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Tuesday 26 August 2014

Review: Mania - A Short History of Bipolar Disorder by David Healy

Johns Hopkins University Press, 2008, 296 pages
Mental Disorder: Cultural or Biological?

Are mental illnesses biological or cultural? Do they emerge from a malfunction of brain development or biochemistry, or are they a product of the society in which they appear?

The answer to that question has profound implications for a science of mental health. If mental illnesses are primarily biological in origin, then effective treatment must at some level have a biological impact – and an edge is given to strategies that focus directly on the body: pharmacology, surgical interventions, and the like. The edge is not an outright win: Type 2 Diabetes is unquestionably a biological ailment, but it is often managed behaviorally; ditto chronic pain, much heart disease, and many other documented physical conditions.

If mental illnesses are predominantly cultural/psychological in origin, then treatment must surely address life and lifestyle rather than relying exclusively on pharmacological assists. One of the battles in mental health currently has to do with the reliance on antidepressant medication for depression in cases where the decline in mood and motivation seem clearly tied to circumstance.

In a related vein, the answer might be important in guiding public education efforts. If a biologically-caused and easily-treated disease sits, undiagnosed, in a population, then it makes perfect sense to spread awareness and try to ferret out the hidden cases so that they can be resolved.

If a disorder is cultural, public education efforts might inadvertently “spread the culture,” resulting in more cases. The fashions we see in mental illness – hebephrenic schizophrenia, bulimia, glove anaesthesia – suggest that we may be dealing with memes rather than genes.

In Crazy Like Us (reviewed earlier here), Ethan Watters documents the apparent spread of previously-rare anorexia nervosa in Hong Kong society following a well-intended public education campaign. Some clinicians, myself among them, now regret having taken part in “Depression Screening Day,” an annual patient-finding exercise funded in part through the altruism of the pharmaceutical companies who would then profit from selling product to the (almost invariably subclinical) cases thus discovered.

The Biopsychosocial Model

The traditional dodge to the physical/cultural dichotomy is to speak of biopsychosocial origins of mental illness.  Although appropriately inclusive – most problems have elements of all three (bio, psycho, and social), it can also be a way of avoiding the question. “It’s caused by something or other and we’re not going to look much further.”

It seems clear that the answer varies by illness. No one doubts the biological component of Down Syndrome, nor the experiential element in post-traumatic stress disorder, for example.

One disorder that most clinicians believe to be predominantly biologically-“loaded” is bipolar disorder. One reason for this is the often-miraculous effects of an appropriate dose of lithium in resolving a manic episode. Another is the existence of accounts of what can sound like bipolar disorder in the historical record. Cases described by Hippocrates, are often repeated at conferences as clear evidence that bipolar disorder is a “real” – that is to say biological – disorder, one that has been with us for millennia but only properly understood recently.

Mania: A Short History of Bipolar Disorder

David Healy is widely known as a psychiatrist and historian of psychopharmacology – and as a harsh critic of the role of the pharmaceutical industry in the research and testing of its own products. As a part of the Johns Hopkins University Press series of “biographies” of diseases he has traced the appearance of mania, melancholia, and bipolar disorder from Hippocrates to the present in a fascinating act of medical detective work that reads – at least to mental health nerds – like a whodunit. Maybe a whohasit or a whatisit.

Healy takes a closer look at Hippocrates than is customary, and as usual this reveals that things are not as simple as they seem. Take the story of the woman at Thasos, often cited as proof of the ancient existence of bipolar disorder:

A sensitive woman became unwell, having been sad after a loss, and although she did not take to her bed, she suffered from insomnia, loss of appetite, thirst, and nausea…[Later] she leapt up and could not be restrained. She began raving…

Is this an early case of bipolar 1 disorder?

Healy fills in the ellipses from Hippocrates' account with the deleted details, including fever, spasm, severe pains, and black urine “with substances floating in it.” Suddenly the bipolar picture dissolves, and the details recounted in modern times seem almost to have been deliberately selected to tell a story, as though they were cobbled together by a team from Fox News.

Healy shows that most of the ancient cases held up as examples of bipolar disorder do not fit the description of the modern ailment. Presentations that sound a bit like mania were more likely delirium, and many of the cases – particularly the postpartum ones - seem to have involved severe infections.

Well, so what? The ancients didn’t know what they were looking at, so it’s no surprise that they confused things. But Healy points out that very clear descriptions of other diseases can be clearly identified in the writings of Hippocrates and others. He makes a case that the search for historical precedents for bipolar disorder has been subject to a profound case of confirmation bias – if not outright distortion. As he continues to trace its history, bipolar disorder shimmers at the edges and fades as a distinct ongoing entity.

From ancient times Healy jumps fairly quickly to the 1800s, where he picks up the thread, looking at writers attempting to delineate the boundaries of mental normalcy and illness. He covers the creation of the asylums and the types of difficulties that might land a person within their walls. He talks about early psychiatrists, the alienists, who seem to have described mania and manic depressive illness first. He goes into detail on the lives and contributions of early classifiers of the types of disorder, including Falret, Baillarger, Kahlbaum, and (eventually) Emil Kraepelin.

Some of the best passages in the book concern the files of the Denbigh Asylum in North Wales, opened in 1848 and serving an area that had a relatively stable population for over a hundred years. This multi-year time capsule offers the opportunity to review shifts in symptomatology and diagnosis over time – and raises questions about the incidence of bipolar disorder.

“Sifting through 3872 admissions from North West Wales between 1875 to 1924, it becomes clear that bipolar disorder patients are hard to find. Only 127 such patients were admitted for the first time during this period. This gives rise to 10 cases per million per year, a rate that remained constant across fifty years and continues to hold true to today.” (p. 86).

He further states “there were few if any patients in the Western world described as having manic-depressive disorder before the 1920s. In the United States, few patients had this disease before the 1960s.” (p. 20)

Later he traces the marked upswing in diagnosis: “The National Comorbidity Study reporting in 1994 estimated that 1.3 percent of the American population had bipolar 1 disorder alone. By 1998 Angst was reporting that 5 percent of the population had bipolar disorder of one or another sort.” (p 149)

Treatment Issues

The second half of the book focuses on the treatment of bipolar disorder, including the discovery of lithium’s effects and the subsequent adoption of a variety of other medication-based approaches. This area, the history of psychopharmacology, is Healy’s great forte and his grasp of both the published literature and the backroom politics seems formidable.

Healy reviews how marketing strategy dictated much of the professional education about bipolar disorder for decades, and how this shaped the field and the public consciousness (including the spread of the previously-unheard-of practice of diagnosing very young children with bipolar disorder, then commencing medication treatment using antipsychotics).

Healy’s sense of outrage is palpable regarding how profit motives have distorted the careful development of knowledge about mental illness and its treatment. In reserved though sometimes acid prose, he builds his case that although bipolar disorder is a genuine and treatable condition, it has been subject to such marketing pressures that it has become difficult to see the reality through the haze of disinformation.

The book is seemingly focused narrowly on mania, making it appear to be a marginal reading choice for most clinicians. But Healy has expanded the topic well beyond these boundaries, creating a sweeping and entertaining history of mental health as a whole. He does not shy away from controversy, and it is clear he has no great fondness for the present state of his field.

I sometimes wonder what I would say if someone asked me for a mental health syllabus – something that no one is ever really likely to do. This book would unquestionably be on that list. In fact, I would regard it as essential reading for any clinician treating the mood disorders.

Monday 4 August 2014

Resources: Welcome to the NHK and the Hikikomori Phenomenon

On Tuesday November 18 at 7 pm at the Vancouver Public Library I will be offering a talk entitled “Failure to Launch: The Lost Boys Phenomenon,” about the huge numbers of young, anxious, and unmotivated males who remain in their parents’ home, neither working nor attending school, all but housebound.

Although often bearing strong similarities to agoraphobia and social phobia, this phenomenon does not fit comfortably within any established formal diagnostic category. Nor should it, in my view. We have defined quite enough aspects of human experience as diseases, thank you very much.

The lack of a diagnostic label, however, has meant that different practitioners and researchers have observed and reported on the phenomenon almost independently of one another. Consequently, we have multiple accounts from different countries from different perspectives that are relatively untainted by preconceived notions imposed by the early investigators.

Shoshanna Campbell, helping out at Changeways Clinic for the past few months, has been looking through some of the research for this talk. She has unearthed papers on the topic from cultures all over the world. In Great Britain, for example, the term most often used is NEET – Not in Employment, Education, or Training.

The largest literature, however, comes from Japan, where these young men are known as hikikomori.  Nowhere on Earth has the problem penetrated popular culture like it has in Japan, where estimates have been made that there are an estimated 700,000 young people living these sharply restricted lifestyles. (Estimates for the incidence of issues related to mental health are almost always exaggerated, so it’s best to take these numbers with a grain of salt.)

Hikikomori regularly appear in the news and other media in Japan. In 2002, Tatsuhiko Takimoto published a novel with hikikomori characters, Welcome to the NHK, that was subsequently made first into a manga series and then into an anime television series.

Although I’m not generally an anime fan, I’ve spent part of the past week going through this series (available in a dubbed edition in North America). I have repeatedly been struck by the insights in the series and how closely the experiences of the characters mimic those of clients I have seen in therapy.

These individuals inevitably feel alone and unique. Because they know almost no one, they meet few who are similar to them. I’ve thought often while viewing Welcome to the NHK that I wish my clients could watch the series. Most would be astonished to find aspects of their own lives played out on screen, appearing within the setting of a Tokyo apartment block.


The series begins by introducing us to Tatsuhiro Sato, a 22-year-old who dropped out of college four years before the series begins after suffering what seems to have been a severe panic attack. He has lived ever since inside his tiny one-room Tokyo apartment, imagining that the NHK (Japan’s real-life public broadcaster, but within the context of the series a more wide-ranging organization) is behind a national conspiracy to create hikikomori by producing addictive programming – a delusion that persists and reappears when he is under stress. He rages against his next-door neighbor who blares theme music from an anime series apparently designed for young girls.

The neighbor turns out to be his old school friend Yamazaki, who would be hikikomori himself if he did not have to get out for classes at a school for game designers. A mysterious girl, Misaki, recruits Sato into her “project,” which is to cure a hikikomori with a mix of Freud, Jung, and exposure-like excursions into the outside world. Along the way we encounter suicide clubs, multi-level marketing schemes, polypharmacy, internet pornography addiction, and “girl games” designed to appeal to dateless young men.

The two young men become inspired to create the girl game to beat all girl games, using their ability to understand the longing and isolation of the players of such things as their trump card. I found myself concerned at this point, given the American imperative that any such quest must pay off with wild success in the end, thus countering any shred of realism in the plot up until that point. But Welcome to the NHK has bigger fish to fry, and chooses instead to side with a more sobering reality. The resolution they seek is a relinquishment of narcissistic self-aggrandizing fantasy and a coming to terms with the real world.

Episode 1, the link to which is below, gives something of the flavour of the series, though the conspiracy element quickly fades to the background in subsequent episodes only to recur in snippets. Watching the series should probably come with Continuing Education credits for professionals, given that it constitutes a virtual seminar on the inside world of the problem. At least some episodes are available on YouTube, and the full series is available on DVD (e.g., at Amazon).

Why might Welcome to the NHK be useful for western clinicians? 

Attend any North American seminar on an established phenomenon, and it will tend to resemble other local examinations of the same problem. Attend three seminars and you can sleep through the fourth: Nothing new will be said.

But view a phenomenon from the perspective of another culture, and the focus will be on elements that you have not seen highlighted in programs from your own culture. As a result, it is often possible to learn more from programs from another culture than those from your own – even if you’re not trying to cultivate your cross-cultural sensitivity.

Welcome to the NHK is a terrific introduction to NEETs, Hikikomori, Lost Boys, and the Failure to Launch phenomenon – both for professionals and for those currently stuck in such lives. The series includes difficult elements (including recurrent references to suicide), so it’s best not prescribed unless the prescriber has first watched it in its entirety. Luckily, that’s not hard to do.

Frankly, I’m surprised the English-language distributor, Funimation Entertainment, hasn’t targeted the clinical market, given that the product they are sitting on is so completely suited to it.

YouTube VLog

I have now launched a YouTube VLog on psychological topics called How to be Miserable, with new posts every Tuesday and occasional Thursdays! Come take a visit and see what you think. Consider subscribing (just press the big red SUBSCRIBE button on the page) to ensure that new videos appear in your YouTube feed.  One of the primary topics will be the Hikikomori phenomenon. Here's the intro video:

Online Course

What if one wants to overcome this tendency? One strategy is to seek the assistance of a qualified psychotherapist - preferably one trained in cognitive behavior therapy.

In addition, our clinic has developed a cognitive behavioral guide to self-care for depression. The strategies for working with depression and those for establishing one's adult life are extremely similar. Though not a substitute for professional face-to-face care, UnDoing Depression may be a useful adjunct to your efforts.  The preview is below. For 50% off the regular fee of $140 USD, use coupon code “changeways70” when you visit our host site, here.

We also have courses for professionals and for the public entitled What Is Depression, What Causes Depression, Diagnosing Depression, Cognitive Behavioral Group Treatment of Depression, How to Buy Happiness, and Breathing Made Easy. For the full list with previews and substantial discounts, visit us at the Courses page of the Changeways Clinic website.