Month: January 2016

Bipolar disease is awful. Let’s just get that out of the way right out of the gate. It’s a mood disorder characterized by large swings in thoughts and behavior, from peaks of mania to valleys of depression. To have bipolar disease is to know what it must feel like to be zooming through life on a roller coaster blindfolded.

Most of us know what it is like to feel depressed, or have seen a close friend or loved one go through it. It is characterized by:

-Sleeping too much during the day / not enough at night

-Lack of interest in activities that used to be meaningful

-Feelings of guilt and worthlessness

-Fatigue, lack of energy

-Difficulty concentrating

-Loss of appetite

-Anxiety and lethargy

If anyone feels these symptoms for a significant amount of time, they should seek psychiatric help immediately – this is treatable!

Perhaps less well understood generally is mania. It is a period of incredible intensity which can sometimes lead to overt psychosis. Here are the classic mania symptoms:

-Distractibility, easily frustrated

-Irresponsibility, erratic and uninhibited behavior

-Grandiosity

-Flight of ideas / racing thoughts

-Increased goal-directed, often high-risk activity (gambling, sex, improbable business ideas)

-Decreased need for sleep

-Extreme talkativeness

These are generally thought of as the two ends of the mood spectrum: doldrums on the one hand, and rock and roll on the other. However, to what degree is mania a part of, and even integral for, modern success? Does anyone know an ICU doctor who gets enough sleep? What about a CEO who didn’t have a grandiose vision of the company? Wasn’t Steve Jobs famously easily frustrated? Aren’t most worthwhile investments high-risk?

Enter hypomania. As with most things in medicine, it started with Hippocrates. Its definition has changed a bit since the Greeks were running things, but at varying times it has meant “partial insanity,” “craziness,” and “monomania.” It now generally means “less than mania,” in that it shares similar features, but does not result in psychosis and doesn’t affect people’s functioning as much as mania or depression. Here are the descriptors of hypomania:

-Extremely energetic

-Talkative

-Confident

-Creative ideas

-Excitement

-Highly productive

Now, look at the above list. Pretty impressive. What exactly is this thing? Is it a disease? Or the profile of your dream spouse/senator/graphic designer? Should you be treated for this, or be happy that your brain’s neurochemistry allows for you to be a motivated, competitive member of society? Here are some more ridiculously advantageous benefits of hypomania, from Christopher Doran’s 2007 book called The Hypomania Handbook: The Challenge of Elevated Mood.

-“Euphoric”

-“Visionary”

-“Overflowing with new ideas”

-“Significant correlation between hypomania and creativity”

-“immune to fear and doubt”

-“negligible social and sexual inhibition”

-“life of the party”

-“offer solutions to problems”

-“finds pleasure in small activities”

Again, what is this thing? It’s made it’s way into the DSM-IV, so it’s currently listed as a disease, with treatment options. But what does it mean to have hypomania? Don’t we all get this, to some extent, at varying points in our lives? Think to a time in your life when you’ve been your most productive. That night that you stayed up until 3 AM, made a pot of coffee, and wrote the essay. That day off where you made a list of 10 things, and then gleefully ticked them off as you got groceries, went to the gym, paid your rent, hung up that picture you’ve been meaning to hang, and called grandma. That party where you had a bit too much to drink too quickly…and liked the resulting confidence, disinhibition, and euphoria of finally feeling like you just don’t care what other people think.

I think most of us experience hypomania. If I’m being totally honest, I wish I experienced it more. It’s enjoyable. It’s no wonder that people generally do not want to be treated when they are diagnosed with it. We treat and medicate and diagnose and define deviations from normal. But it’s usually the people who aren’t normal that propel our humble race forward. Building a civilization is hard, and it wasn’t that long ago that we lived in trees. If the key to creativity and success lies in psychological deviation from the norm, is it a disease? Or our salvation?

The field of medicine evolved, principally, as a field of observation. Hippocrates (the first, and perhaps most famous physician, for whom the oath is named) would press his ear up against his patients to listen to their innards, a precursor to the common modern technique of auscultation. People used to dig up skeletons in graveyards and drew them for a better understanding of anatomy.  The french realized that you can tap on wine casks to see how full they are, and then realized you can basically do the same thing to people. Our attempts to understand (and ultimately fix) the human body have relied on thousands of years of looking and listening.

Describing a patient well has, and will always be, useful in medicine. A concise, accurate description of a patient’s history and physical examination remains one of the most elusive and difficult skills to master as a medical student and resident. This skill has proved especially useful in modern medicine, where patients are handed off between colleagues more and more as duty hour restrictions have hardened.

An interesting consequence of medicine’s collision with modernity has been the devaluation of physical exam findings. Ultrasound, CT,  and MRI imaging techniques have all brought the insides of our patient’s bodies into crystal clear focus. What used to be either inferred, missed, or seen retrospectively on dead patients, is now rapidly available, usually in under an hour. Modern imaging is something like a miracle. I dare you to even try to understand the science behind an MRI,  for which the nobel prize in medicine was awarded in 2003. A friend of mine is a medical physicist, which is an entire scientific field devoted solely to understanding the physics of medical imaging modalities like MRI and operating them. He once described the science of MRI’s to me as “basically indistinguishable from magic.”

Modern imaging has collided head on with the physical exam. Because imaging can catch so much that the physical exam misses, the physical often feels somehow fake. Forced. Like the opening ceremonies at the Olympics, it’s glitzy, it’s expected, it’s analyzed (albeit by fashion blogs), but in the end it ends up being a lot of arm waving before the actual games are played.

Recently on the wards, I saw a patient who had obvious signs of congestive heart failure. Edematous, swollen legs. Fatigue. Trouble laying flat. His blood, unable to be pumped fully throughout his body, was backing up into his lungs and his extremities, collecting in places it wasn’t meant to collect. He, indeed, had heart failure. This was proven to the team by echocardiography (sound wave imaging) only hours after he was admitted to the hospital.

He had a special kind of heart failure stemming from aortic insufficiency – blood was flowing back through his aortic valve, causing a buildup of fluid in his lungs. Aortic insufficiency has a characteristic murmur on auscultation: an out-of-place whoosh that trails off in a decrescendo where there should be only silence.

I imagine that in the days before transthoracic echocardiograms, this murmur would have been the crux of the case. The physician that found the murmur would have solved the riddle. I can picture several physicians, stooped over the man’s chest, ruminating for minutes on the exact degree and characteristic of the murmur, comparing it to others they had heard, debating the acoustics and dynamics.

Today, things are different. The murmur was heard, but it wasn’t heard. It was noticed, and promptly forgotten. The echocardiogram was ordered, and it did the heavy lifting. “Severe aortic insufficiency seen. Left Ventricular Ejection fraction 20%. Recommend CT for full characterization of aorta; concern for aortic root dilation.” Pressures, gradients, valve areas, and outflow jets velocities given in neat tables.

After receiving this information, we went back to the patient’s bedside the next day to find the murmur. There it was, waiting for us the whole time.

Hello, internet! I’m excited to enter the blog-o-sphere. It’s not actually as round in here as people make it out to be. Much flatter. Almost dismayingly flat. But I suppose that the ‘sphere’ part is pretty catchy. It’s better than ‘blog-o-normal-dimensions,’ or a BOND. Although, people, let’s be honest. We are not aiming for a BOND. We are aiming for a BAND. A blog-above-normal-dimensions. That’s right. I want this thing to be so good that it proves string theory (string theory is only correct if there are 10 or 26 dimensions). So lets kick this BAND off in style, with some good old-fashioned mind blowing neuroscience quotes. Here are two:

“There are more connections between neurons in a cubic millimeter of brain tissues than there are stars in the milky way galaxy.” -David Eagleman

“There is no such thing as color in the physical universe.” -A neuroscience textbook I read in college

With those thoughts in mind, I’m going to head to bed. Goodnight!