Stir Crazy

Perhaps you’ve heard this one. Antarctica is a harsh content. It’s the highest, driest, coldest continent on earth, and the place most inhospitable to descendants of the small hairy bipeds that once scampered about the African plains.  We’ve already noted that as creatures who evolved in warmer climes nearer the sea, there’s a host of physiologic stressors to life at the South Pole. In addition, one can add a virtual cornucopia of psychologic challenges, given that humans are used to things like night and day, personal mobility, and living in kinship groups.  These factors and others have been implicated in mental health issues at the extremes of the earth.  As our winter ensues, and our story progresses, it’s helpful to think about what’s going on in our heads as well as our hands and our hearts. 

There’s a long history of mental health concerns with in the annals of the continent.  The Belgica was the first ship known to become frozen in the ice and forced to over-winter in 1898.  Dr. Frederick Cook, the expedition physician (and the explorer/physician/scallywag we mentioned before) described the effect of the prolonged darkness on the crew’s behavior:

“We had placed before us the outline for industrious occupation, but we did little of it. As the darkness increased our energy waned. We became indifferent, and found it difficult to concentrate our minds or fix our efforts to any one plan of action. The men were incapable of concentration, and unable to continue prolonged thought.”

Dr. Cook prescribed a diet of milk, meat, and cranberry juice.  More exercise and warmth was advised, as well as increased exposure to light by sitting in a small room where the door to a hot stove was kept open.

If the Belgica crew was merely lethargic, the Deutschland expedition of 1912 was a group of chicken dancing on hot tin plates.  Trapped in the ice over the polar night, tempers flared, and not just because of the well-known Teutonic tendency towards friendship and amicable behavior.  And there is a lesson this for Antarctic doctors, especially one like me who is descended from German stock. (As much as I might like to, I can’t twist my last name into O’Rodenberg and think I’m Irish on St. Patrick’s Day or find the tartan for the Clan MacRodenberg at the Kilt Store.)  

It’s reported in the diary of Wilhelm Filchner, the leader of the expedition, that physician Wilhelm von Goeldel, “fought with both the carpenter and the boatsman.  Goeldel was totally drunk, threatening with a pistol.”  Another crewman noted that, “The expedition doctor had twice threatened members of the expedition that he would shoot them down with his revolver.  And one has to sit daily at table with such gentlemen!”  The doctor was described as “behaving like a madman” and threatened to place his colleagues in “a strait jacket at the first opportunity.”  There was also an attempted shooting on board, and while the bullet was found the culprit was lost to history.  But I suspect it was Dr. von Goeldel, in the Deutschland, with a revolver.  I’ve actually told this story at an all-hands meeting, but I’m not sure if I did so as a caution that we could all trip into this behavior or as a warning to not to cross me. I think it’s better left an open question.

(By the way, we do have a strait jacket sitting on a shelf in my office.  It looks old, with pink lipstick-like stains on the white canvas and cracked leather straps…I wouldn’t be surprised if it was shipped here for the first Operation Deep Freeze station in the 1950’s.  The strait jacket is now mostly used for photo ops, although I do wonder if keeping it in my office means it’s easy to find if I go fully von Goeldel.  We also have a set of leather restrains in an olive green military canvas bag labeled “Mid-Winter Restraints.”  Don’t know why you can’t use them during the summer, but at least it doesn’t say “Recreational Use Only.”)

Things were even worse for one Sydney Jeffryes on the 1912 Douglas Mawson Australian Expedition to the Magnetic South Pole.  Jeffryes was a wireless operator whose mind was swept up in the worst of the polar night.  underwent changes in his personality over the winter. Lawson, the expedition leader, recorded in his diary:

“Last night Jeffryes suddenly asked Madigan to go to the next room to fight…this morning after breakfast Madigan was filling his lamp with kerosene in the gangway and Jeffryes wet out, pushing him Wayne Jeffries without permission and asked him to fight again dance round tower.  Asked him to fight again, danced round in a towering rage, struck Madigan, rough and tumble.  I think his touchy temperament is being very hard tested with bad weather and indoor life.  A case of polar depression.  I trust it will go now.”

But go it did not.  Jeffryes would sabotage the radio every evening so nobody else could use the wireless, and at one point he telegraphed in Mawson’s name that other members of the expedition were not well and that Mawson and Jeffryes would need to leave the winter shelter to survive. Unfortunately, Jeffryes never did get better, and spent the rest of his life in a mental asylum.

Mental health issues are not simply footnotes in history.  Chess was banned form Soviet Stations due to an irate loser charging the victor with an ice pick.  Russians have also stabbed each other for revealing the endings to books.  Whether these incidents were specially related to mental health issues, moving the rook one unseen one extra square, or ruining the pleasure of War and Peace remains unknown, but it does seem like perhaps the best way to win the Ukrainian Conflict  would be to give thousands of pairs of fabric scissors to the frustrated Russians.

Sometimes people manifest their stress in bigger ways, because sometimes stabbing just isn’t enough.  The Chapel of the Snows at McMurdo Station was set afire in the early 1980’s by someone who wanted to be shipped home early; I suspect the request was granted, though probably not in the same fashion the arsonist had hoped.  The same decade saw the immolation of an Argentine outpost by the Station’s Leader/Physician who had been ordered to stay for the winter. (There’s that crazy doctor stuff again.)  I’m not in favor of anyone burning anything down, but I have a kind of grudging admiration for the torchbearers.  No mere threats or ultimatums.  No random or uncalculated behaviors.  These guys did it right.

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When we speak about mental health issues in the polar regions, using the right words is important.  We’ve previously mentioned Seasonal Affective Disorder (SAD). This is a form of major depression where the symptoms occur at the same time each year. Most of the time this is a winter phenomenon, but occasional cases are associated with spring and summer as well. The key is that this is a recurrent form depression seen in a cyclical fashion, and while it seems to be more common in those living at higher latitudes, it’s not something unique to polar regions.

“Winter-Over Syndrome,” however, is something that that is exclusively ours.  The Winter-over Syndrome refers to a spectrum of behavioral disturbances which only occur when someone is spending the winter in polar lands.  Winter-Over Syndrome usually resolves when one is removed from the environment, and does not recur seasonally once the patient is returned to more temperate latitudes as does SAD.  A related finding is known as the “Polar T3 Syndrome,” where decreased thyroid hormone levels are associated with depressed mood at higher latitudes.  Finally, there’s the “Antarctic Stare” or “Antarctic Fugue,” an extreme manifestation of Winter-Over Syndrome.  It’s the Antarctic equivalent of an episode of The Walking Dead, where the bodies move across the land in silence with soulless eyes and empty minds, but without the eating of brains.  I think.

Let’s talk about Seasonal Affective Disorder (SAD) in more detail.  While we tend to think of it as a distinct problem (it does have a pretty unique moniker), it’s really a specific type of depression.  According to the DSM- V, which is the Bible of Psychiatric Diagnosis, it falls into the category of “Major Depression with a Seasonal Pattern.”  Descriptions of likely SAD are seen as early as the 6^th century, but the entity was not formally identified until the 1980’s.  The incidence of SAD varies with latitude, ranging from about 1.5% of folks in Florida to 10% Alaska (though I suspect the rate of all kinds of mental pathology are higher now in Florida, and especially in the Governor’s Mansion, under the Kingdom of Ron.)

Symptoms of SAD would be similar to what you expect with depression, albeit with the seasonal pattern. People become fatigued, have trouble sleeping, and are initially prone to overeat.  As the problem worsens, there’s a loss of interest in normal activities, social withdrawal, loss of appetite, and feelings of sadness and worthlessness.  The depressed mood interferes with concentration and decision-making, and the victim may enter a spiral which seems to reinforce the low self-esteem.  In it’s worst form, SAD may present with homicidal or suicidal ideations. 

There are a host of proposed causes of SAD, but there seems to be no single smoking gun.  More than likely the cause is a combination of factors, including an individual predilection to develop the problem. One of the more interesting theories out there is that SAD is actually an evolved adaptive response to winter.  A host of our furry friends hibernate during the colder months, and while not everyone sleeps like the squirrels and the bears (and I like bears a lot), most mammals tend to shut down physiologically in response to the metabolic demands from the weather and the scarcity of food.  So the idea is that what appears to be a depressed state is, to some degree, a manifestation of a survival response to a time when a lack of food meant decreased activity in the winter.

There are more “usual” explanations for SAD as well.  There’s the changes in cycles of outside light and dark at higher latitudes, with prolonged periods of darkness resulting in changes in melatonin production and disruption of sleep cycles. The body makes melatonin in response to darkness, so longer nights may lead to excessive sleepiness.  Decreases in serotonin, a chemical within the brain that impacts mood, has also been implicated as a cause.  Certain personality traits have also been associated with the diagnosis.

The most natural way to treat SAD is to replicate the normal light dark cycle. Here at the Pole we use a “Happy Light,” a boxy artificial light source to be used in a controlled fashion to suppress the production of melatonin.  There’s a fair amount of science behind its’ use.  The light should be placed at an indirect angle to the face, and used for up to 60 minutes at the same time each morning.  We’ve got a number of “Happy Lights” on Station issued to individuals and workplaces; the Physician Assistant even set up a separate “Tropical Happy Light” room in one of the vacant berths, complete with carboard cutouts of palm trees from our beach party earlier in the year.  The problem with “Happy Light” therapy is that compliance tends to be poor.  Even with the best intentions it’s hard to do the same thing at the same time for the same hour every day, and even more so if your daily schedule keeps changing as satellites move about and your colleagues Up north can’t seem to fathom the concept of time zones.

Speaking of the folks back home, Polies talk about the stranger questions we get asked by friends and family.  We’ve all had the Polar Bear and Santa questions, to which the answer is “Wrong Pole,” and if we have seals and penguins for pets, to rely “We’re 800 miles from the water.”  One of my favorites was an inquiry about how we interact with the native population, and explaining that there is none.  I was talking with a fellow physician in the States who kindly asked if I wanted to transfer a patient to his hospital, and had to review that it’s really not an option until November.   A friend was asked if she needed to learn a new language to go to Antarctica.  Probably not, but you should stock up on synonyms for cold, snow, and ice.

Then there’s the stranger questions we ask ourselves.  What do we do if our Russian neighbors over at Vostok Station get tired of vodka and borscht and using the Highest Sauna in the World, load up a few tractors with potatoes and fuel, drive like mad, and two weeks later wind up at our front door asking to come in for tea and borrow a cup of sugar?  What if the Chinese decide that that Taiwan is too formidable an opponent, but maybe the South Pole is there for the taking?  There are no firearms on Station, so we’ll probably have to hunker down in the subterranean ice tunnels and fight back with booby traps created in the Arts and Crafts Room and ask the Facilities Engineers to make catapults which we can load up with boxes of frozen food.  Perhaps Information Technology can get Macaulay Culkin on line for advice.  Kevin?  We left Kevin!

Because of the problems complying with light therapy, medication is often used to treat SAD.  The use of selective serotonin reuptake inhibitors (SSRI’s), which cause serotonin to linger longer in the brain, has been associated with improvements in depressive symptoms.  SAD seems to be primarily a biologic issue,  and there has been no particular benefit ascribed to specific psychologic therapies.

(For what it’s worth, SAD is the third best acronym in medicine, as it fits the diagnosis of Seasonal Affective Disorder perfectly.  Number four is SOB, which stands for Shortness of Breath, but may also be used as describing one’s attitude or parentage.  The second best is PNES, for Psychogenic Non-Epileptogenic Seizures.  These are what we used to call pseudoseizures (“fake seizures”) until someone decided that sometimes the poor things just can’t help themselves.  While not a perfect match, the pronunciation of the acronym often suggests the personality characteristics of the patient.  The top prize goes to WNL, which is mostly used to note a physical finding is “Within Normal Limits,” but occasionally stands for “We Never Looked.”)

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“Winter-Over Syndrome” is a different kettle of fish (should there ever be fish at the South Pole.). As opposed to the recurrent seasonal nature of SAD, Winter-Over Syndrome is an acute, non-repetitive constellation of behavioral symptoms seen in those who spend prolonged time in the polar nights.  It’s extremely common; studies note that up to 60% of winter-overs report symptoms such as sleep disturbances, depressed mood, appetite changes, irritability, and difficulties with concentration and memory. At its fullest expression, people become irritable and may exhibit aggressive behaviors.  (Dr. von Goedel again comes to mind.)  The ultimate manifestation of this is called the “Antarctic Stare,” a dissociative fugue state where the lights are on, but nobody’s home.

I have to admit that I’m experiencing some of the symptoms. I haven’t slept well for the last several months, getting maybe two or three hours of sleep at a time and dozing off during the day; and what was a pretty good appetite early in the winter has now degenerated to often just picking at some soup or rice.  As to whether I’ve become particularly aggressive, I’ll leave that to my colleagues to say, but I can say that so far I have not wielded a steak knife to cut anything other than steak.

Just like SAD, there’s a collection of proposed causes of Winter-Over Syndrome, and some of these no doubt overlap with some of the same physiologic factors that influence the recurrent seasonal depression.  However, there are additional unique psychological environmental factors to the polar winter. For example, even in northern latitudes were you have prolonged night, one still exists in the community with your normal range of social interactions and support structures. However, here at the Pole where we’re isolated from February to October, not only do you have restricted social options, you don’t have the emotional support of family and friends in the “real world.”  Confinement is also an issue; most days we spend indoors, and when we do go it’s to another worksite, and there’s really no place else to go. 

The closed nature of the station means that privacy is lacking.  While you can hole up in your room to gain some control over your personal space, you need to come out for meals and work, so it’s very hard to disengage.  And when people make that choice to withdraw for their own peace of mind, it inadvertently feeds the rumor mill and exacerbates social isolation.

We also can’t fully eliminate the role of the physiologic factors like cold and altitude. These physiologic stressors contribute to fatigue, which when coupled with insomnia, lack of appetite, and the unique winter polar environment, tend to snowball into larger problems.  (Antarctic pun intended.)  The problem gets worse with extended durations of the polar night, and it’s also the third quarter of any prolonged overwinter stay is the time of highest risk.

There also appears to be a cultural component to Winter-Over Syndrome.  When studies are done at the United States Antarctic Program South Pole Station, distinct increases in overall tension and fatigue are noted as winter forges on.  However, similar studies at stations operated by other lands such as Russia, China, and India, show decreases in fatigue, tension, and anxiety during the same season.  Are Americans are simply less resilient and more neurotic?  Given the fragile egos that dominate our societal discourse, there’s a large part of me that wants to say yes.  It may be that people from cultures where hardship is expected tolerate the winter better than others, or that symptoms are likely to remain unreported when even the hint of anxiety or depression can cost you your job.  But as an American, I must admit we’re pretty thin-skinned and spoiled. 

Just as with SAD, there’s an evolutionary proposal about why we might experience winter-over symptoms.  This model suggests that the behaviors seen in Winter-Over Syndrome may be a protective mechanism against chronic stress.  Normally when we’re stressed we use psychologic coping mechanisms to try and manage the situation.  But when you’re chronically working through a morass of angst it becomes more fatiguing and uses more mental energy to stay focused.  When we reserve our mental energy by not actively using coping strategies in dealing with our daily stress, our mood flattens and we’re indifferent to the outside world.  Over time, this can lead to the zombified “Antarctic Stare.”

Another interesting hypothesis of the origin of Winter-Over Syndrome is the “Polar T3 Syndrome.”  (There are lots of syndromes around here.)  In the body, thyroid hormone exists in two forms.   T3 is the active form, which exerts physiologic effects; T4 is bound up in plasma and is converted to the active T3 in the body tissues.  It’s been noted that those who overwinter in Antarctica exhibit decreased levels of active thyroid hormone (T3) during their stay.

Thyroid hormone primarily regulates metabolism, but also has an impact on mood.  Low levels of thyroid hormone are associated with depressed mood, and patients with significant hypothyroidism (low levels of thyroid hormone) become lethargic with a flat, expressionless face and a mood to match.  The Polar T3 Syndrome proposes the decreased levels of thyroid hormone seen in those nighttime Antarctic visitors plays an important role in the mood dysfunction seen with Winter-Over Syndrome.

Unfortunately, simply administering tablets of thyroid hormone for prevention isn’t a great solution.   Giving thyroid tablets requires laboratory monitoring of hormone levels so you don’t go too far the other direction, and we don’t have the capability to perform those tests on site.  In addition, Polar T3 Syndrome is not a uniform finding in everyone who over-winters, and you don’t want to medicate those who don’t need it; and since the syndrome can’t be predicted by lab results prior to the onset of winter, you never quite know who to treat.  You can eat foods rich in iodine (a required component of thyroid hormone) such as eggs, dairy products, meats, and there’s always iodized salt, but unless you’re a passable mimic of Cool Hand Luke you can only do so much.

(One of the more interesting bits of medical history I learned here came from Tiny Bubbles the Supply Queen, who related that her old crew was involved in a study of Polar T3 Syndrome when she last wintered in the old domed station.  Everyone who was in the study had been given a tablet to take every morning to see if it improved their mood.  Tiny said that one day she had forgotten to take the pill and by the time she remembered to fish it out of her coveralls, the pill had begun to crumble and she could see that there was another tablet buried inside an outer white coating.  This made everyone aware that this was a placebo-controlled study, in which some would receive active medication, some would not, and nobody would be told which group they were in.  Since nobody wanted to be in the group that didn’t care, everyone simply stopped taking the tablets.  I haven’t talked to the investigators, but it sounds like this study was to see whether or not mood improved with supplemental thyroid hormone.  However, because of Tiny and her colleagues, science has been held back for two decades.)

The best way to deal with Winter-Over Syndrome seem to be simple awareness.   You need to know that it happens, that it will likely happen to you, and that it may impact your thoughts, feelings, responses, and reactions.  Awareness also means that you’re sensitive to its’ presence in others, and to help them compensate the best way they can.  If someone wants to withdraw, let them have their privacy. If they want to interact, encourage it.  Promoting physical exercise and good nutrition as ways of compensating for the physiologic impacts of cold and altitude, and stress management techniques such as mediation, yoga, or hobbies to address the psychologic challenges of polar life is of great importance as well.  Because there is no definitive diagnosis of depression, and no specific biochemical abnormality to address, treatment with medication is usually not helpful.

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We’ve spoken specifically about mental health issues related to prolonged stays about the Pole, but in medicine common things happen commonly.  The usual problems seen Up North are here as well. Polies suffer from anxiety and depression originating in the daily stressors of life, although magnified by our isolation from family, friends, and our usual sources of emotional support.  Still, the polar environment does proffer some unique mental health challenges, and as we approach midwinter and the third quarter of our year, more issues are likely to arise.  (There’s probably a reason they called Angry August and Stabtember.)  I’m hoping we can understand that we may all be suffering in our own ways, and that it’s important to give people space, to respond to their behaviors and not simply to react.  That advice works at temperature latitudes, too.  Don’t be a dick, and we’ll be just fine.