My intention in writing this post is to share the experiences that I went through with my son, starting with the first manifestation of his illness and our journey through numerous subsequent episodes. Also to provide commentary as a parent and psychiatrist on issues that these experiences bring up, such as how the diagnostic process works in mental health, and how to work with treatment providers and medication issues. My hope is that reading this may be helpful for people with mental health issues and also their families and friends.
Bipolar Illness
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Because Bill had profoundly paranoid delusions, for example believing that computers could read his thoughts, he was initially diagnosed as schizophrenic, even though there had been no prodrome (no time period before the onset of illness with some symptoms but not the full-blown illness) and even though his ability to relate to people remained intact when he was not psychotic. Both a prodrome and impaired social interactions are cardinal symptoms of schizophrenia. With repeated hospitalizations as more history was gathered, the diagnosis was changed to bipolar type I with psychosis or schizoaffective disorder, bipolar type. The bipolar diagnoses are based on having first and foremost a manic mood presentation—extremely elevated and euphoric mood and in his case almost always escalating into psychosis as well as decreased need for sleep. The distinction between bipolar I and schizoaffective, bipolar type is whether there are psychotic episodes that occur for at least two weeks outside of manic episodes. From Bill’s descriptions, it seemed as though his illness almost always started with a flareup in mood, usually subtle at first and then raging. As the mood escalated, he often developed profoundly psychotic symptoms.
In addition to gathering information about symptoms, another aspect of diagnosis is family history of mood disorders, which is quite common with bipolar disorder and when present helps to strengthen the diagnosis. It has been estimated that up to 80% of bipolar etiology is genetic. A person with one parent with the disorder has about a 10% to 25% chance of developing bipolar disorder themselves. The closer the relative, the higher the chance that they will also have bipolar disorder. For example, the rate in a twin is 40% to 70% if one twin has the disorder. In Bill’s case, neither parent had bipolar disorder, however it is likely that two different paternal great-grandparents and one maternal great-great grandfather had bipolar disorder, with very colorful associated stories. Thus, perhaps having multiple contributing genetic predispositions may have been a factor. It is a source of discomfort in families that they may have “caused” the illness, however there is no true causation, only an elevated probability that a person will develop the illness, similar to the relationship in diabetes, where a family history of diabetes is associated with the development of diabetes.
Repeated Escalations to Mania
With Bill’s repeated escalations to manic symptoms, he was now diagnosed with bipolar I disorder. The distinguishing feature of bipolar illness is the profound oscillation in moods, with a huge escalation in the positive direction for manic episodes and a dizzying descent into down moods during depressive episodes. The term “bipolar” derives from the two poles of mood—high and low. For some people, the escalation into mania is slow and for others, like Bill, once the increased mood started there was a rapid escalation such that he was flung into the air, flying upwards on the upward ascent of a roller coaster ride, or more aptly, a spaceship launching into outer space. How was it possible that someone wouldn’t recognize this as an aberrant phenomenon? That it might the beginning of illness?
Free Will?
Why wouldn’t Bill (and others?) choose to stop the upward spiral? That he wouldn’t make the choice to stop the ascent if he could challenged my notion of free will and made me wonder how much free will existed in his mind at the time. Perhaps he couldn’t make the choice to stop. The question of free will has been a central concern of philosophers over the ages. This ties in with a discourse by Albert Einstein in his most extensive interviews about life—reflections ranging from science to spirituality to the elemental questions of existence. It was published in the Saturday Evening Post on October 29, 1929—a quarter century after Einstein’s theory of relativity reconfigured our basic understanding of reality with its revelation that space and time comprise a single fabric. In that interview, he stated:
“I am a determinist. As such, I do not believe in free will. I believe with Schopenhauer: We can do what we wish, but we can only wish what we must. Practically, I am, nevertheless, compelled to act is if freedom of the will existed. If I wish to live in a civilized community, I must act as if man is a responsible being.”
I believe with Einstein and Schopenhauer that there is no such thing as absolute free will but rather that there are different degrees of free will conditional upon the mental capacity of the person at the time. When a person is delusional they cannot make an informed decision because they do not understand the nature of their “reality.” And in a progression of steps from sanity to insanity, there is a progressive loss of choice. It seems that once the manic “launch” is initiated a person with mania has already begun to lose touch with reality.
Bill described this transition many times in his writing about being manic, describing the sometimes gradual and sometimes rapid escalation from minimal manic symptoms to full-blown mania. For example, he wrote:
“Over the course of a few days, I felt more than ok before I knew it, and I definitely did not view this new mood and energy enhancement in terms of symptoms.”
Or another description during a different manic episode:
“My mood became extremely elevated, more and more so every day by degrees. Sometimes I would be in the middle of something and then stirrings of a euphoric intensity from deep within would capture the moment and would possess me, and I would feel light, and then these stirrings of intensity became more and more frequent and greater in duration, until my experience of the world had acquired a new quality of intensity that was colored by a deep, pervading euphoria.”
Bipolar Disorder Essential Reads
His descriptions of manic episodes illustrate the profound mood escalations that occur with bipolar disorder, but also how that escalation is woven into daily experience. These episodes occurred over many years but shared characteristics of how profoundly the episodes changed Bill’s daily life. He described his manic episodes as part of his increased ability to excel athletically in his dance classes and his daily growing enthusiasm enabling him to interact without self-consciousness. While he retained some consciousness that he was in an altered state, including a thought disorder, he nonetheless welcomed this state as preferable to ordinary, non-manic experience.
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