Case Study

Bipolar Blessing A Memoir of Transilience

New England bled in autumn, Dry winter cracked in the west

The equinoctial fever, Burned as the south sun undressed

Alaska froze the summer, Sun up, the day s never done

Aurora borealis, Shone at the end of the sun

Take me to the heartland, Listen to the rain

Take me to the heartland, Weather in the vein

Take me to the heartland, Neither south or north

Take me to the heartland, Rock me back and forth

Rock me, rock me

Rain falling in the heartland, Winds blowing over the plain

Internal solstice rocking, Darkness and light in my brain

(Lutz, 2011 p.76)

Bipolar blessing is an autobiographical memoir by Lutz, detailing his personal experiences of living with type II bipolar disorder[1]. In essence, the book is a personal journey from pre-diagnosis, diagnosis and life up until publication. It offers the reader a small window into the murky waters of a life blessed with bipolar. In the memoir Lutz describes himself as a prestigious student, whom studied philosophy and literature. He was also an athlete, singer, poet and songwriter a high achieving and creative individual. Despite these seeming successes, Lutz suffered his first breakdown at 20 years old which led to hospitalisation that was succeeded by a diagnosis of bipolar II disorder.

In pursuit of understanding the causes of bipolar it is recognised that Lutz was vulnerable to onset because his father also suffered with bipolar although he is the patroclinous, generic link to my bipolar disorder my father followed nearly every possible path of destruction for a bipolar (p.29). The aetiology of bipolar has been almost exclusively assumed to develop as a consequence of genetic abnormalities (Benes Beretta, 2001 Phillips, Ladoucer Devets, 2008 Baum et al. 2007) indicating that Lutz was genetically predisposed to bipolar onset. However, recent research suggests that genetic predispositions are only determining part of the full picture and bipolar is viewed from a biopsychosocial perspective (Bender Alloy, 2011), demonstrating that social factors are also extremely important when considering bipolar development (Johnson Roberts, 1995 Post, 1992).

From a sociological perspective, Lutz s bipolar onset could have been a consequence of environmental factors such as academic and personal stress. For example in Lutz s reflection of life prior to his breakdown he was under a lot of pressure. In an academic capacity he was performing exceptionally well, but the underlying consequence of this pressure resulted in stress which potentially acted as a trigger. Psychological theories about the role of stress in relation to bipolar postulate that the course of bipolar is influenced considerably by life stressors (Johnson Roberts, 1995 Dienes, Hammen, Henry, Choen Daley, 2006 Hammen Gitlin, 1997 Kim et al. 2007). In particular the kindling/behavioural sensitisation theory (Post, 1992) suggests that the initial episode of bipolar disorder is triggered by stressful events. Post (1992) proposes that over the course of bipolar, low level external influences of stress (kindling) are also able to ignite episodes (maniac or depressive). Lutz s personal understanding of stress triggers are recognised when defining bipolar as thin skin a feeling of incredible sensitivity to emotions and stress that are critical to his wellbeing.

To reinforce the theoretical understanding of stress, an example of a significant event resulting in bipolar depression is when Lutz s first wife falls pregnant, he becomes increasingly anxious with the anticipation of a new identity she became pregnant I suffered a haunting darkling of my mind in a pre-partum depression. I had been certain of my role in the world as brother, son, uncle-to-be and wrestled with this new, unwelcome identity (p.46). Sadly the child was stillborn and Lutz was saved from the fate of fatherhood (p.47). In his second marriage Lutz committed a suicide attempt simultaneous to the news of his wife completing her doctoral programme. As Lutz possess an acute awareness to his triggers for stress and demonstrates a presence of distinguished reflexive ability he attributes the cause of the breakdown to feelings of emotional stress due to his perceived lack of accomplishment in comparison to his companion s achievements The emotional stress of having become, as it felt to me, a laughable second tier to my wife s bread winning carer as a psychologist, threatened my mental health beyond the bounds of simple repair (p.50). Lutz recognises that the triggers for his bipolar episodes are dependent on his exposure to stressful situations: Where we feel, when we feel, with whom we feel are the critical bipolar stress considerations, not that we feel (p.98). Lutz demonstrations the importance of understanding the idiosyncratic relationship of stress and bipolar in order to effectively manage his condition (Bender Alloy, 2011 Johnson Roberts, 1995 Dienes, Hammen, Henry, Choen Daley, 2006 Hammen Gitlin, 1997 Post, 1992).

As mentioned, Lutz was diagnosed with bipolar II disorder which he identifies with as an accurate descri ption of his mental illness I am unmistakably Bipolar II, which means I have a symptomatic propensity for debilitating depression and for hypo-mania (p.52). This relates to the DSM-5 for bipolar II disorder: For a diagnosis of bipolar II disorder, it is necessary to meet the following criteria for a current or past hypomanie episode and the following criteria for a current or past major depressive episode . The prominence of Lutz s depressed mood are noted in the descri ption of his experiences at the mental hospital losing my ability to speak articulately from medication side effects, offering up the arm with the fewest needle tracks for blood tests, screaming and pounding the walls, by consequence spending time in a padded room, listening to perfect nonsense, knowing that much of it was coming from me (p.38). This descri ption expresses certain aspects from the DSM-5 criteria for depressive mood: Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others) . However, the descri ption from Lutz himself cannot be directly attenuated to those from the DSM-5, given the fact that it is from an autobiographical perspective and his freedom of expression is clearly illustrious. Nevertheless, what can be gained from the quote are the direct effects of medication in sedating the individual and also his expressions of distress in the hospital. Although, the fact that Lutz is on medication blurs the contrast between the organic occurrences of depression and the potentially induced symptoms as a result of prescri ptive medicines.

Moreover, what can be directly related to the criteria are the: recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, a suicide attempt, or a specific plan for committing suicide . For example, Lutz endured a number of suicide attempts, and the threat of suicide haunted him for several years the daydream of dying a thousand ways, is one of the symptoms of bipolar disorder that many of us in our sickness may dismiss as harmless. It comes as comfort when were depressed and takes the edge off . Suicidal ideation was my drug of choice for the eleven years before my third breakdown (p.21). This withstanding relationship with suicide permits the reader to grasp an element from the surface of what coping with the depths of bipolar disorder feels like a state of despair so palpable that even the thought of taking your life is of some consolidation.

Depressive moods are mentioned intermittently throughout the book, to gain insight his experiences of depression the reader has to essentially read between the lines . For example, when Lutz refers to a hospital experience: the closest experience of hell on earth a twenty year old philosophy and literature student can imagine (p.37), we have to conceive what consequences this experience had on his life a shift of identity from being an aspirational intellect to a high risk inpatient. Lutz divulges that 5 months of life in hospital were spent in depression, which relates to the criteria for depressed mood: Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, or hopeless) . During the hospitalisation Lutz discloses some compelling thoughts about himself I became aware of the horrifying fact that I no longer knew what it meant to be normal I couldn t even impersonate myself (p.37-38). This expresses feelings of a certain loss of self due to the experience of bipolar.

When considering theories about loss of self throughout bipolar, deeper insight of how Lutz may have felt succeeding his diagnosis can be accomplished. Inder et al. (2008) postulated that bipolar disorder has a considerable influence on the development of self and identity. These psychologists express that the experiences of bipolar manifests in feelings of confusion and contradiction about the self, and individuals often express difficulty integrating themselves as whole (Inder et al. 2008). In Lutz s journey through bipolar, similar concepts are recognisable Loss of confidence and identity, distortion of self, fear of the outside world and the scourge of suicide (p.9). The unambiguous perception of the scattered self can be acknowledged in this statement what can be discomforting about the return to self, when we bipolars are slowly putting the thousand piece puzzle back together is that some of the pieces simply no longer fit (p.65).

In relation to experiences of self, an interesting part of the autobiography is Lutz s transcendent relationship with bipolar, as many of the attributes manifest in the form of a bipolar bear. The bipolar bear is framed as separate to his being Bipolar disorder is to me a separate entity, a wild apex predator I have walked nearly twenty-five years with a ten foot bipolar bear next to me, sharing the path, threatening to tear me emotionally apart any minute. (p.13). When considering this relationship, it appears that his coping process (Lazarus, 1993) may involve some elements of disassociation, where the more negative aspects of bipolar are attributed to a separate entity , perhaps making the experiences of bipolar more manageable. Moreover, when we consider the suggestions from Inder et al. (2008), whom concluded that the focus of interventions for bipolar should promote acceptance and integration of the self we can acknowledge how integration and self-acceptance were vital for Lutz s recovery process. This is noted when Lutz pledges to accept the bipolar bear as a guide I must make authentic peace with the giant bear by my side, have it become my guardian and guide (p.16). Throughout his journey Lutz develops an admirable acceptance for his condition this process of integration ultimately played an important part in his ability to manage bipolar symptoms.

The polarity of depressive episodes in bipolar II disorder is unequivocally the manic state. An example of Lutz s experiences of mania is a reference to creativity I did sample some of the smaller glowing embers of the infamous fire of the creative fury in what would be any young artists dream: a sustained, focused, bipolar hypo-manic state (p.13). The reader can only imagine what the experiences of mania were like for Lutz as manic episodes are not referred to in detail. This may be because of the euphoric and positive elements of mania (Mason, O Sullivan, Bentall El-Deredy, 2012 Galvezb, Thommib Ghaemia, 2011). The DSM-5 states that the characteristics of mania are inflated self-esteem or grandiosity, decreased need for sleep, flight of ideas or subjective experience that thoughts are racing and literature related to the experiences of mania document that manic episodes can be enjoyable (Mason, O Sullivan, Bentall El-Deredy, 2012). Thus, whilst enduring manic episodes there is less time to ruminate about experiences due to racing thoughts and incessant feelings of energy, which may be why Lutz s refrains from expanding on these experiences. Nevertheless, in a normal mood state Lutz nurtures his creative nature as a poet, singer, musician and writer. The significance of the reference to the fire of creative fury during mania can be understood when considering research into mental illness and creativity as there is a long standing parallel relationship of interest between them (Andreasen, 1987 Lombroso, 1985). Specifically, bipolar disorder and creativity have been recognised to coexist (Lombroso, 1985 Santosa et al. 2007 Richards, Kinney, Benet Merzel, 1998, Richards et al. 2008). Richards et al. (2008) discovered that a significant number of people experiencing manic episodes also displayed a propensity for enhanced creativity. This evidence could explain part of Lutz s innate source of creativity as it is postulated that a genetic component may exist that underlines the association between creativity and bipolar (Karlsson, 1970).

In regards to Lutz s treatment of bipolar, he describes that a transmogrification of his physical appearance occurred during pharmacotherapy. This began with lithium, a well-established treatment for bipolar (Sproule, Hardy Shulman, 2000 Muller-Oerlinghausen, Berghofer Bauer, 2002) of which Lutz endured extreme side effects chronic toxicity, unquenchable thirst, sluggishness (p.23). He then moved to Depakote[2] for 7 years, gaining excessive weight despite regular exercise. Disheartened with this change he was prescribed lamictal[3] which encouraged weight loss. Bipolar disorder is typically treated with pharmaceuticals early research attributed biological vulnerabilities to the cause of bipolar, deeming that this was the only treatment (Fromm-Reichman, 1949 Scott, 2006 Scott, 1995). However growing empirical evidence confirms that medication alone does not consistently prevent bipolar episodes, thus psychological therapy combined with adherence to medication is now recognised as the most suitable treatment (Reinares, S nchez-Moreno Fountoulakis, 2014).

A relevant psychological treatment which could support Lutz s is interpersonal and social rhythm therapy a therapeutic practice derived from the opinion that bipolar is a consequence of genetic predispositions to circadian rhythms and sleep/wake cycles (Frank, Swartz Kupfer, 2000). It is understood that disruptions to sleep patterns (Leibenluft et al. 1996) and social and personal demands can interrupt biological functioning, thus leaving the individual vulnerable to mood disruptions (Ethlers et al. 1988). Essentially the aim of therapy is to integrate consistent rhythms including regular sleeping/waking cycles, daily routines and adherence to medication specifications. Therefor Lutz could benefit from learning to structure and regulate his lifestyle and expand his insight into external factors which cause vulnerability to mood episodes (Frank, Swartz Kupfer, 2000).

In addition to this, dialectical behaviour therapy (DBT) is directed at individuals that experience difficulty in the regulation of their emotions, thus helpful for bipolar (Dijk, Jeffrey Katz, 2013). During group sessions, DBT core mindfulness skills are taught to participants, this encourages awareness of emotions, thoughts and behaviours. The aim of this therapy is to increase the individual s level of self-control and capacity to manage difficult thoughts and emotions. In addition, distress tolerance skills and alternative coping strategies to manage the urges of suicide or self-harm are taught. This type of psychoeducation has been found to reduce depressiveness in bipolar (Dijk, Jeffrey Katz, 2013). As Lutz s intellectual capacity for cognitive appraisal is eminent throughout his book, DBT could encourage the development of the already present self-awareness and specifically target the suicidal thoughts of which he confessed. Alternatively, art therapy[4] could be a very effective form of treatment as creativity is an important element of his life. This would permit Lutz to advance the talents he already possesses through a type of catharsis, in a direction that is conducive to his mental health, encouraging self-healing and understanding (British Association of Art Therapists, 2015).

Aside from psychological and medical treatments, it is documented that psychosocial environments predict alterations in bipolar (Johnson, Meyer, Winett Small, 2000). In particular, positive social support effects alterations to self-esteem in bipolar depression (Johnson et al. 2000) reflection of positive social experiences can act as protection against suicide, negative social experiences worsen suicidal ideation (Owen, Gooding, Dempsey Jones, 2015) and low levels of social support predict onset of manic episodes (Cohen, Hammen, Henry Daley, 2004). It is evident that the inclusion of a cohesive support network is vital for those coping with bipolar. The impact of social support is instilled in the reader when Lutz beautifully describes the necessity of friendship another fine friendship moment the gift that he gave me on that hill is one that changed my life, and one that continues to give: the privilege to touch my friends pain as he is reaching out to touch mine (p.63). Lutz also has an encouraging relationship with his mother she has welcomed me no matter my state of mind, embraced me in my need, and never once reminded me that in her presence I was ever so sick (p.75) . The presence of social support has inevitably had an impact on Lutz s recovery as these networks offered him complete acceptance.

In addition to social support, what appears to have helped Lutz the most was his personal process of spirituality and self-acceptance bipolar disorder is to my imagination, a clinical diagnosis to a spiritual path (p.67) . He also professes an acceptance of truth which is clearly important for his recovery process: the truth is a bipolar s most valuable tool when he or she is building a new life. Denial of truth carries the metaphorical prospect of pounding nails with one s fist. Being fearless of true self, of the fruit of one s own tree is the beginning of a bipolar breakthrough, a forging of a new identity (p.55). Although recovery from bipolar was gradual Understandably, I was easier to embrace as a thousand piece puzzle in a box than I was a puzzle in a thousand pieces poured out of the box onto my own life path. Recovery, as ive marked before, is slow (p.61), Lutz feels confident to claim that he has recovered. Amongst the therapeutic strategies and adequate social support that could support this recovery, Lutz details some specific elements that facilitated the process the rites of my religious bipolar practice exercising, eating mindfully, sleeping well, taking medication, communing with nature, and the quiet, and writing new songs and stories in a setting that has never caused a breakdown (p.68).

As well as introducing rhythm into his life, ultimately Lutz s found meaning from his condition, he integrates the parts of himself that were shattered by bipolar disorder and learns to live beautifully (p.67). In this sense he attains a new acceptance of self, an identity that encompasses all aspects of the whole There is my new, singular, bipolar form: a bear. One eye is mine one eye is wild. Integration must have always been the bipolar bears dream for me (p.101). Feasibly, this indispensable teaching of self-acceptance is integral for us all perhaps it is only in the acceptance of ourselves that we can soothe the war that starts within, and externally the peace of life can then begin.