Touched With Fire: Manic-Depressive Illness and the Artistic Temperament

Jamison, Key Redfied, Ph.D. New York: The Free Press, 1993. Hardback, 370 pages; also in paperback.

I think continually of those who were truly great.
Who, from the womb, remembered the soul’s history
. . . . . . . . . Whose lovely ambition
Was that their lips, still touched with fire,
Should tell the spirit . . . . . . . .
Who wore at their hearts the fire’s centre.
--STEPHEN SPENDER

Kay Redfield Jamison, associate professor of psychiatry at The Johns Hopkins University School of Medicine and a featured speaker at the 1993 DRADA symposium, has penned another groundbreaking book. (Previously, she coauthored the definitive medical reference Manic-Depressive Illness [1990, Oxford University Press].

Her newest effort, Touched With Fire, is about manic depression—the “disease of perturbed gaieties, melancholy, and tumultuous temperaments, and its relationship to the artistic temperament and imagination.” Dr. Jamison offers literary, scientific, and biographical evidence for a symbiotic relationship between the creative process and the “fires” of manic depression (or related mood disorders) that touch many writers, poets, composers, and artists.

Dr. Jamison defines the symptoms of manic-depressive illness and details the history of the view that artists possess a “divine madness,” citing the lives of famous artists such as Robert Lowell, Robert Burns, Hector Berlioz, Hugh Wolf, Theodore Roethke, Edgar Allen Poe, Samuel Taylor Coleridge, John Berryman, William Styron, Leo Tolstoy, and Percy Bysshe Shelly, among others. She clarifies the relationship between “moods and the creative process,” illustrating that for these creative individuals, “elation in mood often preceded the creative periods rather that being entirely a result of them.” She further documents seasonal fluctuations in productivity cycles for many of these artists.

Using George Gordon, Lord Byron as her vehicle, Dr. Jamison examines the genealogy of manic-depressive illness and its related temperaments. She develops a fully integrated picture of Byron’s “tumultuous passions,” weaving quotes from his physician, friends, biographers, and wife, as well as from his own journals, letters, and poetry. Byron becomes the picture of the manic-depressive artist, in his own words,
The apostle of affliction, . . . [who] knew
How to make this madness beautiful, and cast
O’er erring deeds and thoughts, a heavenly hue
Of words.
(“Child Harolde’s Pilgrimage”)
Dr. Jamison documents more briefly the genealogies of Tennyson, Schumann, James, Melville, Woolf, Hemingway, Johnson, Van Gogh, and others, showing evidence that “manic-depressive illness is a genetic disease, running strongly, not to say pervasively, in some families, while absent in most.”

Although Dr. Jamison also examines the treatments available for manic-depressive illness, this book is not a comprehensive introduction to the illness for the newly diagnosed or their family members. It is better suited to someone particularly interested in the artistic temperament and the problems, ethical issues, and misconceptions associated with tempering creative thinking.

Dr. Jamison should be recognized not only for the incredible scholarship of Touched With Fire (she cites over 800 pieces of scientific, literary, and biographical information), but also for her literary efforts. Dr. Jamison’s style is exquisite—although provoking, laced with lush images and poetry, and highly readable. In addition, her admiration and concern are obvious for these artists who create ‘in the wind’s eye,’ and [bring] back with them words or sounds or images to ‘counterbalance human woes.’

By Connie Pryor

Personal History, 1998. Graham, Katharine. New York: Vintage Books. (Paperback, 642 pages, $15.00)

Personal History is the Pulitzer Prize-winning autobiography of Katharine Graham. There are many stories threading through the 80 years it covers. One is of the author's role with the Washington Post, from the time her father bought it at an auction in the 1930s through Mrs. Graham's tenure as primary owner and chairman of the Post.. She led the paper through several of its crises and its rise to preeminence. An equally dramatic story, and our focus, is the story of her husband, Phil Graham, whose life ended tragically in suicide.

This story, in one sense, is a familiar one: a bright, charming person, full of energy, who is stricken by periods of depression and periods of mania. But this story plays out at a highly visible level. Phil Graham, a top Harvard law school graduate, was a major player in the Washington political and financial scene. President Kennedy himself was the recipient of some of Mr. Graham's angry tirades and late-night calls—and he attended Mr. Graham's funeral. In that pre-lithium age, despite the family's wealth and connections, Mr. Graham did not receive what would be considered basic treatment today. The diagnosis of manic depression did not even surface until five years after the onset of his severe depression—a few weeks before his suicide.

In relating this painful story, Mrs. Graham manages both to convey her own distraught feelings of that time and to provide perspective gained from her present understanding of the illness. When his severe depression struck, starting suddenly with a night of weeping, Mr. Graham sank into months of severe depression, became housebound, and insisted that his wife stay with him at all times. Her conviction at the time, which she now views as counterproductive, was that she should not tell anyone (other than his doctor) of his condition. The reader can feel her exhaustion at the double effort of constantly talking to her husband and reassuring him, while at the same time making cover-up explanations to others about what was going on. During a later period, when her husband was manic, Mrs. Graham had to cope with the opposite problem: his irrational behavior became very public, and he left her to live with another woman. As the mania slipped into depression again, she agreed to take him back, and she and their friends rallied around to help him.

The reviewers of Personal History have uniformly praised the book, using such phrases as "disarmingly candid and immensely readable" (Time) and "riveting, moving" (New York Times), and it has been a bestseller.

Mrs. Graham has said that she included painful descriptions of her husband's illness to increase the public's understanding of manic depression. She has succeeded. She has brought a vivid, moving description of manic depression, and its impact, to thousands of readers—many of whom undoubtedly have had no previous of knowledge of the illness.

Ed. notes: Personal History can be purchased from DRADA. Order form.

by Delphine Peck
DRADA Book Committee.
Smooth Sailing: Spring 1998

What is Bipolar Disorder?
Bipolar disorder, also known as manic-depressive illness, is a serious brain disease that causes extreme shifts in mood, energy, and functioning. Men and women are equally likely to develop this disabling illness, which affects approximately 1 percent of American adults ages 18 to 54 in a given year. Different from normal mood states of happiness and sadness, symptoms of bipolar disorder can be severe and life threatening. Bipolar disorder, which tends to run in families, typically emerges in adolescence or early adulthood and continues to flare up across the life course, disrupting work, school, family, and social life. Bipolar disorder is characterized by symptoms that fall into several major categories.

What Are the Symptoms of Bipolar Disorder?
Episodes of Depression: Symptoms include a persistent sad mood; loss of interest or pleasure in activities that were one enjoyed; significant change in appetite or body weight; difficulty sleeping or oversleeping; physical slowing or agitation; loss of energy; feelings of worthlessness or inappropriate guilt; difficulty thinking or concentrating; and recurrent thoughts of death or suicide.

Episodes of Mania: Abnormally and persistently elevated (high) mood or irritability accompanied by at least three of the following symptoms: overly inflated self-esteem; decreased need for sleep; increased talkativeness; racing thoughts; distractibility; goal-directed activity done to excess such as spending money; physical agitation; and excessive involvement in risky behaviors or activities. Episodes of hypomania, or mild mania, include symptoms such as increased energy, elevated mood, irritability, and intrusiveness, which may cause little impairment in functioning but are noticeable to others.

Psychosis: Sometimes, severe depression or mania is accompanied by periods of psychosis. Psychotic symptoms include; hallucinations (hearing, seeing, or otherwise sensing the presence of stimuli that are not there) and delusions (false personal beliefs that are not subject to reason or contradictory evidence and are not explained by a person’s cultural concepts). Psychotic symptoms associated with bipolar disorder typically reflect the extreme mood state at the time.

“Mixed state: Symptoms of mania and depression are present at the same time. The symptom picture frequently includes agitation, trouble sleeping, significant change in appetite, psychosis, and suicidal thinking. Depressed mood accompanies manic activation.

Episodes of mania, depression, or mixed state typically recur and become more frequent across the life span. These episodes, especially early in the course of illness, are separated by periods of wellness during which a person suffers few to no symptoms. When four or more episodes of illness occur within a 12 month period, the person is said to have bipolar disorder with rapid cycling. Bipolar disorder is often complicated by co-occurring alcohol or substance abuse.

What Treatments Are Available for Bipolar Disorder?
A variety of medications are used to treat bipolar disorder. But even with optimal medication treatment, many people with bipolar disorder do not achieve full remission of symptoms. Certain forms of psychotherapy, in combination with medication, often can provide additional benefit. These include cognitive-behavioral therapy, psychoeducation, and family therapy.

Lithium has long been used as a first-line treatment for bipolar disorder. Anticonvulsant medications, particularly valproate and carbamazepine, have been used as alternatives to lithium in many cases. Newer anticonvulsant medications, including lamotrigine and gabapentin, are being studied to determine their efficacy as mood stabilizers in bipolar disorder. Some research suggests that different combinations of lithium and anticonvulsants may be helpful.

During a depressive episode, people with bipolar disorder commonly require treatment with antidepressant medication. The relative efficacy of various antidepressant medications in this disorder has not yet been determined by adequate scientific study. Typically, lithium or anticonvulsant mood stabilizers are given along with an antidepressant to protect against a switch into mania or rapid cycling, which can be provoked in some people with bipolar disorder by antidepressant medications.

In some cases, the newer, atypical antipsychotic drugs such as clozapine or olanzapine may help relieve severe refractory symptoms of bipolar disorder and prevent recurrences of mania. Further research is necessary, however, to establish the safety and efficacy of atypical antipsychotics as long-term treatments for bipolar disorder.

Fact Sheets, Major Mental Disorders; Symptoms and Treatments
Mental Health: A Report by the Surgeon General
Department of Health and Human Services

The entire 487 page report, Mental Health: A Report by the Surgeon General is available online.

For more detailed information on bipolar disorder (manic-depressive illness), be sure to visit our Reference Shelf. Supplemental information can be found in our First Person Experiences, Books, and Videos sections.

Return to Basic/General Information About Depression and Bipolar Disorder (Manic-Depressive Illness)

POST-TRAUMATIC STRESS DISORDER

Post-traumatic stress disorder (PTSD) is the only psychiatric condition for which we claim to know the precise environmental cause. Although it is an ancient, very common condition, it is newly understood. Our knowledge of the way it develops is helping us understand how the brain works, both in health and in disease. Many forms of treatment are available, but so far, there is no best treatment. It is likely that many people will be affected by PTSD in the aftermath of the terrorist attacks in the United States and elsewhere. These events certainly qualify as traumas [significant, upsetting experiences or events that may precipitate or aggravate a mental disorder].

History. The disorder now known as PTSD was first described in wartime about 300 years ago. It has had many colorful names, such as "nostalgia" (Civil War), "shell shock" (World War I), and "traumatic war neurosis" (World War II). Other names have included "soldier's heart" and "railway spine." The term "post-traumatic stress disorder" was coined after the Vietnam War and formalized in 1980 with its inclusion in the definitive Diagnostic and Statistical Manual of Mental Disorders, Third Edition.

The new term was more than just a clever phrase; it reflected a change in the thinking about the how the disorder developed. Previously, childhood developmental problems were thought to be the basis for the symptoms. Now, current research and changing attitudes about mental illnesses were leading to a different conclusion-that lasting symptoms such as those in PTSD could result from exposure to severe trauma and intensely stressful situations. This newer model of the disorder was welcomed by many patients and families.

Epidemiology. At some point during their lifetime, more than 50 percent of the U.S. population experiences a trauma severe enough to cause PTSD, and almost 8 percent of the population is actually affected by the disorder. These figures show that almost 20 percent of people exposed to a trauma will go on to develop PTSD. Almost 4 percent of the U.S. population experiences PTSD in any given year.

We cannot predict with certainty who will develop PTSD after exposure to a severe trauma, but the some of the risk factors are prior traumatic experiences (especially in childhood); preexisting psychiatric disorders; poor social supports, and a family history of psychiatric disorders. A person's proximity to the traumatic event and the severity of the event are important. Not all traumatic events are equally likely to result in PTSD; for example, being raped is far more predisposing than is witnessing a killing, being seriously injured, or being caught up in a natural disaster. Being held hostage or being kidnapped are among the events most likely to cause the disorder. Women are twice as likely as men to have it.

Diagnosis and Symptoms. A diagnosis of PTSD is based on specific symptoms that begin after a person is exposed to a traumatic event. Here, the term "exposed" means that the person both

experienced, witnessed, or was confronted with an event involving actual or threatened death or serious injury, or a threat to the physical integrity of self or others; and

experienced intense fear, helplessness, or horror.

The person then must develop symptoms from each of the following three clusters:

Reexperiencing: Remembering the traumatic event, sometimes intensely. This may

occur during waking or sleeping (dreams),

be triggered by external cues or (apparently) be spontaneous,

be so intense that the patient briefly believes he or she is back at the scene of the traumatic event,

take the form of a mental picture or just be a feeling, and

be associated with intense psychological stress.

Avoidance or numbing: Exerting effort to avoid anything that may trigger a memory of the traumatic event. Patients may

avoid people, places, activities, or conversation that might remind them of the event;

experience a numbing of emotional responsiveness and a suppression of feelings, leading them to withdraw from their usual social relationships; and

be unable to remember certain important aspects of the traumatic event.

Hyperarousal: Showing signs of an overexcited nervous system. The patient is

unable to fall or remain asleep, sometimes waking with nightmares;

irritable, and commonly has outbursts of anger;

continually tense and easily startled; and

unable to concentrate well and sometimes is continually on alert, looking for signs of danger.

The symptoms may begin immediately after a traumatic event, and they are considered normal for as long as a month afterwards. If the symptoms last three months or longer, the disorder is considered chronic; if they last less than three months, acute. If PTSD symptoms emerge months or years after a trauma, the disorder is called delayed-onset PTSD.

Treatment. We have a rich array of insufficiently tested treatments for PTSD. The disorder has generated a great deal of interest and study by psychiatrists and other health-care workers, perhaps because it causes so much suffering and its symptoms are dramatic. A tremendous amount of research on PTSD is under way, and we are beginning to get data on the effectiveness of various treatments. Because PTSD encompasses a variety of symptoms, and each patient has his or her unique mixture, no single treatment is likely to help everyone who has it.

Below are some guidelines that should help people decide what to do about their symptoms.

Get a diagnosis. All treatment depends on an accurate diagnosis. You must know what you are up against if you hope to overcome it.

Get treatment early. If left untreated, PTSD tends to become chronic and may have devastating psychological, physical, and social consequences. The earlier the treatment, the better the outcome.

Consider a combination of treatments. In 70 percent of cases, combining psychotherapy and medication will have an additive effect!

Treat any other conditions. People with PTSD very often have other disorders such as depression, alcoholism, or substance abuse, and are at an increased risk for suicide.

Try available psychotherapies. Behavioral, cognitive, interpersonal, and psychodynamic psychotherapies are at least partially effective. Group therapy and family therapy can help also. All these psychotherapies are designed to help people "process" the traumatic experience and move forward in their lives.

Consider, in consultation with your psychiatrist, the possibility of taking medications. They are often an important part of the treatment process. Medications may reduce the frequency and intensity of reexperiencing symptoms and dampen hyperarousal symptoms such as anxiety attacks, nightmares, and insomnia. Avoidance symptoms are difficult to treat with medications, but the SSRI [selective serotonin reuptake inhibitor] drugs (Zoloft, Paxil, Prozac) have shown some promise in this area. Medications may successfully treat concurrent psychiatric conditions. Finally, medications may quiet the nervous system enough to enable the patient to make use of psychotherapy and come to grips with what he or she has experienced.

Conclusion. Not only is PTSD a frightening and disabling disorder, it is also quite common. As we study this disorder, we become more able to help people who are suffering from it. Unfortunately, the tendency to avoid the reexperiencing symptoms and associated hyperarousal often keeps a person from getting help. Although there is no best treatment for PTSD, many available good and helpful treatments are evolving.

By David M. Goldstein, M.D.
Director, Mood Disorders Program
Clinical Professor of Psychiatry
Director, Psychopharmacologic Research
Georgetown University School of Medicine
Washington, DC

References

American Psychiatric Association, Committee on Nomenclature and Statistics. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Revised. Washington: American Psychiatric Association, 1994.

Kessler, Ronald C., et al. Posttraumatic Stress Disorder in the National Comorbidity Survey. Archives of General Psychiatry 52 (Dec.), 1995.

Shalev, Arieh Y., et al. Treatment of Posttraumatic Stress Disorder: A Review. Psychosomatic Medicine 58: 165-182, 1996.

Foa, Edna B., et al. (eds.) Effective Treatments for PTSD. New York: Guilford Press, 2000.

International Society for Traumatic Stress Studies 60 Revere Drive, Suite 500 Northbrook IL 60062 www.ISTSS.org Tel: 847-480-9028

________________________

Reprinted from Smooth Sailing, Fall 2001, pages 1-3
Smooth Sailing, the quarterly newsletter of the Depression and Related Affective Disorders Association (DRADA)

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