Bipolar Visions

Having Bipolar Disorder versus being bipolar

2011-12-21T10:21:00.002-06:00

Bipolar Disorder is a disease. It is not who I am. I am so much more. To say that I AM bipolar may imply that there is no hope of transcending the worst symptoms. The term bipolar itself shows attention only to the extreme moods of mania and depression. Moods do not exist only as these extremes. There is rather a continuum of moods marked by at least 6 divisions. Starting with low mood, there is not only major depression, but also minor depression. People with Bipolar Disorder can also go through long periods of euthymic , or "normal" mood. Then there is mild mania, known as hypomania and full-blown mania. Another point on the continuum would be mixed states, where symptoms of mania and depression are combined,

It may be best also to distinguish between being an addict and having addiction. I am more than my addiction. Even when I was using i had positive qualities and potential. Our self-esteem may be damaged by identifying ourselves with this scourge on humanity. We are learning that there are various markers or "stages" of abstinence and recovery. Our unifying factor is that we are all somewhere on the journey. Also, I believe that those of us with bipolar disorder can be at different places in our recovery.

So what is recovery as applied to bipolar disorder? it seems that medication compliance has been the standard of recovery for many mental illnesses, This seems to assume that the disorder has been properly diagnosed and that the optimal medication is not only currently in existence, but has been correctly prescribed, Unfortunately, it has unfolded that different people with the same disorder respond better to different medications or combinations of medications.

Research has shown that non-medicine approaches to the treatment of bipolar disorder are also effective. To be fair, the best results were achieved with pharmacotherapy (use of medication plus the therapy). One example of this is Interpersonal Social and Rhythm Therapy (IPSRT) developed by Ellen Frank and others. They developed a 5 item social metric which advocates for regularity with 5 behaviors: getting out of bed, first contact with another person, Starting work, school, volunteering or family care, dinner and bed-time. They found that clients gained more mood stability as they got closer to performing theses function about the same time every day. There is also a 17 item version of the social metric. Attention to the consistency of sleep may be another factor in mood stability. Frank and associates seem to have begun the work of helping clients to change their daily routines.

Other empirically supported psychosocial treatments include Cognitive Behavioral Therapy and Marital and Family Therapy. A specific form of family therapy, known as Family Focused Therapy has been shown to be effective for clients with bipolar disorder and their families. A growing body of evidence-based practices implies new parameters for being in recovery from bipolar disorder. My own experience is that different people are attracted to and therefor more likely to practice different behaviors that contribute to mood stability, Perhaps we can see recovery tools as a buffet. As more of the tools are selected and used we can become healthier and healthier. After all, isn't it all about balance?

Who Does Best on Lithium?

2011-10-25T11:57:00.006-05:00

Genetic clues could help fine-tune treatment for bipolar disorder

By Marjorie Centofanti

The amygdala is hit hard in bipolar disorder. The small almond-shaped structure that nestles in each temporal lobe assumes a major role in quality of life. It’s a crossroads for fear, anger,and emotional learning. It also affects mental state. But something happens to the organ in bipolar disease. Blood flow increases and MRIs don’t look the same; there’s a clear loss of volume.

Enter lithium. Although the mood-stabilizing mineral doesn’t help everyone with bipolar disorder, for many, results are remarkable. Functionally, the amygdala acts healed.

But what happens to it physically? Can lithium actually reverse the organ’s structural damage? Pamela Mahon, whose specialty combines neuroimaging and genetics, aims to find out. AS part of Project Match, a broad effort to help people with bipolar disorder find the best medication as quickly as possible, Mahon is surveying brain MRIs from each new patient who joins the study. “We’ll be comparing the images of those who respond well to lithium with those who don’t,” she says. The hypothesis is that the amygdala will plump out to normal size in people helped by the drug.

At the same time, Mahon’s colleagues are doing animal studies and analyzing patients’ DNA sequences, combing for genetic clues that signal who will be a lithium responder.

The next step, she says, will be to match the genetic variations with any physical differences the images reveal. “If things work out, that will let us connect the genes, ultimately, to the mechanisms of bipolar disorder itself. You’re linking gene to brain understanding disease.”

But a clinical benefit could come sooner. With positive results—admittedly a leap, at this point—and more medications tested, comes a prize: a set of genetic markers packaged as a routine lab test. A blood sample could tell physicians if lithium or Depakote is better to even out a patient moods. More studies could tailor antidepressants—Prozac? Effexor? Wellbutrin?—to a person’s brain chemistry. Hitting that goal would change the face of mental illness worldwide.

Hopkins Medicine Fall 2011 (used by permission)

As someone who himself has thrashed about with and from plenty of antidepressants, lithium, Depakote, and now stabilized on Trileptal, wouldn’t it have been preferable to have utilized genetic techniques to or away from lithium, often regarded as the “gold standard” of mood stabilizers. Likewise, down the pike, such investigators may find a superior route to the right antidepressant for those with unipolar mood challenges. We are all hopeful for a smoother journey to peace and tranquility, perhaps going first class rather than coach.

Peter J. Dorsen, MD, LADC

Hypomania

2011-08-26T08:53:00.003-05:00

By Tim Kuss, LFMT, LADC

Hypomania is sometimes hard to distinguish from true mania. Rather than clear lines between mild mania(hypomania) and “full-blown mania, it seems that there is a continuum of symptoms, thinking and behavior that stretches across from euthymia (normal) to psychosis. I think of psychosis and milder delusional states as belonging to mania. Having said this, some degree of delusional thought seems to exist across such a continuum of mood states. Because of such a spectrum of dysfunction, hypomania although certainly enjoyable to sa person with bipolar disorder, has definitely resulted in self-defeating behavior for me.

I cannot be sure when hypomania first appeared in my life, but it was there before any of my psychotic episodes. Following the start of my recovery from chemicals, I did not have psychotic episodes for almost 10 years. I managed to stay out of psych wards, but experienced other negative consequences from my mood disorder.

Some of the symptom of hypomania can be grandiosity, irritability, rapid thinking, insomnia, loss of appetite, and hyper sexuality. On the positive side I tend to be very motivated and energetic and can get a lot of work done when I get hypomanic. Like many others with bipolar disorder, I frequently can use these positive mood swings while filtering out the negatives.

Hypomania, or mild mania is one of at least 6 mood states of bipolar disorder. By my own personal experience and through observation, I have learned that hypomania can last for months and perhaps years. Hypomania is very seductive, as it feels so damn good! It tends to have benefits such as perceived clarity of thought and decision-making. I have more creativity and psychic energy and use that creativity in an artistic form, which for me is writing and expansiveness which promotes relationships and connections with others. In hypomania, there is unfortunately also a high risk that a person may get into self-defeating behavior that is self-destructive. Three aspects of hypomania have been particularly self-defeating for me.

The first is grandiosity. I have made poor decisions when hypomanic, since I have not had the necessary mental filter to consider that I may be wrong. I have not had the necessary humility to ask others for feedback (or to hear their feedback). Grandiosity combined with expansiveness went into the equation of deciding to use drugs in my early 20’s, which precipitated deeper and deeper mania until I became psychotic and had to be institutionalized. I now have a firm rule about not using any amount of alcohol or other drugs and also limit my caffeine intake. This rule helps my mood to stay more stable.

Irritability is the second aspect of hypomania that has caused me a lot of trouble. I had role-models in my life that were irritable and became aggressive with others. I learned to blame others for “making” me angry and to act out my anger by yelling, throwing things, and, I must admit, on occasion hitting or hurting others. I have been fortunate in restraining my physical acting out to a few isolated incidents that did not hurt others excessively, but I did break valuable things early in my first marriage and I did scream at the top of my lungs at several partners and my oldest daughter. This behavior scared others and most likely created more distance in our relationships. I may have “won the battle, but lost the war”. Sometimes, my earlier behavior sometimes colors my present efforts to connect with those I have always loved.

I have had a long struggle sharing the third aspect of hypomania that caused me a lot of problems. It makes it easier that I speak of it from the perspective of a man in an 18 year committed relationship, with zero acting out with others during that time.

Some of my earlier partners had to deal with a series of affairs I had with other women. I have now learned that hyper sexuality can be a warning sign of growing mania that can lead to psychosis. I used to think that guilt was the main factor in contributing to psychosis after the first of these affairs, Later, I learned that my alcohol use was contributing to a kindling effect to increasing mania, Now, I know that hyper sexuality is a symptom of increasing mania, which could end in psychosis with or without chemical use.

Today, my perspective is that hyper sexuality does not need to be a negative thing as long as one makes positive choices about one’s behavior. These choices could include more sexual activity with my partner or simply pleasuring myself.

Wild thoughts can continue like adrenaline that doesn’t go away. I can’t sleep, have enhancement of my senses, feel irritable and euphoric, am incapable of continuing attention, neglect employment, have accelerated thoughts and speech, flight of ideas, unrealistic self-esteem with grandiosity, delusions, and increased activity. This all can lead to exhaustion, spending sprees, increased sexual activity, increased alcohol and drug use, and, for the unfortunate, death. These are notes from readings on hypomania. As I write many of these words, I am experiencing them. I have so much mental activity that I have been unable to sleep for hours. Luckily, I slept for at least 4 hours before this wakefulness. Fortunately, I was teaching my group about sleep management last night.

I do notice that it is hard to focus and concentrate. I have learned over time to keep redirecting myself to a task. No delusions today. I have my wife, friends, and co-workers to validate or challenge my perception of reality. I am over the buying sprees, the increased sexual activity, the my impulses of increased drug or alcohol use. I’m, planning on not going there again and am practicing my recovery program with help of my support network. Learning and writing about bipolar disorder is part of my recovery with not from bipolar disorder.

I am expecting soon to enter into my daily routine, which helps me stay grounded. It is 5:48 AM and I only need to survive until 6:15 when my wife wakes up. Meanwhile I am using this journaling as a grounding force. Later, I have 3 friends with bipolar disorder to talk with about my hypomania. They will “get it”. They will support me to continue with my routine, attend my support group tomorrow, keep taking my meds, and keep practicing my coping skills. I’m taking a break now to practice progressive muscle relaxation.

So I’m through another episode. My wife is up and we talk. I leave for work. Work keeps me grounded in reality. For 8 hours I will be held responsible by more objective measurements utilizing coherent thoughts and behavior. It is a place where I can apply my mental energy in a positive way. If I have too many days of continued hypomania I know I will need to talk to my doctor about adjusting my meds, as one of my supportive friends has suggested.

Jail Cells

2011-08-13T13:09:00.003-05:00

By Tim Kuss, LMFT, LADC

I’ve had several experiences with arrest and incarceration. With two of them I showed manic behavior. The first of these happened when I was about 21 years old. I had been using hallucinogens like LSD and mescaline experiencing hallucinations and delusions when high. I also had a series of what I considered to be “flashbacks” in which I experienced mostly pleasant delusions when not using. I understand now that my chemical use had triggered my bipolar disorder, serving as “kindling” contributing to increased symptoms.

I had been thinking that billboards and other signs were sending me personal messages and was ”following” these messages to a special place. I believed that my “true love” and good friends would be waiting for me at the end of the message trail, where we would be together. I began thinking that they had arranged a surprise party for me.

At one point my delusions led me to being hospitalized in a psychiatric ward. Later, I was following yet another “sign trail” which included barging through the back yards of some expensive homes on Summit avenue in St Paul. I imagine someone must have called the police. When they caught up with me, I had taken my shirt off and discarded it because I believed that I was supposed to do that. The police arrested me on Vagrancy charges, and put me in a jail cell.

They had taken my belt and shoes, asked me where I lived and my phone number. I began to think of myself as an oppressed man suffering from discrimination. I had been an anti-war protester in college and had spent a month marching with Father Grappi’s people in Milwaukee. i started singing the songs we had sung while marching:

“Oh Freedom, oh freedom over me...and before I’ll be a slave, I’ll be buried in my grave...and go home to my lord and be free” then on with several verses, including a few that I made up to go with the situation.

Then “We shall overcome” and several other songs. I had attended Buddhist temples while out in California, I went next to chanting “Nam myoho rengae kyo” and “Om” for my second hour of vocal renditions. The police did not attempt to put others in my cell. I spent some time attempting to lie on the spring on the lower bunk, as they had not provided a mattress. I think I was into my third hour of singing and chanting when my father showed up. He had gathered the few belongings taken from me and had paid my bail. We drove home quietly.

A similar occurrence happened about 19 years later. I had 15 years of sobriety and had been functioning as a chemical dependency counselor for 11 of those years. I was working the evening shift at a halfway house and went over the center line while making a left turn. It was a difficult turn and I imagine that I was tired. It was July 2nd, just before a three day weekend. One officer followed me into the parking lot behind my apartment building. For some reason, I commented that he had taken quite a risk by following me into this dark, isolated spot. He ran my driver’s license and found that I had a warrant, which turned out to be for a parking ticket I had forgotten about.

I wound up cuffed and put in the back of a squad car, despite protesting that my two daughters, ages 1fourteen and ten, were waiting for me to come home. In the jail cell, I had a deja vu experience of thinking that I had been discriminated against and began my routine of singing freedom songs alternating with chanting. This time I heard fellow prisoners yelling at me to shut up. It was a long 2 hours before my girlfriend arrived to pay the parking ticket and court fees.

Nida Takes on Co-occurring Illness

2011-07-08T17:23:00.001-05:00

Peter J. Dorsen, M.D., LADC

Nora Volkow, M.D., Director of the National Institute of Drug Abuse(NIDA), in a recent research report, notes: “ Drug addiction is a mental illness.” She also emphasizes that with addiction, drug-induced changes in brain structure and function occur in some of the same brain areas (as) mental disorders…” Wow! Like we didn’t know this already? Unfortunately, society at large fails to put two and two together (if you will excuse the pun here) and believe that collaborative treatment is a must.
Major populations seem to be slipping through the cracks when it comes to treating those saddled unfortunately with the duality of drug dependence and maybe a preexisting mental challenge: schizophrenia, PTSD, bipolar disorder, you name it. Our prisons are teaming with co-morbidity ( 75% of offenders at the state or local level have co-morbidity yet “ services are greatly lacking within these settings.”
What about all those brave men and women returning from Afganistan or Iraq with PTSD ( maybe even 38,000 in the past five years!). You’re damned if you do and damned if you don’t. It’s a case of the lumpers and splitters once again: PTSD programs that don’t accept individuals with active substance problems versus traditional substance abuse clinics(SUDs) clinics who defer treatment of trauma-related issues (combat or noncombat).
When it comes down to discrepancies of treatment there is even an implicit paradox that physicians run the mental health facilities and WILL treat with antipsychotics and anxiolytics while substance abuse venues are skewed to treating just that and may not even have personnel who can or will prescribe despite the predominance of co-morbidity.
Volkow and her team from NIDA emphasize that there is a 40-60% vulnerability to addiction attributable to multiple genes, genetic interactions, and environmental influences. One can joke as one way of relieving angst how mental illness and substance abuse co-mingle by wondering if such predilections start with the drinking water. The study correlates psychosis and marijuana use, how nicotine may lessen symptoms of schizophrenia( a 90% rate of smokers). They note a significant association between mental illness and smoking: “schizophrenics have higher rates of alcohol tobacco, and other drug use.”
They remind us how the neurotransmitter dopamine is pivotal; that it is affected by addicted substances as well as depression, schizophrenia, and other psychiatric disorders.
The chaotic process often begins in adolescence: abusing “gateway” drugs and mental illness. I can relate yet all we had in the sixties was alcohol and nonetheless did a pretty fair job at abusing it. Currently, educators like Dartmouth’s President Kim spend anxious reflective moments disturbed by fears when the next undergraduate will die from alcohol on his campus.
We have on our table promising behavioral therapies that include multisystem therapy (MST) dealing with attitudes, family, and peers; brief family therapy(BSFT) for the oppositional-defiant youngster with a conduct disorder; cognitive behavioral therapy(CBT) helping us change harmful or maladaptive beliefs; therapeutic communities (TC’s) for resocialization, the neglected youth; assertive community treatment(ACT) with an individual approach; dialectical behavioral therapy (DBT) especially for the borderline personality who will self harm; exposure therapy (ET) to create real or simulated reruns and remove fear; and integrated group therapy (IGT) great for bipolar disorder and drug addiction.
The NIDA report is filled with theme and substance offering new ideas for approaching co-occurring illnesses. I heartily recommend obtaining the full report to explore further the direction thinking and treatment must go to better deal with these two illnesses. Not only do they appear to exist in the same part of the brain but should and can be treated better simultaneously often with the right medications and therapy.

Bipolar Label Soars Among Kids

2011-06-25T11:50:00.003-05:00

Peter J. Dorsen, M.D., LADC

Frankly, I am glad that author Jeremy Olson of the Minneapolis Star Tribune in his recent “exclusive,” reports that the upcoming Diagnostic and Statistical Manual( DSM V) due out this summer will categorize a new disorder replacing bipolar disorder in children. It will be called Disruptive Mood Dysregulation Disorder(grade school children with outbursts in more than one location and irritability between outbursts). You may recall, I discussed my own belief of a separation in fact between BD and explosive anger in my last posting.
I have long struggled how people label outbursts or inappropriate behavior simplistically and even inaccurately with the label a “bipolar moment.” The author of this excellent and well- documented article, alludes to the marked concern many parents have with psychiatrists labeling their children with BD and the likelihood of carrying this stigma indefinitely.
Olson offers statistics and interviews how potentially dangerous antidepressant use leveled off since 2004 with the concern about child suicide. Antidepressants leveled off but atypical antipsychotics like Seroquel and Risperdal “surged.” Spending for antiseizure medications like Depakote or Gabapentin increased “sevenfold.” Meanwhile he, explains, how there is a tail wagging the dog process how psychiatrists must label children with BD. Children “ can’t gain insurance coverage for even short stay unless a patient has a major diagnosis.”
The reporter alludes to some worrisome allegations circulating within the academic community particularly Dr Joseph Biederman of Harvard who albeit the “father of the childhood bipolar movement,” has allegedly been part of what many like John Whitaker in Mad in America (Perseus, 2002) allege experts do is travel and speak about off-label prescribing, distort research for the pharmaceutical companies and make handsome sometimes unreported fees.
This article is a wonderful overview of what is perhaps terrifying about what appears to have become a tendency to over call BD in children. As I mentioned in an earlier posting, what about achieving a level playing field especially with adequate and appropriate medication. How we as clinicians define that ball park may depend on how our friends, loved ones, ourselves or our patients continue to remain compliant to treatment. Certainly Kay Redfield Jamison( An Unquiet Mind, Free Press) is living proof that a return from the ashes is possible. In an upcoming posting, I plan to review Maria Angell’s article “Why is there an epidemic of mental illness,” in The New York Review of Books(June 23, 2011. Vol LVIII.
Like the protagonist, Ms Beckman, of Olson’s solid recent montage, whose defiance for a bipolar diagnosis weakens as the intensity of her daughter’s tantrums and outbursts worsens, living with BD day-to-day means constant reevaluation of our belief system toward this protean illness.

Counterpoint to the "Splitters," anger and bipolar disorder by Peter J. Dorsen, M.D., LADC

2011-05-29T22:11:00.000-05:00

I thought this response to my challenges with Billy would be interesting counterpoint to my own thoughts on anger in someone with bipolar disorder.

Dr Gove Hambidge, an unique psychoanalyst who prefers to go in depth with his clients, emphasizes that it is crucial for Billy to "self discover." He further adds that there is implicit danger if you " give instructions"(as I seem to have done with Billy); that he "might think you incompetent." However, “preferably, if he discovers the fact( call it truth) himself, it becomes self-fulfilling."

In his opinion, however, in respect to a relationship between Billy’s explosive anger and his bipolar disorder, "they are always linked.” This “ social organization”, as it were, is part of him: anger-mania-hypomania.

"But Billy is a good learner." In answer to my question why Billy’s mother is calling canceling her son's appointment is that it could represent "a power struggle you are having (with the mother). " You are like a pair of boxers in the ring and she can win by canceling the appointment."

"Keep in mind, it's his job to discover. Be subtle. Empathize. Invite him to look at his behavior (like the incident hitting the door recently." Dr Hambidge added, " He's certainly pissed at his mother. It is for him to look and say "intolerable"-- that's why I recommend self-discovery."

"I suspect you have been suckered into the role of giving instruction. Instead, hand power over to the client/patient.
But the good thing, is that you are (now) more familiar with the family dynamics."

Sometimes, it just seems like such a painful way to learn!

Definitely insightul!

Bipolar Visions: What About explosive Anger?

2011-05-24T13:24:00.000-05:00

It has frequently come to my attention that people who happen to have bipolar disorder get “accused” more often than not of having a often inaccurate “bipolar moment.” However, I must be one of those splitters rather than lumpers and think such unfortunates have an independent entity called Intermittent Explosive Disorder(IED).

What I have consistently come to believe is that what we are witnessing, especially in someone diagnosed with bipolar disorder (especially Type 1 more frequently than Type 2), is what the Diagnostic and Statistical Manual of Mental Disorders (DSMIV) has categorized as 312.34, under the broad umbrella of impulse-control disorders(not elsewhere classified.

Here is a case from my practice:

Billy, age 17, enrolled in a special school and additionally carefully supervised there for his bipolar disorder(not otherwise specified, 296.80), is currently participating in a specially tailored weekly outpatient CD program with me, biofeedback and therapy from a mental health counselor, and obtains in-depth psychotherapy and medications(Depakote) from a psychiatrist. He has \demonstrated rapid alterations(over days) between manic and depressive symptoms that meet symptom threshold criteria but not minimal duration criteria for manic, hypomanic, or major depressive episodes.

Billy entered the legal system as a minor at 16 and received probation after totaling his parents’ car while under the influence and discovered carrying an illegal amount of marijuana a week later at school(a possession charge). He also has suffered chronically from anxiety and panic attacks for which his PMD prescribes a long acting anxiolytic(Valium) which is monitored. He endures an abusive dependent relationship with a schoolmate and accepts victimization.’

A week ago, his girlfriend called him out of class while he was on a short break enlisting another girl in a dialogue over a rumor that they were breaking up. He violently and uncontrollably punched the door behind the girl several times and immediately screamed four-letter epithets how she should stay the F out of his business. An xray was taken of his hand that was suspicious of a hairline fracture. In our conversation he admitted regret what he had done but said he could not control himself.. His girlfriend was suspended for 10 days for instigating the incident.

I believe this case is illustrative for demonstrating impulsive aggression (that) is unpremeditated and so characteristic of IED. Curiously, IED belongs to the larger family of Axis I impulse control disorders such as kleptomania, pyromania, and pathological gambling. By definition, it is a “disproportionate reaction to any provocation, real or perceived.” Keep in mind that, prior to the incident, my client was sitting quietly in chair in a “comfi” chair in a short break from a class movie.

It comes as no surprise to me that “the disorder itself is not easily characterized and often exhibits comorbidity with other mood disorders, particularly bipolar disorder or, as I am inclined to say, “true-true, but not related. Here’s where I’m in the “splitters” camp. I believe the two are separate entities.

The consistent pattern of this illness is that outbursts are brief( less than a half hour) and, certainly in our patient, often associated with panic and anxiety. There is an association as well with chest tightness, twitching and palpitations, somatic experiences. One of the comments my client volunteered was, “ I could never hit a woman.” She very quickly scurried off to class immediately after this encounter. He said he wished he had been capable of reacting differently. It was all so instantaneous. It was as if he had explained, “The Devil made me do it!”

Except for known and diagnosed bipolar disorder, my patient lacks other possibilities for his behavior: an antisocial personality disorder. He is not borderline, and does not have ADHD. I am unaware of prior brain injury and he has four months of sobriety from all illicit drugs verified by negative regular and random urine screens. He has had witnessed consumption of Depakote, his mood stabilizer, although admittedly he has not had a level drawn and has requested increasing his dose from 250 twice a day to 500mg twice a day. “I feel better on the higher dose.”

Certainly, there are some exotic theories for an etiology for IED such as a low brain serotonin turnover rate(low 5-HIAA) in the CSF as well as an increased insulin secretion. I am personally aware how volatile any of us can become with low blood sugar certainly a consequence of elevations of insulin.

It is important to address treatment issues for IED. In Billy’s case, we are utilizing the aforementioned interdisciplinary approach to our patient’s documented polysubstance addiction problems. Our method includes addressing mental and physical health issues. Unquestionably, a concern for family dynamics as well as Billy’s difficult dependent relationship with his girlfriend are important in our focus. We are treating him for bipolar disorder as well as endeavoring to find the best anxiolytic because so much of his challenge has been his own self-medicating with marijuana, MDX, alcohol, and opiates.

It is my opinion that Billy definitely has issues with bipolar disorder which we are in the process of stabilizing. We are working with his family as well as generating as much cooperation from Billy who I want to begin assuming more and more responsibility for his treatment as well as his behavior. As with other issues like cursing out his mother, I am trying to help Billy create better alternatives. Cognitive behavior therapy(CBT) is one of the mainstays of therapy. I like to think ours is eclectic and may as a result be even more successful. I am not so quick to incriminate Billy’s primary illness, bipolar disorder as what instigates his IED.

My plan is to approach Billy’s IED both independently and simultaneously with his bipolar disorder and addiction to relearn “uncontrollable” responses to frustration. I would like to see him divert impulsive and disproportionate rage reactions elsewhere or help him anticipate ways of avoiding potential trigger events like the one described he had at school.

In this event, I am attempting to assist Billy prepare by avoiding any potential for such an reoccurrence. I advised developing preventive skills. There is no way I can guarantee we can fully eliminate IED in our client. However, I believe it helps to view IED as an independent entity with its own combustion point that can be anticipated and hopefully modulated.

Taking Step 1 with Bipolar Disorder

2011-01-29T21:01:00.003-06:00

Timothy Kuss, LADC, LMFT
I am in recovery from bipolar disorder and chemical dependency. I also currently work as a CD counselor and family therapist in outpatient and residential CD treatment. I believe that taking step 1 for Bipolar Disorder is a lot like taking step 1 for our addiction. Many of us go through a period of denial. People in our family also go through a period of denial about our bipolar disorder.

Mental illness carries quite a stigma and is often seen as untreatable. Sometimes it is seen as a permanent disability, especially if we’ve seen family members or acquaintances suffering long hospitalizations and recurring tragedy related to episodes over the course of decades. Most people don’t understand that with today’s medications and therapy, hospitalizations can be avoided fewer, or at least briefer. Tragedies can be averted and clients can lead relatively normal lives and have careers and families.

My own Step 1 with bipolar disorder was delayed due to a series of misdiagnoses of Schizophrenia. Bipolar disorder, unfortunately, shares a typical age of onset with schizophrenia of 20 as well as the potential for psychosis during manic episodes. My experience with delusional thoughts was probably heightened by the fact that I had used LSD and other hallucinogens frequently. I was hospitalized and treated for an incorrect diagnosis with anti-psychotics such as Thorazine and Haldol, which made me feel and look like a zombie. Such an error in diagnosis served to make me deny my mental illness. However, fortunately this resulted in volunteering myself for long-term chemical dependency treatment.

Twenty-five years later while continuing my sobriety I had a series of manic episodes resulting in short hospital stays and finally got the diagnosis of bipolar disorder. My reaction was one of relief. They finally got it right! As I learned more about the symptoms of bipolar disorder, I was finally able to understand what had been happening to me. As a professional I have encountered many clients with the same reaction of gratitude after finally getting the right diagnosis. Many have had co-occurring addiction and mental illness.

Unfortunately, many of us struggle with the need to take medications to treat our Bipolar Disorder. I tried to wean myself off them at first, just as I had done with those incorrectly prescribed antipsychotics. Today, I understand that my mood-stabilizing meds do not have any negative side effects. They are my insurance policy. They keep me out of the psych wards and out of potentially life-threatening situations that seem to predictably occur when I get psychotic. During my last psychiatric hospitalization I spent 3 days in intensive care due to high blood pressure that resisted medical efforts to bring it down. I have also put myself in dangerous situations when manic, like when I wandered outside in the dead of winter with no clothing and only a sleeping bag and tennis shoes for cover. Another time, I became paranoid of aliens trying to kill my daughter and almost put her in grave danger.

OUR step 1 includes recognition of some “crazy” behavior and thinking. Others also with bipolar disorder can laugh with us about these old episodes just like other drunks can laugh with us about our crazy earlier drinking episodes. Accepting unmanageability comes with accepting that reality is different from our delusions. We were powerless as individuals to cope with our illness. But together and with help we can be in recovery. Step 2!

In summary, Step 1 of our dual recovery includes recognition that our chemical use increased our mental health dysfunction(symptoms). This is different than saying that the chemical use caused the symptoms. I proved after 25 years of sobriety that I can STILL have symptoms WITHOUT using. I can see, however, a constant stream of clients entering the doors of our MI-CD program because their chemical use led to repeated hospitalizations for psychosis. I’m pretty sure that I wouldn’t have struggled with 5 years of psychiatric admissions if someone had helped me understand that I had to stop using chemicals.

As a family therapist I have seen many co-dependents struggle with accepting the reality of the dual diagnosis of a loved one. To help them with their fears I have done my best to help them understand how addiction and mental illness coexist. Besides referring them to Alanon or Naranon I also refer them to NAMI, the National Alliance for the Mentally Ill, which has both education and support groups for clients and family members. In dual recovery just as with following the twelve steps of alcoholism or other addictions, we all need to practice recovery one day at a time.

I do.

Here's a Heads Up on Bipolar Options

2011-01-18T22:39:00.000-06:00

Categorization of Bipolar Illness: DSM IV Resources: For Health Professionals
Mood Disorders
Major Depressive Episode: 2-weeks See Beck Inventory, Appendix A
Manic Episode: 1 week, elevated, expansive or irritable mood
Mixed Episode: Both manic and Major depressive Episode: 1-week
Hypomanic Episode: At least 4 days/No hospitalization required
Major Depressive Disorder(MDD). Single or Recurrent(2 Mo Int)
Dysthymic Disorder: Depressed Mood, at least 2 years
Depressive Disorder NOS, Not Otherwise Specified
Bipolar Disorders
Bipolar I Disorder
Single Manic: Presence of only one Manic Episode, no past MDE
Most Recent Episode Hypomanic*: At least one Manic Episode or
Mixed Episode
Most recent Episode Manic*( at least 1 Maj Dep Ep, Manic Ep, or
Mixed Ep
Most Recent Episode Mixed*
Most Recent Episode Depresssed*
Most Recent Episode Unspecified*
*Note: Any of these entities can be associated with rapid cycling

Bipolar II Disorder (recurrent major depressive Episodes With Hypomanic Episodes)*
One or more MDE, at least one hypomanic episode(no manic)
May be in partial or full remission
Note: May occur as rapid cycling
Cyclothymic Disorder
At least 2 years, hypomania, depressive symptoms(not
MDE). One year in children
Can see superimposed bipolar 1 or 2 after 2 years
Bipolar Disorder Not Otherwise Specified
Very rapid alternation (over days) between manic and depressive symptoms meeting symptom threshold criteria but not minimal duration criteria manic, hypomanic, or MDE. Also, the clinician may be unable to determine primary, medical, or substance induced.
Substance-Induced Mood Disorder
The problem developed within a month of substance use or withdrawal

The Latest Info On Life As I Know It

2011-01-18T22:35:00.000-06:00

It’s been a few years since my last entry to Crazy Doctor. I am no longer a practicing medical doctor. I surrendered my medical license in 2005. While I was in the transitional process, I became a licensed drug and alcohol counselor (LADC) and tried my hand albeit perhaps less than successfully at two drug treatment jobs. The first offered minimal opportunity to function as an actual bone fide CD counselor and the second left me unhappy both with my new milieu and I encountered insufficient help to unravel the mysteries of the new technology of charting.

So what’s a professional gonna do? I never considered some of the alternative potential of my degrees only recently discovering a teaching opportunity at a Twin Cities acupuncture and Oriental medicine academy teaching Western medicine. Way back then, at the demise of my career as I had known it for thirty years, my ever so tolerant wife had off handedly suggested Sam’s Club which, on a lark, I joined first as a greeter until later moving to their gas station where I quickly discovered how to write, read, and even grade papers on the sly.

My sojourn with “big box” retail has had its heads and tails but a steady paycheck has definitely helped supplement my meager Social Security check. Now too, my teaching stipend has also helped crawling out of credit card debt. Oh, the woes of bankruptcy, divorce, and professional demise.
I have been relatively as clear as anyone can be of problems at Sam’s and have persevered for over four years through heat, rain, snow, and cold. None of the potential problems or issues have arisen as my multiple psychometric testing suggested could. But we were warned, of course, of more intellectual or stressful situations I was told rather glibly. I have shown good judgment, been responsible with work assignments and almost always been timely and never had an unexcused absence ( although I continue to pursue personal diversionary opportunities at a brainless job).

I and a fellow CD counselor who is bipolar 1 also with an addiction history have taken a shot at speaking about bipolar disorder and co-occurring addiction, Tim on bipolar 1 and I on bipolar 2. His journey has been scarred with several hospitalizations for psychosis. Mine has been marked with failures personally and professionally. Together, we have established and manage the blog, Bipolarvisions.blogspot.com and mutually try to report on our experiences with the co-occurring challenges of addiction and mental disorder.

It is extremely comforting receiving consistent feedback from intimate friends of a positive transformation to a euthymic state show compared with an earlier emotional lability. People with bipolar disorder are known to wreak havoc with marriage. I know, I’m on my second and so is Tim. Although neither of us are ready to report a bliss state, gone are the impossible psychotic episodes or, in my case, explosive anger.

Those of us with this challenge, are known to change jobs frequently sometimes with the frequency “normies” change underwear. I have been at Sam’s over four years and am engaged in a monogamous relationship and marriage I must work at continually. Sure, I still make my share of mistakes, have my emotional ups and downs, trials and tribulations. I still cherish that I can be there to give what I can to this relatively new relationship. I often must struggle just to offer another adult presence for my wife’s four now-adult children. Sometimes, it is hard for me not to judge her children or to adjust to the lack of space in my new family environment.
It has been readily clear from the outset that my moods can certainly reflect conflicts or challenges dealing with stepchildren but only rarely with my new primary relationship. I show impatience dealing with stubborn post adolescents who very much deserve a mind of their own.

My medications, the anti seizure mood stabilizer, Depakote has no side effects other than lowering my platelet count. I have none of the tardive dyskinesia (TD) I experienced on Zyprexa with or without Abilify ( in my mind falsely advertised as an antidepressant). I am readying my two classes for next trimester and feeling comfortable with these challenges. My biggest challenge in one will be how to enliven the presentation to keep students awake.

Those in the Mankind Project (New Warriors), where I derive so much peer support, respect my “gold,” as we call our strengths or accomplishments for which we must take credit. My fellow “I” or “Integration” group partners with whom I meet for three hours biweekly, encourage me to risk change and seek greener pastures. I have grown increasingly disillusioned with cognitive behavioral therapy(CBT) and received recent strokes from a practicing octogenarian psychiatrist that I demonstrated an impressive gift for dynamic interactive therapy. He has offered to supervise me with any clients I should undertake to counsel. I am heartily prepared to go that direction. There are some delightful opportunities awaiting me just by opening up the myriad of possibilities that await me

Avoiding The Holiday Blues By Tim Kuss, LADC, LMFT

2010-12-12T11:37:00.002-06:00

As we approach the winter holidays it’s good to remember that they can be difficult to negotiate for some of us.
I remember, for example, visiting my parent’s home in a small town for a few days around Christmas. I became delusional and found myself driving around town in the middle of the night. I eventually wound up at the power plant because there were people there.
I was into my old “There’s something special for me” thinking. They eventually figured out who I was and called my parents.
One of my theories about holiday stress is that we have such high expectations. When we were kids it was a magical, miraculous time. As adults we may become aware of the loss of that magic. Now, our losses and our lack of accomplishments may loom large.
It may be best to keep our expectations down. Just plan to have an OK time for the holidays. Aim for comfortable get-togethers with your family and friends.
Forget about big presents!
Survive. If anything better happens then you’re ahead.
It’s hard to be disappointed if you don’t set yourself up for it.

Social Rhythm Tim Kuss, LADC,LMFT

2010-11-02T22:04:00.002-05:00

It should come as no big surprise to those of us in recovery from chemical dependency that consistent, predictable contact with other people is a stabilizing force. For years as a counselor, I have been advising clients to find a “home” AA or NA group to attend on the same night at the same time every week and to meet with a sponsor for at least an hour a week outside of meetings. We have also recognized that support from spouses, parents, siblings and friends can be an important part of recovery. I have also advocated for finding “mentors”, respected “elders” like ministers, teachers, etc, not necessarily in recovery, to connect with regularly.

So when Ellen Frank suggested that social rhythm is important in managing bipolar disorder it seemed to make sense. As part of Interpersonal Social and Rhythm Therapy she suggests that we keep track of our contact with others, as well as other daily events. Her 5 item social metric asks people with bipolar disorder to track their time out of bed, first contact with another person, the start of work, school, or other activity, dinner time and bed time.

I have long recognized that structured, “meaningful” activity aids with stability, chemical or psychological. I have seen many clients start patterns of heavy drinking after retirement, while other elderly people seem to create a new structure in their lives that gives them things “to do”. Unfortunately, some clients with chemical and mental health problems are unable to work, or are, at least, temporarily out of work. I advise them to find volunteer work and to create a “busy” schedule at least 5 days a week, which can include social activities, like cards at the senior center, church activities, projects at home, visits to museums, libraries, etc. Most communities have community education programs that offer inexpensive classes. One of the main assets of a schedule could be spending time with and around other people.

Contact with others provides “grounding” and “reality testing”. It’s harder for our thinking to get off track if we are communicating with others. Also, we are more likely to experience a sense of well-being if we are in positive, supportive relationships. It is important for families to learn positive communication and conflict resolution skills. Sometimes family therapy is necessary for this. It is also possible for one person to learn better skills and to teach by example.

I think that individuals within a couple or family may each need their own support network to some degree. It is OK for men to go to a men’s group and to spend time with buddies and for women to have their own groups and friends It is also a good idea for the couple or family to have support as a unit. Churches, temples and synagogues used to provide predictable support for families. Unfortunately, we have increasingly busy lives and often do not think of the concepts of “self-care” and “nurturing”. Predictability and regularity count a lot in terms of mood stability.

So, the concept here is “Social rhythm”. The thing to think about is our amount, types and quality of human contact. If you experience episodes of mania or depression, whether mild or severe, it may be a good idea to look at your social rhythm and how it could be adjusted.

The first step in changing social rhythm is to notice our “routine” of social contact. When one is depressed it is generally a good idea to increase our contact with others. When one is manic it is a good idea to look at the quality of our connections with others and to be on the lookout for making too much of new relationships based on too little. The type of connection we need is consistent, predictable and nurturing.

Managing Anxiety Tim Kuss, LADC, LAMFT

2010-11-02T22:02:00.003-05:00

This assignment is for anyone who experiences anxiety, which includes worry and fear. You may or may not have a diagnosis of anxiety disorder.

1. Describe how you experience anxiety, fear or worry.
a. If you have fear, what are you afraid of?
b. If you worry, what do you worry about?
c. Obsessive compulsive behavior can be a sign of anxiety. If you have this behavior, what is it about?
d. Are there physical symptoms? How do you breath when anxious? What happens to your heart rate? Your blood pressure?

2. Dysfunctional behavior?
a. Did you use chemicals to feel better? If so, what kind of chemicals? What effect did they have? How did you feel when the chemicals wore off?
b. What other things did you do to try to feel better? Sex, gambling, spending? How did those things work?

3. Did you know that some medications can relieve anxiety?
a. Anti-depressant meds, specifically SSRI’s can help. Are you willing to try that?
b. Benzodiazepines, such as Valium, Xanax and Klonopin are NOT good ideas for people with chemical dependency.

4. Individual therapy could be helpful
a. If you are willing to try this, please ask the therapist if they have experience with working with people with anxiety.
b. Some group therapies, such as cognitive or rational-emotive therapy can help.

5. Even if you take meds and go to therapy, it’s still a good idea to learn other COPING SKILLS for managing anxiety
a. Mindfulness skills include deep breathing and progressive muscle relaxation, including imagery and affirmations.
b. Yoga, acupuncture, or meditation may also be helpful
c. Cognitive restructuring is another positive method. This means noticing your negative self-talk, and learning to challenge and change it.
d. Distraction can help. This means doing activities like tv, reading, video games, housework, walking, work, etc,
e. Have a support network and connect with them on a regular basis
For example, find at least one person who you can share your worries or fears with and talk with them at least once a week. You can tell them that you don’t need advice and just need someone to listen. Or you can ask for suggestions some times.

6. Be involved in healthy activities that help you prevent anxiety
a. exercise for at least 15 minutes 3 to 4 times a week.
b. maintain a healthy diet. See your doctor if you need a plan for this
c. sleep 6 to 10 hours a day, depending on personal need
d. Have a daily schedule go to bed and get up about the same time every day
eat meals about the same time every day
e. Do fun stuff every day. Set aside time to do fun stuff for 1 to 3 hours at a time every week.
f. Connect with people who care about you regularly. Put it on your schedule.

7. Take a daily inventory of your anxiety, fear and worry
a. Make a plan to use coping skills to manage each one.

Questions:
What new things did you learn about anxiety, fear and worry?
What coping skills and/or strategies do you plan to use in the next week?
What skills or strategies do you plan to improve, or to develop through practice?

Read pp 12-15: Overcoming Major Anxiety Disorders and Addiction by Ihson M. Solloum, MD, MPH and Dennis Daley, MSW to get more ideas.

Understanding Depression Tim Kuss, LADC, LAMFT

2010-11-02T21:50:00.002-05:00

I am suggesting a bio-psycho-social approach to understanding and coping with depression. The biological component comes in as we have noticed that mood disorders, such as depression, bipolar disorder and anxiety disorder tend to be found in successive generations of a family. As with alcoholism, what is inherited is a genetic predisposition to mood disorders. That means, if you have a parent, grandparent or other family member with a mood disorder, you are more likely than others to have one. It might not even be the SAME mood disorder. For example, someone’s grandmother may have had Major Depressive Disorder (depression) and that person may have bipolar disorder. We have learned that people with depression and bipolar disorder have a chemical imbalance. Medications can allow our bodies to work properly and maintain the right balance of neurotransmitters.

SSRI’s and other chemicals work as antidepressants, while lithium and certain anticonvulsants work as mood stabilizers to help manage bipolar disorder. Taking medications consistently can help us avoid episodes of depression.
The biological approach for managing depression intersects with the behavioral approach in that behaviors such as regular exercise, proper nutrition and sleep hygiene help us to avoid or cope with episodes of depression. Exposure to the sun or artificial sunlight also helps our body relieve depression.

The best psychological approach for managing depression is Cognitive Behavioral Therapy(CBT). In their book, Depression:Causes and Treatment, Aaron Beck and Brad Alford state that major depression is the leading cause of disability worldwide. They note that studies have shown changes in thyroid hormone levels in response to cognitive therapy, showing that our bodies and minds are linked. They say that depression results in a complex pattern of deviation in feelings, thoughts and behavior.

Symptoms of depression include low mood, pessimism, self-criticism, agitation, problems with memory and concentration, and physical complaints such as pain. There may be a loss of gratification with activities that starts with a few areas and expands. Activities that involve responsibility, obligation or effort become less satisfying and there is greater satisfaction in passive pursuits, including recreation, relaxation and rest..

People with depression begin to distort reality, They become preoccupied with continuous, repetitive negative thoughts(perseveration). There is often a contrast between a depressed person’s image of themselves and the objective facts. They dwell on mistakes, imperfections and inabilities, convinced that others will reject them, and that they will lose jobs, relationships, and friendships. They continue to think in themes of deprivation and defectiveness

Depression seems to be a reversal of human nature, of the survival instinct to eat and sleep and the desire to experience pleasure. Others need to respond with concern, empathy and acceptance and to be aware of the client’s difficulty in concentration and in formulating thoughts. People with depression are hypersensitive to rejection and discouragement.

The cognitive approach to managing depression involves recognizing the negative thoughts or negative self-talk that continues and increases depression. We can learn to challenge the negative thinking and replace it with neutral or positive thinking. For example, if I notice that I’m not functioning as well as normally at work, I can encourage myself to do the best I can. Instead of thinking that “I can’t do anything right” or “I’m doing so badly, that I might as well quit”, I can realize that this thinking doesn’t help the situation, and pay more attention to what I am doing well and think about what I can do today to improve the situation.

The behavioral approach involves doing things that help relieve depression. A depressed person is likely to withdraw from emotional attachments and tends to isolate from others. We can notice this and purposely spend time with others. If necessary, we can ask others to just let us be there without demanding conversation or interaction. Depression includes lethargy, but it is better to be active. Daily rituals such as walking the dog, biking, walking or swimming several times a week can be helpful.

Routine and structure can provide relief from nagging negative thoughts and feelings, so it is best to go to work or school, or to do volunteer work, or be involved in group activities, like crafts or sports. A person with depression needs to “push the envelope” in terms of involvement and activity, striving to get beyond his or her comfort zone. It’s best to start with a few small steps and keep expanding.

There is no reason why we shouldn’t pay attention to our biology, our thoughts and our behavior during the same time frame. There is no shame in taking medication for depression. We wouldn’t hesitate to take an antibiotic regardless of what people might think of us. We need to pay attention to seasonal changes including the amount of sunlight we are getting, healthy sleep habits, proper nutrition and exercising. We need to avoid isolation and too much unstructured time. We need to adjust our thinking to encourage ourselves to do all of these healthy things. Depression IS treatable. We are the prime agents in our own recovery!

Managing Depression Tim Kuss, LADC,LAMFT

2010-11-02T21:45:00.003-05:00

Several things influence the development of depression. Some people inherit depression. This means that their body does not work properly and they will probably need to use medications to stop their depression. Things that happen to us also influence depression. People who have bad things happen to them as children may continue to feel sad about these things long after they have grown up. The good news is that we can move beyond these effects by changing our behaviors and our thoughts. Things that happen to us and around us today also influence depression. The good news is that we can learn to cope with life events in positive ways and reduce the sadness and other negative feelings we experience.

Let’s try this.
1. What is one thing that happened or is happening to you that you feel sad about?
2. What do you think about what happened.
3. How have you acted related to what happened?
4. What have been the consequences of your thoughts and actions?
5. What can you do about the situation?
6. How can you think differently about the situation?

Would you consider taking anti-depressant medication? Why?
Would you consider going to individual therapy?

Complete pages 12 to 17 and 20,22,23 from UNDERSTANDING DEPRESSION AND ADDICTION by Daley and Thase

What are 5 ways to improve your mood?

Coping with depression:
People with depression often don’t want to get out of bed. However, getting out of bed and getting active is healthy for us. We also tend to want to stay in the house. It is better to get out of the house. Fresh air and sunshine work against depression. Activity, including exercise and work raise the level of endorphins so that we feel better. We may not want to eat, but a healthy breakfast will give us energy. It is also a good idea to set short-term achievable goals. Having daily goals that are measurable and that we can accomplish will provide encouragement and raise self-esteem. Practicing morning rituals will give us a good start to our day. Our habits can provide good structure for those days when we have low mood and aren’t sure what we want to do or if we want to do anything. Washing your hands and face, brushing your teeth and styling your hair can all provide positive feelings, while lounging around unkempt can contribute to negative thoughts and feelings about yourself.

When depressed we tend to want to isolate. We might think that we don’t measure up to other people, or that they don’t have anything to offer us. In this case we need to challenge the negative thoughts and practice positive behavior. Feel free to comment with your own positive skills for managing depression.

A level playing field: an illusion? Peter J. Dorsen MD, LADC

2010-11-02T20:32:00.002-05:00

It’s been a fair amount of time since I have connected with the blog but am more than ready to do so. The last entry had to do with “ a level playing field,” and whether someone with bipolar disorder can ever return to a place they were at before they were diagnosed and adequately treated.

With a number of additional fiery accusations, I said categorically “yes.” But I have been mulling over my opinion almost continually since I entered my earlier opinion. Between then and now, I have experienced at least one bout of depression and may even have experienced at least one episode albeit brief of hypomania. I usually know about the depression. I actually get irritable. I discussed my emotional state with my psychiatrist and in a collaborative fashion, I began taking a higher dose of Depakote, the anti seizure medication for my bipolar 2 disorder that has served me well of late.

Things all settled back to emotions as usual and the constipation, probably the only physiological manifestation of my mental disarray, vaporized. My ability to deal with day-to-day challenges with my wife and her stepsons improved. Any issues with my sometimes testy students seemed to be of less consequence to them and to me. Perhaps I was showing more tolerance to everyday challenges on all fronts. I doubt this was La belle indifference but more that I was once again properly medicated.

I am not aloof how significant is my interaction with my loved ones or with the students whose tuition goes toward paying my salary. However, that I was once again subject to emotional “issues” even while properly medicated made me look more objectively at what I had written and almost believed as gospel. I don’t doubt that some of my opinions could well have been an element of denial:”I don’t really have a debilitating mental illness,” I insisted. How could I? It’s adequately treated and I am euthymic. Sure, in the same article, I had also taken a poke at psychiatrists in general as drug pushers perhaps even wagged dog-wise by a pharmaceutical industry anxious financially to get a return on their investment after developing all those designer psychotropics.

Recently, the mother of an often oppositional defiant young man still working through grief and PTSD after losing his father in his mid teens, told me an interesting story. Her son thinks anyone wanting to mentor him isn’t genuine. Likewise, he opines, any professional taking on the challenge wanting to guide him along “has to be” motivated by the financial aspect of such a relationship.
However, so much about our patient-therapist relationships get guarded by professionally mandated restraints. For instance, I cannot communicate with my psychiatrist by e-mail. I cannot talk to my psychiatrist directly. I must go through his nurse clinician if I have a problem or if I need medications earlier. This disturbs me. My psychotherapist, a well-meaning MSW therapist tried to categorically explain away this communication pattern as what happens when someone(me) is dealing with a system. My response was certainly testy, “ If we don’t question the system, we will be corrupted.”

There are certainly symptoms and signs that early mania or hypomania, the opposite emotional process to depression, is in motion: am I becoming hypermanic? Here is when taking an inventory by yourself or with the help of a loved one makes sense. How am I sleeping? Am I fairly abruptly needing dramatically less sleep? Am I more edgy with my wife or associates? Am I flying off the handle over seemingly smaller issues? There are co-occurring issues: did you resume drinking or drugging? Then there’s the angle of sexuality. Some is normal, inappropriately more is not.

This addition to the blog is not meant as an apology for what I have said previously but I want it to represent a dramatic reappraisal of how my disorder works. Bipolar disorder sneaks up on you. It wiles you into believing that you don’t own it. I am offering a different message today. We can hope for as level a playing field as compliance with effective medication will allow or by how much an uncontrollable and latent genie inside us will reemerge or fluctuate autonomously. Genuine cooperation with our treatment process may determine a pinnacle we can accomplish despite a chronic illness. I do not eliminate the value of questioning how care is delivered. The studies confirm that collaborative decisions about medications and psychotherapy improve outcome.

A “level playing field” may have some ruts and bumps as those of us with bipolar disorder reconnoiter our opportunities. So, I suppose, I must now say no to my earlier premise that now appears somewhat of an illusion. In my own case I sheepishly admit that all is not as smooth sailing in our perceived “recovery’ as I might have hoped. I have alluded to hints of reemerging depression. It is not unusual that mania and hypomania resurface. Perhaps, we can identify either end of the emotional yo-yo of our illness more quickly and with help collaboratively return to that illusory “level playing field” once again.

Chemical use

2010-09-23T16:46:00.004-05:00

One of the problems is that using will provide temporary relief from anxiety, depression and other uncomfortable feelings common to Bipolar Disorder and other mental health problems. However, the longer-term effect will be increased anxiety, depression,etc. Another problem is that chemical use unbalances our brain chemistry, so that each use becomes kindling leading to more symptoms, including in my case and others, an eventual psychotic break from reality. It is best for folks with bipolar disorder to abstain from all chemical use. It could mean no more psych wards, less anxiety and depression and an overall improvement in one's quality of life. It's NOT a death sentence. Life is perfectly enjoyable without chemical use.

Have Hope!

2010-07-16T17:32:00.004-05:00

I am at work. As I look out my window I can see the large state hospital campus that I left as a patient in 1970, 40 years ago. The old buildings are still there, now leased by the county, and there is a big new "Treatment Center" in another direction. My friends and I picketed this building, which was the cafeteria, advocating for better conditions. My journey has taken me into many situations, and I have learned much along the way. I now work with people with dual disorders and their families. Today I became a Licensed Marital and Family Therapist, another path to walk on. I want everyone out there to know that your dreams ARE possible. you have a lot to contribute and WE NEED YOU! Lift your head up and continue on your journey. Bipolar Disorder and Chemical Dependency are treatable. Tim Kuss, LMFT,LADC

What Happened to My Denial Tim Kuss, LADC, LAMFT

2010-06-28T21:05:00.001-05:00

I’m talking about denial of bipolar disorder and the need to take medications daily.

I believe that failure to take meds is, ultimately a denial of bipolar disorder—mine in particular. It’s not that I never had denial. In 1974, I left a psychiatric ward on pass and signed myself into a long-term chemical dependency treatment. It was easier for me to admit chemical dependency than “mental illness”. I had been in a state hospital twice, on commitment, and while there, had learned that others had been there for 20-30 years or more.

Today, we don’t see a lot of lengthy mental health stays. But two 5-month stays back then scared the be Jesus out of me. Fortunately, my treatment center did not insist that I take those horrid anti-psychotics, which they had prescribed because I had been misdiagnosed with schizophrenia. At that point, I had 25 years of sobriety with no medications and no hospitalizations for addiction issues per se. However, I had had plenty of problems with hypomania over those years, resulting in divorce, breaking up with several partners, and losing several jobs.

When I was FINALLY diagnosed with Bipolar Disorder in 1999, I believed it, but did no truly understand it. I had taken myself off anti-psychotics (and anti-depressants) in the past, and eventually went off my mood-stabilizer. I was hospitalized again in 2002. This time I almost died. My mania had me running myself ragged physically and my blood pressure was dangerously high.

I have been “med compliant” now for 8 years. I think of it as an insurance policy. My body has aged and no longer can take the physical exertion of mania. I used to go days with little or no sleep, walk for miles for days on end, and eat very little food usually with no attention to its nutritional value. Plus, I never liked psychiatric units, or the loss of freedom.

My meds do not provide negative side effects. I read about possible negative effects today, but could find none for the dose I’m taking. So why should I have denial.

I work as a chemical dependency counselor. I have seen literally hundreds of clients hospitalized because they would not accept that their chemical use has contributed to psychosis (“going crazy”). I have also seen clients try to manage without medications. My freedom requires 2 small concessions: 1. don’t use; and 2.I take my meds.

I have a pretty good life. I think I’ll keep it.

Doomed or Can We Reach a Level Playing Field?

2010-06-25T21:27:00.001-05:00

My blogmate, Tim Kuss, recently emphasized accepting one's mental illness-in our case, this is bipolar disorder-just as much as building and maintaining sobriety. You know, it's worked for Tim, I daresay, and for me especially since we both have been clean and sober for an impressive amount of time, take our medications deliberatively, and “take an active role in the design and delivery" of our care.

I really love Mathew Mattson and Sue Bergeson of the Depression and Bipolar Support Alliance (DBSA)'s remonstration that "the ultimate goal of treatment should be to engender hope." However, sometimes I wonder how that can actualize if we realize that we will continue to always have a chronic illness that will be there to haunt us especially if we do not walk the straight and narrow.

Dr. Jeffrey L. Sussman, in The Primary Care Companion to the Journal of Clinical Psychiatry, waxes profound when he notes, " The goal of treatment (for bipolar disorder) has changed in recent years from one of symptom abatement to one of recovery; that is returning patients to their level of functioning prior to the onset of illness."

Mover and shaker psychiatrist, Dr. Nada Stotland, allude to "moving beyond symptomatic recovery to also encompass functional recovery" She advocates ways to make this happen: (1) She wants “ policy and system changes to facilitate recovery.”
(2) She asks for “ improved funding for recovery-oriented care.” (3) She wants “implementation of recovery-oriented, collaborative care models that bring together psychiatrists and primary care providers.” Lastly, (4) She wants the “dissemination of improved tools for monitoring changes in symptoms and level of functioning.

Mattson and Bergeson emphasize that “the ultimate goal of treatment must be recovery” and that “consumers should take an active role in the design and delivery of their own care"

I want to dig deeper because I am not convinced the majority of practicing clinicians buy into this view. Many behavioralists, I suspect, focus on the "flavors" of one or the other presentations of bipolar disorder: are you manic and depressed, just a little off the wall, or rapidly cycling between ups and downs? The DSM IV has a diagnosis that fits you.

There are plenty of naysayers who would suggest that there is a greater tendency to define and treat in this New Age of twenty-minute Psychiatric visits. Is there a fiscal relationship between the plethora of psychotropics on the market and how many the average bipolar patient now takes? Does the tail wag the dog? Has "pushing" psychotropics to whatever extent supplanted interactive psychiatry?

Is there a financial impropriety based on the incredible profits engendered by so many medications? Have psychiatrists literally been "bought out" by the mega pharmaceutical companies?

So what is the incentive that anyone with bipolar illness will actually ever "get better?" I am not advocating that the bipolar patient as soon as they feel good again stop taking their medications. Sussman advocates utilizing an effective treatment team. I heartily agree with him and feel, to the bottom of my soul, that collaboration between the patient and physician is crucial. Such an approach demands mutual communication between physician and someone with bipolar disorder. Also, collaboration between primary care providers and specialists (psychiatrists, psychotherapists) is proven to have better outcomes.

Those lucky enough to have been treated collaboratively admitted better attitude about taking their medications and how bad they felt. They also just functioned better. Here again, these innovative psychiatrists are directing our attention toward returning to a level playing field; that is, somewhere before we began our struggle. Is that possible?

We circle around to the question whether someone like myself with known bipolar disorder can ever function normally again? "But you demonstrate compromise of executive and cognitive function on psychometric testing," they may tell you. However, the same psychologist may have performed testing under less than ideal emotional circumstances or under stressful conditions possibly contaminating the results.

In summary, it is my opinion also that a bipolar patient, collaboratively with appropriate medications from a perceptive yet vigilant psychiatrist and a knowledgeable therapist with co-occurring issues in check (anxiety, alcohol and drugs) CAN return to a level playing field.

Managing Depression

2010-05-03T20:02:00.004-05:00

MANAGING DEPRESSION
Tim Kuss, LADC, LAMFT

I am suggesting a bio-psycho-social approach to understanding and coping with depression. The biological component comes in as we have noticed that mood disorders, such as depression, bipolar disorder and anxiety disorder tend to be found in successive generations of a family. As with alcoholism, what is inherited is a genetic predisposition to mood disorders. That means, if you have a parent, grandparent or other family member with a mood disorder, you are more likely than others to have one. It might not even be the SAME mood disorder. For example, someone’s grandmother may have had Major Depressive Disorder (depression) and that person may have Bipolar Disorder. We have learned that people with depression and Bipolar disorder have a chemical imbalance. Medications can allow our bodies to work properly and maintain the right balance of neurotransmitters. SSRI’s and other chemicals work as antidepressants, while Lithium and certain anticonvulsants work as mood stabilizers to help manage bipolar disorder. Taking medications consistently can help us to avoid episodes of depression.
The biological approach for managing depression intersects with the behavioral approach in that behaviors such as regular exercise, proper nutrition and sleep hygiene help us to avoid or cope with episodes of depression. Exposure to the sun or artificial sunlight also helps our body to relieve depression.

The best psychological approach for managing depression is Cognitive Behavioral Therapy. In their book, Depression:Causes and Treatment, Aaron Beck and Brad Alford state that major depression is the leading cause of disability worldwide. They note that studies have shown changes in thyroid hormone levels in response to cognitive therapy, showing that our bodies and minds are linked. They say that depression results in a complex pattern of deviation in feelings, thoughts and behavior.

Symptoms of depression include low mood, pessimism, self-criticism, agitation, problems with memory and concentration, and physical complaints, such as pain. There may be a loss of gratification with activities that starts with a few areas and expands. Activities that involve responsibility, obligation or effort become less satisfying and there is greater satisfaction in passive pursuits, including recreation, relaxation and rest..

People with depression begin to distort reality, They become preoccupied with continuous, repetitive negative thoughts. There is often a contrast between a depressed person’s image of themselves and the objective facts. They dwell on mistakes, imperfections and inabilities, convinced that others will reject them, and that they will lose jobs, relationships, and friendships. They continue to think in themes of deprivation and defectiveness

Depression seems to be a reversal of human nature, of the survival instinct to eat and sleep and the desire to experience pleasure. Others need to respond with concern, empathy and acceptance and to be aware of the client’s difficulty in concentration and in formulating thoughts. People with depression re hypersensitive to rejection and discouragement.
The cognitive approach to managing depression involves recognizing the negative thoughts, or negative self-talk that continues and increases depression. We can learn to challenge the negative thinking and replace it with neutral or positive thinking. For example, if I notice that I’m not functioning as well as normally at work, I can encourage myself to do the best I can. Instead of thinking that “I can’t do anything right” or “I’m doing so badly, that I might as well quit”, I can realize that this thinking doesn’t help the situation, and pay more attention to what I am doing well.

The behavioral approach involves doing things that help relieve depression. A depressed person is likely to withdraw from emotional attachments and tends to isolate from others. We can notice this and purposely spend time with others. If necessary, we can ask others to just let us be there without demanding conversation or interaction. Depression includes lethargy, but it is better to be active. Daily rituals such as walking the dog, and biking, walking or swimming several times a week can be helpful. Routine and structure can provide relief from nagging negative thoughts and feelings, so it is best to go to work or school, or to do volunteer work, or be involved in group activities, like crafting, or sports. A person with depression needs to “Push the envelope” in terms of involvement and activity, striving to get beyond one’s comfort zone. It’s best to start with a few small steps and keep expanding.

There is no reason why we pay attention to our biology, our thoughts and our behavior during the same time frame. There is no shame in taking medication for depression. Would we not take an antibiotic because of what people might think of us? We need to pay attention to seasonal changes, including the amount of sunlight we are getting, to healthy sleep habits, to proper nutrition and to exercise. We need to avoid isolation and too much unstructured time. We need to adjust our thinking to encourage ourselves to do all of these healthy things. Depression IS treatable. We are the prime agents in our own recovery!

“Recognition and treatment Strategies for Bipolar Disorder Across the Life Cycle,” Primary Psychiatry 17:2 (Suppl 3) adapted by Peter J. Dorsen, M.D., LADC

2010-04-07T22:08:00.000-05:00

The series kicks off with Joseph F. Goldberg, M.D., director of the Affective Disorders program at Silver Hill Hospital in New Canaan, Connecticut, by defining the bipolar entity, “ not otherwise specified,” as sub-threshold mania or hypomania. This type of bipolar disorder had a prevalence rate of 2.4%. This “expert” also notes "approximately a doubling diagnosing bipolar disorder of any type with “greater screening and surveillance.” Also, approximately 2/3 of bipolar patients will identify their first mood symptoms before early adulthood (note a modal peak between 15 and 19).

Hirschfield et al in J Clin Psychiatry. 2003; 64(2): 161-174., has noted that 60% of patients with bipolar disorder were “misidentified with unipolar depression.” As much as 54% of postpartum women appeared to be experiencing unipolar depression but in fact had a history of bipolar disorder. The fact is that there are so many issues that can mimic bipolar presentation: anxiety, substance abuse, steroids, even anti-depressants They ALL can produce secondary manias. They remind us to also consider Cluster B personality disorder which can share with mania or hypomania features such as mood instability or impulsivity.

Eighty five to 90% of children with bipolar disorder also meet the DSM IV criteria for ADHD. Goldberg emphasizes “both the overdiagnosis and underdiagnosis in patients with suspected bipolar disorder.” He advises “examining…symptoms such as decreased need for sleep, increased psychomotor activity, and the cognitive-behavioral and language features that comprise the constellation of mania or hypomania.” Also, he cautions, family history can be “somewhat challenging as bipolar illness does not follow Mendelian inheritance.” Therefore, if a strong family history is not available, this is not a clear negative predictive value.

Charles Borden, an M.D. at the University of Texas, San Antonio Health Science Center, emphasizes that clinicians RARELY see bipolar patients who do not have an anxiety disorder. “If anxiety disorder is present, patients are more likely to have substance abuse disorders, other impulse control disorders, eating disorders, and other personality disorders.” Borden notes: “In particular, if the prevalence rates of all anxiety disorders are grouped together, they are almost as prevalent as bipolar disorder itself, and clinicians rarely see a patient with bipolar disorder who does not have an anxiety disorder.” (Perugi G et al The temporal relationship between anxiety disorder and hypomania: a retrospective examination of 63 panic, social phobic and obsessive-compulsive patients with comorbid bipolar disorder. J Affect Disord 2001; 67(1-3): 199-206).

One in five with major depressive disorder (MDD) has bipolar disorder. Prevalence studies in MDD show at least 20% of patients with depressive episodes have either type I or type II bipolar disorders. He suggests that clinicians perhaps may fail to elicit histories of hypomanic illness because they are not spontaneously reported.

Claudia Baldassano, M.D., from the University of Pennsylvania, reports a significant reduction in mortality ratios for patients actively in treatment (29.2 versus 6.4% from suicide). Judd et al noted bipolar patients were most likely to be symptomatic with depression. Unfortunately, despite this reality, “monotherapy” is twice as commonly prescribed as mood stabilizers. Aripiprazole (Abilify) “fails to show positive evidence” for bipolar disorder ( despite what seems like a major media campaign touting its benefits for depression).

From a personal perspective, I was relieved to learn that divalproex (Depakote) may be effective for bipolar depression symptoms. She also reports for maintenance therapy “less efficacy” but “better tolerability” for the mood stabilizers. She notes that lamotrigine (Lemictal) is “well-tolerated and that it does not cause weight gain.

Noreen Reilly-Harrington, Ph.D from Mass General Hosptial confirms again that “adjunctive psychological treatments can help reduce relapse and provide patients as well as their families with tools…” She notes that three forms of intensive intervention : (1) cognitive behavioral therapy (CBT), interpersonal and social rhythm therapy, and family-focused treatment, were favorably compared with brief three-session psychoeducational intervention(collaborative care).

She found that any of these three showed (1) Median time to recovery 110 days earlier; (2) Higher year-end recovery rates; and (3) More than one to 1.5 times likely to be clinically well during any study month. She did not report any significant differences between the three intensive treatments. It is interesting that CBT, established in the 1960’s, was primarily used for unipolar depression. However, its main focus still remains education and problem solving. CBT is also effective for co-morbid anxiety, panic disorder, OCD, and social anxiety.

Reilly-Harrington advocates regulating schedules and monitoring moods daily to recognize any early warning signs of relapse. “Patients… take part in the planning of their treatment plan and to exercise choice in control.” Mood charting allows patients to develop awareness about their illness. Such a routine allows successful tracking of medication doses and treatment compliance. We as patients with bipolar disorder are not known for our compliance. She advises regulating daily schedules of activity including sleep-wake cycles, meal times, and work schedules.

In summary, these articles further help emphasize the challenges of identifying bipolar disorder especially with the likelihood of co-occurring and co-morbid problems. Anxiety almost inevitably co-exists with bipolar disorder. These authors offer us appropriate, unique, and effective psychotropic treatment advice. Lastly, although medications remain “the mainstay” of treatment, psychosocial modalities unquestionably enhance and improve outcomes.

More on Mania and Mortality Peter J. Dorsen, M.D., LADC

2010-03-23T10:10:00.002-05:00

Dylan Murray et al in Mania and Mortality: "Why the Excess Cardiovascular Risk in Bipolar Disorder?" From Current Psychiatry Reports 2009, 11: 475-480, raises more questions why individuals with bipolar disorder have twice the cardiovascular mortality as the general population(prevalence ratio of 1.6). For one thing, metabolic syndrome is more common in this population.

Just being manic increases your chances for such increased mortality. There is a significant history of sudden death from cardiovascular factors in manic individuals. Confounders include behavior, access to treatment, quality of health care, and underlying pathophysiology. I can relate because I have mentioned previously experiencing an MI requiring angioplasty and two stents three years ago. I did not have any of the criteria for metabolic syndrome that include abdominal obesity, diabetes, dyslipidemia or hypertension.

The authors point out that our U.S. population certainly has its share of both metabolic syndrome and diabetes. Certainly, other studies warn about the dangers as well with associated smoking, an elevated total cholesterol, with specifically a reduced high-density lipoprotein ( the “good” cholesterol).

Because of such significant associations, the authors advocate screening bipolar disorder patients for diabetes and metabolic syndrome especially if they happen to be on second-generation antipsychotics. They warn that bipolar disorder appears to negatively affect fat metabolism in women. Bipolar I patients appear to be at higher risk for cardiovascular mortality than bipolar II individuals. They attribute such disparity to a higher incidence of mania in bipolar I disorder. There appears to be less likelihood that the manic patient will have a primary care physician.

There may well be barriers to optimal medical care. Such patients may have difficulties navigating through the health care system. Murray et al suggest better integrated health care. They are suggesting better lines of communication between psychiatrist and primary care giver. They warn as well about QTc prolongation (the repolarization phase of the cardiogram). Ray et al warn about sudden death among atypical antipsychotic users ( N Engl J Med 2009, 360:225-235).
Perhaps increased mortality can be attributed to increased smoking, medication-related weight gain, or linking genetic risk or pathophysiologic processes of bipolar disorder to elevated cardiovascular risk. They even ruminate about an overactive inflammatory response in bipolar patients.

These authors note that less than half of psychiatrists actually are monitoring lipid levels or waist circumference. Anyone on second-generation antipsychotics deserves to be monitored for family history of diabetes, body mass-index, weight gain and triglyceride levels. They reflect on compliance as well related to “ limited insight, a negative view of medications, and substance abuse.” They allude to studying cardiovascular risk in youth with bipolar disorder thus eliminating confounding variables.

In their own words, “Further education may improve recognition and screening for traditional risk factors and may result in better cardiovascular outcomes for this at-risk population.”

Two New Additions to The Blog: Alzheimer's and Sleep By Peter J. Dorsen, M.D., LADC

2010-03-15T20:41:00.000-05:00

Alheimer's

"Novel treatment options:cognitive decline in Alzheimer’s disease" (Primary Psychiatry 17:1 (suppl 1). As we age, are afflicted with bipolar disorder, and might require a panel of mood stabilizers and more, we certainly can experience a decline in mental function (executive/cognitive as well?). Thirty million individuals will have (some form of ) dementia in 2010!

Andrew McCaddon, M.D. and Peter R. Hudson, Ph.D. of North Wales U.K, note utiliizing plasma total homocysteine (tHcy) as a marker, B vitamins deficiencies were found to be highly prevalent in the elderly. These writers note reports of elevated levels of homocysteine in individuals with clinically and pathologically confirmed Alzheimer’s disease (AD). Neuroinflammatory oxidative stress occurs early in AD. Amyloid plaques and neurofibrillary tangles represent end-stage of such oxidative stress.

They note as well an accumulation of methylmalonic acid that appears to be associated with lower cognitive function scores. There is an association as well between elevated homocysteine (Hcy) levels and stroke. Folate supplements serve as affective stroke prevention. They note the association of high Hcy and brain atrophy reversible with high-dose B-vitamin supplementation.

They recommend a naturally occurring product, cerefolin. They also report the efficacy of high doses of ORAL vitamin B12 (1-2mg/day). They emphasize assessing folate, B12 and homocysteine levels in ALL dementia patients and TREATING those with abnormal findings. Especially important, is that clinicians screen EVERYONE presenting with cognitive impairment who has co-occurring vascular risks such as high blood pressure, elevated cholesterol, diabetes, who smokes, or high homocystein levels. McCaddon and Hudson offer some novel warnings about and treatments for AD.

Sleep Problems

John W. Winkelman, MD. Ph.D. in Primary Psychiatry 16: 12 (suppl 8), differentiates between insomnia and sleep deprivation (reduced opportunity to sleep –voluntary or imposed. He recommends that someone who has trouble sleeping keep a 1-2 week sleep diary. Winkelman stresses that a polysomnogram (PSG) is NOT recommended routinely for insomnia unless a clinician suspects sleep apnea, periodic limb movement disorder or narcolepsy ( falling to sleep anywhere anytime inappropriately).

Many with insomnia spend more and more time in bed trying to get adequate sleep but don’t. He cites one such patient in whom “sleeplessness and anxiety symptoms are locked in a vicious cycle…”

Andrew Krystal, M.D. in this same monograph addresses treatment. He recommends Cognitive-Behavioral Treatment (CBT) for insomnia. CBT deals with such crucial issues as sleep hygiene, stimulus control, sleep restriction, and cognitive therapy. Cognitive therapy addresses “the maladaptive thought and emotional processes that often occur.” Consider “problem solving” BEFORE bedtime and something relatively simple like progressive muscle relaxation (one of Tim’s favorites). CBT compared more favorably compared with progressive muscle relaxation and imagery.

Utilizing medications like the hypnotic Zolpidem seem to work best with CBT when medication treatment at, let’s, say six months moves to an as-needed regimen. Clinicians aim for the speed of onset of pharmacotherapy with the durability of CBT. Krystal recommends a taper at 2-3 months and ultimately deciding whether to stop the medication altogether based on how well someone does.

These investigators emphasize not to minimize the potential side effects of the benzodiazepines for cognitive or psychomotor impairment and abuse potential, They advise: "initiate periodic tapers." One group cited treated patients three nights a week according to the patients’ preference. They reduced cost and minimized adverse effects. M Vaughn McCall, MD. MS, addresses co-morbid insomnia. “Relentless insomnia may be a prelude to development of a classic mental disorder such as depression.” He notes that it is important to investigate for a primary sleep disorder “ if a depressed insomniac complains of both insomnia and sleepiness.” Insomniacs, he reports, DENY daytime sleepiness complaining instead of "tiredness and exhaustion."

Certainly, appropriate for insomnia AND depression are the SSRIs. Insomniacs and depressed persons may well demonstrate remission on these medications. However, a large number continue to experience insomnia. If this does not resolve, and especially if a patient has hypersomnia (sleeping all the time) in addition to insomnia, they advise other modalities that include CBT-I for making changes in sleep schedules (avoiding going to bed too early or staying there too long); and dealing with distorted ideas about sleep (bedtime anxiety or fearing that they will be unable to fall asleep).

Consider bedtime hypnotic therapy. Evidence-based statistics, at this point, supports adding a FDA –approved hypnotic RATHER than a sedating antidepressant like trazadone. They advise “high level oversight” when using “benzo’s” or non-benzodiazepine receptor agonists (NBBRA’s). Why? Suicide! Note too, that insomnia is an independent indicator for suicidal ideation, behavior or death in depressed patients. Especially dangerous is an overdose of an accumulation of hypnotics and alcohol. As a result, clinicians should prescribe only 1-2 weeks of theses medications.Depression and insomnia often co-occur.These investigators offer some helpful advice that can stabilize both successfully.

Bipolar disorder and Medical Co-morbidities Peter J. Dorsen, M.D. LADC

2010-03-03T22:46:00.003-06:00

Three years ago, I experienced excruciating chest pain with exercise, ultimately underwent angiography, required two stents and angioplasty, and subsequently was found to have experienced a heart attack in the process.
I had been taking lithium for an extended period of time for my bipolar II disorder.

What I could not completely comprehend was why, if I was thin and exercised regularly, did I continue to run a modestly elevated total cholesterol as well as an ongoing upper limit normal LDL (the “bad” cholesterol) and, no matter how fit I thought I was, I could never elevate my HDL (the “good” cholesterol) to a favorable level. I had a significant family history of high cholesterol. I chose not to take a lipid-lowering drug like simvastatin for fear of liver injury. Doctors are the worst patients!

The good news is that I have fared well with a “clean” angiogram one year after my stents and an acceptable fairly recent maximal graduated stress test several months ago. Initially, I had an elevated blood pressure transiently but am now off all blood pressure medications. I have never had any of the other criteria for metabolic syndrome such as diabetes or centripetal obesity. Metabolic syndrome is excess fat in one’s abdomen with a reduced sensitivity to insulin’s effects (insulin resistance), a high blood sugar level, abnormal cholesterol levels, and high blood pressure. Some have referred to such an insulin resistance syndrome as “Syndrome X.”

My BMI and waist circumference have never been excessive. However, metabolic syndrome is especially prevalent in developed countries with over 40% of those over 50 having it. This syndrome has the “apple-shape” in men or post menopausal women versus the “pear-shape” more commonly seen in women as adiposity collecting around the hips.

Aripiprazole (Abilify) has been advertised on TV recently as an adjunctive
medication for depression. According to Page CU Expert Opin Drug Saf. 2009 May; 8(3) 373-86, it does have FDA approval for treatment “as adjunctive therapy or monotherapy (manic or mixed episodes) as well as an augmentation therapy of major depressive disorder (MDD).” These reporters state that it has “favorable safety compared to other atypical antipsychotics” with “minimal propensity for weight gain and metabolic disruption.” However they report abnormal body movements(akathisia) “that may limit its clinical use…especially in bipolar disorder and MDD.” It is actually one of the newer “atypical” antipsychotics with all the provisos and considerations that go with that class of drugs.

When I went on the medication, I developed tardive dyskinesia (TD) meaning that my chin began twitching and I developed uncontrollable spastic movements in my right hand. Secondly, it is important that you alert your provider if you have ever had a history of heart failure, a heart attack, high or low blood pressure, or a stroke or seizures if you elect to take this drug. Caveat emptor, “may the buyer beware.” These are not necessarily benign medications!

Here’s an interesting one: there are somewhat anecdotal reports that ginseng of one variety or another, functioning as an anti-oxidant, can lower low density lipoproteins (LDL). Not only is it reputed that ginseng may lower blood sugar in Type II diabetes, but it can decrease the risk of heart disease, improve blood pressure, and decrease symptoms of coronary heart disease. So not try some of this herb?

Wildes et al in J Clin Psychiatry. 2006 Jun; 67(6): 904-15, reviewed 92 studies and found that “(studies) targeting physical inactivity and overeating in bipolar disorders are needed, as are better screening and treatment for binge eating.” The authors want to explain both ” the causes and consequences of obesity…”

McIntyre et al in Ann Clin Psychiatry. 2007 Oct-Dec, advise: “ A comprehensive management approach for depressive disorders should routinely include opportunistic screening and primary prevention strategies targeting metabolically mediated comorbitity (eg. Cardiovascular disease).” Also, they say “ explore innovative treatments for mood disorders which primarily target aberrant metabolic networks.” They go so far as to “propose the notion of ‘metabolic syndrome type II’ as a neuropsychiatric syndrome.”

In an older article, Morriss R, Mohammed FA J. Psychopharmacol. 2005 Nov;19(6 Suppl): 94-101 report that lifestyle, illness and treatment factors in people with bipolar disorder (BD) may confer additional risk of morbidity and mortality to the increasing rates of obesity, metabolic syndrome, diabetes mellitus and cardiovascular mortality in the general population.” They observe increased mortality from cardiovascular causes as well as morbidity from obesity and type 2 diabetes increased compared with the general population. They note an increased risk in people with bipolar disorder as well due to less exercise, poor diet, frequent depressive episodes, and co-morbidity with substance misuse.

Saravane D et al in Encephale. 2009 Sep; 35(4): 330-9 (in French), posit that bipolar disorder is associated with “undue medical morbidity and mortality…with a 15-30 year shorter lifetime…” This is, after all, the same population who have “higher rate of preventable risk factors such as smoking, addiction, poor diet , lack of exercise.” Treatment of such co-morbitities is crucial, they advise as significant “ for their psychosocial functioning and overall quality of life.” Detect medical illness at “the first episode of mental illness.” They admonish: “ identify…crucial modifiable risk factors, such as… obesity, dyslipidemia, diabetes, hypertension, and smoking.

This team relates such metabolic and cardiovascular risk factors in population with significant mental illness “to poverty and limited access to medical care but also to the use of psychotropic mediations.” They advise in the first three to four months of treatment that patients with severe mental illness obtain baseline weight, height, waist circumference, blood pressure, fasting plasma glucose, and a fasting lipid profile. Obtaining a BMI ( Body mass index) which is weight(kg) over height(meters) squared can be extremely helpful.

Getting a baseline EKG is essential if a patient is taking an atypical antipsychotic which can increase your QT interval (the repolarization phase of the cardiogram) and lead to fatal arrhythmias. We need to know about the cardiovascular and metabolic risks of our medications! Prescribing antipsychotics carries responsibility for monitoring metabolic abnormalities as well. An ideal world MUST BE coordination among psychiatrists, GP’s, endocrinologists, cardiologists, nurses, dietitions, our families and US.

It is crucial that clinicians stay vigilant for metabolic syndrome among their stable of bipolar patients. Individuals who develop this complication are susceptible to coronary artery disease ( like I was), high blood pressure, Type 2 diabetes, abnormal fats, fatty liver, gout, polycystic ovaries, and chronic kidney disease. Men with abdominal girth over 40 inches and women over 35 inches may have it.

As Tim has suggested, changes in diet accompanied by a commitment to regular exercise is crucial. Medications that increase the body’s sensitivity to elevated glucose like metformin, thiazolidine, or rosiglitazone WITH exercise can improve sugar utilization. If weight reduction and exercise totally fail and after appropriate screening, bariatric surgery can certainly be a viable alternative. But that subject is for another time and blog.

Bipolar disorder and Exercise Tim Kuss, LADC,LAMFT

2010-02-26T22:41:00.003-06:00

Research by Sylvia, et al suggests that outcomes are suboptimal for patients with bipolar disorder who are treated with pharmacotherapy ALONE. They say that exercise can improve acute and long-term outcomes. Jamie Blumenthal did a study of 150 participants with depression. One third were assigned to take Zoloft, 1/3 assigned to an exercise regimen, and 1/3 to both. At the 6 month follow-up, the exercise only group had a significantly lower relapse rate than the other two groups. In studying this topic, I found numerous personal endorsements of exercise by people with bipolar disorder. There are so many articles about this on the internet that I find it hard to say anything new on the topic.

I will say, however, that I personally get close, if not achieve, the three-times a week of recommended exercise. I walk my dog around our block almost every day, which takes us 20 minutes, walking briskly. I get to the gym two to three times a week, swim for 30 minutes, and am now also gradually increasing my time on the stationary bike. Outdoor exercise is still my favorite because I can get some light therapy from the sun as well. I enjoy flowers in the spring, animals, trees, creeks and other nature "eye-candy."

As with any other healthy goal, it is best to start small and gradually improve. I am quick to forgive myself for getting off schedule. However, I don’t forget about the "big" plan. Here’s where my manic grandiosity pays off as I believe that I have a lot of important stuff to do and can’t afford episodes that disable me. Besides, hospital wards are not much fun.

“Bipolar disorder self-care”, www.mhsanctuary.com
Raven, Robin,“How to exercise for bipolar disorder”, ehow.com
“Dreaded exercise”, McMan’s depression and bipolar web

Healthy Diet for Bipolar Disorder Tim Kuss LADC, LAMFT

2010-02-26T22:20:00.001-06:00

Diet in this case does not indicate a goal of weight loss, but rather a regimen that will promote physical health AND mood stability. However, besides promoting mood stability, these diet suggestions may also help to prevent stroke, heart problems, and diabetes.

Eat at least 3 meals a day. Six smaller meals are better. Try to have these meals about the same time daily. Breakfast is IMPORTANT!

Omega-3 fatty acids have been proven to help PREVENT manic episodes. For example, Northern European countries in which people eat larger quantities of fish, have lower rates of bipolar disorder and manic episodes. In our home, we try to have three meals of fish a week. Avoid breaded fish entrees. Broiled fish is best.
Tuna, salmon, and trout, high in omega-3’s, are excellent choices. We eat salmon 1-2 times weekly. Just microwave it and add a little lime or lemon juice, YUM!

Fish oil supplements are available in many health food stores, pharmacies, or vitamin stores. While you are at it, pick up a multivitamin to take daily. Look for a multivitamin that contains the daily requirements of B6 and B12.

Flax seed oil actually has a higher concentration of Omega-3’s than fish oil. Flax seed needs to be ground to avoid releasing “free radicals," so be cautious of commercial brands. Canola oil, olive oil, and sunflower oil also have omega-3’s.
Omega-3 is also found in beets

Folic acid in many multivitamins has been shown to relieve bipolar depression and mania. Folic acid is present in dried beans, peas, oranges, whole wheat products, broccoli, Brussel sprouts, and spinach.

Inosital is a B vitamin that is reputed to provide relief from depression, panic attacks, and obsessive compulsive disorder (OCD). It is found in oranges, nuts, seeds, bran cereals, and legumes.

Make sure that you eat the daily recommended 6 servings of fruits and vegetables. Leafy green vegetables such as spinach, are vitamin rich and good for your diet. Fresh fruit is great! Use it as a substitute for high calorie sugary deserts.

USE whole grains if possible. We enjoy whole grain pasta in spaghetti and there are many whole grain cereals. Use 1 or 2% milk.

Eggs, soy products, nuts, and seeds are protective and nutrient dense. Include them in your meal plans. For example, my wife has several salad recipes that include nuts. We put walnuts and brown sugar substitute in oatmeal. I am a Type II diabetic.

Cut down on red meat. Limit that to 1 to 3 times a week. Such alternatives as chicken, turkey or tuna are better for you. Avoid saturated fats, trans fats and simple carbohydrates(candy bars, rich deserts, ice cream).

Avoid fried foods as they increase omega-6, which competes with Omega-3.
Grapefruit juice may have negative interactions with some bipolar medications.
Reduce sugar intake as much as possible. Splenda,according to my review, seems to be the best sugar substitute (No indication of negative effects)
Avoid caffeine, alcohol, and drugs

Bibliography:

Reese Heather, “A healthy diet: tips for individuals with bipolar disorder.” healthcentral.com.

“Bipolar disorder self-care.” mhsanctuary.com

“Bipolar diet: “foods to avoid.” WebMD.com

“Diet and manic-depression.” Bipolar-Lives.com

“Managing bipolar disorder.” www.psychologytoday.com

Sleep Hygiene #2

2010-02-24T14:03:00.005-06:00

Here are some tips on getting the sleep you need:

1. Try to go to bed and get up about the same times every day. This will help you establish a rhythm and structure to your sleep pattern.
2. The ideal setting is a cool dark room. Also, reduce the noise level. Use ear plugs or eye shades if needed.
3. You can always put a CD on with mellow relaxing music.
4. I reommend that you learn and practice deep breathing, visualization, and progressive muscle relaxation. Many bookstores sell CD's that help guide you or make your own!
5. Avoid napping during the day.
6. Use your bed only for sleeping and sex. If you can't sleep, go into another room and read, or do something else relaxing and quiet
7. Too much light can keep you awake. Keep light levels low.
8. Avoid stimulating activities, including video games, internet surfing, or social networking close to bedtime
9. Exercise regularly, but not for 6 hours before bedtime, as it is stimulating.
10.Try to eat your heavy high protein meals earlier in the day. Breakfast is best.
11. Avoid caffeine in coffee, tea, and certain soft drinks, especially in the evening. Set limits!
12 Nicotine is stimulating. Don't smoke before bed or if you wake up.
13 Alcohol and other drugs may make you "pass out" but will contribute to disrupted sleep. Your balance and sleep cycle are endangered by chemical use.
14. Try changing your sleep position, like sleeping on your side rather than your back.
15 Yoga, tai chi and other disciplines can help you relax and sleep
16 Exercise for at least 20 minutes every other day
17 Try to have your meals at about the same times every day
18 Avoid rigid, rapid weight loss, use a slow, sensible plan!
19 Get enough calcium. Calcium and vitamin supplements can help
20 A glass of milk and a turkey sandwich could help
21 Have a pre-bedtime ritual, like washing, getting into pajamas, or reading a chapter in a book
22. Writing in a journal can help. Also, use a day planner so you worry less about getting to appointments. I also write "to do" lists before bedtime
23. Don't be afraid to ask your doctor for sleep meds. Use them "as needed"
24 Connect with people who love or support you on a regular basis
25. Use visualization to imagine that you are in a beautiful relaxing place
26. Accept your wakefulness when you have it. Relax, enjoy
27 Hide the bedroom clocks
28. Try a warm bath before bed
29 Affirm yourself. Make lists of your abilities, deeds, gratitude, etc before bedtime, and use them as part of your relaxation
I would like suggestions and feedback on this post. Tim Kuss, 2-24-10

Sleep Hygiene

2010-02-22T20:12:00.005-06:00

I have Bipolar Disorder, type 1 and have experienced numerous problems in regulating sleep. I have learned by reading and personal experience to manage sleep better. Sleep and mania provide "Catch-22" situation. When one becomes more manic, one tends to sleep less and when one sleeps less, one becomes more manic. Several of my manic episodes started after several days of reduced sleep, for example, sleeping only 3 to 5 hours a day for 3 or more days. People with bipolar disorder tend not to feel the need for sleep. We get wrapped up in our various "meaningful" projects or our compulsions and lose track of how much sleep we are getting. Sleep is important to positive functioning. For example, during the Rapid Eye Movement (REM) stage of sleep, we dream and in dreaming process our daily experiences and prepare to face challenges. There are other advantages to the other 4 stages of sleep. Sleep is part of the natural "Circadian rhythm" of our body. If we don't get needed sleep, both our mental and physical health deteriorate. In this blog I hope to present positive ideas about how to practice positive "sleep hygiene." For starters, I am suggesting keeping a sleep log in which you enter the hours of sleep you get every night. It's also a good idea to track the time you go to bed and the time you get up as well as any interruptions, like my old trick of waking up at 3:00 AM. Fortunately, while we can't totally control waking up at night, but we can change what we do when we wake up. We CAN do things to manage our sleep/wake cycle. More to come. Tim

Cognitive and Executive Dysfunction: Effect of Age and Medications

2010-02-21T20:01:00.003-06:00

Issues about cognitive or executive dysfunction as well as general matters of intellectual deterioration with bipolar disorder continue to interest me. I am adding some fairly recent articles to the blog pertaining to such phenomena. Peter J. Dorsen, M.D., LADC

Neurocognition in bipolar disorders—a closer look at comorbidities and medications. Bulanza-Martinez V et al Eur. J Pharmacol. 2010 Jan 10; 626(1): 87-96.
Their research is of neuropsychological study in bipolar disorder associated with persistent neurocognitive impairments EVEN during periods of euthymia in the broad domains of attention, verbal memory, and executive function. They also showed that there was a poorer functional outcome among bipolar disorder patients. Cognitive dysfunction is gene-environmental, drug–induced cognitive adverse effects ie there are confounders. It is important to look at the contribution medications plus medical and psychiatric co-morbid conditions have on bipolar disorder.

The longitudinal course of cognition in older adults with bipolar disorder Gildengers AG et al Bipolar Disorder. 2009 Nov; 11(7): 744-52.
“…elders with bipolar disorder (BD) may be at increased risk for dementia…”
Findings: Subjects with BD performed significantly worse on the Dementia Rating Scale (DRS) compared to mentally healthy comparators. In their study, “older adults with BD had more cognitive dysfunction and more rapid cognitive decline than expected given their age and education.”
The consequences of such decline was decreased independence and increased reliance on family and community supports with EVEN potential placement in assisted living facilities.

Cognitive features in euthymic bipolar patients in old age Delaloye C et al Bipolar Disord. 2009 Nov; 11(7): 735-43. Their conclusion relates to the notion that cognitive changes observed in older BD patients is similar to that observed in younger BD cohorts. However, issues relating to processing speed and episodic memory are two CORE DEFICITS that appear to differ in elderly BD patients.

Identifying and treating cognitive impairment in bipolar disorder Bipolar Disord. 2009 Jun; 11 Suppl 2:123-137. Goldberg JF, Chengappa KN. These investigators found that circumscribed cognitive deficits may be both iatrogenic and intrinsic to bipolar disorder. They concluded that cognitive deficits involving attention, executive function, and verbal memory are evident across ALL PHASES OF BIPOLAR DISORDER.

Clinical predictors of functional outcome of bipolar patients in remission Rosa A et al Bipolar Disorders VII(4):401-409, showed that 60% of 71 euthymic patients had overall functional impairment.Bipolar patients showed a worse functioning in all areas of the Functioning Assessment Short test (FAST). Previous mixed episodes, current subclinical depressive symptoms, previous hospitalizations, and older age were identified as significant predictors of functional impairment.

In the J Clin Psychiatry. 2009 Jul; 70(7):1017-23., Martinez-Aram A et al emphasized : “a close relationship between poor treatment adherence and cognitive impairment, but the causal inferences of these findings are uncertain.” They conclude that such poor treatment adherence may worsen the course of bipolar disorder and so indirectly worsen cognitive performance (thus, more severe illness).

A comparison of cognitive functioning in medicated and non medicated subjects with bipolar depression Holmes MK et al Bipolar Disord. 2009 Nov; 10(7): 806-15. This study demonstrated deficits in affective processing in the medicated group. They saw more errors in the “happy” conditions, indicating a potential attentional bias in subjects with bipolar depression on mood-stabilizing medications.
Excellent quote: “The present study also implicates impairment in sustained attention for medicated subjects with bipolar disorder PARTICULARLY those with bipolar II.

High achievers more likely to be bipolar

2010-02-11T23:26:00.000-06:00

MacCabe J, Lambe M, Sham P, Hultman C. Excellent school performance at age 16 and risk of adult bipolar disorder national cohort study. The British Journal of Psychiatry (2010) 196: 109-115.

This study revealed two interesting findings. In a joint study between investigators from Stockholm’s famous Karolinska Institute and London’s King’s College, the final exam results of 15-16 year-old pupils attending High Schools in Sweden from 1988 to 1977 were compared with hospital records of bipolar disorder admissions between the ages of 17 and 31.

The students with A-grade results had an almost four times greater chance for such admissions than average students. Variables such as income and education levels of parents were controlled. Males predominated.

Also, students with low exam grades had a greater risk for developing bipolar disorder than average pupils.

Once again and consistent with facts listed before in this blog, these scientists found the highest rate of bipolar disorder among those who excelled in the humanities such as literature or music, classically subjects most frequently associated with madness.

“….the scientists suggest there are two distinct groups of people with bipolar disorder: the high achievers who are aided by their manic stages, and low achievers who have poor motor skills, which may be caused by ‘subtle neurodevelopmental abnormalities’”. Submitted by Gary Jedynak

Primary Psychiatry 16:12 (Suppl 10): Practical Management Strategies for Acute Mania and Mixed Episodes of bipolar disorder reviewed by Peter J. Dorsen, M.D., LADC

2010-02-08T22:07:00.000-06:00

Article 1 Primary Psychiatry 16:12(Suppl 10)

Goldberg, Joseph F. “Overall assessment of mixed episodes in bipolar disorder.”
Dr Goldberg is a clinical associate professor of psychiatry at The Mount Sinai School of Medicine

“…mixed episodes…often present with co morbid anxiety or substance misuse…”

Interesting comment: “Although DSM-IV recognizes mixed episodes as occurring ONLY(ed) bipolar I disorder…mixed polarity symptoms may be EQUALLY(ed) common in patients with bipolar II disorder.

He states: “syndromic mood states” are a constellation of signs and symptoms.

Think of mania or hypomania when there is “nocturnal hyperactivity.” Likewise, if the patient is “flooded with thoughts,” look for “accelerated thought processes.” Psychomotor agitation can also go hand in hand with self-destructive behavior.

Goldberg advises: utilizing a corroborative historian especially in adolescents or young adults. Why? A clinician may need all the help she can get to identify prior depression or manic/hypomanic events.

Ref: Birk et al “Bipolar mixed states: the diagnosis and clinical salience of bipolar mixed states. Aust NZ J Psychiatry.2005; 391. 215-221. Agitated depression may overlap with mixed episodes.

Differentiate between true anxiety, iatrogenic signs, akathisia, drug intoxication/withdrawal effects, psychomotor agitation, and acceleration suggestive of mania or hypomania. (a potpourri of possibilities).

Psychosis (delusions, hallucinations, or formal thought disorder) occur in a half or more of those with bipolar I!

Here’s a gem: “subsyndromal mania symptoms may be eclipsed by more prominent depressive features.” Such patients may demonstrate fewer mania symptoms than would meet the DSM-IV criteria for a full mixed episode, they may show distracted thinking, psychomotor agitation, flight of ideas, or racing thoughts.

Some resources: Clinical Monitoring Form (CMF; www.manicdepressive.org.)

Diagnosis of bipolar disorder is based on the comprehensive interview!

Another resource: Hirschfeld, RM et al. Development and validation of a screening instrument for bipolar spectrum disorder: the Mood Disorders Questionnaire. Am J. Psychiatry.2000; 157:1873-1875.

He debunks “mood destabilization.”

He adds: “…transmission of bipolar disorder is non-Mendelian, conferring only moderate importance to the categorical presence or absence of bipolar disorder in a first-degree relative.”

In a 15-year follow-up study of late adolescents hospitalized for unipolar depression, 45% met criteria for mania or hypomania!

Delineate identification of prominent mood disturbances in the absence of acute intoxication states. Look for loss of need for sleep, flight of ideas, or racing thoughts not “mood swings.”

Important factoids: “Age of onset, psychosis, high rate of recurrence with brief episodes, atypical depressive features, cognitive deficits, and family history…help differentiate unipolar from bipolar disorder….”

Article 2 (Primary Psychiatry 16: 12 ( Suppl 10)

Frye, Mark A, M.D. “Treatment guidelines for acute manic and mixed episodes of bipolar disorder.”
Doctor Frye is professor of psychiatry and director of the Mayo Mood Clinic and Research Program, Rochester, Minnesota.

“It is important to look at evidence-based data set to guide treatment selection for mood stabilization.”

Pearl: “ …rapid cycling, mixed mania, psychotic symptoms…influence medication selection.” ( bipolar disorder is highly co-morbid with Axis I, II, and III illnesses).

Pearl: …dysphoric mania predictive of nonresponse to lithium and better to divalproex.

Benzodiazepines CAN work: “…lorazepam and clonazepam can be successfully used as adjunctive anti manic agents to treat acute mania”

Lithium (narrow therapeutic index), valproate, carbamazepine for acute mania. Valproate and carbamazepine: mixed episodes and a growing small evidence-based potential for alcohol withdrawal symptoms or relapse

Dysphoric mood: Nay lithium, Yay divalproex.

Lamotrigene: Yay bipolar depression(FDA: maintainance); Nay Acute mania

Atypical antipsychotics: Acute, mixed episodes. However increased associated mortality

Co-morbidity: alcohol abuse/dependency: earlier onset, higher rates mixed, rapid cycling, impulsivity, aggressivity, suicidality, and treatment-emergent mania.

Article 3 ( Primary Psychiatry 16: 12 (Suppl 10)

Bowden, Charles L. “Maintenance treatment in bipolar disorder.”
Doctor Bowden is clinical professor of psychiatry and pharmacology at the University of Texas health Center, San Antonio.

Doctor Bowden advocates efficacy versus adverse effects. He stresses carefully evaluating the patient who frequently presents as depressed. Start with an anti manic drug. If the patient persists psychotic or develops manic symptoms, choose an atypical antipsychotic. He advocates lamotrigene or valproate rather than carbamazepine as they are better tolerated. If devalproex was the right drug for the acute problem, it also had better maintenance outcomes.

He realistically discusses the finding of “poor set-shifting, processing speed predicted by any antipsychotic use.” So the goal must be to achieve a good dose yet avoid cognitive dulling and psychomotor slowing.

He reports “poorer executive function on WCST categories in subgroups taking antipsychotics.”

Two articles address a matter very close to my heart and I will list them for your perusal:
Frangou S, et al. The Maudsley Bipolar Disorder Project: executive dysfunction in bipolar disorder I and its clinical correlates. Biol Psychiatry. 2005;58:859-864.

Altshuler LL, et al. Neurocognitive function in clinically stable men with bipolar I disorder or schizophrenia and normal control subjects. Biol Psychiatry. 2004;56:560-569.

Such issues of deteriorated cognitive function ( in this case related to antipsychotics) certainly can relate to “ unrealistic fear of side effects on the part of patients or the patient’s family.”

Bowden notes that outcomes are less positive if there is preexisting anxiety. He alludes to a new comprehensive scale, the Bipolar Inventory of Signs and Symptoms Scale (BISS).
Ed: His message is that it is not just mania or depression but also anxiety, irritability, or psychosis that is pivotal how this illness performs. This is why the majority of patients are treated with multiple medications during acute mania and maintenance care.

He cites Goldberg et al in their study, manic symptoms during depressive episodes in 1380 patients with bipolar disorder: findings from the STEP-BD. Am J Psychiatry. 2009;166: 173-181. More than 1000 entered the program depressed but more than 2/3 had clear manic symptoms especially distractability, activation, excessive energy, or risky-type behavior.
His summary: “All of the different features associated with bipolar disorder-depression, mania, irritability, anxiety and psychosis; cognitive symptomatology; and adverse effects from medications used to treat the disorder—makes for a complex challenge for the patient and the clinician.”

PS: Bowden warns: don’t forget “... attention over time to appropriate sleep hygiene practices.”

Article 4 (Primary Psychiatry 16:12 (Suppl 10)

Sajatovic, Martha. Medical comorbidity and recovery in individuals with bipolar disorder.
Doctor Sajatovik is Professor of psychiatry at Case Western University School of Medicine in Cleveland, Ohio.

She opines: “Medical conditions are the rule rather than the exception among individuals with bipolar disorder.”

The range for the co-occurrence of metabolic syndrome ranges from 20-50% or greater.

ED: This has always been one of my pet peeves: “Psychiatrists often tend to operate in a vacuum when they need to be in communication with primary care (givers) and colleagues.”

She warns us that there is actually a lot of medical co-morbidity in individuals with late-life bipolar disorder compared with rather low rates in the community. One such strong statistic is that bipolar disorder is present in 17% of geriatric patients presenting to psychiatric emergency departments (ed question: with metabolic syndrome?)

Although the incidence of adverse drug reactions in bipolar patients is actually low under forty, 20% of hospital admissions are due to adverse events over 80!

She warns: “ …illness does not go away or ‘burn out’ in late life.”

It is crucial to (1) Characterize the target symptoms; (2) Identify and characterize any medical co-morbidity (especially in the geriatric patient). (3) Treat (parsimonious and step-wise in the elderly). Nothing will remain static! (4) Review on an ongoing basis medications for their toxicity or withdrawal; (5) Incorporate nonpharmacologic interventions; (6) Have multidisciplinary coordination.

surviving a manic episode

2010-02-04T02:23:00.003-06:00

Unfortunately, I have experienced many hypomanic episodes that I did not recognize. Recently, however, I have survived two manic episodes, including delusional thinking. The biggest challenge seems to be in recognizing the symptoms of mania. I have had enough experience with my delusions that I recognized that my thinking was off track. A second positive factor is having a support network that you trust. I trusted my wife and my friend enough that I told them I was having an episode. My wife reminded me that sleep management is important to my stability. I contracted with her to stay off my computer(especially games and the internet!) and to read instead, We have also practiced meditative skills together and I agreed to go to the living room and listen to relaxing music while practicing deep breathing, progressive muscle relaxation and affirmations. It took about 3 days to get out of the woods the first time and about 24 hours the second time. Also, it helped to do some "normal" activities like walk around the block with my dog. watch movies, read, go shopping, read e-mail, etc. While I enjoyed my "'inspired" thoughts, I was also aware of the consequences of former manic episodes and was thus motivated to continue to challenge the delusional thoughts. I kept reminding myself of the "real" positives in my life. including my family, my career, my friends, my men's group, etc. This decreased my attraction to the promised benefits of my false reality. I hope that some others can use this information to survive manic episodes, Tim Kuss, 2-4-10

So what type of intelligence is best to have?

2010-02-02T22:30:00.000-06:00

Submitted by “Jerry” Westcott who has consistently pointed out the similarities between his own ADHD and those with bipolar “cognitive” struggles.

Michael Bond, a London-based consultant to New Scientist, quotes Keith Stanovich, “ I.Q. isn’t everything. Notwithstanding that IQ tests determine…the academic and professional careers of millions in the U.S.) (The SAT’s for instance). In his book, What Intelligence Tests Miss(Yale University press, 2008), he claims standard IQ tests “measure only a limited part of cognitive functioning.” Stanovich and other reaearchers focus attention on cognitive faculties that go beyond intelligence. In fact, our brains use two different systems to process information. One is intuitive and spontaneous. The other is deliberative and reasoned.

Intelligence, as we know it, can be a poor predictor of “good thinking.” People with higher intelligence excel in certain situations like number ratios, probabilities, deductive reasoning, and the use of hindsight. However, correlation between intelligence and successful decision making is weak. Stanovich adds, “ intelligent people perform better only when you tell them what to do.”

Wandi Bruine de Bruin notes: “those who displayed better rational-thinking skills suffered significantly fewer negative events in their lives such as credit card debt, having an unplanned pregnancy, or being suspended from school.”
Interestingly, Baruch Fischhoff reports in the Journal of Behavioral Decision Making V 18, p1 that adolescents who scored higher on a test of decision-making competence drank less, took fewer drugs, and engaged in less risky behavior overall.” He notes that “irrational thinking (not IQ) may be more important than intelligence for positive life experiences.”

Unfortunately, to date, there is no “rationality- quotient (RQ) test.” Also, although IQ tests excel in measuring brainpower or for academic selection, “RQ tests” might be the way to select managers and leaders. The same researchers also warn that, unlike IQ tests, it may be easy to train people to do well on RQ tests; that is, “to ignore intuition and engage reasoning.” The affirmative, however, is “ that everyone can improve their rational thinking and decision-making skills.”

One conclusion that is possible from this information is that there can be special psychotherapists who may offer their skills correcting such conditions trauma-related cognitive-executive deficits or bipolar and ADHD “misfiring” that register on the RQ scale instead of the standard IQ scale. Food for thought anyway. Adapted by Peter J. Dorsen, M.D., LADC

2010-02-02T06:17:00.003-06:00

Bipolar Visions/as adapted from the presentation to the M.A.R.R.C.H. 2009 fall conference

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

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

2010-01-13T10:52:00.002-06:00

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.

Three Exciting ? Controversial Videos/ A Quiet Mind: Sean Blackwell

2010-01-03T20:35:00.000-06:00

These three videos came to me from a relatively new friend who himself has struggled with accepting the diagnosis of traditional bipolar disorder. Interestingly, he recently updated me that he has begun a combination of lithium and lamictal but it is too early certainly to comment on his improvement or that he might be experiencing problems. I feel he is brave to give medications a try nonetheless. Peter J. Dorsen

Addenda: Practicing attorney Jim Gottstein's opinion about bipolar disorder

2009-12-25T20:58:00.002-06:00

I don't view it as an illness. I view it as an attribute to be managed. Your experience, of course, could be different. There is no legitimate science as far as I know validating the brain defect theory of bipolar disorder, or any of the other mental illnesses that are not identifiable neurological problems. Your brain scan is probably hocus pocus or only demonstrates the damage from the drugs.

Mental Health Recovery Stories by Jim Gottstein

2009-12-25T20:53:00.001-06:00

In 1982, when I was 29, I got into a situation where I didn't sleep for days. I tried to do too much. I went psychotic. When I heard someone coming down the hall, I thought the devil was after me and jumped out of my father's second-floor window in the wee hours in my underwear (since I knew how to do a parachute landing fall, I really didn't think I would get hurt, and I didn't). After I was captured, I was taken to Alaska Psychiatric Institute (API) in a straight-jacket, and pumped full of a whole lot of Mellaril.

Prior to this, I was a practicing attorney. I had gone through college in three years at the University of Oregon by averaging 21 hours a term, rather than the normal 15 hours. After graduating from college I was admitted to Harvard Law School. Since graduating from law school, I had been practicing law in Anchorage. Before my episode I had never run into a situation where I couldn't do all the work that "needed to get done."

When I woke up in the hospital, still groggy from the medication that forced me (finally) to sleep, a young man was sitting in a chair at the foot of my bed with a clipboard. He asked me what day it was. I asked him how long I had been asleep. He wrote down that I didn't know what day it was. Things didn't get better from there. I was somewhat belligerent since I was used to being free and being able to make my own decisions. Sometimes I would just go limp to make them catch me. One time, they didn't catch me before my head hit the floor and I decided that that really wasn't such a good idea. I was slow to learn that until I did the things that they wanted me to, things were going to go poorly for me. When I told members of the staff that I was an attorney, some didn't believe me and the others said I would never do that again. I refused to believe them. According to them, I was in "denial."

At the end of 3 days, I was given the choice of signing a "voluntary commitment" or they would take me to court for a court ordered commitment. Well, I had the presence of mind to recognize that I didn't really want to be dragged into court in the condition I was in so I signed. It was hardly voluntary, though.

There is no doubt that I was confused. It didn't help that when I noticed that my hospital shirt was inside out (there was a pocket on the inside) and changed it, that it was still inside out (there was still a pocket on the inside). At that time those who were on "Suicide Watch" or "AWOL Alert" could not wear their own clothes and were given surgical scrub clothes which could be put on either way. It also didn't help that in some of the elevators, the button for the ground floor was a "B" and in others it was "G" (I mentioned that this was confusing to patients to every Director of API since 1985 (there were many), but it was not until 1995 or 1996, when Randall Burns took over that this was changed).

I mainly needed sleep, but API was so scary and noisy that I didn't sleep well. The Mellaril added to my confusion and to this day, after the first few days there, I don't know how much of my confusion was the Mellaril and how much of it was the sleep deprivation. Well, in spite of the heavy medication and the poor sleeping conditions, I gradually learned that I had to behave. I ceased being uncooperative at the stupid daily "group therapy" sessions that was only humiliating to the patients. I went to the asinine "occupational therapy" where we literally had to weave pot holders for god's sake. Since I was a private pilot, I knew that I couldn't keep flying if I was on medication, but they insisted that I should be on Lithium. Fortunately, my creatin clearance test didn't pan out and they didn't put me on it (I was also sent to a kidney doctor to have a biopsy, but he couldn't find my kidney -- honest).

Anyway, I was let out after a month, still being told that I would never again lead a normal life. My official diagnosis at discharge was "atypical psychosis," which at least meant that they weren't sure about me. My family had a lot of financial resources to get me the best help, but they didn't know what to do either. I was even sent to New Rochelle, New York, to see a psychiatrist there. He was a very nice guy, but really didn't do anything for me. He diagnosed me as bi-polar. When I got back, sure enough, I went into a major depression. I couldn't get off the couch for months. However, I finally found a psychiatrist, Robert Alberts, who said, there was no reason why I couldn't manage the situation and recover. After about six months, my father arranged for me to get a job with a law firm, which I appreciated, and I dragged myself there and forced myself to go to work and get my work done. However, it wasn't a good fit and in less than a year I became an in-house counsel for my father's company. That was better.

However, by that time I had gotten involved in the Mental Health Trust Lands Litigation and in 1985, I allowed myself to get into a sleep deprivation situation again. Sometimes when I have a project with a lot of moving parts that need to be sorted out, usually on a time deadline, I can have a hard time getting to sleep. I am working on solving the problems, working things through my head and I have trouble "turning it off" so that I can go to sleep. In 1985, even though I recognized that I was getting into trouble and tried to stop it, I didn't act fast enough, nor strong enough and ended up back in the hospital. This time, however, I had Dr. Alberts who admitted me into Providence Hospital's psychiatric unit. The difference between it and API are like night and day (or heaven and hell?). Instead of psychotropic drugs, to make me sleep, he gave me Seconol. He said it took an incredible amount to get me to sleep. This time I was in the hospital for only a week. I took Navane for awhile to settle my brain down. I went into another depression.

My father said I would have to either give up the Mental Health Trust Case or work somewhere else. I decided to open my own law office. This was only three months after my second episode. I really never felt fully recovered until after my second episode and I haven't had another one. I have learned to recognize the warning signs and take action before anything serious happens. The first thing, of course, is if I'm not getting proper sleep. But more than that, I recognize certain thought patterns. This will be the first thing. Next, my speech patterns will change. I will start making really quick, sharp remarks. This can get to the point where other people notice. But, before things get out of control, I now know to take medication to get some sleep. Personally, I like the much-maligned Halcyon. It works great for me, particularly because I don't use it long term. Another option I have is a Restoril/Xanax combination. This is particularly useful when I don't think the Halcyon will get me to sleep long enough. Also, the Halcyon takes at least an hour to work, while the Xanax kicks in very quickly. When I see that I am going down the road towards trouble, I make sure that I take my medication.. I only need a small dose, and usually just for one night. Then, I've gotten a good night's sleep and the vicious cycle is broken.

During the Mental Health Trust Case, when things really heated up, particularly the incredibly short time-frame in 1994 when they jammed the settlement through, I had to take my medication more than I ever had (basically during the hearings and when we were writing briefs). During the hearings, my normal medication regime was not enough to stop the wheels from turning in my brain. So, I called Dr. Alberts and we adjusted my dosage. I got through this extremely difficult time without any problems. I mismanaged our time for the opening appeal brief before the Alaska Supreme Court for the Mental Health Trust Case and ended up working too many hours at the end and had to use medication then too. Now, I normally go about six months between uses. But, I do take it in an instant when I need it.

To me the main thing is that I have learned to recognize the warning signs and have been able to work out things that work for me. I could just quit taking assignments that lead me into the situation where I need to take the medication. But that wouldn't be a full life for me.

Now, some people will say, "But Jim is not really mentally ill. He's not like the rest of them." First, I was lucky not to have been made permanently mentally ill by The System. I could have very easily become "chronically mentally ill." It was pure luck that I didn't. Second, when I have listened to other people who have recovered from serious mental illness, they uniformly say that is what people say about them too. I do think that my problem is easier to manage than a lot of other consumers. But I have heard other recovery stories from people who were much worse off than I. As far as I know, there are some things that are true for everyone that recovers from serious mental illness:

1. You have to take responsibility for your own mental health and behavior
2. You have to learn to recognize your symptoms.
3. You have to learn what works for you.

Bipolar Visions by Tim Kuss LADC, LAMFT, M.S. ED, Adapted by Peter Dorsen, MD, LADC

2009-12-12T23:40:00.007-06:00

This part of our dialogue is about bipolar I disorder primarily. This is the form of the mood disorder I personally experienced for too many years yet its discovery occurred considerably later in my life than when I actually relinquished chemicals and alcohol.

Just in terms of numbers, two million Americans suffer from bipolar disorder. Yet, as many as 15 to 20% of those who have it never get treated. Although suicide potential, actual attempts and “success” are less with bipolar I than II, the actual risk of suicide for anyone with bipolar disorder is greater than any other major depressive disorder (unipolar depression).

Scientists heartily concur that bipolar disorder is primarily an imbalance in brain chemistry. It comes as no surprises as well that desperate attempts to self-medicate resulted in worse chemical brain imbalances, poorer outcomes, and a higher incidence of mixed or rapid cycling forms of this disorder.

There is plenty of difference of opinion how mania disrupts the life of anyone unfortunate to experience bipolar I. Mania can escalate the dysfunction of someone with bipolar I to the point of psychosis that may include extreme paranoia, rapid thinking, the decreased need for sleep, delusions of power, and the tendency to be argumentative, agitated or defiant. We who have this dysfunction may experience increased mental energy, creativity (good?), or intuitive energy. Seventy per cent of bipolar I is genetic, 60% have anxiety(Johnson), 30 % will attempt suicide (Burgess), and 20% will succeed.

Those with bipolar I disorder also tend to experience a mixed state with rapid sometimes pessimistic thoughts, “big” ideas yet no energy. We are more irritable and often self-directed. We rapidly cycle between mania and depression, mixing anxiety and depression.

Bipolar disorder is a chronic dysphoria—months to years of normal moods (euthymia) and days to weeks of mania, hypomania, or depression. Abstinence from alcohol and drugs promotes mood stability. Committing to a realistic balanced recovery program promotes mood stability. Individuals with bipolar II disorder have more depressive episodes that can also be more severe. Women are more likely to be type II compared with men who are more frequently type I.

A manic patient with bipolar I is just more likely to take risks believing nothing can hurt them. I was certainly there. Bipolar individuals are more likely to abuse chemicals than someone in the general population. They are prone to depression and often anxious enough to self-medicate. Sixty to eighty per cent experience alcoholism or drug abuse(Burgess).

Estroff and Collaprea report 58% of manic bipolar patients abuse cocaine compared with 30% who are in a depressive cycle. Fifteen to sixty-five per cent who are bipolar have co-occurring marijuana abuse issues. Clients report that alcohol relieves irritability, restlessness, and agitation from mania. Marijuana, some report, relieves symptoms of anxiety. Thirty- eight per cent who are bipolar are likely to increase alcohol use while depressed compared with 15% who are experiencing unipolar depression.

Yet, drug or alcohol use in bipolars still appears to have its supporters. Gavin and Kleber note that 80% with bipolar I report their mania improved toward hypomania when using. We could hypothesize that such purported positive effects of drugs are transient but in reality they may ultimately experience increased depression, anxiety, or other deleterious symptoms.

The differential diagnosis of bipolar I ranges from schizophrenia ( 20 is also the usual age of onset); alcohol or drug induced psychosis, or a medical presentation of a metabolic illness like hyperthyroidism. It is no wonder that I was diagnosed with all of these conditions as I struggled over the years before doctors finally made the correct diagnosis. I am not alone when it comes to a significant delay for a diagnosis with this dysphoria.

Both Peter and I had our share of misdiagnoses. Seventy per cent are mis- diagnosed more than three times. It is not unusual for clinicians to misdiagnose bipolar illness especially in children as ADHD or, like Peter, an adult conduct disorder. Clinicians fail to link cyclical depression to bipolar I or II disorders. That is what happened clearly for Peter. The proper diagnosis is very difficult and symptoms can easily overlap other co-occurring problems. All bets can be off when there is associated alcoholism or drug abuse. Goodwin and Jamison note that substance abuse can lead to more severe problems for anyone unfortunate to have a bipolar disorder. They rapidly cycle, have the mixed form, relapse more, and recover slower.

Abusing chemicals leads to more severe psychopathology and less favorable outcomes (Jamison). In a genetically predisposed setting, abuse can precipitate mania and depression. One study of 500 bipolar I patients, showed that they were more likely to abuse and rapidly cycle. This contradicts the usual data that shows that bipolar II ‘s do. Substance abuse can increase the risk for switching into mania while taking antidepressants. Longer periods of marijuana use are reported to lengthen periods of mania.

Clients may report that they take substances to medicate away their depression. They tend to abuse in the manic phases of their illness. Someone just tends to take greater risks when manic and we may be more likely to desire increasing or extending periods of euphoria with drugs. Taking drugs (including alcohol) can mean a disorganized lifestyle further contributing to destabilization and poor compliance of taking medications. Attempting to mix drugs and prescribed psychotropics can also contribute to destabilization and poor medicine compliance.

There are plenty of family dynamics that come into play for all those living with bipolar individuals. There is the tendency to use denial to avoid dealing with our anger or anxiety in such circumstances. Families are likely to show unrealistic expectations. Low self-esteem tends to pass from parent to child.

Life must go on for the person who is bipolar. Problems invariably Arise at work, at home, or in our everyday relationships. It may not be enough to simply remain chemically free and continue taking one’s psychotropic medications.

It can be difficult for the family of someone who is bipolar to express their anger. Sometimes, family members feel extremely guilty for what they imagine is their part in the bipolar equation at home. They may ask, “ How can I set realistic limits to how a loved one’s chronic illness affects me? Do I have realistic expectations for how a process that never is going to go away will turn out?” Instead, family members experience a sense of loss and may mourn the reality that their loved one will never be the same. They grieve the loss of hopes and dreams.

The dysfunctional bipolar family member can easily become like the mythical elephant in the living room that everyone refuses to admit exists. The family’s external network may shrink to adapt as they try to hide their secret problem. There may be increased stress related physical and psychological ramifications affecting everyone in the family. It becomes crucial to educate the entire effected family about the interaction of chemical dependency AND bipolar disorder.

Schizoaffective disorder becomes an important entity to understand in a review of bipolar I disorder. This is the diagnosis when psychosis occurs separately from manic or depressive episodes. Further categorization is that the “bipolar” type is when psychosis occurs with intermittent flashes of mania or pits of depression. The “depressive” variety is bipolar disorder interspersed only by severe depressive episodes.

Anxiety frequently accompanies the bipolar cycles of depression, mixed states, or mania. Thirty-nine percent of bipolar patients demonstrate anxiety symptoms. Anxiety manifests as agitation, accelerated thought processes, restlessness, social anxiety, irritability, or dysphoric mood. Panic Disorder and Obsessive Compulsive Disorder frequently coexist. Panic Disorder(PD), Obsessive Compulsive Disorder()CD), Post Traumatic Disorder(PTSD), Phobia also co-occur with bipolar disorder.

Anxiety and bipolar disorder tend to be more severe when co-occurring. A deregulation of serotonin, norepinephrine, or GABA may be the etiology of this worrisome difficulty. Bipolar individuals may especially suffer PTSD. Why? They tend to have poor judgment and be at a higher risk of trauma.

We must avoid denial that we have BOTH addiction and mental health issues in order to successfully accomplish full recovery. Each of us took years to accomplish that. We advise:
(1) Take your medications every day.
(2) Abstain completely from drugs or alcohol.
(3) Learn on a daily basis how to cope with a chronic illness.
Professionals clearly need to have dual training in addiction and mental health. Recent buzzwords in all medical fields seem to be “evidence based practice.” Several treatment methods successfully treat such dual problems. One, Interpersonal Social and Rhythm Therapy (ISRT), shows clients how to stabilize their rhythms. This discipline advocates journaling daily activities and how they affect our moods. ISRT encourages consistent sleeping, eating, and taking medications. It advocates managing our time, breaking down tasks, and the overall simplification of our lives.

The goal for ideal sleep is rapid eye movement (REM) sleep when we can dream adequately, successfully process our lives, and problem solve. Clients who medicate themselves to sleep with alcohol or drugs simply “pass out” and bypass REM sleep. We advocate:
(1) Alternatives to drugs, i.e. inappropriately used licit or illicit drugs to achieve “acceptable” sleep patterns.
(2) Getting regular exercise
(3) Limiting caffeine, nicotine and sugar especially before bedtime.
(4) Trying relaxation techniques.
Maintaining a healthy diet includes fish or flax seed oil supplements.
Don’t forget protein especially in the morning. Aim for six servings of fruits and vegetables a day. Push the whole grains when it comes to carbohydrates in the food pyramid.

We advocate 30 minutes of aerobic exercise at least four time a week interspersed with strength or anaerobic strength training three times a week. There are those of us who just combine a little of both in our four times a week ritual. Such a regimen can result in releasing our own natural endorphins and successfully reducing depression and anxiety.

Develop a regular program. Aim for structure in your life.
We advocate employing relaxation techniques. They can run the gamut of deep cleansing breathing, progressive muscle relaxation, visualization, Yoga, or mindfulness.

Separate disturbing data from feelings in terms of our relationships with someone who is bipolar. This can be a successful way of reducing stress. Learn to communicate honestly and assertively. Remain wary of isolation so not to go off track too easily. In recovery look to friends and family for support if that is possible. The “healthy” family must look toward conflict resolution and shared problem solving. Your family, loved ones, and peers are there to identify warning signs of incipient mania or depression. The family focused therapist is capable of identifying difficulties or conflicts in a co-dependent family that may be producing client or family stress. A therapist can help identify critical, hostile, over-involved attitudes or behaviors in family members. The ultimate goal should be that family members become less controlling in their concerns and manage their stress more healthfully.

Kathleen Sciacca advocates working with both aspects of the co-occurring problem. Recent literature incorporates motivational interviewing including stages of change.

Dennis Daley advocates “assignments” so that clients can increase their awareness, improve their problem solving, and develop improved recovery coping skills. Cognitive Behavioral Therapy(CBT) teaches clients to incorporate positive “self talk.” CBT wants us to recognize irrational negative thoughts, all or nothing thinking, and blowing things out of proportion. CBT says, we just don’t have to live with dysfunctional distortions. Instead, clients can deal with impending or precipitated manic episodes. This mode of therapy helps clients offset negative moods of depression. Ideally, we become mindful of automatic thoughts, thinking distortions, or errors in perception.
Relapse prevention becomes vital with bipolar disorder that is chronic. It becomes vital to recognize warning signs, triggers, or high-risk situations. The goal is to better cope with factors that can make us relapse. Chemicals and their abuse are relapse factors that allow bipolar symptoms to escalate.

Those with bipolar disorder fail either by getting the wrong psychotropics or just neglect taking them as directed. Sometimes people do not realize that taking medications for mood disorder is just as important as being properly medicated for diabetes or heart disease. The right meds for mood stability plus abstinence from chemicals result in less mania and mixed mood risk taking (even suicide). The right medications are not mood altering.

Recovery can be as simple a formula as saying no to chemicals that once destabilized you. A daily regimen of correct medications, proper choice of coping techniques, following daily schedules, watching for warning signs of mania or depression in yourself or from friends can translate into longer periods illness free. Participate in positive recovery activities that you or your therapists have recommended.

It is not your fault that you or a loved one have bipolar disorder. Merely stopping prescribed medications can be enough to precipitate chemical use and relapse. Don’t be reluctant to ask a friend, client or loved one WHY they appear to be reluctant to consistently stay on their medications. You can be the reality factor. Recommend they return to their psychiatrist, their psychotherapist if they appear to be poorly compliant especially if it affects you. Sometimes, a certain wizardry by a psychiatrist may be necessary to rediscover the right blend to stabilize a bipolar patient.

Watch for negativity or self-put-downs. You can be the coach helping those with a bipolar disorder conquer mania, hypomania, anxiety, or depression. Observe carefully how someone has learned to adapt to a chronic relapsing condition. What does he or she really want out of life? Is their family safe, supporting, accepting, or nurturing? Or are they judgmental and shaming. The whole process could still simply distill down to “one day at a time.”

We advocate a major shift in thinking. Hopefully, the majority who read these thoughts can shift from self-absorption and self-defeat where we may have lived for so many years until our co-occurring problems were properly diagnosed. Instead, we look toward dual recovery from two destructive forces which if unattended clearly have had an enormous impact worldwide.

Introduction

2009-11-23T10:09:00.002-06:00

The "vision" referred to is the vision that thousands of people who have both bipolar disorder and chemical dependency will be able to maintain a positive recovery by gaining awareness and coping skills for managing this dual disorder. Peter and I have begun the process of doing research on bipolar disorder and chemical dependency and plan to continue that awareness raising process. But most of all we have our personal experience with recovery to offer. I have been in recovery from chemical dependency for the past 35 years and from bipolar disorder for the past 7 years. I HAD bipolar disorder much longer than 7 years, but did not have the diagnosis until 10 years ago and did not start taking my medications consistently until 7 years ago. To start things off I'm going to tell you how my recovery from chemical dependency got started.

I grew up in a very conservative family and spent my last 3 years of high school in a small town. Thus, it was not until I was 19 years old that I started using alcohol and marijuana. I was using marijuana every weekend at age 20. I was in my senior year of college. I had gotten my grade point average above .3 through dilligent study. However, my grades were slumping in that first semester. I took incompletes in 2 of my classes, resulting in them becoming F's when I did not complete them. We had a 1 month term between our semesters called interim and I decided that this would be a good occasion to get away. In other interims I had taken independent study and I did so again. I packed all of my things and put them in the dorm storage area. I filled one suitcase and a duffle bag with things I wanted to take and walked about a mile to the interstate freeway. I stuck out my thumb and soon was traveling to California. I have learned that it is typical for a person with bipolar to travel long distances with very little idea of where they were going or why. In my case, I was going to Berkeley to reunite with last year's roommate, even though I hadn't heard from him in 6 months.

When I got to the Berkeley college campus, I could not find my former roommate registered as a student. This did not discourage me very much. I am sure that I was in a manic episode. I had seen a group demonstrating at the entrance to the campus, so I just turned around to join the group. I spent about a week as an "outside agitator", borrowing home-made picket signs to carry as we marched around in a circle, chanting slogans. I was finding places to sleep, as I had very little money. I kept walking down one street in Berkeley, where young people were shouting out "Lids" and seeming to sell something to passers by. One day I asked one of them if they were selling LSD. He said they were selling pot, but he did have some LSD that he was willing to share with me.

The boy (about age 15) took me to his crash pad. It was an old abandoned building occupied by several groups of young people. He gave me a hit of LSD. I slept for a while, then woke up in the middle of the night and started walking on the street close to the building. I had the illusion that I was taking giant steps that got me 1/2 way down the block at a time, and at other times taking baby steps that got me nowhere. It was a totally mind-blowing experience. One that I was to attempt to repeat over and over.

Since I ran out of money, I went to a grocery store and ate a Hostess Ho-ho in the store. When I tried to repeat that trick the next day, I was arrested and put in the large Marin County jail for 3 days(it was the start of the weekend). When I did see the judge on Monday, he ordered that I leave California. If he saw me again I would go to jail for a much longer time. I hitch-hiked back towards Minnesota and got arrested for hitch-hiking in Winslow, Arizona. I had to call my parents for a bus ticket home.

My parents put me up in their basement. Besides introducing my younger brothers to pot, I spent a lot of time traveling to the West Bank of the University of Minnesota. This was the place to find LSD, Mescaline, Peyote and other psychedelic drugs. I did o.k for a few months, but then had a "bad trip" in which I thought some friends were having a party for me on the West Bank. I got my mother to drive me there. When she made a wrong turn and pulled over, I started hitting her with a hair brush. My parents brought me to Hennepin County General Hospital, where I was put on Thorazine. A week later I was sent to Anoka State Hospital on a commitment.

I stayed at Anoka for 3 1/2 months, got a job and got out, returning to my parents. After 9 months of no drugs and work, I moved out to live with some friends I had made. After 2 more months, they suggested that we take some LSD together. Again I fell asleep, then woke up in the middle of the night. I had the delusion that I was on a different planet. I was supposed to go out with no clothes in the middle of winter. It was o.k to throw on a sleeping bag and a pair of tennis shoes. After the cops caught up to me I was sent back to Anoka State Hospital for another 4 1/2 months.

Now we will flash forward a few years. In 1974 I was 27 years old and was married. My wife and I had a 2 year old daughter. I had recently lost a job. I started a new job with a group of work friends that drank alcohol frequently. I had giver up LSD after my second time in the hospital and had given up Marijuana after a very scary experience. Now, I thought, alcohol is a social drug and everybody drinks, so why don't I? The answer, I know now, is that alcohol, like other drugs, can set off a manic episode. I started drinking every weekend at the bar with friends and trying to keep 12 packs chilling in the fridge at home.

One night my wife went out with 2 of her girlfriends and left me to care for our 2 year old daughter. I began to experience delusional thoughts. I have always been a fan of science fiction. Now I began to think that the earth was being invaded by aliens. They had chosen our apartment complex as the lauching pad for their invasion! We lived on the 7th floor of a high-rise apartment building at the time. I had the fleeting thought that I should throw the 2 year old off the balcony to "save" her from the aliens. Thankfully, that thought passed. Instead I brough her down the elevator and picked her up and began to run with her from one building to another. I tried hiding us behind trees, behind the cement supports of the buildings and other places. After an hour of so, I had the thought of returning to our apartment.

Meanwhile, my wife and her friends had returned with her girlfriends and had been frantically calling all over, afraid that something had happened to us. I ranted on about how they needed to come with us to hide from the aliens. My wife and her friends had a conference and decided that one of the friends would stay with our daughter, while the other one would come with us to the nearby hospital. I was soon put in the pscyhiatric ward and placed on anti-psychotic medications.

Three weeks later, I had returned to some degree of sanity and was tremendously scared about almost having killed our daughter. I had been doing well and was given a pass to go home. Instead of going home, I went to a long-term program for chemical dependency and checked myself in. This was the start of my 35 years of sobriety. Unfortunately, I did not learn that I also have bipolar disorder until 10 years ago. During the first 25 years of my sobriety I went through 3 committed relationships and 7 good jobs. I didn't have full-blown manic episodes during that time, bu only "hypomanic" episodes. When my symptoms flared up, I became irritable and aggressive, rather than psychotic. Although staying sober improved my life, the quality of my life continued to suffer until I began to treat my bipolar disorder. I am now in Dual Recovery.

Peter and I hope that by sharing our stories and our research, people with bipolar disorder, their friends and families and professionals that work with them will gain more hope. Unfortunately, studies have shown that clients with dual disorders have a lower rate of treatment success. It doesn't have to be that way! If we can treat both illnesses together, we can do better! We hope to show that we can use evidence-based practices developed for bipolar disorder to treat dual disorder. We also hope to generate interest and discussion that will lead to new and innovative practices to cope with dual disorders. We have nothing to lose. We have much to gain! Tim Kuss

Bipolar Visions: Bipolar Disorder and Chemical Dependency:A Continuation of part I, by Peter J. Dorsen, M.D., LADC

2009-11-19T21:58:00.006-06:00

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.

Bipolar Visions: The Ravages of Bipolar Disorder and Co-occurring Addiction By Peter J. Dorsen, M.D., LADC

2009-11-18T21:55:00.004-06:00

Adapted from a talk given at the 40th Annual MARRCH Conference, St Paul River Centre: October 21, 2009

Everything is pretty calm in our kitchen this Monday night as I am pensively carving a roasted chicken just out of the oven long enough to have cooled and be ready for slicing. It’s been a week of hassles. It seems like minutes ago that I was sorting through a horrendous pile of bills looking for the few that I absolutely had to pay or “The Man” would be shutting off the phone, the electricity, or the paper delivery.

It seemed like only a week ago that the attic roof had almost burned off from an errant candle in my sixteen-year old Gabi’s recently renovated attic digs a bare few seconds away taking the rest of the house with it. Whew, I’m working on overload and am in imminent danger of imploding.

My wife at the time is into her share of problems. She’s got to deal with me and the kids. Meanwhile, her mother is back in southern Minnesota languishing at The Mayo with some unspecified form of metastatic cancer. Her usually likeable father continues to struggle from cryptic alcoholism either neglecting himself or just not always acting so nice. He’s usually blitzed by noon. We never know where or how he comes by his drug of choice. It just seems to happen between hardware or food runs. Miraculously, no DUI’s but we figure it’s because he he’s an expert at driving with one eye for all these years.

What happened next was painful for the whole family. I recall vividly turning to Gabi and telling her to “get off her phone and turn my laptop off, it was time for dinner.”
“No,” she answered without blinking an eye.
“What did you say,” I asked incredulously looking up from my chicken surgery.
“No,” she glibly repeated.

It was at this point that, while still holding the carving knife, I grabbed the phone from her simultaneously ripping the cord out of the wall. Then, of course, there was yelling and screaming from all sides: my wife at me, My wife at Gabi, Gabi at my wife, me at both of them.

That’s when my fuse blew and I said: “When I tell you to get off the phone and my laptop, I expect you will listen.”
Bria, Gabi’s elder and more theatrical sister, appeared at the top of the stairs at this point and chimed in:
“Wow, that’s pretty good stuff,” she added.
“That applies to you too, God dam it,” I shouted. You shut up and go to your room.” No one was listening to what anybody was saying especially what I was commanding ex cathedra.
“You can’t talk that way,” my wife chimed in.

By now, I had completely lost it. I couldn’t see myself gesticulating ridiculously. But it was as if I was trying to conduct an orchestra with a carving knife rather than a baton, waving it in the air like a madman. My daughters took the hint and retreated for safer territories upstairs. Here was an example of my tsunamic rage at its worst . My wife, with predictable stubbornness, stood her ground. I kept looking stupider by the moments.

As the dust began to clear and the silence became loud, we all just stood there stunned. I knew that I needed to get out and to remove myself from the craziness I had significantly created by losing control. I ran upstairs and gathered all the clothes I would need for work the next day at my outstate job. So, rather than leaving early the next morning, I took off.
When my wife talked to me the next day, the first thing she asked me the next day was, “How are you?”
“OK,” I lied having already told several of my friends how crazy and out of control I must have seemed swinging that knife around like a fiend.

One friend enlightened me that what I had done was certainly enough to have landed me in jail to protedct my family from what very well might have been perceived as their imminent danger. In hindsight, it was difficult for me to comprehend how I had lost control in the way I had.

I probably was only a 911 call away from sharing a commode, a sink, and a pull-down bunk with a roommate in jail for a DUI.
“Can I come home? I sadly asked my wife fully expecting her to say “No,” and that I would be setting up light housekeeping at some low-budget motel with plastic walls and a paper binder around the toilet certifying cleanliness.
“You can come home but only if you do something about your uncontrollable anger,” my wife warned.

Thank God, she was able to discern my pain and understand the insanity living with an illness known as bipolar II, a dangerous mixture of hypomania and disabling depression complicated by using drugs. The subsequent postings will serve to better help you understanding the mysteries of bipolar disorder and co-occurring addiction.

Bibliography from the 40th MARRCH Annual Chemical Health Conference at St. Paul, MN (Oct. 27, 2009)

2009-11-17T13:33:00.000-06:00

BIPOLAR VISIONS
Peter Dorsen, M.D., LADC and Tim Kuss, LADC, LAMFT
Bibliography

Basco, Monica and Rush, A John, Cognitive Behavioral Therapy for Bipolar Disorder
Guilford Press, London, 2007

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

Candida, Frank and Kraynik, Joseph, Bipolar Disorder for Dummies Wiley Publishing Inc, Hoboken, NJ, 2005

Castle, Lana R, Bipolar Disorder Demystified Marlease and Company, New York, 2003

Daley, Dennis and Moss, Howard Dual Disorders: Counseling Clients with Chemical Dependency and Mental Illness Hazelden Publishing, Minneapolis, MN, 2002

Duke, Patty and Hochman, Gloria, A Billiant Madness: Living with Manic Depressive Illness Bantam Books, New York, 1992

Frank, Ellen, Treating Bipolar Disorder: A Clinician’s Guide to Interpersonal and Social 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, Kay R, An Unquiet Mind Vintage Books, New York, 1995

Johnson, Sheri 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, MD, 2006

Miklowiz, 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

Oliwenstein, Lori, Taming Bipolar Disorder Alpha Books, New York, 2005

Article
Sciacca, Kathleen, “Removing Barriers: Dual Diagnosis and Motivational Interviewing”, Professional Counselor, 12(1) 41-46

Web Resources
Dual Diagnosis Website, www.users.erols.com/ksciacca
“McMan’s Depression and Bipolar Web”, www. McManweb.com
National Alliance for the Mentally Ill, www.nami.org

Videos
Daley, Dennis, “Understanding Bipolar Disorder and Addiction”, Hazelden, 1995
Dow, Tony, “Dark Glasses and Kaleidoscopes”, Depression and Bipolar Support Alliance, 2006

Workbook
Haskett, Roger and Daley, Dennis, “Understanding Bipolar Disorder and Addiction”, Hazelden, 1994

Support Groups
Depression and Bipolar Support Alliance
Dual Recovery Anonymous
National Alliance for the Mentally Ill

MY STORY

2009-11-17T12:05:00.001-06:00

Let’s get one thing straight, I’m not native-born Minnesotan. Rather, I was born in Queens, one of the boroughs of New York City at 9am by C-section. The family constellation that would interweave my life for the next 35 years would be dad, Buddy or Maurice and his beautiful wife My mother, Doctor "Lydia" (Adler); my grandparents, "Anuka and Popuka," as they were called in Hungarian, and my Aunt and Uncle, Verna and "Happy," Doctor "Howard," as he was known.

My mother had escaped from Nazi-infested Prague, where she had attended medical school not unlike Julia, Dashielle Hamut’s primary character in the book Julia. She was a determined physician who got bounced out of Flower Fifth’s obstetrics and gynecology residency because of one of her legitimate pregnancies. She would hold her own with predominantly male medical colleagues handily earning their respect. “I am A PHYSICISIAN not a WOMAN physician,” she would say when she quit the American Women’s Medical Association. She would share a practice with her more flamboyant brother Howard. I meanwhile would escape to the anonymity of his six children and away from what I felt was often the more controlling atmosphere of my own home as an only child. It was up to her as well to stabilize our family after my father, a pharmacist working for a pharmaceutical company was stricken with bulbar polio and confined to an iron lung for two years. She commuted almost daily to see her husband thirty long miles away in New York City. For Meanwhile for me, there were nannies, some good and some bad.

I would discover how to excel once I got off on my own to Peddie, a New Jersey boarding school. I would attend Dartmouth, majoring in Classics. I attended New Jersey College of Medicine and Dentistry followed by two years each at Johns Hopkins--Baltimore City Hospital and then Hennepin County Medical Center (HCMC) completing my residency in internal medicine. It was the nights off that were so exhausting. I was a player.

I spent eleven years in the inner city specializing in "diseases of the poor." I married. I had three beautiful loving daughters and I did my best to watch over my mother after my dad passed on of lung cancer in 1982 at 65. Lydia ultimately elected to succumb to her renal failure after a successful triple bypass WHILE on dialysis when she discovered she had metastatic breast cancer. I probably became depressed with her death, quit medical practice, and took to writing for any magazine or publisher that would publish me. I cranked out The Vikings Change The Play Against Alcohol and Other Dangerous Drugs, contributed to Being a Father (with Patch Adams), and Dr D’s Handbook for Men Over Forty.

I delighted cross country ski racing in my forties and was also elected a Fellow in The College of Sports Medicine. I also got some notoriety appointed by Minnesota Governor Perpich to a commission investigating the safety of fluoride. I was one of three experts who fluoridated the state of Minnesota. Dentists here love me. Plenty in some small towns up north hate us for messing with their "precious bodily fluids," to quote Doctor Strangelove.

There was the downside as well. Until 1982, I pretty consistently smoked marijuana while for decades, I suffered from episodes of depression in the Fall and Spring. After too many run ins with the Board of Medical Practice for "behavioral issues," I would first be censured and supervised but ultimately, on the second or third time around, choose to voluntarily surrender my medical license. By that time, it was all too clear that I had bipolar II disorder with some cognitive/executive dysfunction. Later, with bankcruptcy, divorce, and loss of my medical license, I had a short relapse with marijuana, and voluntarily entered chemical dependency treatment at Fairview University of Minnesota Hospital. I attended Metropolitan State University during my two year hiatus from medicine, tried practicing counseling for a year, and then threw in the towel. It just wasn’t my cup of tea. I have a part time job at Sam's Club as an associate and enjoy the responsibility and friendships there.

I am the proud father of three beautiful women, 20, 23, and 28. Although none have as yet chosen college, they are artistically inclined and continue to demonstrate that they love me. My first wife, a flutist –turned jazz vocalist, left me for her musical partner. She had had enough of my mercurial mood swings. I am remarried to Jep, a Kenyan. Her two sons, Jackson and Japheth 19 and 21, live with us. Japheth attends a local junior college where he is an honors student. Her two daughters, 23 and 25, attend universities in the Dallas area in nursing and pre-med, respectively

I anticipate getting out on the "circuit" speaking with my recent co-speaker, family therapist and counselor, Tim Kuss about bipolar disorder and co-occurring addiction. We are in the embryonic stages of embarking on a book project, Bipolar Visions—the Ravages of Bipolar Disorders.

I am not convinced there is that much power in the observation the psychiatrist evaluating me for social security disability had: "You really have had a hard life haven’t you?” he suggested sympathetically. It’s the cards I was dealt. I am not about to feel sorry for myself. I am interested with this blog, speaking, and writing a book, to reach more people challenged with this dual disorder.

I’ve married twice, practiced medicine for thirty years, tried my hand at counseling, fathered three beautiful daughters, and even fluoridated Minnesota. Uncle "Happy" always said to leave a party at the peak rather when everybody is crying into their drinks. Maybe I left medicine a tad early. However, I believe my life is filled with growth. I am active in the New Warriors also called The Mankind Project, a Robert Bly-inspired mens’ movement. Hopefully, I am developing more sensitivity toward my wife's sons I live with. Jean, 23, visits for vacations and is an added gift to me. We gladly squeeze her into our lives for Christmas.

My life continues to remain fulfilling. There have been ups and downs yet, especially recently, I have had more time to explore new horizons and possibilities. I walk on the shoulders of two sets of grandparents as well as Lydia and Buddy and, to a significant extent, because of his love of life and huge presence in my life, "Happy," another role model as a physician, father, and man. I endeavor to pass such legacies on to both my biological and step children. I struggle not to repeat what Gibbons warns: the mistakes of history. In this case, I try to balance an ongoing disorder, honor and treat my new wife respectfully, and serve as an adult presence for her young men and daughter.

Just as, Ernest Hemingway suggested, I continue try, to the best of ability, to live life as “A Moveable Feast.”