Wednesday, August 10, 2011
Bi-polar disorder can be a lifelong illness
Bi-polar disorder can last a lifetime. Although, there are often periods that are symptom free, bi-polar disorder is a recurrent illness. It is estimated that 90% of those who have a manic episode will go on to have future episodes. Often, episodes of depression and mania can follow quickly, at times caused by the medication used for treatment. In my experience, it was common to see patients become manic after a depressive episode as a result of the introduction of antidepressants.
Bi-polar disorder is viewed primarily as a mood disorder. But it is common for people with serious bi-polar disorder to have some symptoms of thought disorder associated with difficult episodes. Psychosis that may include hearing voices or paranoia may be part of the symptom pattern. These may occur during the extreme phases of mania or depression. Whether the symptoms are primarily mood symptoms or thought symptoms, the person’s ability to have good judgment is impaired. The incident I recount is an example of how the illness can be a lifelong problem.
The woman with the knife to her throat was shrieking at me through the door, “I’m going to kill me! There’s nothing you can do to stop me.” When I peered through the glass I saw the big kitchen knife, the largest in the set, clasped in her right hand, the sharp edge against her throat. Four dogs surrounded me on the small deck in front of the trailer, barking furiously and nipping at my legs. All of them were old and tired, but could not ignore their master’s screams.
Mrs. Johnson must have been in her mid-seventies. She’d had a lifetime of bipolar disorder and had spent from her early twenties through her forties at Willard Psychiatric Center, a big old fashioned state hospital in farm country along Seneca Lake in upstate New York. She’d had several hundred electro convulsive therapies (ECT) also known as shock treatment. She’d had insulin shock treatment that involved insulin injections that made her comatose. In the late 1950’s she’d been scheduled for a lobotomy, but had improved enough to escape that procedure.
She was a patient at the county outpatient clinic for twenty years and like everyone who had treatment there I’d looked at her records, including volumes from Willard that filled four three ringed binders. They didn’t tell me much about her, but they did tell me what happened to her; the treatment they provided, the long years she’d spent “improving”. Her family information introduced me to a rural extended family that lived along a few roads in a deep valley a dozen miles from Ithaca. Their ancestor was one of the original settlers of the Finger Lakes who’d fought in the revolutionary war and received a land grant. He’d then purchased more grants to create a homestead of a couple of thousand acres. Now days the family has a broad reach of education and vocation. They are dirt farmers, shade tree mechanics, college professors, nurses and every other sort of person a family can produce in over 200 years. What they had in common was the land that the family inhabited in every form from mcmansion to broken down trailer. It appeared that no family member ever left. When you reached 18 or got married or returned from college, they cut out a piece of land and it was yours. That was how Mrs. Johnson got her two acres. A cousin drilled a well, someone else brought in a backhoe to dig the septic system and after the electric pole was put up her brother brought in a ten year old trailer and set it on cinder blocks. It was a single wide, long and narrow, surprisingly pleasant and comfortable on the inside.
In recent years, Mrs. Johnson had been doing very well, taking her medications, having her blood work done and eating and sleeping on a regular schedule. She was an avid gardener. The flowers that lined her path and surrounded the base of her trailer began to bloom in early spring with daffodils and ebbed and flowed throughout the summer and fall, a riot of color that reflected many of Mrs. Johnson’s moods.
This latest episode had begun almost two months earlier, when at a regular clinic appointment she announced to her psychiatrist that she had stopped taking her medications. When the doctor presented her case in a meeting, he described a failed attempt at reminding her that two thirds of her life had been taken from her by illness and that she currently had a terrific existence that she was putting at risk. Her response, read from his notes stated: “I don’t care one damn bit about your opinion. I feel fine, better than I felt in my whole life and I don’t need your pills.” Our crisis team had one more name added to out “hot” list.
From that time until my visit, it had been like watching a slow motion train wreck. First her brother called, heartbroken but resigned, he described her coming to his house at two in the morning to renew a family dispute from a decade earlier. Her family doctor called me the following week to say that she’d shown up without an appointment demanding he give her a prescription for birth control pills because she was going to become sexually active. Next, was a State Trooper who had written her a ticket for speeding and passing a school bus. “She was really crazy. I don’t know what you can do, but you better do something because she’s going to hurt someone.” I’d visited her at home twice and she yelled at me through the door. Two days earlier she’d hung up on me when I called. Her mania had moved into an agitated depression that had her lashing out at anyone she had contact with.
That morning her brother called as soon as I got to work. “She is out of control. You need to bring the cops with you when you come.” I walked away from the door when I saw the deputy’s car stop near the edge of the property. When I waved, he pointed his thumb backwards and reversed the car, hiding it behind a row of bushes. When I got to his door he got out, unfolding himself to a height of 6’6”. He was as broad as he was tall. We’d known each other for a while and I was happy he’d been the one on duty. “What have we got?” He asked. When I told him, he said, “Oh yeah, I dealt with her before. She can really get going, but otherwise she’s a nice old lady.
He went to the trunk of his car and got a pry bar. “Anybody else coming?” I asked. “Nope! Sorry, but there was an accident up at the airport and the trooper from this side of the lake is up there. I called an ambulance; they’re about three minutes out. It’s just us playing cowboys and Indians by ourselves. Here’s the plan: If she knows I’m here that will make it worse. So, I want you to go to the door and see if she’s still screaming with the knife. I’m going to sneak up along these bushes and get in next to you. Try to get the dogs behind the screen door when you open it. I’m going to pop the door with this bar and land on top of her. You get the knife.”
As I walked past her car I opened the rear door and three of the dogs jumped in. That got me a thumbs up from the deputy. Approaching the trailer, I could hear that the screaming was louder. Up on the porch I wrapped my jacket around my right hand and got in place while the deputy, who’d come up behind me, placed the bar between the door and frame. “Go!” He yelled. The door hit her when he banged through it and he was on top of her trying to hold her arms. I put my coat on the knife and pushed it to the floor. I then carefully pried her fingers off the handle and pushed the knife away. He rolled her and cuffed her and called the EMT’s on his radio to come and get her.
Her brother was walking down the road towards us while they were loading her onto a stretcher into their rig. “Hey Andy”, the deputy called, “good to see you. When you come over next week, bring your boys, we’ve got some new dirt bikes.” He turned to me, “Andy’s married to my wife’s cousin.”
The stories are my remembrances. Each of them is based on a true event in my work for Tompkins County Mental Health in Ithaca New York. I have changed the names of every client, patient and co-worker except for Beau Saul, of the Ithaca Police Department, who I was fortunate enough to have as a partner. When confidentiality demanded it, I have changed details. The dialogue is my reconstruction of what was said at the time. I have felt honored to be let into the lives of so many individuals over the years. Their stories are a gift I have been given. Please enjoy them in the spirit with which they were written; to educate and inform.