Unit 4 Section 3 Exercise 11Bipolar Illness

Clinical correlate #10 Bipolar disease

Purple haze all around
Dont know if Im comin up or down
Am I happy or in misery?
What ever it is, that girl put a spell on me

Jimi Hendrix - “Purple Haze”

Re-read Aaron Kheriaty’s “The death of Matthew Allen,” with Dr. Kheriaty’s comment below, and then review the case history below.

Aaron Kheriaty: A comment on manic-depression

Manic-depression is a disease that interrupts a young person’s life—usually beginning in their late teens or early twenties—without warning, and is typically chronic and unremitting.  It descends like a tornado, overturning years of life’s work and plans, often leaving destruction in its wake.  The disease involves both biological factors—dysregulation of the brain regions responsible for “affective states” of mood and mental energy, as well as psychological and social factors—adverse life events and stressors.  Its hallmark is mania, a chaotic state of psychosis where the person experiences racing thoughts, grandiose delusions, pressured speech, extraordinary physical and mental energy, extreme agitation, and loss of sound judgment.  When in a manic state, patients can go days on only a few hours of sleep, yet not feel fatigued.  Manic patients are typically euphoric, full of chaotic energy.  They frequently get in trouble with the law, or spend all their money on foolish projects, so impaired is their capacity for rational thought.  The manic states last a week or more, and are inevitably followed by a plummet into severe depression.  Here, suicide is common.  Half of all bipolar patients attempt suicide; one in six kill themselves.

A case history

Mr. MD has ‘bipolar disease.’ He had a manic episode followed by a severe depression, during which he drank very heavily and swallowed ‘all the pills around the house.’ He was discovered in his room, extremely ill, and taken to the emergency room at X university hospital, where he was admitted for treatment. He was then transferred to another hospital for psychiatric treatment. Mr. MD’s hypomanic episode began about 9-10 weeks prior to admission. He had been working effectively as a central telephone operator, and during the 7-8 week of hypomania did not feel any difficulty meeting its demands. He felt ‘on top of the world,’ felt warm and collegial towards his coworkers and that he could ‘handle anything.” At home, he enjoyed reading and listening to music. He slept only a few fours each night. In the 8^th week of his hypomanic phase, he no longer felt so well. Things ‘started going wrong at work. He felt that he was going 90,000 miles per hour,’ and working harder and harder without being able to keep up with his tasks. He felt exhausted. In addition, his therapist went on vacation. Friday of that week, he came home from work feeling deeply depressed. He stopped taking his Lithium—he had stopped taking Antabuse 5 days before. He began drinking very heavily. His plan was to keep drinking until there was no alcohol left in the house, and then to ‘lie down and die.’ He also took the remainder of Lithium and of an antidepressant that he had at home. He had not phoned his employers to inform them of his condition. Eventually they became sufficiently concerned to call the rehabilitation center that had originally referred him. The center sent a social worker in the company of two policemen to his home. They found him ‘half dead.’ He went to the ER without resisting, and was admitted for medical treatment. He was seriously ill, with ‘electrolyte imbalances.’ He was then transferred to a psychiatric facility where was further found to have fractured his back, the result of a fall during his drinking binge.

Mr. MD grew up in a home characterized by frequent moves, marital discord between his parents, and his father’s manifest manic-depressive disease. This depression was followed by a hypomanic period, but the patient did not know what was happening to him. He felt ‘ups and downs’ during high school, but these were not as sharply demarcated as his later episodes. Since high school, he continued to cycle through periods of hypomania followed by depressions. He went off to college, where he began to ‘medicate’ his depressions with alcohol. During this time, and for many years subsequently, the patient exercised vigorous denial about what was happening to him. He wanted to think of each episode as an ‘aberration.’ And that he would ‘get better.’ On another level though he realized that there was something seriously wrong with him.

Study Questions

1. Compare your reactions to Dr. Kheriaty’s essay on his friend and the case history. Is the case history a ‘story?’ In what sense is it a story, and in what sense is it not? How does a person react emotionally to a story as compared to a case? And are you a more effective learner or practitioner if you are engaged emotionally? When are emotions a help or a hindrance in dealing with patients with mental illness?
2. In reading about Matthew Allen and Mr. MD, to what extent is the patient in control of his illness? What indications are there of control and lack of control?
3. Refer to the brief description of the patient’s mother in the previous exercise on anxiety/OCD. Identify the factors in the patient’s part that might have aggravated his illness.
4. In addition to mania and depression, what other health problems are associated with bipolar disease in the patient discussed in the case?
5. Based on the case history, how does the case of Mr. MD differ from those who suffer from major (unipolar) depression?  How does this often discourage them from seeking care?