Bipolar Expeditions (19 page)

Student:
Someone help me out here!

Dr. Dean:
Jaspers says if an experience is not a perceptual experience then it is just thought. We have expressions for this: my conscience was talking to me; I saw it in my mind's eye.

The difference between image and perception is that you can locate a perception in space and it has properties like clarity. You can't be persuaded it is not there. Jaspers calls this indubitability. It is also important whether the phenomenon is received passively or actively. If passively, it is an object independent of our will; if actively, you have to do something to conjure it up. She gave a mixed description just now. [To the students:]
You
try to see which it is most like.

Jaspers also defines “pseudo hallucinations,” which are inside your head. Outside your head in external objective space is “real.” Ms. Simmons knows this lingo and so says the voices come to her through her ears, but when asked, she cannot locate them in space. People say that on medication, the voices get farther away, less clear, or they go inside the head. She has pseudo hallucinations or vivid images. Her feeling of being criticized is typical of depression.

What is at issue here is teaching medical students to distinguish the defining characteristics of psychiatric conditions, such as true versus pseudo hallucinations. Dr. Dean led them to see that Ms. Simmons's hallucinations were “pseudo hallucinations,” which lent credence to the diagnosis of manic depression and cast doubt on another diagnosis such as schizophrenia. Her fear of others talking about her was laid at the feet of her depression, adding further credence to the manicdepressive diagnosis rather than something like paranoid psychosis. Ms. Simmons described her experience, but when what she said was inconsistent with Jaspers's categories, her description was discounted. Partly as a result, she came across as a difficult and manipulative patient, wanting the latest medications Wellingtown Hospital had to offer, but not willing to stay long enough to be treated properly. Taking all the episodes of her hospitalization into account, some of the doctors concluded that she deliberately tried to sound more psychotic than she really was in order to merit serious medical attention.

(4) Who Is Manic?

Dr. Morrison, wearing a bow tie as usual, presided while a resident presented the patient.

We have Mr. Czermanski, a twenty-eight-year-old Slavic male with no psychiatric history. He comes from the state of Moldovia, which is part of the former Soviet Union. He worked as a librarian there, and had incidents of verbal aggression. He and his wife are living in Ronald McDonald house in Baltimore while their three-year-old undergoes a spinal fusion. The daughter is in a body cast. He has no medical or psychiatric history. One month ago he became religious and began to have revelations. He was getting messages from the television and saw films in his head. He had ideas about suicide but said he would not act on them because of his wife and child. He shows pressured speech, he is irritable, and he had a delusion that he was a psychoanalyst. On admission, he was tangential in speech, had loose associations, and was hard to follow. He is not very willing to take meds.

Dr. Morrison said Mr. Czermanski's wife might be coming in with him, and he arranged a second chair for her. They entered together, both young, lithe, and thin, with broad faces and open, interested expressions. After Mr. Czermanski sat down, he immediately shook his head, pointing to his mouth. His wife explained in articulate English that his tongue was swollen, and thus he couldn't talk very well.

Dr. Morrison:
But just this morning it was OK—when did this happen?

Mrs. Czermanski:
This afternoon.

Dr. Morrison:
We will look into that.

Mrs. Czermanski:
Back in Moldavia, he had a kind of conversion experience, where he saw a lot of ethical issues clearly, and I liked this, because he was thinking just as I did about a lot of issues. Then when he was here for our daughter's operation, he was not making sense. Since starting the Zyprexa, only yesterday, he is improved I think. He does make more sense today.

Dr. Morrison:
Mr. Czermanski, what do you hope to get out of being here?

Mr. Czermanski:
Your bow tie! I want
all
your bow ties. [Laughter.]

Dr. Morrison:
What do you think is wrong? Why would you say you are here?

Mr. Czermanski:
I don't know.

Dr. Morrison:
Have you heard of mania? Do you think you have mania?

Mr. Czermanski:
You
have mania! You have bow tie mania!!

Shortly, in the wake of the group's laughter over this remark (in which he sheepishly joined), Dr. Morrison turned his attention to Mr. Czermanski's swollen tongue and decided he needed to be accompanied out to the clinic to be treated for it. Perhaps because of his foreign nationality, his educated and professional status, or his exuberant mania, Mr. Czermanski managed, if only briefly and humorously, to turn the tables between the diagnoser and the diagnosed. Mr. Czermanski entered the room in the midst of a manic episode with a probable diagnosis of bipolar disorder. Part of being in such a state is being out of touch with reality, exaggerating one's abilities and one's importance. That is, the person is not aware of reality, including his own mania. But Mr. Czermanski startles the group into laughter because he shows he is aware of reality, including the reality that his doctor, the diagnostician of his mania, so frequently wears jaunty bow ties that he could be said to have a mania for them. When Mr. Czermanski turned the tables, he did not reverse the power relations between doctor and patient: these were left intact, as Dr. Morrison made clear by sending Mr. Czermanski out to the clinic. What Mr. Czermanski did was capture Dr. Morrison in the ordinary rules of the social game: faced with the presence of the audience, who implicitly understood the etiquette of the situation, he had to laugh at the joke or show himself to be a person with no sense of humor.
⁶

(5) What Is Bipolar 2b?

Dr. Lerner presiding, a resident presents the case.

Mr. Lawrence is a twenty-one-year-old single African American male. He has been irritable and volatile. In his family history his mother is bipolar; he had a paternal uncle with bipolar who committed suicide and an aunt who committed suicide. He was born at full term and met his milestones. He comes from a poor family: his parents are divorced and after they separated he stayed with his father. He went to public school, and was in the gifted and talented program. In school he got into fistfights, had difficulty holding down jobs, and difficulty following rules because he felt otherwise he would become a conformist. Past medications include lithium, Prozac, and Celexa. He is now on Depakote and Zoloft, with a trial of Prozac.

He reports getting messages from the television, and that someone understands him and is talking to him directly through the television. He is not keen on mood stability or management and he is not very compliant. But he definitely wanted the ECT he was given in the past. He has had eleven ECT courses so far, ten unilateral, one bilateral.

He tends to spend six months up and six down, manic and then depressed, and he says he is a different person in each period. Not long ago, he believed the world would end, but he made no plans. When asked, “What is missing?” he said, “My soul.” When asked, “Why don't you take your meds?” He replied, “I would miss my hypomanic states.” He has a lot of “push to speak,” and some delusions, such as believing the year 1999 really signifies the satanic number 666.

At this point, the patient, Mr. Lawrence, a slim, neatly dressed, very alert young man, came in. There were the usual introductions, explanations, and thanks. Dr. Lerner asked him open-ended questions about what it was like to be depressed or manic. He described his depression at length, and then, in the following excerpt, his mania.

Mr. Lawrence:
When you are hypomanic, it is the greatest feeling in the world. It is all about brain chemistry. Cocaine gives you a high by changing the chemistry in the brain, but mine changes by itself. I describe myself as Mr. Hookup because I know how to get freebies.

Dr. Lerner:
Are you very persuasive?

Mr. Lawrence:
Yes, I can sell anything, I worked in sales, I sold vacuum cleaners, and I mess with a lot of women.

Dr. Lerner:
You told your psychiatrist you had periods of greatness, when you can do no wrong?

Mr. Lawrence:
Yes.

Dr. Lerner:
Did someone tell you that you were bipolar?

Mr. Lawrence:
No one said I was bipolar. I started reading books myself, like Kay Jamison's. I also read
Moodswing.
It hit so on the point, I diagnosed myself: I am Bipolar 2b. It is hard to deal with jobs, when the whole world is nothing but consistency and you are not.

The group then suddenly realized the hour was almost up and that this discussion had gone on much longer than the usual half hour or so. Dr. Lerner thanked the patient with feeling and assured him the group would try hard to shed more light on his treatment. When the patient had left, the group began a hurried discussion with many simultaneous remarks.

Dr. Lerner:
Is he Bipolar 1 or 2? Are there psychotic beliefs?

A second psychiatrist:
Is he really depressed? He loved mania so much….

A third psychiatrist:
I think he has hyperthymic temperament, it is hard driving and it fits him. He gives such a good description of depression. But because he has this up quality, it does produce a little cognitive dissonance.

Student:
What is Bipolar 2b anyway?

The rounds ended on this question, confused and unresolved, as students rushed out of the room for their next class. I was confused, too, until I looked it up and discovered that actually there is no category Bipolar 2b in the DSM-IV. Usually in rounds, the patient is asked about his or her experiences and the doctors discuss the correct diagnosis after the patient goes out. Here the patient described his own experiences as usual, but then went on to diagnose himself using the DSM. He even elaborated the categories in the book to produce a new subcategory and thus extended the rational order of the classification system. This event upset the usual role of diagnosis as a “ritual of disclosure” and so left the group in some disarray. Ordinarily, the occasion of diagnosis would legitimate the physicians' and medical system's authority because scientific knowledge and technology would disclose the hidden cause of illness.
⁷
Here the ritual was derailed. The group lost its usual focus and organization during this rounds, something that is all the more remarkable in light of the hierarchy that was palpable, in this case, between the mostly white doctors and medical students employed or enrolled in this prestigious medical center and an African American man, living without the benefit of many resources, in the same city.

(6) I Ain't Gonna Mess with It Backwards

Resident:
Ms. Miller is a sixty-two-year-old married African American woman. She was admitted one month ago with bipolar disorder, sent to the day hospital, and then she was readmitted here. Her father and mother are deceased from heart attacks, but neither had mental illness. Her niece is schizophrenic. She grew up in Baltimore in a poor family and she is now on disability [Social Security Disability Insurance (SSDI)] because of mental illness. She was recently married. There are some indications the husband is abusive. She has two kids, one of whom died by suicide. She is a Jehovah's Witness, very involved in her religion. There has been some alcohol abuse in the past. [Here the resident describes her many hospitalizations.]

In June 2000 she had a psychotic episode. She was paranoid, religiously grandiose, very talkative, agitated, and manic. Then she was begun on Zyprexa and lithium.

In the day hospital this time she was delirious and manic. It was hard to treat all this as an outpatient, so readmission was recommended. On readmission, she had formal thought disorder. Asked what year it was, she said, “The fourth.” But it was the fourth of the month.

We thought the delirium was from the lithium or drug interaction. So we stopped all but the Zyprexa. She refused an EEG [electroencephalogram] because she said it would mess up her hair and her brain. This case is interesting because of the various competing categories: manic depression versus schizophrenia and mania versus delirium.

At this point Ms. Miller was escorted into the room. She was dressed in a neat blue sweat suit and running shoes. Her long, braided hair hung straight down, all but covering her eyes. Dr. Dean thanked her for coming and explained that the group wanted to learn from patients and hoped to improve treatment of her condition.

Ms. Miller:
I didn't want to come.

Dr. Dean:
How do you feel?

Ms. Miller:
Fine.

Dr. Dean:
Not confused?

Ms. Miller:
No, my normal self.

Dr. Dean:
Do you drink?

Ms. Miller:
Only in moderation.

Dr. Dean:
Do you want to go home?

Ms. Miller:
I sure would. I am not good with crowds of people, like here.

Dr. Dean:
You are active in Jehovah's Witness, and there are crowds there, right?

Ms. Miller:
Yes, I was able to accept those crowds. I was born out in field service, so my best spot is on the corner.

Dr. Dean:
How is your temperament, your mood? Are you pretty even-keeled?

Ms. Miller:
I am moody today. My moods are a little off. I am not sad, I
put
myself in a happy mood.

Dr. Dean:
What have you been doing?

Ms. Miller:
OT [occupational therapy]. It is terrible! Oh!! [seeing the OT therapist in the room] I didn't see you sitting over there.

Dr. Dean:
I am going to name three things: baseball, airplane, cactus. Can you remember?