Japanland: A Year in Search of Wa - Couverture rigide

CHAPTER 1

THE DECADE OF BIPOLAR II

Until recently, much of the scientific information, research, and treatments concerning manic depression were focused on Bipolar I, a major affective (that is, mood) disorder in which a person alternates between the extreme states of deep depression and intense euphoria.1 This serious illness is characterized by elated mania with sleeplessness (often for days), hallucinations, psychosis, grandiose delusions, and/or paranoid rage. Starting in adolescence or early adulthood, Bipolar I typically persists throughout a person's life. Because of the psychotic features, those with Bipolar I almost always require hospitalization for periods of time. Well aware of Bipolar I, the general population and media have received too little information on Bipolar II, a subtype of manic depression.

I first began to notice this less-extreme version of manic depression (officially called manic-depressive psychosis at the time) in 1971 while I was in charge of the acute psychiatric service at the New York State Psychiatric Institute. Many of these milder manic-depressive patients were dynamic and industrious men and women with exuberant moods and high energy. Initially, they had come to the clinic for treatment of major depression. Yet, unlike others I had treated with manic depression, these men and women had had episodes of mildly elevated moods with high energy and tremendous productivity. In fact, these people were the proverbial "movers and shakers" of New York City. They were extremely motivated, talented, and strong-minded producers, artists, writers, musicians, doctors, lawyers, investment bankers, CEOs, sales professionals--in other words, women and men who had achieved lofty goals and the highest levels of distinction in their professional lives. Now they were sitting in front of me in my office, asking me to help stop their relentless depression.

During the years that followed, I treated literally hundreds of these mildly elated individuals for recurrent or episodic depressions--sometimes mild, but usually quite serious. Unlike their manic-depressive counterparts who alternated between extreme highs and lows, these men and women seemed to get over their depression after effective doses of antidepressants for several months, often combined with psychotherapy. During their so-called well phases, I rarely saw them.

One of these mildly elated patients whom I treated in the mid-1970s was James, who at the time was in his early twenties. The youngest of four children, he was referred to me by his sister, Susan, also a patient.

"James's personality has changed dramatically, almost overnight, and we are extremely concerned," Susan said. "Depression runs strong in our family, and James has suffered with depressed mood for almost a year.

"Recently, he became a totally different person that none of us could recognize. He hardly sleeps, and he's overly confident, flirtatious, and flamboyant, which is not like my brother at all. Also, James went with a 'hunch' last month at his securities firm and made a dreadful investment, losing more than a million dollars of his clients' money."

When James arrived at my office, he was immaculately dressed. After exchanging greetings, I asked James about his past, including his childhood and adolescent years.

"There's nothing impressive about my childhood," he said nonchalantly. "I was overweight, shy, and had few friends. In high school, I was more outgoing and was elected student body president at a private school in New England. I graduated when I was 16, and then I went to Yale on an academic scholarship to study business.

"About a year ago, I went through a horrible low period in my life," James told me. "When I sought medical care, our family doctor said it was depression and prescribed medication. I tried the drug but could not stand the way I felt. Finally, after a few weeks, I stopped the medication."

To mask his depressed feelings, James admitted that he had started drinking alcohol heavily from "breakfast until bedtime" and was using marijuana, but usually only after work or on weekends. He then told of a mystery mood transformation that had occurred over the previous month.

"Over the past couple of weeks, the depression resolved, and my mood has switched into this amazing high. I feel like I've had several cups of strong coffee, and this buzz lasts all day until late at night. I have never felt so incredible in my entire life, or had such creative ideas and high motivation," James said.

I wanted to know more about his risky investment and how he was handling the loss of a large sum of money. James brushed it off as no big deal. In fact, he was quite arrogant, remarking that no problem--even losing a million dollars--was unsolvable to him. In fact, he hinted that some insider knowledge he had on a little-known stock would more than cover the loss. And because of his "insightful brilliance," he would triple his earnings by playing the futures market over the next few months.

As I listened to James go on about his financial "genius," I could tell that he had an inflated sense of confidence with no fear of repercussions. He talked incessantly about extravagant spending on a red Jaguar, a mountain chalet in upstate New York, and wild sexual escapades that he agreed were out of character but highly enjoyable.

I recognized that James was living with a softer type of manic depression, one that we now call Bipolar II disorder. As I had observed in patients for almost a decade, this milder cyclical illness produces the enthusiasm, fervor, and incredible capacity for hard work that can be seen in many of the superachievers in our society. During the hypomanic (mildly manic) times, I saw that many of the often-brilliant high achievers were able to push themselves. It was during these times when they made the most of their ingenious ideas and productivity. But I had also witnessed a downside to this disorder, as it is accompanied by periods of bad judgment as well as episodes of deep depression, as James had experienced, that leave these men and women feeling helpless, hopeless, and worthless. When the major depression hit--and it always did--these patients usually came to see me for medication. Or if they extended too high, like James did with his investments and excessive spending, a family member or colleague would persuade them to seek medical treatment.

After talking with James for more than an hour and doing a full medical evaluation, I explained the diagnosis of this soft Bipolar subtype--not yet naming it Bipolar II--and his specific treatment plan, which included stopping drinking and starting Alcoholics Anonymous (AA). All forms of bipolar disorder go hand in hand with alcoholism, and the conditions are probably related genetically. I talked with James about the ill effects of using cocaine, heroin, alcohol, marijuana, amphetamines, potentially addictive tranquilizers, and sleeping pills in an attempt to self-medicate a mood disorder.

I recommended psychotherapy to James so he could openly talk about problems that were fueling this need to drink alcohol and smoke marijuana, as well as begin to face the emotional and financial damage he had done to his personal relationships while in his hypomanic state. I then started James on a very low dose of lithium carbonate, a mood-stabilizing com£d that had been approved by the FDA in 1970 for treatment of mania in bipolar disorder. Lithium, as I'll explain further in chapter 8, is highly effective in leveling the mood swings of bipolar disorder, as well as helping to prevent future episodes.

Within a few weeks, James's mood was completely stable. He had to spend a lot of time mending fences at work and in his social life, but he was able to save his job and his reputation. Today, James is in his fifties and is still my patient. He is married with three daughters, owns a conglomerate of retail chain stores across the United States, and continues to come to my office monthly (for 30 years) to have his lithium level monitored. James also spends time periodically with a psychologist at my office, discussing any problems that may arise so he can handle them methodically and responsibly in case his mood swings threaten to dominate his thoughts and behaviors.

Within 5 years of my diagnosing James with the softer bipolar subtype, the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) was published, in 1980, and released to the medical community. This manual, published by the American Psychiatric Association, provides physicians with diagnostic categories and criteria for making accurate diagnoses. In the third edition, the former diagnostic term "manic- depressive psychosis" was changed to "bipolar affective disorder." Over the next decade, I continued to observe periods of hypomania in bipolar patients and published numerous journal studies on the same. Yet it wasn't until the early 1990s that other psychiatrists and psychopharmacologists also began to catch on and differentiate between Bipolar I and Bipolar II disorder. (A psychopharmacologist is a psychiatrist who is an expert in using medications to treat psychiatric chemical imbalances.) In 1994, the American Psychiatric Association officially recognized the differences between Bipolar I and Bipolar II in the fourth edition of the DSM (DSM-IV). Since then, the national media have reported on Bipolar II, and terms such as "hypomanic" are now in more regular use in the medical community.

3 Feelings of Depression

1. Helpless

2. Hopeless

3. Worthless

HOW THIS BOOK CAN HELP

Despite the increasing attention Bipolar II disorder has been given since I first began diagnosing it, most psychiatrists and primary care physicians today vastly underuse the diagnosis of this softer bipolar disorder. In fact, it is not uncommon for a patient to see four or five doctors before coming to my office and finally obtaining the proper diagnosis of Bipolar II and effective treatment--or no treatment at all. When I speak before manic-depressive support groups, at medical gatherings, or consult with patients, it surprises me that so many patients and their families are still unaware of Bipolar II disorder and assume that all manic depression falls into the category of Bipolar I with its wildly manic psychosis and devastating depressions. But I continue to educate patients, physicians, and the population about the wide variations in mood and the high prevalence of Bipolar II disorder, hoping that some day it will not be thought of simply as a serious form of bipolar illness, but rather accepted as a potentially beneficial condition with enormous advantages.

As you read through this book, you will see that it quickly moves beyond a discussion of Bipolar I and Bipolar II disorders and on to page after page of groundbreaking medical studies and real patient stories, describing how Bipolar II manifests itself with its exuberant hypomania and how this disorder is diagnosed and treated.

Here's how I'll accomplish this.

In part one, Bipolar II Defined, I will give you the full description of Bipolar II, from the signs and symptoms to sleep problems to more serious outcomes such as hypersexuality and financial ruin. Starting in this chapter, The Decade of Bipolar II, I'll introduce you to Bipolar I with its wild mania and psychotic hallucinations and explain how it differs from Bipolar II, with its episodes of major depression and mild mania or hypomania. The real patient stories are intriguing and will help you fully grasp the wide range of moods and symptoms that frequently occur with this common mood disorder.

Chapter 2, The Bipolar Spectrum at a Glance, is perhaps the most important chapter in the book as I focus on the wide range of mood swings that can occur in the bipolar spectrum and specific criteria psychiatrists use for making a diagnosis.

You'll learn about the link between your family tree and Bipolar II in chapter 3, Mood Swing and Family Genetics. I will describe celebrities and ordinary patients who have realized the bipolar linkage in their family trees, as well as the latest journal studies linking Bipolar II to other behaviors such as attention-deficit/hyperactivity disorder (ADHD), alcoholism, depression, gambling, and even high achievement.

Sleep and biological rhythms are the focus of discussion in chapter 4. Through years of clinical trials with bipolar patients, I have found that the lack of need for sleep--referred to as the hypomanic alert--oftentimes initiates a hypomanic phase and is absolutely critical in making an accurate diagnosis of most Bipolar IIs. I will discuss the lack of sleep and Bipolar II more extensively in chapter 4 and give you and your family some self-help strategies.

I believe that chapter 5, Sex, Drugs, and Other (Mis)behaviors, will open your eyes to some risky patterns associated with Bipolar II disorder. While not everyone who has Bipolar II is hypersexual, abuses drugs or alcohol, and has financial indiscretions, it is important to be aware of these frequently co-occurring behaviors. You and your family can take steps early on to avoid high-risk situations and an impending crisis.

While bipolar disorder traditionally has had a negative connotation, I will educate you about some extremely positive aspects of this disorder in chapter 6, The Hypomanic Advantage of Bipolar II Beneficial. I coined the term "hypomanic edge" and talked about it on the Today show with Barbara Walters in the mid-1970s after realizing that about 50 percent of my Bipolar II patients were some of the most successful high achievers in New York City. I'll discuss the hypomanic advantages I have identified and elaborate on how these attributes can be used to improve the patient's life, as well as impact society as a whole.

In part two, Diagnosis and Treatment of Bipolar II, I will explain how this disorder is diagnosed and treated and help you gain insight into specific situations such as pregnancy, when doctors, patients, and families must work closely together for the best outcome.

In chapter 7, The Bipolar II Consultation, I'll elaborate on the various questions I usually ask patients when they come for the initial consultation and explain the medical protocol used for making the diagnosis, including blood chemistries, electrocardiogram (ECG), chest x- ray, and urinalysis, among other tests.

Treatment varies with Bipolar II disorder and in chapter 8, Modulating Moods, I will give you the history of my pioneering studies with lithium in the United States. I'll also discuss other mood stabilizers and medications commonly used today and give you further insight into effects and side effects.

There are certain stages in the life cycle, such as pregnancy, childhood, or the elderly years, when patients and doctors must work closely to find safe and effective treatment for mood swings. I will explain these delicate life stages in chapter 9, Special Situations That Complicate a Bipolar Diagnosis, and also give new insight into diagnosing and treating children and adolescents with ADHD and/or Bipolar II disorder.

Looking to gain a competitive edge in her judo practice and maybe a fresh perspective on "meaning" in her own life, documentary filmmaker Karin Muller commits to living in Japan for a year to deepen her appreciation for such Eastern ideals as ritual and tradition. What she's after—more than understanding tea-serving etiquette or the historical importance of the shogun—is wa: a transcendent state of harmony, of flow, of being in the zone. With only her Western perspective to guide her, though, she discovers in sometimes awkward, sometimes awesomely funny interactions just how maddeningly complicated it is being Japanese.

Beginning with a strict code of conduct enforced by her impeccably proper host mother, Muller is initiated in the centuries-old customs that direct everyday interactions and underlie the principles of the sumo, the geisha, Buddhist monks, and now, in the 21st century, the workaholic, career-track salaryman. At the same time, she observes the relatively decadent behavior of the fast-living youth generation, the so-called New Human Beings, who threaten to ignore the old ways altogether.

Broad in scope, intimate in relationships, and deftly observed by an author with a rich visual sense of people and place, Japanland is as beguiling as this colorful country of contradictions.