Bipolar Disorder: A Genetic Issue in Utero?

This is a longitudinal, retrospective account going back to my conception in October 1943. I make reference to a genetic predisposition to bipolar disorder(BPD) due to a family history of affective disorder in a first-degree relative, my mother(1904-1978). She had BPD, although her disability was never given that medical diagnosis. About half of all patients with BPD have one parent who also has a mood disorder. There is, therefore, a clinical significance in my mother?s mood disorder in the diagnosis of my own BPD. The high heritability of BPD has been well documented through familial incidence, twin, and adoption studies. There is an unquestionable justification for the inclusion of my family in my understanding of BPD. No specific gene has yet been identified as the one "bipolar gene." It appears likely that BPD is caused by the presence of multiple genes conferring susceptibility to BPD when combined with psychosocial stressors. I make this point as an opening remark and pass on to my story.(1) :dance:
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(1) For an elaboration of the subject of the genetic connection of BPD and in utero BPD see: David Healy, Mania: A Short History of BPD, Johns Hopkins, 2008. Genes may also contribute to the age at onset of BPD and a phenomenon called genetic anticipation. Anticipation refers to the phenomenon of an illness occurring in successive generations with earlier ages of onset and/or increasing severity. In a recent study using registry data of bipolar subjects, age at onset of first illness episode was examined over two successive generations. Subjects born from 1900 through 1939(my mother) and from 1940 through 1959(myself) were studied. The median age at onset of the first episode of BPD was lower by 4.5 years in subjects born during or after 1940. The goal of what is sometimes called ?personalized medicine? is to utilize a person's genetic makeup for appropriate disease diagnosis and treatment, an idea conceptualized initially in the era of Human Genome Project.
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(2) The diagnosis that has been made in my case, in addition to the several I have received over the years from psychiatrists, is a diagnosis that is standardized according The Diagnostic and Statistical Manual of Mental Disorders(DSMMD-4th edition-1994) which provides diagnostic criteria for mental disorders. I use the term bipolar disorder not manic-depression throughout this document and the acronym BPD. In the DSMMD there is a 5 axis/level system of diagnosis that is used and, in my case, axis/level 1 is for clinical disorders that are mood disorder. Axis 3 in this system is for what they refer to as acute medical concerns that relate to BPD; axis-4 is for psycho-social and environmental problems that contribute to BPD and axis-5 is an overall caregiver?s assessment of my functioning on a scale 1 to 100. In my case, my caregiver, namely my wife, evaluated me at 61-70 on the numeric scale which reads as follows: ?this adult has some mild symptoms as well as some difficulty in social and occupational functioning. Generally, though, he functions pretty well. He also has some meaningful interpersonal relationships." The bar is set much higher by government departments in order for my wife to get a Caregiver?s Allowance. My symptoms are not sufficiently extreme. Readers wanting access to this diagnostic tool can easily find it on the internet. I have appended it to this statement in appendix 2. I should emphasize at the outset of this statement that any research showing that some form of psychotherapy or talk therapy is an effective substitute for medication is, at best, arguable and not something I am prepared to entertain anyway after 28 years of dependence(1980-2008) on medication. Likewise any research showing that health food and nutritional supplements like fish oil, for example and/or vitamins and minerals and/or amino acid(s) are effective for BPD. The literature now available to those wanting to explore the subject, the field of BPD, is massive both on the internet and off and much of it may be more useful than this statement to readers at this site.

BPD is not medically curable but it is possible through psychiatry, medicine, some types of talk therapy and nutritional adjuncts to achieve varying degrees/periods of long-term stability. I feel I have achieved this by degrees since the 1960s. That is not to say that I have never had any more episodes since those 1960s, that I have not become hypomanic again nor exhibited other symptoms of BPD--I have and I still do.

My wife, Chris, has suffered from different disorders all of our married life and her years before our marriage in 1975 were also beset by different troubles. Her story is long, but I have not included it here except in a tangential sense when it seems relevant to my own experience of BPD. My references to marriage, family, work and values are emphasised in this account, but briefly and only en passant. My religion, the Bahai Faith, which provides the base for my values, beliefs and attitudes, is also important--but I do not focus on this Faith here, except in an indirect way. However important this religion has been to me in the past or in the present, I do not refer to it in my elaboration of my experience of BPD.
----------------INSTALMENT #2 TO COME IF READERS DESIRE IT-------Ron

Ron,
I would be interested in reading more.

1.2 My account also provides a statement of my most recent experiences in the last two years, 2007-2009, with manic-depression(MD) or BPD as it has come to be called in recent years. Some prospective analysis of my illness is also included with the view to assessing potential long-term strategies, appropriate lifestyle choices and activities in which to engage in the years ahead. For the most part, though, this account, this statement I have written here in some 32,000 words is an outline, a description, of this partially genetic-family-based illness and my experience with it throughout my life.

1.3 Some of the personal context for this illness over the lifespan in my private and public life, in the relationships to my family of birth and my two families of marriage, in my employment life and now in my retirement are discussed in this document. I include some of what seems to me my major and relevant: (a) personal circumstances as they relate to my values, beliefs and attitudes on the one hand--what some might call my religion as defined in a broad sense; (b) family circumstances; for example, my parents? life and my wife?s illness; (c) employment circumstances involving as they did: (i) stress, (ii) movement from place to place and (iii) my sense of identity and meaning; (d) a range of other aspects of my day-to-day life and their wider socio-historical setting and (e) some details on other aspects of my medical condition to help provide a wider context for this BPD in the last two years.

1.4 This lengthy account will hopefully provide mental health sufferers, clients or consumers, as they are now variously called these days, with: (i) a more adequate information base to make some comparisons and contrasts with their own situation, their own predicament whatever it may be, (ii) some helpful general knowledge and understanding and (iii) some useful techniques in assisting them to cope with and sort out problems associated with their particular form of mental illness or some other traumatized disorder that affects their body, their spirit and their soul.

1.5 This document was originally written in 2001 to assist others in assessing my suitability for: (a) employment, (b) for a disability pension of some kind and/or (c) a volunteer public or private office. This is no longer the case. Although this document no longer serves the purpose of helping others to make such an evaluation and make such a decision a more informed one; although there is no need for others to assess my capacity or incapacity to take on some task or responsibility, I have kept this original general statement, what was a first edition in 2001 and have extended it to what is now a 7th edition eight years later.

1.6 Many do not feel comfortable going to doctors, to psychologists and, more especially, to psychiatrists. Perhaps this is part of a general distrust of certain professional fields in our world today. Perhaps it is part of a general public being more critical. Others do seek help; still others try to work things out themselves and there are, of course, various combinations of those who try, those who have given up and those who go back and forth between the two poles of trying and not trying to sort out their disorder. Many often find the journey through the corridors of mental health problems so complex, such a labyrinth, that they give up in despair. Suicide is common among the group I refer to here?the sufferers from BPD and I could include depression(D) as well as a range of other illnesses and life battles of a traumatic nature. This account may help such people obtain appropriate treatment and, as a result, dramatically improve their quality of life. I think, too, that this essay of more than 32,000 words and sixty-four A-4 pages(font 14) is part of: (a) my own small part in reducing the damaging stigma associated with BPD and (b) what might be termed ?my coming out.?

1.7 The wider framework of my experience which I outline here is intended to place my BPD in context and should provide others with what I hope is a helpful perspective, as I say above, in relation to their own condition, their own problems and situations. Perhaps my statement may help some BPD sufferers describing and understand their personal histories. My BPD exists on an affective spectrum which is a grouping of related psychiatric and medical symptoms which accompany bipolar, unipolar and schizoaffective disorders at statistically higher rates than normally exist in the general population. These disorders are identified by a common positive response to the same types of pharmacologic treatments. They also aggregate strongly in families and may therefore share common heritable underlying physiologic anomalies.

1.8 This essay, as I say, of eighty-two A-4 pages(font-14) is written: (a) for doctors and various medical professionals who have dealt with or will come to deal with my disorder and especially for those who are now, at this present time, involved with my treatment should they find such a statement useful; (b) for internet sites and those registered/inquirers on the www at a range of health and mental health sites, especially the sections of sites dealing with D and MD/BPD; (c) for some of my relatives, friends and associations over the years with whom I still have contact in these early years(60-65) of my late adulthood(60-80) and to whom it seemed relevant to give such a statement; (d) for government departments, voluntary organizations, interest groups and Baha?i institutions who require such statements for reasons associated with our relationships and interactions; and (e) for myself as a reflection, for my own satisfaction, to put into words the story, the results, of an illness, a sickness, a disorder that has influenced my life for over more than six decades.

1.9 This document, this statement, originally written in 2003 for the Australian government?s now department of Human Services, its Centrelink section which with Disability Support Pensions, has been revised many times after further reflection. Now in its sixth edition after feedback from various doctors, friends and internet respondents as well as after an increase in my own knowledge of the illness as a result of further study, this document is an ongoing and changing entity as my experience of the disorder continues into the middle years(65-75) of my late adulthood(60-80). In eight months I will go on the Old Age Pension in Australia with this BPD still a part of my life.

1.10 I do not claim to possess a specialized and/or professional expertise in the field of the study and treatment of BPD. I do not work with people who have such problems, nor do I have a desire to do so, except as a participant at a number of internet sites concerned with relevant mental health topics and with people who cross my path serendipitously with various related problems. This long piece of writing, too long for some perhaps for most, not as sharply focussed on my actual day to day experience as some respondents on the internet have already indicated and not particularly relevant to the experience of others in an illness that has a very wide range of behavioural typicalities---this long piece of writing is but one of the many pieces of my writing these days. The vast majority of my writing and my interests both in and off the internet has nothing to do with this disorder.

1.11 After more than 60 years of dealing with this medical problem in my private and public life, I would be only too happy to put it to bed, to put it into some final corner and forget it. Sadly, or perhaps fortuitously, I can not do so because I still suffer, even after more than 60 years, with problems that are part of this disorder?s long history and current manifestation in my life. I have also become more conscious as I have come out, or so it is said colloquially, of how this statement has come to be of great help to many, especially at the 90 mental health sites on the Internet where I place all or parts of this document. Major affective disorders continue to be the leading causes of psychiatric disability and the need to develop safe, effective, and efficient long-term treatments for these disorders is of extreme importance not only to professional but to the millions of sufferers. People like myself with life experience of BPD have stories that can be of use to other sufferers. That is the core of my motivation for all the internet posting I do at mental health sites related to BPD.

1.12 Readers who are busy and not inclined to read a long statement like this are advised to skip especially to section 10.3.8 below and some of the following sections after 10.3.8 to avoid reading much of the history and much of this statement that is not relevant to their needs. They can then: (a) make some practical assessment of this account, an assessment relevant to their present and personal needs; (b) obtain a shorthand account of whatever information in this document is relevant to their particular situation; (c) assess my suitability to: (1) undertake some form of employment: FT, PT, casual or volunteer; (2) some task that they think I could take on or some social or leisure activity in which I could engage with profit to others; (c) go onto a pension of some kind and, finally, (d) understand my background of BPD more fully and so contextualize my life in order that they might understand me better.

1.13 Data from the United States on the lifetime prevalence of this disorder--and mine has been a lifetime of BPD--indicate a rate of 1 percent for Bipolar I, 0.5 to 1 percent for Bipolar II or cyclothymia and between 2 and 5 percent for sub-threshold cases meeting some but not all criteria

1.14 I would like to close this introductory section with a general comment about the increasingly close relationship between the pharmaceutical industry and the American Psychiatric Association (APA) and about a sub-field of philosophy and sociology known as hermeneutic phenomenology.

1.14.1 Since at least 1980 when by illness was given the label BPD, there has been a growing tendency in the mental health professions to interpret everyday emotional suffering and behaviour as a medical condition that can be treated with a particular drug. Hermeneutic phenomenology, a field within both philosophy and sociology, is uniquely suited to challenge the core assumptions of this particular form of the medicalization of BPD, among other psychiatric disorders. Hermeneutical phenomenology can function within psychiatry: (a) to expand psychiatry's narrow conception of the self as an enclosed, biological individual and (b) to assist psychiatry to recognize the ways in which our experience of things--including mental illness--is shaped by the socio-historical situation in which we grow. Informed by hermeneutic phenomenology psychiatry's first priority, so it could be argued, is to suspend the prejudices that come with being a medical doctor in order to hear what the patient is saying. To this end, psychiatry can begin to understand the patient not as a static, material body with a clearly defined brain dysfunction but as an unfolding, situated existence already involved in an irreducibly complex social world, an involvement that allows the patient to experience, feel, and make sense of their emotional suffering.

1.14.2 This increasingly close relationship between the pharmaceutical industry and the American Psychiatric Association (APA) and this sub-field of philosophy and sociology known as hermeneutic phenomenology offers the sufferers of BPD a potentially useful line of inquiry in the future, but it is not a line of inquiry that I investigate in this statement. For my story, my account and my analysis, I see these two directions of inquiry as tangential to the central thrust of both my story and its treatment both in the last and the future.

2. My Experience of Manic-Depression:
Phase One--The First 37 Years 1943 To 1980

2.1 In the first 37 years of my life I had many episodes of various kinds of emotional imbalance or disorientation, themselves of varying lengths and intensities, ranging from a euphoric, impetuous, expansive or high mood to a depressed, grey, low energy or despondent mood. Indeed the range of mood in these 37 years was much more extreme, but the complete/extreme range was rarely experienced. In these years I learned various self-monitoring skills as well as some self-reinforcing tactics. Sometimes these symptoms affected my day-to-day life severely and negatively, sometimes positively and sometimes the affect was non-existent, insignificant and hardly noticeable.

2.2 After many experiences on the fringe of a normality that was my usual modus operandi or modus vivendi, as it is said in Latin , on the fringe of what I saw as my general everyday experience of life, an experience that is sometimes called the quotidian by writers, poets and novelists, I was diagnosed as a MD in May 1980. I was treated by a psychiatrist in Launceston Tasmania while in hospital. I had often been on the fringe of this disorder, as I say above, a borderline zone, a limen as some historians call it, a border territory, a zone between normality and various behavioural extremes and eccentricities from my birth in 1944 to 1980. But in 1980 the symptoms were extreme and required hospitalization. The treatment regime in 1980 was lithium carbonate, an antimanic medication for the treatment and prophylaxis of BPD. Lithium was the first really successful mood stabilizer used by doctors to treat MD, an illness that in the 1990s began to be called BPD. This medication cushioned the effects of extreme depression and hypomania and prevented their effects from striking at my life. The perils of BPD lie in what I did in the midst of hypomanic episodes to deal with: decreased need for sleep, decreased self-control, increased sexual desires, irritability, rage, risk-taking behaviours and, in my 1968 and 1979-80 episodes, schizo-affective or psychotic states; and in the midst of depression periods with moroseness, extreme melancholia and suicidal wishes.

2.3 My history to that point, to 1980, had been far from smooth and linear as my remarks above indicate. Those thirty-six years had often been bisected, polarised and traumatised. As I indicated above I have written a more detailed account of these years elsewhere but this outline, this brief sketch here, of particular episodes and the periods between episodes will suffice. My experience of these highly diverse emotional and psychological swings of mood in everyday experience away form the norm, from my norm, is only part of my story. But it is a crucial part. Everyone has their story for everyone experiences all sorts of abnormal eccentricities and health problems in life, some people of course more than others and some more traumatic and intense than others.

2.4 My account of the years from 1943 to 1980 follows. I try, in writing about and in summarizing these first 37 years of my life, not to overstate my case, nor to understate it, but give an account of those first 37 years which I refer to here in this general statement as phase one of my bi-polar life. In some ways the inclusion of the names of those doctors who treated me over the years in this first phase and in later phases would personalise this account, but names are not that important and to include them here in this narrative causes confidentiality problems and raises privacy issues for some readers and for people in my own past who might not want to be mentioned. This question of confidentiality and privacy is especially true at some internet sites where posts are rejected if names are included in any posting at the site concerned---and so I leave names out. Those whose names I could mention would not be troubled by their inclusion here, not now, not in 2008 after an extensive destigmatization of the disorder in recent years and after so much of my experience and so many of the people concerned are now, what you might call, ancient history.

2.5 1 I certainly appreciate the medical and clinical work of: (a) several of the doctors I went to in my childhood, adolescence and adulthood, (b) the psychiatrists who have treated me since June of 1968, nearly four decades ago and (c) many family members, friends, colleagues and associations, some known well and others hardly at all, who have helped me ride the waves when the disorder raised its head yet again along the way, the road of life.

2.6 Comments on My Ante-Natal, Neo-Natal,
Childhood and Adolescence Life: 1943-1963

2.6.1 As I refer to above, I had some experience of what may well have been BPD in childhood as far back as infancy and at the toddler stage, all of the pre-school years, 0-5, of early childhood development. My mother nearly died in the first month after my birth, the implications of which it is not my intention to go into here. If there are any significant implications of this birth process and/or events in my ante-natal and neo- natal phases of my life, I do not examine here, however important they may be in the aetiology of this illness. Before the age of five there is evidence that my behaviour had some of the features of what is now called: (a) Attention-Deficit/Hyperactivity Disorder (ADHD) or (b) Oppositional Defiant Disorder, but it is difficult to disentangle those features from those of BPD. For the most part, though, I did not manifest BPD symptoms like: elated mood, grandiose behaviours, decreased need for sleep, racing thoughts or hyper-sexuality. Children are developmentally incapable of many manifestations of BPD described in adults; for example, children do not "max" out credit cards or have four marriages, pre-puberal and early adolescent age equivalents of adult mania behaviours. Still, as David Healy emphasizes in his book Mania: A Short History of BPD, some doctors are now associating BPD as beginning in utero.

Perhaps in a later edition of this essay I will attempt a more detailed outline of what I recall from these years of early childhood, but my recollections are minimal and it is difficult, if not impossible, to excavate my memories from those years at this late stage of my life. It is not my intention to comment further on these early years except for the occasional passing reference when it seems appropriate.

2.6.2 Through middle and late childhood, say, the age of 6 to 12(1950-1956) into the puberty cusp of 12/13 in 1956/7, I did exhibit personality features, behaviours or symptoms that had features of BPD, at least to a limited degree, or so it could be argued if not proved: (a) a lack of control of my emotions, impetuosity, lack of emotional restraint, hyper-sexuality and (b) a far too intense activity threshold what is now called hyperactivity, mild mania or hypomania. It should be emphasized in this context, though, that mania is now considered by many in popular culture as a pleasantly grandiose, somewhat overactive feeling and behaviour orientation, but is not considered as evidence of a disorder or of a maniacal posture. I recall at the age of 12/13, at the onset of puberty, exhibiting inappropriate or precocious sexual behaviour, although the particular manifestations only involved one episode which constituted groping and an attempt to kiss a girl who did not want to be kissed. In addition, in my years of late childhood(8 to 12) I was involved in: (a) stealing items from shops and selling them; (b) one breaking and entering experience in which the charge was dropped and (c) excessive intensity expressed in sport and other activities.

Adolescent BPD or adolescence presented me with an accentuation of puberty and teen-turbulence caused by hormonal shifts. Society value shifts in the 1960s accentuated my tensions and behavioural problems even more, or so it seems to me, as I look back from the perspective of half a century. My mother?s understanding, commitment, perseverance and patience, even though she did not know that I even had BPD, is now in my memory bank and in my greater appreciation for my mother than ever before.
------------INSTALMENT #3 TO COME IF DESIRED-------------Ron::dance:

That's Enough, Probably Too Much....but, as I have already said, if you want more I've got nearly 100 pages of the stuff and 37,000 words which you can google with the words: Ron Price BPD.-Ron in Tasmania