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

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

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

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

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

“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

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