Bipolar Expeditions (18 page)

Ms. Peterson:
Depression is a whole world: I am in a hole; all around me is dark. I can't make the smallest decision, so the simplest thing, like taking a shower, is horrible.

Dr. Murray:
Does it really seem darker or is that just a metaphor?

Ms. Peterson:
There is constant negative self-talk. There is no hope. I feel scared and overwhelmed.

After about twenty minutes, Dr. Murray ended the interview politely, accompanied Ms. Peterson to the door, and then led a discussion with the audience about the importance of continual efforts to adjust and modify the combination of drugs she was taking. This case was relatively uncomplicated. There were no perceptible disagreements among doctors about her diagnosis or about how to treat her depression. The patient, quietly and sweetly, offered her succinct and telling descriptions of the experience of depression without questioning her diagnosis or its treatment.

(2) I Thought I Was Normal When I Was Speedy

At a grand rounds event I attended later, the medical history presented by a resident went this way:

Ms. Vincent is a forty-something-year-old African American woman, separated from her husband. She has a history of cocaine abuse and was admitted in a bipolar state. Her father was alcoholic, her sister was once admitted with hallucinations, and her brother may be a schizophrenic. All family members are [drug] abusers and there is a family history of suicide…. Herwork has included being a model and working for a design agency. She was a business manager at one point and she is a college graduate.

She has a six-year-old child who is now in Texas protective services. Ms. Vincent was jailed for second-degree manslaughter (a man beat her and she killed him to defend herself), so the child was put in foster care.

In 1998 she was diagnosed as bipolar by Health Care for the Homeless. At age eleven she was hypomanic; at age sixteen she had postpartum depression. She has a long history with many episodes. (You wonder why they didn't notice that she has this bright energy! It is a driven kind of energy.)

She had peculiar hallucinations. She saw herself jump in front of a train. Once before she had seen herself jump out of a window. She admitted herself to the Wellingtown inpatient ward and was given Zyprexa and lithium. She was very cooperative. She tended to be depressed in the morning and revved up in the evening. She was then discharged to the Wellingtown day hospital [a clinic that patients visit daily without overnight stays] but seemed downcast, and under that downcast mood was animation. She felt ugly inside, like she must have done something wrong. She has a fear of the dark and agoraphobia and she understands that she has a mood disorder. Because the Zyprexa caused side effects that bothered her, it was discontinued. Effexor was begun instead and lithium was continued. She was still depressed, but on Effexor she has had only one day of hypomania. She has gotten gradually more depressed and she is fearful of being hurt. They have now raised her dose and today she is somewhat hypomanic. She has been completely reliable in coming into the day hospital. Even on the snow day when the hospital was closed, she showed up, and she was the only patient to do so. Her goal is to get back to Texas and get her daughter back.

Dr. Murray summarized this as “a case of chronic and refractory illness.” Ms. Vincent, a tall and solidly built woman, stately and dignified, was then ushered in. She was the only African American person in the room. Dr. Murray sat in a chair turned slightly toward her and began.

Dr. Murray:
How are you feeling today?

Ms. Vincent:
Speedy, high.

Dr. Murray:
Is it pleasant?

Ms. Vincent:
No.

Dr. Murray:
What is speeding? Your thoughts? Your actions?

Ms. Vincent:
My hand movements and all are fast. I can't keep still.

Dr. Murray:
Do you feel bad about yourself?

Ms. Vincent:
No.

Dr. Murray:
Are you depressed?

Ms. Vincent:
I don't feel suicidal, I feel real sad.

Dr. Murray:
Is it worse than being speedy?

Ms. Vincent:
It scares me.

Dr. Murray:
Why?

Ms. Vincent:
I can't control myself.

Dr. Murray:
What is it like when you're well, when you're yourself?

Ms. Vincent:
I don't know. I just found out I'm sick. I thought I was normal when I was speedy.

Dr. Murray:
Did you see in the hospital that you were different?

Ms. Vincent:
I saw the difference.

Dr. Murray:
Did the medications help?

Ms. Vincent:
Until they found out the medications have to keep changing. I just want the medications to make me normal, and to make me not be depressed.

Dr. Murray:
How long has it been since you were on an even keel?

Ms. Vincent:
I cannot remember.

Dr. Murray:
Does this upset your estimation of yourself? There must have been times when you were on an even keel and you felt okay. When were those?

Ms. Vincent:
In 1995 and 1996 in Texas, but I was speeding all the time.

Dr. Murray:
It would be a problem to decide when your ability was normal. You're a bright and lively person, but we wouldn't want to confuse that with being speedy. Can you remember times when you were doing OK? When you could keep a job? When you could control yourself? What kind of state is it when you can go to work?

Ms. Vincent:
I am responsible even when speeding. So as I said I thought this was normal.

Dr. Murray:
A lot of people go pretty fast! What is your state now?

Ms. Vincent:
I'm speeding but normal.

Dr. Murray:
So too much speeding gets to be abnormal? How was your weekend?

Ms. Vincent:
It was a good one. I was with friends and I slept over with them.

Dr. Murray:
I understand they raised your medications some.

Ms. Vincent:
Because I had hallucinations. I was in my third-floor apartment and I saw myself going up to the window. I was wide awake. It was like my body left me. I came to the hospital, but I was scared of it and of the security guards.

Dr. Murray:
Are you convinced to take your medications?

Ms. Vincent:
I'm not going to attempt suicide today.

Dr. Murray:
I hope you don't ever do it.

Ms. Vincent:
I have Prisoners' Aid, and they are helping with my medical, legal, and housing expenses. Psychological aid is part of the treatment.

Dr. Murray:
Life—we are for it.

Dr. Murray thanked the patient and she went out of the room. Turning to the audience, he said,
“That
was an awkward interview. I think we could get some idea about her ‘speediness.' She is quite a lively person, but she is dangerous to herself. She has experienced the disruption of a lifetime. You can see the deterioration of the person this illness brings out. It's not clear what she means by her ‘normal' state and we have to work on this.”

Of the fifty minutes devoted to grand rounds, the time given to detailing the patient's medical history is comparable to or even exceeds the time given to interviewing the patient. The history frames the interview, both questions and responses. Within this frame, the interview is intended to bring out the experiential aspects of the illness. The patient is there to tell the audience “what it is like” to be depressed or manic. But the setting of grand rounds is no doubt intimidating for the patient. The auditorium has seats for hundreds of people, arranged in steeply tiered rows that look down on the stage. Often, the gender and/or race of the patients (many of whom are African American because the hospital's cachement area is an African American neighbor hood) place them at an additional disadvantage vis-à-vis the audience and interviewer (almost all of whom are white). In this hierarchical setting, patients may elaborate on their experiences, but they are not likely to question how doctors apply the categories of illness themselves. It is remarkable that even hints of questioning appeared in these events, such as Ms. Vincent's effort to say that she regarded her “speeding” as normal, and only her depression as in need of treatment. Dr. Murray preferred to have her see her “speeding” as abnormal, and in need of increased medication.

In the teaching event called clinical rounds, the physical layout is certainly less intimidating than the one in grand rounds: the room is the size of a large living room and the chairs are arranged informally in a circle. Below I describe six cases presented in clinical rounds during my fieldwork, which will illustrate interactions between doctors and patients that involve considerable ambiguity and contestation.

(3) What Is the Diagnosis?

A resident presented the first case, which serves to illustrate the complex social, physical, and emotional conditions that bring people to this tertiary care hospital in the inner city.

Ms. Simmons is a thirty-two-year-old unmarried African American female who works as a paralegal. She has audio hallucinations and difficulty thinking clearly. In her family history, her father was manic depressive and he was a murder victim. Her mother was depressed. Her brother died of cerebral hemorrhage. Two other maternal relatives were schizophrenic. She experienced sexual abuse from ages seven to fourteen from her cousins. Her sexual preference is homosexual. Her religion—she mentioned Buddhism.

In her medical history, she has asthma and is a chronic steroid user. She has an inherited condition that involves a seizure disorder. As for medications, she is now on Depakote and Mellaril, but she has been on many others—she has tried them all. In her psychiatric history, she has had twenty-five admissions. In kindergarten she was diagnosed with ADHD and given Ritalin. At age seventeen she entered Jackson Hospital [pseudonym for a local residential psychiatric hospital].

As far as her previous diagnosis goes, there has been much debate over whether she has Bipolar 2 or schizoaffective disorder. For a time, she had trouble with paraphilias [nontypical sexual interests] involving kids aged two to five. [Dr. Dean: Did she act on them?] Apparently not, they were just fantasies. She did take Depo-Provera. She has had bulimia, and there is also a possible borderline diagnosis. She has done some self-injury. She has had many suicidal gestures, and has been given over fifty ECTs. Drugs she has taken include Haldol, Mellaril, Risperdal, and Depakote.

For the last two months she has expressed fear of the outside. She can't go to the supermarket and she fears people are laughing at her. She thought her coworkers would call her names if she went to work. During this time she also experienced less need for sleep and racing thoughts. She quit her job and then began to have delusions about her uncle and grandmother, with whom she lived. She thought they were involved in witchcraft and were plotting against her because of their homophobia.

We stopped the Mellaril and with this change in medication she looks much better. [This opens a door into a disagreement among the staff about the patient's condition. Dr. Morrison breaks in: Yes, but what is the real reason she looks better? The real reason is she wants to go home. Her motivation is strong to look good enough to get out because she does not like to be in hospital, once she gets in. She spent a long time in Jackson Hospital when she was younger. She has said she has to be home to pay the rent, even though it is clear she could mail the check. The only possibility she admits is that she must be there physically to do it.]

At this point, Ms. Simmons was accompanied into the room. She wore a short Afro and a casual T-shirt and jeans. Her manner was subdued but she was responsive to Dr. Dean's gentle but persistent questions. After thanking her and explaining that the group is made up of students and researchers interested in understanding what her experiences are like so that they can develop improved treatments, the interview began.

Dr. Dean:
What brought you in?

Ms. Simmons:
I couldn't go out even to get to the grocery store. At work I got the sense the others were talking about me. It is a law office, legal aid. They talked about everyone else, and they were also talking and laughing about me.

Dr. Dean:
Are things looking better now that you are here?

Ms. Simmons:
Yes, I got back my sense of “why would they be talking about me?” But I also hear the voices of my cousins.

Dr. Dean:
Where are the voices?

Ms. Simmons:
They are my own thoughts.

Dr. Dean:
Where are they?—Here? There? Up? Down?

Ms. Simmons:
They are mine but it is Andrew [her cousin]! It is this insidious giggling. I have had a fear of dying, I feel sure I am going to die. But I am not suicidal. My depression is I can't get going. To talk is hard, the worst. If I could go to work and there would not have to be any talking, that would be ideal. If I take antidepressants, they make me manic, irritable, and angry to the point of violence. I can't be around people.

Dr. Dean:
Why did you choose to come to Wellingtown Hospital?

Ms. Simmons:
I knew you used the new medicines.

Dr. Dean ended the interview here, expressed the group's appreciation, and walked her to the door. Turning to the group, he led us through the intricacies of diagnosis.

Dr. Dean:
How do we know she is not just shy and introverted? The voices—are they hallucinations?

Student:
Not as Jaspers describes it.

Dr. Dean tried to help the student recall exactly what Karl Jaspers, whose classic early twentieth-century accounts of abnormal psychic phenomena are required reading for students in the department, had written.

Dr. Dean:
A true hallucination is a perception without a stimulus. But she describes the voices as being among her thoughts. Jaspers has two lists, each with six questions—can you recall them?