My first academic article, entitled, “Dissociation and Psychotic Symptoms” is published in The American Journal of Psychiatry (1). It was a case report of a young girl who experienced visions and voices. We thought that she had dissociative symptoms and we had taught her how to control these experiences through self hypnosis.
In the same month, an article was published in another academic journal (2). This was entitled, “Treatment of Bulimia and Rapid-Cycling Bipolar Disorder with Sodium Valproate: A case Report .”
We were describing the same young girl. Our treatments were concurrent. How could this be?
Further review gives some clues as to how psychiatry evolved in those years.
The teen-ager was one of my first patients when I was started my psychiatry residency in 1982. She had been transferred from another hospital. In those days many insurance policies covered 60 days in a psychiatric hospital. Patients who were not considered well enough to return home after 60 days were often transferred to a psychiatric unit located within a general hospital and this is where I was working at the time.
She had been diagnosed with Bipolar Disorder, rapid cycling type, a new diagnosis at that time. She had been treated with valproic acid, an anticonvulsant which was just starting to be used in psychiatry. I can no longer remember why she was transferred to us because when she arrived, she was mildly depressed but otherwise doing fairly well.
We learned was that she was a troubled young woman who came from a troubled family. She had already been hospitalized a number of times since the age of 13 for problems that included mood disturbance, auditory and visual hallucinations, and bulimia. When we reviewed her record, we noticed that she often improved rapidly after being admitted to the hospital.
One of the senior psychiatrists in our department, Fred Frankel, had a long standing interest in hypnosis. For a number of reasons, we thought she was experiencing dissociative episodes. We asked her if we could try to hypnotize her and we found that she easily entered into a hypnotic state during which she experienced her voices. We explained to her, her family, and her outpatient psychiatrist, that this capacity – to enter a trance like state – could be thought of as a gift but that it was one that she needed to learn to control. We taught her how to induce and end a trance. We thought that she entered into these states at times of stress. We hoped that with psychotherapy she might learn more about why this happened and also how to be in better control of her tendency to dissociate. We did not continue her on the valproic acid.
We thought this was an important observation – that sometimes psychosis could be a manifestation of a dissociative state – so we wrote our paper.
The doctors who referred her to us were in the midst of studying the effects of valproic acid on people who they had diagnosed with rapid cycling Bipolar Disorder. We had been in contact and they knew of our observations but they viewed her response to treatment differently. They report that she responded extremely well to this drug and they reiterated this point when they included her in another paper published a few years later (3).
Reviewing all of this 30 years later, it is hard to know from a close reading of the papers that we were describing the same person. Beyond our varied etiological explanations for her symptoms, our description of the outcome over the ensuing 18 months is not the same. I was in contact with her treating psychiatrist and recorded what he told me. According to his report, she had experienced some ongoing challenges, but she was learning to control her dissociative experiences. According to my colleagues, her symptoms waxed and waned in fairly close correlation to her level of valproic acid and our decision to stop it was ill advised.
I wrote a letter to the editor suggesting that given her high level of suggestibility, she was not a good person to include in a case report (4). In their response, they chided me for having concerns about the potential risks of valproic acid and reiterated how much better she had done when she took the drug (5).
What is so interesting to me is how one’s perspective can influence what one observes. Daniel Kahneman in his book, Thinking, fact and slow drives home the point that our view of reality is so easily distorted by our biases. That seems to have been what happened here.
What I did not realize at the time was that this was something of a turning point in the field. This was the beginning of the franchise of Bipolar disorder – type II, rapid cycling, NOS – to encompass a broad array of people who experienced shifting mood states. Valproic acid, marketed as Depakote, became one of the first blockbluster drugs in psychiatry and it continues to be widely prescribed. The authors of that article became well-known and highly respected leaders of my field.
At the same time, the use of hypnosis in psychiatry and psychology had its own notoriety. Dr. Frankel spoke often of the need to be cautious in the use of hypnosis. He warned us that it was easy to “induce” symptoms. A few years after these articles were published, the notion of recovered memories became a prominent and sensationalized topic. This did much to discredit and impede our understanding of dissociation and our use of therapies that might help individuals who are prone to this experience. However, the notion of trauma has achieved a growing recognition as being an important factor in so much of the emotional distress people experience in their lives.
I wonder about this young girl who is now a grown woman. I suspect she continued to face serious challenges in her life. The treatment we suggested was no panacea and if there was a drug that was truly effective I would have gladly suggested she take it. I wonder if one day she realized that the notion of chemical imbalance was not as definitive as she may have been led to believe at that time. I wonder if she remained on medications and if she went on to try any of the other drugs that were marketed in the next two decades. I wonder if she ever was able to make sense of some of the difficulties she faced as a young teen.
1. Steingard, S and Frankel, F. Dissociation and Psychotic Symptoms. Am J Psychiatry 142:953-955, 1985.
2. Herridge PLand Pope HG. Treatment of Bulimia and Rapid-Cycling Bipolar Disorder with Sodium Valproate: A case Report. J Clin Psychopharmacol 5:229-228, 1985.
3. McElroy, SL,Keck,PE, and Pope, HG. Valproate in the Treatment of Rapid-Cycling Bipolar Disorder. J Clin Psychopharmacol 8:275-279, 1988.
4. Steingard, S Valproate in the Treatment of Rapid-Cycling Bipolar Disorder, J Clin Psychopharmacol 9:382-383, 1989.
5. McElroy, SL,Keck,PE, and Pope, HG. Reply from Dr. McElroy and Associates. J Clin Psychopharmacol 9:383-384, 1989.
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