The Personal Journey of Jamison and Bipolarity, Book Review Example

From Mountaintops to Gorges: The Personal Journey of Jamison and Bipolarity

Summary

Kay Redfield Jamison was a highly-lauded Professor of Psychiatry at the prestigious John Hopkins University and was the author of Touched with Fire: Manic-Depressive Illness and the Artistic Temperament and a co-author of the standard medical text on manic-depression before she wrote An Unquiet Mind. She was praised for the insight that she showed on the subject. This insight did not extend to her personal life; her therapist finally told her that she was manic-depressive.

The warning signs were not subtle. During her adolescent years she had been emotional and alternated between bouts of creativity and energy and a tired, desperate preoccupation with death. She would often ask herself “Which of the me’s is me?” (68). Still, the years leading to adulthood can be hormonal and traumatic. Also, identity crisis is a typical stage in cognitive development, so for a long time she chalked those challenges up to the normal teenage experience. She was in denial.

The drawback of the “mental condition” label often depicts any unusual quirk of the human brain as a straightjacket situation, but the truth is that manic-depressive people often behave and appear exactly the same as everyone else, except for the occasional attacks of their god complex. Furthermore, because of their need to feel needed, bipolar people tend to work in high-demand service professions. As stated by Raab in his Case Study 2, one bipolar patient conveyed “a strong need to be helpful to people—to save them, believing that this is what Jesus wanted of her”.  This particular manic person also believed that she was the second coming of Christ sent to save the world from damnation (10). Therein lays the stigma of mental peculiarities; the extreme cases and few negative effects are all that are remembered.

With her fingers crossed behind her back, she encouraged her students to take lithium in an effort to control their mania, whilst herself refusing medication in an effort to keep the acquaintance with “a gray, bleak preoccupation with death, dying, decaying, that everything was born to die”, as she herself said in An Unquiet Mind (38). While many give their lives willingly over to substance abuse, bipolar patients generally struggle with the conflict between the fluctuations of their god complex and their need for lithium. As intimate as it is (and as potentially embarrassing for a Professor of Psychiatry to admit), Kay Jamison herself alternated between rebellion and faithfulness to her medicinal schedule. She even shares her personal thirteen rules for “the gracious acceptance of Lithium” (Jamison, 97-98).

After she came to grips with the condition and medication, she began to educate other medical professionals who worked with similar patients. Jamison began to show interns journals of the mania and depression that their patients went through, so that they could hear it straight from the horse’s mouth, as they say, and both understand and sympathize with the patients who require so much of their patience. She even inspired a personal friend to create a concert drawing from the body of musical works which were composed by manic-depressive masters Robert Schumann, Hector Berlioz, and Hugo Wolf (Jamison, 28-29).

She fancies herself grandiose, fancies herself a martyr, fancies that she has a different experience from her patients. Those are all characteristics of her condition which can make her particularly hard to like. Love begins with understanding.

DMS-IV Axes

The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) has been used to psychiatrically and psychologically analyze the status of an individual according to its five axes of evaluation: clinical disorders, personality and/or mental disorders, medical and physical disorders, psychosocial stressors, and the patient’s current and normal Global Assessment of Functioning (GAF) or (in children) Children’s Global Assessment Scale (CGAS) scores.

Bipolar moods, according to the DSM-IV, include psychotic features, including delusions of grandeur, hallucinations which confirm a sense of having more worth, power, or influence over matters natural and/or supernatural (Raab, 4).

Typically, even the preliminary evaluations of a patient are completed vis-à-vis. However, the less expensive, convenient, and private analysis of the Mood Disorder Questionnaire (MDQ) was intended to detect a variety of depressive disorders, including bipolar disorder (I, II and not otherwise specified or NOS), major and minor depression, dysthymia, mood disorder due to a general medical condition, a substance-induced mood disorder, or any anxiety disorder (3). Its adoption was based upon a relatively small number of subjects for study. Thus the validity of the MDQ was unreliably tested before its application to the patient body, and later studies soon concluded that it was much more receptive to the psychiatric patients than to the population at large (1-2). However, even recent French and Spanish translations have been validated with results of eighty-one and seventy-six percent sensitivity to respondents, respectively (3). However, in a larger study of 1066 women, the MDQ could only identify twenty-five percent of those women with bipolar disorder (Dodd et al., 4). You may find a copy of such a questionnaire at www.dbsalliance.org.

Jamison was diagnosed with bipolar disorder and was in excellent health- but was further psychologically burdened by the death of David. She divulges the specifics in her book. She has recurrent bipolar I disorder with psychotic features (Jamison 181). She further examines the offensive nature of the label “bipolar” and of other common labels, such as “cracked…squirrel… nut… loon” (180).

Ins and Outs of Manic-Depression

Despite the presence of these different stages, twenty percent of those identified bipolar persons will attempt suicide (Bentall et. al, 2). Those are not good odds. What makes manic-depression so lethal?

Causes

Millions of men and women suffer from bipolar disorder/ manic depression (Raab 3). According to Stober, the human dopamine transporter gene, SLC6A3, is correlated with psychiatric conditions such as ADHD, Parkinson’s disease, and manic-depression (1). Thirty-nine percent of manic-depression patients also have relatives with similar psychological conditions. The results produced by studies on these two subjects have increased the interest in more comprehensive studies of the relationship between genetics and psychoses. Studies of dysfunction in the transmission of dopamine, in particular, have yielded a definitive statistical link but have yet to establish the strength of the influence of this dysfunction beyond a doubt (3).

An established family history of mental disorder puts offspring at a decidedly increased risk of developing the same or other disorders. In “The Stigma: Worse than the Ailment”, Victoria Jack (2008) cited the case of a woman who “suffers from anxiety and depression…overwhelming pressure of life [as a caregiver] for four children, three of whom have a mental illness” Her teenage son suffered from Asperger’s syndrome and chronic depression, while two daughters were manic-depressive (Jack, 1).

Symptoms

Because of the god complex and the common defense technique of denial, recognition of symptoms of bipolarity are particularly important. The Beck Depression Inventory (BDI) employs twenty-one areas to ensure reliability and validity of precarious psychological studies.

The Hamilton rating scale for depression (HRSD) is also often employed and utilizes seventeen main points with three to five less-significant, related points per major item on the scale. The Mania Scale is often also used- but can effectively place suggestions for appropriate behavior and prevent further disclosures (Bentall et. al, 5).

Goodwin and James write that the most reliable symptom of bipolar disorder is mania, which is recognizable from the upbeat disposition, quicker speech tempo and thought, shorter bursts of physical activity, bursts of sudden mental clarity and sexuality, and an increased frequency of impulsive action (as cited by Raab, 2). There are “normal” levels and mild mania, and then there are severe cases. Consider the following statement made by H.G. Hamilton:

“They [bipolar patients] deny their weaknesses and develop a sense of omnipotence. They attempt to do everything themselves and have difficulty accepting help. When frustrated, they can fly into tantrums or tirades’’ (p. 148). While externally, many bipolar patients display an omnipotent, ‘world-is-my-oyster mentality,’ inwardly they may feel hopelessly insignificant” (as cited by Raab, 3).

Self-representation differs wildly in the manic-depressive patient. Typically they view others the same in both their depressed and manic states- albeit pessimistically. In contrast, the image that patients hold regarding themselves is typically unstable and shifts between the god complex and a self-deprecating state devoid of self-esteem (Bentall et. al, 3). The grid technique has been used by psychologists to objectively record the cycles of mania and depression (3).

States

Bipolar disorder is not merely high points and low points. There are many gray areas between these two extremes. In particular, there are four different states representative of all of the stages of manic-depression: depression, remission, mania, and mixed. With the exception of mixed states of bipolar representation, bipolar diagnosis can be made in all states of manic-depression (Bentall et. al, 3-5).

Earlier we discussed self-representation. Self-discrepancy theory (SDT) takes a different viewpoint. Self-representation considers the person as one single type. In reality, people “read” the context of the situation and adapt according to their perceptions and what they believe to be the perceptions of others. Thus SDT considers the real self, the ideal self, and the ought self. The difficulty is that a comprehensive idea of these perspectives requires extensive interviews, which frankly vary wildly according to the position of the interviewee. The patient, the significant other, and the friend all have drastic differences in their view of behaviors. They may be used to them and see them as ordinary or may look more or less harshly upon the reality of the mental condition’s manifestations in behavior. In general, “autobiographical memory” is a relatively stable indicator of future mood and self-representational shifts (Bentall et. al, 3).

Jamison once provides the example of the party after her appointment to UCLA full professorship. She- in a manic state- perceived herself as magnetic and charming to the point of being irresistible. A colleague of hers (who would later become her therapist) would eventually reveal that Jamison had been dressed provocatively, presumptuously introduced herself to prominent figures at UCLA who had no inclination who she was, and had worked her way through the soiree speaking and acting erratically and impatiently (Jamison).

Stigma

During Mental Health Week, an article on the stigma of mental health said that its goal was “promoting wellbeing and tearing down the wall of judgment and fear that alienates the sufferers of mental illness” (Jack 1). In An Unquiet Mind, Jamison expresses a constant distaste for the labels and misconceptions which affect the manic-depressive patients and herself. There are many struggles to overcome before reaching a level of acceptance of an abnormality, a mental health condition which carries much baggage with the label. One patient diagnosed with anxiety and depression had this to say: “There is a big stigma in society regarding mental illness. People who have not been around someone with a mental illness who they are close to I am sure don’t understand. Then there are those who are in denial, who feel it is too much and don’t want to know” (Jack, 1-2).

Largely prosecutors have had more reason to study mental health disorders and their effects upon the patients involved. There is not much medical support for afflictions which are not physical in nature. Even the medical fields turn the other cheek to disorders which are considered as less important than bodily health (Raab, 5). This common outlook within the medical community does nothing to encourage manic-depressive persons to overcome the denial and humbling nature of their mental disorder long enough to seek help (Jack 2).

Treatment

Psychiatric treatment is a tricky proposition. After all, what works in one situation may not suffice in another. This necessitates an individualized treatment plan according to the person’s background and psychological condition, the severity of the episode, and the time-frame over which the condition affects the patient. Some prescriptions are helpful to either unilateral depression or bipolar depression (Raab 2).

Medication adjustments take a great deal of time and energy for the patient and psychiatrist. In the meantime, psychotherapy is the recommended course of action. The other courses of action are precarious at best. In the consideration of the treatment plan, validity and reliability are easily established by examining the source of new information and the methods employed to reach a definitive conclusion (Fountalakis, 3).

The first step is always quick reference to the guidelines. Psychiatry has large novel-proportioned manuals of guidelines and diagnoses. Invariably, a bipolar diagnosis will require a touchy combination of several medications, including the controversial Lithium as the only measure proven to be effective against all levels of manic-depression. Other than that, specific guidelines differ by the source from which they were obtained (Fountalakis, 4). Just such a lack of appropriate organization and funding for research is an ongoing struggle for psychiatry.

Defense Mechanisms

There are many defense mechanisms commonly employed by bipolar patients: denial, rationalization, withdrawal, and fantasy. Bipolar patients report lower levels of undesirable side effects and thus display their tendency to overestimate their ability to cope with their condition as another example of the god complex that often accompanies the diagnosis (Bentall, Kinderman, & Manson, 1). However, when the embarrassing elements of manic-depression are recognized by the patient, it can be poignant. “Violence, especially if you are a woman, is not something spoken about with ease” (Jamison, 120).

When Jamison purchased half a dozen snake bite kits in preparation for saving her family and friends, she justified it by reassuring herself that she “was doing all that [she] could to protect… those she cared about” (Jamison, 76). This rationale also exhibits clear elements of fantasy. Neale (1988) argued that a wildly-varying self-esteem and godlike standards culminate in high risk of developing bipolar disorder (as cited by Bentall et. al, 2).

Theoretical Perspectives

In A spiritual strategy for counseling and psychotherapy, Richard and Bergins suggested three strategies for approaching bipolar treatment from a religious perspective. These strategies revolved around goals, the therapist, and techniques. Their approach urges that the goal selection is important- but should establish religious identity, assess personal impact of religion, help the patient “grow as a person”, and help resolve any religious doubts or questions The therapist is responsible for establishing a mental diagram, if you will, of the interrelationship between religion and action in each patient’s life and intervene when necessary. The final aspect, technique, mainly addresses any religious uncertainties. The therapist attempts “cognitive restructuring” and educates the patient in spiritual doctrine and imagery (as cited by Raab, 7). Koenig and Pritchett devised six steps bearing roots in the previously-discussed approach of Richard and Bergins. Their six-step system involves the identification of religious coping skills, an education of positive religious texts, the examination of religious coping gone awry and/or manic, the use of the patient’s beliefs to support evaluations of maladaptive coping, the referral to a spiritual and psychological specialist, and the act of prayer (as cited by Raab, 12).

Interestingly enough, in the course of the very same essay, a spiritual therapist/counselor is advised not to pray with a manic person and is also advised to limit their access to their religious materials. During non-manic time periods, these spiritual specialists are advised to utilize the “normal” religious tenets of their patients’ personal spiritual beliefs to gently disprove the manic delusions (Raab, 9).

Jamison’s Treatment

Jamison’s “insider knowledge” of manic depression was to the personal advantage of her patients. In An Unquiet Mind, she wrote that she was “aware of how critical psychotherapy could be in making some sense out of all the pain…keeping one alive… It could help… reconcile the resentments at taking medication with the terrible consequences of not taking it” (Jamison, 128).

Her psychiatrist tried every trick in the book: psychotherapy, observation, involuntary medication, family networking, etc., and she subtly recognizes his worthiness as a psychiatrist. Yet- due to her own pride and the wishy-washy nature of her affliction- she would not believe him of her own accord.

Chillingly, Jamison commented that lithium is used “to teach coyotes to stop killing sheep” (Jamison 116). That is how society views patients with mental disorders, and Jamison herself, looking back, seemed inadvertently to agree. Still, the eventual discovery of the correct individualized dosage of lithium has invariably had a positive impact on the author’s life. She expresses a nostalgic longing for the ephemeral high points of her manic episodes but can connect more deeply with her patients and recognize her limitations.

As morbid as it sounds, Jamison is still alive; she is a success story. One posthumous examination of bipolar suicides entered the heads of thirty-five victims of their mental condition. The first obstacle- besides patient denial- is confidentiality. Even after death, the family members and court systems ironically tend to promote the “ideal self” remembrance of the deceased above the research which could potentially save others from the same fate. Surprisingly, most of the cases had developed before the age of twenty. On average, the patients struggled with their disorder for approximately eleven years before they could endure it no longer. One male patient succumbed to his illness during a depressive episode thirty years after his original diagnosis (Keks et. al, 4).

After so long a struggle, the obvious question considers what factor(s) ultimately led to the patients’ deaths. Three-fourths of the deceased being studied had stressors occur repeatedly during the year preceding their deaths. About one half  of the patients were involved in substance abuse- against doctor recommendations. This “self-medication” is a common approach to coping with manic-depression, but it inevitably worsens the condition of the patient (Keks et. al, 2-4). For good reason, research on the correlation and prevention of substance abuse and bipolar suicides is gaining ground.

Jamison glorifies herself a lot in her book. Yes, she is a success story, but the strong sense of self-admiration, i.e. “I can be my own hero” outlook, bespeaks a deep-seated inability to rid herself completely of the shadows of mental disorder. It is to a good end, though; it encourages others to come forward as bipolar and not crazy, as society would often have us believe. Without the manic episodes, living in the “throat of exaltation” (122), Jamison finds joy and worth in her life. She considers herself a modern philosopher and a better psychiatrist and claims that she would choose manic-depression if she had a say in it. She does not say that it was an easy or a quick fix- or even that she is totally fixed. She does say that each day is not within the scope of the cycle between “grace and godlessness” (213).

Works Cited

Bentall, Richard P., Peter Kinderman, and Kerry Manson. “Self-discrepancies in bipolar disorder: Comparison of manic, depressed, remitted and normal participants.” British Journal of Clinical Psychology 44.4 (2005): 457-473. Academic Search Complete. EBSCO. Web. 1 July 2010.

Dodd, Seetal, et al. “Reliability of the Mood Disorder Questionnaire: comparison with the Structured Clinical Interview for the DSM-IV-TR in a population sample.” Australian & New Zealand Journal of Psychiatry 43.6 (2009): 526-530. Academic Search Complete. EBSCO. Web. 25 June 2010.

Fountoulakis, Konstantinos, et al. “Treatment of bipolar disorder: a complex treatment for a multi-facet disorder.” Annals of General Psychiatry 7.(2008): 1. Academic Search  Complete. EBSCO. Web. 29 June 2010.

Jamison, Kay. An unquiet mind. Vintage, 1996. Print.

Keks, Nicholas A., et al. “Evaluation of treatment in 35 cases of bipolar suicide.” Australian &  New Zealand Journal of Psychiatry 43.6 (2009): 503-508. Academic Search Complete. EBSCO. Web. 28 June 2010.

Raab, Kelley A. “Manic depression and religious experience: The use of religion in therapy.” Mental Health, Religion & Culture 10.5 (2007): 473-487. Academic Search Complete. EBSCO. Web. 1 July 2010.

Stöber, Gerald, et al. “Association study of 5?-UTR polymorphisms of the human dopamine transporter gene with manic depression.” Bipolar Disorders 8.5 (2006): 490-495. Academic Search Complete. EBSCO. Web. 18 June 2010.