As presented to the Jewish Recovery netwrk on 1-10-10

Bipolar Visions: Ravages of Bipolar Disorder &

Chemical Dependency-A Dialogue

By Peter J. Dorsen, M.D., LADC

Tim Kuss, LAMFT, LADC

Peter: “An evening with the Dorsens: the chicken.” 10 minutes

Tim Kuss: “A family adventure to Valley Fair as a bipolar individual.” 10 minutes

Give and take between Tim and Peter 30 minutes

Peter: Tim, what does bipolar disorder have to do with chemical dependency?

Tim: According to Burgess, sixty to eighty percent of people with bipolar disorder suffer from alcoholism or drug addiction during their life time

Also, a growing body of research indicates that chemical use tends to set off episodes of mania and depression and increases the intensity of symptoms.

Peter: Tim, do you think that total abstinence is necessary for someone with bipolar disorder?

Tim: No, but it is highly advisable. Mental health professionals may tell clients with bipolar disorder that they can take an occasional drink but unfortunately some clients misinterpret this and instead might have a double Scotch instead of a glass of wine or think they can have one drink every day instead of one drink occasionally. What we are after is BALANCE. This is a disorder of destabilization and alcohol and other drugs contribute to destabilization. Those of us with this dual disorder need to stick to our commitment of sobriety

Peter: Tim, how can those of us who have bipolar disorder monitor such a balance with sleep, diet, exercise, and social interaction? How can we have stable relationships with other people?

Tim: Ellen Frank and others have developed IPSRT or Interpersonal and Social Rhythm Therapy. They advise their client to have regularity in their daily lives: to get up, go to bed, and eat meals at about the same time every day, as well as have predictable human contact and daily structure such as work or school. They ask clients to keep track of their activities by a “social rhythm metric,” which I plan to put on the blog soon.

Peter: Tim, what can you tell us about addiction and bipolar disorder?

Tim: People tend to use chemicals in abundance when they have bipolar disorder. We certainly did. For example, they might use cocaine to amplify mania or hypomania. They might smoke marijuana or abuse alcohol to reduce their personal mania, depression, paranoia, or anxiety. Unfortunately, chemicals of any variety tend to increase all of these problems.

Peter: Why Tim, is it difficult for professionals, friends, or loved ones to detect chemical abuse in someone with bipolar disorder?

Tim: We learn to be good at hiding our chemical abuse. I, for example, was afraid that revealing my chemical use would get me into legal trouble. Clinicians also may fail to s adequately screen for chemical abuse. Unfortunately, as well, professionals have are inadequately cross-trained to recognize and treat BOTH chemical dependency and mental health disorders like bipolar illness. We may be just beginning to emerge into an era where professionals are learning to treat clients holistically: working with their chemical and mental health together.

Peter: What should the clinician look for to determine if a client with bipolar disorder might be abusing chemicals?

Tim: Look for more rapid cycling, more episodes of depression or mania, and “mixed” episodes, involving simultaneously occurring mania or hypomania and depression. Interviewing the family, as well, can help a clinician recognize these symptoms.

Tim: Isn’t it true, Peter, that people with bipolar disorder are frequently misdiagnosed many times?

Peter: Yes, you told me that you were misdiagnosed five times, leaving you untreated for 29 years. Remember also that bipolar disorder is all too often “under diagnosed.” Psychiatrists just all too often can “miss” sub-threshold mania. Bipolar II and unipolar depression are most frequently misdiagnosed, especially in women. Tim, tell me how we can know that treatment works.

Tim: Some treatment approaches are evidence-based, meaning that research their effectiveness is based on research. According to Miklowitz, there is increased recovery, fewer manic or depressive episodes, symptoms are less pronounced, and there is a greater time between episodes when a family participates in Family Focused Therapy(FFT).

Peter: What is FFT?

Tim: FFT includes psychoeducation, which raises the awareness of clients and their families so that they are less afraid about their illness and more knowledgeable about treatment and recovery methods. They can then cope better with a chronic illness like bipolar disorder. They begin work on improving relationships. FFT helps family members be less critical and more supportive and this helps clients take more responsibility for their own recovery.

Tim: Peter, what are the differences between bipolar I and II?

Peter: Bipolar I occurs less frequently. Episodes of mania can include psychosis, requiring hospitalization, Tim, as you experienced. This compares with bipolar II with less severe “hypomania” but sometimes longer periods of severe depression. Men have more bipolar I, women more bipolar II, Women also have more unipolar depression and mixed episodes. BOTH forms of the disorder can be socially debilitating. Either can require up to several medications.

Tim: Can either form be managed by psychotropics alone?

Peter: The studies predominantly show that medications are most effective when combined with psychosocial interventions such as: (1) FFT; (2) IPSRT as developed by Ellen Frank and others; or (3) Cognitive Behavioral Therapy (CBT) as described by Basco and Rush

Peter: This is as good a time as any, Tim, for you to enlighten us about cyclothymia, which many believe can be a precursor of bipolar disorder.

Tim: Cyclothymia is like rapid cycling in a way. Cyclothymia represents multiple episodes of mania, hypomania, or depression (episodes are less severe) over a two-year interval. Unfortunately, statistics do suggest that cyclothymia can progress into bipolar I or II.

Peter: Can you speak to the definition of so-called bipolar III or “soft” disorders?

Tim: This term is applied to individuals with a strong family history of bipolar disorder, and others, who show minor symptoms of bipolar disorder. The kindling effect could result in progressiom to Bipolar Disorder

Peter: There is significant evidence to substantiate that mania and hypomania may be tripped by the onset of taking antidepressants. Frequently, this occurs in individuals who have had a “mixed” presentation. I myself may have fit into this category showing years and years of depressive cycling temperament.

Tim: Isn’t it true, Peter, that light therapy can help people with bipolar disorder?

Peter: Many of us have SAD or Seasonal Affective Disorder. Twenty to thirty percent with SAD have bipolar disorder. Lights work ( 10,000 lux) for a little as ten minutes a day but an hour a day seems to have a better effect. It seems to help with bipolar disorder by boosting the level of Serotonin for the entire day.

Tim: One hears the word kindling quite a bit. Peter, what does that mean to someone who has bipolar disorder?

Peter: The simple explanation of this phenomenon is to think of using twigs and small pieces of wood as kindling to start a big fire. The smaller pieces of wood, which represent stressors in a person’s life, make a person especially vulnerable if they have not been treated. At first environmental stressors may be needed to kick off episodes of mania or depression.but later they may occur spontaneously without triggers. Studies demonstrate that alcohol and drugs have a kindling effect in he progression of bipolar disorder. Also, not getting proper treatment with mood-stabilizers can result in kindling.

Peter: Tim, can you say a few things about other co-occurring issues?

Tim: Besides chemical abuse, other psychiatric and medical problems often co-occur with bipolar disorder: 75% of bipolar disorder appears to be genetic. Sixty percent of us also have anxiety disorders (Johnson). Symptoms of anxiety and bipolar disorder tend to be more severe when co-occurring. Thirty three to fifty percent of us have personality disorders. Thirty percent will attempt suicide, and 20% of those attempting suicide will succeed.

There are plenty of people out there who think they deserve to suffer because of the way they have been living their lives. Peter, what’s your read on that notion?

Peter: It is important that we realize that bipolar disorder is a DISEASE. It is a medical CONDITION. It’s not a punishment or a judgment on the way you’ve lived your life. It is not a weakness or a failure. Bipolar disorder is about differences in your genes that lead to changes in your behavior, your personality, and your emotions.

Tim: What about diagnosing bipolar disorder in children?

Peter: Recent reports set the onset of bipolar disorder as young as eight. Emil Kraepelin, “The Father” of this diagnosis, found a slightly older age of onset at eleven. The initial episode is usually a major depressive event. Children rapidly cycle with a “mixed” chronic picture. They recover poorly between episodes. Twenty to thirty percent of children who have experienced major depression develop mania later in life. They can experience cycling between mania and depression several times or hourly during the day. In children, frequently there is a co-morbidity between ADHD and bipolar disorder. There is a significant correlation between both disorders and heredity. Children with bipolar disorder frequently are diagnosed with conduct disorders as well.

Tim: From a medical perspective, Peter, tell us a little about what’s out there in the way of medications for bipolar disorder.

Peter: There is always lithium, the first mood stabilizer available. Research shows that it reduces the rate of suicide. Certainly, it may have some side effects , which generally are reversible with good medical management. Careful monitoring of blood levels are necessary because therapeutic levels can be dangerously close to toxic levels.

The anticonvulsants such as valproic acid (Depakote), which I started taking relatively recently, are excellent for treating acute mania, rapid cycling, cyclothymia, bipolar III, or mixed patterns of the illness. As with lithium, you must also monitor blood levels of the drug as well as platelets and liver functions.

Other anticonvulsants include Trileptal, Tim, which you take, Lamictal, Tegretol, Neurontin, and Topamax.

The SSRI’s and the SNRI’s , which are antidepressants, must be watched carefully because they can precipitate mania. Television ads taut Abilify, which is one of several “atypical” antipsychotics used for bipolar disorder. However, any one of them can cause extrapyramidal side effects like abnormal movements or twitching as they did to me. It was as if I had early Parkinson’s Disease and that was no fun. In fact, I chose to switch psychiatrists and therapists over the whole matter. There have been recent reports of sudden death from Zyprexa or Seroquel, two popular atypical antipsychotics. Unfortunately, as I experienced, there are elevations of cholesterol and the incidence of adult onset diabetes and heart disease from some of these drugs. I required two-vessel angioplasty and stents three years ago after years on lithium and persistently elevated cholesterol levels despite adequate exercise, normal blood pressure, and maintaining ideal weight. To avoid negative side effects, medications need to be monitored by a psychiatrist and your medical condition reviewed periodically by a trusted family physician or internist.

Tim: Do you have anything to say about electroconvulsive therapy or ECT?

Peter: ECT may be better at treating mania but it is also known to work effectively in lifting patients out of heavy unrelenting depression. One of its advantages is that it can be effectively used in pregnancy especially during the early trimesters when medications can produce birth defects. With ECT, there are less depressive episodes, less time in the hospital, and fewer admissions. ECT may be the only avenue that works for pediatric patients especially with ultra or ultradian cycling.

Peter: Tim, tell us a few things about complimentary treatments for bipolar disorder.

Tim: Diet is crucial emphasizing Omega 3 fatty acids. Andrew Stoll at Harvard’s McClean Hospital has demonstrated that those who take them are relapse free longer with significantly reduced symptoms. Flax seed oil has twice the content of omega 3 as fish oil without the taste or smell.

Peter: Taurine, may work for rapid cycling. Vitamins B6 and B12 are effective for depression. Vitamin E is recommended if on Depakote. Calcium, magnesium and tyrosine are considered important as well. Treatment should include coping skills needed to get restful sleep. Drugs in general, including “sleepers” interfere with rapid eye movement, REM sleep, when we process during the dream state and make sense of our world.

Tim: It would be best to do at least 20 minutes of aerobic level exercise ever other day. Meditation or other relaxation techniques can help reduce stress and promote sleep.

Peter: Tim, many of us with bipolar disorder wrestle with feeling that in treatment we feel we are repressing unleashed creativity, but know that going off meds leads to living dysfunctional lives. What does Kay Redfield Jamison and others have to say about this?

Tim: Redfield Jamison writes, “ I know plenty of people who have gone off their meds because they want to be manic again. It’s very alluring.”

Many famous people probably had a form of bipolar disorder: for example, Abraham Lincoln, Vincent Van Gogh, Virginia Wolfe, Ernest Hemingway, and Patti Duke. Those with bipolar disorder are highly creative and can often be highly intelligent.

Peter: In fact, Jamison concludes that among 47 British artists and poets, 17% of the poets required lithium and a hospital stay. University of Iowa’s Carver College of medicine’s Nancy Andreasen,M.D. has reported that 43% of an Iowa’s Writer’s Workshop had bipolar disorder. Miklowitz 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…” In retrospect, I would have to concede that it did so for mine.

Tim: How can we identify warning signs that an episode is coming on?

Peter: Alison Perry in The British Journal of Medicine, suggests teaching patients to identify early symptoms and giving them fool-proof ways to seek prompt treatment. Group psychoeducation decreases the number of relapses and increases the amount of time between mixed episodes, episodes of mania/ hypomania, or depression.

Signs that a manic attack might be coming on are sleep disturbance (77%), Symptoms of psychosis (43%), speeded up movements (34%), loss or increase of appetite (20%), or increased anxiety (16%).

Peter: Tim, why is suicide a major consideration when we discuss co-occurrence of bipolar disorder and chemical addiction?

Tim; Bipolar disorder is the Axis I disorder with the highest rate of suicide. Use of alcohol and other drugs has been shown to increase the risk.

Peter: I suspect that co-occurring alcoholism may not only precipitate rapid cycling and mixed presentations of the illness, but can lead to loss of inhibition contributing to suicide. Chemical use tends to increase both mania and depression

Tim: What are some simple do’s and don’t about treating bipolar disorder, Peter?

Peter: Bipolar disorder is definitely a chronic, relapsing and debilitating disorder for those of us who are experiencing it first hand, and our families and loved ones, and it can be quite challenging for those who treat it. Redfield Jamison, who has thrived professionally despite having bipolar disorder herself, speaks to the allure and destructive capacity of this highly prevalent condition. For some us so afflicted, cognitive abilities and executive function may become compromised.

If anyone is overtly suicidal, call 911 or SUICIDE(1-800-784-2433). Do not have extra medications lying around the house. No firearms allowed. It is best to abstain from alcohol and drugs . Look for a dual recovery support group and attend weekly if able. If you are unable to locate a dual recovery group, then seek out a twelve-step group and a sponsor that seems to understand your dual disorder. . Mental health support groups, such as Depression and Bipolar Support Alliance also work with dual disorders

Peter: Are we doomed to suffer our whole life because of our dual disorder?

Tim: As you know, Peter, alcoholism and many types of mental illness were once considered” untreatable.” All a family could do was hope for recovery. Although bipolar disorder is considered chronic and can often be life long, we know that there are MANY who stabilize and even recover with this dual disorder. By increasing awareness of these issues, by promoting methods of treatment and recovery, and by bonding together, we believe that we will be able to provide more hope for ourselves and others.

Q and A Period: 10 minutes

Bibliography

Basco, Monica Ramirez and Rush, A. John: Cognitive Behavioral Therapy for Bipolar Disorder, Guilford Press, New York, 2008

Burgess, Wes: The Bipolar Handbook. Penguin Group, New York, 2006.

Frank, Ellen: Treating Bipolar Disorder: A Clinician’s Guide to Interpersonal and Social Rhythm Therapy. Guilford Press, New York, 2005.

Goodwin, K. and Jamison, K: Manic Depressive Illness: Bipolar Disorders and Recurrent Depression. Oxford, New York, 2007.

Jamison, K: An Unquiet Mind: A Memoir of Mood and Madness. Knoph, New York, 1996.

Jamison, K: Touched With Fire: Manic Depressive Illness and the Artistic Temperament. Simon and Schuster, New York, 1993.

Johnson, Sherri and Leahy, Robert: Psychological Treatment of Bipolar Disorder. Guilford Press, London, 2004.

Mandimore, Francis: Bipolar Disorder: A Guide for Patients and their Families. John Hopkins Press, Baltimore, 2006.

Miklowitz, David, and Goldstein, Michael: Bipolar Disorder: a Family Focused Treatment Approach. Guilford Press, New York, 1997.

Miklowitz, David: The Bipolar Disorder Survival Guide. Guilford Press, New York, 2002.

Popolos, D and Popolos, J: The Bipolar Child. Broadway Books, New York, 1999.