Bipolar Visions: Bipolar Disorder and Chemical Dependency: A Continuation of part I

by  Peter J. Dorsen, M.D., LADC

Hopefully, I have already whetted your appetite about what can be the ravages of oc-occurring bipolar disorder and chemical dependency with my story about going berserk in our family kitchen.

We would like to tell you a little bit about what are the differences between bipolar I and bipolar II disorders. We will discuss the continuum of severity of this devastating illness. By doing so, we will talk a bit about rapid cycling and who is prone to it as well as the mixed pattern and why suicide is such a danger with it. If you are a chemical dependency counselor, our presentation will allow you to better screen for bipolar disorder and refer more effectively and quickly. If you are just a curious reader, this will help you understand more about this illness. We will discuss the latest treatment modalities used to work with different degrees of severity of the disorder and chemical dependency.

Put very simply, bipolar I disorders are episodes of mania interspersed with episodes of severe depression. Bipolar II, on the other hand, are “less serious” episodes of hypomania interspersed by episodes of severe depression. There is also a phenomenon that occurs with both forms of the illness and that is “kindling.” What this means is that, like a growing fire, small inciting incidents (pieces of wood) initially lead to the spontaneous combustion suddenly even erratically later in the course of the process. There is even a 5-15 per cent chance of someone de novo developing a full-blown manic episode given enough kindling.

Bipolar disorder is a dis-ease. It’s a medical condition. It is not a punishment or a judgment on the way you’ve lived your life. It’s not a weakness or a failure(Taming Bipolar Disorder). Bipolar disorder is about changes in your genes that cause changes in your brain that cause changes in your behavior, your personality, your emotions.

So, there are plenty of things you can do if you know you are cursed, as it were, to avoid getting sick. Get enough sleep. Eat the right foods. Manage your stressors and relationships. You need to trust your instincts when you sense you may be “going under.” It frequently helps to listen to those around you who may be intimate with your moods. Remember, knowledge is power. You are well-served to learn as much as you can about this malady. It is a chronic illness that experts like Kay Redfield Jamison tell us will be with us throughout our lives.
True, there may be something “sick” about any one of us who is bipolar. Jamison notes, “ I know plenty of people who have gone off their meds because they want to be manic again. It’s very alluring” (Touched with Fire: Manic Depressive Illness and Artistic Temperament). Here’s some interesting data: Among 47 highly celebrated British writers and artists, 38% had actually been treated for affective disorder. Thirty three per cent needed to be medicated for depression. Seventeen per cent required lithium and a hospital stay at the minimum (Jamison).

Another “celebrity” in the brain chemistry approach to psychiatric illnesses, Nancy Andreasen, M.D., found that of 30 Iowa Writers’ Workshop participants, 80% had some kind of affective disorder compared with 30% of “less creative” controls. Forty three percent of the writers were diagnosed as bipolar: a helluva price to pay for creativity. Arnold Ludwig at the University of Kentucky, who reviewed 2200 biographies of 1004 artists, writers, and musicians found 34% among the musicians with symptoms of mental illness. He detected only 9% mental illness among scientists, athletes, and business oriented interviewed.

There has perhaps unfortunately been a tendency to believe that being bipolar confers a little edge on being creative. David Miklowitz in The Bipolar Disorder Survival Guide, notes: “ The paradox of bipolar disorder is that it can be beneficial conferring a higher degree of creativity on many it touches…while at the same time it can be destroying your life…” There are plenty of notables out there with bipolar disorder and willing to “come out.” That has included Patty Duke, Connie Francis, Margot Kidder, Jimmy Piersall, Linda Hamilton, and Jane Pauley. There are the historians as well who have noted the illness in Alexander The Great, Napoleon, Oliver Cromwell, Lord Nelson, Alexander Hamilton, maybe Abraham Lincoln, Teddy Roosevelt, Winston Churchill, and Benito Mussolini.

Our primary mission may be to focus on the relationship between bipolarity and addiction. My associate Tim Kuss has promised to focus perhaps to a greater extent on this subject. A 1998 National Institute of Mental Health (NIMH) study notes: “ People who were depressed and who abused or were dependent on alcohol had a much worse outcome than did depressed people who did not drink heavily.”
Nonetheless, the reality is that one third of those with bipolar disorder have a substance abuse problem. Women especially with bipolar disorder, in particular, are seven times more likely to abuse alcohol than random women in the general population.

More tidbits are that using recreational drugs or alcohol (in excess) is going to predispose you to relapse and substance use will lead to bipolar relapse harder to stop or treat when they happen. And so it is, downers like alcohol or historically barbiturates are often the drug of choice. Those struggling with manic episodes like to “medicate” with stimulants like cocaine, amphetamines, or Ecstasy. Issues like rapid cycling or mixed presentations which we will talk about later, are more common in someone with a substance abuse problem (Goldberg et al).

A process that I can intimately relate to is the fact that there may well be cognitive compromise when there is coexisting bipolar disorder and cannabis abuse(Cahill et al, 2006). Then there is the fact that bipolar disorder is the Axis I psychiatric disorder with the highest rate of co-occurring substance use disorder (R.D. Weiss, 2004). Others warn that substance use can worsen the course of the disorder(A.J. Rush, 2003). R.S. McIntyre( Dialogues in Clinical Neuroscience. V10.no 2, 2008 et al) discuss “Medical and substance –related co-morbidity in bipolar disorder: translational research and treatment opportunities.”

Then there’s the phenomenon of rapid cycling. It occurs in both bipolar I or II forms of the disorder and means at least four episodes of either mania (hypomania) or depression in a year. The time sequence ends up generally being two weeks for a depressive episode, one week for a manic episode, or four days of a hypomanic episode. In children, all bets end up being off because they can cycle as many as two times a day with the ultra rapid form compared with cycling many times in just one day with ultradian cycling. Two quotes sum up the perversity of this affliction: “ If diagnosing bipolar I in adults seems complex, diagnosing it in children can be downright Byzantine,” or “ If bipolar disorder is scary for adults, it must be absolutely terrifying for children…” Rapid cycling is more difficult to treat. It is more frequently associated with bipolar II. Lastly, always remember that antidepressants can precipitate mania as rapid cycling.

There is a higher suicide rate with bipolar II than bipolar I(G. MacQueen, T.Young, 2001). There is an inevitable co-morbidity of abuse , anxiety, and personality disorders and bipolar disorders. It’s just a fact that psychiatrists have classically “missed” sub threshold expressions of mania. After all, with hypomania, we do not experience psychosis and rarely require hospitalization or marked impairment in functioning.

Baldessar et al found an eleven year delay in diagnosing women with bipolar disorder compared with 6.9 years in men. It seemed like an eternity before Tim or I were correctly diagnosed bipolar. Although these two reporters got into plenty of trouble from mania or hypomania, MacQueen et al in 2000 noted comparable degrees of psychosocial disability from either bipolar I or II, and that depression in bipolar disorder ends up being a stronger predictor of psychosocial outcome. I had cyclical depression, was treated with antidepressants, and finally pissed off the wrong people. Tim went “crazy” and got hospitalized plenty of the time often with the wrong diagnosis

The French investigator, Falret, was one of the first to note an unfavorable outcome course with a biphasic or “mixed” form of bipolar disorder. The description that fits this presentation best is the person slumped on the couch yet her mind is racing frantically. There is unfortunately a higher rate of suicide associated with the mixed state.

In cyclothymia, the sine curve is decidedly less pronounced. The person with this form of bipolar disorder alternates between a milder presentation of hypomania and depression than someone with bipolar II disorder. Unfortunately, it is, however, the more chronic form of the illness. It presents as short irregular cycles (days) with only short periods of “normal “ moods. Individuals wake up with mood changes. It tends to appear in the late teens and early twenties. For the longest time, cyclothymia was categorized a “personality” disorder (DSM III). Not any more. It now sits squarely in the DSM IV as a dysphoria, a mood disorder. Noteworthy, cyclothymia has the tendency six per cent of the time to develop into bipolar I or bipolar II.

I am currently struggling with issues of cognitive impairment. My dysfunction has manifested itself as executive function issues, poor judgment or the inability to successfully complete complex tasks. A study from Barcelona of 71 euthymic subjects ( individuals with normal moods) demonstrated that the bipolar groups showed significant deficits in most cognitive tasks including work memory, digit span backwards, and attention. Cognitive impairment appears to exist in both subtypes, bipolar I and II but moreso in bipolar I. The best indicators of psychosocial functioning in bipolar II were subclinical depressive symptoms, early onset of the illness, and poor performance on a measure related to executive function. Spooky, but this study hits directly home for me.

Any responsible chemical dependency counselor these days knows the importance of reinforcing that their clients stay on their meds. Lithium has been the old stand by to which all the other newcomers have been compared. It was basically discovered by Australian physician, John Cade in the late fortieshe but did not “take off” until the late nineteen sixties in the U.S. Mondimore reports a fair share of unpleasant side effects with lithium that include nausea and diarrhea, tremor, hypothyroidism, and renal failure. But they are all, for the most part, preventable or reversible. Another concern is that there is a so-called “induced refractoriness” effect. One investigator has reported 20% showing a poor restart response when lithium was stopped.

Lithium does well with euphoria. It is especially effective in those with a strong family history of bipolar disorder. It decreases the incidence of suicide six-fold. Nassir Ghaemi in Cambridge, Mass reports a thirteen-fold decrease in suicide. However, lithiuim like depakote has been reported to show an inordinately high drop-out rate. Researchers at Case Western failed to show that devalproex was more effective than lithium, the old stand by. Perhaps there is a need to reassess current prescribing away from lithium.

Depakote, the medication that I personally take, is considered excellent for treating acute mania. Yes, it may make you sleepy at the outset. It appears to prevent the severity and reoccurences of episodes. It may be better treating depressive symptoms than lithium. It is touted as being more effective treating rapid cycling and mixed forms of the disorder. It appears to be less toxic than lithium. It is helpful across the board with cyclothymia, bipolar II, “soft” bipolar disorders, and those with previous episodes of bipolar disorder. However, it is important to monitor levels and to periodically check liver function tests (LFT's) as well as blood counts.

Carbamazepine (Tegretol) may be of importance treating “resistant” bipolar disorder. Care must be exercised as tegretol can decrease the efficacy of normal strength birth control pills. It is also important with this drug to monitor "LFT’s" and blood counts. Oxcarbazepine (Trileptal) has developed a reputation for treating mania. Lamotrigine (Lamictal) has gotten the nickname, “ The child prodigy among the medications for bipolar disorder. It has a long half-life (24 hours) and may be just as effective in a long-term study as lithium. Its low side effect burden is complicated by the rare but disastrous incidence of Stevens-Johnson Syndrome or epidermal necrosis (TED). So, psychiatrists are obliged to start low and slow to ultimately achieve a daily dose of 200-400mg.

There are neurontin (Gabapentin) and topiramate (Topamax) which delightfully have been associated with weight loss. The danger of the SSRI’s especially is the danger of precipitating mania. They also carry their share of libido and erectile dysfunction issues. There are the SNRI’s like Effexor, Cymbalta, or Wellbutrin. Buproprion (Wellbutrin) and paroxetine(Paxil) seem to carry less of the danger for causing mania or associated rapid cycling.

The atypical antipsychotics like aripazole (Abilify), clozapine)Clozaril, olanzapine)( Zyprexa), quetiapine (Seroquel), respiridone (Resperdal), or zyprasadone (Geodon) have their share of issues. They block dopamine receptors and are also active at serotonin receptors. But they have the funky effect of extrpyramidal side effects; that is, involuntary movements including tardive dyskinesia which is what I experienced after a run of Zyprexa and Abilify.
No fun twitching and drooling. They are certainly considered helpful in all phases of bipolar disorder and as ongoing treatment to prevent relapse. For most and especially noxious to women patients is the reality of weight gain with this class of drugs. Recent literature is also warning about the possibility of sudden death from this class as well. We strongly suggest you consult your physician if you have any questions about them There is certainly nothing wrong with getting a second opinion.
At the risk of repetition, adults have an initial episode of mania while kids
( pediatric age and adolescents) manifest as major depression.

Kids frequently rapidly cycle as much as many times in a day whereas adults have a discrete episode. The duration in kids is chronic and continuous and discrete in adults. The adult improves between episodes while his junior counterpart does poorly. It should come as no surprise that 20-30% of children with major depression go on to develop mania later in life.

Lastly, there is a high co-morbidity of 75% between ADHD and bipolar disorder.
There is a greater incidence of rapid cycling and depression in women. Some might hypothesize that the more frequent treatment of depression in women is a setup for a higher incidence of rapid cycling. There is no time in the life of a male or female bipolar patient, when the risk of an episode is higher for a female than the post partum period. Worrisomely, lithium, valproate, and carbamazepine are all associated with birth defects. It is imperative that these medications be avoided in early pregnancy but they can be safely restarted in the latter pregnancy but certainly as soon as possible post delivery. Alcoholic women end up being much sicker with bipolar disorder.

No discussion about bipolar disorder could be complete without touching on Seasonal Affective Disorder, SAD, as it has been called. Twenty to thirty per cent of people with SAD actually end up having bipolar disorder. One treatment that has been shown to work especially in environments where there is insufficient sunlight, is exposing yourself to 10,000 lux for from ten minutes to one hour daily. This appears to be sufficient to stave off depression. The nice thing about this safe and relatively inexpensive method is that it works for bipolar disorder as well just by boosting levels of serotonin throughout the day. It works.

Psychotherapy, along with appropriate mood stabilizers, remains a vital means of treatment. Cognitive Behavioral Therapy popularized by the legendary therapist, Aaron Beck, believes that “people become depressed or manic in response to life events (and) are doing so …because they are thinking and processing these events in an inappropriate or problematic way.” There is a triad that (1) You (must) address your thought processes; (2) Make an in-depth assessment of how you interpret things; and; (3) Modify that interpretation putting you at risk of a mood disorder. The common denominator in this school of therapy is that a cognitive therapist will recognize your problematic thought processes and teach you alternative ways to think about life’s stresses. There are some good results coming out of this discipline: Lam (2003) showed a 44 versus 75% relapse rate or a lower duration of illness of 27 versus 88 days when meds were combined with psychotherapy.

Miklowitz et al, in a full two-year study, has demonstrated 52% without relapse compared to a control of 17% when an individual underwent Family Focused Therapy (FFT). FFT keeps relapse at bay instead of dealing with “crisis” management. It is important, according to Miklowitz, “… teaching family members to focus on expressing positive attitudes and emotions and to avoid criticism and negativity (which) helped these patients avoid relapse for longer and relapse less frequently and decrease symptoms of depression.

ECT, electroconvulsive therapy, has always been a controversial treatment option to me. However, it is good or better at controlling mania. It is good at lifting depression. It is useful in pregnancy for the reason that a significant number of medications are dangerous to the fetus. It is acceptable and potentially even preferable especially in intractable ultrarapid or ultradian cycling. Sure, there is the stigma popularized by Jack Nicholson in “One Flew Over The Cuckoo’s Nest.” The bottom line remains that those who end up being treated with ECT have fewer depressive episodes, spend less time in the hospital, and and have fewer hospitalizations. The downside remains that there are certainly some side effects from ECT that include at the top of the list, memory loss.

Let us not forget “Alternative Therapies.” First on the list is attempting to achieve a balanced diet. My partner reminds me that this should include plenty of leafy vegetables, go lightly on the saturated fats and processed fast foods. Studies from Harvard’s McClean Hospital advocate the linolenic fatty acids. Studies at that institution report longer time relapse free and that symptoms are significantly reduced. It is very interesting that countries where there is a high consumption of fish have a low incidence of mood disorders.
Flax seed oil has two times the content of Omega 3’s as fish oil and lacks some of the undesirable smell issues.

We are told that Vitamin E should supplement the consumption of Depakote. Zinc and copper attack bipolar disorder as does calcium and magnesium and tyrosine. Methionine may have an antidepressant effect. Several books by Dr. Andrew Weil are very informative about these issues (Healthy Aging in particular). All the information is not in on St John’s Wart. Like the antidepressants, care should be exercised about this over the counter natural product precipitating mania.

Here are the changes to watch out for that you might be becoming manic. Watch out for sleep disturbance (77%), psychosis (43%), Speeded up movements, or mood change (34%), loss or increase in appetite (20%), and increased anxiety (16%). On the other hand, depression can creep up on the best of us. Be on the look out for: mood changes(48%), slowed down movements (41%), increased anxiety (36%), increase or decrease in appetite (36%), suicidal thoughts or feelings (29%), sleep disturbance (24%). Taming Bipolar Disorder, p.192. Alison Perry in the British Journal of Medicine advocates, “ teaching patients to identify early symptoms and giving them fail-proof ways to seek prompt treatment.” Likewise, “Group psychoeducation on the signs of relapse was able to decrease the number of relapses…and the number of episodes of mania, hypomania…and depression.”

The bottom line is that anyone with bipolar disorder should not have extra medications or firearms around their home. If you are bipolar, you should abstain completely from alcohol and drugs. If you have a chemical problem, try AA or NA-- whatever works for you. Don’t self-medicate. If you have a sex addiction, get help. If you or someone you know or love is bipolar and contemplating suicide, get help. Don’t hesitate to call 911 or 1-800-SUICIDE (1800-764-2433).

Peer-run services are effective. DBSA (Depression and Bipolar Support Alliance www.dbsalliance.org (1-800-826-3632) works. The facts support that those who utilize them are hospitalized less. They have better communication with their doctors. Peer groups have the ability to empower individuals with bipolar disorders. They have the power to bring individuals into support settings who might otherwise be isolated. Suicide rates with bipolar disorder especially bipolar II are frighteningly high. Peer support opportunities offer a sense of belonging, camaraderie and friendship when none seemed to exist before. DBSA has 1000 support groups out there. They are easily available, free, and not intimidating.

“Soft” bipolar disorders include those who have a family history of bipolar disorder. Most importantly, these with "soft" bipolar disorder are the ones who some well-meaning provider may have prescribed antidepressants before a mood stabilizer. This may be someone with a history of mixed mood states. He or she may have a depressive or cycling temperament. This is the person who may ( like myself for so many years) have had recurrent depressions. I definitely struggle to categorize my illness. For a time I even wondered if mine might have begun as cyclothymia.

I queried if I had a mixed variety which had, as the tip of the iceberg, episodes of disabling and angry depression. I do know that a combination of Depakote and Celexa appear to be handling my struggle beautifully. Paul Keck notes that most people with bipolar disorder require as much as three medications to stave off further episodes of this chronic illness.
Bipolar illness is missed all too frequently.

It is a chronic, treatable illness not altogether to be considered differently from diabetes or heart disease. It is better to treat it earlier than later. It has the highest incidence of related suicide (especially bipolar II) of any psychiatric diagnosis). It has the highest likelihood of a coexisting illness than any other mental illness.

Anticipate and intervene if there is alcohol or substance abuse. They are all different: bipolar I, bipolar II, cyclothymia, or “soft” bipolar disorders. Seek a knowledgeable experienced psychologist and psychotherapist. Utilize peer support. Get evaluated for cognitive impairment at the first signs of executive or intellectual impairment. Bipolar disorder is a chronic illness from which we can survive and even excel.