Category Archives: Film

Bipolar Disorder

Britney Spears

Bipolar affective disorder (BAD) is a lifelong psychiatric illness characterized by severe and extreme mood instability. Also referred to as manic depression, people with bipolar fluctuate between periods of intense high and low moods like baseball fans following their beloved team deep into the October playoffs (Go GIANTS!!!). Many mainstream films have portrayed characters suffering from BAD – Mad Love, Bulworth, Running With Scissors, and King of California. Numerous famous folks have also been associated with the illness, including Beethoven, Edgar Allen Poe, Vincent van Gogh, and Britney Spears.

As its name suggests, people with bipolar vacillate between poles of euphoria, irritability, and depression, like a perpetually swinging pendulum. The mood episodes are sustained, autonomous, and occur independently of external circumstances and are not caused by substance use. For example, a person who flies high on cloud nine by winning the lottery, falls despondent after carelessly losing the winning ticket, and then becomes enraged when intoxicated at the bar is not bipolar. Moreover, people who experience severe mood instability that is triggered by interpersonal relationship difficulties are often misdiagnosed with BAD, but instead may suffer from borderline personality disorder (BPD).

The expansive or abnormally irritable moods are referred to as mania or hypomania, with the former being more intense and severe.  A manic episode lasts for at least one week and is accompanied with symptoms such as decreased need for sleep, grandiosity, hypertalkativeness, racing thoughts, increased goal-directed behavior, and impulsivity in pleasurable activities like spending money and sexual indiscretion. Psychosis may even ensue. Feeling energetically on top of the world, manics may generate many creative and innovative ideas. Our world would definitely not be as advanced and inspiring as it is today without the actors, entrepreneurs, mathematicians, musicians, and writers who lived with bipolar disorder.

Mania becomes concerning and problematic when people begin to lose their insight and judgment, making ill-advised decisions and engaging in destructive behavior – remember Britney Spears shaving her head completely bald and attacking an SUV with an umbrella? Social and occupational functioning may be profoundly impaired, necessitating involuntary inpatient hospitalization and mood-stabilizing medications.

Depressive episodes are more psychologically distressing to the individual than manic ones. Would you rather be anhedonic and socially withdrawn or elated and running around Nordstrom maxing out your credit cards?  Depression occurs 3 times as often than mania and raises the risk of suicide. Up to 50 percent of people with BAD attempt suicide, and 15 percent die from completing it.  Kurt Cobain, who was suspected of suffering from bipolar depression, sadly ended his life with a self-inflicted gunshot wound to the head.

BAD is a chronic illness which causes episodic and persistent functional debilitation. Psychiatric treatment is necessary to stabilize mood and maintain day-to-day functioning. Referred to as an illness that “benefits mankind at the expense of the individual,” I wonder if the aforementioned famous manic depressives were aware of their generosity in bestowing upon us The Fifth Symphony, The Tell-Tale Heart, and Starry Night, respectively. And I certainly cannot forget to include Oops!…I Did it Again.

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Darkness


Shutter Island (2010)

Shutter Island, the recently released psychological thriller, fortified by the Scorsese-DiCaprio combo, brings to light the dark history of psychiatry (I will not reveal any spoilers, so no need to fret if you plan on seeing this movie). I definitely recommend this film- it’s gripping, eerie and suspenseful, and not gratuitously scary. I watched the movie with several of my psychiatry co-residents, and most of us were quite impressed.

The story is set in the 1950’s, which happens to be a revolutionary period in psychiatry. Two key medications were discovered around that time to treat severe mental illnesses once thought to be unmanageable. Lithium, a mood stabilizer, was used in 1948 to successfully treat bipolar disorder and Thorazine was found to be the first effective antipsychotic medication to treat schizophrenia in 1952.

The use of medications to treat mental illnesses, or psychopharmacology, was instrumental to paving the way to deinstitutionalizing psychiatric patients- that is, transitioning patients from living permanently in locked institutions to living functionally in the community. Prior to the practice of psychopharmacology, many of the therapeutic methods of psychiatric treatment in the early part of the twentieth century were not only experimental, but harsh, cruel, and extreme.  The one that undoubtedly ranks at the top is the lobotomy.

Lobotomy is a surgical procedure performed to damage the frontal lobe of the brain, which sits directly behind the forehead. This region of the brain is essentially what differentiates us from other animals. It functions to help us make complex decisions, express our unique personalities, and engage in acceptable social behaviors. Without a functional frontal lobe, we would be no better than a donkey (and I’m not referring to the one in Shrek– that donkey has personality, albeit inappropriate). The most infamous type of lobotomy was the transorbital lobotomy, developed by Dr. Walter Freeman in 1946.  He made it a 10 minute “office procedure” using mainly an ice pick and a hammer, approaching the brain through the roof of the eye socket (you’ve got to click on the link to see for yourself).

The premise behind the lobotomy was that psychiatric illnesses were a result of malfunctioned nerves connecting the frontal lobe to other brain regions. In turn, severing the faulty nerves will allow for new healthy ones to regenerate, thus relieving the psychiatric symptoms.  This hypothesis proved costly to be invalid and wrong, at the expense of many patients.  Sadly, despite being a controversial procedure even since its introduction in 1936, it was commonly used and widely accepted by the medical profession in the 40’s and 50’s. By 1951, almost 20,000 lobotomies were performed altogether in the US.

Fortunately, with the advent of the antipsychotic medications in the 1950’s, lobotomy died off almost as abruptly as it rose up (although psychosurgery is still currently indicated and effective for severe OCD). The beginning era of psychopharm helped move psychiatry into its current and brighter age.

As if in the darkness of the time period in psychiatry’s history during which Shutter Island takes place, DiCaprio uses matches to light his way on the creepy island.  The film’s storyline is just as disturbing and dark as its historical and scenic backdrop, if not more.

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Shocking!

One Flew Over The Cuckoo’s Nest (1975)

I recently watched One Flew Over The Cuckoo’s Nest, a classic drama film from the 70s starring Jack Nicholson who plays a patient hospitalized at a locked psychiatric facility. The film is an adaptation of the novel written by Ken Kesey. Interestingly, Kesey gained inspiration for the story from talking to psychiatric patients while high on LSD at the Menlo Park Veterans Hospital in the early 1960s. Coincidentally, I have also worked with patients at the MPVA, sans LSD however. He scored his LSD free of charge from the government, when he volunteered as a Stanford student to be a subject in the covert CIA-financed study of the effects of psychoactive drugs on human behavior.

I don’t usually rent old movies, but I wanted to watch this film because of the infamous “electroshock” therapy scene. Euphemistically referred to as electroconvulsive therapy (ECT) in the medical profession, most people seem to always react with horror and repulse whenever ECT is mentioned. The reason, not surprisingly, is the atrocious image instilled in people’s minds from the movie. After viewing the clip myself of Jack being forcefully “shocked”, I can definitely understand why people are so horrified of ECT  (Check it out for yourself).

I don’t know for sure if ECT was administered in that inhumane fashion back in the spooky days of the asylums, but Jack was definitely wronged¹. Contrary to Jack’s experience, modern day ECT requires informed consent and is done in a controlled environment under general anesthesia and with a muscle relaxant. He shouldn’t have been conscious, convulsing, and writhing in pain. There was no need for the forced insertion of the mouthpiece or the multiple guys pinning him down. More importantly, he shouldn’t have received ECT in the first place- he was not depressed, manic, or psychotic. It was solely given as a form of punishment for his unruly behavior.

ECT is a very effective treatment for severe depression, especially for patients who have not responded to multiple trials of antidepressant medications. It should be legitimately considered by patients for antidepressant treatment, and not reflexively rejected because of the unfavorable depiction from the film.

Hollywood definitely likes to portray ECT as something scary and disturbing, as also featured in Requiem for a Dream.  The entertainment industry will probably never show ECT in its true form, because that would be just too boring and not shocking enough.

Addendum

1. In response to questions about the history of ECT- The procedure was invented in the 1930s. Anesthesia, and later muscular blockade, was not introduced until the 1940s, and took more than a decade to gain widespread use. Thus, many patients suffered from broken bones and ruptured tendons.  Informed consent was also not strictly practiced, if at all, during those days. I guess Jack did receive the standard ECT of the early era.

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