By Anthony Kovatch, M.D., Pediatric Alliance — Arcadia Division
The Black Woolen Hat
“I imagine that having bipolar disorder is like having a brain comprised of two socks where one is always lost in the dryer.” — Anthony Kovatch, M.D.
(Musical accompaniment: “Autumn Leaves” sung by famed French diva Edith Piaf. Known as the “Little Sparrow” Piaf had a tumultuous life and died at the young age of 47, succumbing to drug abuse and possibly undiagnosed bipolar disorder.)
I do not remember the time of the year that he (let’s call him Jack for simplicity) intentionally or unintentionally died by drug overdose, but I do remember the first time I saw him in the office. It was in the early autumn because his skin was becoming dried out by the heating system in the stately home in the well-to-do neighborhood where he lived. Jack was perhaps 8 years old — thin, quiet, sporting a wry crooked smile fixed on a face with small innocent features — said little, smiled a lot. I saw no pain. His head was covered by a black woolen hat that appeared to have been worn for a long period of time or at least frequently. The woolen hat was out of place for the Indian summer temperature.
“Take off your hat, Jack — you don’t need it in this heat. Show off your hair — you have cool hair.” He agreed to take off the hat, but didn’t seem sold on the idea of his cool hair.
Jack did indeed have asthma along with his eczema but never seemed concerned about the suffering it caused and, in spite of his mother’s good intentions, I suspected his compliance with the medical regimen I set up for him was shaky. When I saw him later that autumn for an exacerbation, he was wearing the same hat.
“You don’t need a hat” I argued.
“He’s wearing it for you!” quipped his mother — and as I laughed his smile imploded.
Future visits took a different turn. First, I prescribed various stimulants for ADHD — followed by antidepressants and referral to psychiatry. Later, I was refilling sleeping drugs prescribed by different psychiatrists. Eventually, prescribing was over my head. I learned from his mother that Jack was admitted to rehab for substance abuse — he was 12 years old. Although psychiatry was assuming his complicated care, when I did see Jack back he was always wearing the same woolen hat.
About a year before his death, I learned from Jack’s mother that he had inpatient psychiatric admissions culminating in the diagnosis of bipolar disorder — like his father, and his father before, and his father before that. Jack’s father had died of an overdose recently. A fire had damaged much of their home. Jack himself continued to smile through all this. I asked a psychiatrist shortly after this during a curbside consult what differentiated bipolar disorder from routine unstable adolescent behavior. He replied with a single word: impulsivity.
The last time I saw Jack something was different. He was attending a special “academy” which guaranteed compliance with the multitude of psychotropic medications he was taking. His face was radiant with smile and he talked more than ever. I learned that he was a talented artist and musician. I told him how proud I was of his resilience. His mother agreed that he was finally on the right course. Because of my excitement, I failed to realize that he was not wearing his hat — a serious failure of my clinical acumen.
The following week when I learned of Jack’s death it all slowly came to light. In my ignorance, he had reconciled with his plight — the simple loss of a coin toss at his conception. His good looks, magnetic smile, talents, and wonderful supportive mother could no longer sustain him. Both socks were lost in the dryer. He wished to join his forefathers in a better place — a place where he would no longer have to cover up his inner pain and turmoil with a hat. I had lost a dear little patient friend who wore a hat not only for me but for all mankind — especially for us physicians who continue to be blindsided by depression, anxiety, bipolar disorder, post-traumatic stress disorder, schizophrenia — conditions far more prevalent than Ebola.
One is never too old to acquire continuing medical education, or too experienced to miss a diagnosis that is staring him in the face. But I do feel somewhat at peace since Jack has finally joined the natural order of things.
(Please check out this concise review on WebMD: Children and Teens with Bipolar Disorder. “Although bipolar disorder more commonly develops in older teenagers and young adults, it can appear in children as young as 6.”)