Sunday, August 8, 2010

Message to the "Flat Affect" People - We Don't Want to Be Like You

My last blog piece was a rerun involving a section of a grand rounds lecture I gave at a Princeton psychiatric facility two and bit years earlier. That part was called "The Problem Clinician," which went over like Slobodan Milosevic at a war crimes tribunal. We pick up on the action (drawn from two previous blog pieces and a book I am working on) ...

The first part of my talk - "The Problem Patient" - went somewhat better.

'Marilyn walks into your office," I began. "She reveals her moods have been all over the place. Everything points to bipolar. Okay. How do you treat her?"

Believe it or not, no one raised their hands. I was the one who had to suggest that a mood stabilizer might be a good idea, then I had to make sure we had a consensus. Then I went to the catch, namely how does the most important person in the equation - the patient - feel? After all, even the best med in the world is useless if patients won't take it.

Maybe we need to ask Marilyn a few more questions, I suggested. Consider:

Marilyn is literally larger than life. Over the top is her baseline. It's a legitimate part of her personality. How long do you think she is going to stay on her mood stabilizer if she thinks her personality is getting medicated out of her?

Hypomania is the first thing to come to mind when thinking of Marilyn, but the operative word from the DSM regarding this type of behavior is "uncharacteristic."

"For someone else to act like Marilyn," I said, "that may be hypomanic. For Marilyn to act like Marilyn - that's normal."

"Keep in mind," I said, "a lot of us view the world through the eyes of artists and poets and visionaries and mystics. Not to mention through the eyes of highly successful professionals and entrepreneurs. We don't want to be like you."

How can I describe the look of surprise from my audience? Like I had let rip a roof-rattler and they were too polite to laugh - I think that best sums it up. Honestly, I’ve experienced seaweed with more personality. Then I blurted out: “To me, you all have flat affect.”

Kelvin grade frozen stony cold silence. And this is the part of my talk that went over reasonably well, mind you. At this point I should have tossed away my script and tried to engage them in a dialogue. “Why should this be a surprise to you?” I should have asked. “Let’s talk about this. Tell me where you’re coming from.”

We - those of us living with bipolar - are obviously a lot more animated than the general population, but the way I see it is that not all of this is pathological. Quite the contrary - the rest of the world should be more like us.

A year after my talk, I was in LA touring the brand new Grammy Museum with a good friend of mine. Louis Armstrong happened to come up on the film display. “I love this guy!” I enthused. I practically levitated off the floor.

My friend does not have bipolar, but, for lack of a better term, I would describe her as having a “bipolar personality.” She sparks and sparkles. Not surprisingly, she is drawn to similar people. My over-reaction to Louis Armstrong was music to her ears. She wasn’t dragging a block of wood around the museum with her. 

“Look at that!” she blurted out, several exhibits later. “Three of these people had Martin guitars!”

Yes! I had just noticed the same thing!

From my point of view, I felt emotionally safe. I did not have to worry about a disapproving reaction. I could be myself. I could experience the moment. More important, I had someone I could share the moment with. Neither of us have time for boring. Smart, funny, intellectually curious, creative, and lively are just some of the traits we are drawn to.

But there is the obvious downside, especially when it comes to romantic relationships. But life with the “flat affect” people? I can’t even begin to imagine it.

Two years later, I would be addressing a Depression and Bipolar Support Alliance (DBSA) state convention in Kansas. The audience were mostly individuals living with either illness. "We are peanut butter people trying to fit into a tofu world governed by Vulcans," I related. I had to pause for the laughter to die down. They got it instantly.


Chambly Noire said...

Diagnosis: Bipolar II & ADD
Effexor XR 150 mg 1x/day
Abilify 5 mg 1x/day
Wellbutrin SR 100 mg 1x/day
Adderrall XR 60 mg 1x/day

I have "flat affect" often. Being on mood stabilizers and antidepressants for 15 years does that to a person (I've been on the cocktail above for 8 years). I like the way I am able to function on my meds, but hate feeling unemotional much of the time. I'm afraid that, if I were to go off of my meds, my entire life would fall apart. Do you have any suggestions for me?

John McManamy said...

Hey, Alyssa. I can't make any meds recommendations. But you might want to ask yourself this:

When you were first put on your cocktails, the meds probably needed to do all the heavy lifting. No doubt, over the years, you have acquired deeper insight into your illness and how to manage your triggers and make smart lifestyle choices.

It's obvious you've been compliant and are very responsible. So, you might be asking yourself: In my case, with high-dose recovery techniques, is it possible to go with low-dose meds?

Psychiatrists tend to err on the side of caution and over-medicating us. They tend not to distinguish crisis situations (when over-medicating is appropriate) to restoring us back to fully functioning (when over-medicating us clearly is not).

You may very well need to stay on your meds. But you are certainly justified in reappraising your situation and in giving your psychiatrist the third degree. The onus is on him or her to justify why you need to be on any given med - not on you to take it without question.

In my case, I needed to be on higher doses for a few years till I became proficient at various recovery skills, such as mindfulness. These things take time to master.

When I lowered my doses, I got my feelings back, but it did come at a cost, such as more anxiety and stress, as well as a greater range of ups and downs. But these are things I'm am willing to put up with, as they don't run my life off the rails, and they're a fair price to pay for being able to laugh my ass off and to grieve and otherwise experience my emotions.

Once again, I'm not an MD and I can't tell you what to do. I can only point out things that you need to be thinking about, and to weigh the risks very carefully.

Hope this helps ...

Chambly Noire said...

It does help. I've never thought of the differences inherent in dealing with a crisis situation and maintenance--though now it seems quite obvious.

Thank you.

Willa Goodfellow said...

I want to emphasis one of John's comments to Alyssa -- reinforcing John's constant message, what he means by recovery techniques. Are you learning to manage your symptoms, or relying on meds to do the whole job? Are you dealing with life style issues, diet, exercise, stress, triggers? Do you have a support group? Are you in therapy? Life style, support group, therapy and meds are the total package. Don't try shortcuts.