Harvard Health
The Feelings Are Mutually Exclusive
Navigating the highs and lows of bipolar disorder
by John F. Lauerman
Feelings color all our experiences, and for some
people the filter of emotions can go from rose to purple to
black as quickly and subtly as the setting of the sun. Once
referred to as manic-depressive illness, bipolar disorder
is a baffling condition that affects close to three million
Americans.
The most distinctive feature of the disease is precisely
what it makes it most elusive: patients "cycle" between major
episodes of depression and mania. Sometimes the dips and climbs
can be rapid and confusing, and patients themselves may have
no idea whether they are manic or depressed.
Clinicians also find bipolar disorder hard to spot because
it combines two of the world's most diagnosis-immune illnesses.
On the one hand, the World Health Organization recently acknowledged
that depression is internationally underrecognized and thus
treatment is far from adequate. On the other hand, there's
mania, defined as a "distinct period of abnormally and persistently
elevated, expansive, or irritable mood, lasting at least one
week." Unlike the victims of colds or headaches, who know
something is awry, people in the manic phase of bipolar disorder
often don't hear that message. While the rest of the world
crawls, they feel energetic, confident, in control.
"That was the frightening part of it. I thought I was complete
and whole," recalls 62-year-old Francesca Dodd, of South Yarmouth,
Massachusetts. When she was diagnosed with bipolar disorder
at 45, she says, "It was like a bomb dropped on me. It's hard
to admit you're manic, because it's so wonderful. It's like
the story in Mary
Poppins where they go up and fly with the balloons."
Mania, indeed, has been described as a "key to genius,"
a disorder that has led
to some of the world's greatest artistic
and intellectual achievements. Van Gogh and Freud, Charlie
Parker, Cole Porter, Georgia O'Keeffe, and Emily Dickinson
may all have had bipolar disorder. Who would take medication
to curb the kind of imagination, elation, and energy that
would put one in such a class?
But mania for most sufferers is no ticket to fame. Gary
Sachs, director of the Harvard Bipolar Research Program at
Massachusetts General Hospital, reports that bipolar illness
is often compared to another Mary Poppins episode:
the visit to her Uncle Albert, who loves to laugh. When Mary
and her young charges arrive, they find the old man whooping
uncontrollably and hovering near the ceiling. If only they'll
laugh with him, he says, they can join the fun. Everyone has
a wonderful time until the guests have to leave, and the whole
party crashes to the floor.
"People tend to think of mania as being like that infectious
good mood," observes Sachs, who is also assistant professor
of psychiatry at Harvard Medical School. "But mania is no
laughing matter. In fact, most people are irritable and argumentative
during their manic episodes. They're impulsive and impatient,
and the people around them often just want to duck out and
get away."
Bipolar patients like Francesca Dodd have found that their
high-strung manic episodes often repel the close family members
who could help keep their behavior in check. Alone and unsupervised,
a manic person can be a serious hazard to herself and others.
In An Unquiet
Mind, Kay Redfield Jamison writes about the "wild
blue yonder" of mania, the invincible hours and days when
she did the inexplicable, like buy 12 snakebite kits, or a
horse, or 20 books on Arthurian legend simply because she
had caught a glimpse of a brook that reminded her of a passage
from Tennyson's Idylls
of the King. As the whirlwind of wakefulness and confusion
whips harder, manic people lose all the perspective that could
let them see themselves as sick.
Although poorly understood, bipolar disorder's saving grace
is its relative treatability. Lithium, which has been available
for many years, or newer drugs, such as divalproex, carbamazepine,
and antipsychotic medications, can treat most cases of mania
effectively. Unfortunately, since bipolar patients seldom
complain to their doctors about their manic episodes, nonspecialists
often interpret the underlying problem simply as depression--and
treatment with standard antidepressants often has the unfortunate
effect of provoking manic episodes.
The problem, then, isn't that there aren't drugs to treat
bipolar disorder; it has more to do with identifying the people
who need treatment and persuading them to take it. As Jamison
writes, "That I owed my life to pills was not obvious to me
for a long time; my lack of judgment about the necessity to
take lithium proved to be an exceedingly costly one."
The best way to gain perspective over the "siren call of
mania," as Sachs terms it, is to emulate the plan Odysseus
implemented on his voyage home from Troy. Knowing that he
would sail within hearing range of creatures whose intoxicating
song lured men to destruction, Odysseus filled the ears of
his crew with wax and lashed himself to the ship's mast after
ordering that no one was to let him go, no matter how he pleaded.
Bipolar disorder sufferers must have their own posse of friends
who can be trusted to recognize manic episodes and suggest,
or even insist, that they take their medication.
"Involving friends and family in the process allows patients
to remain captain of the ship," Sachs says, "yet recognizes
that they're not always going to be well. It's a concept that's
hardwired into all kinds of arrangements: even the U.S. Constitution
has a provision for the vice president to take over if the
president isn't able to perform. When this is part of the
patients' plan, it protects them and all the people around
them."
Now psychiatric researchers will try out this approach more
widely in a large-scale clinical trial of the treatment of
bipolar disorder that will enroll some 5,000 patients at 20
treatment centers across the country. Although such mammoth
trials are relatively common in the study of heart disease
and cancer, this will be the largest clinical trial ever undertaken
by the National Institutes of Mental Health (NIMH). Its inclusive
design will enable researchers to examine the effects of a
variety of approaches on many different types of patients
with bipolar disorder.
Equally important, all the psychiatrists involved will receive
training in best practices for treatment of bipolar disorder.
Sachs hopes that improved recognition and treatment of the
disease will encourage more patients to come forward and identify
themselves. Enrollment for the study has already begun, and
Sachs says that patients' families have welcomed the opportunity
to become more involved in helping to manage relatives who
have the disease.
"It seems to be a powerful idea," he says. "We can help
patients with bipolar disorder to continue to set the course
of their own lives. They're no longer in a subordinate position,
and that makes navigating this disease a whole lot less frightening."
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