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Bipolar Disorder

Review of "The Hypomanic Edge"

By John D. Gartner
Simon & Schuster, 2005
Review by Nassir Ghaemi, M.D., M.A., M.P.H. on Nov 28th 2005
The Hypomanic Edge

In the psychoanalytic era, it was common for almost every paper to come back to one theme: the Oedipus complex (or variations on libido, sexuality, and repression).  It was a tired story; one could predict the result no matter what the starting point.  Consequently, the field of psychohistory until recently had become discredited.  This is no way to write any variation on history -- to start with the outcome preordained, and then to make the historical facts fit one's theory.  Even Freud committed this sin. His book on Woodrow Wilson, coauthored by William Bullitt (US ambassador to France and a friend and patient of Freud's) was so horrendous that Freud's family tried for years to deny his involvement.  To describe everything Wilson did as the result of his passive relationship with his father was just ridiculous.  As the great historian of psychoanalysis, the late Paul Roazen, recently wrote in his last published essay (Times Literary Supplement, 4/22/2005), Freud was indeed heavily involved in that book.  If the best psychoanalyst fails at psychohistory, one would expect a great deal of caution among others.

Gartner appears not to be familiar with the history of psychohistory, and he has merely replaced the psychobabble of the past with contemporary biobabble. 

This book is organized around 6 chapters of biography, and a clinical introduction and conclusion.  The non-biographical chapters, which constitute the clinical and conceptual core of the book, constitute only 20 pages. 

Gartner, a clinical psychologist, writes well, and the biographical chapters (about Christopher Columbus, Alexander Hamilton, Andrew Carnegie, Craig Venter, and a few others) are engaging and entertaining.  Simply as historical chapters, one learns tidbits of interest regarding these persons, and the juxtaposition of these leaders from different fields gives one a sense of some of the qualities of leadership.  Also, Gartner, in his acknowledgements, clearly made an effort to interview many leaders in bipolar disorder research.

Yet, the author's treatment of the issue of the risks of diagnosing mental illness in historical figures is quite superficial.  He simply argues that psychiatric diagnosis is primarily based on history, and such historical evidence exists with many persons.  He then interviews biographers of Alexander Hamilton, and uses a 5 point scale to elicit their agreement about evidence for hypomanic symptoms in his life.  He thinks he thereby "proves" that Hamilton had bipolar disorder type II.

As a researcher in bipolar disorder, I diagnose it quite frequently, and I am sympathetic to the bipolar spectrum model:  I agree that we should be more attuned to recognizing hypomania than we are.  But Gartner, as a historian, has written a book reminiscent of those psychoanalysts who saw the Oedipus Complex everywhere.

Examples are frequent; a few should suffice:  Columbus told the Spanish monarchs that he wanted a share of the loot of the New World and some titles:  "His hypomanic grandiosity was breathtaking."  Hamilton stayed up pall night to write a letter:  "The ability to work on little sleep is one fo the m ore concrete diagnostic criteria for hypomania."  Carnegie said "Whatever I engage in I must push inordinately" -- "That was his hypomanic temperament, which he had inherited from his grandfathers."   Craig Ventner said "F--- off!" to a military superior:  "a typical example of impulsive behavior with potentially painful consequences (one of the diagnostic criteria for hypomania)". 

Apparently, anyone who ever says "F--- off" is hypomanic and thus bipolar. (Gartner even diagnoses Theodore Roosevelt as bipolar in a mere footnote (p. 181)). 

The problem with this approach is that it misunderstands the nature of diagnostic validation.  Clinical symptoms in general often overlap between clinical syndromes and normal behavior. Thus, one might say "F--- off" and be the mentally healthiest (though not the most polite) person in the world, or one might do so and be manic, or hypomanic, or depressed, or anxious, or schizophrenic, or in the midst of a panic attack, or….  Clinical symptoms alone do not distinguish hypomania from any other syndrome or from normality.

This is why, in diagnostic research in psychiatry (nosology), the classic approach is to seek to obtain evidence of diagnostic validation from more than just the clinical symptom level.  The other levels used are family history (genetics), course of illness (age of onset, number of episodes, duration of episodes, related stressors), and response to treatment.  In his brief biographies, Gartner occasionally describes family history, but gives us little evidence on course, and none on treatment.  Thus, while it is possible that these ebullient individuals might have been hypomanic, he hardly proves his case with any one of them. 

In contrast, if readers want to read psychologically-oriented history that is much more respectful of both the disciplines of history and psychology/psychiatry, they should refer to the recently published Lincoln's Melancholy, by Joshua Wolf Shenk (2005).  There he carefully correlates all four aspects of diagnostic validation (including treatment Lincoln received for severe depression) much more convincingly than in this book.  Further, Shenk brings out how Lincoln's life story grew organically out of his depressive experiences, as well as how those lessons he drew affected his political beliefs and activities. By contrast, Gartner's biographies are one-dimensional stick figures.

The only relatively convincing story for bipolar illness in this book is the only living person whom Gartner actually interviewed: Ventner.  There is enough detail in that biography to support a probable bipolar-like diagnosis (probably DSM-IV defined cyclothymia).

Despite his interviews with bipolar researchers, Gartner states in his acknowledgements that "I have admittedly synthesized [the bipolar literature] in my own idiosyncratic way."  Such synthesis in the hands of an experienced researcher or clinician might be acceptable. Indeed the book states that Gartners has "published widely in medical journals." However, a Medline search fails to identify a single article published by Gartner on bipolar disorder, and nothing on hypomania (in fact, only one article was found by a JD Gartner, as one of seven coauthors in a 1991 study on personality traits).  While this absence of personal expertise does not disqualify any mental health professional from writing about any topic, it is relevant to readers who may be misled by the book to believe that the author has much personal expertise on this topic. 

The version of bipolar disorder described in this book is indeed idiosyncratic, and though I would not disagree with the idea of a broad definition of bipolar illness (though many clinicians and researchers do reject this notion), I am afraid that many important nuances of bipolar illness are simply missed in this book.  The superficiality of the treatment of bipolar disorder in this book is not necessary simply because it is a popular book. (Kay Jamison manages to avoid this fate). Examples include the following:

Gartner makes much of hypomania as a life-long temperament, though at times he emphasizes its episodic nature as part of type II bipolar disorder (brief hypomanic episodes usually lasting days to weeks, alternating with months of recurrent severe depression).  In general, persons with type II bipolar disorder are not extremely productive, since their depressions far outlast their hypomanic periods.  On the other hand, "chronic" hypomania is not yet an agreed upon diagnostic entity (not found in DSM-IV).  There is such a thing as cyclothymia (episodic hypomania, alternating with mild depressive symptoms), which is more functional than type II bipolar disorder, and would seem to characterize some of the persons Gartner wants to call hypomanic (like Ventner perhaps).  But, more to the point, chronic hypomania as a personality state is called "hyperthymic" personality, and there is a good deal of literature on this topic.  Yet Gartner never uses the phrase, nor refers, as best I can see, to any of the relevant studies on that topic.  Perhaps he knows about this and wanted to make the book more accessible by only using the term hypomania, or perhaps he does not know about the difference.  In any case, it would have been more scientifically accurate to make the distinction, as well as to point out the diagnostically iffy nature of hyperthymic personality. (I personally think it is likely valid, but mainstream psychiatry has not yet accepted the notion). 

He says at one point that depression often is not associated with functional impairment, while hypomania is.  This is a key problem throughout the book. In the introduction, Gartner acknowledges that the symptoms for mania and hypomania are the same, but the distinction has to do with the severity of the symptoms, such that with mania they lead to "significant social or occupational impairment."  Indeed, such is the case; and any objective reading of these biographical vignettes would indicate that much of the time, the "hypomanic" symptoms described lead to significant social or occupational impairment (making them manic, instead of hypomanic, symptoms).  This again may seem minor, but by blurring this distinction, and calling hypomania what may be mania, Gartner is confusing our understanding of bipolar disorder and its relevance for society.  Especially for patients, about half of whom lack insight into manic (or hypomanic) symptoms, such blurring would potentially make them less likely to appreciate the negative aspects of their manic episodes.

Furthermore, the DSM-IV definition of hypomania is one of the few conditions in which one cannot have significant social or occupational impairment for the diagnosis to be made.  Thus, the statement that hypomania is associated with such impairment in that it is observed often by family and friends, while correct for mania, simply is wrong, as it stands, for hypomania.  Indeed depression usually is associated with such impairment, by contrast, and numerous studies show that depressed patients are highly aware of their symptoms, unlike manic (or hypomanic) patients.

A thoughtful book about the positive aspects of hypomania or mania would be useful.  But a book that is expansively unconvincing has the potential side effect of romanticizing, or insufficiently emphasizing, the negative components of bipolar illness as well.  Gartner claims to make the distinction in his introduction, by referring to manic episodes as severe illness, yet throughout the book he persists in calling things hypomania which seem, at least to my clinical observation, to meet current criteria for mania instead.

One aspect of this problem, again never mentioned, is that hypomania is the most unreliable DSM-IV diagnosis.  Clinicians disagree on it the most; whereas mania is much more reliably diagnosed. Thus, there is a great deal of disagreement (not only cross-culturally but within clinicians in a single country) about which patient is hypomanic versus manic versus normal. 

Though the author cites Kay Redfield Jamison in his acknowledgements, Jamison's own work is far more convincing, clinically sound, and historically thought-through.  I would suggest that those interested in this topic should use their time instead to read Paul Roazen, first and foremost, if they want to see the most adept application of psychology to politics and history (Canada's King: An Essay in Political Psychology, Mosaic Press, 1999); or Joshua Shenk if they want to read the best contemporary example (Lincoln's Melancholy); or Kay Jamison if they want to read a much better clinical work in relation to bipolar disorder and historical figures (Touched with Fire, Free Press, 1994). 

As for this book, one might be inclined to summarize the text as impulsive, exuberant, and going far beyond the evidence. (Perhaps the author was hypomanic.)

© 2005 Nassir Ghaemi

 

Nassir Ghaemi, M.D., M.A., M.P.H., Associate Professor, Department of Psychiatry and Behavioral Sciences; Director, Bipolar Disorders Program, Emory University School of Medicine. Dr. Ghaemi is author of The Concepts of Psychiatry: A Pluralistic Approach to the Mind and Mental Illness, Johns Hopkins University Press, 2003.

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