Bipolar 2 From Inside and Out

Grief and Mood Disorders

Grief and mourning are hard for anyone to get through. When you have a mood disorder, it’s even harder.

Depression can linger longer than one might expect. A death, for example, might tip one over into a clinical depressive episode. There are no funeral etiquette books on how to cope with feelings like that. All they will tell you is what to wear to a funeral and what’s an appropriate remembrance to send or what to say at a viewing or funeral service. There are no emotional guides that tell you how long it is appropriate to mourn a loss. The feelings come as they will and stay as long as they stay.

A lot of the emotions associated with depression may visit you, or even move in and stay a while. If you are “lucky,” a period of numbness may get you through the funeral and any other formal observances. But that’s far from guaranteed. Depression may express itself as deep and inconsolable sorrow. Sometimes, there’s no way to turn off that feeling or wait to express it.

There can be anxiety too. Will all my egregious relatives behave themselves or will they do something embarrassing? Are customs from another religion the same as mine or not? It’s easy to get all tangled up and even immobilized. You may be tempted to avoid the whole situation. But if this was a very close friend or loved one, you want to do your best to respect and honor that person, even if you don’t know quite how. It’s even more anxiety if you have to ask yourself how you’re supposed to get through it all.

Grief and mourning are also emotions that may strike you after a death or other loss. You may cry unexpectedly, whenever the emotions hit you. You may wake in the middle of the night and feel the absence of someone all over again.

There aren’t any rules that cover grief and mourning. You feel how you feel for as long as you feel it. Some people try to shame the bereaved into restraining their grief or setting a limit for how long it should go on. The fact is that a loss may leave a hole in your heart for years to come, or forever.

Anger is also an emotion that may come. It’s one of the classic stages of dealing with death, along with denial, bargaining, depression, and acceptance. Anger is harder to understand and harder to control. Some people will not understand that you can feel anger when a friend dies. But my friend just died and I am angry as well as sad that I did not get to see her before she died, even though I know that it was impossible, given the circumstances. People may understand anger a little if the person died by suicide, but it seems inexplicable to many after a natural death.

I can’t tell you how to deal with those feelings. I am dealing with them myself right now. I am trying to hold myself together, to do what is “right” – to keep my grief on hold till I can express it fully. It’s not usually a good idea to stuff your feelings in a box, but sometimes it’s needful, and getting through the ceremonies attendant on a death may well be one of them.

Perhaps the hardest thing to get through is the fact that these emotions and the memories that they bring with them may crop up at unexpected times. Even decades cannot lessen the sorrow of some losses. Good emotions and memories of your loved one – and it need not be a close family member – will help. They may pop out of nowhere, just like the depression does. But these emotions you can hold close to you. If you can remember any of them when the bad times come, that may ease your grief for a while, though it cannot erase it.

Grief, depression, sorrow, anger, and other emotions are appropriate after a death. And don’t let anyone tell you otherwise. They may not understand that such emotions aren’t only for family members and the very closest friends. When someone has touched your life, in whatever manner, your emotions are valid and your grief allows you to express them. Whether you have a mood disorder is irrelevant.

Functioning While Bipolar

Bipolar disorder is a funny thing. Mine leaves me alone part of the time. Until it doesn’t.

I have had full-blown depressive episodes, with the sobbing and the immobility and the wretchedness and everything else associated with it. I have had one major episode that lasted for three years straight, plus everything else from minor breakdowns to that vague, lingering miasma that comes when you’re untreated and you don’t know that what is really happening to you is clinical depression.

I have also had full-blown anxiety attacks, the sort that leave you twitching all over, feeling like you’re about to jump out of your skin, gasping for breath, and imagining that every driver on the road is swerving into your lane. I’ve twitched and shaken and stammered. I’ve scratched myself. I’ve hidden under the covers until I can’t breathe. I’ve taken anti-anxiety meds that did nothing at all.

Right now I am sufficiently medicated and have been relatively stable long enough that I think what I have is functional depression or maybe high-functioning depression, or whatever you want to call it. I have enough wherewithal to work part-time from home, do other writing-related projects (like this blog and my other one), and do assorted tasks like paying bills and making business-related phone calls. (Occasionally, if the phone tree is lengthy enough and the person on the other end is uncooperative enough, I have a small-scale meltdown. My voice goes up in pitch and tears start rolling down my face. My husband takes over the transaction when he notices that.)

But secretly, I know depression is lurking and can rear its ugly head again with little or no provocation – a trigger or nothing at all. So can anxiety, which is how my brain usually responds to hypomania. It’s a little like those commercials for psychotropic meds you see on TV, where the person has a little sign with a smiley face and hides behind it. Except that’s not quite accurate.

I understand that high-functioning depression is also called “smiling depression.” That’s not my experience of it. I’ve almost never been able to “fake it till I make it,” slapping on a happy expression when inside I’m dying. Besides, it doesn’t work, as far as I can tell. The depression or the sorrow always leaks out around the eyes. I’ve seen this in myself and in other people.

Before I was treated, I used to have what you’d call “resting sad face.” Once a boss of mine encouraged me to smile more (and is there anything more annoying?). I didn’t feel particularly sad at that moment, though I’m sure that I had at least a low-grade depression, like a low-grade fever. But I was at my job, and functioning even then, if not very well or cheerfully.

The phrase “high-functioning” gets used a lot to describe certain varieties of autism. I don’t have autism and I’m not an expert on it, but my suspicion is that high-functioning depression is similar in some ways. I don’t always react the way other people expect me to. I feel out of my depth a lot, especially in environments with lots of people or lots of noise. But that doesn’t stop me – or lots of other people – from carrying on with what I need to do to be a functioning member of the populace.

But back to bipolar disorder. Even if someone seems to be “high-functioning” doesn’t mean he won’t have a meltdown sooner or later. Even someone who “slaps on a smile” may let it drop once she is alone. Even someone who is “coping well” may not be coping at all tomorrow or next week or next year. Sometimes you can’t tell on the surface what someone is going through inside. Like I said, bipolar disorder is a funny thing.

I am blessed with many friends, online and off, who are as dear to me as anyone can be. We have laughed together, cried together, eaten together, danced together, sung together, joked together, mourned together, and loved together.

Now that I’m back in my cycles of depression and hypomania, hurtling around like a marble in a shoebox, I haven’t heard from any of them.

A lot of the contact I have with friends is on Facebook, and I have almost entirely stopped posting or replying, or otherwise interacting there. No one seems to have noticed. At least no one has called or IMed to check on me.

Am I ghosting them? No, because I don’t want the relationships to end. In fact I very much want them to continue. My scattered moods, primarily depression, have sapped my ability to reach out. It may be that they assume since I post my blogs every Sunday, I am all right.

I desperately want someone to reach out to me. This is selfish and childish and unworthy. If I want human contact, I should be able to reach out and initiate it myself. But I haven’t been able to. Between the exhaustion of depression and the exhaustion of hypomania, it’s difficult to make any kind of effort.

The memes say that if you have a depressed friend, reach out to them, even when they can’t reach back. And there have been times when my excellent friends did that, back when I had been in the Pit of Despair. And they kept reaching, even when I didn’t respond.

I guess I miss those days – not the Pit of Despair – but the little parachutes of care that rained down and demanded nothing. The phone calls “just to check in” or to distract, the invitations that I was never going to be able to make myself go to or reciprocate, the awful jokes that I might not even be able to laugh at.

I understand that everyone is fighting their own battles these days, with isolation, anxiety, panic, and other reactions to the pandemic, the lockdowns, the vaccines, the separated families. Mental health struggles, especially including depression and anxiety, are spreading to people who have never experienced them before. A lot of people are suffering, and a lot of people don’t know what, if anything, they can do about it. People have had to resort to Zoom weddings and funerals and outside-the-window visits to relatives in nursing homes.

Part of the problem, I suspect, is that I have been so relatively stable and functional for so long now. I made it through a tornado and a year of home dislocation and all the associated disruptions and bureaucracy without having one of my famous meltdowns. So, now, when even I have not been expecting or experiencing any psychological trauma to speak of, it’s easy to understand that no one else has seen it or noticed.

Then there’s my husband. He is my rock, my caregiver, my “emotional support animal.” Ordinarily, he takes up most of the slack in making me feel seen and heard and cared for. But unfortunately, he is having depression and anxiety of his own right now. He has recently had health problems, has changed jobs, and has physically strenuous activities he must complete, within a deadline. Of course, he is reacting with depression and anxiety of his own. And when both of us are depressed and anxious at the same time, it’s not pretty. We don’t have enough psychic stamina to help ourselves, much less each other.

So, I understand why it isn’t happening. But I miss the check-ins I’m not getting. The calls that don’t come. The personal long-distance reach-in. The wave from outside the window.

I’m not quite to the point of, “Nobody likes me. Everybody hates me. I guess I’ll go eat some worms.” But close.

Hypomania and Exhaustion

I’ve done so much. I should feel exhausted. I do feel exhausted. Why do I keep doing so much?

The answer, of course is hypomania, or maybe a mixed state.

I had been thoroughly depressed over my writing, as I sent out query after query to agents, and getting back rejections or the horrifying limbo of “no response means no.” I kept doing this for nearly four months, until I had apparently run out of agents to query. (I know that can’t be literally true. There are thousands of agents in New York alone, but I had been through all the usual lists and gone pretty far down the Google pages.) Yet I trudged along, depressed but pushing myself. Get the queries done. Get my work done. Get these blogs done. Go to bed. The same the next day. Call it functioning depression. I was still in motion, doing what I told myself had to be done, but enjoying none of it (or anything else).

Then I got an invitation to try out for some work-for-hire (which is sort of like ghostwriting, only different). Instantly, preparing submissions (three of them!) for this gig consumed me. And I kept on with the queries, the work, and the blogs. But I was tipping over into hypomania.

I wrote the submissions insanely quickly, when I knew I should have taken the time to analyze them, polish them, try a couple of different drafts. But no. I found myself pushed to get them done and get them out there. Or rather, I pushed myself to do it.

My submissions were rejected, but this time instead of slipping back into a funk of depression, I wrote a nice note saying that if another opportunity like this came up to please consider letting me apply again. They responded to the note, seeming astonished that I had sent it, and complimenting me on my attitude. Nothing like a pat on the head to keep the juices flowing.

It was at about that point that hypomania truly hit. I focused everything on my writing. I reworked the first three chapters that I had been submitting to agents and submitted them to still more. I started taking on extra work assignments. I took only brief breaks to eat a bowl of soup, then plunged back into it again. I had trouble getting to sleep and trouble sleeping, even though I was so exhausted that I turned in early each night. And I woke early, ready to keep on keeping on.

Then the miracle happened. I got a positive response from an agent. They wanted to see more of my work. I tweaked the newly revised first three chapters and sent them in. Now I’m waiting, nearly bouncing out of my chair, for them to respond. I just know that they will want to see the whole novel and become my agents. I do know that the deal is a long way away from being sealed, but hope after so long of slogging through my depression, hypomania has taken control.

I am (sort of) still contemplating my WIP (work in progress, a sequel to the novel that might now become real), thinking I need to rethink it entirely or try a different plot altogether. I am still taking on extra work, though it exhausts me. During my brief breaks from work, I scour the internet for presents for my husband’s birthday, and spend more than I had intended for more presents than I had planned.

And I am writing this blog post the day before I need to post it, rather than the three to four days I usually allow myself to write it. And I still need to polish the post for my other blog. And pay bills. And find a place for us to get a health check that’s required by my husband’s employer. (I have already set up appointments for our vaccine shots.)

I think it is most likely that if the agent rejects my work after all this, I will once again sink into depression – the I’m not worthy anything, I’m a fool to have put this much energy into it, I should just give up kind. Cutting back my activity to the bare minimum – work and blogs. Sleeping more, enjoying it less. Enjoying everything less. My old familiar functioning depression that is only possible because of the meds I take that don’t allow me to swing too far down.

I know people who, when you try to tell them about hypomania, tell you to enjoy it while you have it. They don’t know how wrong they are.

Laughing Out Loud

There’s nothing funny about bipolar disorder. In fact, one of the ways that I know I’m having a spell of bipolar depression is that my sense of humor flies out the window. Nothing brings a smile or a laugh – not my husband’s awful jokes. Not my friend Tom’s silly songs. Not a funny movie like Arsenic and Old Lace.

I have been in a spell of depression for a little while now. As I mentioned last week, part of it may be reactive depression. But here’s the thing. Reactive depression feels the same as bipolar depression. You have the same sense of misery, loneliness, helplessness, hopelessness, anomie. But you know what caused it and that it will end pretty soon, relatively, unless you tip over into a true depressive episode, which can last a lot longer than that.

But yesterday I laughed. And that was a good thing. It didn’t pull me completely out of my depression, but it let me know that escape was possible, and maybe even starting.

It happened like this:

My husband and I were sitting on the couch, watching TV. I was not enjoying it. Then a commercial came on about “man-boosting” pills that increase testosterone. It promised everything: strength, leanness, stamina, and outstanding performance in the bedroom.

Dan turned to me and said, “Hey, honey. Maybe I should try some of that. Improve my performance in bed-woo-woo-woo!

I turned and looked him straight in the eyes. I said, in a solemn, deadpan voice, without a trace of a snicker: Woo. Woo. I never got to the third Woo because we both dissolved in giggles. And it felt good – not only that I could laugh, but that I could make him laugh. Just thinking about it made us laugh all over again.

Today I am back to feeling overwhelmed, if a little less miserable, but still functioning on some kind of level. I don’t think my depression is over with. But for just a moment, I saw a ray of hope. Yes, it was over something stupid. Yes, I delivered the line with a flat affect. No, I didn’t know it was going to be that funny. I even thought Dan might be offended that I was making fun of him. But the important thing is that we both laughed. 

What I’m saying is that laughter, by itself, is not a cure for depression, however much the memes and the positive thinkers tell you that it is. But if laughter happens to you, it at least reminds you that the depression will end sometime – maybe quicker than you think. The giggles are building blocks that will help you climb up out of your hole, or at least see that there is a way out.

That’s a lot of philosophizing about two words (or syllables, really), and I’m not sure the magic would happen again if either one of us said Woo. But I am taking the memory of that moment with me, for whatever strength it can give me and whatever amusement will stay with me when this depression ends.

How Depression Sneaks Up

I had a blog post all written and ready to go. It was about my fluctuating moods and my writing, and how they affected each other. Some of what I wrote is still true. The depression I suffered during my early years and the exceedingly depressive poetry I wrote during that time allowed me to learn something about how poetry works and something more about how depression works.

I wrote about how hypomania affects my writing, and that is still true. Hypomania pushes me to do my writing, even when I don’t feel like it. In fact, at times it pushes me into doing more writing than I can probably handle. Case in point: This week I wrote three samples for a work-for-hire outfit when I should have been writing or at least outlining my WIP (Work In Progress), a sequel to the mystery I have already written and have been sending around to agents.

And last night, that’s where I hit the wall. I figured out that I have sent out about 180 or so query letters and gotten only the most minimal results – rejections that said I had an interesting premise that was not right for them. Most, though, have received plain rejections or the dreaded “no response means no.” I am now second-guessing myself and everything about the manuscript.

Last night, the depression caved in on me. I spent the night in bed, not sleeping except for nightmares, and not wanting to get up in the morning.

Because my identity is invested in being a writer, though, I did get up (late), sent a few more queries, and got to work on rewriting my blog posts, which I had determined were wretched. In the blog post that I abandoned, I had pontificated about how keeping a schedule kept me going with all the writing projects and various other work I do. 

I had also crowed about my relative stability and how that was helping me keep that schedule, which was supposed to be keeping depression at bay. I found out that I lied. The fact that I have maintained functionality for some time did absolutely nothing to prevent the depression that hit me.

Admittedly, this is probably a reactive depression, with my lack of success being the trigger. The thing is, it’s awfully difficult to tell apart from endogenous depression. In fact, I have known the first to melt into the second. At first you have a clear cause that would depress anyone, then you find it clinging to you long after what would seem to be reasonable. (This is subjective, of course. What is the “right” length of time to be depressed over 180 rejections?)

What’s left? Self-care, of course. Trying to sleep if I can, and squeezing in a nap if possible. Eat something, even if it’s only some guacamole and chips or a bowl of soup. Take my meds religiously. Try to cling to that schedule even when I don’t want to.

But the truth is, I’m running out of agents to submit to. I’m running out of energy to try. And I’m running out of the frame of mind to keep me functional. I’ll be okay, I know, but it may be a long, hard climb. 

I was a clumsy child and am a clumsy adult, so I have lots of scars. They can be categorized into three types.

Accidental scars. These are the ones that resulted from my clumsiness. I have a huge scar on the inside of my left leg from tripping over a metal milk box. (For the youngsters among you, this was the box where empty milk bottles were placed and full milk bottles took their place.) Back in the day, you didn’t go to the emergency room for injuries like that, so the scar remains jagged and irregular, coursing across my inner thigh like a river.

There’s also a scar on my right foot from the time I dropped a Coke bottle on it. (Yes, this was during the era when Coke bottles were made of glass. I’m old, okay?) And one that bisects my eyebrow, lengthwise, from when I bumped heads with another child and my glasses were pushed into my face.

Non-accidental scars. The one that I am contending with right now is a medical scar. It came from a punch biopsy of my forehead to determine what a lump was. (It was a sarcoid.) I freaked out when the doctor asked the nurse to hand him the “puncture scalpel.” Seeing my distress, he changed it to “sampling tool.” That scar is fading, though, and I hope it will soon become invisible.

Another non-accidental scar came when I was in fifth grade. Some kids and I were at a bus stop and they thought it would be fun to throw rocks at me – actually crumbled pieces of the street macadam. At first they threw them at my feet, and I “played along” and jumped over the missiles. One kid, though, threw harder and higher than the others. The rock hit me in the forehead, and I started crying and bleeding all over my mittens. I heard one of the kids say, “We didn’t mean to hurt her” as they scattered and ran, a sentiment that I somehow doubted.

My mother was sent for and I was taken to the doctor’s office, where to add more pain to the incident, I received three stitches, which were in some ways more traumatic than the injury that led to them. This scar was right along my hairline, and isn’t really visible these days. But, believe me, it still hurts.

More distressing (and the warning for the trigger warning on this post) are non-accidental scars that I inflicted on myself. These are the scars that resulted when I took a knife to my wrist. Nowadays they call this NSSI (non-suicidal self-injury), and indeed that’s what it was. I wasn’t suicidal. You could call it a suicidal gesture, I suppose. But it was not a serious attempt, was never meant to be seen, and was not “a cry for help.” In fact, for many years I tried to hide the three inch-long white lines on my wrist by wearing a wristband or long sleeves to cover them. Now I view them as reminders of how bad things can really get and what incompetent coping mechanisms I had back then.

Internal scars. Some of these are most likely related to my self-inflicted scars. They came from a variety of situations, not least of which was being literally stoned while I was an impressionable young girl. There were many incidents of threats and bullying, which begin to pile up after a while. There were the internal scars that come with depression – feeling useless and worthless and unlovable.

There were also relationships, those that ended badly and those that were bad from the beginning. They reinforced the idea that I was useless and worthless and unlovable, and scarred my psyche.

Those scars don’t show on the outside, and I have worked hard not to let them become visible through my words and actions, as I used to do. I have not been completely successful, of course. Like the visible scars, I expect they will always be with me in some form. Like the visible scars also, I expect they will become fainter and harder to find unless I go looking for them, which I try very hard not to do.

They remain, but they fade, and I am satisfied with that.

My Triggers

By shane / adobe stock.com

Bipolar disorder is a funny thing. It can come on with no warning. One moment you’re fine, and the next you’re in the infinite doldrums or jagging on a spike of enthusiasm. Most of the time, it’s like that. The moods come on unexpectedly and stay as long as they want.

Sometimes, however, there are things in your life that seem to trigger a bout of depression or mania.  This isn’t quite the same as what’s commonly called a trigger. In the usual sense, a trigger is something in your past, like a traumatic memory, that comes bursting through when you read, see, or otherwise encounter a reminder of that memory. Suddenly, you are thrown back into the situation that triggered you, reliving the trauma, feeling as if you were still there, re-experiencing it. Triggers are most commonly associated with PTSD (or Post Traumatic Stress Disorder). Many people associate PTSD and its flashbacks with veterans and war, but other traumas, such as rape, assault, and natural disasters can also cause PTSD.

Trigger warnings are controversial. Some people need a warning that the content – especially books, blog posts, or films – may trigger a suppressed or otherwise traumatic memory and leave the person caught up in the sensations during a public moment, such as in a classroom. Obviously, people with traumatic memories would prefer to avoid this, so a trigger warning is placed at the beginning of a story, novel, or even a song that deals with rape, domestic abuse, or other traumas, especially ones depicted in a particularly graphic manner.

To other people, reacting to a trigger is an admission of fragility, at best, or at worst, an excuse for avoiding content that most people can easily handle. This is part of the mindset that leads to calling the severely traumatized “snowflakes” for their perceived inability to deal with stimuli that “normal” people take for granted. They do not understand the power of traumatic memories or the power they have over people who have been through trauma. They consider such people weak. They consider themselves strong, even if – or especially if – they have been through traumas themselves.

In general, my life has been less traumatic than some, more traumatic than others. There are memories that invade my dreams, situations that cause me panic, and stimuli that rev me up. I am not in control of these stimuli, or what they do to me.

Most of the stimuli trigger depression in me, as my bipolar disorder is heavily weighted towards depression. (In fact, I was diagnosed with unipolar depression before a psychiatrist finally recognized my condition as bipolar 2 with anxiety.) When I encounter one of these “personal” triggers, I am panicked, unable to communicate, and immobilized, or nearly so, and must rely on the help of others, especially my husband, to get me through. There’s no telling how long that depression will last.

Primary among my triggers is what I call “the rotten ex-boyfriend who almost ruined my life.” It was a toxic, gaslighting relationship that left my soul sucked dry and my emotions shattered. Fortunately, I do not often encounter anything that reminds me of those days. A friend I met during that time, in fact, has helped me heal both then and for many years thereafter.

Still, I have dreams – ones where I am traveling to the man’s house, ones where I am in the house but he is not present, and ones in which he is. I wake feeling vaguely seasick and nervous. The feeling persists like a hangover through most of the next day. It interferes with my ability to do work and to interact with people. My reactions used to be much worse, with specific words even able to throw me into panic and depression.

Another thing that triggers me is disastrous financial matters, or at least ones that I perceive that way. IRS dealings are by far the worst. A letter with that return address throws me into a panic. Once I even collapsed on the street after an IRS engagement and was unable to get up without assistance. Overdue bills and dealing with personal finances are triggers, exacerbated by the fact that I pay most of the bills, despite the fact that I make less than half the money. This is one of my contributions to the household since there are many things I am unable to do. Such situations leave me with my head in my hands, shaking and catastrophizing, unable to do what must be done until I calm down. (My husband is by now adept at helping me do this.)

And I have one of the more “traditional” trauma triggers – a natural disaster. A year and a half ago, our house was destroyed by a tornado. At the time it hit, I was upstairs in the bedroom. I remember the roof coming off. I remember putting a pillow over my head and hoping for the best. For many months I suppressed the trauma. But now it has come out. When the wind blows very hard or the rain blows sideways, I panic. Despite the fact that upstairs is the very place I shouldn’t go, that’s where I end up – in bed with a pillow over my head. (I also avoid movies like Twister. I’m not even sure I should try The Wizard of Oz.)

As for hypomanic triggers, I have few. Most of my hypomanic flights are unexpected, lifting me up with no warning. Although they can be exhilarating, they are also dangerous. One of the hazards is unwise spending, which of course can lead to the aforementioned financial depression triggers.

One trigger that takes me as near as I ever get to hypomanic sexuality, though, is a sensory, rather than a situational, trigger. For some reason, the smell of Irish Spring soap brings up the heat in me. I distinctly remember the first occasion on which I noticed this. A coworker walked past me and I smelled the distinctive scent. It started my juices flowing. Later, we became lovers. My reaction to Irish Spring is less extreme these days, but it still triggers a memory of the feeling. I seldom encounter the scent anymore, as my husband prefers Zest.

At any rate, it is my experience that triggers can arise from sensory memories, from dreams, from upsetting situations. I have few triggers related to textual representations, though I am not immune to those in films (I left the movie “What Dreams May Come” before it was over and waited in the lobby until it was over).

What I can say is that people’s triggers do not make them “snowflakes.” Triggers elicit visceral reactions that are no less real for not being visible to outsiders. While I don’t advise purging any possible triggering material from, say, academic curricula, I do think a trigger warning on syllabi or blog posts is only polite, and possibly psychologically necessary.

 

By Halfpoint / Adobestock

There are a lot of assumptions made about mental illness. One is that all of the homeless population are – or at least predominantly are – mentally ill. That’s far from the truth.

Homeless people get that way for a variety of reasons. Some lose their jobs or are evicted from their housing. Some have no friends who can put them up when that happens to them, so they have time to pull themselves together and find a new job or living situation. Some live on the streets because of alcohol or drug addiction.

And yes, some people are homeless because they are mentally ill. Disorders such as depression and bipolar disorder, schizophrenia, anxiety disorders, and substance abuse disorders are frequently seen in the homeless population. According to the Harvard Medical School, “about a quarter to a third of the homeless have a serious mental illness — usually schizophrenia, bipolar disorder, or severe depression — and the proportion is growing.” 

Psychiatric Times states, “There is clearly a link between psychiatric disorders and homelessness; disentangling the nature of this relationship is complicated….Mental illness had preceded homelessness in about two-thirds of the cases. Homelessness in turn has been associated with poorer mental health outcomes and may trigger or exacerbate certain types of disorders.” 

PTSD is also a factor among homeless veterans and others with traumatic pasts. Many military veterans suffer from it as a result of their experiences in combat situations. A traumatic event such as witnessing or being victim of an attack, sexual assault, and so forth experienced during homelessness can itself cause PTSD. And homelessness itself can be the traumatic event that leads to PTSD.

The system is rigged against homeless people. With no address, phone, no reliable transportation, no place to bathe, it is hard to get and keep a job. Many times homeless people are taken advantage of when they can get day labor such as mopping a store, cleaning toilets, or sweeping a parking lot. The job “broker” for casual labor can easily demand a kickback from the homeless person in exchange for finding the person a job.

Some homeless people have been kicked out of their houses because of their alcoholism, drug addiction, or disturbances caused by mental illness – or because of “tough love” philosophies.

And let’s not forget people who have been released from jail or a mental health facility. It can be almost impossible to find a job and an affordable rental. Thanks to a broken system of both prisons and psychiatric facilities, the recently released have no place to go but the streets. When Reagan closed down and defunded “asylums,” he took away the most common way for the mentally ill to get help. Where did these people end up? Either in prison or a homeless camp.

In fact, being in jail is a luxury for some homeless people. They may commit petty crimes in order to be arrested and put where they know they will receive “three hots and a cot” for at least a couple of months. But there is little to no psychiatric care for homeless people in jails or prisons. Despite this, the prison system is clogged with mentally ill people who have no way to get better and nowhere to go when they are released.

With a few exceptions, people do not choose to be homeless. Many people look down at the homeless, sure that they know what would be best for them or clinging to the outdated notion that a homeless person can “pull themselves up by their bootstraps” and conquer both mental illness and homelessness. People who experience schizophrenia or psychosis are particularly hard to place, even in shelters.

What about those shelters? To begin with, they are overcrowded. Not everyone who needs one is able to get a place. Many are horrible, crowded places, where theft, assault, and rape occur. Many make the residents leave at 7:00 a.m., whether they have a place to go or not. Many others make residents adhere to codes of conduct little better than jail, or insist that a resident profess the preferred religion of those who run the shelter. And don’t forget bedbugs, lice, and infections linked to too many people being in an enclosed space. COVID restrictions make it even harder to find a place in a shelter. There are more shelters for women – and especially women with children – than can accommodate the women who make up 29% of the homeless

And what about the violence associated with both the homeless and the mentally ill?

Lynn Nanos, in her book Breakdown: A Clinician’s Experience in a Broken System of Emergency Psychiatry, makes an excellent case that schizophrenic and psychotic patients, especially those with anosognosia, are the most likely of all psychiatric patients to commit violence and be victims of violence. 

But murderous violence is not the only kind. An NCBI study reported that “mental illnesses only moderately increased the relative risk of any violence, that is, assaultive behaviors ranging from slapping or shoving someone to using a weapon in a fight.” In addition, they said, “the absolute risk was very low; the vast majority of people with diagnosable serious psychiatric disorders, unless they also had a substance use disorder, did not engage in violent behavior.”

In terms of the myths about the mentally ill homeless, much of that is related to the stigma surrounding the seriously mentally ill. When we look at the facts we find that, while mental illness may be one cause of homelessness, it’s wrong to say that all the homeless are mentally ill – just as wrong as it is to say that all of the seriously mentally ill are homeless.

It’s often said that most of the U.S. population is one paycheck, spouse, illness, job loss away from homelessness. Let’s add mental illness to that list of potential causes. As the sign in the accompanying picture says: Once I was like you. We need better programs to serve the homeless, the mentally ill, and the homeless mentally ill.

 

 

 

 

 

 

 

Are Lobotomies Gone for Good?

By alexlmx/adobestock

If I were a few decades older, I might have undergone a lobotomy. Treatment-resistant bipolar disorder (or manic depression, as it was called then) and schizophrenia are some of the disorders lobotomies were recommended for. It was thought that such mental illnesses were caused by faulty connections in the brain and that the cure was to sever those connections. Lobotomy pioneer Antonio Egas Moniz received a Nobel prize for inventing the operation.

The main problem was it didn’t always work as planned. There were other problems as well, such as the flattening of affect and severe brain damage (what a surprise). The most noted person to have a lobotomy (also called leucotomy) was Rosemary Kennedy, the developmentally delayed sister of John and Robert.

There were two kinds of lobotomies, though only the method differed. The prefrontal lobotomy involved drilling holes in the patient’s skull in order to get to the frontal lobes, where the trouble was thought to lie. The other, and to me more alarming, version was called the transorbital lobotomy. The “orbit” in transorbital refers to the eye socket. An instrument was introduced into the brain by going through the eye socket (without disturbing the eye) and used to sever the connections between the frontal lobe and the rest of the brain. Around 50,000 lobotomies were performed in the U.S., most between 1949 and 1952

Doctor Walter Freeman was the champion of the transorbital lobotomy, often called “icepick surgery” for the slender instrument that was inserted and then swooped about, in hopes of severing the faulty brain wiring. Dr. Freeman was so adept at this that he could perform many of these surgeries in a day, and indeed performed around 3,500 during his career, including 2,500 icepick lobotomies. He once performed 228 of the procedures in a two-week period and taught the technique to countless other doctors. Some of his patients underwent more than one lobotomy.

Eventually, the lobotomy came into disrepute for A) being the horrible invasion that it was, B) reducing many patients to an emotionless or brain-damaged state, and C) being depicted in Ken Kesey’s 1962 novel One Flew Over the Cuckoo’s Nest as a punitive, brutal, and unnecessary procedure. The lobotomy all but disappeared from the psychiatric and surgical landscape.

But wait! Lobotomies may be out of fashion, but psychosurgery (or “functional neurosurgery”) is still performed for treatment-resistant mental illnesses. In these operations, however, rather than randomly severing neural connections, the surgeon removes the areas of the brain thought to be the cause of the psychiatric problem. Modern versions of psychosurgery include “amygdalotomy, limbic leucotomy, and anterior capsulotomy,” none of which I know enough about to comment on. Suffice it to say that the days of drilling burr holes in patients’ skulls or taking an icepick to their brains are, as far as I can determine, gone. 

Psychosurgeries are now performed rarely, deep brain stimulation being the preferred form of treatment, especially for non-psychiatric conditions like Parkinson’s or treatment-resistant seizures. And they’re always performed under anesthesia. The patient’s consent is required.

Electroshock therapy is much less invasive and is still used today, although in a lower-key and safer manner than the original procedure – under sedation and with lower amounts of electricity. It still has side effects, such as the loss of short-term memory for the period surrounding the treatment.

Electroshock therapy was considered in my case because of my long-term, treatment-resistant case of bipolar 2, which involved years-long depressive episodes. At first I was terrified, but after doing some research and talking to knowledgeable people, I was just about ready to agree to it. At that point my psychiatrist suggested we try one more drug first – which worked, alleviating (though not curing) my condition like turning on a switch.

(Side note: When I began researching lobotomies, I found that the book My Lobotomy, by Howard Dully, was particularly interesting. The story didn’t follow the usual pattern. Instead, it seems, Dully’s hospitalization and operation (in 1960, when the boy was 12) were largely instigated by his stepmother, who wanted him out of the way, though schizophrenia was diagnosed by Dr. Freeman (see above) before the transorbital procedure.)

 

 

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