Bipolar disorder, also known as manic-depressive illness, is one of the most severe psychiatric illnesses. It adversely affects the patient’s mood, activity, and thought processes. Characterized by one or more manic episodes and typically by one or more depressive episodes, the disorder manifests by an elevated, expansive, irritable mood and a host of behavioral symptoms. Because persons with mania are dangerous to themselves and to others, this disorder is considered one of the few emergencies in psychiatry (Blazer 1996).
Affecting 1% to 1.6% of both men and women, bipolar disorder occurs at about the same frequency in either gender, and without regard to national origin (Leibenluft 1996). Although gender differences have only begun to receive systematic study, there appear to be significant gender related issues regarding the course of this illness and response to treatment. For women, pregnancy and the postpartum period are times of special risk for onset and recurrence. In addition, all the effective mood-stabilizing agents pose special risks during pregnancy.
A recent fellow-sufferer is Kay Jamison who in An Unquiet Mind gives an equally appalling account of the disease’s horror. She concedes that “Depression is awful beyond words or sounds or images,” but when depression brings her close to suicide, this author finds the convincing eloquent metaphor for the situation, “a murderous cauldron”.
It is to Jamison that we should turn for the most enlightening and beautifully written description of the manic phase of the bipolar disease, especially its influence on the creative mind. Writing as an erudite psychiatrist as well as from personal experience – she herself suffers from the disease – Jamison is doubly competent. Her two striking examples of mania are thus Lord Byron (p. 39) and herself!
She loves her manic phases: “When you’re high it’s tremendous. The ideas and feelings are fast and frequent like shooting stars – I have been aware of finding new corners in my mind and heart. Some of these corners were incredible and beautiful and took my breath away.” This is a marvelous account of the moderate mania that through the ages has provided so many great spirits with a flow of new ideas and enraptured creativity. The increased mental fluidity and originality also helped Jamison in her scientific career: “having fire in one’s blood – is not without its benefits in the world of academic medicine.”
As Jamison also had experienced, the exaltation may get out of control: the fast ideas are too fast, and there are far too many, overwhelming confusion replaces clarity. This feeling of becoming enmeshed totally in the blackest caves of the mind, added to the threat of suicidal depression, made medical treatment unavoidable. She had, however, become addicted to the mania: “It was difficult to give up the high flights of mind and mood, even though the depression that inevitably followed nearly cost me my life.”
She eventually gave in; with lithium medication and psychotherapy her symptoms receded — but this was “a rather bittersweet exchange of a comfortable and settled present existence for a troubled but intensely lived past.”
As a happy ending she found that by lowering the lithium level she could recover some of her old spirit with periods of white mania: “infused with the intense, high-flying, absolute assuredness of purpose and easy cascading of ideas.”
In An Unquiet Mind, Kay Jamison reproduces her doctor’s notes: “Patient has elected to resume lithium…. Patient has stopped lithium again…. Patient is not taking lithium…. Patient has resumed lithium.” (33) Although her psychiatrist observed the serious and adverse consequences of Jamison’s decision to stop taking medication, he did not tell her that she was rotting with her rights on, or make any move to force her to take lithium. (34) Thus, the ex-patient movement’s concern with minimizing or halting forced psychiatric treatment (35) is essentially irrelevant to the millions of people who are discreditable.
Such a reality cannot even envision rescue, because it has become the individual. As Kay Redfield Jamison said, in An Unquiet Mind, “It will never end, for madness carves its own reality.”(5) In depression, the faith in deliverance, in ultimate restoration, is absent. The pain is unrelenting, and what makes the pain intolerable is the foreknowledge that no remedy will come.
In her book, Kay Jamison provides a lengthy list of writers, musicians and artists who have had either a depressive or bipolar disorder. They include Hans Christian Andersen, Charles Dickens, F. Scott Fitzgerald, Leo Tolstoy, Graham Greene, William Blake, Robert Burns, Lord Byron, Adam Lindsay Gordon, Emily Dickinson, Sylvia Plath, Irving Berlin, George Handel, Noel Coward, Cole Porter, Paul Gauguin, Michelangelo and Georgia O’Keefe.
While her focus is on the reasons for the link between creativity and mood disorders, Kay Jamison’s list also speaks to the reality that people with mood disorders can achieve and succeed in the most competitive and demanding careers when not restricted or disabled by their condition. As depression becomes less stigmatized we can expect more and more ‘successful’ people, be they professionals, business people or politicians, to discuss and identify how they have dealt with their mood disorder.
During the high, the individual feels terrific and very confident. Talk increases and is so much faster than usual that others are unable to keep up. The mind races with ideas and creativity is distinctly increased—certainly in the mind of the individual, but often in reality too. People with bipolar disorder have lots of energy and need less sleep than usual—perhaps getting up in the middle of the night to do housework or write “The Great Novel”! Sexual interest (and activity) commonly increases. Dressing is often more colorful and singing more common. The world looks brighter and more attractive (trees are greener, water more sparkling).
However, because the world is seen through ‘rose-colored glasses’, judgment may be poor. Purchases, loans, affairs and other commitments can be undertaken without due regard for the consequences. Falling in love at such times, ignoring objectivity and consequences, can lead to a number of emotional hangovers.
Although highs make Jamison feel happy, friendly and amusing, as with alcohol, others can become irritable and aggressive. Experiencing bipolar disorder is as if your brakes have failed; whatever direction you are going in—whether gambling, shopping, driving, having sex, drinking, taking drugs or showing off—you are going too far and too fast.
Kay Jamison describes one of her highs:
…everything seemed so easy. I raced about like a crazed weasel, bubbling with plans and enthusiasms…I felt great. Not just great, I felt really great. I felt I could do anything, that no task was too difficult… not only did everything make perfect sense, but it all began to fit into a marvellous kind of cosmic relatedness. (37)
There is a distinction between Bipolar I and Bipolar II. In Bipolar I the mood state is more severe, tends to be more persistent and is often associated with psychotic features. Delusions are most commonly grandiose, reflecting the mood state. In Bipolar II the mood state may still drive excessive or unnecessary shopping (e.g. a dozen sets of bed linen when only one might have been needed) but, not uncommonly, Jamison says that the mood elevation was useful in stimulating her to buy things that were necessary or to do things that she has been putting off.
Thus, there can sometimes be advantages in experiencing a high and a lot may be achieved as a result. Many of the world’s top creative people have suffered bipolar disorder and, if you have bipolar disorder in your family, you have a distinctly increased chance of being in Who’s Who. But it is an asset with liabilities. If most people were said to have four-cylinder brains, people with bipolar disorder have V8s. Unfortunately, they also have cheap drum brakes. Quite a dangerous combination!
An illness that is biological in its origins, yet one feels psychological in the experience of it. Kay Jamison experiences both highs and lows (although a small number get only highs). The lows are almost always of the melancholic or psychotic depressive type.
Those suffering agitated depression appear preoccupied with what are usually quite mundane things—which are blown out of proportion—and show considerable mental anxiety. They may pace up and down, wringing their hands, or even make little picking movements. Speech is rapid but superficial and without the usual richness—again dominated by mundane concerns and often guilt. Sufferers may look apprehensive or even fearful and their mental anguish is often visible to others.
In An Unquiet Mind, Kay Jamison describes one experience of agitation:
…I became exceedingly restless, angry, and irritable, and the only way I could dilute the agitation was to run along the beach or pace back and forth across my room like a polar bear at the zoo. (45)
Such stereotypical presentations (of observable retardation and agitation) are usually independent of the individual’s personality, and suggest to the professional observer a biological disruption or disease process. In younger people, observable psychomotor disturbance may be less evident. On questioning, however, they will usually describe experiencing motor changes (e.g. an inability to undertake basic things) and, in particular, describe distinct effects on thinking and concentration, perhaps finding it quite impossible to study or concentrate on reading.
I cannot imagine leading a normal life without both taking lithium and having had the benefits of psychotherapy… lithium … diminishes my depressions… gentles me out…But, ineffably, psychotherapy heals. (34)
Somebody suffering from maniac depression can appear either retarded or agitated, or even alternate between the states. Agitation may increase the suicide risk, while severe retardation may reduce the risk. Unfortunately, as treatment progresses and retardation decreases, those suffering melancholic depression can be at greater risk of suicide even though by all appearances they are recovering.
In retarded maniac depression, actions slow down—those suffering from this disorder may walk or talk slowly, pause before moving or talking, use briefer sentences with reduced conversational richness. They are not able to brighten (at all, superficially or temporarily) at the introduction of pleasant topics. Many say that they find it hard to get out of bed and do such basic things as having a shower, as if there is some kind of mechanical failure to function. The normal ‘light in the eyes’ is diminished or lost, facial movements are less mobile, hair may become brittle and skin pale and even pasty.
We have argued that there are multiple expressions of depression. In a sense, depression is, at the first level, a non-specific signal like pain—but one requiring analysis and interpretation. The diagnosis of pain is not as important as diagnosing the cause of the pain, for then treatment becomes more rational and predictable. To prescribe an analgesic for pain may be helpful (and, at times, sufficient), but it may also be less important than determining what is causing the pain and addressing that cause.
Recommendations for managing maniac depressions are less clear; it is not a pure class and, as noted, published studies suggest similar levels of success across contrasting treatment approaches. This unsatisfactory finding reflects current limitations in the way that multiple expressions of these conditions are grouped into pseudo-entities or ‘things’, such as ‘major depression’ and ‘dysthymia’, rather than acknowledging that maniac depressions are probably better seen as a reflection of the painful impact between life stresses and a person’s personality or temperament.
Hallucinations and similar illusions, connected with epilepsy and migraine, have often had a profound effect on the creative process and have consequently been reflected in the book. An association of genius and epilepsy, “the sacred disease”, has been assumed because of the great number of creative minds that have been afflicted, among them Petrarch, Pascal, Moliére, Byron, Flaubert and Swinburne; in none of them was the mental capacity diminished by the disease.
Kay Jamison’s research on moods and madness, her memoir of manic depression, An Unquiet Mind, in which she details moods which remind of Lupe Vélez’s: an electrifying bolt of energy, overflowing with laughter, exuberance, and Xuctuating tides of emotion. Although the phantasmic multiple image of Vélez is an effect of technical manipulation, I believe its photographer, Ernest A. Bachrach, serendipitously (or perhaps knowingly) captured her oscillating temperament. I recognize that I am veering toward speculative psychobiography, even bordering on pseudoscience, in my attempt to diagnose Lupe Vélez with manic-depressive illness. Yet, like Kay RedWeld Jamison, Vélez “lived a life particularly intense in moods.”
In her book, Jamison explores the controversial claim of the relation between artistic temperament and manic depressive illness. The fiery aspects of thought and feeling that initially compel the artistic voyage—energy, high mood, and quick intelligence; a sense of the visionary and the grand; a restless and feverish temperament—commonly carry with them the capacity for vastly darker moods, grimmer energies, and, occasionally, bouts of “madness. ” The opposite moods and energies, often interlaced, can appear to the world as mercurial, intemperate, volatile, brooding, troubled, or stormy. In short, they form the common view of the artistic temperament, and they also form the basis of the manic-depressive temperament.
Depression is commonly viewed as an ‘it’, as if there is just one condition that varies dimensionally— whether by severity, persistence or recurrence. Defining depression in such a way (with official systems listing ‘major’ and ‘minor’ depression as if such distinctions are illuminating) has consolidated the ‘it’ model. Acceptance of this non-specific model has had three main results.
The first is that patients are likely to receive a treatment favored by their practitioner rather than a therapy tailored to their condition on a demonstrated and rational basis. Second, as a consequence there is a ‘one size fits all’ model for viewing treatment for depressive disorders. Evaluative studies have shown a similar response rate for non-melancholic depression across most therapies tested (whether antidepressant drugs, cognitive behavior therapy or counseling), and so the non-specific model has been allowed to proliferate unchallenged.
As psychiatrist Blazer (1996) has observed, classifying depression by severity and not by cause, and then randomly assigning people to a treatment, is about as rational as randomly allocating people in pain “to spend a month in a pain program or to have an appendectomy”.
A third result of the non-specific model is that treatment tends to be prioritized along disciplinary lines. Doctors may view depression as a disease and therefore treat patients with only antidepressant drugs. Clinical psychologists, on the other hand, may see cognitive behavior therapy as the only appropriate treatment for ‘it’.
Some studies suggest that many people with mood disorders do not receive effective treatment despite its availability and efficacy. As many as two thirds of patients with bipolar illness who could receive help do not get it, often because they fail to recognize that they have a treatable illness. In 1979, the U.S. Department of Health, Education, and Welfare estimated that a woman who develops bipolar disorder at age 25 can be expected to lose 9 years of life expectancy overall, with a 14-year loss in productivity during her lifetime (Bowden 1996). This pronounced risk is largely a result of suicide among these patients. With treatment, however, many of the hazards associated with the illness can be eliminated, leading to increased life expectancy, enhanced productivity, diminished risk of suicide, and improved quality of life (Leibenluft 1996).
Bipolar disorder is often complicated by other psychiatric problems, most notably substance abuse (Leibenluft 1996). All persons with bipolar disorder should be counseled to avoid intoxicants, because they can lead to treatment failure. Patients with bipolar disorder may attempt to self medicate—with alcohol or street drugs—their irritability, agitation, sudden mood or behavior changes, and depression. The increased use of psychoactive substances (particularly cocaine and hallucinogens) has resulted in greater recognition and treatment when both bipolar disorder and substance abuse occur simultaneously. Patients with a substance abuse history may complain of manic, hypomanic, depressive, or mixed affective symptoms, leading some authorities to suspect a causal relationship.
An Unquiet Mind, the popular autobiography by psychologist and researcher Kay Jamison, has raised awareness about the clinical presentations and personal toll of this malady. Both professionals and the lay public have developed a working knowledge of the disorder through popular accounts of the lives of artists and writers. The widely acclaimed book charted the spiraling downhill course, punctuated by intensely hyperactive periods of productivity and creativity, of Sylvia Plath, Anne Sexton, Ernest Hemingway, Ezra Pound, Vincent van Gogh, Paul Gauguin, Virginia Woolf, Georgia O’Keeffe, Mark Twain, and Tennessee Williams, to name only a few.
Jamison cited the ability of these artists to function on only a few hours of sleep, their proclivity to work intensely and relentlessly, and their capacity to experience and to express profoundly deep and varied emotions, thus illuminating—for both the professional and the layperson—the cost of human suffering inherent to mania and hypomania. But what becomes apparent in the study is that not all the sequelae of this illness are necessarily negative. Increased energy, increased speed of thought, decreased need for sleep, and grandiosity may be conducive to artistic flair and originality. The enormous productivity and élan of manic-depressive individuals not infrequently stirs resentment in bystanders who are unaware of the price those afflicted must pay.
Only through the writing of a great author who has lived through the disease, may we, ordinary spirits who but occasionally suffer from “the blues” come anywhere close to understanding the height of suffering from depression in its catastrophic form. As an academic psychologist and author of the most respected and informative text on manic-depressive illness, Kay Jamison’s description of her own bipolar disorder in An Unquiet Mind serves as an inspiration.
Jamison’s harrowing description of her own struggle with manic depressive illness is a powerful, gripping, and brutally honest portrait that has spurred others affected by the disorder to ask questions and seek treatment. In the daily practice of primary care, it is increasingly common to find patients who are sophisticated consumers familiar with the “addictive euphoric manias” (restlessness and irritability) and the wildly agitated, paranoid, and physically violent crises that Jamison describes so vividly. This author’s courage to go public with her illness has made it possible for others with a similar personal history and incapacitating symptoms to seek help, with the requisite courage to counter the stigma and sense of personal isolation and humiliation that accompany mental illnesses more than physical disorders.
Kay Jamison received a significant amount of distressingly negative reaction following the publication of her landmark autobiography, An Unquiet Mind, with some colleagues and professionals among the most critical of her disclosure. There is, in fact, a clear tendency for professionals to convey discriminatory, hostile, nonaccepting attitudes toward those afflicted with mental disorders. Indeed, family members report that some of the greatest stigmatization they have experienced often emanates from those charged with helping the relative receiving treatment. It may be that those responsible for treating persons with mental disorders distance themselves too greatly from the afflictions of those in their care, exemplified by extremes of “us versus them” thinking and attitudes. A fellow professional’s disclosure, from this perspective, is tantamount to admitting a huge personal or familial flaw.
In fact, what should the standards be for the mental health of those working in the field? Does the presence of any mental disorder disqualify an individual from serving in such a role? My answer would be, in this regard, “of course not, ” given the high prevalence of such disorders as depression and anxiety disorders in the general population and the distinct possibility that personal experience with such conditions could actually enhance empathy and support. Yet what if the mental disorder in question involves severe levels of depression or psychotic levels of functioning, which could compromise the professional’s ability to work and exhibit sound judgment? Should patients be exposed to the potential irrationality of providers with thought disorder, which can, as I took pains to explain earlier in this work, often accompany severe manias and depressions? And what of serious, judgment-impairing levels of substance abuse on the part of professionals?
The author’s personal torment with bipolar illness is described in this poignant, accessible autobiography. The reader emerges with a sense of what it is like to be manic-depressive. This book will help the patient not only to understand her illness better but also to realize that very successful people who are affected by it can go on to lead fulfilling lives. The benefits of both psychotherapy and pharmacotherapy are described, as is the toll of denying or keeping the illness secret because of stigma. Jamison, in fact, has set up a system of monitoring and consultation related to the possibility of “breakthrough” episodes that she may encounter despite her continued taking of mood stabilizing medication. Clearly, she has given the entire issue considerable thought, challenging the field to do the same.
References
Blazer G. (1996). Lifetime perturbations of bipolar disorder. Am J Psychiatry.
Bowden C. (1996). Dosing strategies and time course of response to antimanic drugs. J Clin Psychiatry.
Jamison, K. (1995). An Unquiet Mind: A memoir of moods and madness, Alfred A Knopf, New York.
Leibenluft E. (1996). Women with bipolar illness: Clinical and research issues. Am J Psychiatry.
