Saturday, October 28, 2006

Nothing Special

A few weeks ago, I received a copy of Ronald Fieve's Bipolar II for review and after finishing it a few days ago, I've been debating about what to say, what I liked and what I didn't.

Whenever I read a book in an analytical way, I'm thinking about not only the content of each chapter, but of how the book is structured and about who the book is written for--is Fieve writing to patients or coworkers or the general public? In a well-planned work, the former two categories rarely enter my mind because the work has a predictable, comfortably flow. That was not the case with Bipolar II. Fieve's work feels very choppy and disorganized, as if he had two dozen topics he wanted to discuss and they were all thrown together. And even as I was reading the final chapter, I wasn't particularly certain that this book was written for patients as it blended the feel of a medical text with the feel of a self-help book, the ultimate result of which was just confusing and frustrating. It certainly was not the guide to tolerating Bipolar II that it was purported to be by some other reviewers.

Fieve's book opens with a preface introducing the reader to his professional work, an impressive record that includes conducting the initial US clinical trials for lithium as a treatment for bipolar disorder. In a habit rather typical of Harvard graduates, Fieve continually finds reason to mention that he authored Moodswing and that he studied at Harvard and Columbia universities. The first time, it was informative. The remaining mentions were like nails on a chalkboard to me, unnecessary self-congratulatory inclusions that served to make me think that Fieve is perhaps a bit megalomaniacal and self-important. Doctors have a tendency to be that way, an unfortunate side effect of wealth, intelligence and success.

At any rate, after our brief introduction to Fieve, the book opens with an introduction to bipolar disorder that felt entirely incomplete and was rendered unnecessary by the second chapter covering the bipolar spectrum. The second chapter opens with a discussion of current theories on what chemical malfunctions might cause bipolar disorder. It then dicusses what medications act on which neurotransmitters, albeit briefly as the topic is taken up again later in the book. And after all that, Fieve backtracks and starts discussing the history of bipolar disorder, discussing the full spectrum of moods that can accompany it. Are you confused yet?

The third chapter explores the relationship between genetics and bipolar disorder in a way that demonstrates everything I'm saying about a tragic lack of organization in this book. Under the heading WHAT IS THE BIPOLAR FAMILY, Fieve first looks at research linking a prevalence of substance abuse, major depression and ADD/ADHD to Bipolar Disorder in families. He then uses the example of Sol Wachtler to demonstrate that bipolar runs in families, although Wachtler's particular family--with one suicidal granny--doesn't seem to provide the strongest anecdotal support for the aforementioned research. Fieve then mentions Jane Fonda as a stronger example of bipolar running in families before shifting gears entirely for a moment to talk about bipolar disorder and associated risks of suicide. He then jumps back to exploring how bipolar runs in families with a patient's life story that included discussion of the patient's father, a man with clearly disturbed moods that followed a seasonal pattern. The remainder of the chapter meanders through a discussion of how hypomania can contribute to success, the human genome project and how drugs that work for one family member may also work for another family member. The stories included within the chapter are at best tangentially related to the larger topic being discussed--genetics--and at worst, serve to obfuscate an issue that isn't entirely clear to begin with.

The chapter reminded me of reading a paper that's been revised so many times, it loses any hint of artistry or flow that might have existed the first time it was written.

Moreover, Fieve shoots himself in the foot as he writes this chapter because he says flat out that "it's difficult to give a diagnosis from secondhand information" (p73) but he goes on later in the book to hypothesize that famous people in history like Abraham Lincoln may have been bipolar (p144-145). Uh, because that's consistent. Retroactively diagnosing historical figures to prove a point is unprofessional and frankly, it should be unnecessary if a researcher has a strong point because there should be plenty of current examples to use that can be definitively proven. I find it equally troubling to see this tendency in the gay rights movement...a retroactive witch hunt to declare successful people gay when codes of behavior are so dramatically different that such declarations are useless.

The fourth chapter covers sleep and sleep patterns as obviously, hypomanic people tend to sleep less than their non-hypomanic counterparts. I personally think that Fieve committed a very basic chicken and egg error in his analysis in this chapter as he basically states that changes in sleep patterns precipitate changes in mood. Well, uh, okay. In my own experience, I feel like the chemical shift that changes my moods occurs before my sleep pattern changes. In other words, I feel like how much I sleep is a symptom of my moods and not the cause of them, as Fieve seems to state with so much confidence.

The fifth chapter covers the impulsive misbehaviors that tend to accompany hypomanic periods, demonstrating rather clearly that hypomania can be a temptress of productivity laced with poisonous and occasionally dangerous, self-destructive behavior. After a prolonged discussion of all of the dumb things that hypomanic people do to themselves and their families, Fieve devotes his sixth chapter to a discussion of the upside of hypomania and its benefits. Bwzuh? In one breath, Fieve tells the reader that hypomanic people are impulsive and gamble their money away, have copious amounts of sex that can jeopardize relationships and generally exercise poor judgment and in the next, he tells us that hypomanic people are creative, effective movers and shakers who greatly benefit society. So which is it?

If the answer is both, then that's a serious, perhaps unforgivable and undeniably irresponsible position to take if this book is targeting patients, the vast majority of who lack the insight to know whether or not a given hypomania is of the beneficial kind or of the impulsive kind, particularly if those hypomanics tend to blend beneficial with impulsive as I would wager is often the case.

The second part of the book discusses the diagnosis and treatment of bipolar disorder, venturing clearly into the self-help realm in a way that's been done better by numerous other authors. Two other books that come immediately to mind are The Bipolar Disorder Survival Guide and the mildly annoying New Hope for People with Bipolar Disorder. These other books offer more concrete examples of how to help yourself in a clearer, more accessible way.

I'm not impressed by this book given the oft-mentioned accomplishments of its author. It doesn't provide a self-help guide the way that pure self-help books do. It doesn't provide empathic insight the way Kay Jamison Redfield's Touched with Fire does. It's a forgettable contribution to a growing literature on bipolar II.