Nassir Ghaemi reads excerpts from his work on the therapeutic relationship in bipolar disorder. We talk about how to empathize with manic patients through the technique of “manic siding,” and catalogue over a dozen types of bipolar depression, including one that Dr. Ghaemi calls “existential despair.” [Link]
Published On: 8/31/2020
Duration: 20 minutes, 30 seconds
"Harlem" by Langston Hughes
What happens to a dream deferred?
Does it dry up
like a raisin in the sun?
Or fester like a sore—
And then run?
Does it stink like rotten meat?
Or crust and sugar over—
like a syrupy sweet?
Maybe it just sags
like a heavy load.
Or does it explode?
Dr. Aiken: Welcome to The Carlat Psychiatry Podcast, keeping psychiatry honest since 2003. I’m Chris Aiken, the editor in chief of The Carlat Psychiatry Report.
Kellie: And I’m Kellie Newsome, a psychiatric NP and a dedicated reader of every issue. For many patients, bipolar disorder is a story of loss. Loss of marriages, jobs, friendships, physical health, and meaningful roles in society… the kind of dreams deferred that the poet Langston Hughes wrote in his 1951 poem from the start of this podcast. It’s not unusual for these patients to complain of depression as these losses stack up, but listen carefully when they do. It’s not always clinical depression they’re speaking of.
Dr. Aiken: There are many kinds of depression in bipolar disorder. There’s full clinical episodes that last two weeks and have the full breadth of DSM-5 symptoms. There what Gary Sachs at MGH refers to as “roughening” – when the patient is not fully depressed but is having early symptoms or high stress and is at risk of going into a full episode. Then there’s temperamental depression – dysthymia - the low-grade but always eating at you kind of depression that patients will tell you they’ve had all their life. There’s premenstrual dysphoria, which is actually more common in bipolar than unipolar and when it happens in bipolar it does not warrant a second diagnosis – it’s just part of the disorder. There’s post-partum depression, winter depression, and atypical depression – all of which are a little more common in bipolar than unipolar disorders. There’s depression caused by medical disorders or substances, and these are so common in bipolar that they are better thought of as contributing. One that’s been recently discovered is inflammatory depression, that we see in patients with obesity and chronic medical problems.
There’s mixed states and dysphoric mania. “Depression” is actually the most common chief complaint during mania – even when it’s not a mixed state¬ - that’s right; mania usually doesn’t feel good, or if it does the euphoric feeling rarely lasts longer than a few days. Instead, mania is a state of heightened emotions, and they are all heightened: anxiety, depression, irritability, and the occasional good feeling. There’s post-manic depression – when the depression comes on right after the mania, often with prominent guilt and low energy – this is where you want to avoid antidepressants because they can flip them back into mania.
In this month’s Carlat Report we brought you unpublished research on a new medication for bipolar depression. It’s a finding that you can use in your practice today, it will work in most of the depressions I’ve just lited, and it’s on page X of the journal. But today we’re going to talk about a different kind depression you’ll see in practice, one where medications may help but they’re usually not the best answer.
It’s something Nassir Ghaemi calls “existential despair.” This is the kind of low grade, constant depression that builds as life’s losses stack up. Now, those losses – divorce, isolation, unemployment – they can cause true clinical depression – but they also cause a very real anguish that doesn’t fit the DSM description of clinical depression. This despair is a very human response to the painful losses that come with bipolar disorder.
In the New York Times Magazine in 2013, Linda Logan called on psychiatry to pay more attention to the self when treating bipolar disorder. “Ask patients about what parts of the self have vanished during the illness and help them come up with strategies to deal with the loss.
She detailed the loss of meaningful roles over several decades of the illness: Motherhood – she felt disconnected from her children and had to pretend to be like the other mothers in the school yard. Teaching career “How many employers would welcome the request for a cot, soft pillow, and half the day off?.” And eventually divorce. “I was slowly fading away”
Dr. Ghaemi wrote about how to work with the self in bipolar disorder with the late psychoanalyst Leston Havens. The 2008 paper – “Existential despair and bipolar disorder: the therapeutic alliance as a mood stabilizer ” – is a rare gem in the bipolar literature - a field that’s crowded with symptom tallies, genetic assays, and images of the brain. Those are all important, but there’s a need to touch on the human side of this work as well. We reached out to Dr. Ghaemi who agreed to read a few paragraphs from his work:
Manic siding goes against the grain in psychotherapy, where we’re usually taught to avoid splitting – not to side with the patient against the world, or the world against the patient. Yet mania is a unique state. It’s a state of non-learning, and one that’s primed for a fight. Confrontation is not going to work here – best to agree. But how do you do that without being dishonest? The answer is to speak in broad generalities – the kind of talk you see on bumper stickers. For example, suppose you work in a large medical office and a manic patient comes in complaining that your receptionist is a Nazi. You don’t have to through your receptionist under the bus, but you don’t want to defend him and risk a destructive spiral of argument. So, you just say, “The world could use more kindness.” Mania doesn’t process language very well, so keep it short and simple – and your non-verbal language is going to matter a lot more than what you say in these situations.
I’ll tell you a story of when I failed at manic siding. I was in residency at Duke, and an agitated woman came in for her first visit at the clinic. On her T-shirt was an image of Jesus Christ hanging from the cross with the words “Dying to know you” below. Before I could ask what brought her in she shouted, “First there’s something I need to know about you – are you a Christian psychiatrist.” I had been raised a Christian, and identified as such, but I didn’t want to mislead her into thinking I agreed with all her beliefs or that I was going to pray during session. So I hedged, “I am a Christian, but that doesn’t change how I work with you - my work as your doctor is guided medical science just as any doctor does.” “That’s all I need to know” she said, and stormed out of the room. She did come back – 5 years later she looked me up and returned to my practice – but because I failed to side with her she lost 5 years of treatment.
Kellie: What would you have said
Dr. Aiken: I would look at her and say with great solemnity, “I can tell that question is very important to you, and I want you to know it’s very important to me too. Yes, I am a Christian.”
Kellie: Well that was before you read Dr. Ghaemi’s article. Tell us about a time when manic siding worked
Dr. Aiken: I worked with a patient who was in a manic state for several years, but the only medication he would take was valium. He had little insight into the mania, so even when we found a tolerable mood stabilizer he wouldn’t stick with it. Now it was tempting to stop the valium as it’s not appropriate to use on its own in bipolar, and though he didn’t abuse it it was probably rewarding in some way and it may have been enabling his avoidance of mood stabilizers. But I chose to side with him – from his point of view valium did what he needed, and he kept coming in for appoint tments and working with me anway. After a few years of this his family dragged him into my office- this time he was out of control and psychotic.
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