McMan's Depression and Bipolar Weekly
May 20, 2005 Vol 7 No 11
Special Readers Respond Issue
Special Feature: Last week?s Newsletter featured a series of articles on hypomania, which challenged how some psychiatrists are medicating this much-misunderstood phenomenon. This week, readers respond.
Also in this issue: Next week, Hypomanic Edge, McMan's Web, Donations.
Speaking Out
Angela (not her real name) writes:
"It was four in the morning. I was crouching in the bushes outside a hospital hiding from the campus police, explaining to a homeless man that I had more strength than he and would never allow him to take my cigarettes or my phone."
Angela had known for years that she was not like everyone else. Then the death of her husband of 32 years sent her into a tailspin. After seeking help, she was diagnosed with bipolar disorder. Says Angela:
"I went on shopping sprees almost daily, buying things I didn't need. I had always done that, but now more so. It made me happy and directed my mind somewhere else. I would stay up nights writing or studying, never could really sleep before, but now everyone said I was mentally ill and that was a symptom. I went on trips on a whim and yes, I had always done that, too. I gave away huge sums of money to my grown children because they asked and their father had treated with generosity, if not downright spoiling them. So there was another sign of my insanity. If I had dinner with several people and paid the tab, I was insane. If I talked, telling stories of my adventurous life, laughed for hours and hours with friends, then they said among themselves afterward that I was mad and in denial of my grief. That was the way I had been before, but now I was supposed to be different, you see."
Finally, after three years, her physician convinced her to take a mood stabilizer and an atypical antipsychotic. What happened?
"I couldn't function like myself. I didn't want to write poetry or stories in the middle of the night when the normal world was sleeping. I didn't want to laugh over conversations at long dinner parties or dance until the wee hours. Art projects I started were gathering dust (I have a BFA in painting). I couldn't even read. I would sit for hours in the same chair listening to jazz, smoking, which I had never done until my husband died. I wouldn't answer the phone. Didn't want to talk. So, okay, I take medication to appease people, then they are angry because I'm almost catatonic."
The meds sent her into a suicidal depression that resulted in a botched hospital admission. That?s how she found herself hiding in the shrubbery, arguing with a homeless person. She stopped taking her meds that night and started standing up for herself:
"I like who and what I am," she relates. "I shall have me be no other way. I am always high but in varying degrees. I bought a ticket to France two weeks ago at 3:00 in the morning, but always put them on hold now so I can cancel the next day. I get in my car and drive to other states just because I feel like it at that moment. I buy five dresses in a day just because I want to. You must understand that I can financially afford to do that and I never have remorse over my spending. I make love to my boyfriend in parking lots or on his office desk because we can't wait to get home to indulge. I will sometimes eat an entire box of chocolates in one day. I will read all night on a subject I'm interested in or putter in the studio till the sun comes up. I'm never tired, in great physical shape, an amazement to my doctor who has given up on medicating me."
Concludes Angela:
"I don't believe, based on my own experience, that hypomania is a condition which should be controlled by medication in most cases. I realize there must be some people who are victims of their disorder and it should be tempered. In my own case, talking therapy has sufficed."
Some Background
Angela was responding to last week?s Newsletter feature on hypomania, based on an interview with John Gartner PhD, a clinical psychologist at Johns Hopkins and author of "The Hypomanic Edge: The Link Between (a Little) Craziness and (a Lot of) Success in America.."
In the interview, Dr Gartner stated: "When psychiatrists become aware that the patient has hypomanic symptoms, then I think their tendency is to over-react, react as if it is the same as mania, which it is not in terms of the risk and the danger."
Some people can obviously benefit from medication, but Dr Gartner talked of the equivalent to microsurgery involving careful microadjustments "to take the edge off of the edge." This involves doctor and patient gradually inching toward that vital "sweet spot" that feels right to the patient.
Unfortunately, he said, psychiatrists trained to treat severe mania tend to overshoot, prescribing high doses based on clinical trials involving bipolar I patients. This often results in depression, weight gain, loss of libido, and cognitive dulling. Frustrated patients wind up quitting on their meds, sometimes with disastrous consequences.
Last week?s Newsletter has been uploaded onto McMan?s Depression and Bipolar Web in the form of an article, Treating Hypomania.
Dr Gartner?s comments clearly struck a chord with readers. Following are their responses:
Not Getting It
Louise writes:
I also wanted to make a comment on psychiatrists not "getting it". I had a psychiatrist for five years and was hoping, somehow, that things would get better. I was at the point of considering disability when I finally decided enough was enough. I?m not saying he didn?t listen to me, but he just didn?t get that my constant hypomania didn?t have to be thwarted with 900 mg of lithium or 7.5 mg of Zyprexa. These meds worked short-term, for severe manic episodes, but they weren?t meant for long-term therapy at those levels.
I?m a proofreader by trade so you can only imagine coming to work everyday and trying to function in a stupor. I finally found a new psychiatrist willing to try Lamictal for the second time. This is the most stable I?ve been in years! I guess sometimes you need someone with a new perspective to give you new options, and a new lease on life.
Must Be Able to Listen
Amelia writes:
Since mania and hypomania appear to be two different animals, it would make sense that the care and feeding would be different for each. I will be looking forward to learning more about hypomania.
As far as feeling my psychiatrist "doesn't listen" or doesn't "get it," I now have one who does, but I did see one recently who did not and would not even try. We often hear how patients mess up, how they do not participate effectively in their own treatment, or how they are not meds compliant, but given experiences I have had with doctors who seem to need total control, I have to wonder how often patients want to participate but are not allowed to. I mean, if I am to eat the pills, should I not have a say in what they are?
After reading this Newsletter, I am even more certain that in order to receive effective treatment, I must be informed, observant, and not shy about speaking up. And my doc must be willing to listen and not afraid to try a different approach.
Thinks I?m in Denial
Shelley writes:
I went to my pdoc because I was depressed. Seriously depressed. Suicidally depressed. After running through those screening questions, he decided the periods of time when I thought I felt normal were really hypomania. To me, they are what I consider feeling normal. Maybe compared to the low side of life with depression, they look really high.
The episodes he cites as proof are overspending and hypersexuality. In my mind, those were things I did to make myself feel better when I was depressed. After attempting to make me take some of the heavy hitters (his favorite being Risperdal), we finally agreed to add Lamictal to the Wellbutrin. I still don't think I need the Lamictal, but it was a compromise. He does listen to me, but thinks I'm in denial about my illness. I'm sure I'll quit the Lamictal someday. I don't believe doctors have any magic insight to our illness. They generally seem to push whatever pills they have samples of.
Unable to Feel
Therese writes:
I am sure my psychiatrist is afraid to let me "feel" anything. I have been flat since I began the regime of meds she put me on in Dec 2004, after being hospitalized for depression and diagnosed with bipolar I "because it runs in the family," if that is a legitimate method of diagnosis.
I do not cry for no reason any more, nor have nightmares about my profession. But I have no energy, sleep far too much, have no motivation to do anything, have not made a meal, feel no sadness (my husband has been diagnosed with cancer in the interim, and mother has had a life-threatening bout of flash pulmonary edema), no happiness. I do not know what has happened to "me". I used to be able to tie into something of interest and enjoy doing it just for the entertainment of having achieved getting the project done. Now I have no interest in beginning it.
Why Treat?
Sandra writes:
It seems odd to me that anyone would want to treat the mild hypomania that I've experienced. It doesn't cause me problems; rather it gives me a chance to catch up on my work and my life after a period of depression. To be fair and honest, my partner does complain about my irritability when I'm in this condition.
It seems to me that the only reason to treat this condition would be to stop the cycling that inevitably leads to depression. I wish someone would do a study on whether any meds besides Lamictal are effective at stopping depressive cycling without mania.
Free At Last
Claire writes:
I take only one medication: one mg of klonopin before bed. I have loads of energy, but it's not hypomanic energy. It's just regular energy. Long story short, being on lithium suppressed my feelings of being in the world - and now I feel I'm truly here, truly alive, feeling my feelings, feeling life in all its glory. I'm just always in a good mood!
Normal or Hypo?
Bill writes:
I have had one major depressive episode a couple of years ago (out of work for 10 weeks), and thought another was coming on a few months ago. Jury's still out. However, I can remember that I have had maybe 3, 4, or 5 days in the last 10 years where I felt "absurdly and inexplicably normal" from sun-up to bedtime. I had energy, I could get things done, I wasn't snapping at my wife or kids, not napping the day away, etc. I felt GOOD (despite other chronic illnesses), like I used to feel. Trouble is, it has been so long since "normal" went away that it's hard to recognize it.
So were these days just "temporary spontaneous remissions" or "hypomanic episodes"? No clue. Sure wish I could bottle that, though.
Why Take Meds?
Christine writes:
I definitely believe that doctors need to closely evaluate each patient before dosing them with a slew of medications. Even if the medicines do not hurt the patient, if they do not help (and we know about the major side effects they can cause), why take them?
Not Out of Control
Muriel writes:
I don't feel out of control when hypo, just on top of the world, like I can get it all done just right, not shy, not afraid but not out of control, not stupid crazy. Just ME!! Why would that ever be a bad thing? Anything less feels depressing to me. Every one else?s normal is my depression. Doctors don't seem to understand that the box they think I should be in emotionally doesn't fit me. I am always sad in that box they try to medicate me into. So I always stop the meds and try to balance by myself.
Better Existence Than This
Raylene writes:
I fear I have lost track of what exactly "feeling like myself" is. I've become unable to communicate this vague state of dysfunctionality to my doctor who I don't feel has any interest in "rocking" what he sees as a stable "boat". All I know is that a goal of "not getting hypomanic anymore" is not enough. I may not feel hypomanic but I don't feel anything else either. I feel nothing. Certainly there is a better existence than this.
Perhaps your article on the subject will prompt me to try again to work with this doctor to obtain a better result.
Watch the Sugar
Ellen writes:
My therapist told me that I am hypomanic and all that I have read makes me think that is just who I am. I am just that way. It's not a disease or something to be treated because I am happy all the time. But sometimes that happiness turns in a flash to supreme impulsiveness or almost as though I am on drugs - spaced out, in the moment right where I am.
I have found that the impulsiveness and scary part is better controlled if I have no sugar at all.
Part of a Team
Lest this Newsletter come across as inciting a rebellion against psychiatrists, one patient informed this writer that her psychiatrist had forwarded last week?s Newsletter to her. And Rebecca writes:
Basically, I feel like a very important part of two-person team - psychiatrist and patient. When I'm well and stable, we work really well together, so I trust that if I'm ever in a place again where I'm not able to make joint decisions he will make the right judgments on my behalf. It's taken time to get to this place.
Not All It?s Cracked Up To Be
Anonymous reminds us:
There are many patients whose "hypomanic" phases are an extreme and very negative experience. As noted by Dr. Jamison, mania can be negative as often as it is positive. The "racing thoughts" can have a very negative focus, especially self-criticism. The high energy can be experienced as a severe agitation, to the point where people feel they must pace the floor for hours at a time. Sleep problems can show up as insomnia: an inability to sleep, rather than decreased need.
Not Part of True Identity
Lynn concurs:
My own experiences with hypomania seem to be different from many people with bipolar. I do not get happy in the slightest to see hypomania arrive on my doorstep. For me, it brings out behavior that I later regret. I can't shut my mouth when it is needed, my spending habits increase, I feel sexual in an inappropriate way, and I get sudden impulses to drink, and to flamboyantly commit suicide. My hypomania perhaps is less mild than others, and closer to actual mania. I do not just get an elevated mood without bad consequences.
Therefore I definitely do not relate to hypomania as my true identity. It is something I want to stop immediately when it happens.
My current psychiatrist has been wonderful. She trusts that I know my cycles better than she does at this point, and so with her help and my own knowledge I have been able to successfully control my spring hypomanic episode. I would not trade my psychiatrist for the world for putting so much trust in me, and allowing me to have a say in the medications.
Hypomania is dangerous to me, and so I assume it is dangerous also to others. I do hope that more psychiatrists will put an emphasis on recognizing this phase. I never understood the questionnaires given to patients asking them how they feel, because many hypomanic people will say they feel great. More research needs to be done in how to recognize this phase and treat it.
Favors Medication
And Denise shares similar views:
As Kay Jamison says, it obviously carries some sort of evolutionary advantage, or it would have been bred out of the population by now. I lean to those who say the condition is both a blessing and a curse, and that it shouldn't even be called a "disease" but an anomaly. As an activist and advocate, that is the stance I have publicly taken. I guess my main reason for doing so is to reduce the internal stigma of "consumers" and their families. Having lived through several severe episodes on the part of husband and both sons, I'm very aware of how destructive full blown bipolar can be, and I would still not argue in favor of complete elimination of the condition from the gene pool. I do, however strongly favor medication and self-management.
Treating Hamilton
Dr Gartner?s book, "The Hypomanic Edge," featured founding father Alexander Hamilton as one of its case studies. Hamilton?s preternatural imagination and brilliance saved a young nation from bankruptcy, but his reckless disregard for his own safety wound up costing him his life in a duel.
This led to my posing this question to psychiatrists in last week?s Newsletter: If Alexander Hamilton were your patient, how would you treat him? Is this the same standard you apply to your other patients?
One psychiatrist was brave enough to answer. S Nassir Ghaemi MD MPH of Harvard and author or co-author of more than 60 articles writes:
On the question about Hamilton, I agree that I would not treat him if I could avoid it. I have suggested the same about depression though: I would not want to treat Lincoln's chronic depression or Washington's slow-thinking introversion. On the other hand, there was a time when Lincoln was severely suicidally depressed, and he in fact sought and received psychiatric treatment. There is a great book on the topic to be published later this year by Joshua Wolf Shenk called Lincoln's Melancholia.
Europeans are Proud to be Crazy, Too
Dr Gartner?s book attributed American success to a generous supply of mania lite genes inherited from the people mad enough to set off in leaky boats for an uncertain life on a strange shore. Dr Gartner observed that Europeans are mystified by American excess, even as they embrace our culture. This prompted a reply from Dr Marlies ter Borg, a self-described bipolar II philosopher. Dr ter Borg has published a book in the Netherlands on bipolar disorder and creativity from a European perspective, "The Flower of Sickness," which is being translated into English. Writes Dr ter Borg:
Actually we love American exuberance. What does dismay us is your provincial arrogance, possibly due to a deep rooted inferiority complex?
Of course you must be aware of the fact that the positive side of bipolar disorder was discovered by the Greek Philosopher Aristotle as early as the fourth century BC.
Many if not all great religious leaders, - David, Saint Paul, Augustine, Luther and of course Mohammed, and even Buddha, could in retrospect be labeled as bipolar- not to mention great writers/ poets/artists such as Goethe, Pushkin, Baudelaire , Van Gogh etc.
Of course those colonizing foreign parts in past centuries were also often a bit hypomanic. However in most countries such as former Dutch colony of Indonesia, they were kicked out by the locals. Do I need to explain why this didn't happen in the S?
Come on guys, let?s not exaggerate the nationalist sentiment, an outdated product from the 19th century hypomanic romanticism. These issues are worldwide.
We, and here I mean mankind, wherever, have centuries experience of how we should get the best out of hypomania without falling prey to destructive extremes.
Last Word
Finally, these insights from Anne:
Perhaps it was hypomania speaking when I told my family doctor, pychiatrist, psychologist, and neurologist that I would not take anything that made me fat or made it difficult to function. Perhaps it was the psych nurse in me that knew I couldn't work and drool at the same time. Perhaps it was the safety of knowing that in spite of a lifetime of experiencing hypomania as a difficult child, epileptic, person with multiple sclerosis, all of that got thrown away for the sake of my new label bipolar.
Perhaps it was the safety of knowing that I never was hospitalized, never attempted suicide, was capable of honors work in 4 majors, raised a son with bipolar who never attempted suicide, went to jail, or was hospitalized, and another who was just simply healthy.
Now I work in my job, and work in reforming the mental health system in our community as a board member. I have not been secretive about my label. Perhaps this is due to my hyperverbal nature. Yet indeed I have done some bold, dangerous, and uncharacteristic things in my life, yet survived my impulsivity, disorganization, hallucinations, and depressed, manic, or mixed states by learning to discipline my mouth, wait until after work to let myself lose it, and rather creative excuses for my giddy behaviors
When my desire is strong enough to overcome tedium, I achieve. It is rarely motivation that is the issue. I can do anything if I can tolerate the snail?s pace for a while. Truly I can relate to the "time warping" factor of the cycles, and have learned when to use them best to accomplish my dreams. I can write 10 pages of a proposal in two hours, and spend the rest of the day writing a paragraph.
Perhaps not everyone has this luxury, as my psychosis has not been particularly disabling, in fact on the contrary. It has been pleasant, comforting, inspiring, and occasionally a bit of an annoyance when I'm trying to sleep or drive and have to pull over. Perhaps that's the difference. I'm not generally so delusional that I can't figure out when to take time out and appreciate the show.
Buy The Hypomanic Edge
This book was as fun to read as "The Da Vinci Code" and far more accurate. Readers can support this Newsletter by buying The Hypomanic Edge: The Link Between (a Little) Craziness and (a Lot of) Success in America from Amazon.com by clicking the link.
Next Week
I?m on my way to the American Psychiatric Association annual meeting in Atlanta, where I?ll be taking lots of notes and reporting back to you. Till then ?
McMan's Web
Check out nearly 300 articles on all aspects of depression and bipolar, plus a bookstore, readers' forum, message boards, and other features at:
http://www.mcmanweb.comNew: Treating Hypomania (last week's Newsletter in article form); Hypomanic Nation (my review of Dr Gartner's book, from Newsletter 7#7)
Oldie but goodie: Vincent and Me (my love note to Van Gogh)
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John McManamy
"Knowledge is necessity."
Copyright 2005 John McManamy
