Bipolar Expeditions (20 page)

Ms. Miller:
Baseball … I can't do the other two.

Dr. Dean:
Can you spell “cloud”?

Ms. Miller:
I'm not good at spelling.

Dr. Dean:
Try.

Ms. Miller:
“C,L,O,D.”

Dr. Dean:
That's “clod.” Try “cloud.”

Ms. Miller:
No.

Dr. Dean:
Can you spell it backwards?

Ms. Miller:
I ain't gonna mess with it backwards.

Dr. Dean:
Just try.

Ms. Miller:
You better figure it out for yourself then.

Dr. Dean:
Can you recall the three items?

Ms. Miller:
No.

Dr. Dean:
Can you recall them?

Ms. Miller:
No.

Dr. Dean:
You have been in treatment for some thirty years?

Ms. Miller:
Yes, the first breakdown was terrible. I was real upset. I didn't get no good treatment, they brought me to the seclusion room and pinned me to the mat. It was not explained to me what it was all about. I just wanted to talk to my husband first.

At this time, the floor was opened to questions from others.

Dr. Murray:
Are you enthused about Jehovah today?

Ms. Miller:
I am not doing that no more.

Dr. Murray:
How many times a day do you pray?

Ms. Miller:
That's an interesting question. About three times.

Dr. Murray:
Do you do any food rituals?

Ms. Miller:
No.

Dr. Murray:
How are you feeling now?

Ms. Miller:
Lively.

Dr. Murray:
How is your thinking? Clear?

Ms. Miller:
To me it is.

The interview ended at this point, and, after Dr. Dean thanked Ms. Miller and a student accompanied her out, the discussion continued.

Dr. Neal:
At her 1992 admission she was off the wall. She invoked Jehovah, would not eat, was paranoid about the food, and finally she had to be put in the quiet room. She was pacing the halls and frequently up during the night.

Resident presenting the case earlier, who wears a yarmulke:
The extent of her praying would not be unusual even among the people I associate with, who practice Judaism.

Dr. Dean:
Is she trying to put her mania under a bushel to get discharged?

The students were asked to distinguish disorientation from attention. Disorientation involves being delirious, whereas lack of attention involves memory. The group decides that she was not disoriented but did have trouble recalling things, even though she could pay attention to some extent.

Of the many countervailing currents in this event, I will mention only a few. On one side lies the legitimacy of religious practice, which is often at odds with the routines of daily life; on the other lies the worry that her religious practices line up with other extreme aspects of her behavior to indicate a serious psychological condition. On one side is her feeling that previous treatment was not explained to her and she felt coerced (together with her preference not to be at this event at all); on the other is the staff's concern that she was subdued because she was out of control and that being presented at rounds might lead to some new ideas about how to treat her. On the one side is her resistance to taking a test based on schoolroom activities, knowing that her mental state will be assessed on the basis of it; on the other is the doctors' need to find out if her thought process is disordered so they can recommend appropriate medication. What is at stake here, among other things, is which side of the DSM distinction between cognitive and emotional disorder she belongs on, or where in between. The rounds presentation is a moment in an ongoing discussion among the staff about whether she is manic depressive (and so best treated with lithium, as well as an antipsychotic like Zyprexa), schizophrenic (and best treated with an antipsychotic alone), or, alternatively, whether her psychosis was caused by the combination of drugs she had been taking on admission.

(7) Maybe He Is a Normal Variant

Resident:
Mr. Anderson is an economics professor at a university in a nearby state. He is Bipolar 1, not presently controlled by medication. He is a rapid cycler. He is married, but it is a conflicted marriage, and his wife is narcissistic and whiny. He was on lithium for twenty years and did well. Then he got renal insufficiency, evidently from the lithium, and was told by his nephrologist to go off the lithium. Then he was all over the place. He was sexually inappropriate with students at a party while drinking, and experienced a general decrease of his social inhibitions. He has tried Depakote, Neurontin, Seroquel, and Tegretol.

His teaching became poor, he was nasty in class, and he pushed at the desk in anger, which students found intimidating. He would break into song in the middle of lecturing (and he teaches one of the core courses). There were student complaints. As of this January, he was relieved of his teaching duties. He is a renowned economist, and he has written textbooks. When he was up, he experienced higher spending than usual, low impulsivity, irritability, and pressured speech. When he was down, he needed increased sleep and he experienced anhedonia. The cycles were every four to five months to hourly.

Mr. Anderson came in, looking drawn and gray, with a shaggy beard. Wearing a casual plaid shirt, jeans, and a cardigan, he walked with a shambling, erratic gait and jerky limbs.

Dr. Dean:
How are you doing today?

Mr. Anderson:
I am where I want to be—I am getting better so I can function in a productive way. I went off lithium in 1996. Since then, things have been erratic, I have had trouble sleeping, I've been waking early and feeling irritable, talking fast, with slurred speech; I've been making mistakes, getting mixed up at the blackboard, but I have great energy and I think I am superman. I am committing myself to grand research projects and big research problems.

My department upgraded the curriculum, and this put my courses out of date. My math is not good enough to handle the newer techniques, and this causes me great anxiety. One of the students complained I put a question on the exam I myself had not been able to answer during class, but I thought that was OK, that students should figure things out for themselves. This happened when I was manic. When I am depressed, I sleep a lot, and come to class unprepared. I talk slowly and I don't meet my duties.

Dr. Dean:
Do you feel normal?

Mr. Anderson:
No, not since stopping the lithium. Since being off the lithium, I would say I have been more manic.

Dr. Dean:
Do you have any delusions?

Mr. Anderson:
That I am competent to do what I can't, to work with mathematical models I don't have training for. I put articles on the syllabus I don't understand.

Dr. Dean:
This is not a delusion, but overconfidence. What is the worst thing about the depressions?

Mr. Anderson:
When I got the letter from the department saying I was out of the classroom. I had lost my job, and was really down.

Dr. Dean:
Do you experience rapid cycling?

[Mr. Anderson describes in some detail the variation in the lengths of his moods.]

Dr. Dean:
Do you go through a normal state there for a minute in between?

Mr. Anderson:
That would be the smallest time, and it is the only time I feel normal.

Dr. Dean:
Can you bring the moods on? Can you change your mood?

Mr. Anderson launched into a long and involved but coherent narrative about his experiences working in industry and his decision to move to academia. Dr. Dean tried unsuccessfully to interrupt him a couple of times. After the interview ended, Dr. Dean turned to the group.

Dr. Dean:
Was this an easy diagnosis to make? [The first two students he called on hesitated and could offer no answers.] We need some help for our friends here. How would we describe his speech? What is pressured speech?

Student:
The person can't get the words out?

Dr. Dean:
No, it is the opposite, you cannot interrupt. You can't get a word in. He qualifies. He goes off on tangents and doesn't answer the question. You could use the word “circumlocution” if he eventually gets back, but I despaired of him ever getting back several times.

Is it a thought disorder? We look at his syntax and semantics. Is the syntax loose, is he distracted? And his semantics—is he appropriate?

Students had trouble answering these questions, but Dr. Dean summed up the consensus that Mr. Anderson did not have thought disorder.

Dr. Dean:
Maybe he is a normal variant. His condition is especially common among professors. This is a gray zone.

Dr. Jones:
It is not clear-cut. His pattern is not at all uncommon, especially among writers and artists.

In this case, since several criteria of schizophrenia or schizoaffective disorder were lacking (delusions and thought disorders), the physicians in the room focused on the diagnosis of bipolar disorder. Since he had many positive signs of manic depression, the treatment recommended at the end of rounds was restarting a low dose of lithium, in hopes that the renal problems would not recur. Nonetheless, Mr. Anderson was placed in a “gray zone” between mental illness and mental health, perhaps because the doctors identified with the patient and his brilliant youth, followed by his faltering middle age. His moodiness, his occasional overreaching of his knowledge, and his travails moving between academia and industry might have been all too familiar. A certain generosity might also have been flowing from Mr. Anderson's gratitude for the medical treatment he received at Wellingtown Hospital and his open expression of insight into the pathological features of his condition.

(8) I'm a Twenty-Year-Old College Student with a 3.75 GPA and I Am Not Crazy

Dr. Paulson presiding, a resident presents the case.

This is a twenty-year-old African American male admitted in the emergency room at Riverside Hospital [pseudonym for a recently built medical complex in Baltimore] with a strong suicidal gesture: he said he wanted to blow off his head with a gun, and he actually did have a gun. He grew up in Newark, where his parents were drug dealers and users. He had a pattern of working at a lot of jobs, at times five at once. He has been in jail, once for a number of years, and he is a college student. His personal history: he was born by Csection, drank bleach at eight months of age and was hospitalized then. Life was poor and chaotic, but he stood out. He was outgoing like all the kids, but he was sensitive, and he would stay inside and study. Assiduous and studious, he did very well at school. But he did get into fights, from age fourteen on, and was jailed for fighting several times. Two years ago he was admitted to State College, in the business program. He kept very busy, often staying up until 2 a.m., during his first year. Now he is home for the summer and has a summer job as an intern at an investment bank, the first job of any substance he has ever had.

One week before admission, he had a dose of Angel Dust [PCP]: unknown to him it was in the marijuana he smoked. In college for the first two years he was on the dean's list. Then there was a downturn because he felt his family didn't visit him and therefore must not love him. After that he only got Cs. He has also been anxious and overactive. He would try to do ten things at once.

Last Tuesday, his family saw an abrupt change. He was very tearful, very labile, and paranoid. He thought the neighbors were going to kill him so he bought a pistol and kept it nearby. (As an aside: this is part of his reality—people do get killed in his neighborhood.) The family called him crazy. He came to Baltimore to see a friend, and at that point he bought
another
gun. Frightened, he called 911 himself. He came into the Riverside emergency room out of control. At one point he ran out naked, and he was then put into the seclusion room. He showed rapid speech, tangential speech; he was labile, tearful, and grandiose. He talked about how he would be rich, a famous rap star. He heard God's voice.

On admission here, I saw someone who was clearly manic. I assessed him as a twenty-year-old with underlying illness who had become floridly manic with all these stressors. Complaining of pain, he was examined and diagnosed with severe testicular torsion, and so he had to have a testicle removed. Now he is close to normal, but he is still intrusive—you can't interrupt him. The reason we brought him in here is to get help with whether his condition is PCP-induced or caused by an underlying illness.

Mr. Burton came in, accompanied by his mother and grandmother. As he entered the room, he looked around at all the people sitting there in white coats, and said, “Hello, I am Keith Burton.” Sitting down, mother on one side and grandmother on the other, he said, “I'm a twenty-year-old college student with a 3.75 GPA and I am not crazy.” Without missing a beat, Dr. Paulson began the interview.

Dr. Paulson:
How are you feeling today?

Mr. Burton:
Great.

Dr. Paulson:
How did it happen that you called 911?

Mr. Burton:
I loved my family and I missed them in Florida, so I came back north. After I got here, my grandmother kicked me out. She said I was crazy to drop out of college, so I told her next time you speak to me I will be calling from a mental institution.

Dr. Paulson:
Do you remember the question I just asked you?

Mr. Burton:
I came to Baltimore, saw my friend, and called 911 emergency. They took me to Riverside Hospital where they injected me with three needles, because they said I had to be calmed down, but I was terrified, I didn't know what it was.

Dr. Paulson:
Were you scared?

Mr. Burton:
No, it was really that I was terrified. I wanted to call my mother, because no one even knew where I was, and I didn't know what the needle was. Now I have needle marks all over and I don't even shoot drugs. After the fourth needle, I again wanted to call my mother and father, but they wouldn't let me, so I ran. I was terrified. They called security on me, restrained me. But I still got shot. Now I am back to my old self.