Physician Heal Thyself
Author of Out of Darkness
Joanna was about to enter her third year of medical school, and was looking forward to a break from her intense course load. On a six-week holiday with friends, she enjoyed time in the sun and fun evenings out.
But one night, a sense of unease set in, which soon spiraled into a frightening cycle of sleeplessness, panic and anxiety. Her symptoms persisted. With prompting to seek help, a psychiatrist diagnosed Joanna with depression and prescribed her medication. But Joanna says the medication did nothing to help.
Over the coming months, however, Joanna says she went from feeling like the world's saddest loser to a warrior who could not be vanquished. Her mind and thoughts raced, and her behaviors were often delusional. Her family eventually brought her to the hospital, where she was given antipsychotic medication and diagnosed with bipolar I, a severe form of the illness marked by the intensity of its manic episodes.
Under her new doctor’s care, and reworking her medications, Joanna returned to medical school with renewed drive and a healthy balance of diet and exercise. And she chose psychiatry as her medical specialty.
In her recent years as a clinician, Joanna has treated many people with bipolar illness. “I think it puts me in a unique position to consider the many aspects of the illness that may affect them and provide really comprehensive care,” she says. “You can read about something in a book and study it and train for it, but there is nothing like a shared experience.”
Joanna has an unusual vantage point on the bipolar illness she was diagnosed with nine years ago: she is a psychiatrist.
The first signs of the illness surfaced in 2008 during a six-week Croatian holiday with friends. Joanna was about to enter her third year of medical school, and was looking forward to a break from her intense course load. By day, she sunbathed on the Adriatic’s rocky beaches, and swam for hours in the clear turquoise sea. At night, she had her fair share of vodka and Red Bull cocktails, dancing until the wee hours. She’d sleep a few hours and start the fun over again the next day.
But one night some weeks into the vacation, she lay awake, tossing and turning as she checked the time on her phone. All the caffeine had finally caught up with her, she guessed, and the next morning she got up feeling anxious and afraid. As the hours passed, her unease bloomed, becoming so overwhelming she couldn’t leave the apartment. The following night was even worse, and over the next week, she descended into a frightening cycle of sleeplessness and panic.
Joanna had never had social anxiety, but she suddenly grew self-conscious and doubtful, weighing her words even in front the friends who had joined her on the trip. Always smart, always funny, always the first to make others feel comfortable, Joanna -- the talker in two languages -- fell speechless. Does that sound stupid? she asked herself. Boring? She lacerated herself for sentences that didn’t even make the trip from her brain to her tongue. Joanna immigrated to Canada from Poland with her parents at age six. Now, twenty years later, she felt like an immigrant all over again, this time to herself.
It was a shock. She had always been propelled by a strong internal motor, approaching everything from school to relationships to dancing, even her parents’ tax forms, with focus and enthusiasm. When she was growing up, her mother and father had beseeched her to take short breaks from her passions – “Relax!” they always told her. But she rarely did, finding solace in her schoolwork, redecorating her room or socializing.
As her Croatian vacation wore on, she retreated entirely, demurring when her friends tried to coax her out. She couldn’t bear to join them. The sensations were overwhelming: the radiant summer heat, the gentle sound of the water splashing, the scent of the garlicky seafood wafting up from the ancient winding streets. She boarded herself up behind the seaside apartment’s heavy wooden shutters, trying in vain to block everything out, and sleep.
Her return to school and the flat she shared with roommates was no salve, and Joanna’s anxiety mounted. She breathed in great giant gasps as if trying to draw more oxygen. Inchoate fears ricocheted from one side of her brain to the other. Even her body didn’t feel like it belonged to her: one day, a friend noticed a faraway look on her face and touched her bare arm with a cold drink. She didn’t even react. “What’s going on, Jo?” he asked her gently. Something was seriously wrong, she knew, so she made an appointment with a psychiatrist at student health services. She arrived for the meeting, at once nervous and hopeful for an explanation.
She was stunned when the doctor brusquely told her: “You’ve got depression, and you need an antidepressant.” Impossible, she thought. “She’s got this wrong,” she told herself. “No, no, no. I don’t have depression.” Still, she filled the prescription, and swallowed the pills each morning.
They did not alleviate her symptoms, and by mid-autumn, Joanna was such a wreck she had to drop out of medical school and move back in with her parents. There, things only deteriorated: within a week, she couldn’t leave her bed. Joanna, who has lustrous long chestnut hair and a dazzling smile, had never been at a loss for taking care of appearance. But now, even showering was a major accomplishment. Her parents, withered with worry, would dangle Joanna’s arms around their waists as they marched her to the shower each morning. Her younger brother, who idolized his sister, watched with growing apprehension. Her father, Wlodek, a somber chemical engineer who never complained about his own sacrifices – early in his stay in Canada he pumped gas to make ends meet – wondered why his daughter couldn’t use the power of her formidable mind to will herself to health. But she couldn’t.
“You’re lying in bed and you know you should get out of bed,” she says now. “Everyone tells you: ‘you should get out of bed,’” she reflected recently on a sunny day in her Toronto home. “But you just can’t freaking do it.”
For Joanna’s mother Barbara, a physical therapist, the dark months of her daughter’s depression were a frightening replay of her childhood – as well as an ominous harbinger. She and her husband, born a few years after World War II, had endured the penury of communist Poland. And when Barbara was 14, her sister was diagnosed, incorrectly it turned out, with schizophrenia. She was hospitalized for weeks in their hometown of Lodz, a garment-industry city that so flourished in the 19th century, even factories had stained-glass windows. After her sister recovered, her own mother was hospitalized with a severe depression, leaving Barbara in charge of the family’s domestic tasks. Now, it seemed, her daughter had inherited some form of the same biologic risk.
Barbara arranged her schedule to drive Joanna to her psychiatrist’s appointments, growing ever more concerned as her daughter sunk from an agitated despair to apathy. The psychiatrist tinkered with medications, adding an antipsychotic drug to her antidepressants, but Joanna’s mood plummeted. Feeling as if she was “a waste of space and air,” she thought constantly of suicide. But always, she decided against it: she couldn’t bear the idea of her parents and brother finding her body.
As the winter passed, Joanna started to regain emotional and physical strength. She summoned memories of her grandparents and great-grandparents, who had survived the brutality of two world wars, the Nazi slaughter of their family members, and years during which they subsisted on rotten potatoes. “I’m made of pretty tough stuff,” she told herself increasingly. “I can do this.” Her appetite returned, and she no longer struggled to get out of bed. She found a job as a hostess in a pizza restaurant, and soon graduated to another as a receptionist in a law firm. She remained on leave from medical school, but she was gaining stability and confidence, and getting out of the house.
As the months grew warmer, so did Joanna’s mood, and by March of 2009 she suddenly snapped into a period of intensely high energy. She went, she says, from feeling like the world’s saddest loser to a warrior who could not be vanquished. She had recently switched psychiatrists from her gruff first doctor to a clinician and professor who had delivered a lecture to one of her classes. He was empathic and optimistic, but she felt no need to contact him now. At this point, she was feeling excessively well: her mind, once again, raced, but now her ideas were productive, positive, and fruitful. She planned to launch an interior design business and start a television channel called “Life is Beautiful.” Oprah, she believed, would call her any day for an interview, and the two would become instant friends.
She had shed her sweatpants for a flamboyant new wardrobe, mostly bright animal prints she bought at the Guess store. She fell in love with a handsome man she had barely met, and moved in with him just weeks later. She marched into a bank and asked for a $65,000 line of credit, which was granted instantly to a medical student with a pristine financial history. She booked a trip to Mexico with a cousin. One day, she saw a $170 Marciano watch with a zebra face. So entranced, she bought ten and gave them to friends. What was $1,700 in gifts, she reasoned, when she would soon become a millionaire?
The mania – which she didn’t recognize at the time – soon hurtled into a paranoid, delusional state in which Joanna believed she had a special code that could save the humanity. The world, she was certain, was divided between those who wished to help her (they were always dressed in blue or white) or those who wished to steal the code (they wore black or red). Early one morning, she got in her silver Corolla and drove at speeds sometimes topping 200 kilometers to Pearson Airport, where she believed her brother and boyfriend were waiting to whisk her to a Caribbean island on a private jet. All she needed was her passport. She roamed from ticket agent to ticket agent, inquiring about the whereabouts of her passport. When no one could produce it, she grew fearful, and began picking up the help phones tethered to airport walls. She became desperate, begging operators to help rescue her. Drained, Joanna sat down at a bar to rest. Moments later, two policemen, dressed in black, approached her menacingly and twisted her hands behind her back. One officer whose nametag spelled out the first name 'Richard', slapped handcuffs over her slender wrists. Her fight-or-flight instinct went into overdrive. Even in her delusional state, Joanna retained her sharp sense of humor, yelling, “Get your (expletive) handcuffs off me, Officer Dick!”
“I wasn’t cognitively rational and my judgment certainly was off, but I was so attuned to people’s emotions,” she says. She remembers the surly expressions of the police officers and the kind face of the woman who looked up from her computer and asked, “She’s just sitting there not hurting anybody. Why do you have to be so aggressive?” Still, they marched her out of the airport, forcibly guiding her into the back of the squad car, just like on television. Joanna was terrified, and spent the ride kicking the seat in front of her. Alarmed by their black clothing, Joanna believed the police intended to extract the mystical code from her brain, and then execute her. The men didn’t bother to respond when she demanded to know where they were going, which only fueled her fear.
They drove her to nearby hospital, where a nurse gave her a dose of olanzapine, an antipsychotic medication whose effects she felt immediately. Exhausted and fearful, she fell asleep. When she woke the next morning in her hospital bed, she was overcome with dread. “Oh my God,” she thought to herself. “I’m on the psych ward.” She didn’t have her clothing. She didn’t have her shoes, and was in a room she shared with four people, including one woman who rambled nonsensically. Just the day before, she had been certain that Oprah would be calling and that she was headed to an island vacation. Now, she walked slowly to lunch with an older male patient who issued counsel. “Be compliant,” he urged Joanna. “Take your meds. Go to your groups, eat the food they give you. That’s how you get out of here.”
As she ate her soup in her hospital gown and fuzzy issued socks, she looked outside at the green grass and the budding trees and realized she was trapped. When her mother and brother came to visit, she crumpled in despair. Her mania had snapped to a halt, replaced by sobering reality. When she spoke to her doctor, he calmly delivered a new diagnosis: Joanna had bipolar I, a severe form of the illness marked by the intensity of its manic episodes. Manic episodes can include an abnormally elevated mood, high energy, grandiose thinking, talkativeness, increased risk taking and pleasure-seeking, almost all of which Joanna had just exhibited.
At first, Joanna was jolted by the news, and wondered what it would mean. How did this fit into her identity as someone with her goals, her energy, her aspirations? Her doctor was calm and reassuring. She could live a normal and productive life, he told her, even returning to medical school. For the next several months, they tinkered with her medications, starting with lithium, a chemical salt and effective mood stabilizer for many people with bipolar disorder. She suffered multiple side effects, including a 30-pound weight gain, acne and hair loss, but continued to try different drug combinations until she was stabilized. Once she was, she called her aunt in Poland to discuss her experiences. In the 1970s, it was common to diagnose anyone who had experienced psychotic episodes with schizophrenia. But now doctors know that delusions are often a hallmark of the manic or depressed periods of bipolar illness, and Joanna was certain that her own experiences mirrored her aunt’s. (Her aunt has since been reassessed, and is now successfully treated for bipolar illness.)
Joanna returned to medical school with renewed drive, making sure to make time for an exercise routine that mixes cardio with yoga and weights, eating healthy regular meals, and sleeping at least eight hours a night. She made high marks and once again was flourishing, wondering which medical specialty to choose. Her psychiatrist suggested psychiatry. “Really? You think so?” she asked him, her hand pointing to her chest. “Me?” He smiled. “I think you’d be great,” he told her. “You not only have the qualities to be a good one, you also have the experience.”
During her psychiatry residency, she met Dennis, a handsome doctor training to become a pediatrician. They hit it off so well that after a few weeks, Joanna could envision a life with him, but wanted to be frank about her condition.
One evening over dinner, she told him everything, from suicidal despair to her delusions. “Call me in a few weeks when you’ve had time to think it over,” she said. He responded immediately.
“You’ve gone through all this and you are where you are now,” he told her. “This makes me care for you even more.” His parents, who had yet to meet her, agreed: “If you love her,” Dennis’ mother told him, “then you accept her for everything she is. You have to know that you’re in it for life, and that you can’t leave when times get tough. This is a commitment, and you’re with your spouse especially when things are difficult.”
The couple married on a bright August day in 2013, and soon bought an airy house not far from Dennis’ parents. Joanna threw herself into decorating it with artful light fixtures, cozy modern furniture, and a dining room table that can seat her entire extended family. The next year, with her doctor’s guidance, Joanna weaned herself off all her medications in order to attempt to become pregnant, and in early 2015, she gave birth to her son Lucas. She was overjoyed with his birth, reveling in his dark brown eyes and hair, and his impish personality. She took a year’s maternity leave. Her parents and in-laws helped take care of the baby, and Joanna remained stable, always making sure to get enough sleep, and to eat regular meals.
Joanna knows that her network of family and friends is crucial to maintaining her equilibrium, and she is in frequent contact with those closest to her. As an extrovert, she knows that she draws energy from social engagements. Alongside raising, and playing with, her son, she makes sure to build dinners with family and friends into her week.
Over the years as a clinician, Joanna has treated many people with bipolar illness. Her psychiatrist’s predictions were spot on. Although she has never discussed it with patients directly, she feels a profound empathy for those who have it, too. “I think it puts me in a unique position to consider the many aspects of the illness that may affect them and provide really comprehensive care,” she says. “You can read about something in a book and study it and train for it, but there is nothing like a shared experience,” Joanna says. “When someone tells you, ‘I can’t get out of bed,’ I believe them. Had I not had that experience, intellectually I’m not sure I would have been able to understand it. I get it. I get that sometimes you are so sick, you can’t physically move.” She paused for a moment, tucking her feet into the couch cushions in her family room. “I understand what it’s like to lose touch with reality, and how scary that can be. I know what it’s like to feel so anxious you can’t leave the house. I know what it’s like to be in a mania that makes you feel so grandiose you don’t need to think ahead too much because all of your abilities and ideas are so amazing, everything will just turn out beautifully.”
Occasionally their challenges make her anxious about her future. “It can be scary sometimes wondering if your illness will get worse one day like this person's has,” she says. More than once she has come home in tears, thinking about a patient who has struggled for years with the illness and now suffers from cognitive issues, someone who no longer responds to medications, or the mother who’s hospitalized and can’t take care of her kids. “Then Dennis calms me down and reminds me I'm my own person and this will not happen to me because my experience is unique and won't necessarily follow the same course.” She pauses. “There are moments when it’s sobering.”
But she also views her illness pragmatically, a genetic characteristic comparable to being tall or a talented musician.
“The same brain that makes me unwell also is likely why I’m so empathic and understanding,” she says. “Its differences help me think outside the box, and come up with creative solutions for myself and my patients.”
Sometimes, she says, she even dreams about her patients’ stories, and wakes up thinking of different ways to frame their narratives. And while she has high expectations for herself, she understands that she alone can’t transform the lives of some patients, many of whom have suffered years of chaos and abuse. “I can provide the same interventions that were offered to me,” she says.
After a series of stressful events last fall, Joanna had a wobbly few months. Her sleep was disrupted, and she slipped back into a mildly manic state. She was speaking more quickly than usual, was uncharacteristically impatient with nurses at the clinic where she worked, and lashed out at her husband and mother-in-law. Her husband and mother were the first to notice – and to tell her. She consulted her psychiatrist, returned to a dose of lithium, and has now stabilized. She switched to a less pressured workplace, and is especially diligent about listening to the mindfulness app she has on her phone. It is a stark reminder of the power of her biology, she says, and just what she helps her patients face daily.
She feels strongly that speaking openly about bipolar illness will increase compassion among everyone from hospital staff to family members, from doctors themselves and first responders.
And it’s important, she says, to look beyond a diagnosis. “There are so many other things that come with that person. That person might be a writer, a mother, someone who loves to dance, someone who’s empathic and kind. The first time someone is diagnosed, it’s important to tell them, ‘Yes, you have this illness, but let’s keep it in the context of you as a whole person.’ When you identify with your illness alone, you get sucked into the vortex. I hate it when people say ‘I’m bipolar.’ You are NOT bipolar. You’re you. You’re someone who has been unwell at one point, and has thrived during others. You have the potential to thrive again.”