“So, basically, before I tell you my story, I need to know if you are Indian.”
The patient, Rajeev as I shall call him, is a 29-year old Indian engineer who comes to my psychopharmacology clinic at the insistence of his wife for, as she had informed me over the phone a week earlier, “unmanageable instability.” Rajeev, dressed Silicon Valley Casual--a custom-fitted dress shirt with silver cufflinks, a dark blue sports jacket and slacks, black Salvatorre Ferragamo loafers-- sits at the edge of the couch in my office, gazing intently at me as he awaits an answer.
“Well,” he gestures impatiently, “I suppose it does not matter.”
Rajeev sits up, cranes his neck to one side, and stretches his arms forward to adjust his shirt sleeves--gestures a conductor might make in the hushed moments before the music begins.
“Basically, I came here to California from India after graduating at the top of my class from the best university in New Delhi--I was, you should know, the top student out of 347 students. From there I went to Stanford for a PhD in triple E, Electrical Engineering and Economics, and from my dissertation, which I completed in 3 years, I published 45 papers and started three different companies and you should know that I have five patents to my name and have been featured in Fortune and have had stories written about me in the Wall Street Journal and New York Times and ... you are not Indian, right?...No, well then you maybe you would not understand my problem... after all, you are not Indian... Basically, I have been having panic attacks and these intense mood swings because I'm afraid that I will not fulfill my destiny as the Vedic astrologers in Bangalore have predicted; it is my destiny, you should know...quite simply....to change the world.”
And with that, Rajeev sits back into the couch, crosses his arms, thrusts out his legs and contemplates the tips of his Ferragamos as he wags them impatiently. A few moments later he glances expectantly at his wife, Sanjita, who sits beside him on the couch.
An attractive green-eyed Indian woman in beige slacks and a white designer blouse, Sanjita, remains silent and continues to gaze deferentially at the carpet in my office. Her silence is broken by the bright tinkling of her bracelets as she raises her hand to her mouth to clear her throat. We collude, sharing in the knowledge that, were it not for her phone call a week earlier to request an urgent consultation, Rajeev would not be here in my office today. While her husband’s frenetic narrative and body language are, I believe, an easy read to my psychiatric/detective eye, Sanjita remains elusive--her minimalist facial expressions and body language neither confirm nor deny the truth of her husband’s account. Nevertheless, I suspect that Rajeev’s impetuous temperament, fast-paced talking, restlessness, and grandiose delusions are suggestive of one and only one condition, and in the silence that ensues I furtively scribble my working diagnosis: Bipolar disorder
Bipolar disorder, or manic-depression as it was once termed, affects more than two million Americans every year. In its classic manifestation, symptoms can include any of the following: increased activity and restlessness; extreme irritability; racing thoughts; distractability (often mistaken for attention deficit); a decreased need for sleep; poor judgment; spending sprees; substance abuse (especially of alcohol and cocaine); and, tragically, denial that anything is wrong. “How could anything be wrong”, patients often protest, “I’m more productive than ever!” Experts in the field concur that the two million figure is a gross underestimate of the actual prevalence of bipolar disorder, as this figure does not include sub-syndromal manifestations at the softer end of the bipolar spectrum. Researchers in the field have identified as many as six different subtypes of bipolarity and place the actual prevalence closer to seven million, more than seven times the population of San Francisco. It also turns out that, contrary to what most Americans believe,“mood swings” are not the most characteristic feature of bipolar disorder. Instead, the disorder reveals itself in an insidious crescendo of sleepless nights and eighteen-hour work days, in an obsessive quest for perfectionism at any price, of high stakes risk-taking and fast-talking--characteristics, some might say, of any successful entrepreneur. Many times, anxiety and panic attacks, not mood swings, are the harbingers of an impending manic episode. It is not until this behavior spirals out of control and threatens to sabotage million-dollar deals or undo marriages that they come to me, as Rajeev has, seeking reprieve to a life interrupted.
For the last ten years I have practiced psychiatry in the Silicon Valley and have witnessed the emotional aftermath of the internet bust in 2001. Prior to the bust, I have had the privilege of working with the nouveau riche as they struggled to embrace their new found glory; the privilege of listening to their stories of how they struggled, persevered, and finally reached their promised land of venture capital funding; the privilege of sharing a sliver of their American Dream. As I psychiatrist, I was trained to remain indifferent to the personal fortunes of my patients, but after dozens had recounted their victories, I could not help but feel a tinge of envy. Although I was born and raised in quite a different valley, I too longed for my own slice of the American Dream.
In the 1960s and ‘70s my family lived in the outskirts of Chino Valley, located about 40 miles east of Los Angeles. While long known by locals for its quaint dairy farms and fragrant walnut groves, Chino was at that time beginning a process of gentrification that would eventually supplant the dairies and walnut groves with housing developments for the Hispanic laborers who worked the fields. My family lived in one of the first housing developments, the 13th Street Housing Project, comprised of clusters of cinder-block housing units stuccoed over in pale pink. It was here, among the undulating, redolent hills of the valley and under the watchful eye of Cousin Bruno, that I began my journey into psychiatry and the mysteries of bipolar disorder.
“No, no, Cuz. You have to jump back as high as you can, and when you feel yourself coming down to earth, then you shoot. Don’t wait ‘til you’re already down. And shoot the ball above your head, not from your chest, ‘cause then you look like a chavala, a sissie.”
We are on the basketball court at Gird Elementary and Bruno is sharing with me the secrets of his fade away jump shot. Bruno is twelve-years old, three years my senior, and is recognized among the 6th and 7th graders as the best outside shooter in town. Slender, with a slight muscular build, the apple of his biceps flexes as he executes a perfect shot. As he stands there in the schoolyard with his t-shirt sleeves rolled above his shoulders, black pompadour hair slicked back and one hip jutting forward, he resembles a younger, slightly darker-skinned version of James Dean.
“See, you have to keep on top of your game... keep it tight.”
And Bruno had kept on top of his other games. Two years prior, just after his 10th birthday, his picture appeared on the front page of our local paper, The Chino Champion, with the title, “Local Talent Sweeps Chess Tournament”. Bruno sits poised before the the chess board, nibbling contemplatively on the fingernail of his pinky. Surrounded by a sea of privileged well-to-do spectators who lived on the other side of the railroad tracks, his is the only brown face in the photo. Later he would confide in me his secret to taking the tournament, “King’s Indian Defense--pendejo.”
And, if excellence in games of physical and mental strategy weren’t enough, Bruno was universally praised by his math teachers for the high marks he attained in algebra. To this day I can still picture the cryptic pages of equations he would post on Grandmother’s refrigerator, especially the thick scrawl of red ink-- “Great Job, Bruno!” Several years later, in his 9th and final year of public education, Bruno dated the Junior Prom Queen of Chino High, the daughter of a wealthy Dutch family of dairy owners. She would go on later that year, rumor had it, to make a guest appearance on the Brady Bunch as Greg Brady’s girlfriend. Only decades later would I understand the pattern behind Bruno’s victories, only later would I recognize the pattern behind his thrill-seeking, fast-paced, no regrets way of life, the pattern behind his sleepless nights spent prowling the streets in search of something, anything, that would lull the incessant rumblings of his unquiet mind.
“Basically what you have prescribed has worked. I am 70% better I would say ... maybe 75%”
Rajeev is back in my office, alone this time, for his one week follow-up visit. He appears calmer, more relaxed, as he takes his seat. A triumphant smile flickers across his face. “Sanjita agrees. We are not arguing as much.”
After the initial consultation, I had diagnosed Rajeev with Bipolar Disorder, Type I, and had prescribed a combination of an antipsychotic, risperidone, and a sedative-hypnotic, clonazepam. The pharmacologic armamentarium for the treatment of bipolar disorder, though far from perfect, has progressed in the last decade; gone are the days where our options were limited to older antipsychotic medications, lithium, or valproate--all medications whose side effects (involuntary muscle movements, tremors, kidney and liver toxicity) were in some instances worse than the symptoms they were intended to treat. Today, no less than ten medications are indicated by the Food and Drug Administration for the treatment of Bipolar Disorder. They include all of the next generation antipsychotics (now relabelled as “mood stabilizers”), a new class of anticonvulsant drugs that include lamotrigine (a mood stabilizer with antidepressant properties), time release versions of valproate and carbamazepine (less toxic and easier to dose than their parent drugs), and in a reincarnation of an old concept, combination capsules that mix an antidepressant with an antipsychotic (Symbyax=fluoxetine + olanzapine). Yet despite these advances, there remains one vexing fact in the management of bipolar disorder: more than sixty-percent of patients do not adhere to their medications. Patients, the experts believe, eventually yearn for the creative highs of their hypomanias, a time when symptoms are just below the threshold of chaos, a time of effortless flow and peak performance.
“I need to know one thing, Dr. Lara. Do these pills that I am taking, will they take away my ambition and drive to succeed? I think I mentioned last time that my biggest fear is that I will not fulfill my destiny to change the world. And one other thing: As soon as I am back to 100%, I plan to stop these medications.”
Rajeev’s predicament is not uncommon. Like many of my other bipolar patients, Rajeev really wants to know when he can discontinue his medications so that he can resume his demanding work schedule. My immediate concern is that, despite taking antipsychotic medication, Rajeev persists in his grandiose delusions. Or so I thought. It turns out that everything that Rajeev has said about appearing in Fortune magazine and The Wall Street Journal, about starting and selling companies--every word of it--is absolutely true. In the years I have treated bipolar disorder, or “Valley Fever” as I sometimes refer to it , I have come to appreciate the utility of the internet search engines in verifying the incredulous narratives of my patients. In Rajeev’s case, I did not learn of the veracity of his account until after I had given him my diagnosis and started him on medication for bipolar disorder; only later did I google him and discover the extent of his Silicon Valley stardom.
Rajeev’s case raises some interesting questions for psychiatrists who treat bipolar disorder: do we really want to medicate away hypomania, however prevalent? It is worth remembering that some of the most brilliant minds in history have suffered from the illness: Vincent Van Gogh, Lord Byron, Emily Dickinson, Edvard Munch, Robert Schumann, Jackson Pollock--the list goes on. And in my own generation it turns out that entrepreneurs like Rajeev have disproportionately high rates of bipolar disorder compared to the general population. The experts are divided on this issue: some argue that it is better to let patients “run warm” for a while (they will, after all, stop their medications, and besides, they make a hell of a lot of money when they are hot) while others argue that it is best to medicate at the earliest symptoms--decreased sleep and increased irritability--invoking the kindling hypothesis, which maintains that with each excursion into mania, it becomes increasingly easier to cycle up into subsequent episodes.
I last met with Bruno during Thanksgiving of 2004. Now in his mid 40s, he is but a shadow of the athlete that he once was. Gaunt and balding, he walks with a cane (the consequence of gunshot wound to the knee) and takes a seat across from me at my aunt’s kitchen table. He is wasting at the temples and the sagging skin of his neck and arms are covered with faded tattoos in bleeding Gothic script. For the last 24 years he has been locked up at Pelican Bay, California’s highest security prison, for various drug and gang-related offenses.
“So, Cuz, what you up to?” I notice a rattling sound emanating from deep within his chest as he struggles to enunciate.
“You know, I told the vatos at Pelican Bay that I had a cousin who went to Harvard and Stanford, a cousin who was gonna be a doctor. None of them believed me. Shit, half of them never even heard of Harvard or Stanford. Pinche pendejos. So what you up to?”
“I am a psychiatrist... a psychopharmacologist.”
Bruno cocks his head back in disbelief. “A psychiatrist? I thought you wanted to be a doctor?” The rattling in his chest becomes louder.
“Well, what I do is treat illness--mental illness-- with medications and talk therapy.”
“Oh, so you give drugs to people?”
“Yeah, that’s essentially what a psychiatrist does.”
“You give drugs to people to make them feel better?”
“Yeah, I guess so. I suppose you could say I give drugs to people to make them feel better.”
“And you get paid to do this?”
“So let me get this straight: you get paid to give drugs to people to make them feel better?”
“So tell me one thing: how is that any different from what I used to do on the corner of 13th back in the day? Shit, go figure...you go to Harvard and get paid and I go to Pelican Bay and get 24 years. Well, I guess I taught you right, Cuz, you kept it tight and kept on top of your game after all”
And in a way Bruno is right. The sad truth is that Bruno had everything Rajeev had, and more--intelligence, good looks, ambition, notoriety, beautiful girlfriends. But, unlike Rajeev, Bruno had the misfortune of growing up in a time and a place that did not recognize manic depression, in a time and place where there were no psychiatrists, in a time and place where treatment choices were limited: to self-medicate or to self-destruct. The irony is that Bruno showed as much promise in his earlier years as my most accomplished executive patients; the irony is that Bruno, not my medical school professors, was my best psychopharmacology teacher; the irony is that Bruno, a jaded convict, was and still is capable of moments of unmatched tenderness as he shared with me secrets of the King’s Indian Defense and the fade away jump shot.
Rajeev and Bruno, at different times and in different places, were victorious despite their illness. The essential difference is that Rajeev had access to the best chemicals medicine could offer to combat his illness. Bruno had neither the access nor the means and so, like any good entrepreneur, he invented his own.