Manic Depression
I first was introduced to manic depression while teaching undergraduate religious studies courses at a liberal arts university in the northeastern United States. During my first year at the university, I was asked to read an honors thesis on ethics and mysticism written by a religious studies major. It was an outstanding thesis, and the student, "Robert," was awarded honors in religious studies. Robert continued to live in the vicinity of the university for several years post-graduation, since his girlfriend was a student at the same university. We began a casual acquaintanceship, meeting for lunch or coffee every few months to discuss mysticism. Robert was a thoughtful young man, very bright, introverted, and depressed (although I didn't realize it then). As it turned out, Robert's girlfriend became a student of mine in a religious studies course during her senior year of college. "Maria" was also quite bright and presented as vivacious and energetic, but there was something a bit off that I couldn't quite discern. Despite her abilities, Maria had difficulties completing her work. Robert sometimes spoke to me about their relationship, and one day he told me she suffered from manic depression. At the time I knew virtually nothing about it. Maria had had a manic incident a few years ago, he informed me, during which she was found climbing a university building and had to be restrained. This incident had followed from her self-initiated withdrawal from lithium. One of the issues Robert faced was pressure from Maria's family to take care of her. It was becoming too large a responsibility for him, and a few years later I heard that he had broken off the relationship.
I felt sorry for Robert - he was a compassionate young man who really wanted to help Maria but did not know how. Indeed, it is difficult to know how to help someone with manic depression, or bipolar disorder as it is also known. In my present position as a chaplain at a psychiatric hospital, one facet of my work involves counseling patients diagnosed with manic depression. Not all are religious, of course, and I try to offer support when appropriate. Religious patients are more likely to seek my counsel, and in the following sections I discuss my work with several such individuals. Religious and spiritual resources, I believe, can be of great benefit in recovery, provided that individuals obtain assistance in discerning between healthy and maladaptive beliefs and behaviors. From a psychoanalytic perspective, the patient's use of religious symbols and beliefs express deeply ingrained convictions about the self and one's object-world. Yet the role of culture in manic depression should not be overlooked, and it will be addressed in due course.
Before proceeding, some background material on manic depression is in order. Manic depression is a relatively common psychological disorder, shown in one American study (Karno et al., 1987) as affecting between 0.8% and 1.6 % of the population or at least 1 in every 100 persons. Growing evidence suggests that the estimated lifetime prevalence of less than 1%, often quoted in Europe and
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the United States for bipolar disorder, may underestimate its true prevalence. Montgomery and Keck (2000), for example, suggest that at least 5% of the general population can be said to display features of the bipolar spectrum. Men and women are affected equally, and the disorder typically begins in one's late teens or early twenties (Goodwin and Jamison, 1990). There is strong evidence for a genetic vulnerability to manic depression. While long-term outcome is difficult to evaluate, Goodwin and Jamison assess that more than one third of bipolar patients seem to have some chronic (i.e., continuous) symptoms.
Manic depression strikes millions of persons in North America and Europe. Classified as an affective disorder, manic depression is characterized by mania and, most frequently but not always, depression. Depression and mania are primarily disturbances of mood, although disturbances in attention, thought, motor activity, and sleeping and eating habits often are found as well (Endler 1982). Goodwin and Jamison (1990) explain that manic states are typically marked by heightened mood, faster speech, quicker thought, brisker physical and mental activity levels, irritability, perceptual acuity, paranoia, heightened sexuality, and impulsivity. Endler (1982) elaborates:
In the manic phase a person may be over confident, elated, argumentative, angry, and irritable. Speech is usually rapid and incessant, grandiose plans are made that are unrealistic, changes from one topic to another are frequent, and poor judgement [sic] is often shown. An increase in motor activity sometimes reaches the point of meaninglessness and purposeless hyperactivity. Distractibility is prevalent, focusing on a task may be difficult, and sleep as a rule is only fitful, (p. 13)
In sharp contrast to the manias, bipolar depressive states usually are characterized by a slowing or decrease in almost all aspects of emotion and behavior: rate of thought and speech, energy, sexuality, and the ability to experience pleasure. In all of the depressive states mood typically is bleak, pessimistic, and despairing (Goodwin and Jamison, 1990). Endler (1982) explains:
The symptoms of depression include a sad, dejected and apathetic mood, a feeling of hopelessness, a negative self-concept and low self-esteem, indecisiveness, loss of appetite, loss of sexual desire, sleeplessness, loss of energy and interest, lethargy and agitation, guilt, lack of concentration, and often recurrent thoughts of suicide and death, (p. 13)
The cyclic and contrasting nature of manic-depressive illness is perhaps its most defining clinical feature (Jamison, 1993). Moreover, manic depression is one of the few psychiatric illnesses in which "shadow syndromes," such as bipolar II and cyclothymia, have been established (Ratey and Johnson, 1998). For example, a cyclothymic temperament is characterized by mild depressions and mild manias. Hypomania, associated with bipolar II disorder, is marked by an expansive mood,
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decreased need for sleep, increased goal-directed activity, and at times impulsivity concerning hedonistic behaviors (Newman et al., 2002). The changes experienced in hypomania are less severe than in mania and may or may not result in serious problems (Goodwin and Jamison, 1990).
From a psychoanalytic perspective, individuals diagnosed with bipolar illness exhibit characteristics similar to that of a toddler in the practicing-subphase of development. As Hamilton (1990) writes, "They [bipolar patients] deny their weaknesses and develop a sense of omnipotence. They attempt to do everything themselves and have difficulty accepting help. When frustrated, they can fly into tantrums or tirades" (p. 148). While externally, many bipolar patients display an omnipotent, "world-is-my-oyster mentality," inwardly they may feel hopelessly insignificant. I have observed this dichotomy in my own work with patients. Some express bravado on the hospital wards, for example, presenting themselves as far superior to the staff, yet in confidential conversations they are self-disparaging. For Melanie Klein (Mitchell, 1986), a feature specific to mania is the utilization of the sense of omnipotence to control and master objects. Winnicott (1958), Klein (1940) and Guntrip (1962/1969) describe ways that individuals with manic-depressive illness deny feelings of helplessness by turning them into their opposite, omnipotence, and the tendency to experience help as an insult.
