make a difference?) overdosed and killed herself on Mother's Day. Barbiturates had been prescribed to my grandmother as a wonderful new nonaddictive medicine for headaches and insomnia.

If you want to pick out the people who go crazy from time to time in my family, find the ones in the photos who look ten or more years younger than they actually are. Maybe it's because we laugh and cry a lot and have a hard time figuring out what to do next. It keeps the facial muscles toned up.

It's the agitation and the need to do something about the voices that get you into trouble. If you could just lie there and watch it all go by like a movie, there would be no problem. My mother, who was radiant, young, and beautiful even as she lay dying, heard voices and saw visions, but she always managed to make friends with them and was much too charming to hospitalize even at her craziest.

If you don't have flights of ideas, why bother to think at all? I don't see how people without loose associations and flights of ideas get much done.

The reason creativity and craziness go together is that if you're just plain crazy without being able to sing or dance or write good poems, no one is going to want to have babies with you. Your genes will fall by the wayside. Who but a brazen crazy person would go one- on-one with blank paper or canvas armed with nothing but ideas?

The psychotic state is a destructive process. A fire can't burn that brightly without melting circuits. Making allowances for individual tolerances and intensity and duration of the breaks, complete functional recovery becomes increasingly unlikely much beyond about eight or nine breaks. Fixed delusions, fears, loss of flexibility, loss of concrete thinking, and low stress tolerance make relationships, jobs, and family next to impossible and then impossible. The biggest risk factor in determining whether or not you have a nineteenth psychotic episode is having had the eighteenth.

Life for the unwell is discontinuous and unpredictable. Things just come out of nowhere. People try but mostly do a lousy job of taking care of you.

Excerpted from Just Like Someone Without Mental Illness, Only More So: A Memoir by Mark Vonnegut. Copyright 2010 by Mark Vonnegut. Excerpted by permission of Delacorte Press.

Tags: Mark Vonnegut, Just Like Someone Without Mental Illness, Only More So, NPR, Kurt Vonnegut, Genevieve Wanucha, bipolar disorder, authors, books, bipolar, mental illness, writing, Psychology, autobiography, review, excerpt, The Eden Express, alcohol, family

Archives of General Psychiatry - Ketamine May Relieve Depression Quickly for Those With Treatment-Resistant Bipolar Disorder

Another study confirming that ketamine can extinguish even the most treatment resistant forms of depression - this time it is in treatment resistant bi-polar depression. For some, this treatment could be the proverbial light at the end of the tunnel.

Journal Reference:
Nancy Diazgranados, Lobna Ibrahim, Nancy E. Brutsche, Andrew Newberg, Phillip Kronstein, et al. (2010). A Randomized Add-on Trial of an N-methyl-D-aspartate Antagonist in Treatment-Resistant Bipolar Depression. Arch Gen Psychiatry. 67[8]:793-802

Ketamine May Relieve Depression Quickly for Those With Treatment-Resistant Bipolar Disorder

CHICAGO—A single intravenous dose of the anesthetic agent ketamine appears to reduce symptoms of depression within 40 minutes among those with bipolar disorder who have not responded to other treatments, according to a report in the August issue of Archives of General Psychiatry, one of the JAMA/Archives journals.

"Bipolar disorder is one of the most severe psychiatric disorders and ranks in the top 10 causes of medical disability worldwide," the authors write as background information in the article. About 4 percent of Americans will develop bipolar disorder in their lifetimes, and depressive symptoms dominate for most of the course of the illness. Several treatments for bipolar depression are currently approved, but some patients do not respond to these therapies despite adequate trials. In addition, existing treatments are associated with a lag of onset; most patients do not respond within the first week of therapy, resulting in considerable illness and increased suicide risk.

One reason for the lack of better therapies is a limited understanding of the neurobiological basis of bipolar disorder, the authors note. However, recent research suggest dysfunction in the brain's glutamatergic system—which plays a role in information processing and memory formation—may contribute. Nancy Diazgranados, M.D., M.S., and colleagues at the National Institute of Mental Health, Bethesda, Md., assessed the effectiveness of one modulator of this system—ketamine hydrochloride, commonly used as an anesthetic—for bipolar depression.

From October 2006 through June 2009, 18 participants with bipolar depression that had failed to respond to the medications lithium or valproate received an intravenous infusion of either ketamine or a placebo on two test days two weeks apart. The order of the infusions was randomly assigned. Participants were assessed using a depression rating scale before each injection and then 40, 80, 120 and 230 minutes and one, two, three, seven, 10 and 14 days afterward.

Within 40 minutes, those who received ketamine experienced a significant improvement in depressive symptoms compared with those who took placebo, an improvement that was largest at day two and remained significant through day three. At some point during the course of the trial, 71 percent of participants responded to ketamine and 6 percent responded to placebo.

"These findings are particularly noteworthy because a substantial proportion of study participants had been prescribed complex polypharmacy regimens in the past with substantial treatment failures," the authors write. "The mean [average] number of past antidepressant trials was seven, and more than 55 percent of participants failed to respond to electroconvulsive therapy. The toll of this protracted and refractory illness on the subjects was evident, in that two-thirds of participants were on psychiatric disability and nearly all were unemployed."

No serious adverse effects were reported during the study. The results lend support to the hypothesis that the glutamatergic system is implicated in the development of bipolar disorder, and that targeting it may lead to improved therapies. "Future research will need to address whether differences in kinetics associated with intravenous administration—which allows for faster absorption and avoids hepatic metabolism—are important or necessary for rapid antidepressant effects to occur," the authors write. In addition, "future studies should examine strategies for long-term maintenance of ketamine's rapid antidepressant response."

Editor's Note: Funding for this work was supported by the Intramural Research Program at the NIMH, National Institutes of Health, Department of Health and Human Services, and by a National Alliance for Research on Schizophrenia and Depression Award. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

Tags: depression, bipolar, Psychology, brain, Ketamine, Relieve Depression, Quickly, Treatment-Resistant, Bipolar Disorder, glutamatergic system, Archives of General Psychiatry, JAMA, neurobiology, neuroscience

One-quarter of bipolar I disorder patients experience cycling episodes

Interesting research summary from Psychiatry Matters. It might be time to revise the bipolar section of the DSM in the new 5th Edition (due out in 2013 now).

One-quarter of bipolar I disorder patients experience cycling episodes

14/12/2009

Researchers have found that cycling episodes constitute a quarter of all episodes in bipolar I disorder, suggesting that such a classification should be added to current diagnostic criteria.

MedWire News: Researchers have found that cycling episodes constitute a quarter of all episodes in bipolar I disorder, suggesting that such a classification should be added to current diagnostic criteria.

Currently, alternating syndromes with no intervening period of recovery are classified as separate mood episodes that may wrongly be treated independently.

“This issue is important because it has a direct impact on diagnosis, treatment, and prognosis,” David Solomon (Rhode Island Hospital, Providence, USA) and colleagues explain.

Using data from the ongoing US National Institute of Mental Health Collaborative Program on the Psychobiology of Depression, the team identified 219 individuals diagnosed with bipolar I disorder who had been followed-up for a mean of 17.3 years.

The researchers identified a total of 1208 recurrent mood episodes, with a mean of 5.5 episodes observed per participant. Episodes consisting of a single pole of psychopathology comprised 75% of all mood episodes.

Classification of mood episodes showed that major depression (30.9%) occurred most commonly, followed by mania (20.4%), cycling (17.3%), minor depression (13.0%), hypomania (10.4%), cycling plus mixed state (7.8%), and mixed episodes (0.2%). Overall, cycling episodes constituted 25.1% of all episodes.

Further analysis showed that in the 153 cycling episodes that began with depression, the depressive state was followed by an immediate switch to mood elevation or a mixed state in 64% of cases.

In the 143 cycling episodes that began with mood elevation, the elevated state was followed by an immediate switch to depression or a mixed state in 56%.

When the team examined somatic therapy received during the 1208 mood episodes, they found that 85% were treated with a mood stabilizer and/or an antidepressant for at least 1 week during prospective follow-up.

Furthermore, 40% major depressive episodes, 39% of minor depressive episodes, 12% of manic episodes, and 24% of hypomanic episodes were not treated with a mood stabilizer. In total, 28% of 471 depressive episodes were treated with an antidepressant in the absence of a mood stabilizer.

Writing in the British Journal of Psychiatry, the researchers conclude: “Work groups revising the International Classification of Diseases-10 and the Diagnostic and Statistical Manual of Mental Disorders-IV should add a category for bipolar I cycling episode.”

Reference:
Br J Psychiatry 2009; 195: 525–530

Tags: Psychology, brain, bipolar, Psychiatry Matters, bipolar I, cycling episodes, mania, mixed episodes