As absurd as that tableau may seem today, it comforted my friend. At least she knew her mom would come back. She did; drugged up and passive, but there. She seemed to sleepwalk through her days for the next couple of years but then gradually became some echo of who she had been. My friend and I pretended she was okay, graduated from high school, lost touch, and went on with our lives. Or at least I did. I now wonder what happened to that family in the wake of the silence and the shame and the long road back to mental health.

Things are different now. We have become more knowledgeable about mental illness. Science has developed medicines and psychology has developed therapeutic techniques that promise relief and sometimes even a cure. American culture has generally shifted from shame to sympathy thanks to the Internet, advocacy groups, and people willing to tell their stories through blogs, YouTube, and books. Mental illness is still with us but families no longer need to suffer in silence.

David Lovelace has been part of this generational journey. In his memoir, Scattershot: My Bipolar Family, he chronicles growing up with two parents with bipolar disorder and his own struggles as he moved from denial to acceptance of his own illness. The only treatment for his mother was long-term hospitalizations, electroshock, Thorazine, and a dependent sheltered life in her family. Lithium and the new neuroleptics, talk therapy, and a more supportive community coupled with his own determination have given her son a much different life.

His mother was always artistic and fragile, and suffered from anxieties and fears. She had her first break in 1949 and was diagnosed, as most people with delusions were at that time, as being schizophrenic. She suffered twice with postpartum depression; following both David’s birth and his brother’s eight years later. Her periodic descents into madness were depressive episodes that sometimes rendered her catatonic. The family worried about her and protected her. Within the circle of her family, she could be a great mom but the social world put her under constant stress.

Eccentric and often grandiose, his minister father infused the family with a fundamentalist Christian faith and the belief that Satan was always lurking in wait. Nonetheless, he taught the boys fishing and hunting, collected reptiles that perfumed the house with a base note of rot, blasted classical music from his stereo, and lived life with more bravado than judgment. No one recognized that he was often in a hypomanic state that fueled both his creativity and his eccentricity but sometimes put himself and his family at great risk.

For Lovelace, boyhood was in many ways idyllic, if unusual. He distanced from his mother’s illness and his father’s insistent religiosity by wandering the woods and fields, getting dirty, terrorizing the wildlife, and having self-narrated adventures with himself as hero. His sister retreated into books and being her mother’s friend. His brother, 8 years younger, sometimes shared adventures but was left too much on his own.

Lovelace’s parents loved their Puritan-style god and each other. They were interdependent and yet helpless to help each other in their respective illnesses. Fortunately, they also loved their children. Lovelace is clear that however bizarre his family life was at times, he felt loved and that has made a difference.

At a recent reading, Lovelace said that having struggled with depression when he was a teen and having watched his mother’s periodic bouts, he always felt that the illness was a dog nipping at his heel. As he began having episodes of depression and agitation, he did what people do when threatened. He ran. He ran by joining a Christian mission in Brazil, by traveling in the Colorado mountains, by crossing the country on a motorcycle, by wandering aimlessly through South America and Mexico, and by joining up with squatters in Manhattan. When things got tough, he ran – often drugged out and soul-weary.

As a carpenter, Lovelace could pick up work now and then; at least enough to eat and support his efforts at self-medication by weed and alcohol. He lived from day to day as one of those lost and self-satisfied young wanderers. His adventures can read like a romantic coming of age story, especially since Lovelace’s writing is often more poetry than prose. But the romantic haze around his “war stories” of times he ran out of money or weed or luck don’t obscure the desperation. The tales of exotic places and youthful self-destructiveness are shockingly bereft of concern for the people he left behind; often not contacting family or friends for months. He loved his family but he ran.

When his father had his first manic break at 56, and his brother had his first break three months later, Lovelace ran some more. Three months after that, he had his own first manic episode and his father fetched him home. He tried to get better. He overmedicated himself and landed in a hospital. Falling in love gave him a reason to stay on his medicines and get well. His girlfriend was a kindred adventurer and they ended up joining friends to live the squatters’ life in Manhattan’s Lower East Side, kicking around South America, and then returning to New York. It all makes a great story but a marginal life.

Self-centered young people do grow up, sometimes in spite of themselves. Living on the edge loses its glamour. Illusions about the moral and spiritual superiority of dropping out lose their luster. Responsibility kicks in. A fire provided a convenient end to the squatting life. Lovelace and his girlfriend moved to western Massachusetts. She started graduate school and he got lucky. A carpentry customer left him with an old gristmill turned bookshop, tucked away in an obscure corner of an old mill town but within reach of the five colleges of the Pioneer Valley. He wrote a slogan that is the envy of marketers (“Books you don’t need in a place you can’t find”) and book lovers made it a destination. Pot stopped working as an antidote to agitation and inner pain so he finally made an appointment with a psychiatrist. He began taking lithium, got into therapy, and started building a life. He married his girlfriend and they had two children. The bookstore was a reasonable, if marginal success.

But mental illness doesn’t let go easily. When his children were 8 and 6, Lovelace grew tired of taking lithium, ditched the medication, and had yet another manic break. The episode cost him his business and friendships; frightened his wife and children; and scared him into a new level of self-awareness. He finally accepted that without the lithium, episodes got worse and the cycles sped up. He has reconciled himself to taking lithium for the rest of his life and describes himself as still recovering. Both parents had another recurrence, this one terrifying because it happened simultaneously and his mother nearly died. They too have had to come to terms with their illnesses and with the bald fact that without medication they are in danger. Having done so, they can enjoy a peaceful retirement surrounded by books and art and their family.

Lovelace has faced the family demons and written a book for the rest of us. He speaks eloquently of his journey from depression to empathy and uses his story as an allegory of hope. He educates us with gentle humor and hard facts. Yes, bipolar illness can be devastating but it also comes with gifts of creativity and sensitivity. When a person with bipolar illness accepts the diagnosis and stays with treatment, that creativity can be channeled into a book and a life of quieter beauty.

Scattershot: My Bipolar Family
David Lovelace
September 2008: Dutton Adult
Hardcover, $24.95
304 pages

The difference is really quite simple, though. Manic depression — or bipolar disorder — includes clinical depression as a part of its diagnosis. You can’t have bipolar disorder without also having had an episode of clinical depression. That’s why the two disorders shared similar names for many years, because they both include the component of clinical depression.

Such a depressive episode is characterized by the common signs and symptoms of depression:

• Feeling sad and unhappy for an uninterrupted period of at least 2 weeks
• Crying for no reason
• Feeling worthless
• Having very little energy
• Losing interest in pleasurable activities

Because both depression and bipolar disorder share this commonality, somewhere between 10 to 25 percent of people with bipolar disorder are first mistakenly diagnosed with only depression. It’s only when the professional learns more about the person and their history do they later discover episodes of either mania or hypomania.

Mania Distinguishes Manic Depression from Depression

Mania is the distinguishing symptom of bipolar disorder and what differentiates it from clinical depression. A person with bipolar disorder has experienced one or more manic episodes (or a lesser form of mania known as hypomania). What’s a manic episode?

• Feeling overly happy, excited or confident
• Feeling extremely irritable, aggressive and “wired”
• Having uncontrollable racing thoughts or speech
• Thinking of yourself as overly important, gifted or special
• Making poor judgments, such as with money, relationships or gambling
• Engaging in risky behavior or taking more risks than you ordinarily would

A person with is experiencing the lesser form of mania — hypomania — may only experience a few of these symptoms, or their symptoms are far less severe and life-impairing. A person with clinical depression experiences none of these symptoms.

Depression isn’t the only disorder that is confused with bipolar disorder. Especially in children and teens, sometimes other disorders — such as attention deficit disorder (ADHD) — may be misdiagnosed, when the teen may instead be suffering from a form of bipolar disorder. That’s because children and teens with bipolar disorder may display hyperactive behavior — a common symptom of ADHD. Teens with bipolar disorder are especially more likely to engage in antisocial or risky behaviors, such as those involving sex, alcohol, or drugs.

People who are diagnosed with the more severe form of bipolar disorder are said to have Type I Bipolar Disorder. Those diagnosed with the less severe form — those who have hypomanic instead of full blown manic episodes — are said to have Type II. Learn more about the different types of bipolar disorder here.

Bipolar disorder, like all mental disorders, is treatable through a combination of psychotherapy and medications. You can learn more about the treatment options available for bipolar disorder here.

Drawing on personal experience with bipolar disorder, the lives of the saints, and feedback received through workshops he has led, Wootton suggests a new paradigm for understanding and coping with mood disorders.

The book is directed primarily at mental health consumers, while professionals may become frustrated with the easygoing style and lack of conclusive evidence to support Wootton’s theories. It was worth a read, but I can’t see myself recommending it to any of the clients I work with as a counselor.

Tom Wootton is the author of Bipolar Advantage as well as the founder of Bipolar Advantage, a consumer-run organization working to change the paradigm for mood disorders for both professionals and consumers.

Wootton traces the start of his unstable and fluctuating moods to when he was nine years old; however, it was not until his forties that he was diagnosed with bipolar disorder. Much of Wootton’s life was spent seeking spiritual fulfillment and he spent many years in a monastery seeking growth and guidance.

After a brief introduction to himself and his journey, Wootton begins to explain how he understands depression, which is not simply as an emotional illness:

“For me, and so many others I have met in talks and workshops, depression has four components: physical, mental, emotional and spiritual” (p. 33).

He then outlines each of these areas and describes how the combination creates what is referred to as clinical depression.

Next, Wootton discusses the concept of “functionality.” After discussing specifics of functioning while both manic and depressed, he proposes a new definition of functionality—that it should be looked at in terms of personal growth and insight.

“Every great change in my life was precipitated by insights gained during depression. Depression has served the function of changing my life for the better” (p. 47).

After wrapping up his discussion of functionality, Wootton moves on to discuss the scale people use to evaluate mood disorders. Without pictures it’s a little hard to explain, but basically he shows that we generally use a linear, one-dimensional scale to try to understand a very nonlinear illness. A frequently used scale goes from one to ten, with one being practically dead and ten being amazing.

Of course, people with bipolar disorder must be evaluated on both depression and mania scales; however, a linear scale is still often used. Wootton proposes a new, three-dimensional scale, consisting of two pyramids, point to point, which cover physical, mental, emotional and spiritual components.

In the next, and largest section of the book, Wootton presents the lives of five saints (four Christian, one Buddhist) and their journeys with depression. Using the examples of Teresa of Avila, Anthony, Milarepa, John of the Cross and Francis of Assisi, he shows how some of the largest influences in spirituality and monasticism grappled with mental illness. He then discusses the advantages that today’s mental health consumers have over the saints, reminding readers that they have shown the way by going before us. Those dealing with depression have advantages such as therapy, medication, research and advocacy that the saints did not have.

Finally, drawing on workshops he has led, Wootton discusses how a person can come to see depression as an advantage:

• acceptance
• introspection
• focus
• creating a business plan for success
• getting
• your own hard work

He places great emphasis on looking inward, learning about yourself and coming to terms with your illness. He is also a vocal proponent of medication and meditation. It is important to note the author’s understanding and acceptance of the fact that this is a process that takes time. When creating a business plan for success, Wootton encourages people to set both short- and long-term goals, acknowledging that change does not completely happen overnight.

I was not convinced of Wootton’s hypothesis that depression is an advantage. While I agreed with his holistic emphasis, he almost made it sound too easy. Proponents of Wootton’s work might argue that he was in fact very realistic in his thinking, but I just didn’t see it.

The book’s biggest strength is its emphasis on depression as a multifaceted illness. Though consumer groups and social workers seem to have begun to embrace this, many physicians still work from a medical model of mental illness. This comes across both directly and indirectly throughout the book as Wootton discusses his new ideas for measuring mental illness.

The part of the book I found most frustrating was the section on the lives of saints. This portion took up the largest percentage of the book, but did not seem entirely relevant. While Wootton’s purpose in including it was clear, to help people understand that the saints came before us and grew through their journeys with mental illness, less detail into their lives might have been more effective. Further, in describing their lives, Wootton uses websites such as Wikipedia to gather his facts, which makes his retelling far less credible.

As a person who has struggled with anxiety and depression for quite some time, as well as a mental health social worker, I really didn’t find this book presented anything radically new and different.

The Depression Advantage
By Tom Wootton
Bipolar Advantage, 2007
196 pages
$18.95 (paperback)

People with this illness are treated like modern-day lepers. They are ridiculed, stereotyped and misrepresented in society. No matter how skilled or educated they may be, the dark cloud of this disease follows them everywhere. In order to maintain employment, they must resort to lying.

I know this because I am one of these people. Moreover, although my situation might seem unique, it is more common than you might think.

Now, I am warning you that, when I reveal the identity of this dreaded illness, your initial reaction will more than likely be, “Oh, that’s not so bad.” However, given a few minutes, as you ponder in your mind all of the images of the people down through history who have been likewise afflicted, your attitude will surely change. You will look for the nearest exit from the situation. Even if you were my friend before, now you are afraid. People in the past who had this disease usually didn’t fare well in society.

Of course, that is not the case today. By looking at me you don’t even know I’m sick. However, the moment you know, you change; you become afraid. Because I am mentally ill, if you are one of the 95% of people, you have now labeled me untouchable.

I am a United Methodist pastor, and I have a form of mental illness called bipolar disorder. I am not alone, and my situation is not unique. In the conference where I serve, a study discovered that nearly 65% of the pastors appointed to it were prescribed antidepressants in 2007. Though not unique in diagnosis, we all share a commonality—our employer doesn’t know.

I was diagnosed nearly 16 years ago, at 35 years old. My illness, which manifests in many unique, yet similar ways, can be managed, but not cured. There are times when the symptoms of this illness can be extremely exhausting and disorienting. It strikes unexpectedly, without warning. Unfortunately, you are usually unaware of any symptoms. When you are sick, you become the disease, and together you move along as if everything is just fine.

For the past eight years I have been, and still am, a full-time pastor at a mainstream, Protestant denomination. Prior to my call to ministry, I spent nearly 25 years in various positions in manufacturing management. I have only served one church, and the church is doing well. I have spent the time faithfully serving God, and have experienced the problems that all pastors experience. I have conducted weddings, performed funerals, sat at the bedside of a dying member, performed baptisms, and conducted bible studies. I have done what is expected of a pastor, and sometimes more, and I feel I have done it well.

My problem is that I am living a lie. I haven’t told anyone about my secret, other than those who need to know. I am sick. What I have is incurable, but it can be controlled through medication. It isn’t fatal, but often the sweet release of death would be a welcome relief.

When people hear of this disease, they act as if the person were on the streets of 1st century Jerusalem, crying “Unclean, unclean!” the way that lepers were required to do.
Anyone who hears of an illness such as cancer or heart disease does all they can to support and encourage the afflicted person. If I become paralyzed and am confined to a wheelchair, I will have assistance at every corner, every door and every grocery store. Although it may not be wanted, I can have help with everything I do or wish to do. That is wonderful, and it is deserved.

When people hear of my disease, their eyes open wide, they stutter a few words of sympathy, and they get away as quickly as possible. I will get few visits, if any at all. Nobody will offer to help me get to the doctor, or to the hospital or to the emergency room late at night. I will be on my own. Other than a few very close family members, I sail this ship solo, through uncharted waters that a seasoned mariner would choose to avoid. Being alone with my disease is exactly what I don’t need or want.

Now you see my problem. My entire purpose as a pastor is to help people to know Jesus Christ, which requires a great deal of trust. In most situations, when they come to me for advice, they are actually asking me what I think they should do. They trust in my judgment. They expect my advice to be sound and true, brought about by experience, training and the leading of God. I’ll be around their children. I’ll be present at church and family functions. In their mind, they don’t know when I’m “gonna blow.”

If they know, they won’t come around to take me to doctor appointments, or water my plants when I’m hospitalized. They won’t drop by to try to cheer me up when I’m down. They won’t bring food by the house when I’m so depressed that I can’t even get out of bed. Now all of a sudden, the advice, which was good yesterday, is tainted, questionable and unreliable. Everything, and I mean absolutely everything, that I do will be studied and unnecessarily brought into question. Although none of my church-related activities would change, I would be scrutinized with new, different eyes. The same hand and mind that put together the sermon last week is this week called into question; these new eyes seeing things a little differently, and its delivery a little out of place.

Not surprisingly, I am not the only pastor faced with this dilemma. During 2007, in one conference of the United Methodist church, 65% or approximately 300 of the nearly 500 pastors were prescribed antidepressants. My fear of “coming out” must be common, since I don’t know even one of these pastors suffering from a mental illness. The people need a place to go for information, to share problems and to feel safe. The purpose of my blog is to provide just that place.

I pray that pastors, as well as other professionals, suffering from mental illness, will someday be able to “come out” without fear of retribution or being ostracized. I pray that people will understand that mental illness does not mean evil, but is simply a disease of an organ in the human body. However, this will only happen when those with this diagnosis stand up and reveal that they are functioning, responsible, productive members of society. We need to stand up, take responsibility for who we are and be willing to accept the consequences.

OK, who wants to go first?

While I can see some truth in this viewpoint, I offer a different opinion: In nearly every case, a person with mental illness experiences some form of extreme thinking, a black-and-white viewpoint. Let’s profile bipolar disorder and depression right now to see what I’m talking about.

Bipolar disorder is characterized by mood swings, sleep disruption, and extreme behaviors. These mood swings can include irritability, energetic happiness, impulsive and erratic behavior, deep depression, anger, or even agitated confusion. None of these states is healthy over the long term, yet this is the world of a person with bipolar disorder.

Bipolar I is the most extreme and dangerous form. A person with Bipolar I behaves in life-threatening ways—driving dangerously, abusing illegal drugs, and performing other acts of self-harm—spends recklessly, shows dramatic behavior changes, has disrupted sleep, and has strong mood swings. Bipolar II is similar except the level of danger and risk to self and others is generally lower. Cyclothymia is even one step milder with little risk of anything truly dangerous, but is still disruptive to the person’s life.

Many people with bipolar say that they really like their unmedicated manic state. They feel so alive, energetic, and creative. They have endless ideas and the motivation to keep them flowing. They feel there’s nothing they can’t do. While a person in a manic state may feel full of life, this is absolutely unsustainable. Nobody truly can have endless energy with little sleep and random eating habits.

In a manic state, a person may forgo or limit most other necessities aside from their passion of the moment. This could include family time, work, exercise, relaxation, hobbies, housekeeping, grocery shopping or shopping for other necessities, cooking, etc. The ideas may be flowing strongly, but what good are they if the person becomes too exhausted to act on them?

Major depressive disorder has hallmark symptoms including strong feelings of sadness, despair, emptiness, and sometimes anger. This burden is so heavy, a depressed person’s pain shows in his or her behavior and thinking patterns. Nothing ever seems to go right; they don’t feel happy enough to be social; they sleep too much so they miss out on exercise. While they may have periods or moments of happiness, the bulk of their emotion is marked by depression.

Several famous painters, authors, and actors have done their most memorable work while living through depressive episodes. But their bodies and minds were burdened with a smothering blanket of despair and loneliness. The depressed mind is often so scrambled that thoughts and feelings don’t come out clearly. How can true creativity flourish in this environment?

Many of these talented people have died younger than necessary or developed addictions. Their greater creativity was effectively strangled because it shortened or greatly impaired their lives. The imbalanced nature of their lives knocked them down many times, and some did not survive their fall.

• Musician Kurt Cobain of the rock group Nirvana reportedly was diagnosed with bipolar disorder. He was also addicted to heroin and survived at least one drug overdose. Cobain died in 1994 from a self-inflicted gunshot wound.

• Wolfgang Mozart was a prolific composer, but also was prone to drinking, depression, hyperactivity, and working excessively with little rest. He died of an unknown illness at age 35.
• Actor Heath Ledger suffered from depression and drug addiction. In 2008, he died of an accidental overdose of prescription medication. Six months before his death, he began to go through dramatic mood swings with deep depression.
• Ernest Hemingway wrote several novels that went on to become world literature classics. He struggled with depression and excessive drinking throughout his adult life. He shot himself to death in 1961.

Depression and bipolar often play a cruel joke. Both disorders both produce an excess of thoughts and overflowing emotions. They can prompt the flow of ideas, but they also create mental confusion and overload. Thoughts and ideas can be easily lost before they are expressed. Creativity is both stimulated and stunted by the same force.

The artists, actors, poets, and authors who have managed to express themselves in spite of their mental illness deserve our respect and appreciation. They have managed to push their ideas out in to the world, past the jagged edges and barbed wire inside their souls. They have given us a glimpse into the mind and heart of someone with significant emotional imbalance and pain. Most are not so lucky.

Approximately 2.6 percent of American adults have bipolar disorder (formerly called manic depression and manic depressive disorder), according to the National Institute of Mental Health. These mood swings include “highs” (mania), when individuals feel either on top of the world or on edge, and “lows” (depression), when they feel sad and hopeless. Suicide attempts are common in bipolar disorder, especially during depressive episodes.

Bipolar disorder can be effectively treated with medication and psychotherapy. With proper treatment, individuals with bipolar can lead fulfilling, productive lives. This is why it’s so important to recognize the symptoms and see a mental health professional for an evaluation.

What Causes Bipolar Disorder?

There is no single cause for bipolar disorder. Indeed, like all psychological disorders, bipolar disorder is a complex condition with multiple contributing factors, including:

• Genetic: Bipolar disorder tends to run in families, so researchers believe there is a genetic predisposition for the disorder. Scientists also are exploring the presence of abnormalities on specific genes.
• Biological: Researchers believe that some neurotransmitters, including serotonin and dopamine, don’t function properly in individuals with bipolar disorder.
• Environmental: Outside factors, such as stress or a major life event, may trigger a genetic predisposition or potential biological reaction. For instance, if bipolar disorder was entirely genetic, both identical twins would have the disorder. But research reveals that one twin can have bipolar, while the other does not, implicating the environment as a potential contributing cause.

What Are the Different Types of Bipolar Disorder?

• Bipolar I is considered the classic type of bipolar disorder. Individuals experience both manic and depressive episodes of varying lengths.
• Bipolar II involves less severe manic episodes than bipolar I; however, their depressive episodes are the same.
• Cyclothymia is a chronic but milder form of bipolar disorder, characterized by episodes of hypomania and depression that last for at least two years.
• Mixed episodes are ones in which mania and depression occur simultaneously. Individuals might feel hopeless and depressed yet energetic and motivated to engage in risky behaviors.
• Rapid-cycling bipolar individuals experience four or more episodes of mania, depression or both within one year.

What Are the Risk Factors for Bipolar Disorder?

Risk factors include having:

• Cyclothymia (see definition above). About half of individuals with cyclothymia will experience a manic episode.
• Any other psychological disorder
• A family history of bipolar or other psychological disorders
• Alcohol and substance abuse
• Medication interactions. For instance, antidepressants may trigger mania.
• Major life changes
• Severe stress

Symptoms of Bipolar Disorder

There are four possible bipolar states:

1. Mania
2. Hypomania
3. Depression
4. A mixture of mania and depression (called a “mixed episode”).

Mood states are highly variable. Some people can experience mood changes in one week, while others can spend months or even years in one episode.

What Does Mania Look Like?

• Feelings of euphoria and elation or irritability and anger
• Impulsive, high-risk behavior, including grand shopping sprees, drug and alcohol abuse and sexual promiscuity
• Aggressive behavior
• Increased energy and rapid speech
• Fleeting, often grandiose ideas
• Decreased sleep (typically the individual doesn’t feel tired after as few as three hours of sleep)
• Decreased appetite
• Difficulty concentrating; disorganized thoughts
• Inflated self-esteem
• Delusions and hallucinations (in severe cases)

What Does Hypomania Look Like?

Hypomania is less severe than a full-blown manic episode. Hypomanic individuals can seem pleasant, friendly, energetic and productive. Though it doesn’t sound problematic, increasing hypomania can lead to risky behaviors and full mania.

What Does Depression Look Like?

• Feelings of hopelessness and sadness
• Inability to sleep or sleeping too much
• Loss of interest in formerly enjoyable activities; loss of energy (sometimes to the point of inability to get out of bed)
• Changes in appetite and weight
• Feelings of worthlessness and inappropriate guilt
• Inability to concentrate or make a decision
• Thoughts of death and suicide

What Does a Mixed Episode Look Like?

Mixed episodes involve simultaneous symptoms of mania and depression, including irritability, depressed mood, extreme energy, thoughts of suicide and changes in sleep and appetite.

A Note about Suicide

Because of the high suicide risk in those with bipolar disorder, it’s important to note the warning signs. In addition to those mentioned in the depression symptoms above, others include:

• Withdrawing from loved ones and isolating oneself
• Talking or writing about death or suicide
• Putting personal affairs in order
• Previous attempts

For more information about suicide, check out Frequently Asked Questions about Suicide.

How Is Bipolar Disorder Diagnosed?

There are no medical tests to diagnose bipolar disorder. However, a psychologist, psychiatrist or other trained mental health professional can diagnose the disorder by conducting a face-to-face clinical interview. Your clinical interview will include detailed questions about your and your family’s medical and mental health history and your symptoms.

What Treatments Exist for Bipolar Disorder?

Bipolar disorder can be effectively managed with a combination of medication and psychotherapy to help in reducing both the number of episodes and their intensity. Treatment also can help prevent future episodes if the individual is willing to work on personal issues and develop healthy habits.

What Kinds of Medication Are Used for Bipolar Disorder?

• Mood stabilizers. These medications are prescribed to help stabilize manic symptoms, prevent future episodes and reduce suicide risk. The most well-known of these is lithium, which is effective in 60 to 80 percent of manic and hypomanic episodes. Anticonvulsant (or anti-seizure) medications also have mood stabilizing effects. These include valproate (Depakote), carbamazepine (Tegretol), lamotrigine (Lamictal), gabapentin (Neurotin) and topiramate (Topamax).

  Every medication has its own set of potentially serious side effects. For instance, Lamictal can cause Stevens-Johnson syndrome, a potentially fatal skin disease, though this is rare and is entirely avoidable by careful, slow dose titration.

• Atypical antipsychotics. The newest medications, atypical antipsychotics were originally developed to treat psychosis (a symptom of schizophrenia). Like the mood stabilizers above, atypical antipsychotics help to control mood swings. These seven medications are commonly prescribed for bipolar: aripiprazole (Abilify), risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel), ziprasidone (Geodon), clozapine (Clozaril) and olanzapine/fluoxetine (Symbyax).

  Contrary to popular belief, these medications aren’t without significant side effects, including rapid weight gain, high cholesterol and risk for diabetes, which occurs most commonly with olanzapine and clozapine. In some cases, atypical antipsychotics have been associated with a life-threatening condition known as diabetic ketoacidosis (DKA).

  In June 2004, the U.S. Food and Drug Administration (FDA) requested that all companies who manufacture atypical antipsychotics include a warning about the elevated risk for hyperglycemia and diabetes (see here ).

  In addition, several organizations, including the American Diabetes Association and American Psychiatric Association, have published recommendations for doctors on how to treat patients taking these medications. For more information, read the press release at the American Diabetes Association website.

• Calcium-channel blockers. Used to treat angina and high blood pressure, these medications — including verapamil (Calan, Isoptin, Verelan) and nimodipine (Nimotop) — also have mood stabilizing effects. They have fewer side effects than other bipolar drugs but aren’t as effective.
• Combination therapy. When one medication isn’t working, a doctor might prescribe two mood stabilizers or a mood stabilizer along with an adjunctive medication to treat symptoms such as anxiety, hyperactivity, insomnia and psychosis. For example, Xanax (alprazolam), a fast-acting benzodiazepine, typically is taken for two weeks before mood-stabilizing medication starts to work. Antidepressants might be prescribed for patients who are in a depressive phase, but research suggests they aren’t effective, can trigger mania and exacerbate episodes long term.

Psychotherapy

Psychotherapy is a crucial component of long-term bipolar disorder management. Even when your mood swings are under control, it’s still important to stay in treatment.

Several different psychotherapeutic methods have proved to be effective in treating bipolar disorder.

• Cognitive behavioral therapy (CBT) helps individuals develop strategies to cope with their symptoms, change negative thinking and behavior, monitor their moods and predict their mood to try to prevent a relapse.
• Interpersonal and social rhythm therapy is a combination of interpersonal therapy and CBT. This newer treatment focuses on circadian rhythms to help clients establish and maintain routines and build healthier relationships.
• Psychoeducation teaches individuals about their disorder and treatment and gives them the tools to manage it and anticipate mood swings. Psychoeducation also is valuable for family members.

How Else Can I Manage Bipolar Disorder?

• Take your medication.
• See a therapist regularly.
• Learn more about bipolar disorder and its treatment
• Participate in online communities or in-person support groups
• Adopt healthy habits, including exercising, practicing stress management techniques, eating healthy, avoiding alcohol and drugs, getting seven to eight hours of sleep and avoiding any potential triggers.

What Do I Do Next?

By starting to learn about bipolar disorder, you’ve already taken a significant first step. If you’d like to learn more, check out our detailed guide here.

If you think you or a loved one has bipolar disorder, it’s important to be evaluated by a trained mental health professional. To find a therapist in your area, use a search engine such as this one, or check with your primary care physician or community mental health clinic for referrals.

Further Reading

The Numbers Count: Mental Disorders in America

National Institutes on Mental Health

University of Maryland Medical Center

National Alliance on Mental Health (NAMI)

Depression and Bipolar Support Alliance (DBSA)

Be careful when you wrestle with monsters, lest you thereby become one. For, if you stare long enough into the abyss, the abyss also stares into you.
— Friedrich Nietszche

Now I want to tell you about the symptoms that schizoaffective disorder shares with schizophrenia – the disorders in thought.

I find this difficult. It seems I haven’t ever written much, publicly anyway, about what it’s like to be schizoid. I think right now will be the first time I have written about it at any length. I have found it difficult to communicate my experience as compellingly as I had set out to do. It’s taken some time to understand why.

The problem I have is that it is dangerous for me to have the kind of experience that would allow me to write vividly about my illness. I have found in the past that to experience memories of my symptoms with too much clarity causes me to experience the actual symptoms again. It can happen that simply reflecting on my past in a deep way can bring about the insanity. This happened once during a time when I was corresponding regularly with a bipolar friend, and when I told her what it was like to really remember, she very anxiously pleaded with me to stop, let go and forget lest I be drawn into the darkness again.

After some reflection I realize that the danger is in remembering the feelings I have had when I’ve been symptomatic. There is no problem with recalling the events, looking at old photos from the time, or reading what I wrote when I was wigging. What is dangerous is remembering the feelings by actually feeling them again. Remembering that I felt afraid is OK, what is not is to actually feel the same fear I once felt. To write the best I could hope to I would have to recall the actual feelings again, and I think it is best I not do that.

For that reason I have found it necessary to approach this topic with a certain protective detachment that has resulted in the clinical tone my article has so far. I hope you can forgive me for it. I’m finding it a little more difficult to stay so detached as I write about being schizoid. Maybe I will be able to write more effectively here but just between you and me I find the experience more than a little frightening.

For a long time I have found it easy to admit to being manic depressive. I do it casually sometimes, even flippantly. Even before I decided to go public with my illness I was comfortable telling trusted friends that I was manic depressive. But I have always been much more reluctant to own up to actually being schizoaffective. What I said before, that I describe my illness as I do because no one understands schizoaffective disorder, is only part of the truth. The full truth is that even now, after so many years, I still find it hard to face the part of myself that is schizophrenic.

Many manic depressives will tell you that despite the pain it causes that there is something romantic about being manic depressive. As I said manic depressives are known to be intelligent and creative people.

However, despite its extremes, the symptoms of manic depression are mostly familiar human experiences. It is not hard to find completely healthy people who act just like I do when I’m either hypomanic or moderately depressed. It’s just the way they are. Psychotic mania and psychotic depression are not so familiar, but they are different in degree, not in kind.

The schizoid symptoms I experience are just plain… different.

This really gives me a serious case of the creeps.

Hearing Voices

Yet it is in place to appeal to the fact that madness was accounted no shame nor disgrace by men of old who gave things their names; otherwise they would not have connected that greatest of arts, whereby the future is discerned, with this very word ‘madness’, and named it accordingly.
— Plato Phaedrus

Auditory hallucinations are the key sign of schizophrenia. After the summer I was diagnosed, when I related my experience to a fellow UCSC student who studied psychology, he said that the fact that I heard voices by itself made some psychologists consider me schizophrenic.

Everyone has an inner voice that they talk to themselves with in their thoughts. Hearing voices is not like that. You can tell that your inner voice is your own thinking, that it’s not something you’re actually hearing someone saying. Auditory hallucinations sound like they’re coming from “outside your head”. Until you come to understand what they are, you cannot distinguish them from someone actually talking to you.

I haven’t heard voices very much, but the few times I have is quite enough for me. While I was in the Intensive Care Unit at the Alhambra Community Psychiatric Center that summer of ‘85, I heard a woman shout my name – simply “Mike!” It was distant and echoey, so I thought she was shouting my name from down the hall, and I would go look for her and find no one.

Other people hear voices whose words express much more disturbing things. It is common for hallucinations to be harshly critical, to say that one is worthless, or deserves to die. Sometimes their voices keep up a running commentary about what’s going on. Sometimes the voices discuss the inner thoughts of the person who hears them, so they think everyone around can hear their private thoughts discussed aloud.

(One might or might not have a visual hallucination of someone actually doing the speaking – the voices are often disembodied, but for some reason that doesn’t make them any less real to those who hear them. Usually those who hear voices find some way to rationalize why the speech does not have a speaker, for example by believing that the sound is being projected to them over a distance via some kind of radio.)

The words I heard weren’t disturbing in themselves. For the most part, all my voice ever said was “Mike!” But that was enough – it wasn’t what the voice said, it was the intention that I knew to be behind it. I knew that the woman shouting my name was coming to kill me, and I feared her like nothing I’ve ever feared.

When I was brought to Alhambra CPC, I was on a “72 hour hold”. Basically I was in for three days of observation, to allow myself to be studied by the staff to determine whether lengthier treatment was warranted. I had the understanding that if I just stayed cool for three days I would be out with no questions asked, and so although I was profoundly manic I stayed calm and behaved myself. Mostly I either watched TV with the other patients or tried to soothe myself by pacing up and down the hall.

But when my hold was up and I asked to leave, my psychiatrist came to me to tell me he wanted to stay longer. When I protested that I’d met my obligation, he replied that if I didn’t stay voluntarily he would commit me involuntarily. He said something was seriously wrong with me and we needed to deal with it.

He told me I’d been hallucinating. When I denied it, his response was to ask “Do you ever hear someone call your name, and you turn, and no one is there?” And yes, I realized he was right, and I didn’t want that happening, so I agreed to stay voluntarily.

Hallucinations aren’t always menacing. I understand some people find what they have to say familiar and comforting, even sweet. And in fact another voice I think I heard (I can’t be sure) came when I was hanging out by the nurse’s station in the ICU. I heard one of the nurses ask me an inconsequential question, and I answered her only to be surprised to find her looking down at her desk, ignoring me. I think now she hadn’t addressed me at all, that the question I heard was one of my voices speaking to me.

I became very determined that the voices were going to stop. They really bothered me. I worked hard to determine the difference between real people talking and my voices. After a while I was able to find a difference, although a disturbing one – the voices were more convincing to me than what real people actually said. The concreteness of my hallucinations’ apparent reality always struck me immediately, before I ever heard what they said.

Some of my other experiences are this way too: the conviction of their reality always strikes me before the actual experiences do. People have often told me I should just ignore them, but I haven’t had that choice, by the time I can make the decision to ignore something I have already been frightened by it.

After a while I decided I just wouldn’t listen anymore. And after a short time the voices stopped. It only took a few days. When I reported this to the hospital staff, they seemed quite surprised. They didn’t seem to think I should be able to do that, to just make my hallucinations go away.

Still the voices bothered me enough that for years afterwards it startled me to hear anyone call my name when I didn’t expect it, especially if someone I didn’t know was calling someone else who happened to be named “Mike”. For example, there was someone named Mike who worked on the night shift at the Safeway grocery store in Santa Cruz when I lived there, and it would frighten me when they would call his name on the public address system, asking him to come help at the cash register.

Dissociation

At times, particularly that summer of ‘85, I would have the experience that I was not participating in my own life anymore, that I was an detached observer of, rather than a participant in my life.

The experience was like watching a particularly detailed movie with really high-fidelity sound and a wraparound screen. I could see and hear everything going on. I guess I was still in control of my actions in the sense that some guy who everyone else referred to as “Mike” seemed to be speaking and doing stuff from the same point of view as I was watching from – but that person was definitely somebody else. I didn’t have the feeling that the part of me who was called I had anything to do with it.

At times this was frightening, but somehow it was hard to get worked up about it. The person who was feeling and exhibiting the emotions wasn’t the one called I. Instead, I just sat back and passively observed the goings-on of the summer.

There was a philosophical theory that I had long been interested in, that I think I first encountered in a science fiction story I read when I was young. Although I was originally fascinated with it in a conceptual and academic sort of way, solipsism took on a terrible new importance to me that summer – I didn’t believe anything was real.

Solipsism is the notion that you are the only being that exists in the Universe, and that no one else really exists, instead it is a figment of your imagination. A related concept is the idea that history never happened, that one has just this instant sprung into being with one’s lifetime of memories readymade without the events in them ever having actually occurred.

At first I found this interesting to experience. I had always found ideas like this fascinating to discuss and debate with my schoolmates, and now I would talk about it with the other patients. But I found that it was no longer an interesting concept that I held at a distance, that instead I was experiencing it, and I found that reality terrible indeed.

Also related to solipsism is the fear that everything one experiences is a hallucination, that there is some other objective reality that really is happening but which one is not experiencing. Instead one fears that one is living in a fantasy. And in fact that is not far off from what many of the most ill psychiatric patients face. The concern I had is that (despite my experience of actually being in a psychiatric hospital) I wasn’t really free to move around the ward and talk with the doctors and the other patients, but that I was actually strapped in a straightjacket in a padded cell somewhere, screaming incoherently with no idea of where I really was.

There. I told you this was creepy. Don’t say I didn’t warn you.

I once read somewhere that solipsism had been disproved. The book that claimed this didn’t provide the proof though, so I didn’t know what it was, and this bothered me tremendously. So I explained what solipsism was to my therapist and told him that I was upset to be experiencing it and asked him to prove to me that it was false. I was hoping he might give me a proof of reality in much the same way as we worked proofs in Calculus class at Caltech.

I was appalled at his response. He simply refused. He wasn’t going to give me a proof at all. He didn’t even try to argue with me that I was wrong. Now that scared me.

I had to find my own way out. But how, when I knew that I could not trust the things I heard, saw, thought or felt? When in fact my hallucinations and delusions felt much more real to me than the things that I believe now were really happening?

It took me quite a while to figure it out. I spent a lot of time thinking really hard about what to do. It was like being lost in a maze of twisty passages all alike, only where the walls were invisible and presented a barrier only to me, not to other people. There on the ward we all lived in the same place, and (for the most part) saw and experienced the same things, but I was trapped in a world I could find no escape from, that despite its invisibility was a prison as confining as Alcatraz Island.

Here is what I discovered. I’m not sure how I realized it, it must have been by accident, and as I came across it accidentally a few times the lesson began to stick. The things I felt, not with my emotions, but by touching them, by feeling them with my fingers, were convincingly real to me. I could offer no objective proof that they were any more real than the things I saw and heard, but they felt real to me. I had confidence in what I touched.

And so I would go around touching things, everything in the ward. I would suspend judgement on things that I saw or heard until I could touch them with my own hands. After a few weeks the feeling that I was just watching a movie without acting in it, and the concern that I might be the only being in the Universe subsided and the everyday world took on a concrete experience of reality that I had not felt for some time.

I wasn’t able to think my way out of my prison. Thinking was what kept me imprisoned. What saved me was that I found a chink in the wall. What saved me was not thought but feeling. The simple feeling that there was one small experience left in my world that I could trust.

For years afterwards I had the habit of dragging my fingers along walls as I would walk down halls, or rapping my knuckles on signposts as I passed them on the street. Even now the way I shop for clothes is to run my fingers over the racks in the store, searching by touch for material that feels particularly inviting. I prefer coarse, robust and warm material, rough cotton and wool, dressing in long-sleeve shirts even when it is hot out.

If left to my own devices I would (and used to) buy clothes without any regard to their appearance. If my wife didn’t help choose my clothes they would always be hopelessly mismatched. Fortunately my wife appreciates my need for tactilely appealing clothes and buys me clothes that I find pleasant to wear and that she finds pleasant to look at.

The importance of touch comes out even in my art. A friend of mine remarked once about my pencil drawing – pencil is my favorite medium – that I “have a love of texture”.

It is typical of schizoid thought that a simple but disturbing philosophical idea can overwhelm one. No wonder Nietzsche went mad! But I will explain later how studying philosophy can be comforting too. I will tell you how I found salvation in the ideas of Immanuel Kant.

Paranoia

Just because you’re paranoid it doesn’t mean they’re not out to get you.

Paranoia is the one of my schizoid symptoms that bothers me the most. While I’ve only heard voices a few times, if I weren’t taking an antipsychotic drug called Risperdal the paranoia would happen frequently. As I’m sure you could imagine, being paranoid is distressing and so I’m very careful to always take my Risperdal. Visual hallucinations happen quite a bit too (when I’m not taking my medicine anyway) but except for startling me they happen suddenly, I don’t find them as upsetting.

Paranoia is commonly thought to be the delusion that others are plotting against oneself, but it is a little more complicated than that. And you may be surprised to hear that even if one is self-aware enough to know that one is experiencing paranoia, to understand clearly that what one thinks is a delusion, it doesn’t make the delusions go away.

The paranoid are commonly thought to be deadly dangerous. While there have been cases of the paranoid attacking those they thought had it in for them, most paranoids are perfectly safe to be around and in fact are commonly found living among you in society where they lead more or less normal lives. You don’t have to be schizophrenic to be paranoid – it can arise as a neurosis, for example in response to early child abuse, and exist in a pure form without other schizoid symptoms like hallucinations.

I was interviewed in the March 30, 2000 edition of the Metro San Jose, in an article called Friends in High Places. I answered an ad seeking bipolar Silicon Valley engineers for anonymous interviews, but I told them they could feel free to use my name and even my photo. If you click the link, down towards the bottom of the page you will see me sitting on the driveway of the house I used to live in in Santa Cruz.

The article quotes me as saying “I can work effectively even when I’m wigging, even when I’m hallucinating, even when I’m severely depressed.” And by wigging, I meant that I could develop software while severely paranoid. I’ve spent a lot of productive hours at the office, laboring at my computer, while trying to avoid thinking of the fact that a Nazi armoured division was holding maneuvers in the parking lot.

The article goes on to say:

“Programming is more tolerant of eccentric activity,” Crawford says. “Even though I might have been weird, I was a good worker.”

The essence of paranoia is that one’s interpretation of events is deluded, not the perception of the events themselves. In the absence of hallucinations, everything a paranoid experiences is really happening. What the paranoid is mistaken about is why they’re happening. Even inconsequential events take on a significance that is personally threatening. This makes it hard to know what is real. Although one can test one’s sensory perceptions by, for example, asking other people, it is much harder to objectively test one’s beliefs about why something is happening, especially when you don’t feel you can trust what other people say.

For example, a stylishly dressed, attractive young woman approached me on the street one day in downtown Santa Cruz and bluntly said “it’s all been a plot”. It seems that there had been a conspiracy to rob her of her money. She explained it at some length while I listened in awestruck fascination:

She had a book checked out of the library, and meant to return it on time, but a diversion created by the conspirators delayed her. When she finally returned the book, she was assessed a fine. As evidence of the plot she cited the helicopter that flew overhead, spying on her as the left the library.

Anyone can have an unexpected delay and be charged a fine when they return a library book late. Helicopters fly over Santa Cruz all the time – I have no doubt that she really saw a helicopter. But what was special in her circumstances was why she was delayed: she did tell me what happened (I’m sorry I don’t remember) but was convinced that the delay had been caused by those who plotted against her. Many people see helicopters fly overhead; what was special for her is the reason she felt the helicopter to be there.

I don’t actually have such a hard time distinguishing most of my paranoid delusions from reality. It’s because they’re all so ridiculous – I really have spent a lot of time worried about the military coming to attack me. It’s not that I hallucinate my attackers. If I look I can see they’re not there. But when I turn away I feel their presence again. I know very well I experience paranoia and I try to tell myself it’s not real, but I’m afraid that simply knowing it’s a delusion is no comfort at all.

As I said I often feel the fear from my experiences before I have the experiences themselves. People try to tell me to ignore the paranoia but that doesn’t help – first I feel panic, and only then do I think the men with guns are out there waiting for me.

The only comfort I can find is to face my fear. If a Nazi Panzer division is tearing up my front yard, the only recourse I have is to steel my courage and go outside to look for them until I’m satisfied they’re not there (I have to search carefully – perhaps they’re hiding in the bushes). Only then does the paranoia subside.

Walking around Pasadena late in the evening I was discharged from Alhambra CPC, I came across a large white stone, about three feet across and fairly round. There were some wrinkles in its surface. It looked just like an ordinary stone, but I knew it wasn’t – it was someone waiting for me, crouching on the ground, and I feared him. It didn’t look like a real person at all – it looked like someone wearing a very clever stone-like disguise.

I stood there paralyzed for some minutes, unsure of what to do, until I summoned all the courage I could muster – and kicked the stone as hard as I could. After that, it was just a stone.

Now about the little joke with which I introduced this section. Everyone, even perfectly sane people, have challenges they struggle against. You don’t have to be paranoid to have enemies. Perfectly sane people get robbed, beaten and even murdered all the time. Probably the worst part of all about being paranoid is when the paranoid has a real enemy, and that enemy uses the paranoid’s illness against them. You might beg others for help, but the person who is trying to hurt you is easily able to convince them that your complaints are just delusions, and so your pleas fall on deaf ears.

There is a very real stigma against mental illness in our society. Stigma can kill – I once received word from the wife of a European diplomat that his doctors refused to treat his heart condition because he was manic. He died in the hospital of a very real, unimagined heart attack.

There are people who harbour a deep seated hatred for the mentally ill for the simple fact that we are different. And these people do grievous harm to those who suffer, in large part by using the symptoms we exhibit to convince others not to support our cause, to convince them that the hatred we sense from them is all in our heads.

I have been at the receiving end of some of the worst of this stigma. That is why I write web pages such as this, to promote understanding in our society so that in a hopeful future day the stigma will be gone and we can live among you as ordinary members of society.

Geometric Visions

One evening as I was walking across a parking lot at the California Institute of Technology, I looked up to see a Yin-Yang symbol in the sky stretching from horizon to horizon. Shimmers of energy radiated from Mt. Wilson to the North. I felt a deep chord resonating through my body, the vibration of the Universe penetrating deep into my bones. I was as tall as giant striding across that parking lot that evening.

At that instant I Knew. I knew my Purpose.

I had been walking to my weekly appointment with my therapist in downtown Pasadena. I hurried on to our meeting, and when I arrived I excitedly explained my revelation to her.

“Mike,” she replied, “you’re not making any sense”.

For a while after I cracked up at Caltech, and every now and then after that, I would see things like Yin-Yang symbols in the clouds. I would see other things too, like the energy waves from Mt. Wilson, which at the time was a powerful symbol for me. Sometimes the Yin-Yang symbols were animated, and would spin. The might be recursive, with smaller Yin-Yangs in each of the spots, and so on ad infinitum. I found that I could see them if I stared into the snow on a television set that wasn’t tuned to a station.

After I dropped out of Caltech, I started pursuing various artistic endeavours. I learned to draw from Betty Edwards’ Drawing on the Right Side of the Brain, and would construct crystalline latticeworks from painted wooden dowels.

I started to teach myself to play piano. I had a friend show me a few basic chords, and then I would just bang on the keyboard randomly until something that sounded like music came out. All the pieces I can play now I composed myself through improvisation – I still can’t read music. Much later in Santa Cruz I took lessons from a wonderful teacher named Velzoe Brown, and learned to play quite a bit better, but still find interpreting musical notation difficult and tedious.

And I first got into photography in a serious way that Fall at Caltech. A housemate lent me a nice SLR camera, a Canon A-1, and I would walk around campus and Pasadena taking pictures. My sense of sight was vivid in those days and I found that photography came naturally. The expensive Canon could accurately meter a 30-second night exposure, so a great deal of my photos were ghostly shots in the dark. I still enjoy night photography.

I would photograph my hallucinations too. I would try to anyway, only to be disappointed that they didn’t turn out when I got the prints back from the developer. However I can see even now where the seeds of my visions lay in the photographs. For example I would commonly see Yin-Yang symbols graphically floating in the sky, but in the photographs now I can see the hint of shapes in the clouds where one could easily imagine a real Yin-Yang.

Imagining what they see in clouds is a common game among children. But I would take it an extra step, as the shape would take on a stark reality that didn’t look like a cloud at all.

Eventually the visions in the sky went away, but for much longer I was bothered by illusions that I would see out of the corner of my eye. Lots of people catch glances of things that aren’t really there, that go away when you look straight on. But in my case they were rather more distinct than I think most people experience.

My illusions also are based on real objects. The most common (and bothersome) illusion I have is to see flashing police car lights where a real car has a luggage or ski rack. This would combine with my paranoia to give me the urge to dive into the bushes when such cars would drive by.

Risperdal is effective for me at eliminating the hallucinations. I found it very helpful in bringing me back down to Earth during my graduate school manic episode, but it is expensive and I resented taking it at the time, so I stopped for a few months. I finally decided to go back on Risperdal and take it faithfully one night while dining in a restaurant with a friend, only to be bothered by flashing blue police car lights and billowing red flames out the window to my left. Each time I turned to look, I would see only the headlights of cars driving up the street towards the restaurant.

In many ways I miss the visions. Not the squad car lights, but the many beautiful and inspiring things I saw. While living without visions is certainly more placid, it’s not nearly so interesting.

The psychologist who did my intake at Dominican Hospital in 1994 told me that in many more traditional cultures, the schizoaffective people are the shamans. If you wonder why there are no more miracles as in the Biblical days, it’s because we lock our prophets up in mental hospitals.

And my purpose? Very simple: my purpose is to unify Art and Science. In high school I had been active in the theater and the chorus, and also enjoyed literature and writing, but stopped all my artistic pursuits at Caltech because I had to study so hard. I felt the need to restore balance to my life, and I felt the need to bring that balance to Caltech itself, where I felt the lack of right-brain stimulation was damaging and depressing to both the students and the faculty.

I don’t know why that didn’t make sense to my therapist. It made perfect sense to a different therapist I saw a half a year later, just as I was about to get myself in a position to be diagnosed. I don’t think it’s such a bad thing to want to be a well-rounded person, or to want to restore balance to a society suffering from a fetishistic obsession with technology.

In the end, I don’t think it’s such a bad thing at all that I changed my major to literature.

Next: How To Deal with Mental Illness

In Part III, I will discuss what to do if you think you might be mentally ill: the importance of getting treatment as well as an accurate diagnosis, what else might be causing mental and emotional disturbances, seeking psychotherapy and how to build a livable new world for yourself.

I will explain why I am so bold as to write such things in such a public way, and finally I will cite some websites and books you can read to learn in greater depth what mental illness is and how to recover from it.

Manic depression is characterized by a cycle of one’s mood between the opposite extremes of depression and a euphoric state called mania. Schizophrenia is characterized by such disturbances in thought as visual and auditory hallucinations, delusions and paranoia. Schizoaffectives get to experience the best of both worlds, with disturbances in both thought and mood. (Mood is referred to clinically as “affect”, the clinical name for manic depression is “bipolar affective disorder”.)

People who are manic tend to make a lot of bad decisions. It is common to spend money irresponsibly, make bold sexual advances or to have affairs, quit one’s job or get fired, or drive cars recklessly.

The excitement that manic people feel can be deceptively attractive to others who are then often conned into the belief that one is doing just fine — in fact they are often quite happy to see one “doing so well”. Their enthusiasm then reinforces one’s disturbed behaviour.

I decided that I wanted to be a scientist when I was very young, and throughout my childhood and teenage years worked steadily towards that goal. That sort of early ambition is what enables students to get accepted into a competitive school like Caltech and enables them to survive it. I think the reason I was accepted there even though my high school grades weren’t as good as the other students was in part because of my hobby of grinding telescope mirrors and in part because I studied Calculus and Computer Programming at Solano Community College and U.C. Davis during the evenings and summers since I was 16.

During my first manic episode I changed my major at Caltech from Physics to Literature. (Yes, you really can get a literature degree from Caltech!)

The day I declared my new major I came across the Nobel Prize-winning Physicist Richard Feynman walking across campus and told him that I’d learned everything I wanted to know about physics and had just switched to literature. He thought this was a great idea. This after I’d spent my entire life working towards becoming a scientist.

When Did it Happen?

I have experienced various symptoms of mental illness for most of my life. Even as a young child I had depression. I had my first manic episode when I was twenty, and at first thought it was a wonderful recovery after a year of severe depression. I was diagnosed as schizoaffective when I was 21. I’m 38 now, so I have lived with the diagnosis for 17 years. I expect (and have been emphatically told by my doctors) that I’m going to have to take medication for it for the rest of my life.

I have also had disturbed sleeping patterns as long as I can remember – one reason I’m a software consultant is that I can keep irregular hours. That’s a primary reason why I went into software engineering at all when I left school – I did not think my sleeping habits would allow me to hold a real job for any length of time. Even with the flexibility most programmers have, I don’t think the hours I keep now would be tolerated by many employers.

I left Caltech when my illness got really bad at the age of 20. I eventually transferred to U.C. Santa Cruz and finally managed to get my physics degree, but it took a long time and a great deal of difficulty to graduate. I had done well in my two years at Caltech, but to complete the last two years of classes at UCSC took me eight years. I had very mixed results, with my grades depending on my mood each quarter. While I did well in some classes (I successfully petitioned for credit in Optics) I received many poor grades, and even failed a few classes.

A Poorly Understood Condition

I’ve been writing online about my illness for a number of years. In most of what I have written, I referred to my illness as manic depression, also known as bipolar depression.

But that’s not quite the right name for it. The reason I say I’m manic depressive is that very few people have any idea what schizoaffective disorder is — not even many mental health professionals. Most people have at least heard of manic depression, and many have a pretty good idea of what it is. Bipolar depression is very well known to both psychologists and psychiatrists, and can often be effectively treated.

I tried to research schizoaffective disorder online a few years ago, and also pressed my doctors for details so I could understand my condition better. The best anyone could say to me is that it is “poorly understood”. Schizoaffective disorder is one of the rarer forms of mental illness, and has not been the subject of much clinical study. To my knowledge there are no medications that are specifically meant to treat it – instead one uses a combination of the drugs used for manic depression and schizophrenia. (As I will explain later, while some might disagree with me, I feel it is also critically important to undergo psychotherapy.)

The doctors at the hospital where I was diagnosed seemed to be quite confused by the symptoms I was exhibiting. I had expected to stay only a few days, but they wanted to keep me much longer because they told me that they did not understand what was going on with me and wanted to observe me for an extended time so they could figure it out.

Although schizophrenia is a very familiar illness to any psychiatrist, my psychiatrist seemed to find it very disturbing that I was hearing voices. If I had not been hallucinating he would have been very comfortable diagnosing and treating me as bipolar. While they seemed certain of my eventual diagnosis, the impression I got from my stay at the hospital was that none of the staff had ever seen anyone with schizoaffective disorder before.

There is some controversy as to whether it is a real illness at all. Is schizoaffective disorder a distinct condition, or is it the unlucky coincidence of two different diseases? When “The Quiet Room” author Lori Schiller was diagnosed with schizoaffective disorder, her parents protested that the doctors really didn’t know what was wrong with their daughter, saying that schizoaffective disorder was just a catch-all diagnosis that the doctors used because they had no real understanding of her condition.

Probably the best argument I’ve heard that schizoaffective disorder is a distinct illness is the observation that schizoaffectives tend to do better in their lives than schizophrenics tend to do.

But that is not a very satisfying argument. I for one would like to understand my illness better and I would like those from whom I seek treatment to understand it better. That can only be possible if schizoaffective disorder were to get more attention from the clinical research community.

Interpersonal and Social Rhythm Therapy (IPSRT) is founded upon the belief that disruptions of our circadian rhythms and sleep deprivation may provoke or exacerbate the symptoms commonly associated with bipolar disorder. Its approach to treatment uses methods both from interpersonal psychotherapy, as well as cognitive-behavioral techniques to help people maintain their routines. In IPSRT, the therapist works with the client to better understand the importance of circadian rhythms and routines in our life, including eating, sleeping, and other daily activities. Clients are taught to extensively track their moods everyday. Once routines are identified, IPSRT therapy seeks to help the individual keep the routines consistent and address those problems that arise that might upset the routines. This often involves a focus on building better and healthier interpersonal relationships and skills.

When Interpersonal and Social Rhythm Therapy is combined with psychiatric medications, research has shown that people can achieve gains in their targeted lifestyle routines, reduce both manic and depressive symptoms, and increase days of maintaining a consistent, regular mood. Like most psychotherapies, not everyone will respond to a course of IPSRT, but for those people who do respond, most have a reduction in the symptoms associated with bipolar disorder.

Interpersonal and Social Rhythm Therapy is practiced in both inpatient and outpatient settings, but is most often used as a treatment for people who have bipolar disorder in an outpatient, office-based setting. IPSRT is virtually always prescribed in conjunction with psychiatric medications used to treat bipolar disorder, such as lithium or an atypical antipsychotic.

Interpersonal and Social Rhythm Therapy was developed at the Western Psychiatric Institute & Clinic at the University of Pittsburgh by Ellen Frank and her colleagues.

Psychotherapy for Bipolar Disorder

Psychotherapy can be helpful for someone grappling with bipolar disorder, because it can help the person learn to deal with the psychological aspects of this disorder that aren’t helped by the medication. Therapy can help a person learn to change inappropriate or negative thought patterns and behaviors associated with the disorder.

Both individual or group therapy are appropriate and recommended for someone with this disorder. Therapy is usually supportive in nature, helping a person learn how to increase their coping skills and education about the disorder. With specific episodes of depression or mania, additional therapy can focus on the treatment of those disorders. For instance, therapy can help a person learn to better predict his or her own fluctuations in mood (which may be related to situational or seasonal changes). This in turn can decrease the likelihood of relapse in the future.

Prevention of future relapses is often a focus of therapy, with medication compliance as an important topic. This is especially true with individuals who may be experiencing a manic episode (or may be more predisposed to being on the manic side), but is can also be an issue for those who are experiencing no specific episodes of mania or depression.

Therapy should be flexible in its approach, since the needs of people suffering from bipolar disorder are diverse. Family therapy is sometimes warranted. For instance, bringing in a family member or close friend (or spouse) who keeps track of the patient can be beneficial to touch base with and ensure that everyone is clear about appropriate behavior and treatment. People with bipolar disorder can sometimes wreak havoc in their own personal lives when in a manic stage. This sometimes spills over to the person’s family or friends and should be an aspect of treatment in psychotherapy. Education of family members or significant others can help them better manage the patient at home and ensure medication compliance.

Followup care for someone with bipolar disorder is imperative. Whether this takes the form of regular group therapy sessions, case management, medication appointments, or the like, touching base with a professional will help a person to remain compliant in taking their medication as directed.

Discharge planning should take these factors into account; failure of a person to appear for the next scheduled appointment can be an ominous sign. Unfortunately, many such individuals easily fall between the cracks in the mental health system because followup is either not conducted or not conducted in a timely manner. This is especially true when the client is moving from an inpatient or day-treatment program to an outpatient program.

Self-Help Strategies for Bipolar Disorder

A person with bipolar disorder can help themselves stay balanced by taking an active approach in their treatment. Most people with bipolar disorder experience a relapse when they discontinue mood-stabilizing medication prescribed for the disorder because they “feel better — I don’t need to keep taking the medication any longer.”

Support groups offer an excellent adjunct to continuing medication check-ups once a month, and a way to gain emotional and social support through the community. These groups also allow others to ensure the client is doing well and promotes the client’s independence and stability. Many online bipolar support groups exist that are devoted to helping individuals with this disorder share their commons experiences and feelings.

Such support groups are recommended to individuals suffering from this disorder, especially if they have found therapy unhelpful or too expensive. Self-help mutual support groups, though, are unlikely to benefit a person with this disorder as much as they could, unless they are also under the care of a psychiatrist or another mental health professional.

Unlike most adults who have bipolar disorder, however, children who have pediatric bipolar disorder are characterized by abrupt mood swings, periods of hyperactivity followed by lethargy, intense temper tantrums, frustration and defiant behavior. This rapid and severe cycling between moods may produce a type of chronic irritability with few clear periods of peace between episodes.

Because the current diagnostic manual of mental disorders doesn’t recognize childhood bipolar disorder, there is no official symptom criteria. However, researchers have used criteria similar to that of adult bipolar disorder, requiring a child or teen to meet at least four or more of the following:

• an expansive or irritable mood
• extreme sadness or lack of interest in play
• rapidly changing moods lasting a few hours to a few days
• explosive, lengthy, and often destructive rages
• separation anxiety
• defiance of authority
• hyperactivity, agitation, and distractibility
• sleeping little or, alternatively, sleeping too much
• bed wetting and night terrors
• strong and frequent cravings, often for carbohydrates and sweets
• excessive involvement in multiple projects and activities
• impaired judgment, impulsivity, racing thoughts, and pressure to keep talking
• dare-devil behaviors (such as jumping out of moving cars or off roofs)
• inappropriate or precocious sexual behavior
• grandiose belief in own abilities that defy the laws of logic (ability to fly, for example)

Keep in mind that many of these behaviors, in and of themselves, are not indicative of a possible disorder and are characteristic of normal childhood development. For instance, separation anxiety, by itself, is a normal fear of being separated from one or both of the parents (for instance, attending the first day of first grade or if the parents want to go out for a night).

Childhood bipolar disorder is characterized by many of these symptoms, taken together, and marked by rapid mood swings and hyperactivity. These symptoms must also cause significant distress in the child or teen, occur in more than just one setting (e.g., at school and at home), and last for at least 2 weeks.

Because the existing diagnostic manual doesn’t recognize pediatric bipolar disorder, and there is still debate within the professional community about the validity of this diagnosis, insurance companies may not reimburse for treatment of this disorder. In addition, some professionals may not recognize the disorder and misdiagnose the child or teen with attention deficit disorder or depression.

Cyclothymia is a mood disorder characterized by cycling periods of hypomania-unusual emotional highs-and periods of mild to moderate depression. The condition is similar to the better known bipolar disorder, but cyclothymics never experience episodes of full mania or deep depression. In order for a therapist to diagnose someone with cyclothymia, the cycling of moods must continue for at least two years. Since the emotional episodes of cyclothymics tend to be more mild, they often go undiagnosed and untreated. Clinical studies have demonstrated, though, that leaving these symptoms untreated carries a particular risk: between 15 and 50 percent of cyclothymia sufferers will eventually develop a diagnosable bipolar disorder.

This book, the first written specifically to cyclothymia sufferers, helps readers learn more about this condition. It explores hereditary and stress-related possible causes of the disorder, as well as the history of the condition and its treatment. The book offers exercises to help readers recognize their emotional cycles and any conditions that might trigger changes from one phase to another. The book introduces readers to cognitive behavioral techniques that are effective at limiting and controlling shifting moods. Later chapters explore treatment options-medical and psychotherapeutic-and offer advice on how to manage relationships when one partner suffers from cyclothymia.

Softcover, 197 pages.

The voice of the recovered narrator provides context, reliability, and credibility. Where the manic narrator is relentlessly entertaining and delusional, the recovered narrator is tough minded, concise, and determined to reveal the truth, no matter how painful. With a cold eye he examines the forces that shaped him in order to shed light on the psychological architecture driving the episode. The interplay between these two perspectives underscores the bipolar nature of Manic Depression; the greatest personal challenge is reconciling them. Ultimately, the narrator must confront his own worst nightmare and in doing so gain character, insight, and acceptance.

About the Author

Alistair McHarg spent his early years in Edinburgh and Amsterdam, moving to Philadelphia with his father, Ian, and mother, Pauline, at age six. He attended Germantown Friends School, Haverford College, and the University of Louisville. Convinced at an early age that fate had chosen writing as his calling, he followed a characteristically slow and circuitous path. McHarg has found employment as deck hand on a Norwegian tramp freighter touring South America, Bureau of Land Management Emergency Fire Fighter in Alaska, guide at a Canadian wilderness survival camp, truck driver crisscrossing Colorado’s continental divide, and inner city cabbie. Alistair has been arranging words on paper for a living since 1983. He is the author of three novels, a memoir, innumerable poems, hundreds of book, film, and music reviews, and an ever growing catalog of cartoons.

Softcover, 240 pages.

Here now is Marya Hornbacher to push the image further with her memoir, Madness. Hornbacher is a gifted writer who’s navigated the positive and negative effects of the illness on her writing career. She writes about writing while relating her life events in a way that isn’t self-aggrandizing. Well, not too much. This is a person who has had some very grandiose moments during her manic episodes, and enjoys sharing them in Madness.

But, she has led a truly grand life. Her first memoir, Wasted, a detailed (very detailed) account of her struggle with an eating disorder, made her rich and adored by millions. By reflecting her mirror image to readers she showed them that she was similar to what they see in their own mirrors, and inspired some to recover. Wasted helped readers with bulimia and anorexia to perceive themselves in new ways.

There is a similar dynamic here in Madness, using bipolar disorder. Revealing herself in this memoir about the turmoil of manic depression in her life (she wasn’t diagnosed until after Wasted was published, which is why that book doesn’t go into it), she created a doll to carry away. It’s a vividly and detailed replica of a person who lives with bipolar, its features both unique and universal. It’s all made of text.

Separating a behavior from a symptom is a challenge to everyone fighting stigma. Is the person acting strangely due to a moral failing or biology? Obnoxious or manic? Lazy or depressed? Slutty or hypomanic? By laying down snapshot after snapshot Hornbacher creates overlays, patterns clearly found in symptoms that are absent between episodes. In doing this she also shows us cracks in the mental health system: an early therapist ignored signs of mania and told her to self-soothe with a bubble bath, while a nurse accused her of malingering when she protested that Prozac was making her more manic and agitated (a common reaction to Prozac among people with bipolar, in the early days of SSRI antidepressants most doctors didn’t connect the dots – some still don’t). She describes these encounters with psychiatrists and therapists with humor, but it’s wry to bitter humor.

A spoonful of whipped cream is lavished on top. With ECT and the disorder itself causing amnesia, memories are lost, memories are blurred, and some are perhaps fantasized in impressionistic streams, but they do swirl into place as sincere and emotionally accurate. Hornbacher is diagnosed with Bipolar I ultra-rapid cycling. She describes her mood swings as diurnal (waking depressed, becoming hypomanic at night) as well as longer underlying cycles in seasonal episodes. Predictable for her is to be manic in summer, depressed in winter. Studies have also identified people who are manic in spring, and suicide rates also peak at that time of year. But in the bipolar spectrum, it’s different for every body. In the DSM-IV a manic episode is defined as four days or more of sustained symptoms. As more researchers are learning lately, though, and as Hornbacher describes from her own life, mixed states with symptoms of both depression and hypo/mania are more common than previously believed. It’s a problem when some mental health professionals don’t recognize or treat it appropriately, and this happened to her more than once.

The book jacket boasts that this memoir will “…powerfully change, too, the current debate on whether bipolar in children actually exists.” Memories plucked from childhood, going back as far as age four, are offered as proof of its existence. Developing an eating disorder at nine and doing cocaine at thirteen are explained as self-medicating her mood swings. I’m not sure that her testimony on the existence of childhood bipolar is compelling, but obviously she was not just, as one psychiatrist condescendingly labelled her, an “angry little girl.”

Hornbacher seems to have that competitive streak sometimes seen among people with severe mental illness: her disorder is the worst and she is the sickest. She’s an admitted perfectionist and overachiever so I suppose it’s no wonder. In some chapters she describes going into episodes so bad that she wanders around dazed and lost (but always somehow finds her way home) or can’t think well enough to work (but does finish writing a novel). She may be more capable than she’s giving herself credit for. But she would win a few “most extreme” prizes. The book opens with a scene describing a “slip” that severed an artery, the gory images and sequence far more dramatic than things most people have done. Heightened by vital, kinetic words.

This book is more than a memoir; it’s beautiful prose that exemplifies what is almost a new sub-genre. Work about her process, about herself, through her process, with exquisite insights that surely didn’t come from a mind that is too cognitively impaired. But describing helpless psychosis makes for better heroism, more to admire as clarity re-emerges from dark fogs.

Ultra high-achieving women who’ve written memoirs about bipolar disorder: Kay Redfield Jamison, Patty Duke, Terri Cheney, Jane Pauley, and now Marya Hornbacher. She’d invite them to a fabulous dinner party, perfect in every detail from the crystal and silver to non-alcoholic wine. Even in that ideal setting, among the books of those extremely smart and talented women, her memoir shines just a little brighter.

Softcover, 299 pages.

Raw, honest and brazen, The Bipolar Advantage draws its examples from the real-life experiences of its author, other people with a bipolar diagnosis and those who have relationships with bipolar people. Pulling no punches, Tom Wootton paints a realistic picture of the bipolar condition in its many faces, then gently guides the reader through the steps necessary to lead an introspective life that greatly ameliorates those symptoms, with the ultimate goal of helping bipolar people gain control of their lives.

Tom takes the reader on a journey through the good and bad aspects of bipolar, transforming negatives into positives and nurturing a mental environment where bipolar people can reshape their views of their condition and move fluidly from concepts of illness to excellence.

Ultimately, The Bipolar Advantage will stand as a guide book for those who don’t want to accept a diminished view of their lives after a diagnosis of bipolar. It s a road map to wellness and strength that will stand the test of time and the changing winds of popular bipolar treatment modalities.

Softcover, 200 pages.