Bipolar: Sick or Special?

Let me be clear: bipolar is a disease listed in the Diagnostic and Statistical Manual (DSM). It is diagnosed by psychiatrists, and treated with medication. There’s no question of its legitimacy as a medical condition. But having had the opportunity yesterday to interview a standardized patient with bipolar disease, I was awakened to the idea that these patients often disagree about being ill.

As the name suggests, bipolar involves alternations between the two extremes of mood: depression and mania. No doubt you’ve heard of and could recognize depression, but do you know what mania looks like? Manic patients are incredibly friendly and likeable; they have an elated, un-deflatable mood, and are very busy people. They rarely sleep, eat copiously, and socialize even more than they eat. They’re relatively disinhibited, and will make friends with strangers, spend money freely, and will try any new activity (including drugs). True mania is accompanied by delusions –  usually delusions of grandiosity. The typical manic believes that they are an especially remarkable person and that they will accomplish legendary success.

The “problem” with mania, is that in the extreme it can be profoundly damaging. In an episode of mania, a bipolar patient may spend all of their money, or make new sexual contacts that they later regret. Jobs are lost, relationships are strained, and medical illnesses are worsened because often the manic forgets to take their medication. Manic patients are sometimes arrested for their indiscretionary behaviour.

Bipolar disease is treated with mood stabilizers. When effective, these drugs reduce the frequency of both depressive and manic episodes. The reality is, however, that many bipolar patients don’t want to take them! The personal perception of mania is such a positive, exhilarating experience that people with bipolar look forward to, and try to prolong their manic episodes. Those who are artists have their most creative moments when manic, and those in business make the most of their money.

So whose assessment of “ill” trumps the other? It’s a very difficult question. Legally, there is guidance available to assess whether a patient is capable of making their own decisions or not. Mostly this involves determining whether the patient fully understands the options available to them, and the consequences of each one. If incapable, patients can be legally held and provided with the treatment that they need.

All of this leaves me asking the question: who am I to deem that you are too happy? When does it become the doctor’s right to decide your mood? And yet at the same time, doesn’t your doctor have the responsibility to look out for you, and advocate on your behalf when you are incapable of doing so? Even if that means protecting you from yourself?

I present all this solely to ask the question. I don’t have the answer. I’m confused and unsure about it. But asking the question is an important first step. I welcome your ideas!

Anorexia Nervosa

Anorexia is a high-profile psychiatric disorder; most people know about it – or at least, they think they do. Today’s lecture on eating disorders challenged many of my pre-concieved notions about anorexia nervosa. Here are a few points that I found interesting/significant:

1. 12% of people with anorexia will die from the disorder. This disease is far more serious than just low self-esteem about body weight/shape.
2. Some anorexics engage in binge-eating and purging (such as self-induced vomiting). This behaviour is not restricted to just bulimia, but is seen in anorexia also.
3. There’s an element of “psychosis” in anorexia. Psychosis is believing/perceiving something that isn’t real. Most anorexics will deny that they are underweight. When asked to outline her reflection in the mirror, one woman with anorexia drew the line three inches too wide on either side. Anorexics truly perceive (see and feel) that they are overweight!
4. The prevalence of anorexia is not increasing. Although Western culture’s preoccupation with beauty in thin-ness contributes to the maintenance of anorexia in already ill patients, it has not driven up the incidence.
5. Gay men are particularly susceptible. There are ten times as many women with anorexia nervosa as men. But a particular sub-group, gay men, are especially susceptible to this disease. The reason is presumably gay culture’s preoccupation with body shape/size.
6. There’s a strong genetic component. If you have an identical twin who has anorexia nervosa, there’s a 70% chance that you’ll get it too. That’s pretty strong for a disease that we usually consider as having environmental triggers.

Made a Fool

Today was the first day of Psychiatry block. One day’s impression: engrossing, perplexing, and not like anything I’ve done before.

This afternoon we broke into small groups to practice the psychiatric interview. It took place at the hospital. After greater than an hour of conversation with a woman who was describing significant symptoms of depression, I felt quite involved in her story. I was disquieted by her lack of self-worth. Pangs of empathy welled up when she began to cry, and the urge to hug required active suppression. What a wretched affliction this poor woman is enduring, I thought.

It wasn’t until after the interview that I found out from my colleagues that she was acting. She was not a patient! Rather, she was a ‘Standardized Patient’, performing a role written for her by our psychiatrist instructors! What a fool ! I feel completely taken-in! She sure did her job well.

TED Talk: Vilayanur Ramachandran

If you haven’t yet discovered TED.com, go check it out! But choose sometime when you don’t have much to do, because it is highly addictive. On this website, the world’s brightest minds give ‘TED Talks’ on their most creative ideas. Topic areas are unlimited – whatever your subject, you can find a TED Talk right up your alley! Seriously, check it out.

From time to time, I’ll feature a TED Talk here on my blog – one that I found particularly interesting / creative / inspiring. 

Vilayanur Ramachandran is a neuroscientist. In this TED Talk, he uses psychiatric case studies to explain some aspects of how the mind works.

@ Introduction: Now that’s a fascinating paradox! Can a human brain ever be fully understood… by a human brain?

@ Phantom limbs: Ramachandran’s idea of how important optical input is to “programming” the nervous system (seeing the phantom limb moving was enough to convince the brain that it was no longer paralyzed) made me think of another example from my anatomy professor. Stroke recoverers sometimes have trouble initiating muscle contraction. To walk, they can throw a crumpled piece of paper (or other aide) in front of them. Having the visual cue of a target to aim for for helps to initiate the muscle movements needed to get there.

@ Synesthesia: That’s a creative definition for creativity!