Treatment of Bipolar Disorder Goes Psychotic

 

Ever since I did my psychiatric residency training way back in 1974-1977, bipolar disorder (then called manic-depressive illness) was the easiest of the major psychiatric disorders to treat medically. There was (and is) absolutely no evidence the craziness of the patient during a manic episode or a bipolar depressive episode is amenable to any psychotherapy technique, although therapy might be important when the patient is euthymic (that is, not in a manic or depressive episode – which is most of the time) to deal with the aftermath of their having been psychotic or for other co-morbid psychological problems. Euthymic bipolar patients can have co-occurring personality disorders and anxiety disorders and anything else just like anyone. Since, when euthymic, they are in fact just like everyone else.

If you want to see what a manic patient looks like, look at this video of Charlie Sheen (https://www.youtube.com/watch?v=pipTwjwrQYQ). He actually took a show on the road but had no act. Now, cocaine can mimic mania, but he’d taken cocaine before and he never acted like this. See videos of him when he was back to his usual self to see the difference. Sheen denies he was manic, but I’m not sure I believe that.

Anyway, about 80% of these patients could tolerate and were responsive to lithium for prevention of manic episodes. The longer they took it, the more likely it would be to also prevent depressive episodes as well. If the patient got depressed while taking lithium, antidepressants worked just great. Journal articles saying they do not were full of crap – the most important of these is discussed in this post.  Most of my patients on lithium were basically symptom free for decades, no matter if I saw them in a public clinic, an academic clinic, or a private practice environment.

 

When patients first got manic, we used antipsychotic medications to bring them down, usually in inpatient settings, because lithium takes a couple of weeks to kick in. Once lithium was on board, we discontinued the antipsychotic medication because they didn’t need it any more. The only other time we used antipsychotic medication in bipolar patients was during depressive episodes in which the patient also had delusions and hallucinations (psychotic depression). Again, the antipsychotic meds could often be discontinued after the episode was over.

 

When a patient couldn’t tolerate or was not responsive to lithium, we would then use antipsychotic medications as the only alternative back then, but always had to worry about them causing a neurological disorder (tardive dyskinesia [TD]). Until it was found that the anticonvulsants Tegretol and Depakote were good for mood stabilization – so then they became the second line drugs.

 

When the new, “second generation” antipsychotics came out, which can cause huge weight gain and diabetes in addition to TD, the drug companies started to push them. The use of lithium started to plummet. After it was found that some of them had some antidepressant effects – although usually only to augment an antidepressant – Pharma started to push them even more. Despite the major risks, use of them increased from 12% of cases to 53% of cases between 1997 and 2008.

 

Not only that, but the number of patients diagnosed with bipolar disorder inflated by more than double since 2000. Everybody and their brother who had any mood symptoms at all were misdiagnosed with it, most due to the insane idea known as “bipolar spectrum,” or as I call it, B.S. Another study in the Journal of Clinical Psychiatry that I wrote about previously  showed that 40% of patients in their sample who met clear DSM criteria for borderline personality and not for bipolar had been misdiagnosed as bipolar by a prior mental health professional, as well as 10% of all of the other patients.

Caveat emptor, which in this case means, let the patient beware!

Book Review: The Kevin Show by Mary Pilon

In this impressively well written book – I may have to steal a few of her cool phrases, like when she discusses situations in which people walking on eggshells start to feel more like they are walking on landmines – Mary Pilon tells the story of Kevin Hall and his family. Kevin Hall was a championship sailor who on one occasion made the Olympic Team, although he did not win a medal. At the same time, he struggled with Bipolar Disorder. The real illness, not what passes for bipolar disorder these days.

The author’s discussions of what went on inside of Hall’s head during a manic episode are some of the best I’ve ever seen. After reading them, readers will know that this has absolutely nothing in common with normal human thinking. After coming down off of a manic high, a sufferer knows that. Although they may question themselves about the “reality” of what they had experienced during an episode, it still seems to them to be bizarre and alien.

The book also does a great job of describing the traumatic effects on parents, spouses, and siblings in having to deal with a family member with a major mental illness – especially one who is not always cooperative with treatment but doesn’t let them know when he goes off his meds.

Hall’s delusion when manic was that he was some part of a larger “Show,” run by some all-knowing “Director”  - sort of like the movie “Truman Show,’ which indeed is mentioned several times in the book -  in which he is meant to save the world by interpreting various “signs” in the environment. The signs could be things he happened to see in the environment, unusual coincidences like his having been a college classmate of one of the doctors who treated him, song lyrics, or passages in various books he liked to read.

Unfortunately the author, who seems only to have a limited  familiarity with mental illness and, in particular, the treatment of manic-depressive illness, falls a bit into the trap of starting to wonder if it may just be some variation of normal. After all, with the rise of Instagram, selfies, and social media, everyone is seemingly thinking of themselves as in some sort of show and as having an almost national presence in the minds of others.

Mary Pilon

Not only that, but the author adds that certain delusions are more common in certain cultures than others, and some only seem to exist in a single culture.

In fact, the difference between psychotic delusions and false beliefs that are due to groupthink, everyday human foibles, wishful thinking, and just plain kidding oneself is colossal and not in the least bit subtle. Of note is that the author spends almost no time describing Hall’s thinking during periods of bipolar depression. She only mentions one episode in which he maintained that he was depressed but not delusional - but we do not know if he ever experienced a psychotic depression.

Either way, when depressed, it is mentioned almost in passing, he believed the exact opposite of what he felt while manic – that he was a born loser, loony-bin screw-up who was worth absolutely nothing despite his fairly spectacular accomplishments in love and work while euthymic (neither manic or depressed – in other words, normal).

Hall kept going off his medication because he felt that it was drugging the real him, which is why he kept having recurrences. While I obviously can’t say for certain anything about his reasons for stopping his treatment, the frequent reason bipolar patients discontinue their meds is that mania feels so good in so many ways that normal feels like down to many sufferers, and they want the high back.

Another possibility is that he was taken off lithium -  which generally does not make people taking it feel drugged – not because it was ineffective but because the doctors thought it was ineffective when in actuality he had stopped taking it or his blood level was too low. Good doctors monitor lithium blood levels.

He was apparently put on the antipsychotic Haldol at one point, which definitely does make people feel drugged. Antipsychotics, while they do prevent mania, should only be give in acute mania (because it takes time for lithium or depakote to kick in) – and then discontinued after the other drugs start working. Or used indefinitely only if all other options fail or are not tolerated. The author does not really tell us any details about Hall's treatment.

And what about the cultural aspects of delusions? Well of course delusions concern things that people with the disorder are familiar with. You can’t think the CIA is following you around with ray guns if you have never heard of the CIA or ray guns. And just like with Alzheimer’s disease, in which underlying personality traits affect the expression of impaired memory issues and cognitive confusion, they affect the content of delusions as well. 

Pointing out the cultural differences as a possible reason that bipolar is not a real brain disease is a bit like doing the same by pointing out that the delusions of Japanese people are expressed and thought about in the Japanese language, while the delusions of Spanish people are expressed and thought about in Spanish.

Just Another Manic Mom Day

So mental illness is a myth, huh? 

"How do You Grab a Naked Lady" is a gripping memoir by Sharon L. Hicks that is hard to put down. It mostly centers around her crazy-making relationship with her legitimately bipolar mother, particularly during the mother’s manic episodes. Her mother certainly did not have bipolar, myass disorder, or bipolar “spectrum” disorder (B.S.).

Of course, having a parent with a severe mental illness can itself lead to severe family dysfunction that adversely affects other, completely normal family members, particularly children. What follows are a couple of examples of Mom’s behavior while in the manic state. Ask yourself how you might turn out if your mother routinely did things like this in front of you - and often in public:

"Sharon, are you listening to me? I had a 24K gold necklace made for me with the letters   F-U-C-K to dangle across my chest. It cost me $15,000. Let's go pick it up."...
"I'm sorry Mrs. Hicks, but management would not allow us to make the necklace." 
"Oh yeah, well fuck you!...Mother spun around and headed for the escalator or the 2nd floor...In one fluid motion, Mother pulled her muumuu over her head..
"Yes, sir, completely naked."
...As she paraded down the escalator, she yelled, "You're all a bunch of shitheads."

Or another time: “I’m calling President Kennedy. He absolutely must take these pills! And I’m calling everyone I know to tell them about the divorce [from the author’s dad]…And the flies on the wall agree with me…I know because they are fluttering their wings. That’s how they talk to me…I’m the only one who understands how they communicate…they have names. I’ve named them all. They really like their names. They told me so.”

And no, people with personality problems do not act like that, or seriously say things like that. Seriously.

The patient’s childhood was further complicated by the mother’s behavior when the mother was in the euthymic state (neither manic or depressed). In the euthymic state, bipolar patients are just like everyone else. Their moods completely span the normal range. They can have the same problems as anyone else. They can be very functional, or they can have severe personality problems. They can also react poorly to the consequences of their own crazy behavior when they had been in the manic state.

In the case of the author, her mother is described as having been very narcissistic and self centered while euthymic, and as having rarely asked her daughter how the daughter felt about anything. Furthermore, Mom seemed to love being in the manic state, even though it frequently led to her being arrested or thrown into a mental hospital and given electroshock treatments. (This was during the 1940’s, 1950’s, and early 1960’s when patients had few rights, and there were few effective medications).  

But later, when there were effective medications, the mother would refuse to take them. She seemed to feel that even the depressed episodes were worth it, because there would also be those exciting manic highs. While manic, she particularly liked the hypersexuality that came with the territory, even when that meant running naked in public.

At times, the author felt that maybe mother really had control of her behavior even while manic, and was using it to get what she wanted. She read Thomas Szasz, who wrote about how mental illness was a myth. For a short time, she considered it. 

Naaah! She knew her mom was just crazy during manic episodes.

Another factor that affects both the way diseases like bipolar disorder present themselves as well as their effects on other family members is the ambient culture. This idea in no way diminishes the FACT that psychosis is a brain dysfunction. 

The author was born at a time during which gender role stereotypy was the norm. The dream of the author’s father was that she would marry a professional man who made a lot of money, move into the suburbs, and have lots of children. Sort of what her mother did, although she complained about it her whole life. She loved telling her husband what a sh*thead he was.

The author actually didn’t really like the whole sexist white picket fence fairy tale, wanting rather to get her doctorate in philosophy and do great things. On the other hand, she did not want to be anything like her mother. Yet somehow she spent most of her life living out the worst of the two worlds. Her career aspirations were halted when she got pregnant - several times - and married two men whom she did not love but who provided the picture perfect world that her father wanted for her. 

In this world, even men who appeared to be supportive of women's careers nonetheless saw them as lesser beings. When the author had to quit the graduate philosophy program (because she "accidentally" allowed herself to become pregnant, of course), the department chair said, "We need women like you to become professors. So the men can do the research."

In line with the family dynamics of someone without a psychotic parent, the author allowed her husbands and even her son to verbally abuse her, much like her mother frequently did whenever the author had to rescue Mom from her manic escapades. Between husbands, the author became somewhat hypersexual herself, though not nearly in the same way that her mother did during mania. After spending much of her life trying – and failing for the most part, even while not being mentally ill herself in the least - to be everything her mother was not, she came to realize that she admired her mother’s free spirit.

As she struggled to break free from her sexist upbringing, the author brilliantly describes the existential terror that results when someone tries to do something like that: “…might strip away a lifetime of beliefs about who I was, who I was supposed to be. Then what?  What happened after that? That’s the part they didn’t tell you. What happened when you didn’t recognize your life or even yourself any more? When there was only a smoldering void where familiarity used to live?”

So are all of the people society labels mentally ill just eccentric folks who just do not fit in with society?  During her many trips to mental hospitals to visit her mother, the author relates the following conversation with another patient:

“Don’t eat the food,” he told me.

“Why not?”

“Because it’s poisoned.”

“How do you know?”

“The aliens told me. They communicate with me through the fillings in my teeth.”

“Thanks for the advice.”

The thoughts of a functioning normal brain?  Yeah, right.