If we ask the right questions, maybe we can come up with the right answers.

by John McManamy


IN A BLOG, I asked:

Is your bipolar part of the "real you?" Or do you consider your illness alien to you?

In other words, is crazy your true normal? And, if so, is this something we can work with?

The issue cuts to the core of who we are (or who we think we are). Psychiatry makes a clear distinction between "state" and "trait." Traits are heritable and make up our personality or temperament - in effect, our default "me." State, by contrast, is equated to an illness, also heritable but generally out of character with our true "normal." Let's see how this works in the context of our ups and downs:

Exuberance/Hyperthymic vs Hypomanic

Kay Jamison PhD of Johns Hopkins has written about "exuberance," with Teddy Roosevelt as her poster boy. Hagop Akiskal MD of UCSD, favors the term, "hyperthymic," a temperament opposite to "depressive." Dr Akiskal views temperament as coexisting on the same spectrum with illness, ranging from advantageous to pathological.

The DSM views hypomania as an "episode" that is part of bipolar disorder, but, unlike depression, it is not considered an illness in its own right. People may act a bit strange when hypomanic, but they tend to be able to hold onto their jobs and personal relationships. Indeed, when hypomanic our productivity and creativity and sociability tend to make us the envy of the rest of the world.

The catch is nothing lasts forever. Even when feeling great, many of us experience the dread of knowing that our mood is either about to ratchet up intomania or crash into depression.

Consider Marsha and Melanie, both dancing on tables. Mutual friends know Marsha as exuberant and Melanie as the quiet one. Marsha is just being Marsha, but what is up with Melanie? Same behavior, far different implications.

As I am fond of saying, for Marilyn Monroe to act like Marilyn Monroe - that is probably normal. Anyone else acting like Marilyn, on the other hand, probably can expect bad things to happen.

Thinking Deep vs Depression

Now let's flip it to depression, what used to be called melancholia, from the ancient Greek meaning "black bile." Many of us have downbeat personalities without necessarily having clinical depression. Indeed, depressive types can possess the enviable qualities of thoughtfulness and introspection. Blogger Therese Borchard of Beyond Blue has contemplated this sort of thing for some time. "I spent my adolescence and teenage years obsessing about this question," she wrote in a recent piece. "Am I depressed or just deep?"



To return to Marsha and Melanie, this time they are both isolating in separate bedrooms, noses buried in their respective books, contemplating the futility of life. Quiet Melanie is just being Melanie, at home in her dark thoughts, perhaps even excited over the prospect of turning her ruminations into a brilliant essay. Marsha, on the other hand, is way out of her comfort zone, perhaps unable to cope.

Asking the Right Question

Recall that Dr Akiskal views state and trait as occupying the same spectrum. Making a clear separation, then, is not as easy as checking off a DSM symptom list. Indeed, personality and illness may feed off of each other. As Alex describes it, in his reply to my Question of the Week:

I consider this illness to be an alien to me, but at the same time it brings up my weakest points of my personality making me work harder on those to stay stable ...

So who the hell are we? It's a question we seldom ask.

Akiskalogy and Temperament

I was in Philadelphia in 2002 attending my very first American Psychiatric Association annual meeting. Twenty thousand psychiatrists and industry hacks (it’s often hard to tell the difference) were in town for the six-day extravaganza. Biological psychiatry was singing high praises to itself. New meds were coming on the market and the best brains in the business were figuring out smarter ways to use the current ones.

Even the highly critical commentary supported the basic paradigm - namely that there was a pharmaceutical answer for just about everything that went wrong beneath the hood. Even if we didn’t yet have all the answers, they were well within our reach. 

So it was that I entered a dark and crowded room to hear Dr Akiskal for the very first time. Although I was familiar with the name, I only had the barest superficial knowledge of his work. I had been expecting him to elaborate on why some forms of depression should be regarded as bipolar, when a bunch of “It’s Greek to me” stuff came up on his PowerPoint.

Literally. Up went slides of the Greek four humors (or temperaments), such as “melancholia” (literally meaning black bile).




What did this have to do with psychiatry? was my first reaction. Then again, I rationalized, Akiskal was probably just setting the scene. It’s a recurring problem with medical doctors who probably took arts courses in their undergraduate years. But then he started elaborating on the four humors. Not only that, he came up with his own version of the four humors. And not only that, he came up with evolutionary reasons for the four humors.

Okay, this has gone far enough, I thought. Enough, already, with this rambling prelude on ancient history. Let’s cut to the fugue. I’m here to find out about depression and bipolar.

I won’t say I was disappointed. Rather, I was confused, like listening to a difficult piece of music for the first time. I had a lot of stuff to report from that first APA meeting, but Akiskal’s presentation wasn’t one of them.

Such are the pitfalls to being deaf-dumb-and-blind to the thinkers and visionaries in our midst.

By temperament, Akiskal is referring to heritable “stable behavior traits with strong affective coloring,” throughout life. Thus, downbeat may be your baseline personality “trait”, which is a very different proposition than being in a temporarily depressed “state,” but the two are related. So much so that understanding how this state-trait dynamic works for us is crucial - absolutely crucial - to our wellness.

Drawing upon the work of the German psychiatrist Ernst Kretschmer writing in the 1930s, Akiskal points out that temperament and various related personality constructs may not only set us up for mood disorders, but can be considered as sharing the same continuum, from healthy to extreme (though much more research is needed to bear this out).



And, of course, wherever you find Akiskal, you find Kraepelin. As Akiskal describes it in a 2010 article:

The concept that different kinds of temperament are constitutionally based types of behavior can be traced back to the ancient humoral theory of Hippocrates. About 90 years ago, Kraepelin described four basic affective dispositions (depressive, manic, cyclothymic and irritable), which he believed to be subclinical forms and many times the precursors of major affective psychoses.

Moreover, these temperaments can be found in the blood relatives of those with manic-depression (which would include recurrent depression as well as bipolar). Indeed, as I heard Akiskal point out in a talk in 2010, it’s the relatives of bipolar patients who tend to benefit from having bipolar characteristics (namely in a genetically dilute form), not necessarily the patients (who unfortunately get hit with the illness full strength). Indeed, relatives and bipolar IIs are more likely to have creative accomplishments (borne out in surveys he has conducted) rather than those with bipolar I, who have far too much to contend with.

In Philadelphia, Akiskal substituted “hyperthymic” temperament for “manic,” and these are the ones who obviously benefit from having a “little bit” of bipolar. These are your exuberant upbeat types, highly energetic and super-confident, out to conquer the world. Hyperthymic is the “trait.” By contrast, “hypomanic” is the “state.”

To very loosely translate Akiskal, imagine two individuals giving very dazzling presentations in a large room. One is on the way to a brilliant career. The other is headed for a crash. Same behavior, very different result. The naturally upbeat individual will power on through thick and thin, and be abundantly rewarded. The temporarily upbeat individual is living on borrowed time.

But it’s much more complicated than that. Even hyperthymic individuals can go over the top (just ask Monica Lewinsky’s erstwhile boyfriend). And hyperthymia overlayed with a depressive state is playing with fire.

Confused? So was I back in Philadelphia in 2002.

Finding the Right Answers

My friend Tom Wootton, author of "The Bipolar Advantage" and "The Depression Advantage", offers the example of a Ferrari (that can handle tight curves at high speeds) and a Volkswagen van (that would flip over if you tried to drive it like a Ferrari). Yet both are equally stable sitting in the garage.

"But I don't want to sit in a garage," Tom contends. Hold that thought ...

A lot of what used to hold me back (and to a certain extent still does) is that I came across to others as far too weird. My depressive philosophizing and exuberant ramblings were simply too way out there for me to ever get invited back into most people's homes.

Since my behavior clearly resulted in a noticeable lack of ability to function in social situations, I do not question that I was laboring under a mental illness. To make things worse, being a social leper both isolated me and gave me cause to feel hurt, which made me a sitting duck for severe depression. And because the world was a hostile place to me, I acquired some fairly heavy duty social anxiety along the way.

Yet my inner world was amazingly rich. What seemed inappropriate and crazy on the surface to others contained its own nonlinear beauty and logic to me. Indeed, over time I learned to express these thoughts on paper. In essence, I was transcribing my nonlinear world to linear, and I even managed to make a career of it. In a similar manner, over time I learned to adjust my social behavior, so I came across as smart, funny, and even thoughtful. I can also come across as overbearing and over-the-top, but at least people are not edging toward the exits.

How do I feel when a zinger goes down well? Pretty damn good, thank you very much. How does it feel walking into a room where people are actually glad to see me? A bit anxious still, but safe and not frighteningly anxious - thanks for asking.

To return to Tom's example, I am able to take my Ferrari out of the garage. It's the same mind I'm working with, the same personality, but now I'm functioning, arguably even highly functioning. I still have a serious mental illness to contend with - which often drives me to despair - but in one important area of my life I have successfully wrested a vital part of my personality - the true me - from the death grip of my illness.

Also check out: Depressed or Thinking Deep

Reviewed June 27, 2016


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Bipolar Stuff in the Shack with John and Maggie