Facing the Demon

Outsmarting the Bad Guys

2012-01-07T01:24:00.002-05:00

My various Wordpress blogs have been plagued with malicious script, and what with the demands of work and life I haven't yet found time to address the issue decisively.

Luckily, it dawned on me that I could redirect Facing the Demon to its original home--the place you've just landed.

A New Home

2009-12-15T10:00:00.003-05:00

I've received enough feedback about this blog to decide that it's worth further investment. So I've purchased a domain name, "facingthedemon.org," and transferred this blog to a Wordpress platform. To those without a technical background this means little, except that the new platform is a lot more versatile than this one. When you visit it, you'll see what I mean.

Here's the new address.

I've been encouraged by the people who've joined this site through Google Friend Connect. I've installed the same widget on the new blog, so please come over and join up again. I'd sure appreciate it.

Mood Watch - 48

2009-12-13T09:18:00.003-05:00

For a couple of years I kept track, intermittently, of my shifts of mood in a series of numbered posts entitled "Mood Watch." All in all I composed forty-seven of these, the most recent one dated April 3, 2008. I've decided it's a habit I ought to resume, partly because it has intrinsic value and partly because, well, it gives me something to post about on a regular basis. I have some "major" posts in mind to publish but obviously, amid the press of other business, I haven't had time to get to them.

Bipolar Disorder varies from one person to another according to individual biochemistry, life style, the level of support received, and temperament (I think people have a temperament that is independent of, though inflected by, their biochemistry). Some people with the disorder have to deal mainly with the manic side: the "highs." I struggle mainly with the depressive side: the "lows." In classic terms, depressions take the form of mainly of lethargy and a sense of worthlessness. The last time I felt this way was in the spring of this year. It lasted for a couple of weeks and was pretty awful.

Since then, however, I've had periods of energy and lethargy but without the other criteria associated with bipolar disorder. Typically I'll have a period of a week to ten days in which I can't sleep for more than three or four hours at a time, and when I wake up I'm wide awake immediately. At such times I'm on guard against an incipient hypomanic episode. I look for things like heightened creativity, inflated self esteem, a temptation to take on new projects, an inability to focus on a single task because of a desire to head off on tangents, and so on. But I don't find them. In everything except sleep I function normally. Even then, I take enough naps that in any 24-hour period I get around seven hours of sleep, which for me is a normal amount. I just can't get them all at once.

When such periods end I quickly dip into a period when, try as I might, I can't get enough sleep. I don't feel despondent, or worthless, I don't lose interest in things that ordinarily give me pleasure, and I don't lose my appetite. I just can't seem to wake up. These periods typically last about four days, seldom more than that. Their onset is abrupt. They also lift abruptly. Last week was such a period. Until last Sunday (the 6th) I felt fine. Sunday evening, though, I went to bed early, and Monday I felt as drowsy as if I hadn't slept at all. It was the same thing Tuesday. And Wednesday. And Thursday. And Friday.

The only other feature I noticed this time was a kind a vague anxiety. I didn't feel like being around people -- though at least in this instance, I didn't mind talking on the phone. I tended to stay away from email, blogging, and so on. I could say that's simply because I'm tired but it felt like something more, as if I connected these activities with something unpleasant.

Saturday I still didn't feel quite myself, but I managed to get up and about and generally had a pretty good day. The one residual effect is a sense of discouragement. I lost a week of productivity. I can't afford that. This is particularly acute in the case of my professional research and writing. It's really devastating in that department. All the same, the worst thing one can do in such situations is dwell upon it. I try to regard these periods as no different than a physical malady like the flu.

Family to Family

2009-11-14T14:57:00.002-05:00

I'll be speaking at a NAMI Family to Family class on Monday evening. This video tells a bit about the Family to Family program--a 12 week educational course for families of people with mental illnesses.

Depression: One in Six

2009-11-08T05:43:00.002-05:00

About One in Six Americans Report History of Depression
Income, marital status, gender all appear to play a role

by Brett W. Pelham

WASHINGTON, D.C. -- The Gallup-Healthways Well-Being Index reveals that 17% of respondents -- or about 40 million American adults -- report having been diagnosed with depression. The results are from more than 250,000 interviews conducted in 2009 as part of the Gallup-Healthways Well-Being Index.

Full story from Gallup.com

Facing Facts - Update

2009-11-05T08:03:00.003-05:00

Prior to my talk at the Ohio Academy of History -- reprinted here as Facing Facts -- a professor sent me an email saying that he looked forward to hearing it. Of course, he didn't know what "it" was, since nothing had been advertised beyond the mere fact that I was going to be the after dinner speaker.

Following the talk, a gratifying number of people came up to thank me for what I had said. This particular professor did not.

A few days ago I ran across his email and decided to ask what he'd thought of the talk. I had a pretty good idea already. Still, I thought I'd give him a chance to prove me wrong.

His response: "I had known about your condition for a long time so I would have preferred more substance on the Civil War."

Wide Eyed

2009-11-01T05:00:00.000-05:00

When I met him on a sidewalk
He was preaching to a mailbox
Down on 16th Avenue
And he told me he was Jesus
Sent from Jupiter to free us
With a bottle of tequila and one shoe
He raged about repentance
He finished every sentence
With a promise that the end was close at hand
I didn’t even try to understand

He left me wide eyed in disbelief and disillusion
I was tongue tied, drawn by my conclusions
So I turned and walked away
And laughed at what he had to say
Then casually dismissed him as a fraud
I forgot he was created in the image of my God

When I met her in a bookstore
She was browsing on the first floor
Through a yoga magazine
And she told me in her past life
She was some plantation slave’s wife
She had to figure out what that might mean
She believes the healing powers of her crystals
Can bring balance and new purpose to her life
Sounds nice

She left me wide eyed in disbelief and disillusion
I was tongue tied, drawn by my conclusions
So I turned and walked away
And laughed at what she had to say
Then casually dismissed her as a fraud
I forgot she was created in the image of my God

Not so long ago, a man from Galilee
Fed thousands with His bread and His theology
And the truth He spoke
Quickly became the joke
Of educated, self-inflated Pharisees like me

And they were wide eyed in disbelief and disillusion
They were tongue tied, drawn by their conclusions
Would I have turned and walked away
And laughed at what He had to say
And casually dismissed Him as a fraud
Unaware that I was staring at the image of my God

– Nichole Nordeman, “Wide Eyed” (1998)

(From Christian Lyrics Online)

The Invincible Force - Pt 1

2009-10-30T05:00:00.000-04:00

"I felt that something had broken within me on which my life had always rested, that I had nothing left to hold on to . . . . an invincible force impelled me to get rid of my existence, in one way or another. It was a force like my old aspiration to live, only it impelled me in the opposite direction."

-- Leo Tolstoy

Part 1 - Part 2 (coming)

Weight Gain Associated With Antipsychotic Drugs

2009-10-29T05:00:00.002-04:00

Back in 1999 I was put on Depakote, a prophylactic against mania that, as it turned out, had the effect of slowly but steadily ratcheting up my weight. When I started taking it I weighed 168; within five years I was very nearly at 200 pounds -- sometimes even a bit over. Since I'm only 5'8", that was obviously a problem, both intrinsically and because of a history in my family of heart disease.

Fortunately I managed the disorder conscientiously enough that my psychiatrist felt comfortable eliminating the Depakote and relying principally on Lamictal (which is prescribed mainly as an anti-depressant but has some anti-manic properties as well), coupled with disciplined sleep hygiene.

Lamictal is weight-neutral. I still managed to gain weight while on it, but as it turned out, that owed mainly to eating out a lot (especially fast food) and drinking a lot of beer. In mid-July I started the Weight Watchers program. I have so far lost a bit over twenty pounds, with fewer than eight pounds to go.

Still, not everyone has the luxury of such an option....

In the New York Times, October 28, 2009

Weight Gain Associated With Antipsychotic Drugs
By DUFF WILSON

Young children and adolescents who take the newest generation of antipsychotic medications risk rapid weight gain and metabolic changes that could lead to diabetes, hypertension and other illnesses, according to the biggest study yet of first-time users of the drugs.

The study, to be published Wednesday in The Journal of the American Medical Association, found that 257 young children and adolescents in New York City and on Long Island added 8 to 15 percent to their weight after taking the pills for less than 12 weeks.

The patients, ages 4 to 19, added an average of one to one-and-a-half pounds a week.

“The degree of weight gain is alarming,” said Dr. Wayne K. Goodman, head of a Food and Drug Administration advisory panel on the drugs last summer and chairman of psychiatry at Mount Sinai School of Medicine in Manhattan. “The magnitude is stunning,” he said.

Full Article

Change A Mind About Mental Illness

2009-10-28T05:00:00.000-04:00

Facing Facts

2009-10-23T16:28:00.006-04:00

What follows is an after dinner talk I gave last week to a group of academics at Capital University in Columbus, Ohio. I'd been asked to offer some reflections on an exhibition in Capital's Schumacher Gallery concerning the lives of Ulysses S. Grant and Robert E. Lee. (It was, incidentally, a traveling exhibit organized by the Virginia Historical Society and New York Historical Society, funded by the National Endowment for the Humanities, and supplemented by artifacts fom the Motts Military Museum.)

I dislike giving presentations that don't build toward projects underway, and since the next speaking engagements on the horizon have to do with mental health advocacy, I decided this would be a good opportunity to experiment with one. The talk was something of a high wire act, interweaving personal observations of Grant and Lee with those concerning bipolar disorder. But judging by the response I received, it worked.

It’s a pleasure to talk with you this evening about Robert E. Lee and Ulysses S. Grant, particularly in light of the exhibition at the Schumacher Gallery. I’ve heard it said that an exhibition, even when installed, is not really an exhibition. It becomes one only people come to experience it. They see in it, and take from it, meanings that the designers of the exhibition did not necessarily intend to impart. This is so because people bring to it their own experiences of life, their own concerns, and above all their own imaginations. Were this not the case, I doubt if exhibits would be at all worth the investment of time, money, and energy required to create them.

During the Civil War a pair of Union officers climbed atop a mountain to survey through telescopes the Confederate encampment beneath them. They saw soldiers brewing coffee, writing letters, reading newspapers, and washing clothes. To one of the officers this was a revelation. “My God, Adjutant,” he said to the other. “They’re human beings, just like us!” The Grant-Lee exhibition invites us to reconsider these two icons of the American military tradition, these central characters in the American Iliad. Their lives had the same common place experiences and the same complexities as our own. They were human beings, just like us.

I grew up with Grant and Lee. I got to know them through children’s books, and particularly got to know Lee through a biography entitled Robert E. Lee and the Road of Honor, written for young people by the Southern progressive journalist Hodding Carter, which I read at the age of eight. But the really critical experience occurred when I was twelve and first read A Stillness at Appomattox, Bruce Catton’s brilliant evocation of the epic struggle between these two commanders in the Civil War’s final year. When I say that I grew up with Grant and Lee I mean this, of course, in an imaginative sense, and yet the imaginations of the young can be so vivid and intense that I still sometimes feel as if I grew up with them in a literal sense. And in terms of their impact on my life, that is quite likely true in the deepest sense of truth.

Recently I turned fifty years old. That makes me just seven years younger than was Lee in 1864 and actually eight years older than Grant when he led the Army of the Potomac across the Rapidan River and into battle against Lee’s Army of Northern Virginia. My life has gone in directions very different from theirs and has taken a very different shape. But in dealing with the challenges of my life, I have often looked back on these two men, both what I thought I knew of them as a youth and what I think I know of them now.

The biggest challenge that has faced me in life began to confront me in 1986, when I was diagnosed with bipolar disorder — what used to be called manic depression. For reasons I’ll explain in a bit, it has become important to me to talk about what it is like to live with the disorder, but at the time it was something that I simultaneously acknowledged and ignored, with an odd kind of doublethink that, I have discovered, is not uncommon with people confronting facts that are unavoidable and yet still something one wishes to avoid. For the first few months I saw a psychiatrist and took medications, but then I simply stepped away from that and for eleven years thought and lived as if bipolar disorder were something I had in theory, not in fact.

A hypomanic episode I had at age 38 finally brought me to reality. With hypomania a person can be charismatic, unusually creative, and brilliantly high functioning. But those who know them well recognize that something I wrong. And if the person is wise, so does he. So early one morning, refreshed and wide awake after only two hours of sleep — notwithstanding the fact that given the pace I’d been keeping and the sleeping pill I’d taken I should have been out cold — I came to realize, and I mean really realize, that I had bipolar disorder and always would have it and was lucky during the preceding decade not to have met with disaster. I sat down at my computer and composed a sort of memorandum to myself. I’m going to read some of it here. At first it will seem to have no relevance to Grant or Lee, but then it will take a turn that should surprise you. It certainly did me.

“I’m obliged to do the one thing we humans hate: face facts. There is nothing harder. I have long been amazed to discover how even very intelligent people can so readily run from the facts. It never occurred to me to realize that I have spent eleven years running from the facts. Yet that is what I’ve done.” I went on to say that I had two main thoughts about it. The first one was obvious: “So far I’ve managed to get through the cycles through my ability to cope, though at what unnecessary personal cost I cannot imagine. How long can I expect my luck to hold? I’d better get with a psychiatrist and do what the hell he directs.”

“The second thought,” I continued, “will seem unrelated and perhaps inappropriate to the context, though I assure you it is not. It is that, while neither I nor anyone else could ever prove it, I think I now know why General Robert E. Lee halted his army on the Sharpsburg ridge on September 15, 1862, rather than do the “prudent” thing and recross the Potomac River. Instead he turned to face his much larger enemy and fought a pitched battle (the bloodiest single day of the Civil War) with a wide, unfordable river about a mile to his rear. Military historians have wondered ever since why he did it. Most of the explanations center on operational or political factors. But is it possible that Lee stood at Sharpsburg because something in his own personal history combined with these impersonal factors to compel the decision he made? If so, I think it was his father.

“Light Horse Harry Lee was, in some respects, a more successful man than Robert. He was a hero of the Revolutionary War and a governor of Virginia, among other things. Yet Harry Lee wound up dying far from home and penniless, for reasons that have to do ultimately with a refusal to face facts or to stand and face the consequences of his life. He fled the country rather than go to debtors’ prison for debts he’d contracted in a series of risky land speculation ventures. In September 1962, Robert took a risk by crossing the Potomac and embarking on a raid into Maryland while his army was reduced in numbers and ill-equipped. After the defeat at South Mountain he should have departed from Maryland as soon as he could. But perhaps something in him resisted the idea of running from the consequences of the risk he had taken. Perhaps he realized that if he did so his future generalship would be compromised. (Generals are human beings first of all; the same psychological dynamics that affect the rest of us affect them.) Perhaps in a much different way than I am doing, Robert E. Lee was also facing facts when he made his stand on the high ground west of Antietam Creek.”

I have visited Antietam many times since then, have conducted historians, laymen, West Point cadets and field grade officers on staff rides of the battlefield. I’ve thought a lot about the insight I had on that particular evening. It is still not something I can prove, and yet if anything I feel even more strongly than I did that basically I got it right. I think Lee understood that if he had withdrawn without a fight he would forever have been one kind of commander and that his army would have been one kind of army. By making a stand on Sharpsburg ridge he became another kind of commander with another kind of army — a commander and an army that enjoyed a psychological mastery over its opponent that it never really lost.

I certainly know that if I had continued to evade the fact of my own mood disorder, I would have been a very different man. I would certainly not have come to see that a central task of my life must be to talk openly about the disorder. It isn’t much fun to do. Like anyone else, I would like to lead a “normal” life, whatever that is. I don’t like having to bring upon myself so directly the stigma that attaches to mental illness. But if I, as a high functioning individual who leads what most would deem a reasonably successful life, don’t talk about it, then I’d simply be an accomplice in the perpetuation of the stigma. To give just one example: only about one college student in four believes that someone with a mental illness can eventually recover. And since about one college student in a hundred has been or will be diagnosed with bipolar disorder — to say nothing of a range of other mental illnesses — the stigma, if unaddressed, still has a very large capacity to damage.

In ethical terms, there’s no deontological or consequentialist moral imperative at work here. I’m not coming within a country mile of saying that high functioning persons with a mental illness are not allowed the option of maintaining their privacy. The moral reasoning at work here is aretaic; which is to say, it is character-driven. It flows from a personal sense of right and wrong as it applies to me. It’s impossible to trace the roots of the sense of duty I feel about this matter. But it would surprise me very little to learn that it tracks back to Lee, or Grant, or both.

I am the readier to believe this because the ethical reasoning involved is identical to that of three American generals — two of them four-star generals — who have publicly disclosed that they are in treatment for Post Traumatic Stress Disorder. And indeed, at the U.S. Army War College I have found an unusual degree of understanding and support for the choice I’ve made, because of the high incidence of PTSD in the current fight. Bipolar disorder is an illness, PTSD is an injury, but they share key features in common. Both must be managed. Both have a stigma.

I have found that in managing the disorder I regularly drawn upon my military training and experience, my understanding of military culture and history, and my background in strategic studies. The most critical feature is that this background has taught me to avoid making what I consider to be the disastrous errors of conflating the illness with one’s identity — “I am my diagnosis” — or of romanticizing the illness because bipolar disorder is associated with many creative people. I regard myself as being at war with an entity that will never rest until it has killed me, either by lifting me into a manic episode of such heights that I do something lethally foolish, or by casting me into a depression so deep that I end my life by suicide.

I cannot think of a stronger way to externalize the illness. Nor can I think of an inducement more likely to get me to manage it with sustained seriousness of purpose. Neither Grant nor Lee ever read the Prussian military theorist Carl von Clausewitz, but they instinctively understood his observation that, “in war, the best strategy is always to be very strong, first in general and then at the decisive point.” Translated metaphorically, what this means is that if you have bipolar disorder you muster every resource you can. If you have access to a psychiatrist and a therapist, you see them regularly. You take your medications. You make a priority of what the mental health professionals call “good sleep hygiene.” You work out regularly. You find environments and people that are supportive. And when necessary you divorce yourself, calmly but ruthlessly, from environments and people that are not.

You take the illness seriously, but you don’t let it rule your life. I said before that Lee achieved a psychological mastery over the Army of the Potomac that he never really lost. It was a source of enormous frustration to Grant when he tried to use that army as a tool, because it seemed to have over caution encased in its organizational DNA. Confronted on one occasion by a frantic general who warned him of a fatal blow he believed Lee was about to deliver, Grant snapped, "Oh, I am heartily tired of hearing about what Lee is going to do. Some of you always seem to think he is suddenly going to turn a double somersault, and land in our rear and on both of our flanks at the same time. Go back to your command, and try to think what we are going to do ourselves, instead of what Lee is going to do." It is the same with bipolar disorder. Although the disease is an adversary one must respect, it should not be so intimidating as to prevent one from taking the normal risks necessary to achieve success in ordinary life.

By now I hope you can see some of the personal resonance the Grant-Lee exhibition has for me. If it seems as if this understanding derives as much from the mythic dimensions of these men as from the down to earth dimension, that gets at something that as an historian, I’ve learned to accept as being true of most people who find fascination in, and derive meaning from, the human past. Myths can be myths in the sense of falsehood. They can also be myths in the sense of isolating and inscribing deeper truths. So will we ever shake the grip of our myths about Lee and Grant? I doubt it. We need it too much. Although perhaps no longer necessary as an embodiment of the Lost Cause, the myth of Lee has a more universal resonance. Sooner or later, everyone loses. The dreams of youth are left behind, the fatal diagnosis is pronounced. The idea of facing inevitable defeat with courage, dignity, and humanity — as Lee is rightly said to have done — therefore has powerful attraction.

But if we need the myth of Lee, so, too, perhaps, we need the counter myth of Grant. The world is as full of obstacles as it is of losses, and to get anywhere in life one must possess grit, drive, determination, persistence. And so we also need the image of Grant: Grant the implacable, Grant the hammerer, Grant the man who, despite everything, keeps moving on.

Note From a Consumer

2009-10-13T07:19:00.006-04:00

Last Thursday I attended a showing here of Minds on the Edge: Facing Mental Illness. (My last entry showed the promo.) The documentary, the latest in the Fred Friendly Seminar series, is being aired on PBS this month. It uses a format you may have seen over the years in previous installments (since its inception there have been over a hundred):

The Seminars always begin with a little story and a problem that could confront almost anyone. The implications of this problem, whatever it may be, then ripple out to encompass larger and larger issues and trigger ethical, emotional, legal, and public policy questions that are always overlapping and sometimes in conflict. Each Seminar program brings together a carefully chosen panel that contributes professional expertise as well as personal experience to the discussion. As the panelists wrestle with the issues presented in the hypothetical story, they are encouraged not just to say what they think about an issue, but to say what they would do in difficult decision-making situations if they were personally involved. The viewers are along for the ride, emotionally and intellectually, as the story creates a link for citizens between their lives and issues in the headlines that so often seem remote, abstract and unconnected to their day to day concerns.

It's an effective method. Minds on the Edge addresses mainly the problems involved first, in getting persons experiencing a mental illness crisis into treatment (the assumption is that most such persons resist treatment); and second, the way in which the mental health "system" takes care of persons once they do get treatment. I place "system" in quotes because, as the program makes clear, no system exists, merely a jumble of well intentioned but underfunded and uncoordinated efforts by a variety of hospital, outpatient, governmental, and non profit organizations.

You can find the entire program online. It runs just slightly over an hour, and on the whole it's fascinating but pretty depressing.

In addition to watching it on PBS or online, you can watch it at a screening at some church, civic organization, or similar venue. This screening I attended was organized by the local chapter of NAMI (National Alliance on Mental Illness). About forty people were also in attendance. NAMI divides the mental health world into three types of person: providers, consumers, and loved ones. Providers are mental health professionals, advocates, etc. Consumers are people like me; i.e., those who have a mental illness and are therefore consumers (or at least potential consumers) of mental health care. Loved ones are the friends and family -- usually parents and/or siblings -- of consumers. The categories can overlap. Providers, in several instances, are also consumers. I suppose they could be loved ones as well.

By the way, I'm not wild about being called a consumer. Words carry freight. The phrase consumer not only sounds kind of weird to me but also implies that being in treatment for a mental illness is central to my identity. As I hope I've made clear by now, I dislike any phraseology that conflates an illness one has with a statement of what one is. Still, it's plain that consumer was chosen faute de mieux, so I guess I can live with it.

Following the screening was a sort of panel discussion that involved a consumer (who happened also to be the chapter president), a provider, and two loved ones (a father and mother with a son who has bipolar disorder). Early in the discussion it became apparent that most of the audience consisted of self-identified loved ones. I seemed to be one of the few consumers in attendance.

I had learned about the screening following a brief conversation in August at the annual Army War College "county fair," an elaborate event in which dozens of local merchants, non profit groups, etc., congregate for an all day event designed to give the incoming resident class and their families an idea of the services locally available. I had a brief exchange with the people manning the NAMI booth, mentioned that I had bipolar disorder, and offered to join their speaker's bureau if they had one. They did. The most appropriate one seemed to be a program called In Our Own Voice. Here's a description from the web site:

In Our Own Voice (IOOV) is a unique public education program developed by NAMI, in which two trained consumer speakers share compelling personal stories about living with mental illness and achieving recovery.

The program was started with a grant from Eli Lilly and Company.

IOOV is an opportunity for those who have struggled with mental illness to gain confidence and to share their individual experiences of recovery and transformation.

Throughout the IOOV presentation, audience members are encouraged to offer feedback and ask questions. Audience participation is an important aspect of IOOV because the more audience members become involved, the closer they come to understanding what it is like to live with a mental illness and stay in recovery.

IOOV presentations are given to consumer groups, students, law enforcement officials, educators, providers, faith community members, politicians, professionals, inmates, and interested civic groups.

All presentations are offered free of charge.

My first presentation is slated for November 16 at a Family to Family Education Program, a free, 12-week course for family caregivers of individuals with severe mental illnesses.

I have, of course, written in several venues about having bipolar disorder. But, aside from speaking to a psychology class at Dickinson College, this will be the first time I've given a regular talk on the subject. I feel slightly daunted at the prospect. To begin with, I'm fortunate enough to have a mental illness that, compared to what others have to face, is mild. It's a pain in the ass sometimes, but it's never seriously interfered with my ability to function normally. Indeed, I've always felt that from a mental health advocacy standpoint, my chief value is as a high functioning individual willing to say forthrightly that he has a mental illness. People who can keep their diagnosis private generally tend to do so.

As a corollary, I worry that anything I have to say will be a) irrelevant to the situations of my audience; or worse b) will convey the disastrous impression that if I can manage the illness so "easily," then so could their family members if only they applied themselves. The only solution I can think of is to offer the appropriate caveats, concentrate on my own experience, and avoid saying anything that sounds prescriptive. And anyway, the main thing I would want to convey is how impressed I am that they are actively supporting their loved ones -- I mean consumers. Aside from being under the care of a psychiatrist and therapist, I can think of nothing more critical to helping someone with a mental illness manage it most effectively.

Minds on the Edge

2009-10-08T17:34:00.000-04:00

Ambushed

2009-09-29T17:23:00.004-04:00

Dana Jennings, who blogs in the New York Times about his struggle with prostate cancer, writes today that he is "recovering well from an aggressive case of prostate cancer" and that all "physical signposts of health are pointing in the right direction."

Which would be fine, except that he is depressed. And feels ambushed.

This isn’t about sadness or melancholy [Jennings writes]. It’s more profound than that. Broadly, I have a keen sense of being oppressed, as if I were trapped, wrapped up in some thick fog coming in off the North Atlantic.

To be more specific, I’m exhausted, unfocused and tap my left foot a lot in agitation. I don’t much want to go anywhere — especially anyplace that’s crowded — and some days I can’t even bear the thought of picking up the phone or changing a light bulb. All of this is often topped off by an aspirin-proof headache.

The fatigue frustrates me most. When I envision myself it’s as a body in motion, walking or running, not foundering in bed. On one recent day, I slept till 10 in the morning — getting 11 hours of sleep — then took a nap from noon to 2. And I was still tired.

I’ve had occasional depression over the years, but nothing as dogged as this. When I first learned that I had prostate cancer, I wondered about depression. But after the shock of the diagnosis wore off, I was sharp and clear-headed. I wasn’t depressed as I went through treatment — surgery, radiation and hormone therapy. I was buoyed by a kind of illness-induced adrenaline.

Jennings' description resonates with me in two respects. First, it resembles my own experience of depression. With me the dominant symptoms are usually hypersomnia and fatigue. And he's not kidding when he says there are days when changing a light bulb seems impossibly hard; with me that's standard.

Sure, there's also a general sense that my life is awful and will never get better, but most of the time I'm able to dismiss that as the distorted thinking typical of depression. In and of itself it isn't bad. What sucks is the loss of productivity, so that even when I'm back to normal I feel -- accurately -- that I'm badly behind in my work. And if only two or three weeks elapse before the next depression, the biochemically induced sense of hopelessness is reinforced by an existential sense of despair. I feel like I'm in a ditch so deep I will never be able to claw my way out.

Second, it confirms something my therapist has told me for years: People who have experienced both cancer and depression often maintain that of the two, depression is worse. Of course, as Jennings' case indicates, it isn't an either/or proposition. For at least one cancer patient in four, it's a both/and.

Toward the end of his post, Jennings declares, "It’s harder to write about the weight of depression than it is to write about prostate cancer and its physical indignities. Cancer is clear biological bad luck. But depression, no matter how much we know about it, makes part of me feel as if it’s somehow my fault, that I’m guilty of something that I can’t quite articulate."

Of course, that kind of guilt has nothing to do with depression. It's an artifact of our culture. Physical illness okay (with some exceptions), mental illness not okay (with no exceptions at all).

The Perpetual Voyage

2009-09-25T06:46:00.004-04:00

I rather dislike having been so critical of my parents in the previous series. It isn't so much that I now disagree with anything I wrote back in 1997 (the posts, you'll recall, are excerpted from a journal I kept back then), as it is that nowadays I have a much stronger sense of the personal burdens my parents faced. I cannot say I miss them or look back on them affectionately. But I do feel great sympathy for them, and a sense of regret that they were never able to escape the traumas of their own childhoods and find the life they expected would be waiting for them once they reached adulthood, settled down, and had a family.

I think most of us at some level expect that eventually our lives will find safe harbor somewhere. That was true of them. It certainly was once true of me.

I remember a few lines from MacKinlay Kantor's Glory for Me, a book-length poem that was the basis for the Oscar-winning 1946 film The Best Years of Our Lives:

When all my labors and trials are o'er
And I am safe on that beautiful shore
O, that will be
Glory for me.

The poem has to do with the return from war and the "beautiful shore" is home. But if it applies at all, it applies to heaven. In life the voyage is perpetual. You simply exchange one series of challenges for another. Or rather, the challenges arise, and you can choose either to meet them, resent them, or ignore them. But they don't ignore you. And if you don't face them, they wind up owning you.

At some point I'll return to the narrative of the onset of bipolar disorder and discuss with candor what it's like to experience a manic episode or a bout with clinical depression. But for now I'll just say that having long internalized the idea that the disorder is something I have, rather than a component of who I am, the challenge has not been--as it is for some--to figure out where my personality ends and the effects of the disorder begin. Rather, aside from simply managing the disorder from day to day, it has been to separate the effects on my life that stem from the existential pain of my childhood, and the effects that stem from the biochemical abnormality.

Onset - Pt 5

2009-09-23T05:00:00.005-04:00

The revelations in Notebook 11 kept me up until 3 a.m. or so, particularly the entry in which I told Mom something was wrong with me and she blew me off. I talked about it today with my sister. Even before I broached this new information she said, “Do you ever feel that when we were growing up, nobody was really paying attention?” When I read her some of the entries I’d come across, she concurred that they did sound redolent of a mood disorder, and when I got to the entry about Mom she was not surprised. It seemed to us that Dad and Mom alike were determined that there would be just one designated patient in the family and Mom was it. By 1977 she had learned to exploit it—it was her main leverage on Dad, even more than her knowledge of his affair—and she pressed it for all it was worth. It was always very striking to me how courageously Mom dealt with her breast cancer and how craven she was about the manic depression.

Dad, for his part, resented the hell out of the fact that he had to pay Mom’s medical bills. I ran across an entry which reports that Dad had told their marriage counselor as much. I was surprised he’d admit it. As with a lot of the stuff I read, I had no memory of it, though it certainly sounded like Dad. My sister said she recalled the incident vividly. Moreover: “Do you remember,” she asked, “the expression ‘You get yours.’?” In Dad’s book, if he was paying for your medical bills (in the case of my Mom), or for ballet lessons (in the case of my sister) then they were getting theirs. The idea that a husband and a father owed his family things like time, energy, attention, and empathy was alien to him. Anything he did for you, he generally did so you’d get off his back.

Prologue - Part 1 - Part 2 - Part 3 - Part 4 - Part 5

Onset - Pt 4

2009-09-21T05:00:00.005-04:00

To my surprise--because I don’t recall this at all--it turns out I wasn’t totally clueless about what was going on:

13 February, 11:16 p.m. . . . For what it’s worth, I think lack of sleep has a great deal to do with my emotional condition, much more than is usual with most people. I hope this proves the case. If so I may be able to end once and for all my more severe attacks of melancholy. . . . Must be cautious, must not stick my fragile mind in situations it cannot cope with.

I don’t remember this next incident, either, and when I saw it I just sat for a long time, staring in disbelief:

17 February, 12:16 p.m . . . I talked with Ma, briefly, about the mental peculiarities that have plagued me since June [1976]: how I oftimes seem to live in unreality, suspended in twilight, how my decisions & actions have not been of the first order. She dismissed the surreality as melodrama, and the “decisions & actions” bit by saying I had never been much of a decision maker & the ones I’m making nowadays are as good or better as any I’ve ever made. Also that, on balance, I am outwardly better adjusted than ever before. I could not make her see that inwardly I feel chaotic.

Oh you made her see, all right, I thought. It’s just that our family already had a designated patient and you weren’t it.

You bitch. You fucking bitch.

By this time I’m skipping school on a regular basis. No one seems to notice. A few days later I impulsively hop in a car with several potheads with whom I worked. Soon after occurs an amazing string of flirtations, make-out sessions, all night drunks, and so on with an array of girls--just off-hand I can think of a half-dozen, and I’m probably missing at least a couple--at the center of which soon emerges Jennifer, of suicide note--“I love Jennifer, desperately and impossibly”--fame. Barely three months separate the day I penned my entry about vainly trying to convince Mom that something was wrong, to the day I swallow a bottle of barbituates like so much popcorn.

Prologue - Part 1 - Part 2 - Part 3 - Part 4 - Part 5

Onset - Pt 3

2009-09-18T05:00:00.004-04:00

The more I read, the more certain patterns began to appear: rapid cycling from euphoria to despair, disproportionate anger in response to slights, a loss at times of a sense of boundaries. Re the latter, for example, here’s my entry concerning a live broadcast of the high school quiz show In the Know, in which I was a contestant:

25 January, 11:20 p.m. . . .We lost by 180-125. I did well; I think everybody did, but there was one fellow on the other team who was really very good; he accounted for almost all their pointage. At halftime I included “failing French II my junior year” when listing my accomplishments; afterward a girl approached me and asked, “You said you failed French. How come?”
“How come I failed, or how come I said it?”
“Both.”
“Well,” I smiled, “I failed French ‘cause I didn’t study, and I said because it was a hell of a thing to say.”
B--- C--- & the old 1st team were there; B--- tried to console me but I didn’t need consoling. “I enjoyed myself. It was probably the most enjoyable game I’ve played.”

By February I am having trouble sleeping--up all night and having to sack in half the day to make up for it. I begin to take long, restless evening walks.

10 February, 2:34 p.m. - I permitted myself to sleep late yesterday, intending so far as possible to go easy on myself and insure I wouldn’t get fatigued . . . Worked 4:45-9:15, closed. Once home I watched “Rollerball” on TV, then abruptly set out on a long run that carried me [a distance of about 4 miles] before a police cruiser pulled up in front of me. The cop asked me where I was going, I explained, briefly, whereupon he told me to go back home. I was angered but wanted no trouble, and so complied. I spent several long moments up among the apartments where Sharon [a former girl friend--not her real name] lives, staring at that hillside and at the cold gleaming stars. It was a mistake for me to do this, because it thrust me almost immediately into a violent spasm of confused despair. Running back to the house I noticed that everything looked strangely alien, as if I were on another planet. Flashing automobiles looked futuristic, the dawn-like glow of the city gave me the impression I was light-years from home. A blood moon was out, hanging dully on the horizon, oval and hazy. The telephone poles looked like crucifixes. I could almost see men nailed upon them. Mighty weird.

Prologue - Part 1 - Part 2 - Part 3 - Part 4 - Part 5

Onset - Pt 2

2009-09-16T05:00:00.004-04:00

I decided to rewind the tape to the beginning and dub the tape onto a fresh one. But when I played it all I heard were satanic warblings like something out of The Exorcist. I quickly realized what had occurred: the tape, in rewinding, had bent over on itself, so that I was now listening to the two tracks backwards. The problem looked reparable but I didn’t want to fool with it that night, so I put it aside and cracked open Notebook 11.

Arbitrarily I began reading the entries from mid-November 1976 onward. Very quickly I realized why I seldom take these strolls down memory lane. It is hard to confront the fact that you were once seventeen and lacked your present-day “maturity,” though in practice maturity often amounts to nothing more than an ability to disguise one’s real personality and foibles. Indeed, once I got into the entries I had a lot of respect for the young author, who somehow did not quite seem to be me. Since my memories of that period are as vague as anyone’s after the passage of twenty-one years, I found that reading the entries from 1976 did not so much jog my memories as create them, the way a good novelist can “create” a memory of, say, Lady Chatterley with her lover.

The journal has three striking attributes. First, it is on the whole astonishingly well-written. Although a first draft, hastily dashed off night after night, many of the developments it describes come alive on the page, and I think that even if I were wholly unfamiliar with my life I’d still be able to get a pretty good feel for what it was like. Second, it is preoccupied with girls to a degree that, even to me—who certainly remembers that part of the story—is just incredible. Third and (I think) a corollary of the second, the moods of the author are all over the map, and the cycling from upbeat joy to gloomy melancholy is very rapid—so rapid that it reminded me of Kay Redfield Jamison’s criticism of using the term “bipolar disorder” to describe the illness. The imagery of “bipolar” is linear—a swinging pendulum from one extreme of the emotional spectrum to another. Jamison postulates offhandedly that mania may in fact be a frantic flight from an incipient depression. But whatever the case, it was evident that I had some sort of mood disorder, and just as evident that, except in broadest terms, it was hard to shoehorn the symptoms into a classic framework of bipolar disorder.

Prologue - Part 1 - Part 2 - Part 3 - Part 4 - Part 5

When a Parent’s ‘I Love You’ Means ‘Do as I Say’

2009-09-15T05:00:00.000-04:00

From yesterday's New York Times. It reinforces the point I made in the Onset prologue:

More than 50 years ago, the psychologist Carl Rogers suggested that simply loving our children wasn’t enough. We have to love them unconditionally, he said — for who they are, not for what they do.

As a father, I know this is a tall order, but it becomes even more challenging now that so much of the advice we are given amounts to exactly the opposite. In effect, we’re given tips in conditional parenting, which comes in two flavors: turn up the affection when they’re good, withhold affection when they’re not.

Thus, the talk show host Phil McGraw tells us in his book “Family First” (Free Press, 2004) that what children need or enjoy should be offered contingently, turned into rewards to be doled out or withheld so they “behave according to your wishes.” And “one of the most powerful currencies for a child,” he adds, “is the parents’ acceptance and approval.”

Likewise, Jo Frost of “Supernanny,” in her book of the same name (Hyperion, 2005), says, “The best rewards are attention, praise and love,” and these should be held back “when the child behaves badly until she says she is sorry,” at which point the love is turned back on.

Conditional parenting isn’t limited to old-school authoritarians. Some people who wouldn’t dream of spanking choose instead to discipline their young children by forcibly isolating them, a tactic we prefer to call “time out.” Conversely, “positive reinforcement” teaches children that they are loved, and lovable, only when they do whatever we decide is a “good job.”

This raises the intriguing possibility that the problem with praise isn’t that it is done the wrong way — or handed out too easily, as social conservatives insist. Rather, it might be just another method of control, analogous to punishment. The primary message of all types of conditional parenting is that children must earn a parent’s love. A steady diet of that, Rogers warned, and children might eventually need a therapist to provide the unconditional acceptance they didn’t get when it counted.

But was Rogers right? Before we toss out mainstream discipline, it would be nice to have some evidence. And now we do.

Full article

Onset - Pt 1

2009-09-14T04:30:00.004-04:00

Excerpted from journal entries made in December 1997

For weeks now I have found myself fascinated by the revelation that I have manic-depressive illness, as opposed to having had a manic episode eleven years ago from which I heroically recovered. It has been a powerful distraction from almost everything else that has a claim on my life. I manage to tear myself away, but “tear” is definitely the correct verb. As soon as I decently can I’m drawn back into the bipolar world like a dog to its vomit. Outwardly my life looks as bland as can be, but inwardly I’ve embarked on one of the most absorbing adventures I have ever had. I’ve been learning about the illness, reflecting on what it means to have one’s personality so powerfully shaped by moods, and spelunking down long shafts of memory. It’s a pity so much of this will have to be recorded in summary form if it’s to be recorded at all. But that’s the only realistic possibility.

I could start at lots of points, but I think I’ll just start with last night. I was watching Mystery Science Theater 3000. Usually if anything can distract me from the cares of the day, MST3K will do it. But after a while I noticed I wasn’t following the film or the wisecracks very well. I was too busy ruminating about the probable onset of the illness.

My gut feeling has been that it probably began with an undiagnosed manic episode in the winter of 1976-77, followed by a suicidal depression in May 1977. To test this theory I cracked open Notebook 17, the fourth installment of a journal I’d begun keeping in April 1975. The first entry was for March 15, 1977. I had not read far before I had the sense that I was reading the words of someone who was hypomanic, but of course when you’re looking for something as subjective as evidence of a mood disorder you’re quite likely to find it, especially in the writings of someone seventeen years of age. I quickly decided to backtrack into the previous installment, Notebook 11 (forget trying to understand my numbering system), but before doing so I skimmed through up to the point of the suicide attempt, which occurs on page 59. It’s introduced with deadpan flippancy: “Monday Jennifer [a girl friend with whom I’d just broken up—not her real name, by the way] was not at school. Tuesday I saw her, Wednesday I sent her flowers. Thursday I committed suicide.”

The preceding three weeks of entries are unhelpful, because they’re not really entries, just obscure notes to remind myself about events that, for the most part, have long passed from memory. For example: “Tuesday, 10 May—No school—OHC—The Kent Affair—I Was There—1:30—Olan Mills Proofs—Morse Rd: IWT—Ponderosa for lunch—5:35-10:35.” I can guess at some of this, judging from my general recollections of the time, but in terms of any direct recollection of that particular day, I haven’t a clue. And it goes on like that for an entire page: nine days of entries, the last of them just eight days prior to the suicide attempt, for which a catch-up entry dated June 2 provides the basic background. But those nine hectic days probably held a good clue to what was going on with me that shifted my thoughts toward suicide, and it seemed a pity I could not unlock the code.

Finally at the bottom of the dehydrated entries I found a notation, “Taped Entries For These Dates are on Cassette Two.” Great, I thought. “Cassette Two,” whatever that is, is long gone. Then abruptly I realized it wasn’t—I’d just seen a cassette tape by that label among some stuff I brought up from the basement. I checked, found the tape, played it, and sure enough, I heard my own voice from across half a lifetime.

Prologue - Part 1 - Part 2 - Part 3 - Part 4 - Part 5

Onset - Prologue

2009-09-13T23:30:00.006-04:00

Until now my posts have concentrated mainly on the challenge of managing bipolar disorder. In effect, I’ve looked at the illness from the outside. Yet what exactly am I trying to manage? I could rehearse the clinical criteria for manic depression. But you can easily get that elsewhere. The way in which this blog can be of most utility is, in addition to explaining the methods by which I manage the disorder, to explain the metaphorical demon that I face in terms of the subjective experience of having the illness.

This won’t be fun to do. But quite some time ago I wrote the first series of posts that focus on what it’s like when the demon attacks. I’ve long held them in reserve, partly because I did not want to post anything on impulse – it is imprudent for people with bipolar disorder to take any major step impulsively – but primarily because, well, this won’t be fun to do. You just put this stuff out there. Anyone can read it. Anyone can make of it anything they want. And while I anticipate that most people will be supportive, inevitably there are people out there who will not.

Even so, I’ve taken a deep breath and scheduled the series to begin publishing tomorrow morning. The entries will appear at staggered intervals, usually about every other day. The series will deal with the onset of the disorder, which in my opinion occurred nearly a decade before it was diagnosed. And rather than adopt a narrative approach in which I base the account on what I knew at the time, I'll write in the full light of what I've learned from therapy and from long personal reflection.

But before the first post appears, I have time to make one final comment about my parents. As I’ve said in the past, while by and large I can leave specific persons out of this and future accounts, my parents are another matter. And of all the things about this venture that give me pause, the principal one is that, in the nature of the case, I shall have to criticize my parents. To be precise, I shall have to hold my parents responsible for the errors they made in raising me.

No one, surely, would deny that parents have incalculable impact on their children, particularly during the early years when the family environment they create for a child becomes his template for understanding the world in general.

Although few people have heard of Dorothy Law Nolte, most are at least passingly familiar with her poem, “Children Learn What They Live,” written in 1959 and originally circulated in the Torrance (California) Schools Board of Education newsletter. In the decades that followed, Nolte revised the poem several times. Here is the last version, published in the book Children Learn What They Live (New York: Workman Publishing, 1998):

If children live with criticism, they learn to condemn.
If children live with hostility, they learn to fight.
If children live with fear, they learn to be apprehensive.
If children live with pity, they learn to feel sorry for themselves.
If children live with ridicule, they learn to feel shy.
If children live with jealousy, they learn to feel envy.
If children live with shame, they learn to feel guilty.
If children live with encouragement, they learn confidence.
If children live with tolerance, they learn patience.
If children live with praise, they learn appreciation.
If children live with acceptance, they learn to love.
If children live with approval, they learn to like themselves.
If children live with recognition, they learn it is good to have a goal.
If children live with sharing, they learn generosity.
If children live with honesty, they learn truthfulness.
If children live with fairness, they learn justice.
If children live with kindness and consideration, they learn respect.
If children live with security, they learn to have faith in themselves and in those about them.
If children live with friendliness, they learn the world is a nice place in which to live.

The poem underscores the power that parents wield and consequently the responsibility they must accept. In psychotherapy a very common initial approach is to explore the way in which the client was raised, the way they perceive their parents as having treated them, and the life lessons they learned from their parents, good and bad. The sessions tend to concentrate on the bad. This is necessary in order to revisit, and begin to undo, the damages of childhood, which vary in type and intensity from one client to another but which involve deep existential pain and distorted thinking (for example “you can’t trust anybody” or “I’m not worthy of love, success, etc.”) based on messages ingrained on the client, sometimes deliberately but usually inadvertently, by their parents.

The relevance of this to bipolar disorder is that I have found that a key to managing the illness is the ability to distinguish between depressions that are a function of biochemistry and depressions that have an existential source. Even more crucially, in order to find the strength to face the demon of bipolar disorder, I have had to confront, and cease to be haunted by, the ghosts of the past.

While in my opinion unavoidable, the process gives rise to the stereotype that therapy is all about blaming the parents and excusing clients from their own decisions and behaviors. It is true that some clients, unwilling to take the next step -- where are you in all of this, you’re no longer a helpless child, you don’t have to stick with the patterns you grew up with, you have the power to improve your life -- remain immobile for a long time or else terminate therapy altogether. However, the purpose is never to blame the parents, which is pointless and self-defeating, but simply to acknowledge that, relative to the child, they for years exerted almost god-like power and the impact of that power must be well understood.

And of course, it’s not as if these parents themselves had perfect fathers and mothers. They often also emerge from childhood with pain and distorted thinking, and while raising their children they either grapple with, or repress, or act out the imperfections of their own childhoods.

The Prussian military theorist Karl von Clausewitz maintained, “In war everything is simple, but the simplest thing is very difficult.” Parenting is like that. Your objective is to love your children and raise them as best you can. Some parents think hard about the best way to do this and some pretty much follow the playbook learned from their own parents, but parents are almost continually shaping their children’s lives. There’s almost no downtime. And seemingly benign words and actions can have far different impacts than intended. The simplest thing frequently turns out to be very difficult indeed.

For instance, yesterday I heard a father rebuke his toddler with the words, “Why aren’t you minding your mother?” And I thought to myself, what possible response could the toddler give to such a question? So why couch it as a question? Maybe it just rolled off the kid’s back, but growing up I heard such rhetorical questions all the time, followed by the command, “Answer me!” It was a classic Catch 22. If you didn’t answer, you were insolent. If you did, you were insolent. And yet I doubt my parents ever considered this, still less that they intentionally placed me in a double bind. They were simply aping what they’d often heard other parents say within their immediate and extended families.

So in the posts that follow, bear in mind that I have neither the intention nor the desire to blame my parents for anything. But I am going to hold them responsible for the choices they made during the years when they had all the power and I had none, just I must hold myself responsible for the choices I make, now that I hold the power over my own life.

Prologue - Part 1 - Part 2 - Part 3 - Part 4 - Part 5

The Normal

2009-09-10T05:00:00.006-04:00

Sorry for the long hiatus between posts. It's the consequence of three things.

First, the academic year here at the Army War College has again gotten underway. I've been very busy.

Second, I've felt tired a good deal of the time, for reasons I don't really understand. I had supposed it might be a manifestation of the mood disorder. The disorder takes a variety of forms, including a waxing and waning of energy level. But after living with this frequent fatigue for a while and talking it over with my therapist, I don't think that's the case. It seems to be more physically based. It may be simply that it's taking me longer to get used to my workout regimen than I anticipated.

Third, I haven't had much to tell you.

Actually, that's not quite correct. I've got plenty to tell you. I'm just not that anxious to do it.

It's funny. On the one hand, I grew up with, and to some extent have internalized, the stereotypical American male tendency to play the strong, stoic type. On the other, I've had a lifelong itch to share what I think, feel, and believe--it's the central trait that has made me a writer. And I can think of few things more worthwhile than to communicate candidly about what it is like to live, day in and day out, with bipolar disorder. So you'd think it wouldn't bother me to get on with it.

But despite everything, there's still the urge to keep silent, to just be "normal." As if anyone were normal. And yet the desire to be "normal" exerts a powerful tidal pull, intensified by the ubiquitous signals in our society that reinforce it. It puts me in mind of a soliloquy from Equus, Peter Shaffer's amazing play. In it, the psychiatrist Martin Dysart meditates on the nature of his work:

The Normal is a Holy Ghost. . . . The Normal is a murderous, non-existent phantom. And I am his priest! My tools are very delicate. My compassion is honest. I have honestly assisted people in this room. I've talked away terrors. I have relieved many agonies. But also--beyond question--I have cut from them parts of individuality repugnant to this God.

As I hope by now is obvious, I consider bipolar disorder an illness that I happen to have. I don't think of it as something that defines me and certainly not as part of my individuality. I wince every time I hear phrases like "he's bipolar"; to my ears it's the same as saying that someone with cancer is cancerous. No: the part of my individuality repugnant to this God is the part of me that has the courage to be genuine. And neither my psychiatrist nor my therapist nor my friends try to cut it from me. All too often, I want to cut it from myself.

The Ethics of Disclosure

2009-08-17T17:30:00.005-04:00

For many years now I've chosen to be candid about having bipolar disorder, and I have a variety of reasons for doing so. Many are pragmatic. But one is not: "[Being up front about bipolar disorder] gives me a chance to combat, in a small way, the stigma that still attaches to mental illness. If a professor protected by tenure cannot summon the modest courage required for such an act, I do not know who can."

The quotation comes from a column I wrote three years ago. And although in it I used the phrase "modest courage," it would be more accurate to say "moral courage." That is to say, I would feel craven or gutless if I remained discreet about having bipolar disorder, even though the fact that I'm high-functioning means that people are oblivious to my having the disorder unless I tell them.

So if I kept this information to myself, would it be unethical? And if so, why?

Here at the Army War College we're midway through a ten-day course in "Strategic Thinking." I'm responsible for most of the remaining lessons -- the Uses of History and the capstone Gettysburg Staff Ride, for obvious reasons. And a bit less obviously: Ethical Reasoning, which comes up tomorrow. (I say "a bit" less obviously because anyone who knows my body of work is aware that much of it deals with the problem of moral judgment in war.)

At the AWC we faculty do not have carte blanche to prepare our own lessons. The readings, learning objectives, and the basic approach are designed by a lead instructor. The rest of us can adapt the lesson within certain limits, but we can't leave the reservation entirely. This sounds like a strait jacket, but it's really the only workable approach given the way that education is delivered here; i.e., within twenty tightly knit seminar groups with faculty members assigned to teach one particular group, and that group only, for most of the academic year.

This year the lead instructor has adopted what strikes me as a reasonable, easy-to-grasp approach. We're asked to discuss ethical reasoning through just two lenses: deontological, or principle-based reasoning; and teleological, or results-based reasoning (the latter primarily taking the form of utilitarianism).

What light do these forms of ethical reasoning shed on the ethics of disclosure? Indeed, are ethics even involved?

Certainly to me it feels unethical to keep silent about having bipolar disorder. From experience I know that my candor has been helpful to people who either have a mood disorder or know someone who does. So from a teleological perspective, I suppose a case could be made that if I remained silent I would deny those people whatever assistance or comfort I might otherwise provide. And one could add that my silence would do nothing to undermine the stigma associated with such disorders.

All the same, this strikes me as a pretty weak case. Equally weak would be to argue from a deontological perspective -- that I must be candid about the disorder as a matter of principle.

It therefore seems to me that only two conclusions are possible: either I'm mistaken to believe myself under a moral obligation to be open about having bipolar disorder; or else some other ethical framework must apply.

It seems to me that another ethical framework does apply: aretaic, or virtue-based reasoning. This basically flows from a moral imperative that is rooted in character, that comes from within. It differs from deontological and telelological ethics in that, unlike these two, it does not attempt to be universally prescriptive. Put simply, just because I perceive it as a moral imperative to publicly acknowledge having bipolar disorder, doesn't mean that everyone should. This was the basic problem with the tactic of "outing" gays. Yes, it would show that being gay was fairly common and would thereby reduce the stigma of being gay. It would also increase the political clout of the gay community. And one could certainly advocate in favor of having gays come out of the closet. But to strip from a person the option of privacy was wrong.

As I've pointed out in the past, my situation with bipolar disorder has certain analogs with battle stress injury, in particular the need to manage the two conditions and the stigma that clings to them. Military policy has become quite enlightened about encouraging service personnel to seek treatment for battle stress injury and, as much as possible, eliminating the adverse consequences of doing so. Here at the Army War College it's estimated that as many as a third of the incoming resident class have some symptoms of Post Traumatic Stress Disorder, and there are several ways by which officers can seek treatment confidentially. (The most obvious of these is to visit a chaplain, all of whom have both training and experience in counseling persons with PTSD.)

But policy will get you only so far. The culture remains one in which battle stress injury is still too often regarded as weakness. It may be okay for an enlisted man to receive treatment for PTSD. It may even be okay for an officer or senior NCO to receive treatment for PTSD. However, as I often heard officers maintain during my first year here at the Army War College, it is not okay for officers or senior NCO's to disclose publicly that they are being treated for PTSD. My comment in a post I wrote last year about the military use of antidepressants, etc., also applies here:

How does this relate to military personnel who take psychotropic meds? First, I wonder how many officers and NCOs self-disclose that they are taking the same meds. If they keep this info away from their soldiers, they send a double message: overtly it’s OK for you to take these meds, but tacitly it’s really not because I wouldn’t be caught dead letting you know that I take them myself. It would require real moral courage, but an officer willing to talk matter of factly about taking these meds, and at the same time functioning effectively as an officer, would serve as a powerful role model. (I find that’s the role I often play with my students.) Such an officer’s example could not only reassure the soldiers who take the meds, but would also help shift the military culture toward one in which other soldiers would find it easier to trust and support their comrades in arms.

I broached this subject to a number of officers and national security analysts and got the same response. Double messages, they acknowledged, do have adverse effects on organizations. But in this case it was just too bad. It would be fatal for officers who took medications for combat-related anxiety or depression to discuss it with their soldiers or, for that matter, anyone else. To command effectively an officer has to appear strong, and the stigma of weakness attached to battle stress injury was too potent to challenge.

In the months since, however, I've discovered that a few generals have done exactly as I proposed.

On November 8, 2008, USA Today reported that Maj Gen. David Blackledge had received "psychiatric counseling to deal with wartime trauma, and now he is defying the military's culture of silence on the subject of mental health problems and treatment." His decision to speak up apparently came from two sources: First, a statement from Admiral Mike Mullen, the Chairman of the Joint Chiefs of Staff, for leaders to set an example for all service personnel: "You can't expect a private or a specialist to be willing to seek counseling when his or her captain or colonel or general won't do it." And second, a campaign developed by Brig. Gen. Loree Sutton, an Army psychiatrist heading the defense center for psychological health and traumatic brain injury, to encourage service personnel (and their families) to share their stories. Blackledge volunteered to help.

On November 26, 2008, in an article picked up by Army Times, USA Today highlighted a four-star general, Carter Ham, who had also disclosed publicly that he was getting treatment for battle stress injury, partly to serve as an example to other service personnel -- "You need somebody to assure you that it's not abnormal. It's not abnormal to have difficulty sleeping. It's not abnormal to be jumpy at loud sounds. It's not abnormal to find yourself with mood swings at seemingly trivial matters" -- and partly to undercut the stigma surrounding battle stress injury. The article went on to discuss Brig. Gen. Gary Patton, who had also chosen to talk publicly about having battle stress injury.

A March 2009 CNN article further explored the cases of Generals Ham and Patton, and offered clues about their reasons for coming forward:

"If you go ask for help somehow you believe it or you might believe others think it of you, that you're somehow weak. That's wrong and intellectually we all know it's wrong, but it's still there. It's still palpable in some communities," Ham said.
Patton wants to see a change in the way post-traumatic stress disorder is viewed by the military.
"We need all our soldiers and leaders to approach mental health like we do physical health. No one would ever question or ever even hesitate in seeking a physician to take care of their broken limb or gunshot wound, or shrapnel or something of that order. You know, we need to take the same approach towards mental health," Patton said.
Having two generals talk publicly about their own battles with stress and how counseling helped should help remove some of that. Patton said he wants servicemen and women to know that they can come forward.
"Know absolutely that your chain of command and your leadership in the military at our highest levels recognize this issue and want to encourage our soldiers to seek out that mental health assistance," Patton said.

Again, neither deontological nor teleological ethical reasoning seems to apply here. Generals Blackledge, Ham, and Patton (and for that matter Admiral Mullen and Brig. Gen. Sutton) do not come close to arguing that it is a moral imperative for all officers to publicly battle the stigma associated with battle stress injury. But plainly, it seems to have been a moral imperative for them -- a case of aretaic reasoning in action.

The Nick and Betsy and Diamond Head

2009-08-05T05:00:00.000-04:00

Three years ago veterans of the USS Nicholas -- "the Nick," they call it -- a World War II era Fletcher-class destroyer on which my father served, created an online discussion forum. Since I was already on the mailing list of their reunion association, I got an invitation to join.

I promptly posted a message asking to hear from personnel who had served aboard the Nicholas during the same time as my father, and of course I was particularly interested to hear from anyone who actually knew my father. Since any such individual would have to be on the high side of seventy, I had low expectations. But to my surprise I heard from someone almost immediately. Though I gather he had only a nodding acquaintance with my father, he had a clear recollection of the part of the ship where my father worked. Moreover, he had compiled a database of info on Nicholas personnel and could tell me more or less the exact dates of my father's service on the vessel.

That sent me poking around boxes of old photos to see what images might exist of Dad's service on the Nicholas. I found a few from his days in basic training at San Diego, but nothing Nicholas-specific save for a yellowed clipping from the Honolulu Star-Bulletin reporting the ship's arrival at Pearl Harbor. The story included a photo of the Nicholas and two sister ships in her destroyer squadron.

I knew for sure that Dad had slides of his days on the Nicholas, so I tracked them down in a storage box and went through them, using I checked out a 35mm slide projector from my university. I don't think I'd seen the images in thirty years. Quite a few slides had been ruined in a basement flood back in the 1970s. But I still found about two hundred from his time in the Navy and about fifty that dealt specifically with the Nicholas. The best of them I scanned using a transparency adapter and uploaded to the forum site.

It was very odd to go through all those slides. Since most of the boxes weren't labeled, I viewed quite a few that proved to be of our family in the 1960s and early 70s. Many of these had not been completely destroyed by the flood but still had damage from too much humidity. Bleeding and discoloration in the dye had made them like something from an opium dream. Others were in perfect condition but had people in them -- friends or extended relatives of my parents -- whose names are now forever lost.

Those of my father's days in the Navy showed him having the time of his life. Many slides depicted his friends at parties, holidays, or excursions in California and Hawaii. A surprising number were of "Betsy," his first car, a 1950 Ford sedan purchased in March 1956 for $478.80 (he kept the bill of sale). And whenever my father appeared he had a cocky stance and a flashy grin, displaying the trademark gap between two upper incisors that gave the grin an infectious, boyish charm.

Of those involving the Nicholas, comparatively few depicted life at sea. But he was a sucker for sunsets, particularly if a companion ship were silhouetted against the red horizon. He also liked ports of call: Hong Kong, Yokohama, Nagoya, and so on. And whenever Nicholas returned to Pearl Harbor, he could never resist a shot of Diamond Head. (Decades later, when he and my mother took lessons in oil painting, he would try his hand at capturing a sunburst falling on Diamond Head after a storm.)

In short, between the images of him and the images he took, my father seemed jaunty, happy, alive -- striding into the wider world, making new friends, his whole life ahead of him. This was the man I still dimly remember from my earliest childhood, the man I rarely saw thereafter. Who could know, looking at that grinning face, the rage that lay beneath?

Thirsting for Love

2009-08-04T04:26:00.005-04:00

Of late I've been thinking a lot about how to pursue certain issues -- the onset of the bipolar disorder and significant episodes that convey some idea of the subjective experience of the illness. But I've been concerned about how to do so without bringing specific persons into the narrative. Even if I omitted their real names and disguised certain of their characteristics, they would still be recognizable to friends and acquaintances.

In the main I think I can work around this. The unavoidable exception is my parents, both of whom are long deceased but whose lives I would like to address with fairness and empathy. Consequently before raising matters that involve them, I would like to introduce them a bit.

To start things off, here is something I wrote four years ago:

Seventy years ago today my mother was born in Norfolk, Virginia. I cannot say she led a happy life. Her childhood home was drenched in anger and abuse. Her troubled 23-year marriage ended in divorce. At age 29 she was institutionalized for several months with a mental illness diagnosed first, erroneously, as schizophrenia and later, correctly, as bipolar disorder. Ten years later she was diagnosed with breast cancer. The disease finally killed her a few weeks after her forty-seventh birthday.

My mother was part of the last generation of American women raised to embrace what Betty Friedan would call “the feminine mystique”: the idea that a woman’s highest calling was to be a wife and mother. She usually described herself as a “professional homemaker.” She never read The Feminine Mystique. She didn’t have to. She lived Friedan’s critique of it day to day. She would like to have escaped, but hampered by her bipolar disorder in addition to the usual difficulties of women of her era and station, she stayed in the trap. But she never stopped trying to get out. She immersed herself in self-help books. She drowned herself in religion. Once or twice a year she overdosed on sleeping pills. Through it all she composed short, didactic essays on how to live life and wrote a lot of clumsy poems.

I seldom think of her without recalling these lines from Spoon River Anthology, especially the last two:

I AM Minerva, the village poetess,
Hooted at, jeered at by the Yahoos of the street
For my heavy body, cock-eye, and rolling walk,
And all the more when “Butch” Weldy
Captured me after a brutal hunt.
He left me to my fate with Doctor Meyers;
And I sank into death, growing numb from the feet up,
Like one stepping deeper and deeper into a stream of ice.
Will some one go to the village newspaper,
And gather into a book the verses I wrote?—
I thirsted so for love!
I hungered so for life!

A Futile Consistency?

2009-08-02T05:49:00.007-04:00

"The most successful people," I once heard the entertainer Kenny Rogers say in an interview, "are the most consistent." I was never a huge Kenny Rogers fan, but I had to admit he was certainly successful and certainly consistent, so he probably knew what he was talking about.

That's not particularly good news for people like me.

If, as Ralph Emerson famously maintained in Self Reliance, "A foolish consistency is the hobgoblin of the little minds," then I suppose a futile consistency is the hobgoblin of minds afflicted with bipolar disorder.

On the one hand, depressions drain you of energy, pushing even the most modest of projects beyond your ability. People looking from the outside assume that if you had sufficient will power you could just power through, but will power is among the very first things that depression strips from you. The former talk show host, Dick Cavett, suffers from periodic depressions. He once explained that when you're depressed the cure for depression could be on a night stand fifteen feet from you, and you would not have the will power to rise from your bed and get it.

It is, on the other hand, not much better with hypomanic episodes, which though characterized by energy and creativity also increase distractability and decrease impulse control, so that you go off on tangents instead of focusing on whatever main task lies before you.

The best solution I have found is, at best, a partial one. It involves finding ways to be as consistent as possible in at least one area of life. Consistency in that one area helps you understand that whatever the strength of the illness, you are not powerless against it. The thing I fear most about the disorder is that it creates the temptation to give up.

Hence these almost daily reports of my comings and goings to the gym. Although working out is a good thing in itself, it's also a tangible way to show myself that I am still capable of consistency. To try and be consistent in all areas is a recipe for despair, but if I can drill down on one area then I can remind myself that inconsistency -- one might also say unreliability -- is an artifact of the illness, not a flaw in my character. The great mistake would be to confuse the illness with my identity.

Why the Hell Did I Wake Up at 2 A.M.?

2009-07-30T06:22:00.008-04:00

Basic to the management of bipolar disorder is what health professionals call "good sleep hygiene." This consists not only of getting enough sleep but of observing habits that maximize the chances of getting a good night's sleep. Although I consider this a critical skill, I've found it difficult to master, and some of the things that work for me run counter to the usual advice. For instance, it's recommended that one not watch television before retiring and above all that one should not sleep with the television on. Television, observes the Sleep Disorders Center at the University of Maryland, "is a very engaging medium that tends to keep people up."

At the same time, the Center advises the aspiring sleeper to "leave your worries about job, school, daily life, etc., behind when you go to bed." In my experience, this has proven almost impossible. From childhood I've nearly always lain awake for at least an hour, worrying about this or that. A solution that has worked for me is a modification of the "no television" rule. I leave the TV on, but I have it play a DVD that I practically know by heart. It distracts me from worrisome topics and because I'm thoroughly familiar with the story line, it doesn't engage me enough to keep me awake.

Some DVDs work better than others. The most reliable, oddly enough, is a war movie, Twelve O'Clock High, I think because it consists mainly of dialogue and has almost no combat scenes.

Still, my sleep pattern tends to oscillate between a lot of sleep -- last week I found myself sleeping as many as twelve hours -- and comparatively little, generally only four hours a night. Last night was an extreme example. I slept only ninety minutes and awoke with the certainty that I would not be able to get back to sleep. In such instances the advice is not to force sleep but to read quietly or maybe take a warm bath. In no case should one do office work, housework, etc. This is a rule I nearly always violate, because once again it doesn't work for me. I have found it more effective to push through the day and then retire at an early hour but not too early -- say at 9 p.m. This usually results in getting sufficient sleep the next night, and I'll take an Ambien to try and make sure of it.

Although I don't become alarmed when I get too little sleep, I do start looking for signs of a potential hypomanic episode. As a checklist I use the relevant criteria in the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association, which I have more or less memorized (and also own a copy).

The first question I ask myself is whether I feel refreshed, as if I had gotten a full night's sleep. That would be bad. Fortunately on this occasion I don't feel that way. I feel functional but kind of tired, and were it not for the proscription against taking naps during the day, that's probably what I'd wind up doing. (I sometimes take cat naps anyway. Even twenty minutes can restore a measure of vitality without compromising my ability to get to sleep that evening.)

Second, I ask myself whether I feel unusually creative and raring to go. Again, that would be bad.

Third, I look at whether I am easily distracted, which is another symptom of hypomania. If I can stay on task, whether it's doing dishes or paying bills, I'm less concerned.

Lastly, if the condition persists for four days, then getting a good night's rest becomes an absolute priority, and on such occasions my psychiatrist has authorized me to double the dosage of Ambien. This generally does the trick.

There are other criteria indicative of a hypomanic episode -- e.g., an unequivocal change in functioning uncharacteristic of the person when not symptomatic, and the disturbance in mood and functioning are observable to others -- but I seldom find evidence of the former and as for the latter, I am continually amazed by how rarely anyone picks up on a change in my mood and / or functioning, at least not on the "high" side of normal. Depressions, my principal bête noire, are more noticeable to friends, though not to colleagues (or if they do notice they rarely say a word).

In any event, the object is to avoid as many symptoms of a hypomanic episode as possible. And one thing I definitely avoid is the temptation to "ride the wave" of increased creativity that often characterizes a hypomanic episode. I have heard of writers, artists, etc. who firmly believe their creativity is inextricably bound to their hypomanic episodes and therefore resist treatment. I say the hell with that.

Meds - Pt 2

2009-07-29T07:40:00.014-04:00

Every evening I take between three and six pills --invariably two of Lamictal and one of Zocor (a cholesterol-lowering drug), to which I often add one or two Klonopin and occasionally one Ambien.

Even after all these years, I still find this a little strange. From an early age I disliked the very idea of taking anything stronger than the occasional aspirin or cold medication. I didn't begin taking psychotropic medications on a consistent basis until my mid-thirties, and I somehow doubt I will ever get used to it. I've just learned to accept it as a fact of life.

Little in my civilian background equipped me to deal with bipolar disorder. Within my family a taint of shame and weakness, usually covert but hard to miss, attached to it with regard to my mother. It was not much different when I was diagnosed in 1986. Most of my friends just sort of fell away, as if my life were over and I was no longer worth the investment. Many years later, when my life was on track and the bipolar disorder obviously in hand, I became reacquainted with one of these friends and asked what had happened. "We just didn't know what to do," she replied. Which was slightly odd coming from a devout Christian as well as a registered nurse.

Within academe scarcely anyone ever inquires about the disorder. I think it makes them feel awkward. And as I've written elsewhere, a common reaction is to consider it "inappropriate" for me to openly discuss it. Almost no one has said this outright, but an academic generally has a lousy poker face. Over the years it has been increasingly difficult to find a plausible alternative explanation. And of course I live in a society that still prefers to see mental illness as a character disorder ("Snap out of it!") or as an all or nothing proposition (you're either normal or you're abnormal).

Almost the only thing that has equipped me to handle the disorder is my experience with the Army. Back in basic training the Army drilled into me a vital core principle: You do what it takes to accomplish the mission. The aesthetics don't matter. You don't need to look like John Wayne. A manly attitude is irrelevant if it doesn't translate into effective action. It doesn't matter what other people think. The mission is everything.

A second thing the Army did for me -- as it does for most recruits -- is to show you that you are stronger than you think you are.

Even so, the need to be "normal," to be like everyone else, is powerful, particularly in young people who have not yet realized that no one is normal, that no one is like anybody else, and that we all carry wounds. Initially I took medications -- lithium and Imiprimine (an early antidepressant) -- for perhaps nine months, and even then without much conviction in their efficacy. It was tough on me psychologically. Taking the pills always seemed like a bizarre eucharist, a daily acknowledgment that I was now as broken as my mother had been.

Then for over ten years I took nothing. It took not only a brush with an unmistakable hypomanic episode to bring me to my senses. It also took the maturity that comes with being older and the basic confidence that comes with having securely established myself in life.

To my surprise, the first psychiatrist I consulted prescribed nothing stronger than a sedative to help me sleep. "You've had the disorder for eleven years," he pointed out, "and during that time you've gone to graduate school, gotten your PhD, succeeded in getting a faculty position, published a prize winning book, and gotten tenure a year early. Clearly you've been able to manage the disorder. So until I know more I'm not in a big hurry to put you on psychotropic medications."

Within a couple of months, however, the hypomanic episode had been succeeded by a depressive episode that seemed unrelated to anything in my day to day life and was sufficiently debilitating that it became difficult -- though not impossible -- to function normally. Certainly, though, I could not function at my usual level and on top of that, life seemed flat and meaningless. Small reversals suddenly loomed large. The memory of old failures and regrets constantly tugged at my thoughts.

So I consulted a second psychiatrist -- not because I disliked the first but because the second one was in my health care network. The first had not been. I wanted an antidepressant but I knew enough to recognize that an antidepressant alone carried the strong risk of vaulting me into a manic episode. Consequently I would have to take lithium as well.

In July 1999 -- precisely ten years ago, come to think of it -- I had a manic episode that simply blew through the lithium, and when the second psychiatrist somehow refused to accept this fact, I got rid of him and found the psychiatrist I continue to see to this day. I'll call her Jennifer -- it's hard to call her "Doctor" since we both have doctorates, although mine is merely PhD. Jennifer put me on depakote, which worked fine except that, as I mentioned in Part 1, it had the effect of ratcheting up my weight. When I discontinued it, I was startled by how rapidly my weight returned to normal.

As I indicated earlier, we substituted Lamictal and gave it the dual role of antidepressant and prophylactic against mania. But in the depakote years we tried and discarded any number of antidepressants after experimenting with different dosages of each over a period of months. There were so many I can't recall them all. Looking over a list of antidepressants, however, I recognize at least four: Celexa, Lexapro, Effexor and Wellbutrin. I'd bet money there were at least one or two others. [Update: Seroquel and Neurontin, though in both cases quite briefly.]

None of them, as far as I could tell, worked worth a damn. We finally hit upon Lamictal (even when I was on depakote). Lamictal is interesting in that you start with a negligible dose and it takes over a month to gradually ramp up to therapeutic levels. That's because in rare instances it has an undesirable side effect, namely a severe, life-threatening rash that from descriptions sounds practically like spontaneous combustion.

Fortunately I had no problems with it. It seemed to mitigate, though it did not eliminate, the depressions, and gradually we came to suspect that the depressions were often triggered and / or exacerbated by environmental factors, of which (perhaps) more in a future post. This past spring, however, although I was here at the Army War College, an environment in which I have thrived, I experienced a series of depressions in which the reprieves were so fleeting it was basically a single continuous depression lasting almost three months. We responded by doubling the Lamictal (from 100 to 200 mg per day). I've been fine since then.

Part 1 - Part 2

Meds - Pt 1

2009-07-28T09:53:00.008-04:00

These are the medications on which I rely to manage Bipolar Disorder. (The generic name for each medication is given in parentheses.) Because the disorder varies in intensity from one person to another, and because each person's biochemistry is unique, what works for me would not necessarily work for someone else.

Main line of defense: Lamictal. Has anti-manic and anti-depressant properties. Basic tool for combating the disorder.

Close support: Klonopin. Mood stabilizer. Comes in handy for mitigating serious depressions and anxiety attacks. Also has some sedative properties.

Reserve support: Ambien. Used occasionally when it seems likely I will not otherwise get enough sleep.

Discontinued: Depakote. Along with lithium, the standard prophylactic against mania. But even at low doses usually results in weight gain -- in my case as much as thirty pounds -- and given the history of heart disease in my family and the conscientious way in which I have addressed the disorder, my psychiatrist and I decided two years ago to rely exclusively on Lamictal coupled with good sleep hygiene. Has worked well: no hypomanic episodes during that period.

Part 1 - Part 2

Room 101 - Pt 3

2009-07-24T16:42:00.008-04:00

People with bipolar disorder almost invariably have a psychiatrist, who prescribes their medications. Frequently they also have a therapist -- in my case a clinical psychologist whom I'll call Laura. Laura's office is typical of most. It is comfortably furnished. It is uncluttered. Its walls are light in color and the few prints and photographs on those walls are light in tone. Sunlight pours in through large picture windows. All in all, the room seems cheerful, reassuring, and safe.

In many ways that impression is accurate enough. Laura is good at her job and I have always felt as if I were in safe hands.

In one key respect that impression is wrong. Decidedly wrong.

The worst thing in the world is in that room.

As in Nineteen Eighty-four, the worst thing varies from individual to individual. And as in Ninety Eighty-four, the interlocutor often knows what it is, if not in the early sessions then usually after a few months. That's because although each person is ultimately unique, the symptomology falls into broad patterns that offer an experienced therapist -- O'Brien, to pursue the analogy -- solid clues as to the likely underlying problem. Certain patterns, for instance, are common to adult children of alcoholics. Others are common to persons with borderline personality disorder, still others to persons who have been sexually abused.

The worst thing, however, is seldom evident to the client, because they have spent most of their lives excluding it from their awareness. The techniques of exclusion have usually taken the form of the very attitudes and behaviors that eventually bring them to the therapist's office in the first place. As Carl Jung once explained, "People will do anything, no matter how absurd, in order to avoid facing their own soul." Or more famously: "Neurosis is always a substitute for legitimate suffering."

And yet, when finally confronted with the worst thing in the world, the client is seldom surprised. Because in order to avoid a thing they must, at a a semi- or subconscious level, have an idea of what that something is. They know that they have been, all along, on a journey to discovering what specifically is in Room 101. But unlike Winston Smith, they have usually entered Room 101 by choice.

They have done so notwithstanding the stigma attached to psychotherapy. It is common to hear people pour scorn upon psychotherapy or uncritically accept the crudest caricatures of it. Upon encountering someone like myself, who no longer minds saying that he sees a therapist, their attitude is at best one of incuriosity.

In their disdain the scoffers are powerfully abetted by ubiquitous media images of therapy. In the culture wars it is common to hear of a "therapeutic society" that promotes victimhood and diminishes individual responsibility -- it is no accident that blaming one's parents is thought to be the alpha and omega of therapy. In commercials the therapist is usually portrayed as an eccentric disciple of Freud, distant and detached, scribbling on a pad of paper while the client, recumbent on the proverbial couch, says all sorts of wacky things. On television the therapist character is often brought in to deal with someone accused of a serious crime or whose behavior, at the very least, is utterly bizarre. (Favorable depictions of therapy, by the way, are almost equally unrealistic.)

If the suggestion is made that therapy might be helpful to them, the scoffers rule it out of bounds, even when the presenting problem -- a marriage that is failing, an uncontrolled temper that is wreaking havoc on their personal or professional lives -- is screamingly obvious.

These are people who have not made an informed or reasoned decision about therapy. Their choice comes from their gut. They understand instinctively that the worst thing in the world is in the therapist's office, and no way in hell are they going there.

Part 1 - Part 2 - Part 3

Room 101 - Pt 2

2009-07-23T05:00:00.001-04:00

“You asked me once,” said O’Brien, “what was in Room 101. I told you that you knew the answer already. Everyone knows it. The thing that is in Room 101 is the worst thing in the world.”

The door opened again. A guard came in, carrying something made of wire, a box or basket of some kind. He set it down on the further table. Because of the position in which O’Brien was standing, Winston could not see what the thing was.

“The worst thing in the world,” said O’Brien, “varies from individual to individual. It may be burial alive, or death by fire, or by drowning, or by impalement, or fifty other deaths. There are cases where it is some quite trivial thing, not even fatal.”

– George Orwell, 1984, Book III, ch. 5

Part 1 - Part 2 - Part 3

Room 101 - Pt 1

2009-07-22T05:00:00.001-04:00

Winston lay silent. His breast rose and fell a little faster. He still had not asked the question that had come into his mind the first. He had got to ask it, and yet it was as though his tongue would not utter it. There was a trace of amusement in O’Brien’s face. Even his spectacles seemed to wear an ironical gleam. He knows, thought Winston suddenly, he knows what I am going to ask! At the thought the words burst out of him:

“What is in Room 101?”

The expression on O’Brien’s face did not change. He answered drily:

“You know what is in Room 101, Winston. Everyone knows what is in Room 101.”

– George Orwell, 1984. Book III, ch. 2

Part 1 - Part 2 - Part 3

Stones of Memory - Pt 2

2009-07-20T05:00:00.003-04:00

Originally published, in slightly different form, on Blog Them Out of the Stone Age in August 2005

This is a post I've been reluctant to write. But except for me, the people principally involved have long since passed away, and what happened to us was no different than what happens to thousands of families each year.

Five days before Christmas, 1974, my father suffered a heart attack. He was barely forty years old. The day after Christmas my mother summoned me into her room and told me that my father wanted to leave the marriage. There were a number of reasons he wanted to do that, and there's no need to review them here. I think that fundamentally it had hit home to him that he had only one life and he wanted to grab for happiness while he still could.

My mother did not know what to do. She seemed lost. She asked me for my advice. She was very serious about it. I knew nothing about marriage or relationships so I drew upon the one thing I did know something about, which was war. I had been steeped for years in military history. It seemed to me instinctively that this situation -- Dad wanting to leave the marriage -- was like a kind of war. Mom was wondering about how she might plead with Dad to stay. I told her flatly that the best thing to do was to give him an ultimatum: that he either had to agree to marriage counseling or leave the marriage, and that she should start finding herself a lawyer.

The whole idea ran counter to Mom's instincts, which were to try to do something that would win him back. But she was so benumbed by the situation that she decided to take my advice. It worked. My father, shocked at the sudden reversal of momentum, agreed to enter marriage counseling. I wish I could say that things improved between them, but they never did. Eventually they divorced, but not for another eight years.

When I advised my mother to confront my father with an ultimatum, I was operating on a strategic principle I had learned from Robert E. Lee: In war you do not let the enemy keep the initiative if you can possibly help it. It was not until my late 30s that I finally understood why the strategy worked. I found the explanation in a book by sociologist Diane Vaughan entitled Uncoupling: Turning Points in Intimate Relationships (1986). On the basis of interviews with 103 people, Vaughan argues that relationships tend to end according to a certain pattern. It begins with a secret -- one member of the couple is dissatisfied with the relationship, but keeps it to herself or himself to avoid rocking the boat, or because the level of their dissatisfaction is not yet apparent even to them. Eventually the discontent comes into the open and larger confrontations ensue -- but still within the context of an on-going relationship. Finally the dissatisfied person announces that they wish to leave. Vaughan calls this person the "initiator," and her analysis indicates that they hold most of the cards.

Often, however, the initiator's desire to leave comes out before they have completed the financial and psychological preparations for abandoning the relationship. Their problem is eased by the fact that the partner -- the person who wants the relationship to continue -- makes desperate efforts to save the relationship. The partner may respond by trying to change themselves so as to become someone the initiator can again love. They may make concessions of other sorts. They may agree to a trial separation, which in their minds is an effort to save the relationship but to the initiator simply reduces the social costs of moving out, while supplying the comfort of knowing that until their preparations are finished, they always have the option of coming back.

The initiator's advantage is so pronounced that Vaughan devotes 13 pages -- an entire chapter -- to explicating it. Mostly the advantage turns on the fact that the initiator has already had lots of time to prepare for the break, and that the partner tends to supply whatever additional time is needed through various efforts to save the relationship. The solution, strategically, is for the partner to make no effort at all to save the relationship; on the contrary, to push toward an end to it at the earliest possible moment. Either one of two things will happen. The erstwhile initiator will be confronted with an end to the relationship before their financial and psychological preparations are complete, and, shaken, may try to return to the relationship. Or the partner gets the break-up over with as quickly as possible.

My ultimate point is that war turns out to be a dynamic that applies, metaphorically, to many other areas of life. And if a = b, then it follows that b = a. Other areas of life apply metaphorically to war. Thinking about the options faced by a small kid having to deal with a playground bully can deepen our understanding of war, because it forces us to think in fresh ways. So can thinking about the conflicts within a relationship. The single most interesting review of The Hard Hand of War was offered by my sister. She said it was an allegory of our parents' marriage.

Manic Depression Didn’t Kill Your Dog

2009-07-19T05:00:00.000-04:00

For the past couple of days I've dipped into blogs maintained by people with bipolar disorder and, as I've done so, have constantly tinkered with the blogroll. Blogrolls become useless if the lists are indiscriminate (which most of them are). I try to limit mine to ten or twelve. I just added ... salted lithium, which is maintained by "Gabriel," a Canadian journalist who describes himself as being in his fourth year of recovery after eighteen years of dealing with undiagnosed bipolar disorder, which he prefers to call by its traditional name, manic depression. It's one of the better blogs I've read so far. This is one of the better posts:

Manic Depression didn’t kill your dog. Manic depression didn’t rape you. Manic Depression never picked up a gun. People are not their cancer and you are not “A Manic Depressive”, you “Have manic depression”.

You are not your disease. It’s a trap that we all fall into eventually. After I was diagnosed I was “A Manic Depressive” for the better part of eighteen years. Being “A Manic Depressive” gave me excuses that could easily explain why I was who I was. I would tell people “I am A Manic Depressive” and they’d be uncomfortable for a little while and that was it. The reaction was there was no reaction because people have no idea what A Manic Depressive does, or have any idea what Manic Depression does to us.

But it was an excuse I could offer — from one ignorant to another, and it worked because calling yourself “A Manic Depressive” or “A BiPolar” sounds like it should mean something Important. Unlike most diseases manic depression has been romanticized, captured in paint and in song, so people — including us — do not fear manic depression. So the people around us do not fear for us. So the people who care about us, the people who care for us, just shrug their shoulders and give no reaction because those people have no idea what manic depression even means… because I had no idea what manic depression meant for the first eighteen years.

For too long we’ve deluded ourselves into believing manic depression was either something to be perversely proud of or something to be desperately ashamed of… but the mystique is a lie, it’s just a fucking disease. Why do we have such a hard time convincing ourselves and others about the horrible effects this disease has on us when there are a million fucking web sites and blogs about Manic Depression and every Pharmaceutical company sells an anti-depressant or a mood stabilizer, and there’s certainly no shortage of websites dedicated to selling the pills or telling us why those pills are evil… so, with all of this information so available, why is this disease so misunderstood?

Full post

Patient Voices: Bipolar Disorder

2009-07-18T05:00:00.002-04:00

From the New York Times, July 16, 2008

"What is it like to have bipolar disorder? To be labeled 'crazy'? How do you balance the ups and downs? Here, in their own words, are the stories of nine men and women living with bipolar disorder." A series of audio clips of about 2 minutes each. Poignant, perceptive, illuminating, and very much worth a listen.

(Hat tip to Heather Soyka)

Stones of Memory - Pt 1

2009-07-17T05:00:00.011-04:00

Abridged and slightly revised from an account I wrote some years ago.

My early life was dominated by two events that occurred before I was born. I knew nothing of them until I was nine or ten years old. I know little about them even today. I suppose I could investigate, but the precise details don’t matter much. What matters is that these two events decisively, elementally shaped the battlefield on which my life has been fought, and they were all the more powerful for being glimpsed only intermittently. Strategists speak of a “fog of war.” Personal lives are subject to much the same thing.

The first event: In 1937 a foolish young man decided to make some easy cash by counterfeiting fifty cent pieces in his native eastern North Carolina town. He was caught, tried, sent to jail. His wife could not afford to keep their brood of children, so she farmed them out to friends and relatives. My father, then three years old, had been known to toddle behind a certain milkman on his daily rounds. The milkman and his wife had recently lost a child to illness and so decided to take my father in when the chance arose. (They did not formally adopt him until many years later) My father knew that in a material sense his life was better as a result, but he could never understand how his own mother could give him away like that. Particularly since within a few years his siblings were folded back into his biological family and he was not. I know this only second hand; I never heard him speak of it.

The second event: In 1958, a tortured wife and mother of five, once beautiful but slipping into middle age, bright and gifted but thwarted and unappreciated by a limited, sometimes abusive husband, put a revolver in her mouth and pulled the trigger. She did it during the day while the house was empty: her husband at work, her children at school. The husband usually came home for lunch and undoubtedly she expected that it would be he who discovered her body. Instead it was her youngest daughter, thirteen years old. She had forgotten her school lunch money and come home to retrieve it. The scream that filled the house that day never left it.

The woman who killed herself was my maternal grandmother. From the little I know of her I think she had bipolar disorder, though the young daughter, who grew up to be a registered nurse, thinks it was more likely schizophrenia.

My parents at that point had been married less than a year. They had met in January 1958 and were married four months later. They had little business sharing a cab, much less a marriage, but for better or worse they stayed together for almost twenty-five years.

Ten months later I came into the world. For the first five years of my life that world seemed warm and safe and happy, and my two parents seemed the best and most beautiful people in the world. In point of fact, they were good-looking. My father was slim, knew how to dress and carry himself, and had an infectious grin that managed simultaneously to be both boyish and masculine. My mother was a local belle who had once won a beauty pageant sponsored by a Norfolk television station. Among her prizes was an all-expenses paid trip to New York. A fashion photographer trailed around her, snapping pictures of a poised young woman who believed she had a great future ahead of her. I still have the photos. I almost never look at them.

Because her family had money and position in the rural North Carolina county in which she grew up, and because she had graduated second in her high school class, my mother went to college at Duke University. But her high school served a community of five hundred residents, her graduating class numbered exactly twelve, and she was not prepared for Duke. Overwhelmed, she left after a semester or two and went to a safer, less challenging school. Later in life she called that decision one of her greatest regrets. She went first to her mother’s alma mater, Guilford College, and then transferred to East Carolina College (now University) in Greenville. There she met my father.

My father hailed from New Bern, a town on the Neuse River not forty miles from Greenville, but he came to East Carolina by way of San Diego, Tokyo, and other ports of call on the Pacific rim. After graduating from high school in 1953 he had joined the U.S. Navy and served aboard a destroyer escort. He credited the experience with turning his life around. In high school he had not been a serious student. He ran with the popular crowd and played football but did not apply himself. It galled him, however, to take orders from ensigns just a few years older than himself. He once told a particularly obnoxious ensign, “The only difference between you and me is that you have a college degree and I don’t.” He began buying books to broaden himself, and when he got out of the Navy in 1957 he entered East Carolina.

My parents lived in Greenville until they graduated, then moved to a town not far away. Both became teachers: Mom taught Home Economics and Dad taught English. But they quit soon after my birth, she in order to be a full-time mother and he in order to take a better paying job. He found it working as an underwriter for an insurance company in Raleigh. He worked for that company for the rest of his life. He fell into the job almost by sheer chance; it was not something he chose to do. He spent most of every year working hard at a job he did not particularly like so that he could support his family. To reconcile himself to this fate, he convinced himself that when you’re an adult, your dreams have to die, and that maturity consists of accepting this hard reality.

My first memory is of my parents’ apartment in Raleigh and of my father riding me on his shoulders across a dirt road a few yards distant, so that I could see the excavators and tractors that were constructing the belt line around Raleigh. I can also remember our move to a modest ranch house in the suburbs. By then my brother had been born, followed three years later by my sister.

Shortly after my sister's birth, Mom had her first manic episode. It was really pretty florid, with delusions that her dead mother was Christ and that she herself was the Virgin Mary. Her doctors thought it was schizophrenia (in those days a common misdiagnosis). She was hospitalized for three months. During that time Dad sent my brother and me to stay with our paternal grandparents.

In June 1968 the family moved from the ranch house to a Cape Cod not far from the campus of North Carolina State University. Mom thought the move would revitalize our family life -- by which she meant her life -- because her marriage to Dad was getting pretty barren. We lived there less than a year. Then my father accepted a promotion and transfer to Lynchburg, Virginia. Shortly after we moved -- the boxes containing our belongings had not yet been unpacked -- Mom had a second manic episode. My father had to scramble to locate a hospital and a new psychiatrist for her. It was at this time -- I was then just shy of my tenth birthday -- that Dad decided to tell me that Mom had a mental illness. The point of telling me was to secure my help around the house and with my two younger siblings. From then on I functioned as a deputy parent, not continuously but more or less in accordance with my parents’ whim. I wasn't much good at it. Certainly my parents didn't think so.

If Dad dragooned me into functioning as a deputy parent, Mom roped me in as a kind of surrogate husband. I’ve heard this dynamic described as emotional incest. That began when I was about eleven and continued until I was fifteen.

In June 1971 I went off to a Boy Scout camp, and I recall that on the day I left Mom was manic, though not yet hospitalized. She pranced about the house, hugging a Bible and declaring in a sing song voice, "I'm going to read the Good Book! I'm going to read the Good Book!" On her face was a ghastly, unworldly grin.

Two months later she attempted suicide for the first time -- certainly the first time as far as I know. The rescue squad came and took her to the hospital, where she had her stomach pumped. She came home the next day. I remember standing in the carport, practicing semaphore for some Boy Scout merit badge, when Dad brought her home. She walked up the driveway and into the house. We kids did not know how to react, so we were pretty low-key. Evidently that distressed her, because Dad came out and asked us to go in and tell Mom how much we loved her. Actually it’s not quite correct to say we did not know how to react -- we’d been mirroring how Dad was handling it, and he was pretty much stone-faced. Had he been more demonstrative, we would have been.

It was after this episode that Mom got a new psychiatrist, Dr. Novak, who was one of the few psychiatrists in the country authorized to prescribe lithium, a then-new treatment for manic depression. (New, that is, in the United States. The efficacy of lithium had been recognized in the 1940s and in Europe by the 1960s it was a common treatment.) Mom improved a lot once she started taking it. She became a substitute teacher and was so good at it that when a regular teacher fell ill and would be out the rest of the school year, Mom was asked to take over the class. Within a couple of weeks, however, she had a third manic episode. I don’t know whether the lithium was ineffective, or whether she’d gone off her medication, or what exactly occurred to trigger the episode beyond the fact that she was having fun teaching and feeling energized and productive. But she had to be hospitalized and her days as a teacher ended, this time for good.

Part 1 - Part 2 (coming)

A Bipolar Blogroll

2009-07-16T05:00:00.004-04:00

You can't have a blog without a blogroll, so I've created one here. With the exception of Blog Them Out of the Stone Age (my military history blog), all of them deal primarily with bipolar disorder. I've encountered one or two of them before. The rest are drawn mainly, though not exclusively, from PsychCentral's list of the Top Ten Bipolar Blogs of 2008.

The selection is tentative. Whether they'll remain on my blogroll is going to be a function of time and utility. Time in the sense that so far I've scarcely done more than skim a few entries; utility in the sense that some of them will probably prove more useful for my purposes than others. Then too of course there are the considerations that apply to pretty much any blog. Is it well written? Does it have a voice? Does it stay generally on topic? Is it updated on a regular basis?

From what I've seen thus far, blogs about bipolar disorder tend to have three characteristics.

First, they are heavily didactic in tone. They seek to educate others about the illness and/or to help those with the disorder manage it better. Sometimes they critique the mental health establishment, particularly the prescription of psychotropic medications.

Second, many take a rather catastrophic view of the illness. For most of them it seems to be a huge struggle that dominates their lives, as in some cases it indisputably does . All in all, the effect is to create the impression that bipolar disorder is not something they have, but a major component of who they are.

Third, and perhaps as a corollary of the second characteristic, the authors commonly refer to themselves and others with the disorder as being bipolar or, in at least one case, terming persons like myself "bipolars," as if we were a unique subset of humanity.

People are entitled to view the disorder in any way that seems helpful to them. I mention these characteristics not to judge, but rather to say that while I find most of them interesting, I identify with few of them. That's because I conceptualize the illness as external to me and simply something to be managed.

Nonetheless, they do provide a window into the disorder, and probably as time goes by I'll discover other blogs more relevant to my own situation and perspective.

A Mood Watch Retrospective

2009-07-15T05:30:00.003-04:00

On another blog, since discontinued, I had a category entitled "Mood Watch." In those posts I made an effort to track my moods, something that persons with bipolar disorder are often encouraged to do. I've decided to incorporate them here, using the dates of the original posts, so that they seem to antedate the beginnings of this blog. The first such post is here.

It took a while to transfer these posts, partly because there were rather a lot of them, and partly because I was careful to date stamp them precisely -- not just with the month, day, and year but also with the exact time of publication. The exact time can be useful because it usually provides a clue as to how well I was sleeping, and good sleep hygiene (which is to say going to bed and waking up at about the same time, getting sufficient sleep, etc.) is an important element in managing the disorder.

As I went through these old posts, two things stood out. The first was how few there were, considering that I had composed them over a period of about two years. It just isn't a lot of fun to keep track of one's moods. The second was how many encouraging comments the posts received. Without them I would probably have ceased the practice long before I did.

As to whether I'll resume these posts, I can't yet say. I probably will describe what the disorder feels like subjectively, particularly the depressions, which for me are much more frequent than the hypomanic episodes. Indeed, I haven't had a significant hypomanic episodes in years.

In fact, it's hard to know exactly what shape this blog will take. Like any writing project it eats time and it's not exactly a comfortable sensation to put so much of myself out there for people to read. Still, I regard it as a useful service; and if you find it worthwhile, I'd sure appreciate your leaving comments. They're likely to be one of the more important things that keeps me going.

Twitter in Direct Support

2009-07-14T13:39:00.003-04:00

Originally published in Blog Them Out of the Stone Age on July 9, 2009

If you scroll down on the sidebar of this blog, you'll find a section labeled "Twitter Updates," thanks to a widget I installed a few days ago. The question is, how does this relate to military history?

As long time readers of the blog are aware, I have bipolar disorder. The subject is covered in the category "Facing the Demon," along with battle stress injury -- not because I think the two are identical: one is an illness, the other an injury -- but because both require management and both carry a perceived stigma that requires a degree of courage to address. In my own case, I was diagnosed with bipolar disorder when I was twenty-six and have probably had it since the winter of my seventeenth year. It took a long time to come to grips with it. Until I was thirty-seven I didn't fully accept the reality of the disorder -- that it was something I had and would always have and that it needed to be managed precisely as one would manage any other chronic illness, such as diabetes, which in some respects it resembles. Both are abnormalities in one's biochemistry.

In the years since, I've gradually become conscious of the fact that in dealing with the illness I instinctively draw upon a number of concepts derived from a lifetime steeped in military history, strategic studies, and my own modest military experience. The most basic insight derives from Clausewitz: "In war, the best strategy is always to be very strong." This translates metaphorically into identifying as using as many tools to combat the illness as I can. Many of them are predicated on a crucial decision I made as soon as I received the diagnosis; namely that I would acknowledge it openly. As I've written elsewhere:

People often think that because I’m so up front about having bipolar disorder, that being candid about the illness must be an easy thing for me to do. In fact, it scares me. I’m up front about it only because I’m convinced that candor is better than the alternative. Being open with my colleagues, for example, populates the department with observers who have a decent chance of identifying unusual behavior as an artifact of the illness rather than erroneously attributing it to something else: simple high spirits instead of hypomania, for example. It enables me to ask for help when necessary without having to explain the illness from scratch. And it gives me a chance to combat, in a small way, the stigma that still attaches to mental illness. If a professor protected by tenure cannot summon the modest courage required for such an act, I do not know who can.

So where does Twitter come in?

I've decided to use this social utility as a way to discuss the illness, not abstractly, but as it affects my day to day life. (The updates, by the way, appear not just on the blog but are immediately cross-posted as a status update on Facebook.) Since I find the prospect of doing so a bit daunting -- it is one thing to state publicly that I have the disorder, quite another to state on a given day that I'm depressed -- I've begun with something reasonably safe: namely to keep public track of my workouts at the gym (and other forms of exercise). This has more to do with bipolar disorder than one might suppose. Coping with bipolar disorder involves more than taking medication. There are things one can actively do to manage the illness, among them getting enough sleep and getting enough exercise, which releases beneficial endorphins.

So announcing each trip to the gym is not based on vanity or the assumption that people are fascinated with the mundane details of my life. It's the early stage of what I expect will be a larger experiment in publicly sharing the experience of managing bipolar disorder, partly as a means to expand my network of support, but primarily to model in practical terms how one goes about it, and to treat the illness as one would any other: not something of which to be embarrassed or ashamed but a simple fact of existence.

What If Churchill Hadn't Tamed His "Black Dog"?

2009-07-14T13:38:00.002-04:00

Originally published in Blog Them Out of the Stone Age on May 22, 2009

Reprinted with permission of World War II Magazine

In March 2006 a statue of Winston Churchill went on display in Norwich, England. It might have attracted little attention but for one disquieting detail: it showed the prime minister in a straitjacket. The statue was part of a campaign by Rethink, the mental health advocacy group that commissioned it.

“We are trying to break down the stigma of mental illness,” explained a spokesman. “Churchill documented his depression and referred to it as his ‘black dog.’ Nowadays it would be described as bipolar disorder or manic depression. We all know that Churchill was a great leader and this statue is an illustration of what people with mental illness can achieve” —- that is, without the cruel caricatures that too often burden those with such illnesses.

Indeed, the controversy in the wake of the statue’s unveiling underscored the point Rethink was trying to make. Many Britons cried foul. “It’s not only insulting, it’s pathetic,” growled Nicholas Soames, grandson of the former prime minister. The outcry forced Rethink to remove the statue after only a few days. The organization had miscalculated the public’s receptivity to such a portrayal of a national icon. But had it been mistaken about Churchill’s illness itself?

Full article (PDF)

Pharmaceuticals in Direct Support

2009-07-14T13:35:00.002-04:00

Originally published in Blog Them Out of the Stone Age on June 9, 2008

The current Time magazine features a cover story entitled "A Medicated Army," discussing the practice of prescribing antidepressants and antianxiety meds to soldiers in combat environments:

For the first time in history, a sizable and growing number of U.S. combat troops are taking daily doses of antidepressants to calm nerves strained by repeated and lengthy tours in Iraq and Afghanistan. The medicines are intended not only to help troops keep their cool but also to enable the already strapped Army to preserve its most precious resource: soldiers on the front lines. Data contained in the Army's fifth Mental Health Advisory Team report indicate that, according to an anonymous survey of U.S. troops taken last fall, about 12% of combat troops in Iraq and 17% of those in Afghanistan are taking prescription antidepressants or sleeping pills to help them cope. Escalating violence in Afghanistan and the more isolated mission have driven troops to rely more on medication there than in Iraq, military officials say.

As many readers know, I have bipolar disorder, and consequently have a long acquaintance with many of the meds being prescribed. At the moment, for instance, I take Lamictal on a daily basis and clonazepam (the generic equivalent of klonopin) as needed. The former operates as an antidepressant. It has mood stabilizing properties that make it a reasonably good prophylactic against mania -- in fact I've had no trouble with incipient "highs" since I began taking Lamictal about two years ago. The latter is a mood stabilizer and anti-anxiety med. The biochemical manifestations of bipolar disorder are more complex than most people suppose. I have had days when I felt neither up nor down, but had such an insistent sense of generalized anxiety that I had to cancel class because I felt too light-headed to responsibly drive down to campus. Once I grasped its beneficial properties, clonazepam has done a lot to alleviate that problem. I also take the generic form of Ambien on a fairly regular basis in order to make sure I get a good night's rest. Regular sleep -- what's known as "good sleep hygiene" -- is a bedrock element in managing the illness.

The situation of a college professor in the midwest is obviously dissimilar from that of a combat soldier in Iraq or Afghanistan, but I think my experience can contribute a degree of insight. To begin with, I think it's important to regard the meds as simply a tool to assist with the overall task of maintaining good health. There's a tendency for those who take them to regard them as a sort of query against their character: that if they were somehow stronger they wouldn't need to take the meds. That leads to problems. First, it reduces self-confidence and self-esteem. Second, it often creates a state of partial denial in which a person may take the med, but does not acquaint himself closely with the medication's properties. He may not follow the guidelines for taking the med responsibly and when he feels better may quit taking the meds entirely. (Medication noncompliance is the single biggest problem among those with bipolar disorder.)

Third, there can be a tendency to regard the meds as shouldering the whole burden of managing the problem, whereas I have found it helpful to take an active role in managing the disorder rather than just passively taking the pills. I monitor myself for symptoms, even subtle ones that no one around me would recognize. I try to exercise on a regular basis. I make use of as many other tools as I can gather to help with the job: a psychiatrist, a therapist, and also the support of friends. There's too much tendency to let fears of the stigma prevent a person from letting others know about one's situation. But I've found that for every jerk there are many people who welcome the opportunity to be of assistance.

Finally, I have made a personal commitment to be public about having bipolar disorder. In each course I teach, I find a topic that lends itself to disclosure that I have the illness (in the U.S. history survey, for instance, the work of 19th century reformer Dorothea Dix provides a good opportunity). In a class of 200 students, statistically two students have been or will be diagnosed with bipolar disorder. I have never yet disclosed the illness and not received subsequent contact from a student who has the same diagnosis. They express appreciation for my candor and particularly a sense of relief in realizing that they are not alone, and that someone they regard as highly functional can have the disorder and lead a reasonably normal life. I often wind up meeting with them to discuss the illness and how best to manage it. Students usually have a lot of concerns: What will their life be like? what degree of stigma will they face? Frequently they do not yet have in place a good support system for managing the disorder. I recently spoke with a student who has no psychiatrist and therapist; her prescriptions are written by a general practitioner. I've been able to assist with referrals to good psychiatrists and therapists within her health care network.

How does this relate to military personnel who take psychotropic meds? First, I wonder how many officers and NCOs self-disclose that they are taking the same meds. If they keep this info away from their soldiers, they send a double message: overtly it's OK for you to take these meds, but tacitly it's really not because I wouldn't be caught dead letting you know that I take them myself. It would require real moral courage, but an officer willing to talk matter of factly about taking these meds, and at the same time functioning effectively as an officer, would serve as a powerful role model. (I find that's the role I often play with my students.) Such an officer's example could not only reassure the soldiers who take the meds, but would also help shift the military culture toward one in which other soldiers would find it easier to trust and support their comrades in arms.

Second, I think it's important to de-mystify these drugs as much as possible, so that the fact of taking them does not, in its own way, add to the issues that soldiers must face. To repeat, taking a med to assist with a problem is not a confession of weakness or bad character. On the contrary, it takes strength and maturity to face up to a problem squarely and do what it takes to accomplish the mission -- whether that mission is to maintain one's health as a civilian or one's effectiveness as a soldier.

Third (and as a corollary), I have found it useful to apply, metaphorically, the warrior ethos to the task of managing the illness. I conceptualize bipolar disorder as an enemy that will never cease in its efforts to destroy me -- either outright or by destroying my quality of life -- and that consequently I have to work conscientiously and intelligently to keep it in check. I've found that my military training and my familiarity with strategic studies have come into play, in various, sometimes unexpected ways, to help me do this.

It would be wrong to create a sunny picture. Even in my safe suburban life, the task of managing bipolar disorder requires a lot of vigilance and is not without its setbacks. For obvious reasons the problem is compounded for those in combat zones, and the last thing I would ever want to suggest is some sort of situational equivalence. At the end of the day, shorter tours of duty and regular rotation into safe areas (such as they are) is a better solution to the problem. But until then, if the Army is going to pursue what I regard as a sensible 21st century policy -- to treat issues of depression, stress and anxiety as problems to be solved rather than defects to be scorned -- then it needs to shift the military culture to conform with the policy. I hope these insights from my own situation, however modest, may be of some help.

Run to Failure - Pt 2

2009-07-14T13:31:00.004-04:00

Originally published in Blog Them Out of the Stone Age on December 10, 2005

"Run to failure" is a term I learned many years ago in a war and technology course. It's used by engineers when designing something that has lots of moving parts. You design, say, an aircraft engine. You build a prototype and let it run until it fails. Then you root around the prototype until you locate the specific part that failed. You figure out why it failed, design and manufacture an improved version of the part, install it and then run the engine until the next failure. You repeat the process until you have an engine that meets or exceeds the required specifications. That's "run to failure."

Over the last two decades, I've used "run to failure" numerous times to improve the system I've evolved to protect myself from the sort of acute manic episode that evidently killed Rigoberto Alpizar. An analogous concept would be the "lesson learned" analysis commonly employed by the armed forces: you create a doctrine, then revise it in light of practical experience -- war games or actual battle.

I described the core of the system in a previous post. Briefly, it's to marshal as many resources to combat the illness as I can: medications, therapy, good sleep hygiene, regular exercise, and so on. Equally important is to have in place a strong network of friends and colleagues who know that I have the disorder and have been briefed about its symptoms. This network has proven itself so thoroughly that the question of whether to be private or "out of the closet" about the disorder is a settled issue with me. It is better to have as many people know about the condition as possible.

True, there are downsides. I've no doubt that my openness makes some people uncomfortable and that they rationalize their discomfort by telling themselves -- and perhaps others -- that it is "inappropriate" or that I have "boundary issues." It is even possible that I could never get a job in another university. Tough. One of the things I learned in the Army is that you do what is necessary to accomplish the mission. My first mission is survival. Other considerations take a back seat.

The network protects me in two basic respects. First, I have around me a number of people who have received a memo detailing the symptoms of bipolar disorder and explaining what to do in the event they develop concerns about my behavior. The first step is to approach me and inquire. If they're not satisfied with my response, the memo has the name and phone number of my therapist and psychiatrist. The next step is to contact them and relay their concerns. As a last resort, they are authorized to direct me to go to a hospital emergency room, in which I event I am to go there, period. I get no say, since in the nature of the case, my ability to make wise judgments is in question.

Second, on very rare occasions, when I know that I have "decompensated" to a fairly serious degree but when my psychiatrist and I are on the case, so to speak, and working through a treatment plan to get me "recompensated," I will employ a regimen borrowed from one of my hospital stays but which I conceptualize in military terms. At the heart of it are the three general orders I learned in basic training and which are so ingrained in me I can recite them from memory even in the midst of a complete psychotic break:

1. I will guard everything within the limits of my post and quit my post only when properly relieved.

2. I will obey my special orders and perform all my duties in a military manner.

3. I will report violations of my special orders, emergencies, or anything not covered by my instructions, to the commander of the relief.

The idea of adapting these general orders to cope with the bipolar disorder occurred to me when I was first hospitalized for mania in 1986. I felt that I could not fully trust the medical professionals around me -- they gave me meds that back-fired, for instance -- and at the same time I understood that something was definitely very wrong with my own capacity to judge. It seemed a no-win situation.

Trying to think while acutely manic is like trying to read a newspaper in a high wind. I remember saying to myself, "A no-win situation. A no-win situation. I've been in a no-win situation before. When was it?" Finally it came to me: Phase I -- the indoctrination phase -- of basic combat training. During that phase, recruits are constantly placed in situations or asked questions to which there is no correct response: you'll get bitched out for anything you do or say. The purpose is to break down a recruit's resistance and to make them more receptive to training. It also reproduces, in very modest fashion, some of the stress one is apt to experience in combat.

One of the first things we had to do in that environment was to memorize those three general orders. In many respects they were the key to getting out of Phase I and into more advanced phases (there were four in all) in which we were treated more and more as real soldiers. As soon as my manic mind was able to grasp Phase I as the no-win situation I had previously experienced, the next step was obvious. I would use the three general orders as the template to regulate my conduct in the hospital.

Part 1 - Part 2 - Part 3 (coming)

Run to Failure - Pt 1

2009-07-14T13:29:00.003-04:00

Originally published in Blog Them Out of the Stone Age on December 9, 2005

Left: Anne Buechner and her husband, Rigoberto Alpizar

Two days ago the couple in the photo were returning to Florida after a brief missionary trip to South America. The international leg of the flight was behind them. They had cleared customs, boarded a second aircraft, and faced only the final, brief trip from Miami International Airport to Orlando. Suddenly the man, 44-year old Rigoberto Alpizar, began acting in a way that attracted the attention of the flight crew and an air marshal on board the craft. The marshal became convinced that Alpizar had a bomb and, when he bolted from the plane rather than heed the marshal's command to halt and lie down, the marshal shot him dead.

The story has been international news for a couple of days now. The dominant theme has been that it was a "good shoot" -- that is, the air marshal behaved properly in the circumstances -- and serves as evidence that security measures entrenched since 9/11 are working as they should. But it soon transpired that Alpizar was not, in fact, carrying a bomb. His behavior owed not to lethal intent but rather to his medical condition: He suffered from bipolar disorder and, in medical terms, had "decompensated," apparently because he was off his medication.

The fate of Rigoberto Alpizar has begun attracting comment within the mental health segment of the blogosphere. Shrinkette, a psychiatrist in Eugene, Oregon, poignantly juxtaposed a news excerpt with a passage from Kay Redfield Jamison's famous memoir of her struggles with bipolar disorder:

Witnesses aboard an American Airlines jetliner say that Rigoberto Alpizar's wife pursued him, saying he was mentally ill, just before federal marshals shot and killed him. Air marshals said Alpizar had announced he was carrying a bomb.

Later, no explosives were found. The incident remains under investigation.

"She was chasing after him," said fellow passenger Alan Tirpak. "She was just saying her husband was sick, her husband was sick." When the woman returned, "she just kept saying the same thing over and over, and that's when we heard the shots."

"Manic-depression distorts moods and thoughts, incites dreadful behaviors, destroys the basis of rational thought, and too often erodes the desire and will to live. It is an illness that is biological in its origins, yet one that feels psychological in the experience of it; an illness that is unique in conferring advantage and pleasure, yet one that brings in its wake almost unendurable suffering..."

-Kay Redfield Jamison, Ph.D., An Unquiet Mind, 1995, p. 6.

One of Shrinkette's readers left this comment:

I understand 100% why the air marshall did what he did. I really do. But I can seriously imagine the turmoil and pain the man was in. I'm bipolar. I've been in a psychotic state, I've heard things, seen things, nearly cut off my own hand because something in my head was telling me it would be a good experiment. Being bipolar we have a responsibility to take our medication, but even then it can be difficult, a daily struggle. I am not saying that the air marshall was wrong: he discerned a threat to the larger group and was doing as he was trained. But I have an incredible amount of compassion for the man and his wife. NO ONE knows, nor will they ever, what that couple went through, both at that moment, and the days leading up to it.

But Becky, a 22-year old Indiana woman who blogs about her struggles with bipolar disorder at Tidal Moods, was less sympathetic -- in fact, not sympathetic at all:

Some people are suggesting that the air marshals behaved inappropriately. Those people are wrong. A clearly insane person can still have a bomb and just because someone is behaving bizarrely does not mean they aren't dangerous. This man said he had a bomb and authorities have no choice but to take him seriously.

As a person with bipolar, I'm outraged by the media's obsession with the fact that the man's family claimed that he suffered from bipolar disorder. It's irrelevant. It doesn't factor into the air marshalls' deliberations about whether or not the man is a threat and the only reason the media even mentions it is because it makes the air marshalls look like assholes when they aren't.

At the risk of sounding like a heinous bitch, I have little sympathy for this man and his family. By the time you're 44 years old, you know what it's like to live with bipolar disorder and you know whether or not you're one of those people who requires medication to maintain sanity. Clearly, this man could not behave normally without his medication and there is absolutely no reason for him not to take it. It's not like a bipolar person is going to fly off the handle if they miss one dose of their meds. For his wife to be aware of his failure to take his meds, he had to have missed more than a dose and at that point, my sympathy dies. Even if he lost his bag and his medication was gone, he could still go to a hospital or contact a pharmacy and his psychiatrist to get more. There is no excuse for not taking your meds if you know that you pose a danger to others without them. None at all.

Becky's post has so far attracted 21 comments, though most of them are off-topic -- early in the thread someone criticized her for being foolish and "narcissistic" to write publicly about her bipolar disorder. (That little gem of idiocy generated a spate of coments and counter-comments from Becky, the idiot, and several of Becky's readers which is worth reading for its own sake.) But of the responses that addressed her post directly, opinion was about evenly split between those who thought Becky was being harsh on Alpizar and those who thought she had a point.

My personal view is that Becky has a point and also that her stridency on the subject stems from fear. Anybody with bipolar disorder -- me, for instance -- can't help but reflect that in the right circumstances, we ourselves could suffer Rigoberto's Alpizar's fate. One way to deal with this fear is to blame Alpizar for what happened: Alpizar had bipolar disorder. Alpizar did not take his meds. Alpizar got in a situation where he was killed. I myself will take my meds and therefore I will never get in such a situation.

Actually, you can take your meds and still get in precisely that situation. Six years ago I was hospitalized for acute mania exactly one day after a blood test showed that the correct level of lithium was present in my body.

No: meds alone aren't a guarantee. The strategic problem of survival is more complex than that.

It is no coincidence that in the last decade, a significant amount of my research as a military historian has focused on situations in which people have tried to frame workable strategies for resistance in an intractable environment, when the odds are stacked heavily against them. I live that situation every day of my life. And over time I've brought my military training as well as my historical training repeatedly to bear on the problem.

Let me tell you some of the tactics I've evolved to address it.

Part 1 - Part 2 - Part 3 (coming)

Valuable Partners

2009-07-14T13:26:00.002-04:00

Originally published in Blog Them Out of the Stone Age on September 8, 2005

The Ohio State University is still on the quarter system, which means, among other things, that Autumn classes do not begin until late September. So around here the students are just now beginning to return. But four of my five graduate advisees are in town now, so this morning we're going to meet as a group.

Within the history department I have a foot in two fields: American History to 1877 and, of course, Military History. My career has largely been a matter of shifting my weight back and forth between them, sometimes laying stress on the one, sometimes on the other. That is not uncommon. Indeed, I think it is pretty much the norm for professors in thematic fields. Two of my advisees are early Americanists; three are military historians. In other years the balance has actually been the other way. And indeed, two of the three dissertations that I have signed as principal adviser were in early American history.

But the dividing line is artificial. As Clausewitz says, "War has its own grammar but not its own logic." The logic is driven by the policy of governments and the passions of people, among many other things. So a good military historian has to be a broadly grounded historian. And since the United States is a country that was literally made by war, a good American historian must know some military history.

Still, the brute fact of the job market is that positions in American history far, far, far exceed positions in military history. Which is why I insist that my military history advisees, when it comes to their PhD general exams, should be as strong in their second field--which is usually early American history--as their first. I'm not trying to be a jerk about it; I'm trying to maximize their chances on the job market.

I will give an example. The day I gave my job talk here at Ohio State, the first question I received had nothing whatsoever to do with the subject of my presentation. Instead I was asked what I thought of the debate between Eugene Genovese and James Oakes as to whether the antebellum South was a pre-capitalist society or whether it was as capitalist as the North, albeit in different ways. The whole point of the question was to show me up, to demonstrate that I knew nothing beyond pure military history, whatever that is. Guns and battles, I guess.

You might think I resented the question, but that's like thinking a a baseball player at bat resents the pitcher on the mound. It gave me precisely the opportunity I needed to destroy the stereotype about "narrow military historians." I launched into a discussion of the main works of Genovese and Oakes, explained the reasons for their disagreements, and concluded that it was too early to tell which one was right. My questioner later told me he wasn't really satisfied with my answer and I'm sure it wasn't as good a response as he could have given. But so what? Most of the people in the room were non-Americanists who didn't know a damn thing about the Genovese/Oakes debate. To them it sure sounded as if I knew what I was talking about.

Contrast that with the impression I would have made if I had said, "I don't know about that." Or worse, tried to stumble through an answer on the basis of dim memories of a debate on which my grasp had been tenuous to begin with. I would not have recovered. Worse--because to tell you the truth I didn't really believe this department would actually hire one of its own no matter what I did--I would have let down the military history program. I always thought of my real objective as making the program look as good as possible in the eyes of the department. If I got the job, that was gravy.

And pretty good gravy it has turned out to be.

So my military history advisees need to see my early American advisees as valuable partners. But what do the American advisees get out of it? Well, they almost invariably choose me because military history informs their research or because they want to be historians of the Civil War era, and any historian of that era ought to know a good deal about military history. They need my military history advisees as pards, too.

Beyond these remarks I don't actually know what I'll tell them when we meet. In a way my main job is just to bring the coffee and croissants and let them renew acquaintances or get to know each other if they haven't met already. I would tell them about the fact that I have bipolar disorder if they didn't all know it already. It is one of the first things I tell potential advisees. I want them to see that I am not ashamed about it and I think of it, and manage it, as an illness. I explain the symptoms and tell them what to do and/or who to contact if they become concerned about me. I think it is their business to know, because they are placing a good deal of their future prospects in my hands. And if they can't handle the knowledge it is better for both parties if this is recognized at the outset.

But thus far my graduate students have been comfortable with my frankness on this subject and even somewhat reassured, because it implies that they can come to me with their own concerns when necessary. It is, to be sure, a matter that has to be handled in a sure-footed manner, because it is important to maintain a professional demeanor and to preserve, in a healthy way, the distinction between my status as a faculty member and theirs as a student. But they are also adults--actually remarkably accomplished adults--and they deserve to be treated as such.

SITREP

2009-07-14T13:19:00.005-04:00

Originally published in Blog Them Out of the Stone Age on July 12, 2005

It's been nearly a month since my last blog post. That's partly because I have adhered to my rule of making this blog an aid to productive scholarship, not a diversion from it. It's partly because the next posts that follow logically from Crash and, especially, Shadow Warriors, Pt 8, are ones that I have been reluctant to write, much less publish -- though I guess in the next few days I will have to embark on them. But mostly it has been due to the fact that I've spent much of the period in a state of clinical depression.

What does that mean? Well, according to the standard diagnostic manual used by the American Psychiatric Association, it means that I met the criteria listed in Facing the Demon.

As I mentioned in a previous post, I have bipolar disorder, also called manic-depressive illness. The condition was diagnosed when I was 26; I am now 45; I will have this condition for the rest of my life. I have seen it blight the lives of some people but in most cases I have found that people manage the illness fairly well. The medications now available help a good deal, as does the diminishing stigma attached to illnesses of this sort, which makes it easier for people to get treatment rather than avoid it from a sense of shame. In my own case, I have also found it useful to keep a very tight handle on the diagnostic criteria associated with the disorder. (In Facing the Demon, I tried to give an impressionistic sense of this utility.)

Nevertheless, if you look over the criteria you'll find that by definition a major depressive episode can be identified only after a significant amount of time has passed. Officially the period is a full two weeks, though to be sure, a psychiatrist closely acquainted with a patient seldom hesitates to intervene long before then. Still, it takes time for a pattern of symptoms to emerge. Even the depressed person isn't always aware of being depressed until a few days have gone by. And although this site typically gets around 80-120 hits per day, it was not until yesterday that anyone inquired whether the dearth of blog entries might indicate that something was amiss with my health.

I knew that such an inquiry would come eventually, however. I knew which person was most likely to inquire. I knew it would come as an email, and I knew what the subject line would say: "SITREP?"

SITREP is military speak for Situation Report. If somebody asks for a situation report they are asking to know the status of your unit and the progress of its mission.

The person who requested the SITREP was an officer currently posted in Baghdad. I wrote back:

Thanks for checking up. I appreciate it.

Things are OK now, but as you surmised, until recently they weren't going so well. I had another depressive spell, this one longer than usual--probably long enough to qualify formally as a clinical depression. It may have been due in part to some tweaking in my medication. The meds have been tweaked again, and I'm doing better, though whether this is a cause and effect relationship, or correlation, or coincidence, just plain beats me. All I know is that I have had more trouble with the bipolar disorder this year than in any preceding year I can recall.

A subsidiary reason I haven't been keeping a blog is that when I am OK I'm busy doing other things. At the moment, for instance, I'm writing a 5,500-word chapter for The Osprey Companion to the American Civil War. If I needed the blog to help with my productivity I'd use it, but I've never wanted to get in the trap of letting the blog distract me from the stuff I really need to do.

I hope things are going OK at your end. Thinking about what "at your end" signifies sort of puts what's going on in my life into perspective.

Afterward it occurred to me that dealing with this bipolar disorder is a little bit like combatting an insurgency, and vice versa. For instance, I can say in retrospect that a depressive episode occurred, but neither I nor anyone else can say with much certainty what caused it, when it began, why it reached the level of intensity it did, and why it finally lifted. Similarly, although it is obvious that the United States is contending with an insurgency in Iraq, I don't think anyone can say exactly when it began, or explain the dynamic that feeds it, or gauge -- save in a very rough way -- the progress the United States has made in fighting it. Or say when it will end. In the case of bipolar disorder, it will never end, though I am told that the disorder tends to be roughest on people in their thirties and forties and tends to abate with age. Yet the presence of the disorder doesn't preclude the possibility of leading some measure of an ordinary life, just as the presence of an insurgency doesn't necessarily halt the normal functioning of a society. As military historian Eliot Cohen observed in a recent op/ed piece, "Counterinsurgency is inherently a long, long business. Conceivably, the Iraqi insurgency could collapse in a year or so, but that would be highly unusual. More likely Iraq will suffer from chronic violence, which need not prevent the country as a whole from progressing."

"The history of a battle," the Duke of Wellington famously maintained, "is not unlike the history of a ball. Some individuals may recollect all the little events of which the great result is the battle won or lost; but no individual can recollect the order in which, or the exact moment at which, they occurred, which makes all the difference to their value and importance." He wrote those words to dissuade a would-be historian of the battle of Waterloo, but of course his injunction did nothing to inhibit the crafting of hundreds of books on the battle. Societies have a need to find meaning in events just as individuals have a need to find meaning in their own lives. Yet when thinking about this latest depressive episode, I wonder. . . . "The meds have been tweaked again, and I'm doing better, though whether this is a cause and effect relationship, or correlation, or coincidence, just plain beats me." The only battlefield was my own life, and yet I can see what Wellington was driving at. I wonder what simile Wellington would have found to describe the history of an insurgency?

Facing the Demon

2009-07-14T13:17:00.001-04:00

Originally published in Blog Them Out of the Stone Age on June 5, 2005

But besides the achievement of this functional and corporate aim, the rote-learning and repetitive form and the categorical, reductive quality of officer-training has an important and intended -- if subordinate -- psychological effect. Anti-militarists would call it de-personalizing and even de-humanizing. But given -- even if they would not give -- that battles are going to happen, it is powerfully beneficial. For by teaching the young officer to organize his intake of sensations, to reduce the events of combat to as few and as easily recognizable a set of elements as possible, to categorize under manageable headings the noise, blast, passage of missiles and confusion of human movement which will assail him on the battlefield, so that they can be described -- to his men, to his superiors, to himself -- as "incoming fire, "outgoing fire," "airstrike," "company-strength attack," one is helping him to avert the onset of fear or, worse, of panic and to perceive a face of battle which, if not familiar, need not, in the event, prove wholly petrifying.

-- John Keegan, The Face of Battle

Diagnostic Criteria for Major Depressive Episode

For a diagnosis of a major depressive episode, these are the signs and symptoms doctors are looking for:

A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.

Note: Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations.

1. depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful) Note: In children and adolescents, can be irritable mood.

2. markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)

3. significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: in children, consider failure to make expected weight gains.

4. insomnia or hypersomnia nearly every day.

5. psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness of being slowed down)

6. fatigue or loss of energy nearly every day

7. feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)

8. diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)

9. recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

B. The symptoms do not meet criteria for a Mixed Episode [i.e., a Mixed Bipolar Episode in which manic and depressive features are simultaneously present].

C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

D. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).

E. The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.

Reference: These criteria are excerpts from Diagnostic and Statistical Manual of Mental Disorders, DSM-IV, p. 327, © 1994, American Psychiatric Association.

Adapted from HealthyPlace.com

National Public Radio interview with Andrew Solomon, author of The Noonday Demon: An Atlas of Depression (you'll need RealPlayer to access; it's worth it)

The Scare - Pt 2

2009-07-14T13:16:00.002-04:00

Originally published in Blog Them Out of the Stone Age on April 28, 2005

Deception is a fundamental aspect of war. The enemy systematically tries to mislead you as to his real intentions and capabilities, which leads to uncertainty and therefore often anxiety. The most formidable adversaries are usually masters of this. I once wrote on this subject using as my example Confederate cavalry general Nathan Bedford Forrest:

"Warfare, despite its various refinements, touches basic human emotions. The most fundamental of these is fear. It is not difficult to imagine that Forrest's [prewar] days on the Mississippi frontier had educated him in the coarse art of instilling fear. The key was to rattle an opponent and keep him rattled. Forrest had an expression for it: "Keep up the scare." When he advanced toward [the Federal garrison at] Jackson [Tennessee] with kettle drums beating to simulate infantry, and when he suddenly swung on his pursuers at Parkers Crossroads, Forrest was doing his best to generate fear. There was nothing really novel in this approach: the violence of war can have no other purpose than the creation of fear through the threat of wounds and death. But Forrest was unusually clear-eyed about the value of inflicting fear. He did it instinctively and he did it well."

The experience of depression is often much like this. Joy simply drains out of life, replaced by listlessness, anxiety, even outright dread. The actual cause of the depression may be biochemical but the mind, spurred by the illness, searches for a circumstantial explanation and always finds it. In broad outline the illness "keeps up the scare" by playing on universal fears: that one is a failure, that one is unloved and unlovable, that life itself is meaningless. But the details are insidiously specific to each individual because the illness, in effect, knows what scares you most.

Part 1 - Part 2

The Scare - Pt 1

2009-07-14T13:15:00.002-04:00

Originally published in Blog Them Out of the Stone Age on April 28, 2005

Part 1 - Part 2

My Favorite Clausewitz Quote

2009-07-14T13:14:00.001-04:00

Originally published in Blog Them Out of the Stone Age on April 27, 2005

In a previous post, I alluded to having a mood disorder called bipolar disorder, once known as manic-depression.

Note the formulation: "I have bipolar disorder," not "I am bipolar." Though I'll need to sketch some background first, the thrust of this post turns on that distinction, and on the utility of combat as metaphor in making the distinction helpful.

Bipolar disorder is, strictly speaking, a malfunction of one's biochemistry whereby the mind is tricked into varying degrees of euphoria or despair with scant regard to the actual circumstances of one's life. I have often been discouraged by health care professionals from regarding it as a true mental illness at all. I tend, however, to regard such admonitions as well-intentioned efforts to spare me from the shame of mental illness. But rather than duck it, I'd rather work to dispense with the shame itself. If a tenured professor cannot summon the modest courage required to do so, then I don't know who could reasonably be asked.

Most of the stigma derives from the "mind/body split," the view that the mind and body are two almost completely different things and that the one does not influence the other: thus you cannot meditate your way out of a physical malady, on the one hand, and a physical malady does not affect the operation of your mind, on the other. While most people nowadays would reject so extreme a formulation, within broad limits the idea remains influential because it reflects our common experience of everyday life.

And because the mind is where we primarily locate our identities, a physical illness or impairment does not so readily shake our sense of who we are. There are always exceptions. An athlete might find her or his sense of self profoundly changed by the loss of a limb, for example. But a mental illness offers a fundamental challenge because it hits us where we are most intimately ourselves. The diagnosis of mental illness therefore confronts the affected individual with a basic choice: Is the illness something external to self, or is it a part of self? Most people, if asked, would promptly reply that the former is the correct formulation, but I have seen many instances in which people with bipolar disorder choose implicitly and sometimes explicitly to imagine the illness as a part of them. And why not? The whole thrust of the "mind/body split" argues that it is.

I have therefore always worked very hard to locate bipolar disorder as something external to myself, notwithstanding the fact that the biochemical fluctuations influence my moods and therefore my subjective experience of life.

As it happens, I can think of at least one other area of human life in which moods are artificially, systematically, and powerfully modified: war.

Indeed, I have found that war offers a very rich metaphor for understanding the illness and mobilizing one's resources to manage it. I consider myself to be in a permanent state of war against an enemy that will never cease in its efforts to kill me, one way or another--which is about as strong an "othering" of the illness as I can imagine.

"In war," wrote the Prussian military theorist Karl von Clausewitz, "the best strategy is always to be very strong, first in general and then at the decisive point." (On War, Book III, chapter 11) This point seems incredibly obvious, but like a lot of obvious points, it is easy to miss.

I have met my full share of people with mood disorders, for example, who were reluctant to take their prescribed medications because they thought they should be able to control the disorder by themselves. This sort of thinking is exactly like a general needlessly going into battle with only half his forces. Stupid, right?

Meet Maj. Gen. Joseph Hooker, a Civil War general who famously did go into battle with half his forces--and got his clock cleaned as a result. Indeed, as Clausewitz observes, "It seems incredible, and yet it has happened a hundred times, that troops have been divided and separated merely through a mysterious feeling of conventional manner, without any clear perception of the reason."

No self-respecting military historian wants to emulate Joe Hooker in any area of his life. Consequently, when a person with bipolar disorder is offered such things as medications, therapy, self-help books, support groups and/or the support of friends and colleagues, the correct response is not which of these resources to select. The correct response is to take as many of them as possible and to be continually on the lookout for even more.

Moments of Decision - Pt 2

2009-07-14T13:04:00.004-04:00

Originally published in Blog Them Out of the Stone Age on April 14, 2005

I have Bipolar Disorder : what used to be called "manic depression."

I was diagnosed with the disorder in September 1986, shortly before my twenty-seventh birthday. I have since concluded that the actual onset of the disorder most likely occurred almost a decade before that, in the winter of my seventeenth year.

Friends, colleagues and, indeed, almost anyone who has ever met me face-to-face will be unsurprised by this information, since from the outset I made the decision never to act as if I were embarrassed or ashamed to have the disorder. Close friends also know that I have long been looking for the right moment to "go public" with this information. I myself have known, since the day I began keeping a blog, that one day I would be composing this post. On the whole, I am surprised I wound up waiting as long as I have.

The principal reason for waiting is that while I figured I would go public with the news in this medium--and by go public I mean to share this information with people whom I cannot look in the eye as I do so and gauge their reaction--I wanted the focus of the blog to remain unchanged. My principal concern continues to be to assess the prospects of military history as an academic field. It's simply that I wish now to introduce the "canon of military history" as I have experienced it personally: a very rich set of metaphors by which to manage and survive the inevitable struggles of life. True, I could use other examples, but to do so would feel so much to me as if I were dodging the most obvious example that I would be violating my first rule concerning the disclosure of my having bipolar disorder: when, within a given context, the most direct response involves acknowledging the disorder, always acknowledge it.

Acknowledging it, however, turns out not to be the same thing as accepting it. The rest of this entry was composed in November 1997, a day or two after my return from a weekend staff ride on the Antietam battlefield with officers and cadets from West Point. (If you read Starship Troopers, Civic Virtue, and the American Civil War you will be reading an essay that I dashed off in twenty minutes, gave improvisationally to a group of thirty plebes who cheered me at the end, and then revised into present form all while hypomanic . As you'll see, initially I failed to make the connection between my mood and the manic episode in 1986 which led to my hospitalization and diagnosis. But look at my choice of wording and examples when I finally, reluctantly, did make the connection. You'll begin to get an inkling of the ways in which I routinely use combat as metaphor.

***
Three O'Clock in the Morning Courage

It is said that by the age of forty [I was then thirty-seven], every human being has the face he deserves. What is perhaps also possible is that by the age of forty, most human beings have the life they deserve. I never realized how literally that could be the case until now.

About eight hours ago, I was obliged to do the one thing we humans hate: face facts. There is nothing harder. For ten days now I have been amazed to discover how very intelligent people, namely my colleagues within the academic profession, can so readily run from the facts. It never occurred to me to realize that I have spent eleven years running from the facts. Yet that is what I've done.
There is no doubt in my military mind--the phrase, at the moment, is exact--that I am at present in the throes of hypomania. I wasn't in much doubt even when [my wife] and I went to see Don ______ [a close personal friend who was also a psychotherapist] this afternoon. I am in no doubt whatever now.

There'll be time later, I hope, to write down some of what I've thought during the past several days. For now I want to say only that this evening I had a long talk with my wife, and then by phone with my brother, and then by phone once again with my sister. All three in their ways have given me courage to accept what I must: that bipolar disorder is not something I must accept because, however stale the diagnosis, the DSM-IV [Diagnostic and Statistical Manual of the American Psychological Association, 4th edition] yields no way to undo the diagnosis. Rather, bipolar disorder is something I have in the here and now. I've always had it, at least since 1986. As my father would have said, "Mark, even you can learn something if you're hit over the head with a two by four."

From maybe 6 p.m. this evening onward (we left ______ Psychiatric Services at 5 p.m.), I've been seriously coming to terms with my discussion with Don this afternoon. Don is a little too client-centered to say his full piece if the client isn't ready to hear, but as soon as I asked Don what he'd do in my place, he said without hesitation that he'd make an appointment with a psychiatrist and get on meds [medication]. I agreed to make such an appointment. I have one in the morning at 9 a.m, which is why I can permit myself the luxury of writing these words now. Because I'm writing them at 2:29 a.m. in the morning (by the computer clock). I feel fully rested and refreshed, yet I went to bed just three hours ago, and washed down an over the counter sleep aid before doing so.

When I awoke about twenty-five minutes ago, I was certain it must be near dawn. I was amazed to look at the bedroom clock and note the actual time. I could feel a slight "buzz" around my cranium, somewhat the way it feels when you've been wearing a hat for a long period and then remove it. Your head feels like the hat is still there. So too with me, though I can feel the sensation ebbing now. I'm beginning to feel a bit sleepy again, and as soon as I can jot down two more thoughts I'll head back to bed.

The two thoughts are: First, when my family first moved to Columbus back in 1972, my father read us Flowers for Algernon, by Daniel Keyes. In it the main character is a mildly retarded young man named Charlie. He has an operation that makes him normal--indeed, supernormal, because his intelligence expands prodigiously and eclipses even that of the brilliant man who performed the operation. But Charlie's great intelligence only enables him to see more quickly than anyone else the facts: the success is temporary. His findings indicate that his new intelligence is eroding, that he will become retarded again.

My situation is not exactly like that, but it is similar. (Both [my brother and my sister] picked up on this when I mentioned the book this evening, though [one] relished the analogy while [the other] seemed slightly disquieted by it.) I could have used this manic high to embark on grandiose projects. Instead I used it to investigate the age-old question: Something feels wrong. What is it? The conclusion: Something is wrong. I've been cycling through manic and depressive phases for years, not wildly, as Mom did, but within a mostly functional range. I was surely hypomanic on March 4, 1992, the day I gave the job talk that one graduate student called a "tour de force," and which wowed the Department so greatly that it took the unprecedented step of hiring a tenure-track faculty member directly from its grad student ranks. So far I've managed to get through the cycles through my ability to cope, though at what unnecessary personal cost I cannot imagine. How long can I expect my luck to hold? I'd better get with a psychiatrist and do what the hell he directs.

The second thought will seem unrelated and perhaps inappropriate to the context, though I assure you it is not. The second thought is that, while neither I nor anyone else could ever prove it, I think I now know why General Robert E. Lee halted his army on the Sharpsburg ridge on September 15, 1862, rather than do the "prudent" thing and recross the Potomac River. Instead he turned to face his much larger enemy and fought a pitched battle (the bloodiest single day of the Civil War) with a wide, unfordable river about a mile to his rear. Military historians have wondered ever since why he did it. Most of the explanations (which I won't waste time rehearsing) center on operational or political factors. But is it possible that Lee stood at Sharpsburg because something in his own personal history combined with these impersonal factors to compel the decision he made? If so, I think it was his father.

Light Horse Harry Lee was, in some respects, a more successful man than Robert. He was a hero of the Revolutionary War and a governor of Virginia, among other things. Yet Harry Lee wound up dying far from home and penniless, for reasons that have to do ultimately with a refusal to face facts or to stand and face the consequences of his life. He fled the country rather than go to debtors' prison for debts he'd contracted in a series of risky land speculation ventures. In September 1962, Robert took a risk by crossing the Potomac and embarking on a raid into Maryland while his army was reduced in numbers and ill-equipped. After the defeat at South Mountain he should have departed from Maryland as soon as he could. But perhaps something in him resisted the idea of running from the consequences of the risk he had taken. Perhaps he realized that if he did so his future generalship would be compromised. (Generals are human beings first of all; the same psychological dynamics that affect the rest of us affect them.) Perhaps in a much different way than I am doing, Robert E. Lee was also facing facts when he made his stand on the high ground west of Antietam Creek.

Part 1 - Part 2

Moments of Decision - Pt 1

2009-07-14T13:02:00.003-04:00

Originally published in Blog Them Out of the Stone Age on April 13, 2005

Bullfight critics row on row
Crowd the enormous plaza de toros
But only one is there who knows
And he is the one fights the bull.

-- Translation by Robert Graves of a poem by Spanish matador Domingo Ortega

(Photographs by Lester Silva)

Part 1 - Part 2

What This Blog Is About

2009-07-14T12:56:00.005-04:00

I have bipolar disorder -- specifically Bipolar I. It was diagnosed shortly before I turned 27. However, the most likely time of onset was the winter of my 17th year. I've always made a point of being up front about having the disorder. For instance, I'm a college professor, and when appropriate I've disclosed it to my students. I've talked about the disorder with undergraduates in a psychology course and have written about it from time to time, most notably in a column in Inside Higher Ed entitled "An Inappropriate Illness," which appeared in September 2006. I've also discussed it on my principal blog, Blog Them Out of the Stone Age (here abbreviated BTOOTSA), which is devoted to academic military history and national security affairs but which occasionally addresses bipolar disorder (as well as battle stress injury), under the category "Facing the Demon." Which of course inspired the title of this blog. For the sake of convenience I'll republish the relevant posts here. If nothing else, that will save me a lot of repetition.

Over time I've discovered that it helps others as well as myself to be candid about having bipolar disorder. If in a large lecture course I have over two hundred students, then statistically two of them have been or will be diagnosed with the illness. Indeed, in the past whenever I've disclosed that I have the disorder invariably one or two students approached me afterward to talk about it, because they too had the illness. Usually they felt rather isolated. They found it difficult to discuss the illness with others or they had trouble feeling understood. They also wondered about its implications for their future. Would they be able to lead a normal life? And usually they had questions about how best to manage the illness. The same thing has happened with adults as well.

A few days ago I posted the following on BTOOTSA:

If you scroll down far enough on the sidebar of this blog, you'll find a section labeled "Twitter Updates," thanks to a widget I installed a few days ago. The question is, how does this relate to military history?

As long time readers of the blog are aware, I have bipolar disorder. The subject is covered in the category "Facing the Demon," along with battle stress injury -- not because I think the two are identical: one is an illness, the other an injury -- but because both require management and both carry a perceived stigma that requires a degree of courage to address. In my own case, I was diagnosed with bipolar disorder when I was twenty-six and have probably had it since the winter of my seventeenth year. It took a long time to come to grips with it. Until I was thirty-seven I didn't fully accept the reality of the disorder -- that it was something I had and would always have and that it needed to be managed precisely as one would manage any other chronic illness, such a diabetes, which in some respects it resembles. Both are abnormalities in one's biochemistry.

In the years since, I've gradually become conscious of the fact that in dealing with the illness I instinctively draw upon a number of concepts derived from a lifetime steeped in military history, strategic studies, and my own modest military experience. The most basic insight derives from Clausewitz: "In war, the best strategy is always to be very strong." This translates metaphorically into identifying as using as many tools to combat the illness as I can. Many of them are predicated on a crucial decision I made as soon as I received the diagnosis; namely that I would acknowledge it openly. As I've written elsewhere:
People often think that because I’m so up front about having bipolar disorder, that being candid about the illness must be an easy thing for me to do. In fact, it scares me. I’m up front about it only because I’m convinced that candor is better than the alternative. Being open with my colleagues, for example, populates the department with observers who have a decent chance of identifying unusual behavior as an artifact of the illness rather than erroneously attributing it to something else: simple high spirits instead of hypomania, for example. It enables me to ask for help when necessary without having to explain the illness from scratch. And it gives me a chance to combat, in a small way, the stigma that still attaches to mental illness. If a professor protected by tenure cannot summon the modest courage required for such an act, I do not know who can.
So where does Twitter come in?

I've decided to use this social utility as a way to discuss the illness, not abstractly, but as it affects my day to day life. (The updates, by the way, appear not just on the blog but are immediately cross-posted as a status update on Facebook.) Since I find the prospect of doing so a bit daunting -- it is one thing to state publicly that I have the disorder, quite another to state on a given day that I'm depressed -- I've begun with something reasonably safe: namely to keep public track of my workouts at the gym (and other forms of exercise). This has more to do with bipolar disorder than one might suppose. Coping with bipolar disorder involves more than taking medication. There are things one can actively do to manage the illness, among them getting enough sleep and getting enough exercise, which releases beneficial endorphins.

So announcing each trip to the gym is not based on vanity or the assumption that people are fascinated with the mundane details of my life. It's the early stage of what I expect will be a larger experiment in publicly sharing the experience of managing bipolar disorder, partly as a means to expand my network of support, but primarily to model in practical terms how one goes about it, and to treat the illness as one would any other: not something of which to be embarrassed or ashamed but a simple fact of existence.

It would distract from the main purpose of BTOOTSA to constantly inject posts about bipolar disorder, but without supplying context the near-daily announcement that I'm going to, or have returned from, the gym would seem banal. Consequently I've created this blog in order to supply the context.

Mood Watch - 47

2008-04-03T20:36:00.000-04:00

Still OK. The only thing I’ve noticed is that between last Friday and Monday, I felt rather sluggish and tired. I wasn’t in poor spirits and I was getting plenty of sleep, but somehow I never felt rested. Just prior to that, however, I was just the opposite: more energized and focused, and although sleeping sufficiently, was wide awake as soon as I got out of bed.

In both instances, the differences were such mild departures from “normal” that, were it not for the knowledge I have bipolar disorder, I doubt I would have noticed them at all. Still, when managing this illness, it never hurts to keep on your toes. In fact, it’s foolish to do anything else.

Mood Watch - 46

2008-03-26T11:37:00.000-04:00

My mood continues to be good these days. Only caveat (and there always seems to be one) is that for the past couple of nights I have slept less than usual — maybe 3.5 hours/night. I was able to break that emerging pattern, though, by increasing my sleep medication to the maximum allowed by the prescription, and by working extra hard to maintain what is artfully known as “good sleep hygiene.”

As is so often the case, in recent weeks I’ve been in touch with three people, two of them undergraduates here at OSU, who sought me out because they have bipolar disorder and have felt they have know one in their lives who understands the disorder, or, at least, understands it from the inside. Talking with such people always makes me feel as if I’m doing something worthwhile, and I’m proud to have the chance.

Mood Watch - 45

2008-03-22T07:00:00.000-04:00

I had a change of meds almost three months ago and by and large, it’s improved things greatly. My one caveat is that in early February I had a couple of anxiety attacks that initially presented as something like the flu, because the main thing I noticed was a lot of nausea — in fact at one point I actually vomited.

Once I caught on to what was really going on, however, I took 2 mg of clonazepam (the generic equivalent of klonopin), followed by 1 mg each day for the next couple of days. I was amazed by how promptly and completely that took care of things. Which just goes to underscore the fact that, despite the stigma that clings to it, this is a biochemical illness.

Mood Watch - 44

2008-01-04T09:17:00.000-05:00

Overall, I had a very nice holiday break. Didn’t notice any real shifts in mood. I did, however, notice a couple of fluctuations in energy level — the first in mid-December and the second at month’s end. The duration for each was about three days.

Mood Watch - 43

2007-12-09T17:24:00.001-05:00

Since my last “Mood Watch” I went through yet another depression. This one lasted about eight days. It’s hard to know exactly when these things begin, although they lift so abruptly that there’s usually no ambiguity about the terminus. As in most cases, it didn’t prevent me from doing everything I absolutely had to do, but it wiped me out in terms of getting anything else done.

I’ve been OK — in good spirits, actually — for about ten days now. But the depressive spells have been so frequent since mid-September that, although individually I can correlate them to a particular circumstance, in aggregate it now looks more like one long depression with brief reprieves, which certainly suggests a strong biochemical underpinning. However, that’s really just an educated guess. I suspect that would be the case even if a gaggle of psychiatrists observed me every minute. There’s just so much about mood disorders we still don’t know.

One thing we do know: you can’t “snap out of” or “power through” a depression. I don’t get that kind of thing as much as I used to — in fact, most of my close friends are very supportive — but occasionally it still happens. And when it does, for the most part it reflects not a concern for me but rather for the person offering the “advice.” They find it inconvenient to be around someone who is depressed, and the easiest solution is to talk and act as if it isn’t an illness but a character defect.

Ironically, the effect is generally the reverse of the one intended, since it simply increases the sense of shame and isolation felt by a person suffering from depression. Those who experience strong, consistent support generally recover more quickly.

Mood Watch - 42

2007-11-17T06:55:00.002-05:00

From October 31 through November 5 I was on the road again, this time for a brief research trip combined with attendance at the annual meeting of the Southern Historical Association, which has a deserved reputation as one of the more pleasant conferences in the historical profession. Unlike my previous trips, I had no responsibilities that put me in the public eye, I made sure to rest and relax more often, and I had a thoroughly good time. It was almost like a vacation. I returned to Columbus, still in good spirits, and had exactly three more good days. Then I fell into one of the blackest depressions I can recall.

This particular episode lasted about six days. As usual its onset and departure were abrupt. But it felt existential rather than biochemically based, and the very fact of its occurrence exploded the hypothesis that the connection between travel and follow-on depression was principally a function of adrenalin, stress and fatigue. In fact, it plainly points back to an earlier hypothesis, namely that the travels are good for me, and my return from them necessarily involves returning to an environment I do not like and which both my therapist and psychiatrist have warned me for years is a “toxic” environment that, in their view, is heavily complicit in the depressions. Which is to say it plays a significant role in both their frequency and severity.

This is actually good news, I suppose, because it gives me something external to address, instead of supposing that it’s all biochemical and therefore beyond my reach except through pharmacology. The trick, however, is going to be finding a constructive way to address the problem. But I’ll think of something.

To repeat a point made earlier, isn’t exactly easy to set down these thoughts in a forum that anyone with an Internet connection can read. I would imagine that while some people consider it courageous, others consider it self absorbed or even exhibitionist. I wish I didn’t care what people think, but I do. And so writing these entries is often a matter of just gritting my teeth and doing it. Still, emails like this one underscore the fact that I’m performing a needed service. I received it at the end of October, and am sharing it with the writer’s permission:

I just wanted to take a moment to respond to your most recent posts. I’ve been through two periods of depression / anxiety (about 3-6 days each) since moving out to ______, and I wanted to say that reading your post helped me to feel something — “better” or “more normal,” I guess, for lack of a different word at present.

While I obviously wouldn’t wish depression on you, I’m glad that you shared your thoughts. Additionally, I noted your post from 9/21 and frankly, I hope that you decide not to discontinue the blog. It seems like your decision towards openness, including the blog, has made a difference to a number of people (myself included), and I hope that it has brought you more peace and strength than you’re aware of.

Mood Watch - 41

2007-10-29T08:27:00.000-04:00

Since my last post I’ve been through three periods of depression, each of about four to five days’ duration. They’ve followed the same pattern as most of my depressions. That is to say, my energy level will drop, usually for some plausible reason, so at first I just seem tired and in need of rest. I take some time to recharge my batteries, but they don’t recharge. Instead — and quite quickly — my mood drops into such a trough that I can hardly stand to do anything but sleep, and I sleep as much as I possibly can. At such times, not only do I have no interest in my regular work (or anything else), I feel a sense of foreboding about it. It makes me anxious even to check my email. When I go down to campus to teach a class or attend a meeting, I feel no sense of emotional connection. I can’t “read the room” to understand its tone — whether, for instance, I’m making any sense to my students beyond the mere fact that I can speak complete sentences. If I have to type something, I can hardly figure out how to organize my thoughts, and I notice I make a lot of typographical errors (I’m generally a pretty accurate typist).

All in all, the effects are about as debilitating as a bad case of the flu, except that the hallmark is a pervasive sense of misery and shame, as well as the fear that I will never return to normal. Cognitively I know that this is distorted thinking, but at a gut level this is simply hard to believe — it’s striking the extent to which one’s biochemistry informs our impressions of what really makes sense and what doesn’t.

Lastly, although I remember feeling OK, I literally cannot remember what that actually felt like. It seems amazing that I ever enjoyed life or could ever enjoy it again.

In formal diagnostic terms, one would have to exhibit these symptoms for fourteen days to qualify for a major depressive episode. Mine generally last three or four days; occasionally five, but that’s unusual. When I bounce back, it’s abrupt, just a matter of a few hours.

It’s always tempting and sometimes useful to look for correlations with external events which may act as catalysts or triggers. Over the past year a very strong correlation has emerged between business travel and depression. I return from a trip; a depression ensues. My therapist and I have theorized about the possible connection. A couple of explanations have seemed plausible and it’s possible it’s not an either/or question. But at the moment, the front runner is that these trips, in the nature of travel, are tiring and disruptive of my normal routine, and also usually involve giving a public presentation — often two or three in quick succession — so that I have to “gear up” to be animated, energetic, etc. Taken together, it’s no surprise that this would have an effect on my biochemistry.

Since I can’t avoid business travel — it’s pretty much a bedrock component of my professional activity — the issue now becomes whether to just accept the fact that depression will be the likely sequel or, more imaginatively, to find a way to manage the problem. One possible solution would be to make sure I get periods of regular rest during these trips and as far as possible adhere to a normal schedule.

I should have a fair degree of control over my time when attending, say, academic conferences. Invited lectures are a different matter. Having gone to the trouble of flying me in, putting me up in a hotel, and paying me an honorarium, my hosts generally try to get as much mileage out of me as they can. My most recent trip, for instance, involved:

a. dinner with students

b. a 90-minute workshop

c. breakfast with more students the next day

d. a meeting with yet more students at mid-morning

e. lunch with faculty and students

f. another meeting

g. a 90-minute public lecture, including Q&A

h. dinner with faculty

… to which I myself added item g(1): a few afternoon beers with some grad students.

It’s not a question here of being exploited. I liked everyone I met and had a very enjoyable time. Indeed, one could almost posit a connection based on the abrupt transition from a warm, validating atmosphere to, well, the regular workaday world. But if there is something to the thesis of these depressions emerging from my having to remain “on” for extended periods, notwithstanding the wear and tear of travel — then in the future I’m going to have to request what might be called “reasonable accommodation” for the disorder; i.e., a lighter schedule.

Mood Watch - 40

2007-09-21T07:00:00.001-04:00

Plainly this blog interests me a lot less than it used to. I maintain my professional blog with a fair degree of regularity — in part because whenever I attend conferences, visit archives, etc., I invariably meet readers who appreciate the blog and tell me so. I feel therefore as if I’m performing a useful service.

With this blog, however, I feel very differently. I’m not sure I’m performing a useful service even to myself. True, on the positive side I have this year encountered at least ten individuals with bipolar disorder or similar conditions. It’s not that hard. A few have contacted me after reading the piece I did a year ago for Inside Higher Ed. But most contacts have occurred after I drop into a conversation the fact that I have bipolar disorder. The opportunity occurs more often than one would think. When I do so, invariably I am approached afterward, rather furtively, by some individual who also has bipolar disorder. Without exception they have kept the condition a closely guarded secret. They’re afraid. They worry what their families will think, their friends, employers, lovers. Often the conversations they strike up with me mark the first time they have spoken openly about the disorder. They are full of questions — what medications I take, what strategies I employ to lead a (more or less) “normal” life, etc.

But mostly they wonder how it is that I have the courage or foolhardiness to treat the condition as if it were an illness like any other. Don’t people look at me funny? Aren’t my colleagues skittish about dealing with me? Have they not written me off as anyone who could produce work of consequence? And in truth, I am morally convinced that some people regard me as the ghost of a once promising historian.

Too bad. I’m convinced that in being open about the disorder I have made the right decision. It enables me to draw upon the support of friends. It helps me to grow in a spiritual sense: I feel more at home with myself; and I can look at my increasingly middle-aged face in the mirror and believe that I possess at least a smidgin of courage and intgrity. But much more importantly, it gives me the chance to talk to people who are similarly circumstanced. Most of them have hidden their disorder to such a degree that, regardless of what statistics may say, they simply cannot believe that there are others like them — still less that this and similar disorders are as common as dirt.

Anyway, as to my mood itself: Overall it has been surprisingly good for the past several months. And I notice that the occasional bad spells correlate strongly to circumstances. Fortunately I’ve enjoyed considerable success in distancing myself psychologically from those circumstances. I’ve truly been amazed by what a difference that has made. In my opinion it has been a greater factor than any of the several medications in my arsenal.

Mood Watch - 39

2007-08-03T13:30:00.000-04:00

Things have been good, generally speaking, since the last installment of “Mood Watch.” I’ve been productive around the house (especially yard work) and also in my writing. Last week, for instance, I completed an 11,000-word essay for a forthcoming edited volume. I was able to adhere to my writing schedule and on most days composed 1,500-2,000 words.

The one glitch occurred this past weekend, starting on Friday the 27th and extending through Tuesday of this week. When this stuff happens my first thought always runs to biochemistry, but I’m learning to look more closely at my circumstances and the way in which they may be influencing my mood. In this instance, I concluded it was the latter more than the former.

Mood Watch - 38

2007-07-12T07:00:00.000-04:00

Obviously I’ve blown off this blog for nearly three months. I’ve been busy with other things, but mostly I just haven’t felt inclined to write, although I’ve kept up reasonably well with my professional blog.

My mood during this period has, by and large, been quite good. Aside from minor bouts with insomnia or hypersomnia, I haven’t had any trouble. I attribute this to three things: First, I think the Lamictal I’ve been taking for several months is actually doing its job as an anti-depressant. Second, I have a friend who is enthusiastically helping me convert my jungle of a back yard into an orderly, appealing garden — being in pleasant surroundings has done me a lot of good. Third and most importantly, I’ve identified an area of my life that was sapping my energy, creating or exacerbating my depressions, and in general doing me no good at all. I feel no need to be specific, except to say that it has nothing to do with any particular individual. But both my therapist and psychiatrist have urged me to “disinvest” in that environment. I’ve done so and have been startled by how much better I feel.

Mood Watch - 37

2007-04-16T07:00:00.001-04:00

Forgive me, Father, for I have sinned. It has been nineteen days since my last Mood Watch. Though actually, come to think of it, nineteen days isn't all that bad.

Hard on the heels of my last trip (to the Chicago area), I took another, this time to Vermont. I went there to be a presenter at a symposium, but I arrived on Friday, March 30, a couple of days before it began. Checked into a lovely bed and breakfast and spent most of the weekend with a friend of mine who showed me around the central part of the state.

Aside from four quick business trips to Boston, I'd never been to New England before, much less Vermont. Everyone I met apologized for the scenery -- it was "stick season": too late for the winter snow and too early for the green of spring and summer and the beauty of the turning leaves in autum. But I thought the state was just lovely: lots of rushing streams, quaint villages and small towns nestled between the shoulders of mountains. All in all, I had a lovely time.

The symposium was fun, too. It has that reputation -- the organizers brings in good speakers, install them at the Northfield Inn, and everyone gets pretty well acquainted, not just over the rich breakfasts but especially in the evenings, when everyone kicks back in the living room/dining room area, cracks open a beer (or six) and talks into the wee hours.

I boarded a flight home on Wednesday afternoon. It figured that after such an enjoyable six days I'd feel a bit of a letdown afterward, but I was surprised -- even shocked -- by how quickly the bottom dropped out of my mood. By the following day I felt so anxious and nearly faint that I had to cancel a class, something I hate to do. Things didn't improve for a full week. Then, as quickly as it hit, the depression lifted. To my mind, that's the very signature of a biochemically based depression.

My therapist, however, doesn't think so. For maybe a year now she's noticed how unhappy I am in my work environment (a lot of my colleagues feel the same way -- my department is undergoing a difficult transition period, for reasons no one quite understands). She thinks the department culture is complicit in the depressions. Initially I was skeptical about this theory, but over time I've become more convinced. Anyway, by the logic of her thesis, this recent depression came about not just because I was leaving a pleasant environment where I felt well regarded, but also because I was returning to one in which I often feel like a stick of furniture.

Be that as it may, now that I'm back to normal I'm sleeping a bit less than usual -- which tends to be my pattern. It isn't too extreme. I generally get at least five hours of uninterrupted sleep each night, and Saturday night I got about nine. But I didn't sleep at all Sunday night. I didn't feel drowsy, so mostly I just rested as best I could. I'll try to push through the day without a nap and go to bed at 9 or 10 p.m. That usually gets me back on a regular sleep schedule.

I had a nice experience the other day. In one of my classes a context emerged in which it was appropriate to say that I had bipolar disorder. The class had 240 students, which meant, statistically, that two or three of them already had bipolar disorder, or would be diagnosed with it at some point in the future. Sure enough, after class one student approached me to say that he too had bipolar disorder and he thanked me for being so up front about it. He keeps his condition private because of the stigma attached to it, but he could readily see that I'm so frank about it, in part, because it's a way to combat the stigma. When 240 students discover that a professor they like and respect is also someone coping with a serious bioaffective condition, it educates them, and the world moves a tiny bit closer to treating people like me the same as they would someone with a physical illness.

Mood Watch - 36

2007-03-27T07:00:00.001-04:00

From about March 12 through March 21, I hit kind of a bad patch, but of the sort that illustrates the subtleties of bipolar disorder. The symptoms aren’t always the classic ones. During that period I was “down” most of the time, but the two principal features were hypersomnia and what I’ve heard a psychiatrist characterize as a “reduction in mental coordination.” By that phrase, he meant a marked decrease in one’s ability to do sustained creative work (like research and writing).

But in other respects I was okay. For instance, I continued to enjoy activities that I would ordinarily find pleasant; e.g., watching movies, spending time with friends, and working at the animal shelter.

If I can point to anything tangible that pulled me out of it, it was a trip this past weekend to the Chicago area, where I was one of the presenters at a conference. I found the experience energizing. I’m not sure if it was the conference or the travel: I often find that my mood improves when I’m on the road. But in any event the transition comes at a good time, since Spring Quarter has begun and I’ve got a busy schedule ahead.

Mood Watch - 35

2007-03-03T09:43:00.001-05:00

A lot’s been going on of late, and most of it hasn’t been pleasant. But to the extent that I can detach circumstances from biochemistry, I think the biochemical aspect is still running smoothly. Most nights I get enough sleep (but not too much), my energy level is OK (but not too much), and if I feel miserable at times, it’s pretty much the way anyone in my position would feel miserable. The one nice thing in all this has been the way my friends have rallied around me. And anyway, it’s impossible to be miserable all the time. I still have a lot of good moments, too.

Mood Watch - 34

2007-02-23T21:50:00.000-05:00

Still on an even keel. Tending to get up early and go to bed early, a routine I am coming increasingly to like.

I had an interesting experience last week with a woman who was a little freaked out to learn that I had bipolar disorder. The main reason was that she believed her father had had bipolar disorder, though he was never diagnosed, much less treated, and who created a very chaotic family environment. (Her assessment was retrospective and based on reading the DSM-IV criteria, which she said he fit in textbook fashion.)

At any rate, for a couple of days I engaged with her on the assumption that it might be a healing experience for her to be able to talk candidly and at length with someone who had bipolar disorder. She was still dubious about my claim to be able to manage the disorder effectively.

Then I discovered she’d been married three times, had once taken off on impulse with a man she described as a sociopath (and who bilked her out of thousands of dollars), and considered every relationship she’d had with a man to have been abusive. My therapist pointed out how chaotic was the life the woman had created for herself, and thought her skepticism about my ability to handle bipolar disorder was a classic case of projection.

And come to think of it, the people with the most confidence in my ability to handle the illness have been those with the highest degree of self-possession. It’s an interesting insight.

Mood Watch - 33

2007-02-17T07:00:00.000-05:00

I’ve let too much time go by between entries, but generally speaking my mood has been on an even keel from a biochemical standpoint. Any alterations have been pretty clearly due to circumstances or, in one case, a sudden opening of ancient wounds that have yet to heal.

Since my last entry I met with an undergraduate who’d experienced a depressive spell and just wanted to talk it over with someone who’d been there. (Of course, a lot of people have been there; most just refuse to acknowledge the fact.) Anyway, I wound up playing Polonius and offering a lot of advice about forestalling depressions when possible and rolling with the punches when one does occur. Recently got an appreciative email. The student has actually implemented most of my suggestions, and says that they have helped.

Mood Watch - 32

2007-01-21T13:47:00.000-05:00

Little or no change since the last Mood Watch post, except that I am back on a sleep schedule that runs from about 10-11 p.m. to 6-7 a.m.

Mood Watch - 31

2007-01-10T07:00:00.000-05:00

Since my last Mood Watch post I’ve been feeling about as “normal” as I can imagine. Oddly enough, that’s been more or less despite new circumstances that might reasonably be expected to make me feel anxious or depressed. On the other hand, some of them have put me under increased pressure and even created a sort of crisis mode. I usually do well in such situations, probably because they characterized my early life. It’s when things are okay that I tend not to do as well.

I’m sleeping fine: getting roughly 6-7 hours per night. Although I’m generally a night owl, in recent days I’ve conked out around 7 p.m. and got up around 2 a.m. It’s actually almost an optimum schedule because I get a lot accomplished between 2 a.m. and 7 a.m.

I still get emails from people in trouble, most recently from a grad student who struggled last quarter with bipolar disorder and another individual who has recently been diagnosed with the disorder and feels a little freaked out by it. I get a lot of satisfaction out of being able to help.

Mood Watch - 30

2006-12-29T07:00:00.000-05:00

I was on the road for much of December and had neither the time nor inclination to post much on this blog. But I suppose I’m overdue for an update on the status of my biochemistry.

As far as I can tell, I’ve been on a pretty even keel since my last Mood Watch post, except that from December 10 through December 26 I tended to sleep more than usual and often had real trouble waking up, almost as if I were drugged (which, aside from the usual depakote and lamictal, I wasn’t). This was all the more surprising because for most of that time I was in the company of good friends and was doing work I enjoy. And besides that, as a general rule I have always tended to sleep less than usual when traveling. Yet at no point did I feel depressed.

The most I can say is that now and again I wished, as I often do, that I didn’t have to fool with this stuff. I mean, I’m appreciative of the fact that as mood disorders go, mine is comparatively mild; also that life holds far more severe challenges. But I mean, jeez, this has really gotten old. Bipolar disorder once had the virtue of at least being interesting. Not any more.

Mood Watch - 29

2006-12-07T06:21:00.000-05:00

An inability to sleep more than two or three hours at a stretch has replaced that long spell of hypersomnia. Taking a nap here and there mitigates this a bit, but I’m still managing only about five hours’ sleep out of every twenty-four. The good news is that I’m energetic enough to catch up on a lot of things, and I have no trouble focusing on my work (distractibility is a symptom of hypomania and therefore one of the things I watch for). The bad news is, I’m managing only about five hours’ sleep out of every twenty-four.

Last week I had a routine consult with my psychiatrist. I briefly reviewed my mood and energy level over the past month. She wrote the usual prescription for my meds. A thought occurred to me, something I’d heard somewhere. I asked, “Is it true that this illness tends to subside with age, that I’ll ever get beyond it?”

She eyed me sympathetically. “No,” she said. “No. You never will.”

Mood Watch - 28

2006-12-01T07:00:00.000-05:00

Sorry to have been away for so long. The month has pretty much been a blur of trips and conferences, which partly explains the dearth of posts. But I’d be less than candid if I omitted to say that I just haven’t felt much like blogging. Although I’ve never regretted taking up this blog, in the nature of the case I’m putting myself and my struggles out in public, and sometimes I don’t feel up to the task.

In fact, I briefly flirted with the idea of dropping this particular blog. God knows I’ve got so much going on that I’ve had to set aside my other blogs temporarily, and indeed, I suspect I will have to put one or more of them on hiatus. But a couple of days ago I received an email that reminded me of why this blog may be the most necessary of any I’ve undertaken.

It came from an undergraduate who had a course with me last year. Because I’ve been public about my bipolar disorder, he felt that he could approach me about his suspicions that he might have something similar. I don’t know whether or not that’s the case, but based on the symptoms he reported, I encouraged him to visit his family doctor and see if a referral to a psychiatrist was warranted.

It occurred to me that his emailing me, a relative stranger, suggested that he had no one else in his life he could approach on this matter, and that if I had kept silent about my illness, he might well have felt completely isolated. In the end, it always comes back to the same stark question: What kind of man do I have guts enough to be?

As for my mood, I can’t recall a time when I have been so busy and yet so easily exhausted. Excepting the brief period I recounted in my previous Mood Watch post, I’ve geared up to do the things I needed to do, and got them done, and then craved nothing but sleep. Except for a few days last week, it didn’t even feel like depression, just a general, unyielding fatigue.

Things got back to normal — or at least what I insist on regarding as normal — two days ago. And what impressed me is that whereas these shifts in mood often seem unrelated to my circumstances, with this one there was a clear connection, and I’m beginning to discern a pattern I’ve hitherto overlooked (or maybe disregarded) between a certain area of my life and these shifts in mood. I don’t mean to be mysterious, but at this point I see no need to get into specifics. It’s just that I’m reasonably sure that this area of my life has become complicit in my depressive spells, and that’s something I’ll have to address.

Mood Watch - 27

2006-11-09T02:21:00.000-05:00

I’ve been getting a little less sleep than usual lately: maybe 5-6 hours at a time. I think this is mainly due to an upcoming conference for which I’ve been the principal organizer. Especially as the date gets close, there are a lot of last minute details to handle or reconfirm and a few little fires to put out. Otherwise I feel pretty good, and have been since about October 29 or so. If you compare this to my previous Mood Watch entry, you’ll see how suddenly I emerged from that period of hypersomnia. That’s classic for me: abrupt drops in mood, abrupt recovery of mood. In an odd way it’s reassuring, since it underscores the biochemical nature of the disorder.

Mood Watch - 26

2006-10-27T21:42:00.000-04:00

It’s been over two weeks since my last post, and my situation continues to be much as I reported it then: sleeping more than usual and having trouble waking up. To that I would add that my energy level and what might be called my mental coordination are much less than usual. The phrase “mental coordination” is something I picked up several years ago from a psychiatrist after hearing me describe the way in which bipolar disorder generally affects me. It seemed to him that I often had mild depressive episodes whose main impact was to reduce my ability to think as quickly and creatively as I can when I’m feeling more myself.

That’s pretty much how it’s been for the past three weeks. I can’t seem to get much done. When called upon to give a lecture, manage a meeting, etc., I function okay — in fact I would say few people can tell any difference. But whereas usually such experiences are energizing, I walk away from them feeling anything but.

The principal good news is twofold. First, aside from the symptoms I’ve described I don’t feel actively miserable. Second, I had a physical exam recently in which I checked out surprisingly well. I say “surprisingly” because I am within a few weeks of my mother’s age at the time of her death, and seven years older than my father at the time of his first heart attack (by the time he was my age he’d had a quadruple bypass).

I’ll be curious to see if I’ve rounded the corner just yet. Several times now I have felt as if my energy level were returning to normal, only to find myself mistaken. I think I’m starting to improve again, but have no way of knowing until it happens.

Mood Watch - 25

2006-10-11T15:30:00.000-04:00

Still feeling OK except that a couple of days ago I began sleeping more than usual: I got drowsy easier and had trouble really waking up. Other than that, not much to tell.

Mood Watch - 24

2006-10-07T09:23:00.000-04:00

I slept normally last night: In bed around 1 a.m., up at 7:30 a.m. to walk the dogs. This morning I feel normally refreshed — which is to say I’m reasonably awake but still occasionally yawning — and normally energized. Not much to say except that it’s surprising how good normal can feel.

Mood Watch - 23

2006-10-05T03:01:00.000-04:00

Rats. Despite taking an Ambien CR at 11 p.m. in addition to the usual meds, I still woke up at 2:30 a.m.: just 3.5 hours of sleep. The bad news is, I can’t get back to sleep. The good news is, I feel far from fully rested. I imagine that after a few hours I’ll get back to sleep again. Luckily I have no appointments until mid-afternoon.

It’s odd. I feel almost the same irrational shame when I get too little sleep as I do when I’m depressed and sleep as much as possible. In both cases, I have to bear in mind that these are manifestations of the illness, and that beyond taking my meds and keeping a careful watch on myself, there’s not much more I can do. The best thing, I’ve found in my current situation, is to remain quiet and relaxed. Some activity is okay — it seems to keep my mind from over-revving — but it’s not a time for something like, say, cleaning the house from top to bottom. (I once knew a woman with bipolar disorder who would actually do that in the middle of the night, but until she happened to mention it by accident, and I happened to say it sounded like clear evidence of hypomania, it had never occurred to her to connect these bursts of nocturnal energy with the illness. And this was a highly educated woman, too.)

UPDATE, October 5, 1:20 p.m. - Presently I did dose off, while sitting in my office chair. Unfortunately I had a glass of Fresca in my hand and thus baptized a good portion of my lap, which woke me up again. But just temporarily: I slept until 5:30 a.m., got up, fed and walked the dogs, then crashed again until around 11 a.m.

Mod Watch - 22

2006-10-04T02:39:00.000-04:00

Still feeling OK, but my sleep schedule has gotten knocked out of whack. I’ve been falling asleep early in the evening and by midnight am awake again. This is actually a pattern that comes naturally to me. In my early twenties, I worked a full-time office job from 4:30 p.m. until midnight, then turned to my free lance writing and continued to labor until dawn. Similarly, I composed most of my doctoral dissertation between 11 p.m. and 5 a.m.

I like the peace and quiet and the lack of distraction. As a rule, I find that I focus better and get more accomplished. Nevertheless, any change in my sleep schedule always gives me pause. And although I am not running much of a sleep deficit just yet, I’m down to around six hours of sleep in every twenty-four.

Emails continue to appear in my mailbox thanking me for the Inside Higher Ed article last week. Most are a pure pleasure to read, but one was a bit disconcerting. It came from an individual with bipolar disorder who was inspired by my story but at the same time determined not to take medication, work with a psychiatrist, etc. I didn’t want to give the person advice, since often people will not accept unsolicited advice. Even so, I couldn’t let it pass without at least underscoring my own convictions on the subject:

I hope you won’t mind my saying that, for my own part, I regard taking medication, seeing a therapist and psychiatrist, etc., as being of fundamental importance to managing the illness. I’m a military historian, and after a lifetime of studying war I find that using combat as a metaphor comes very naturally to me. As I said in one of my comments under the IHE piece, I regard myself as being permanently at war with an enemy that will never cease in its efforts to kill me, either through a psychotic manic high or a depression so deep I commit suicide. Carl von Clausewitz, perhaps the best known of military theorists, acutely observed that, “In war, the best strategy is always to be very strong.” In the context of managing the illness, I interpret that to mean that I should avail myself of every resource I can possibly bring to bear.

Frankly, I doubt it will do any good. People generally have to learn such things in their own time and in their own way. It took me eleven years to really face up to the reality of my situation, so I certainly have no right to find fault. That said, in retrospect I can clearly see that I was immensely lucky not to have suffered disaster during those eleven years.

Mood Watch - 21

2006-10-01T00:45:00.000-04:00

I’m still in good spirits. Indeed, very good spirits since “An Inappropriate Illness” was published. The response it generated, both the online discussion and private emails, has really given me a sense that my life means something, that I have found a way to be of service, and that’s a feeling of extraordinary power. (To cap things off, a bipolar disorder support association in Perth, Australia, has asked permission to reprint the article in its quarterly newsletter.)

I’ve been sleeping adequately, but my schedule has been thrown off a bit by dint of getting up rather early most days this weeks and being so drowsy at times today I literally could not keep my eyes open. Thus it’s 12:30 a.m. as I write this, but I’ve just awakened after a nap of several hours.

My concentration has been good. I’ve gotten a lot of work done lately, and it’s work I’m supposed to be doing, not new projects dreamt up and pursued on a whim. My impulse control is OK. True, I did go out this evening and spend over a thousand bucks, but that was on a) a new hot water heater whose purchase I’ve delayed until the failing old water heater forced me to take action; and b) the best vacuum cleaner I can afford, because with three dogs my Significant Other and I live in a perpetual desert of dog hair. Lesser measures simply haven’t gotten the job done.

Mood Watch - 20

2006-09-29T06:44:00.000-04:00

The publication of “An Inappropriate Illness” generated a great deal of constructive online discussion. In addition to a number of attaboys from my colleagues in the history department, I also received about ten private emails from people around the country who knew of, or were themselves struggling with, a serious mood disorder.

The rough consensus in both the public comments and private emails was that disclosing the existence of a mood disorder or anything like it remained, even in academe, a risky thing to do. Thus I had people tell me how brave I was. I don’t know about that. I do know that some of the emails were so affecting that they moved me to tears. I felt honored to have been able to strike a blow, however modest, against the stigma that still imprisons too many people with mental illnesses behind walls of silence.

I have also been engaged over the past couple of days with a totally unrelated matter that has reinforced a sense that I can and am making a constructive difference. Thus, on the whole I’ve been feeling about as good as a man can feel. And the very best news is that I continue to sleep around six hours a night.

The only symptom I notice right now is a certain sense of feeling “scattered” — trying to keep track of two many things at once — and that seems less attributable to biochemistry than to how hectic the start of a new school year tends to be.

Mood Watch - 19

2006-09-26T07:24:00.000-04:00

Staying up all yesterday worked — I got a good night’s sleep without having to take an Ambien CR or anything, and feel fine today.

Mood Watch - 18

2006-09-25T07:37:00.000-04:00

A week ago I felt physically fine. Then within 24 hours I got walloped by the fiercest head cold I can recall ever having. “Three days coming, three days with you, three days leaving” is the conventional wisdom about head colds, and it usually holds true with me. This one compressed the first three days into an afternoon. By Tuesday evening I could breathe only through my mouth, and then with so much difficulty I sometimes literally felt as if I were on the verge of suffocation.

It wasn’t quite so bad on Wednesday and Thursday, but it was midday Friday before I felt even slightly like doing any work. Still, as the cold began to subside, my mood and energy level rapidly picked up, and from Saturday until now I’ve been in perfectly good spirits, able to focus on my work (even the stuff that requires creative thought), and very productive.

Needless to say, I slept a lot during the worst of the cold, and as late as Saturday night I slept a good eight hours, and so deeply that I didn’t wake up until after 9 a.m. But that has ended my eleven-day run of hypersomnia. I didn’t feel even slightly tired last night, so I just plowed through a back log of work, and as is my usual practice I’ll try to stay awake today so as to get back on a normal sleep schedule tonight.

Mood Watch - 17

2006-09-18T16:59:00.000-04:00

I continue to sleep more than usual and more easily than usual, though the hypersomnia isn’t quite as pronounced (or maybe I’m just getting used to it). I feel okay when I’m around people but when alone I often feel a sort of free-floating anxiety; and either way my sense of self-worth isn’t much. I try not to think of reasons to justify the lack of self-worth, which is the way one’s thoughts tend to drift. Instead as far as possible I consider it simply an artifact of the illness.

I wrote that column for Inside Higher Ed. The editor had some minor suggested revisions. I made them and sent back a final copy. The piece will most likely run next week.

Mood Watch - 16

2006-09-14T05:33:00.000-04:00

Still sleeping a lot. At such times it’s surprisingly difficult to stay awake, and when I am awake my energy level is perceptibly lower than it has been. I’m starting to feel sort of anxious as well — nothing major as yet, just a vague sense of important things undone, rather the way it feels to leave the house and think you’ve left the stove on. I’m still able to forge ahead with my work, though, and that’s a positive sign.

Mood Watch - 15

2006-09-12T22:47:00.000-04:00

Fell asleep around 11:30 last night; woke up at 2 a.m. By mid-morning I was very drowsy and slept from noon until about 6 p.m. I was awake only an hour before the z-monster got me again and I slept a further three hours.

This sounds pretty ho-hum, I imagine, but sleep is the single biggest indicator of an impending hypomanic or depressive episode, and the rules of the game with bipolar disorder say that “good sleep hygiene,” as it’s called, is imperative. That’s why I pay so much attention to it.

At the moment I still feel fine otherwise, but maybe a shade or two less buoyant. It’s hard to tell what will happen next until it does.

UPDATE, September 13, 4:27 a.m. - Slept an additional four hours, from midnight to 4 a.m. In and of itself that’s a good thing, as it has set me back on what is more or less a “normal” schedule. But the ease with which I did it, having slept so much during the day, is noteworthy, and not necessarily in a good way.

Mood Watch - 14

2006-09-11T06:25:00.000-04:00

Took a 90-minute nap yesterday afternoon and slept from about 11 p.m. to 6 a.m., albeit with frequent awakenings. At such times you feel kinda like a zombie that death itself cannot keep down. Nevertheless, even including interruptions I must’ve gotten seven hours of sleep in the last twenty-four. That’s a good sign.

Mood Watch - 13

2006-09-09T12:24:00.000-04:00

I’m still getting less sleep than usual — only about four hours last night — but otherwise seem okay. That is to say, I detect no grandiose thoughts, flight of ideas, pressured speech, distractibility, or “excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., the person engages in unrestrained buying sprees, sexual indiscretions, or foolish business investments).” I did rent a 10×10 space at a self-storage place a mile or so away and I just now dropped $300 on two four-drawer filing cabinets, the idea in both cases to help myself get better organized. If that sounds nuts, so be it.

While I’ve been sleeping less, I sure don’t feel refreshed after only a few hours’ sleep, which is the hallmark of that particular symptom. On the contrary, sometimes I get drowsy and doze off, albeit only for a couple of minutes at a time.

Ordinarily I take only Depakote (a prophylactic against hypomania) and Lamictal (an anti-depressant), plus, if necessary, Ambien CR (a sleeping medication) at night. But by a standing arrangement with my psychiatrist, at times like this I add Clonazepam (aka Klonopin, a mood stabilizer) to the mix, just to be on the safe side.

Actually, aside from being a little tired, I feel as “normal” as I can recall having felt in quite a while. I’m trying to appreciate it while it lasts, because it won’t. What’ll happen eventually is that all of a sudden my sense of being an ordinary person like everyone else will vanish, my reasons for thinking so will seem illusory, and it will seem crystal clear to me that my life is a waste, that I will never recover my old productivity, and that the attempt on this blog, for instance, to chronicle what it is like to have bipolar disorder will seem not constructive and maybe even courageous, but pointless and even inappropriate. And then I’ll just have to suck it up until things improve again.

Mood Watch - 12

2006-09-08T02:34:00.000-04:00

Wednesday night (September 6/7) I got about four hours of sleep, but was so bleary that by mid-morning I took a 90-minute nap. Thursday evening (September 7/8) I went to bed around 10:30 p.m. and awoke — once again feeling it must nearly be dawn — a little after 2 a.m. Which makes 3.5 hours of sleep, or about nine hours in the last twenty-four. I feel OK otherwise, but until my sleep pattern improves, there’s still some danger of, to invoke the jargon, decompensation. Well, I’ve been here too often to get alarmed. I’ll just have to keep an eye on things.

Mood Watch - 11

2006-09-06T02:20:00.001-04:00

Last night I went to sleep at about 10:30 p.m. This morning I awoke around dawn; I figured 6 a.m. or so. It took me fifteen full minutes to realize it was barely 2 a.m. Except for a bit of clumsiness in my typing, I don’t feel tired at all.

Luckily, I don’t feel like doing anything generative or creative or audacious or whatever. I’m just making a cup of coffee and starting to get on with my day.

Mood Watch - 10

2006-09-05T06:48:00.000-04:00

Slept an unbroken seven hours last night — always a reassuring thing in the context of an overall pleasant mood. Had a good, productive day yesterday and look forward to another today. I sure hope it’s productive; I’ve got a lot to do.

Mood Watch - 9

2006-09-02T07:15:00.000-04:00

I’m wrapping up my trip to Washington and flying home this afternoon. I’ve had a very good time — was interviewed by a film crew making a documentary about Sherman’s March and got to visit with a couple of friends, one of them a fellow Civil War historian, also flown in to be interviewed, whom I hadn’t seen in two years.

As often occurs when I travel, I have been sleeping less than normal. Thursday night it was more or less my own fault: I stayed up late and got up early in order to be as well prepared for the interview as possible. But last night I went to bed around 2 a.m., having spent the evening chatting with my Civil War friend over several pints of Guinness, and awoke around 5 a.m. I was and remain a little bleary but no way was I going to get back to sleep. It just wasn’t in the cards.

It’s always impossible to know for sure what influences my moods — how much is biochemical, how much is existential. Often I have the feeling that, because I am depressed so much of the time, the experience of just feeling normal gets amplified into exhilaration. Thus, paradoxically, feeling normal can feel a bit like the first stirrings of hypomania. And maybe it is the first stirrings of hypomania. To repeat, it’s impossible to be sure, so one just has to be ceaselessly vigilant. And it probably wouldn’t hurt to take a klonopin tablet (an anticonvulsant that, in the Alice in Wonderland world of bipolar biochemistry, is effective as a mild mood stabilizer).

Mood Watch - 8

2006-08-31T07:17:00.000-04:00

The night before last, I was sleeping just fine, thank you, until an excruciating muscle spasm in my calf brought me wide awake. After that, there was no chance of returning to sleep. Instead I got up and I got started on my day, having had maybe four hours of sleep.

I felt reasonably upbeat about the world — how different life seems during the “normal” times — and had a good, solid, productive day. True, I was kind of red-eyed throughout, but it was no big deal. Slept just fine last night: a full seven hours of deep, uninterrupted sleep. And when I awoke, I was glad to face the new morning. Is life routinely like this for most people?

This afternoon I fly to Washington to be interviewed tomorow for a prospective History Channel documentary on Sherman’s March. I was supposed to return tomorrow night, but asked to have the flight pushed back a day when I learned a good friend and fellow Civil War historian would also be in town. I’d like to see and catch up with her a bit. I’ll also be visiting a couple of other friends, including the Army officer with whose family I recently vacationed in the North Carolina Outer Banks. He’s back at the Pentagon now.

Mood Watch - 7

2006-08-29T17:16:00.000-04:00

I didn’t sleep at all last night, Ambien CR notwithstanding. It’s a bit frustrating when that occurs but not, in itself, cause for alarm. I just keep an eye on how I’m doing otherwise. Do I feel tired, the way one normally would if sleep-deprived, or do I feel energetic and raring to go? Are any other symptoms present? If not, my usual practice is to work through the day without a nap, so as not to throw off my normal routine. As they say, good “sleep hygiene” is an important element in combatting the disorder.

The one downside, and it can’t really be helped, is that I’m too tired to do anything that requires serious mental creativity. I can answer email and do more or less mechanical tasks, but that’s about the extent of it. Actually, “downside” is probably the wrong word. It would be cause for alarm if my brain were anything else but sluggish.

Mood Watch - 6

2006-08-28T15:00:00.000-04:00

People unacquainted with bipolar disorder typically think of the mood swings as being like those of a pendulum: a period of elevated mood, followed by a gradual shift to “normal,” and then eventually on to a period of depression. In fact, for many people with the disorder it isn’t like that, and in my own case I would say that the simile doesn’t apply at all. Instead I tend to drop quite suddenly into depressive spells and recover from them almost as abruptly. When I do, I generally feel a great deal of energy and a certain resistance to going to sleep. That’s how it’s been for the past few days.

The energy is, not, in and of itself, a bad thing. To some extent I think it owes to sheer relief at being part of the human race again. The things I have to look out for are along these lines: flight of ideas, pressured speech, distractibility, reduced impulse control — e.g., making a lot of sudden unplanned purchases — and so on. As long as these symptoms are absent, and especially provided I can focus on the main tasks at hand, things are more or less okay. I say “more or less” because I can never let down my guard. This is an illness that is trying to kill me, one way or another, and if it can’t kill me it wants to derail my life. I never forget that.

As for sleep: I’ve always been a night owl and the sort of person who lies awake for an hour or two before drifting off. At times such as this, when I feel a decreased need for sleep, it’s imperative to intervene with something that can reliably put me out. Historically that proved fairly hard to do. I went through quite a few medications before getting a prescription that worked — in my case Ambien CR. The previous options tended to be too clever by half; e.g., anti-seizure meds that had the side effect of causing drowsiness.

Sometimes — not at the moment, but sometimes — even the Ambien CR won’t put me down. I start feeling like a zombie in a Grade B movie: The Thing That Would Not Sleep. Luckily about a year ago my psychiatrist and I discovered, almost by accident, that Geodon is the equivalent of a headshot to that metaphorical zombie. The only problem is, when I wake up I’m groggy for hours afterward.

One final observation is in order concerning the relationship between the illness and working for long periods at the computer. Without a PC I simply could not get my work done. Even so, a hallmark of the disorder, as I have experienced it, is that working with a computer functions somewhat as catnip to the manic side of the illness. I can’t exactly dispense with it. The best I can do is walk away from it and do something else for a while.

I noticed this yesterday, for instance, while refurbishing . . . a political blog I started briefly in early 2005 before realizing I simply didn’t have time for it. For reasons I’ll get into some other time, it’s a blog I need for the next few months, so I didn’t begrudge the time. And I enjoy tweaking the templates and HTML code, etc. For me it’s like doing the New York Times crossword puzzle. But it can really suck you in. You fiddle with the code, check to see how it works, tweak it until you get it right. . . . The continuous incremental feedback seduces you to stick around for just one more fix.

The odd thing about it is, there are other times when I can scarcely stand to look at a blog, much less post an entry or do any fine-tuning.

Anyway, that’s the status for today.

Mood Watch - 5

2006-08-27T09:56:00.002-04:00

Had enough energy yesterday to take care of a back log of chores, most notably the laundry, of which there was quite a stack following my return from vacation. Also spent at least a couple of hours uploading our new church directory to the web site, though for privacy reasons, I’ve limited access to church members only. And I caught up with the ceaseless rain of incoming email correspondence. Doesn’t seem like much. Point is, I felt like a member of the human race again.

Recently this blog has been getting a number of visits from one Shazer, aka Shae (hi there, Shae!), a 20-year old undergraduate at Brigham Young University. Shae, as you can see from her blog, has been writing with unusual honesty about her own experiences with counseling. As I’ve watched her blog evolve to incorporate a short blogroll, I’ve naturally been intrigued by her selections and this has led to my discovering several other interesting blogs, all of them concerned, in some way, shape, or form, with mental health issues.

Finally I stumbled upon Bipolar Planet, a recently created blog that serves as a gateway to a Net Ring devoted to blogs whose prominent theme is the struggle with bipolar disorder. It occurred to me that this was both an audience inclined to be supportive of my venture and also one to which I might have something to contribute. So I threw my blog into the ring, so to speak, and embedded the relevant code at the bottom of the main page. It isn’t active yet, since apparently someone has to visually inspect each applicant blog to make sure it’s indeed appropriate for the ring and not something like Manic Nymphos on Webcam.

A reader comment about the stigma that still attaches to mental illness got me poking around the web in search of sites devoted to extinguishing it. I was particularly interested in finding a sort of patch, like “Another straight for GLBT rights,” that would be a suitable addition to the blog’s sidebar. I did find a few things here and there, but not as much as you’d think, and certainly nothing of the scope that is usual for many other social concerns. And no patch; at least, not one that was sufficiently self-explanatory.

Well, anyway, I’m out of time for this entry. It’s off to church. Oh joy: another chance to warm a pew!

Mood Watch - 4

2006-08-26T18:45:00.002-04:00

Woke up this morning feeling like a normal human being again, whatever that is. In my case, it means waking up from a good night's sleep -- 7 or 8 hours -- and wanting to get up and on with my day. Over the years I've learned to trust this as a good augury.

It also highlights the nature of my depressions. They are not, as some might suppose, like the swinging of a pendulum, with a series of up tempo days eventually giving way, gradually, to a series of bad one, and then slowly vice versa. In my case, depressions arrive and depart quite abruptly, like wading in the ocean and suddenly stepping into a hole in the bottom.

Anyways, it's about time. I've got a lot of chores to catch up on.

Mood Watch - 3

2006-08-26T00:18:00.000-04:00

I'm back from vacation. In general I had a great time with some terrific people, but about midway through I could begin to feel my spirits slip. It's almost impossible to pinpoint a significant change in mood within a day or two, because it takes time for the pattern to become obvious. But by the weekend I definitely felt out of sorts, and for most of this week I've been so low that I've had little energy or interest in anything.

In some ways I've come to regard such times as no different from having a bad chest cold. You don't beat yourself up about having a cold and you give yourself permission to be ill. But in others I still retain a gut-level feeling that this is something to be ashamed of, or at least hidden discreetly away. It's only now that my spirits are improving that I can nerve myself to compose this post.

Coincidentally I saw my psychiatrist today. I have an appointment with her about every other month, mostly just to manage my medication. There's a small arsenal of meds available to deal with bipolar disorder -- both the underlying illness and its symptoms -- but the two principal ones are 1) a prophylactic against manic episodes (typically lithium carbonate or, in my case, depakote), and 2) an antidepressant, for obvious reasons. The depakote works fine for me but in two decades I've never yet found an antidepressant that did any good. I've tried at least a dozen at various dosages and so far, no dice.

The latest candidate is Lamictal. Like any drug it has potential side effects, the worst of which, in this case, is a horrible death, to wit: "severe and/or life-threatening rashes and hypersensitivity reactions." For that reason you begin by taking a 25-day starter regimen that builds up the dosage very gradually so that if you're one of the unfortunate small minority who develops "skin rash; fever; hives; swelling of the lips, tongue, or face; sores in the mouth or around the eyes; or swollen lymph glands," you can discontinue the drug in time to avert the worst.

The fact that anyone would even fool with this should give some indication of just how bad these depressions can be. Actually, it's not how bad they are per se; it's how unrelenting they are.

Mood Watch - 2

2006-08-15T08:00:00.000-04:00

Third day of vacation. Mood still good and I'm sleeping better. Got nearly ten hours last night, and needed it after two days on the road.

Mood Watch - 1

2006-08-13T04:06:00.000-04:00

A couple of days ago I was talking with my therapist as I usually do most weeks. Since I have bipolar disorder my insurance is happy to pay for the visits. It's a lot cheaper to spend money paying for a therapist to supplement my psychiatrist and meds than it is to pay for a two-week hospitalization.

Anyway, I invariably begin the sessions by reporting on my mood. After that we typically move on to other subjects. Because my therapist -- a clinical psychologist -- is a standout in her profession and because I've been seeing her for a bit over eight years now, the experience has proven very helpful in coming to grips, not just with the bipolar disorder, but also with a lot of old wounds. Since I doubt I would ever have landed in her office except for the bipolar disorder, I suppose having this particular illness has not been entirely devoid of an upside.

On Friday we talked mainly about this blog and the direction I've decided to take it. I think she has seen this coming for a long time. She wasn't surprised. She thinks, more than I do, that I know what I'm doing. But at the same time when I mentioned the idea of using the blog as a place to keep regular track of my moods, she thought that was a good idea too. Hence the first in what I expect will be a series of posts published every day, or nearly so.

For the uninitiated, here's the basic symptomology, shamelessly cribbed from Harbor of Refuge.

Bipolar disorder involves cycles of mania and depression.

Signs and symptoms of mania include discrete periods of:
increased racing and rapid talking

Excessive "high" or euphoric feelings

Extreme irritability and distractability

Decreased need for sleep

Unrealistic beliefs in one's abilities and powers

Uncharacteristically poor judgment

A sustained period of behavior that is different from usual

Increased sexual drive

Abuse of drugs, particularly cocaine, alcohol, and sleeping medications

Provocative, intrusive, or aggressive behavior

Denial that anything is wrong
Signs and symptoms of depression include discrete periods of:

Persistent sad, anxious, or empty mood

Feelings of hopelessness or pessimism

Feelings of guilt, worthlessness, or helplessness

Loss of interest or pleasure in ordinary activities, including sex

Decreased energy, a feeling of fatigue or of being "slowed down"

Difficulty concentrating, remembering, making decisions

Restlessness or irritability

Sleep disturbances

Loss of appetite and weight, or weight gain

Chronic pain or other persistent bodily symptoms that are not caused by physical disease

Thoughts of death or suicide; suicide attempts

Got all that?

My mood for the past two weeks has been good. I have been able to focus and enjoy my work and I have not experienced any racing thoughts, euphoric feelings, or increased distractability. The one thing I have noticed is a decreased need for sleep. I get maybe five or six hours in any twenty-four hour period, and usually not all at one time. For instance, in the day just past I slept a total of six hours but in three two-hour increments. That's the one element right now that bears watching.

I'm up early this morning because I'm about to leave for a week or ten days of vacation. I travel first to Abingdon, Virginia, to see some old friends, and then on the Outer Banks of North Carolina where I've been invited by an Army lieutenant colonel to spend a few days with his family at their seaside condo in Duck, just north of Nags Head. As far as I know, I'll have regular Internet access, so at the moment I see no reason I won't be able to compose these daily posts. But if I miss a day or two, consider it no big deal.