HYPERGRAPHIA - the compulsion to write in bipolar disorder

It was not easy finding a 'reputable' definition of hypergraphia so I will accept the one from About.com as it is comprehensive and consistent with other definitions found in various more reputable sources.


A Definition
About.com definition (not the most scientific of sources):
Hypergraphia is a condition in which a person feels an overwhelming compulsion to write. People with bipolar disorder, especially during mania or hypomania, may find themselves writing for hours at a time, not necessarily realizing that this is unusual. It may take the form of journalling, creative writing, or copying page after page of a book. Hypergraphia may also be associated with temporal lobe epilepsy and schizophrenia, as well as certain brain injuries. 


The Experience of Hypergraphia
I realized that my hypergraphia was associated with both  hypomanic and depressive episodes but in different ways. When I am hypomanic I get creative and write all sorts of things - poetry, magazine articles, blogs, academic articles, abstracts, and long emails to friends. I also find myself entering notes into my blackberry, when I dont have access to paper or a computer. When depressed, I write dark poetry but have no other creative productivity. When I am hypomanic I have no desire to write poetry. My brain is just not so inspired. So in my search to understand this pattern, I found some interesting information I wanted to share with you and I would love to hear your stories.


What the Scientists Dont Say
It was not easy to find information on this condition. It did not show up in a search on the Merriam Webster online dictionary. A search on the website of the National Institutes of Mental Health (NIMH) and the Mayo Clinic also resulted in no entries. No books could be found in my school library database but In the PsycInfo and Medline databases it is primarily associated with temporal lobe epilepsy.


However there are some well known experts in psychiatry and neurology who have been writing about the behavior from personal and scientific perspectives.


What Some Scientists Say
The Midnight Disease - is a book by Alice Flaherty,  a neurologist at Massachussetts General Hospital. She found herself writing compulsively both after the death of premature twin boys and the birth of healthy twin girls later diagnosed herself with hypergraphia. She believes that this behavior is attached to extreme moods that are found in people with manic depression and other people with brain disorders and brain injuries. 

Peter Whybrow, MD, Director of the Semel Institute for Neuroscience and Human Behavior at the University of California in Los Angeles and a specialist in mood disorders, was reported in the The Guardian (March 17 2004) as saying that manic depressives with a predisposition to chronicling their lives or composing poetry are likely to engage in voluminous writing in their darkest hours.disorders.

Dr Kay Jamison, a professor of psychiatry at John Hopkins University, was quoted in The Guardian (March 17, 2004) as saying that "Two aspects of thinking are pronounced in both creative and hypomanic thought: fluency, rapidity and flexibility ... and the ability to combine ideas or categories of thought in order to form new and original connections."

Mood Disorders and Creativity

In a conference at the Library of Congress (Depression and Creativity, Feb 3, 2009 - click link for video), both Dr Jamison, Dr. Whybrow discussed the controversial and long-standing (pre-Grecian) conversation about creativity and mood disorders. The symposium also included Dr. Terence Ketter who is chief of the Bipolar Disorders Clinic at Stanford University, whose research focuses on the relationship between creativity and madness. Though most artists and creatives do not suffer from mental illnesses but many creatives, especially poets, suffer a disproportionately high rate of mental illnesses, particularly depression and bipolar disorder. Dr Jamison refers to Mendelssohn, Virginia Woolf, Van Gogh as creatives with mood disorders. She argues that during periods of depression people are less productive and are more productive when they are manic or hypomanic.


The Advantages and Disadvantages of Hypergraphia

The great thing about hypergraphia for an academic is the productivity. However it is frustrating that there are often so many ideas that cannot all come to fruition. It inspires insomnia. But the indulgence to these intense desire to write is that it compensates for depressive episodes where dark moods interfere with the discipline to complete ideas.

Manic depression has its advantages and disadvantages and though hypergraphia is both blessing and curse (depending on its expression), in a world where productivity is valued, I have no cause to resist its lure or try to medicate it away. There is beauty in seeing words that come from my brain. And one can only hope that others share the same view.

Note: This was written in a hypographic period during a hypomanic phase.

Violence and Mental Health Stigma

The Headlines

Gunman: a life full of rage, a shocking final act

This was the headline in the Seattle Times on Wednesday May 30, Ian Lee Stawicki shot and killed 5 people in 2 locations in Seattle and then turned the gun on himself. As the news reports became one never ending roll of updates, and spread around the world, it was soon discovered that Mr. Stawicki had been showing signs of mental illness and his father suspected he had untreated manic depression (aka bipolar disorder). Once again violence and death became linked with bipolar disorder even though these events are relatively rare. 

The Other Face of Bipolar Disorder and Mental Illness
Most people who have bipolar disorder are like me and so many people I know: they  are employed, have successful careers and families. We are the face of bipolar disorder and mental illness but this is not the face we see in the public sphere. National organizations like the the National Alliance on Mental Illness (NAMI) - which has more than 1100 local chapters in all 52 states,  and the newly founded Seattle-based Professionals Affected by Mental Illness (PAMI) include members that represent a wide variety of jobs and careers and levels of education.

For some reason, we who have a mental illness have not joined the 'anonymous' movement (perhaps Mental Illness Anonymous - MIA). Perhaps if we went to meetings where we would stand up and own our issues we would get praised and supported for staying symptom free. And when we went out in public we could talk about getting our 1 year medal and be supported for our efforts.

The Stigma of Mental Illness
Instead we hide in closets of society's making with our own support. So that when people talk about the mentally ill they think of people who are homeless shouting at the moon or just another mass killing; but most people do not think about their boss, friend, neighbor or cousin. The TV shows such as Law and Order, Criminal Minds or CSI do not help our image any. But if our image is to change we have to change it.

Because the public links 'danger' to those of us with mental illness, many who are affected with mental illness often refuse to seek help because of the stigma that is attached to being ‘one of them’. We have to step out and show the world that with available, accessible and high quality care we can manage our symptoms and function well, just like those with diabetes do. 

It is also a sign of stigma that we say ‘mentally ill’ to describe someone with mental illness as we do not say ‘cancerous’ to describe people with cancer. We are much more than the parts of our brain that do not function as they should. The reality is that mental illness is physical – unless my brain is not part of my body.


Mental illness is also stigmatized within the health professions because if someone with a mental illness is receiving health on the public dime (Medicare or Medicaid) then it is most likely that they will access care only when they are "a danger to self or others" and the kind of care that could prevent or ameliorate symptoms before a crisis is simply not available or if available, it is only for the lucky few. Feeling mentally unwell is not enough to get care because healthcare is such a precious commodity in this country - whether public or not.

Why We Should Step Out of the Stigma Closet
If women had not stepped out of the secrecy and shame of losing a breast we would not have the movement for research, support and for public education. They had to let everyone know that breast cancer affected women of all colors, classes, creeds, nationalities etc. 

If our only view of the mentally ill is one of limited achievement or of rare violent episodes that end up on the front pages, then the newly diagnosed are at risk of not achieving their full potential because they have no idea of what that may be. Nor do their families or their employers.

Who Are the Mentally Ill
We are a diverse group of people whose biochemistry has gone awry, just as it has for people who suffer from other biochemical disorders. Why stigmatize me because of my brain when my brain works well in so many other ways (such as compassion, humour, and complex problem-solving?

We are friends, family, colleagues and even your healthcare providers. Just like any other illness, it does not discriminate and everyone has a unique experience that is not summarized by scary headlines.

As more people ‘come out’ as mentally ill we can reduce the fear, change stereotypes and give hope to people who are affected by a mental illness. Employers can also see that we can be productive employees who have illnesses that can be treated effectively with the right support.

Coming Out
To those of you out there who are dealing with mental illness, take a brave step and tell someone. The more diverse the faces and lives of the mentally ill, the less shame and stigma we will experience and the more resources will be put into helping to understand and treat one of  the most debilitating health conditions.

For more  information on bipolar disorder and other mental illnesses and ways to advocate for mental health services contact: Depression and Bipolar Support Alliance, National Alliance on Mental Illness, the American Psychological Association and the National Institute of Mental Health

The Nutrition Of Sanity: Using food to reduce the intensity and frequency of bipolar symptoms

People living with mental illness know that the little pills that come along with sanity make a difference to feeling good or bad. But it is good to know that food, yes food, can also help our brains function at a much more even keel. What we put in our mouth really does matter to whether or not our moods stay in check.

First, without thinking on what type of food we should eat, we should generally eat a healthy meal several times a day. That is a meal with lots of color: fruits and vegetables. But what foods and vegetables make our brains healthy while making our bodies happy.

In keeping with one of the principles of this blog, I will not make a long list (I can add more later) nor use technical scientific language nor give you a long page to read. If you know of other nutrients, other research or I have misrepresented something, please let me know by sending me a note in the comments section. And follow me on my Psychology Today blog as well where I write more generally about mental health.

So here are some nutrients to consider. I will acknowledge that I use Vitamin D and Omega 3 supplements in addition to other pharmaceuticals, as recommended by my doctor. I think they make a difference in reducing the amount of medication I need but who knows. My body utilizes these micronutrients for other good things so it can't harm.

1. VITAMIN D. Free from the sun but in the winter its harder to get and the 'stay-out-of-the-sun' recommendations from the dermatologists may be interfering with our manufacture of this very essential micronutrient. One of the side effects of taking anti-epileptic drugs is to reduce Vitamin D in the blood (Ovsiew, 2004) which can lead to osteoporosis in people living with mental illnesses who take atypical anti-psychotics like olanzapine for the treatment of bipolar disorder. At the very least, being in the sun will make you feel better whether science understands exactly how it works or not. Vitamin D3 is found in fatty fish and because it is so important to our bodies it is added to many foods such as milk and some juices.

2. OMEGA 3 Found in cold water fish and seeds such as flaxseed, omega 3 fatty acids are not only great for glowing skin but lubricates our brain's machinery and keeps it running smoothly.  Omefa 3s can be found in cold water fish, like salmon and vegetable sources such as flax and chia seed. Jerome Sarris (2011) and a team of researchers did an analysis of studies that looked at 'nutraceuticals' and how their effect on bipolar disorder symptoms and found that though there were mixed effects of omega 3's on symptoms, there was a mostly positive effect on depression but not on mania.

3. COFFEE AND ALCOHOL: Avoid these substances because they have been overwhelmingly proven to alter mood in ways that are unclear and as our moods are already problematic, it is best to avoid these so that we can also get good sleep at night. If you really need a cup of brewed beans to get you started in the morning it is best to drink before noon so that the effects wear off before night.

4. L-TRYPTOPHAN: Sarris et al. (2011) and his team found that this nutrient had a positive impact on moods. This amino acid is used by the brain to make serotonin that is mainly linked to depression. Some foods that contain L-Tryptophan include nuts, seeds, eggs, meat, fish, tomatoes and cheese among other foods.

References
Ovsiew, F. (2004). Anti-epileptic drugs in psychiatry. Journal of Neurology, Neurosurgery and Psychiatry, (75) 12, 1655-1658

Sarris, J., Mischoulon, D., Schweitzer, I. (2011). Adjunctive nutraceuticals with standard pharmacotherapies in bipolar disorder: A systematic review of clinical trials. Bipolar Disorders, 13 (5-6), 454 - 465.

Trading your brain for your kidney and other medication conundrums

This is a blog about cutting edge science and bipolar disorder.

And here's the problem with cutting edge science and bipolar disorder: we get the treatments that could kill us or make us feel awful in a different way.

Of all the things I hate about being mentally ill (and there are many), it is the trading off my brain function for liver function, or one kind of brain function for another. Tweak one med and it means more frequent blood tests to make sure that my sanity doesn't kill the rest of me.

If you're like most people with a mental illness, this is the major reason people do not take their medications: side effects. Sometimes it doesn't even  make sense to read the list of likely side effects, never mind the unlikely ones, because not taking psych meds can result in other ugly things happening. So you trade one bad thing for one good thing and hope it all works out in the end.

Lucky for me, I have a combination that works. Very well. But there are times they need an upgrade because the brain is not static. And the pill count gets higher or more complicated and if you have something else wrong with you it eliminates most of the drugs that could help with that problem.

For example, taking lithium means that lots of hypertensive drugs are off the table. If you take olanzapine, you may end up with diabetes (hmmmmm...... sanity or diabetes??). Benzodiazepenes which are used for sleep could make you an addict.

The reason people with mental illness are so bad with their medication compliance is not just that we feel better from taking them (which in any illness this is true) but because the side effects can be so irritating and health threatening. Anyone who takes lithium knows how annoying dry mouth is and the volumes of liquid consumed means that there are many trips to the toilet. And every 3 months you hope the blood tests don't show signs of liver damage or kidney trouble or perhaps one day you wake up and your thyroid no longer works.

Well, there dont seem to be very good answers right now. Perhaps one day science will find a way to target the parts  of our brain causing us trouble and zap.... we're done. Until then, science has brought us some compromises that require us to make tough choices about our lives. So we take them as instructed and keep track of our side effects and if they get too bad, we try something else until if we're lucky we find something that works.

What choice do we have???

Getting through exams when you have bipolar disorder

It's that time of year again for the high school or college student.... midterms. And soon it will be finals. If you are a student with bipolar disorder, you must take extra care to make sure the stress does not cause you to have symptoms or a full-blown manic or depressive episode. So how do you stay healthy amid all the demands on your time? The short list of strategies (I don't want to add to your to-do list:). 

1. Make a monthly assignment calendar on which you put all due dates. Place it on your refrigerator, your door or your mirror: some place where you will see it everyday. This prevents surprises.

2. Go see your professors for a check-in about how you are doing and what you can do better and on what areas you should focus. If you have not registered as a student with a disability then you may want to reconsider so that you can have extra time if you need it.

3. Go to student support workshops re:stress, exams, studying strategies etc offered by your university campus.Your tuition pays for all these great resources on campus; don't waste those dollars.

4. Go to a library orientation. This will probably be one of the best spent 30-60 minutes of your entire college career. Understanding databases, references & citations, where to find what, and how to access library help, is essential to getting an A on that paper.

5. Form a study group. Accountability to others is a great motivator for us to do what we often do not like to do. You will learn from each other and you will put some structure into your study life while adding a little bit of social to the solitary study routine.

6. Set a study schedule. Now that you know when things are due, when your study group(s) will meet, and what the professor wants you to do, and how you are going to maximize the library, it's time to set a specific time and place to do your studying. Sometimes you may want to be in the library and other times at home or in a coffee shop. Change up the routine to keep you focused but do what works for you. Tip: If you get your weekend studying out of the way on Saturday and Sunday morning then you are guilt-free to enjoy your weekend night.

7. Take care of yourself. All-nighters are a college staple; minimize them by taking the steps above. Below are some ways to make sure your body is ready for the studying and testing ahead.

• Take your medications as prescribed. This is not the time to be playing around with your medications without the supervision of your doctor.
• Exercise regularly - daily if possible; even if its a walk to run all your errands. Get your heart rate up and stress slowly melts away and sleep comes much easier at night.
• Eat. Fresh fruits, vegetables and protein. Many people snack when they study so pop grapes or munch on carrots to stop that freshman 15 turning into a senior 30. Add in some Vitamin D and Omega 3 supplements and get at least half hour of sun everyday if you can. Best if you get it while going for a walk. Clears the head and calms the mood.
• Sleep. Six to 8 hours of sleep maximizes memory function and brain function overall and keeps you alert in class. It may be best to skip that last hour of studying and go to bed so you can remember what you have already studied instead of forgetting everything. Maintain a sleep routine where you go to bed and wake up at the same time each night. See my post on sleep for more on how to keep your sleep and mood regular.

• No drugs. Avoid all non-prescribed mood-altering drugs such as alcohol and caffeine. They impair your sleep and have a negative impact on the regulation of your moods. DO NOT TAKE ANY UNPRESCRIBED MEDICATIONS especially medications that are prescribed to your friends. These could have dangerous interactions with the medications you  may be taking for bipolar disorder.

• Relax. However it is you do that: yoga, meditation etc. If your mind is clear you will find that there is more room for all the knowledge you're paying for.
• See your doctor if you are not feeling well or think you may need some support to get through this stressful time. Prevention is much better than cure. 

No more points for you to learn here. You may do all this and not be able to prevent having symptoms or a full-blown episode but you will reduce the risk and improve your ability to cope.


This professor is wishing you happy studying and great grades. Now for me to come up with tips on how professors can get through the grading without pulling their hair out. 

Seasons, climate and bipolar disorder. Revisited.

I don't know much about blog protocol but I do know that in the traditional world of publishing, there are times when popular articles get republished. So as we head into the dark days of winter I thought I would re-post an entry from September 2010 with the addition of a study from Finland which came out in 2010.

This study tested people diagnosed with bipolar disorder and their first-degree (immediate family) relatives and found that variations in mood and behavior tended to run in families and influenced performance on a neuropsychological tests that tested working memory, verbal fluency, executive functioning, auditory attention among others.
Rajajarvi et al (2010). The effects of seasons and seasonal variation on neuropsychological test performance in patients with bipolar 1 disorder and their first-degree relatives. Journal of Affective Disorders, 127(1-3), 58-65.

The original post is below.


As fall approaches many people living with bipolar disorder find that the changes in light/dark influence their mood. So I reviewed the literature for a sample of studies on the topic. Not much has been written lately on the topic but there seems to be inconclusive evidence about the influence of seasons and climate on the moods of people living with bipolar disorder. For a small sample of the research in this area, see below:


Using observations were provided by patients from different geographic locations in North and South America, Europe and Australia a recent study conducted by numerous researchers around the world found no relationship between moods in people living with bipolar disorder and seasons, latitude or climate.
Bauer et al (2009). Relationship among latitude, climate, season and self-reported mood in bipolar disorder. Journal of Affective Disorders, Vol 116(1-2), pp. 152-157.


In a large study of lithium serum levels measured between January 1995 and July 2004 in 3 large teaching hospitals in the Netherlands, there was a significant difference found in average lithium serum levels across seasons, with summer being the highest and winter being the lowest. However, these differences were too small to impact the therapeutic impact of lithium. Temperature variations followed the same pattern.
Wilting et al. (2007). The impact of environmental temperature on lithium serum levels. Bipolar Disorders, Vol 9(6), pp. 603-608.


As part of the ongoing STEP-BD (Systematic Treatment Enhancement Program for Bipolar Disorder), there was a study of seasonal and regional effects on people living with Bipolar Disorder I and II. Results showed that study participants who lived in northern areas were more likely to be depressed. Bipolar II patients were more ill year-round than were patients with Bipolar I and had greater monthly fluctuations in illness rates that patients with Bipolar I.
Friedman et al. (2006). Seasonal changes in clinical status in bipolar disorder: A prospective study in 1000 STEP-BD patients. Acta Psychiatrica Scandinavica, Vol 113(6), pp. 510-517.

Sleep: the secret to even moods

According to the National Institutes of Health, chronic sleep loss or sleep disorders may impact up to 70 million Americans and cost up to $16billion in healthcare costs and $60billion in lost productivity. So sleep is a big deal, not only to people living with bipolar disorder, who often have sleep disorders related to the illness

but also to people in general.

GOOD SLEEP is as essential for health as is good nutrition and physical activity. Getting good sleep means going to bed when you are tired, falling asleep within 15-30 minutes, staying asleep for 6-8 hours, and waking up feeling rested.

Sleep has been the bane of my existence ever since I was a child and I have spent a lot of my life trying to sleep when my body has other ideas so I have spent a lot of time researching sleep and trying strategies that work and spent a chapter in my book, Bipolar 101, discussing sleep. Sleep behaviors are on the list of symptoms for both depressive and manic episodes. Lack of sleep triggers bipolar symptoms and makes existing symptoms worse so getting enough sleep is very important to the mental health of someone living with bipolar disorder.

For manic episodes sleep goes bye bye and the rush of being able to just go-go-go eventually puts us in the hospital if we don't get back on track. During a bout of depression many people would prefer not to get out of bed. Treatment for bipolar disord

er usually gets people back on track with their sleep but if sleeplessness continues then they are often treated with medications that induce sleep.

Sleep deprivation (sleep deficit) is also the leading cause of accidents (of all kinds) in the USA because the brain does not function well on lack of sleep. Too little sleep also weakens our immune system so that we are more susceptible to illness. So what I am saying in this post can apply to anyone, not just people living with mental illness.

The latest research suggests that a sleep routine that keeps our circadian rhythms (internal clock) on a regular schedule, also keeps the mind on an even keel.

How do we do this? By developing a sleep routine; and at a minimum your sleep routine should include the following:

1. Going to bed at the same time each night and getting up at the same time each morning. Everyday. No changes on weekends. This sets your internal time clock and helps keep your moods on an even keel.
2. Give yourself 30 - 60 minutes to prepare for bed and find a way of developing a habit in terms of the sequencing of your preparation. The point is to slow down the body so it is ready to go to bed. For example, you could start by taking your medications (in particular, medications that make you drowsy) so they have some time to take effect before getting into bed? Or if they are quick acting you may want to take them last. Make sure you have set your alarm or put a glass of water by the bed (this is especially for people suffering from the dry mouth side effects of many bipolar medications). Some people find a bath calming. Others find a shower either calming or stimulating so find the activities that work best for you.
3. A calming down activity such as meditation or yoga or reading (a calm book:). Drinking a cup of warm milk (which has naturally occurring ingredients that make people sleepy) or chamomile tea is also helpful.

Research has also shown that we sleep better in cool temperatures so make sure to turn off/down the heating in your room. A dark room also encourages sleep and if you cannot create a really dark room then sleep with a blindfold on. TVs should be banned from the bedroom. So should laptop computers and your cellphone, if you are having a hard time with distractions.

One of the best ways to get better sleep is to be physically active on a regular basis. For those who have trouble sleeping it is better if you exercise in the morning, because the body takes some time to calm down when you exercise so if you do it too close to your bedtime, your body may be to revved up to fall asleep.

If you want to know more about sleep and mental well-being and find evidence-based strategies for improving sleep, then check out a new publication by the Mental Health Foundation in the UK, which has published a free downloadable book on sleep called, 'Sleep Matters: The Impact of Sleep on Health and Well-Being', click here.

The National Institutes of Health also publishes a sleep guide called, 'Your Guide to Healthy Sleep' is available free if you click here.