I have personally experienced Bipolar disorder, type I for the majority of my life. Age 20 is considered a “typical” age of onset and I experienced a series of manic episodes resulting in psychosis and hospitalization around that time. At age 26, I started my recovery from chemical dependency, but due to being misdiagnosed at least 4 times. I did not start my recovery from bipolar disorder until 8 years ago, in 2002.
My part of our presentation focuses largely on Bipolar Disorder, type I
Over two million Americans suffer from Bipolar Disorder. About 15 to 20% never get it treated. The risk of suicide is higher for bipolar disorder than for any other mental health diagnoses. Those if us who have it are also prone to taking a lot of dangerous risks, which could also contribute to high rates of death or serious injury.
Bipolar disorder is considered to be the result of differences in brain chemistry. Many of us have attempted to adjust our brain chemistry ourselves, by using alcohol or other drugs. resulting often in more harmful brain imbalances, leading to more negative consequences, including a higher incidence of mixed or rapid cycling.
Mania can disrupt our lives in several ways. For those of us with Bipolar Disorder, type 1, uninterrupted mania can lead to psychosis, including paranoia. rapid thinking, a decreased need for sleep, and delusions of power. Even “mild” hypomania can result in a tendency to be argumentative, agitated, and defiant, In Full-blown mania these qualities become more exaggerated. Our behavior can result in deterioration in our significant relationships,job loss or legal, or other social problems. When we come out of the mania, facing it’s consequences can contribute to a swing to depression.
Depressive episodes can also have consequences, since we tend to have low energy for jobs and relationships. We can also experience “mixed” states of combined mania and depression, In a mixed state, our rapid thoughts may be pessimistic. We might have grandiose ideas, but lack energy to act on them. We tend to be irritable and impatient with others, at times being disappointed with them and at other times devaluing ourselves.
We could experience months to years of “euthymia”. relatively “normal” mood and behavior, interspersed with days to weeks of mania, hypomania or depression. Stability in our moods and behavior is more likely when we abstain from alcohol and other drug. Practice of a “balanced” recovery program also promotes stability. I, for example, experienced a 5 year period of euthymia from 1978 to 1983. I did not use chemicals, attended AA up to 3 times a week, kept a good job, functioned well as a husband and father, exercised regularly, ate responsibly, and had a close circle of supportive friends. During this time, we had 3 foster children, and I was attending graduate classes weekly and was involved in local politics and community activities,
I did not use prior to my next episode, but found that poor choices led to a domino effect in the breakdown of the preventative factors I had built up. When we become manic, we begin to take risks, believing that nothing can hurt us. We are more likely to abuse chemicals. According to Burgess, between 60 to 80% of people with bipolar disorder experience alcoholism or other chemical dependency during their lives. It is generally believed that our chemical use is an attempt to self-medicate. We may distrust our doctors and believe that we can do a better job of managing our moods and behavior ourselves. Estroff and Collaprea reported that 58% of patients abused Cocaine while manic versus 30% who used it while depressed. We may use uppers such as Cocaine and Metamphtamine to intensify and/or to prolong the high, and are more likely to take risks when manic. It is estimated that 15 to 65% of those with bipolar disorder abuse marijuana. We tend to think that pot will bring us down from uncomfortable manic states and will soothe our agitation and anxiety. Clients also report that alcohol relieves irritability, restlessness and agitation associated with mania. We are more likely to use alcohol when depressed. One study found that 38 % of clients with bipolar disorder increased alcohol use when depressed versus 15% of clients with unipolar depression. Clients are also likely to use alcohol when they get worried about the sleep loss that accompanies mania. Unfortunately, chemical use tends to imbalance our body chemistry even more, leading to more sleep loss and more depression.
We really believe that chemical use helps us. Gavin and Kleber note that 80% of bipolar clients reported an “improvement” towards hypomania when using chemicals. Our perceptions of positive effects may prevent us from observing that we actually experience increased anxiety, depression,etc, following chemical use. I have been present when some clients realize this in treatment. This is a gutsy awareness, involving a challenge to the mythology promoted by peers and even poorly informed professionals.
The diagnosis of bipolar disorder is a challenge. A process known as differential diagnosis must be used to distinguish bipolar disorder from other conditions with similar symptoms. For example, i was misdiagnosed twice with schizophrenia. which shares an average age of onset of 30 with bipolar disorder. The psychosis of a manic state can be confused with the more permanent psychosis of schizophrenia. Unfortunately, the antipychotic medications used to treat schizophrenia may provide less than optimal effectiveness for bipolar disorder, especilly if they are not used in combination with a mood stabilizing medication.
I was also diagnosed with hyperthyroidism, which is metabolic illness that affects organ function in ways that are similar to bipolar disorder. Following my last manic episode, I was treated by a wise doctor, who insisted on tests to rule out other medical conditions that could produce the symptoms I was experiencing. There seems to be a high correlation between bipolar disorder and diabetes, which I also have.
Research shows that over 70 % of people with bipolar disorder were misdiagnosed more than 3 times. Peter believes that clinicians failed to link his cyclical depression to bipolar disorder, type II, a common error. Children seem to be often misdiagnosed with ADHD, Differential diagnosis is complicated by a high cooccurence of ADHD and bipolar disorder in children.
Chemical use can complicate proper diagnosis. Conditions such as drug-induced psychosis must be ruled out. Goodwin and Jamison note that substance abuse contributes to more severe episodes of bipolar disorder, including rapid cycling, mixed episodes and slower recovery. Many clinician prefer to observe a period of abstinence for a client before providing a definite diagnosis. Unfortunately, clients may not stop their chemical use long enough to rule out drug effects.
Abstinence is likely to be beneficial in treatment of any patient with bipolar disorder. Jamison reported that chemical use contributes to more severe pathology and less favorable outcomes. Clients with a genetic predisposition to bipolar disorder, determined by a family history of bipolar disorder, or other mood disorder, are likely to discover that chemical abuse precipitates mania and depression. While use of antidepressants can trigger a switch to mania, this is more likely when chemical use is a factor. Jamison cited research that showed that longer periods of marijuana use are related to longer periods of mania.
While many clients report that they use chemicals to cope with depression, studies show that they tend to abuse chemicals more frequently when manic, This may be related to our tendency for increased risk-taking behavior when manic. Another factor in destabilization is that alcohol and other drug use contributes to a disorganized lifestyle, including lack of daily routine and structure,including poor medication compliance.
Family dynamics related to bipolar disorder include use of denial in coping with anger and anxiety, unrealistic expectations for family members, and low self-esteem passed through the generations. Family members may build anger. People with bipolar disorder act very irrationally, causing consequences for the whole family and we become irritable and agitated, resulting in verbal or physical aggression against those close to us. Family members tend to take on guilt for their imagined contribution to the illness. They often grieve,like the client, for the loss of the healthy self, and/or loss of connection or predictability in the relationship. The family’s support network can be diminished as they experience blame by extended family members or friends and try to hide the extent of problems because they believe that they can’t explain them or others won’t understand.
When chemical abuse is present in a person with bipolar disorder, family members, like the client, can be in denial about it’s negative effects. They may, like the client. see a temporary positive effect from the client’s chemical use ot they may be using chemicals themselves to self-medicate the stress and anxiety they experience in dealing with a family member with bipolar disorder. As a result, family members may even encourage chemical use. Professionals who advocate abstinence may be perceived as lacking credibility in having “failed” the client and family in the past. It is also easy to discount the findings of researchers, locked up in their ivory towers. The solution may be psycho-education for the nuclear family, ass well as compassionate therapy to help the family cope with their feelings and build their courage and coping skills.
Schizoaffective disorder may be related to bipolar disorder and there exists the potential to learn how to treat it as we expand our ability to treat bipolar disorder. It is diagnosed as either depressed type or bipolar type, including symptoms of these mood disorders, as well as a “thought disorder” With SD psychosis can occur outside of episodes of depression or mania, with less visible, if any “triggers”preceding episodes.
Friends, family members and professionals who cope with clients with bipolar disorder are advised to distinguish the difference between the person and their behavior. We need to cope with our own feelings and practice proactive stress management. We need to avoid isolation by connecting with a positive support network. We participate with the client in nurturing a new “healthy” family system in which there is shared problem-solving and conflict resolution.
Families can enlist the help of a family focused therapist to identify difficulties or conflicts that produce client or family stress. The therapist can cue into crical, hostile and over-involved attitudes and behaviors in family members that contribute to client and family stress.
Anxiety frequently accompanies the cycles of mania, depression or mixed states. It has been observed that 39% of clients with bipolar disorder demonstrate symptoms of anxiety. This may manifest as agitation,accelerated thought processes, restlessness, social anxiety, irritability, or dysphoric mood. co-occurring anxiety disorders include Panic Disorder, Obsessive Compulsive Disorder, Post Traumatic Stress Disorder and phobias. Anxiety and bipolar disorder tend to be more severe when cooccurring. Bipolar individuals often experience trauma during episodes because of poor judgment and risk-taking.
We need to practice our recovery daily, including: a. taking medications consistently, b. abstinence from alcohol and other drugs, c. using positive coping skills. We can work with professionals who have dual training in chemical dependency and mental health. We can participate in mutual support and self-help with other clients and families in which bipolar disorder is present. Establishment of daily routines and a fairly consistent schedule can help to promote stability in our moods and our lives. It is important to practice positive sleep hygiene. We need a certain amount of REM (rapid eye movement) sleep every day, so that we can dream, successfully process our lives and problem solve.
When people use alcohol or other drugs to sleep, they usually just “pass out” zand do not achieve restful REM sleep. Although some of us will need to use prescribed sleep medications, it would be a good idea to also develop “sleep skills” to achieve sleep as well. For example, I have used “meditation” in the form of progressive muscle relaxation, imagery, and affirmations to get needed sleep. I is a good idea to get regular exercise, but if done too close to bedtime, exercise can be stimulating and promote wakefulness. Stimulating activity, like going on-line, television or stimulating reading can prolong wakefulness. It is best to avoid caffeine, nicotine and sugar, especiallt close to bedtime.
Healthy eating helps those with bd maintain balance. Fish or flaxseed oil supplements can provide omega-3 fatty acids. Protein is important in the morning, but can be too stimulating in the evening. We need 6 servings of fruits and vegetables daily. Leafy green vegetables like spinach and kale are especially good. Whole grains are also important.
20 minutes of aerobic level exercise every other day is the standard for everyone, but possibly more important for those with bd who wish to maintain balance. Periods of meditation are also helpful, even if we are sleeping well. Yoga, tai chi and acupuncture are all positive practices for bipolar disorder..
Professionals working with bipolar disorder may wish to access the website of Kathleen Sciacca. Her recent work shows how motivational interviewing can help individuals and families with mental illness. Dennis Daley has done extensive writing on chemical dependency and mental illlness. He and co-workers have prepared assignments in which clients can improve their awareness, their problem-solving and their recovery coping skills. We also suggest that you investigate the work of Ellen Frank and others with IPSRT(Interpersonal Social and Rhythm Therapy and the work of Basco and Rush with CBT(Cognitive Behavioral Therapy). We will soon be publishing our own workbook for use in treating bipolar disorder and chemical dependency.
I wish to remind you once again of our vision for bipolar disoder, one which we hope you will share. We believe that those of us in recovery from dual disorder have precious awarenesses and coping skills that can overcome the negative effects of our condition. Through sharing these and through mutual support we CAN live meaningful, productive and enriched lives! Tim Kuss 1-18-10
BIBLIOGRAPHY
Basco, Monica Ramirez and Rush, A. John, Cognitive Behavioral Therapy for Bipolar Disorder, Guilford Press, London, 2007
Burgess, Wes, The Bipolar Handboook, Penguin Group, New York, 2006
Candida, Frank, and Kraynik, Joseph, Bipolar Disorder for Dummies, Wiley Publishing Inc, Hoboken, New Jersey, 2005
Castle, Lana, Bipolar Disorder Demystified, Marlease and Company, New York, 2003
Daley, Dennis and Moss, Howard, Counseling Clients with Chemical Dependency and Mental Illness, Hazelden Publishing, Minneapolis, MN, 2002
Frank, Ellen, Treating Bipolar Disorder: A Clinician’s Guide to Interpersonal Social and Rhythm Therapy, Guilford Press, New York, 2005
Fawcett, Jan, Golden, Bernard and Rosenfeld, Nancy, New Hope for People with Bipolar Disorder, Three Rivers Press, New York, 2007
Goodwin, Frederick and Jamison, Kay, Manic Depressive Illness, Oxford University Press, Oxford. England,1990
Jamison, K. R, An Unquiet Mind, Vintage Books, New York, 1995
Johnson, Sheri and Leahy, Robert, Psychogical Treatment of Bipolar Disorder, Guilford Press, London, 2004
Mandimore, Francis, Bipolar Disorder, a Guide for Patients and their Families, John Hopkins Press, Baltimore, MD, 2006
Miklowitz, David and Goldstein, Michael, Bipolar Disorder: A Family Focused Treatment Approach, Guilford Press, New York, 1997
Miklowita, David, The Bipolar Disorder Survival Guide, Guilford Press, New York, 2002
Oliwenstein, Lori, Taming Bipolar Disorder, Alpha Books, New York, 2005
Web Resources
Depression and Bipolar Support Alliance, www.dbsalliance.org
Dual Recovery Anonymous, www.draonline.org
McMan’s Depression and Bipolar Web, www.McManweb.com
National Alliance for the Mentally Ill, www.nami.org
Sciacca, Kathleen, Dual Diagnosis Website, www.users.erols.com/ksciacca
Videos
“Understanding Bipolar Disorder and Addiction”, Hazelden, Minneapolis, MN. 1995
“Dark Glasses and Kadeiloscopes”, Depession and Bipolar Support Alliance, 2006
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