In my most recent Question of the Week, I asked:
Is your bipolar part of the "real you?" Or do you consider your illness alien to you?
The issue cuts to the core of who we are (or who we think we are), which is why in my more than 10 years of researching and writing about my illness I am amazed I have never posed this question to my readers.
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
People who come across as normally upbeat tend to be described as “exuberant.” In 2004 Kay Jamison PhD of Johns Hopkins published a book entitled “Exuberance,” with Teddy Roosevelt as her poster boy. According to Dr Jamison, in a talk she gave at Johns Hopkins in 2002, a contemporary described TR’s life as the "unpacking of endless Christmas stockings."
In her talk, Dr Jamison described TR as "hypomanic on a mild day," an observation that did not make it into her book. Rather, Dr Jamison sees exuberance as a temperament, equivalent to enthusiasm which in Greek means a god within. "Happy is he who bears a god within," she quoted Louis Pasteur, "and obeys it."
A similar term, favored by Hagop Akiskal MD of UCSD, is “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 into mania 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?”
In her piece,Therese describes herself as a child relating more to Christian mystics than to girls her age with their silly crushes on boys. But she concludes: “Now I look back with tenderness to the hurting girl I was and wished somebody had been able to recognize that I was very depressed.”
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.
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.
Much more later ...
Published On: December 11, 2009
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