In the psychoanalytic era, it was
common for almost every paper to come back to one theme: the Oedipus complex
(or variations on libido, sexuality, and repression).  It was a tired story; one could predict the result no matter what
the starting point.  Consequently, the
field of psychohistory until recently had become discredited.  This is no way to write any variation on
history — to start with the outcome preordained, and then to make the
historical facts fit one’s theory.  Even
Freud committed this sin. His book on Woodrow Wilson, coauthored by William Bullitt
(US ambassador to France and a friend and patient of Freud’s) was so horrendous
that Freud’s family tried for years to deny his involvement.  To describe everything Wilson did as the
result of his passive relationship with his father was just ridiculous.  As the great historian of psychoanalysis,
the late Paul Roazen, recently wrote in his last published essay (Times
Literary Supplement, 4/22/2005), Freud was indeed heavily involved in that
book.  If the best psychoanalyst fails
at psychohistory, one would expect a great deal of caution among others.

Gartner appears not to be familiar
with the history of psychohistory, and he has merely replaced the psychobabble
of the past with contemporary biobabble. 

This book is organized around 6
chapters of biography, and a clinical introduction and conclusion.  The non-biographical chapters, which
constitute the clinical and conceptual core of the book, constitute only 20
pages. 

Gartner, a clinical psychologist,
writes well, and the biographical chapters (about Christopher Columbus,
Alexander Hamilton, Andrew Carnegie, Craig Venter, and a few others) are
engaging and entertaining.  Simply as
historical chapters, one learns tidbits of interest regarding these persons,
and the juxtaposition of these leaders from different fields gives one a sense
of some of the qualities of leadership. 
Also, Gartner, in his acknowledgements, clearly made an effort to
interview many leaders in bipolar disorder research.

Yet, the author’s treatment of the
issue of the risks of diagnosing mental illness in historical figures is quite
superficial.  He simply argues that
psychiatric diagnosis is primarily based on history, and such historical
evidence exists with many persons.  He
then interviews biographers of Alexander Hamilton, and uses a 5 point scale to
elicit their agreement about evidence for hypomanic symptoms in his life.  He thinks he thereby "proves" that
Hamilton had bipolar disorder type II.

As a researcher in bipolar
disorder, I diagnose it quite frequently, and I am sympathetic to the bipolar
spectrum model:  I agree that we should
be more attuned to recognizing hypomania than we are.  But Gartner, as a historian, has written a book reminiscent of
those psychoanalysts who saw the Oedipus Complex everywhere.

Examples are frequent; a few should
suffice:  Columbus told the Spanish
monarchs that he wanted a share of the loot of the New World and some
titles:  "His hypomanic grandiosity
was breathtaking."  Hamilton stayed
up pall night to write a letter: 
"The ability to work on little sleep is one fo the m ore concrete
diagnostic criteria for hypomania." 
Carnegie said "Whatever I engage in I must push inordinately"
— "That was his hypomanic temperament, which he had inherited from his
grandfathers."   Craig Ventner said
"F— off!" to a military superior: 
"a typical example of impulsive behavior with potentially painful
consequences (one of the diagnostic criteria for hypomania)". 

Apparently, anyone who ever says
"F— off" is hypomanic and thus bipolar. (Gartner even diagnoses
Theodore Roosevelt as bipolar in a mere footnote (p. 181)). 

The problem with this approach is
that it misunderstands the nature of diagnostic validation.  Clinical symptoms in general often overlap
between clinical syndromes and normal behavior. Thus, one might say "F—
off" and be the mentally healthiest (though not the most polite) person in
the world, or one might do so and be manic, or hypomanic, or depressed, or
anxious, or schizophrenic, or in the midst of a panic attack, or….  Clinical symptoms alone do not distinguish
hypomania from any other syndrome or from normality.

This is why, in diagnostic research
in psychiatry (nosology), the classic approach is to seek to obtain evidence of
diagnostic validation from more than just the clinical symptom level.  The other levels used are family history
(genetics), course of illness (age of onset, number of episodes, duration of
episodes, related stressors), and response to treatment.  In his brief biographies, Gartner
occasionally describes family history, but gives us little evidence on course,
and none on treatment.  Thus, while it
is possible that these ebullient individuals might have been hypomanic, he
hardly proves his case with any one of them. 

In contrast, if readers want to
read psychologically-oriented history that is much more respectful of both the
disciplines of history and psychology/psychiatry, they should refer to the
recently published Lincoln’s Melancholy,
by Joshua Wolf Shenk (2005).  There he
carefully correlates all four aspects of diagnostic validation (including
treatment Lincoln received for severe depression) much more convincingly than
in this book.  Further, Shenk brings out
how Lincoln’s life story grew organically out of his depressive experiences, as
well as how those lessons he drew affected his political beliefs and
activities. By contrast, Gartner’s biographies are one-dimensional stick
figures.

The only relatively convincing
story for bipolar illness in this book is the only living person whom Gartner
actually interviewed: Ventner.  There is
enough detail in that biography to support a probable bipolar-like diagnosis
(probably DSM-IV defined cyclothymia).

Despite his interviews with bipolar
researchers, Gartner states in his acknowledgements that "I have
admittedly synthesized [the bipolar literature] in my own idiosyncratic
way."  Such synthesis in the hands
of an experienced researcher or clinician might be acceptable. Indeed the book
states that Gartners has "published widely in medical journals."
However, a Medline search fails to identify a single article published by
Gartner on bipolar disorder, and nothing on hypomania (in fact, only one
article was found by a JD Gartner, as one of seven coauthors in a 1991 study on
personality traits).  While this absence
of personal expertise does not disqualify any mental health professional from
writing about any topic, it is relevant to readers who may be misled by the
book to believe that the author has much personal expertise on this topic. 

The version of bipolar disorder
described in this book is indeed idiosyncratic, and though I would not disagree
with the idea of a broad definition of bipolar illness (though many clinicians
and researchers do reject this notion), I am afraid that many important nuances
of bipolar illness are simply missed in this book.  The superficiality of the treatment of bipolar disorder in this
book is not necessary simply because it is a popular book. (Kay Jamison manages
to avoid this fate). Examples include the following:

Gartner makes much of hypomania as
a life-long temperament, though at times he emphasizes its episodic nature as
part of type II bipolar disorder (brief hypomanic episodes usually lasting days
to weeks, alternating with months of recurrent severe depression).  In general, persons with type II bipolar
disorder are not extremely productive, since their depressions far outlast
their hypomanic periods.  On the other
hand, "chronic" hypomania is not yet an agreed upon diagnostic entity
(not found in DSM-IV).  There is such a
thing as cyclothymia (episodic hypomania, alternating with mild depressive
symptoms), which is more functional than type II bipolar disorder, and would
seem to characterize some of the persons Gartner wants to call hypomanic (like
Ventner perhaps).  But, more to the
point, chronic hypomania as a personality state is called
"hyperthymic" personality, and there is a good deal of literature on
this topic.  Yet Gartner never uses the
phrase, nor refers, as best I can see, to any of the relevant studies on that topic.  Perhaps he knows about this and wanted to make
the book more accessible by only using the term hypomania, or perhaps he does
not know about the difference.  In any
case, it would have been more scientifically accurate to make the distinction,
as well as to point out the diagnostically iffy nature of hyperthymic
personality. (I personally think it is likely valid, but mainstream psychiatry
has not yet accepted the notion). 

He says at one point that
depression often is not associated with functional impairment, while hypomania
is.  This is a key problem throughout
the book. In the introduction, Gartner acknowledges that the symptoms for mania
and hypomania are the same, but the distinction has to do with the severity of
the symptoms, such that with mania they lead to "significant social or occupational
impairment."  Indeed, such is the
case; and any objective reading of these biographical vignettes would indicate
that much of the time, the "hypomanic" symptoms described lead to
significant social or occupational impairment (making them manic, instead of
hypomanic, symptoms).  This again may
seem minor, but by blurring this distinction, and calling hypomania what may be
mania, Gartner is confusing our understanding of bipolar disorder and its
relevance for society.  Especially for
patients, about half of whom lack insight into manic (or hypomanic) symptoms,
such blurring would potentially make them less likely to appreciate the
negative aspects of their manic episodes.

Furthermore, the DSM-IV definition
of hypomania is one of the few conditions in which one cannot have significant social or occupational impairment for the
diagnosis to be made.  Thus, the
statement that hypomania is associated with such impairment in that it is
observed often by family and friends, while correct for mania, simply is wrong,
as it stands, for hypomania.  Indeed
depression usually is associated with such impairment, by contrast, and
numerous studies show that depressed patients are highly aware of their
symptoms, unlike manic (or hypomanic) patients.

A thoughtful book about the
positive aspects of hypomania or mania would be useful.  But a book that is expansively unconvincing
has the potential side effect of romanticizing, or insufficiently emphasizing,
the negative components of bipolar illness as well.  Gartner claims to make the distinction in his introduction, by
referring to manic episodes as severe illness, yet throughout the book he
persists in calling things hypomania which seem, at least to my clinical
observation, to meet current criteria for mania instead.

One aspect of this problem, again
never mentioned, is that hypomania is the most unreliable DSM-IV
diagnosis.  Clinicians disagree on it
the most; whereas mania is much more reliably diagnosed. Thus, there is a great
deal of disagreement (not only cross-culturally but within clinicians in a
single country) about which patient is hypomanic versus manic versus
normal. 

Though the author cites Kay
Redfield Jamison in his acknowledgements, Jamison’s own work is far more
convincing, clinically sound, and historically thought-through.  I would suggest that those interested in
this topic should use their time instead to read Paul Roazen, first and
foremost, if they want to see the most adept application of psychology to
politics and history (Canada’s King: An
Essay in Political Psychology, Mosaic Press, 1999); or Joshua Shenk if they
want to read the best contemporary example (Lincoln’s
Melancholy); or Kay Jamison if they want to read a much better clinical
work in relation to bipolar disorder and historical figures (Touched with Fire, Free Press,
1994). 

As for this book, one might be
inclined to summarize the text as impulsive, exuberant, and going far beyond
the evidence. (Perhaps the author was hypomanic.)

©
2005 Nassir Ghaemi

 

Nassir Ghaemi, M.D., M.A., M.P.H.,
Associate Professor, Department of Psychiatry and Behavioral Sciences; Director, Bipolar Disorders Program, Emory University School of Medicine. Dr. Ghaemi is author of The Concepts of Psychiatry: A Pluralistic Approach to the Mind and Mental Illness, Johns Hopkins University Press, 2003.

Categories: Philosophical, Psychology