Into the Void

The long awaited Manic-Depressive Illness: Bipolar Disorders and Recurrent Depression, Second Edition, by Frederick K. Goodwin and Kay Redfield Jamison is finally in stores.

Hopefully you have the first edition. It is *the* reference book for bipolar disorder. Over the years many of the hypotheses set forth in the first edition have been proven out. It’s all there. Phototherapy, circadian rhythms, bipolar creativity. The effects of lithium on the suicide rate. Why we must avoid unopposed antidepressants. And that’s what I saw just riffling the pages! I can’t wait to sit down and read the medical roadmap that Drs. Goodwin and Jamison set out for the next 15 years.

A sample chapter is available for download from the Oxford University Press.

If you apply for the Amazon.com Visa when you make the purchase you can get a hefty rebate. Yippee!

Like many folks on psych meds, I’m obese. I make no excuses. I hate being fat and I’m doing what I can.

The other weekend I decided to break my diet and have breakfast at a Perkins Pancake House on a Sunday morning with two family members who are also on psych meds for bipolar disorder.

As the three of us were being led back to the table one of the wait staff looked me over then turned and called out to another staff member, “We got three pork chops!”

There is simply no call for Perkins employees to verbally abuse their customers, not even the lard-asses. It was the low spot of the day, and it has totally dimmed my enthusiasm for Perkins restaurants. I most certainly won’t set foot in the Moorestown, NJ restaurant again. Too bad for them, because when I’m there I eat a lot.

Perkins Pancake House obesity bipolar disorder rude waiters bipolar

Some of the folks on Pendulum and The Bipolar Planet may remember back in 1999/2000 when my employer gaslighted me. Things like writing me up for being unable to get to work during a flood. Refusing to provide reasonable accommodations under the Americans with Disabilities Act (ADA) that would have improved my productivity.

No, really, what I asked for was a little cubicle at one end of the very noisy computer lab to cut down some of the fan noise and block the visual stimulation of people wandering in and out of the room all day. And that instructions be sent via email instead of verbally, and that stated task priority be filtered through my supervisor to assist my then-lithium-impaired memory. And that I be allowed some leeway in the time I start my day because of a co-morbid, or perhaps drug-induced, sleep disorder. All told it may have cost about $1000 for a couple of cubicle walls. Not a hardship for them. Perhaps it would occasionally inconvenience an engineer who wanted some soldering done first thing in the morning, but in the main I worked alone in the lab – nothing but me and ten or so distractingly noisy desktops and servers.

One engineer gaslighted me a number of times – telling another department that I would do a task for them, but not bothering to actually ask me to do the task. Or giving me incorrect instructions that led to two or three days worth of worthless measurements. He would assign the task last thing before he took a couple of days off, so I couldn’t even ask for clarifications. You can guess how bad this made me look. The negative effect on my self-esteem was incalculable.

There were two other handicapped women working there – they got us really cheap, I suppose. This fellow engaged in the same sort of behavior with them. I thought it was rather odd that he often talked about his kid, but never about his wife. At some point I caught on – the gentleman was a truly wretched misogynist.

It got to me. I began to think that maybe it was me, not discrimination and stigma. Maybe I really was incompetent. Maybe the bipolar disorder was really progressing toward total disability. My self-esteem plummeted. I was about to quit my job when one of the other victims suggested that I go on disability for a bit to get my head back together. So I did.

When I came back, the company refused to give me internet access. That meant no searching for component datasheets, no on-line parts orders, no package tracking. I literally could not do my job without it.

It was the worst kind of nightmare, the kind that follows you home at the end of the day, the kind that intrudes into your dreams, the kind that wakes up with you in the morning, the kind that makes your entire world lose its color and taste.

Eventually, the Director of Human Resources called me into her office and forced me to accept a “mutually agreed-to separation.” The woman even told me that I’m not suited to work in the electronics industry.

I want to know one reason why it is good for society to prevent the mentally ill from working.

The victimized co-worker that I mentioned later helped me put together letters to HR, took me along when she went down to the U.S. Equal Employment Opportunity Commission (EEOC) to file a complaint, and took me to her lawyer. I wouldn’t have done these things on my own.

For the record, the EEOC gave me a “right to sue” document, but I had another episode and so was unable to follow through.

Since my self-esteem was so shot, I was unable to find another job. Instead I went back to school and finished up my BS in Engineering Science – with a minor in Mathematics.

It’s been on my mind because I have been cleaning out old files including all my records about my complaint with the EEOC. Folks, if someone discriminates, report them – after you are terminated, of course. Even if you don’t profit from it – and you probably won’t – it lays a groundwork for future employees who experience the same thing you did. Three different women called and asked for my EEOC case number within the next six months after I left.

Yesterday, just out of curiousity, I looked up the Director of HR on the ‘net. She now heads up a local National Alliance on Mental Illness (NAMI) chapter. If that’s what NAMI is all about, teaching HR people how to use our illnesses against us at work, I will never give them another cent.

NAMI.

I went to a local meeting one time. It was frightening.

This fellow brought his college-age daughter and talked about her in the third person throughout the meeting. He kept his arm around her as if she might jump up and run away. As if she might open her mouth and express her own opinion. As if she were his property. No wonder she was sick.

Another couple complained why can’t the doctors medicate their son against his wishes. The son is crazy, he can’t make a rational decision! Well, their son’s wishes are not irrational just because they differ from the parents’. When there are drugs that really work and don’t have debilitating side effects, the seriously mentally ill may feel better about taking them.

The NAMI facilitator glanced at me and then carefully said, “Forced medication is against the law. It violates the patient’s rights.” I know damned well that if I weren’t there the conversation would have gone differently.

I can’t imagine being wrestled to the ground and forcibly injected with intoxicants. I can tell you this – if you tried to do that to me right now I’d fight you until I ran out of strength. Of course, you would then be able to say, “See, see, she’s irrational, she’s being violent.” This is so much more than an issue of the patient’s rights – it is a violation of their person on the order of rape.

My opinions and my wishes are not irrational just because they differ from my family’s – or from NAMI’s.

If someone figures out how to “cure” genetics, let me know. You can’t exactly pick up a bottle of Grecian Formula for Brain at the local pharmacy.

Remission is another thing altogether. That simply means that you are having an extended symptom-free period. Given that the DSM-IV bipolar criteria only require that the patient have ONE episode of mania or hypomania, some folks may remain in remission for the rest of their lives even without meds.

Science *is* empiricism. I would like to suggest that a large percentage doctors are not particularly careful in their application of the science of medicine. If they were scientific, they’d test and retest the bipolar patient’s continued need for meds instead of following the bizarre rule of thumb that once you’re on meds you need them forever. The killer is that as long as the illness is masked by drugs, it is impossible to practice “evidence-based medicine” as they disparagingly call it.

None of us on meds is being treated in an scientific manner. It isn’t scientifically valid to say that bipolar disorder causes cognitive deficits if a large percentage of the patients in the study were on meds. Antipsychotics have been *proven* to reduce the IQ by affecting the short-term memory. They aren’t the only drug to cause cognitive deficits. Lithium makes you feel as if your brain is wrapped in cotton wool.

I don’t believe that it is scientifically valid to say that bipolars must be on meds for life. If the patient stops the meds and experiences a return of symptoms… well, you’ve rewired the brain. The drugs themselves create a continued need for themselves by reconfiguring the brain’s neurons to need higher levels of serotonin in the synapses. The symptoms are bound to return, and much worse than before the drug did its damage.

Another thing about remission is that so many things besides bipolar disorder cause mood swings. Bipolar disorder has periods of remission. Things like the personality disorders, schizophrenia, schizoaffective disorder, PTSD and any of a hundred organic illness all cause mood swings. But they don’t necessarily have periods of remission, and in many cases remission just doesn’t occur.

Here – this is my particular manifestation of bipolar disorder. Three-year cycles. They come no matter what, but fortunately the meds attentuate the episodes. On the other hand, until I was on meds the cycles didn’t seriously impact my salary.

I think that it’s important, if a bipolar isn’t having remissions, to figure out why. Ultra-rapid cycling could be caused by an antidepressant, particularly in women. Newly-diagnosed bipolars often experience a great deal of fear or anxiety that might be better treated with therapy than with additional meds. Antipsychotics may ruin the patient’s ability to effectively manage the illness by dumbing them down. Sometimes it isn’t the illness, it is the meds that make bipolars disabled.

Are your drugs masking periods of remission?

Sometimes I get tired of the reverse stigma that I get for taking fewer meds so that I can continue to have a life. Isn’t that the purpose of treatment? If not, what is?

Most bipolars have the so-called milder varieties of the illness, and many of them are unfairly overmedicated and isolated from society for no good reason. It is unbearably sad to see that happening. So if I can tolerate psychosis instead of trying to medicate away every little nuance of mood or emotion, does that make me somehow inferior? I don’t f*cking think so. It isn’t pathological until it has a negative effect on my life.

Excerpt.
The following is an excerpt from the book Bipolar II
by Ronald R. Fieve, M.D.

Published by Rodale; October 2006; $22.95US/$29.95CAN; ISBN 1-59486-224-9
Copyright © 2006 Ronald R. Fieve, M.D.

Bipolar Disorder and Sleep

“How many hours do you sleep on average at night, and what is the quality of your sleep?” are two of the first questions I ask every patient on the initial interview and all subsequent follow-up visits. While the hypomanic usually gloats over how little sleep he needs, getting by on 3 to 4 hours a night, the lack of quality sleep can wreak havoc on his mood and decision-making abilities. Sleep deprivation results in feelings of malaise, poor concentration, and moodiness, and even accidental deaths.

In a revealing sleep study published in the September 2005 issue of the Journal of the American Medical Association, Judith Owens, MD, and her team of researchers from Hasbro Children’s Hospital in Providence, Rhode Island, followed 34 pediatric residents from Brown University over the course of 2 years to compare post-call performance to performance after drinking alcohol. During this time, the residents were tested under light call (1 month of daytime duty with no overnight shift, or about 44 hours of work per week) and heavy call (overnight duty every fourth night with an average of 90 hours of work a week). The residents performed computer tasks to gauge their attention and judgment after their light call (after consuming alcohol) and heavy call shifts (with placebo). The residents who were on heavy call and had not ingested alcohol performed worse on the computer tests than those doctors who had taken alcohol and were on light call. Dr. Owens concluded that the residents were so sleep-deprived that they didn’t recognize that their own judgment was impaired.

Drugs, stressful situations, and even excessive noise can affect daily body rhythms and moods. Once a Bipolar II mood disorder with disturbed rhythms has begun, it tends to be self-perpetuating, since depression and anxiety are likely to disrupt 24-hour rhythms further. An irregular living schedule can aggravate mood disorders. The old-fashioned sanitarium rest cure was effective with the “nervous” because it put the patient on a regular schedule of sleep, activity, and meals.

Insomnia

How is your sleep? Do you have difficulty falling asleep? Or do you toss and turn most of the night until you fall into a deep sleep just hours before the alarm goes off? A person suffering from insomnia has difficulty initiating or maintaining normal sleep, which can result in non-restorative sleep and impairment of daytime functioning. Insomnia includes sleeping too little, difficulty falling asleep, awakening frequently during the night, or waking up early and being unable to get back to sleep. It is characteristic of many mental and physical disorders. Those with depression, for example, may experience overwhelming feelings of sadness, hopelessness, worthlessness, or guilt, all of which can interrupt sleep. Hypomanics, on the other hand, can be so aroused that getting quality sleep is virtually impossible without medication. In a study at the University of Oxford in the United Kingdom, Allison G. Harvey, PhD, and colleagues in the department of experimental psychology determined that even between acute episodes of bipolar disorder, sleep problems were still documented in 70 percent of those who were experiencing a normal (euthymic) mood at the time. These normal-mood patients with bipolar disorder expressed dysfunctional beliefs and behaviors regarding sleep that were similar to those suffering from insomnia, such as high levels of anxiety, fear about poor sleep, low daytime activity level, and a tendency to misperceive sleep. Dr. Harvey concluded that even when the bipolar patients were not in a depressive, hypomanic, or manic mood state, they still had difficulty maintaining good sleep.

Delayed Sleep Phase Syndrome

This is the most common circadian-rhythm sleep disorder that results in insomnia and daytime sleepiness, or somnolence. A short circuit between a person’s biological clock and the 24-hour day causes this sleep disorder. It is commonly found in those with mild or major depression. In addition, certain medications used to treat bipolar disorder may disrupt the sleep-wake cycle. I often recommend chronotherapy to patients. This therapy — an attempt to move bedtime and rising time later and later each day until both times reach the desired goal — is often used to adjust delayed sleep phase syndrome. To adjust the delayed sleep phase problem, sleep specialists might also use bright light therapy or the natural hormone melatonin, particularly in depressed patients.

REM Sleep Abnormalities

REM sleep abnormalities have been implicated by doctors in a variety of psychiatric disorders, including depression, posttraumatic stress disorder, some forms of schizophrenia, and other disorders in which psychosis occurs. Special tests, called sleep electroencephalograms, record the electrical activity of the brain and the quality of sleep. From these tests, we know that in people who are depressed, NREM sleep is reduced and REM sleep is increased. Most antidepressant medications suppress REM sleep, leading some researchers to believe that REM sleep deprivation relates to an improvement in depressive symptoms. Yet Wellbutrin XL, a common antidepressant, and some older medications used to treat depression do not suppress REM sleep. Researchers are therefore still trying to determine the connection between the REM sleep mechanism and depression.

Irregular Sleep-Wake Schedule

This sleep disorder is yet another problem that many with Bipolar II experience and in large part results from a lack of lifestyle scheduling. The reverse sleep-wake cycle is usually experienced by bipolar drug abusers and/or alcoholics who stay awake all night searching for similar addicts and engaging in drug-seeking behavior, which results in sleeping the next day. This sleep disruption and irregularity make it much more difficult for the bipolar patient’s physician to treat him or her with conventional medications and adjunctive cognitive therapy. In most cases, the patient needs to acknowledge the drug-seeking behavior and get involved in a recovery program such as Alcoholics Anonymous, Cocaine Anonymous, or other group. Talk therapy with a psychologist is beneficial to many patients as they seek to change destructive lifestyle habits and learn new behaviors that will help them adhere to a more normal sleep-wake schedule.

Reprinted from: Bipolar II: Enhance Your Highs, Boost Your Creativity, and Escape the Cycles of Recurrent Depression–The Essential Guide to Recognize and Treat the Mood Swings of This Increasingly Common Disorder by Ronald R. Fieve, M.D. © 2006 Ronald R. Fieve, M.D. Permission granted by Rodale, Inc., Emmaus, PA 18098. Available wherever books are sold or directly from the publisher by calling at (800) 848-4735.

Author
Ronald R. Fieve, MD, has published more than 300 scientific papers in the field of bipolar and depression research. His work has been published in such prestigious publications as The Lancet, Nature, The American Journal of Psychiatry, Archives of General Psychiatry, The Journal of the American Medical Association, L’Encephale, and Lithium. Dr. Fieve has also written two widely acclaimed books on mental health, Moodswing and Prozac (translated into five languages). He is professor of clinical psychiatry at Columbia Presbyterian Medical Center and Columbia College of Physicians and Surgeons, Columbia University, and principal investigator, Fieve Clinical Services, Inc. He maintains a private practice in New York City.

This is an expansion on a comment I left on The Zucchini Patch.

I think they use PET scans for what you want to do. An MRI isn’t capable of telling the difference between a live brain and a dead brain. It can, however, spot a shrunken hippocampus or amygdala or anomalies in the blood vessels.

An fMRI can see more. They can use tagged glucose or neurotransmitters, whatever they want to study. The fMRI shows where the substance concentrates in the brain, where it is used the most. The NIMH has information about this.

It’s all still under investigation, though. The fMRI is not ready to be used to diagnose.

Did you know that in ADHD, the harder the person tries to concentrate, the more the prefrontal cortex shuts down? Oddly enough, motor areas of the brain work harder at the same time. Can’t we just find a way to teach these kids that will fit with that kind of brain response? Running around in circles shouting out calculus problems, perhaps?

Apologies to my friends of the hyperactive persuasion.

Somewhere in this computer I have a letter I wrote to one of the scientists in the movie “What the Bleep Do We Know!?” who works down at Penn. I met him at the preview and asked him a few questions to correct some of my assumptions in writing the “Putting the Genie Back Into the Bottle” article. The study I was interested in was over, unfortunately. (Yes, dogs and cats *do* have Broca’s and Wernickes areas – it’s not just defined by function, it’s a physical location.)

I have an MRI of my head hanging on the wall next the the desk to remind me that I have a brain – you can see it, the small pea-sized thing in the center of the glob of mush. ;-) Several years ago I made an animation out of the scan through the layers. Where the hell did I put that?

Oh, here. I see that this one is from after I had my sinuses repaired in uhhhhh 1996 or thereabouts. Refresh the page to see the animation. My favorite part is the eye stalks. We must have had crustacean ancestors.

When did they decide that the Rorschacht test and the MMPI diagnose bipolar disorder? Bipolar isn’t a personality disorder, it’s a mood disorder. My last psychologist told me that when they modified the inkblot test, it was not longer useful in diagnosing borderline personality disorder, either. I question the whole thing at this point.

I took one years ago. The psychologist took my money out of pocket twice a week for over a year and wasn’t able to catch the bipolar disorder. When we did the inkblot test, I thought about what I’d been reading in the psychology books and created a mindset before we started. He had seascapes all over the walls so I picked an undersea theme – so that undersea pictures would be the first thing to pop off the paper at me. Dancing crabs, an octopus in a Jester’s cap. That sort of thing. The MMPI and the Thematic Apperception test were similarly transparent. And drawing pictures of my house and my family and myself. It might have been easier if I didn’t read so damn much. I read a lot more then than I do now.

Anyway, that’s what you want, a functional MRI rather than a plain old MRI.

I graphed my salary from the Social Security Statement this morning. After diagnosis and meds, my salary increase faltered and I began to have steep drops in salary, usually corresponding to a period of unemployment, every three years.

Just for giggles I’ve uploaded a gif of the graph.
I let Excel do a logarithmic extrapolation based on the pre-diagnosis data and it predicted the same salary as the salary reports in the tech journals say I should be making. A quick guesstimate by counting blocks in the graph shows that my lifetime earnings have been about half of what they would have been if I wasn’t mentally ill. I like to play with numbers when I’m bored. Can you tell?
There is no doubt in my mind that I benefited from being bipolar. I could think quickly, I had a great visual memory, and when I was hypomanic I could work long hours on very little sleep.
There are times when I miss what the meds have taken away.