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
Monday, November 23, 2009
Thursday, November 19, 2009
Bipolar Visions: Bipolar Disorder and Chemical Dependency: A Continuation of part I
by Peter J. Dorsen, M.D., LADC
Hopefully, I have already whetted your appetite about what can be the ravages of oc-occurring bipolar disorder and chemical dependency with my story about going berserk in our family kitchen.
We would like to tell you a little bit about what are the differences between bipolar I and bipolar II disorders. We will discuss the continuum of severity of this devastating illness. By doing so, we will talk a bit about rapid cycling and who is prone to it as well as the mixed pattern and why suicide is such a danger with it. If you are a chemical dependency counselor, our presentation will allow you to better screen for bipolar disorder and refer more effectively and quickly. If you are just a curious reader, this will help you understand more about this illness. We will discuss the latest treatment modalities used to work with different degrees of severity of the disorder and chemical dependency.
Put very simply, bipolar I disorders are episodes of mania interspersed with episodes of severe depression. Bipolar II, on the other hand, are “less serious” episodes of hypomania interspersed by episodes of severe depression. There is also a phenomenon that occurs with both forms of the illness and that is “kindling.” What this means is that, like a growing fire, small inciting incidents (pieces of wood) initially lead to the spontaneous combustion suddenly even erratically later in the course of the process. There is even a 5-15 per cent chance of someone de novo developing a full-blown manic episode given enough kindling.
Bipolar disorder is a dis-ease. It’s a medical condition. It is not a punishment or a judgment on the way you’ve lived your life. It’s not a weakness or a failure(Taming Bipolar Disorder). Bipolar disorder is about changes in your genes that cause changes in your brain that cause changes in your behavior, your personality, your emotions.
So, there are plenty of things you can do if you know you are cursed, as it were, to avoid getting sick. Get enough sleep. Eat the right foods. Manage your stressors and relationships. You need to trust your instincts when you sense you may be “going under.” It frequently helps to listen to those around you who may be intimate with your moods. Remember, knowledge is power. You are well-served to learn as much as you can about this malady. It is a chronic illness that experts like Kay Redfield Jamison tell us will be with us throughout our lives.
True, there may be something “sick” about any one of us who is bipolar. Jamison notes, “ I know plenty of people who have gone off their meds because they want to be manic again. It’s very alluring” (Touched with Fire: Manic Depressive Illness and Artistic Temperament). Here’s some interesting data: Among 47 highly celebrated British writers and artists, 38% had actually been treated for affective disorder. Thirty three per cent needed to be medicated for depression. Seventeen per cent required lithium and a hospital stay at the minimum (Jamison).
Another “celebrity” in the brain chemistry approach to psychiatric illnesses, Nancy Andreasen, M.D., found that of 30 Iowa Writers’ Workshop participants, 80% had some kind of affective disorder compared with 30% of “less creative” controls. Forty three percent of the writers were diagnosed as bipolar: a helluva price to pay for creativity. Arnold Ludwig at the University of Kentucky, who reviewed 2200 biographies of 1004 artists, writers, and musicians found 34% among the musicians with symptoms of mental illness. He detected only 9% mental illness among scientists, athletes, and business oriented interviewed.
There has perhaps unfortunately been a tendency to believe that being bipolar confers a little edge on being creative. David Miklowitz in The Bipolar Disorder Survival Guide, notes: “ The paradox of bipolar disorder is that it can be beneficial conferring a higher degree of creativity on many it touches…while at the same time it can be destroying your life…” There are plenty of notables out there with bipolar disorder and willing to “come out.” That has included Patty Duke, Connie Francis, Margot Kidder, Jimmy Piersall, Linda Hamilton, and Jane Pauley. There are the historians as well who have noted the illness in Alexander The Great, Napoleon, Oliver Cromwell, Lord Nelson, Alexander Hamilton, maybe Abraham Lincoln, Teddy Roosevelt, Winston Churchill, and Benito Mussolini.
Our primary mission may be to focus on the relationship between bipolarity and addiction. My associate Tim Kuss has promised to focus perhaps to a greater extent on this subject. A 1998 National Institute of Mental Health (NIMH) study notes: “ People who were depressed and who abused or were dependent on alcohol had a much worse outcome than did depressed people who did not drink heavily.”
Nonetheless, the reality is that one third of those with bipolar disorder have a substance abuse problem. Women especially with bipolar disorder, in particular, are seven times more likely to abuse alcohol than random women in the general population.
More tidbits are that using recreational drugs or alcohol (in excess) is going to predispose you to relapse and substance use will lead to bipolar relapse harder to stop or treat when they happen. And so it is, downers like alcohol or historically barbiturates are often the drug of choice. Those struggling with manic episodes like to “medicate” with stimulants like cocaine, amphetamines, or Ecstasy. Issues like rapid cycling or mixed presentations which we will talk about later, are more common in someone with a substance abuse problem (Goldberg et al).
A process that I can intimately relate to is the fact that there may well be cognitive compromise when there is coexisting bipolar disorder and cannabis abuse(Cahill et al, 2006). Then there is the fact that bipolar disorder is the Axis I psychiatric disorder with the highest rate of co-occurring substance use disorder (R.D. Weiss, 2004). Others warn that substance use can worsen the course of the disorder(A.J. Rush, 2003). R.S. McIntyre( Dialogues in Clinical Neuroscience. V10.no 2, 2008 et al) discuss “Medical and substance –related co-morbidity in bipolar disorder: translational research and treatment opportunities.”
Then there’s the phenomenon of rapid cycling. It occurs in both bipolar I or II forms of the disorder and means at least four episodes of either mania (hypomania) or depression in a year. The time sequence ends up generally being two weeks for a depressive episode, one week for a manic episode, or four days of a hypomanic episode. In children, all bets end up being off because they can cycle as many as two times a day with the ultra rapid form compared with cycling many times in just one day with ultradian cycling. Two quotes sum up the perversity of this affliction: “ If diagnosing bipolar I in adults seems complex, diagnosing it in children can be downright Byzantine,” or “ If bipolar disorder is scary for adults, it must be absolutely terrifying for children…” Rapid cycling is more difficult to treat. It is more frequently associated with bipolar II. Lastly, always remember that antidepressants can precipitate mania as rapid cycling.
There is a higher suicide rate with bipolar II than bipolar I(G. MacQueen, T.Young, 2001). There is an inevitable co-morbidity of abuse , anxiety, and personality disorders and bipolar disorders. It’s just a fact that psychiatrists have classically “missed” sub threshold expressions of mania. After all, with hypomania, we do not experience psychosis and rarely require hospitalization or marked impairment in functioning.
Baldessar et al found an eleven year delay in diagnosing women with bipolar disorder compared with 6.9 years in men. It seemed like an eternity before Tim or I were correctly diagnosed bipolar. Although these two reporters got into plenty of trouble from mania or hypomania, MacQueen et al in 2000 noted comparable degrees of psychosocial disability from either bipolar I or II, and that depression in bipolar disorder ends up being a stronger predictor of psychosocial outcome. I had cyclical depression, was treated with antidepressants, and finally pissed off the wrong people. Tim went “crazy” and got hospitalized plenty of the time often with the wrong diagnosis
The French investigator, Falret, was one of the first to note an unfavorable outcome course with a biphasic or “mixed” form of bipolar disorder. The description that fits this presentation best is the person slumped on the couch yet her mind is racing frantically. There is unfortunately a higher rate of suicide associated with the mixed state.
In cyclothymia, the sine curve is decidedly less pronounced. The person with this form of bipolar disorder alternates between a milder presentation of hypomania and depression than someone with bipolar II disorder. Unfortunately, it is, however, the more chronic form of the illness. It presents as short irregular cycles (days) with only short periods of “normal “ moods. Individuals wake up with mood changes. It tends to appear in the late teens and early twenties. For the longest time, cyclothymia was categorized a “personality” disorder (DSM III). Not any more. It now sits squarely in the DSM IV as a dysphoria, a mood disorder. Noteworthy, cyclothymia has the tendency six per cent of the time to develop into bipolar I or bipolar II.
I am currently struggling with issues of cognitive impairment. My dysfunction has manifested itself as executive function issues, poor judgment or the inability to successfully complete complex tasks. A study from Barcelona of 71 euthymic subjects ( individuals with normal moods) demonstrated that the bipolar groups showed significant deficits in most cognitive tasks including work memory, digit span backwards, and attention. Cognitive impairment appears to exist in both subtypes, bipolar I and II but moreso in bipolar I. The best indicators of psychosocial functioning in bipolar II were subclinical depressive symptoms, early onset of the illness, and poor performance on a measure related to executive function. Spooky, but this study hits directly home for me.
Any responsible chemical dependency counselor these days knows the importance of reinforcing that their clients stay on their meds. Lithium has been the old stand by to which all the other newcomers have been compared. It was basically discovered by Australian physician, John Cade in the late fortieshe but did not “take off” until the late nineteen sixties in the U.S. Mondimore reports a fair share of unpleasant side effects with lithium that include nausea and diarrhea, tremor, hypothyroidism, and renal failure. But they are all, for the most part, preventable or reversible. Another concern is that there is a so-called “induced refractoriness” effect. One investigator has reported 20% showing a poor restart response when lithium was stopped.
Lithium does well with euphoria. It is especially effective in those with a strong family history of bipolar disorder. It decreases the incidence of suicide six-fold. Nassir Ghaemi in Cambridge, Mass reports a thirteen-fold decrease in suicide. However, lithiuim like depakote has been reported to show an inordinately high drop-out rate. Researchers at Case Western failed to show that devalproex was more effective than lithium, the old stand by. Perhaps there is a need to reassess current prescribing away from lithium.
Depakote, the medication that I personally take, is considered excellent for treating acute mania. Yes, it may make you sleepy at the outset. It appears to prevent the severity and reoccurences of episodes. It may be better treating depressive symptoms than lithium. It is touted as being more effective treating rapid cycling and mixed forms of the disorder. It appears to be less toxic than lithium. It is helpful across the board with cyclothymia, bipolar II, “soft” bipolar disorders, and those with previous episodes of bipolar disorder. However, it is important to monitor levels and to periodically check liver function tests (LFT's) as well as blood counts.
Carbamazepine (Tegretol) may be of importance treating “resistant” bipolar disorder. Care must be exercised as tegretol can decrease the efficacy of normal strength birth control pills. It is also important with this drug to monitor "LFT’s" and blood counts. Oxcarbazepine (Trileptal) has developed a reputation for treating mania. Lamotrigine (Lamictal) has gotten the nickname, “ The child prodigy among the medications for bipolar disorder. It has a long half-life (24 hours) and may be just as effective in a long-term study as lithium. Its low side effect burden is complicated by the rare but disastrous incidence of Stevens-Johnson Syndrome or epidermal necrosis (TED). So, psychiatrists are obliged to start low and slow to ultimately achieve a daily dose of 200-400mg.
There are neurontin (Gabapentin) and topiramate (Topamax) which delightfully have been associated with weight loss. The danger of the SSRI’s especially is the danger of precipitating mania. They also carry their share of libido and erectile dysfunction issues. There are the SNRI’s like Effexor, Cymbalta, or Wellbutrin. Buproprion (Wellbutrin) and paroxetine(Paxil) seem to carry less of the danger for causing mania or associated rapid cycling.
The atypical antipsychotics like aripazole (Abilify), clozapine)Clozaril, olanzapine)( Zyprexa), quetiapine (Seroquel), respiridone (Resperdal), or zyprasadone (Geodon) have their share of issues. They block dopamine receptors and are also active at serotonin receptors. But they have the funky effect of extrpyramidal side effects; that is, involuntary movements including tardive dyskinesia which is what I experienced after a run of Zyprexa and Abilify.
No fun twitching and drooling. They are certainly considered helpful in all phases of bipolar disorder and as ongoing treatment to prevent relapse. For most and especially noxious to women patients is the reality of weight gain with this class of drugs. Recent literature is also warning about the possibility of sudden death from this class as well. We strongly suggest you consult your physician if you have any questions about them There is certainly nothing wrong with getting a second opinion.
At the risk of repetition, adults have an initial episode of mania while kids
( pediatric age and adolescents) manifest as major depression.
Kids frequently rapidly cycle as much as many times in a day whereas adults have a discrete episode. The duration in kids is chronic and continuous and discrete in adults. The adult improves between episodes while his junior counterpart does poorly. It should come as no surprise that 20-30% of children with major depression go on to develop mania later in life.
Lastly, there is a high co-morbidity of 75% between ADHD and bipolar disorder.
There is a greater incidence of rapid cycling and depression in women. Some might hypothesize that the more frequent treatment of depression in women is a setup for a higher incidence of rapid cycling. There is no time in the life of a male or female bipolar patient, when the risk of an episode is higher for a female than the post partum period. Worrisomely, lithium, valproate, and carbamazepine are all associated with birth defects. It is imperative that these medications be avoided in early pregnancy but they can be safely restarted in the latter pregnancy but certainly as soon as possible post delivery. Alcoholic women end up being much sicker with bipolar disorder.
No discussion about bipolar disorder could be complete without touching on Seasonal Affective Disorder, SAD, as it has been called. Twenty to thirty per cent of people with SAD actually end up having bipolar disorder. One treatment that has been shown to work especially in environments where there is insufficient sunlight, is exposing yourself to 10,000 lux for from ten minutes to one hour daily. This appears to be sufficient to stave off depression. The nice thing about this safe and relatively inexpensive method is that it works for bipolar disorder as well just by boosting levels of serotonin throughout the day. It works.
Psychotherapy, along with appropriate mood stabilizers, remains a vital means of treatment. Cognitive Behavioral Therapy popularized by the legendary therapist, Aaron Beck, believes that “people become depressed or manic in response to life events (and) are doing so …because they are thinking and processing these events in an inappropriate or problematic way.” There is a triad that (1) You (must) address your thought processes; (2) Make an in-depth assessment of how you interpret things; and; (3) Modify that interpretation putting you at risk of a mood disorder. The common denominator in this school of therapy is that a cognitive therapist will recognize your problematic thought processes and teach you alternative ways to think about life’s stresses. There are some good results coming out of this discipline: Lam (2003) showed a 44 versus 75% relapse rate or a lower duration of illness of 27 versus 88 days when meds were combined with psychotherapy.
Miklowitz et al, in a full two-year study, has demonstrated 52% without relapse compared to a control of 17% when an individual underwent Family Focused Therapy (FFT). FFT keeps relapse at bay instead of dealing with “crisis” management. It is important, according to Miklowitz, “… teaching family members to focus on expressing positive attitudes and emotions and to avoid criticism and negativity (which) helped these patients avoid relapse for longer and relapse less frequently and decrease symptoms of depression.
ECT, electroconvulsive therapy, has always been a controversial treatment option to me. However, it is good or better at controlling mania. It is good at lifting depression. It is useful in pregnancy for the reason that a significant number of medications are dangerous to the fetus. It is acceptable and potentially even preferable especially in intractable ultrarapid or ultradian cycling. Sure, there is the stigma popularized by Jack Nicholson in “One Flew Over The Cuckoo’s Nest.” The bottom line remains that those who end up being treated with ECT have fewer depressive episodes, spend less time in the hospital, and and have fewer hospitalizations. The downside remains that there are certainly some side effects from ECT that include at the top of the list, memory loss.
Let us not forget “Alternative Therapies.” First on the list is attempting to achieve a balanced diet. My partner reminds me that this should include plenty of leafy vegetables, go lightly on the saturated fats and processed fast foods. Studies from Harvard’s McClean Hospital advocate the linolenic fatty acids. Studies at that institution report longer time relapse free and that symptoms are significantly reduced. It is very interesting that countries where there is a high consumption of fish have a low incidence of mood disorders.
Flax seed oil has two times the content of Omega 3’s as fish oil and lacks some of the undesirable smell issues.
We are told that Vitamin E should supplement the consumption of Depakote. Zinc and copper attack bipolar disorder as does calcium and magnesium and tyrosine. Methionine may have an antidepressant effect. Several books by Dr. Andrew Weil are very informative about these issues (Healthy Aging in particular). All the information is not in on St John’s Wart. Like the antidepressants, care should be exercised about this over the counter natural product precipitating mania.
Here are the changes to watch out for that you might be becoming manic. Watch out for sleep disturbance (77%), psychosis (43%), Speeded up movements, or mood change (34%), loss or increase in appetite (20%), and increased anxiety (16%). On the other hand, depression can creep up on the best of us. Be on the look out for: mood changes(48%), slowed down movements (41%), increased anxiety (36%), increase or decrease in appetite (36%), suicidal thoughts or feelings (29%), sleep disturbance (24%). Taming Bipolar Disorder, p.192. Alison Perry in the British Journal of Medicine advocates, “ teaching patients to identify early symptoms and giving them fail-proof ways to seek prompt treatment.” Likewise, “Group psychoeducation on the signs of relapse was able to decrease the number of relapses…and the number of episodes of mania, hypomania…and depression.”
The bottom line is that anyone with bipolar disorder should not have extra medications or firearms around their home. If you are bipolar, you should abstain completely from alcohol and drugs. If you have a chemical problem, try AA or NA-- whatever works for you. Don’t self-medicate. If you have a sex addiction, get help. If you or someone you know or love is bipolar and contemplating suicide, get help. Don’t hesitate to call 911 or 1-800-SUICIDE (1800-764-2433).
Peer-run services are effective. DBSA (Depression and Bipolar Support Alliance www.dbsalliance.org (1-800-826-3632) works. The facts support that those who utilize them are hospitalized less. They have better communication with their doctors. Peer groups have the ability to empower individuals with bipolar disorders. They have the power to bring individuals into support settings who might otherwise be isolated. Suicide rates with bipolar disorder especially bipolar II are frighteningly high. Peer support opportunities offer a sense of belonging, camaraderie and friendship when none seemed to exist before. DBSA has 1000 support groups out there. They are easily available, free, and not intimidating.
“Soft” bipolar disorders include those who have a family history of bipolar disorder. Most importantly, these with "soft" bipolar disorder are the ones who some well-meaning provider may have prescribed antidepressants before a mood stabilizer. This may be someone with a history of mixed mood states. He or she may have a depressive or cycling temperament. This is the person who may ( like myself for so many years) have had recurrent depressions. I definitely struggle to categorize my illness. For a time I even wondered if mine might have begun as cyclothymia.
I queried if I had a mixed variety which had, as the tip of the iceberg, episodes of disabling and angry depression. I do know that a combination of Depakote and Celexa appear to be handling my struggle beautifully. Paul Keck notes that most people with bipolar disorder require as much as three medications to stave off further episodes of this chronic illness.
Bipolar illness is missed all too frequently.
It is a chronic, treatable illness not altogether to be considered differently from diabetes or heart disease. It is better to treat it earlier than later. It has the highest incidence of related suicide (especially bipolar II) of any psychiatric diagnosis). It has the highest likelihood of a coexisting illness than any other mental illness.
Anticipate and intervene if there is alcohol or substance abuse. They are all different: bipolar I, bipolar II, cyclothymia, or “soft” bipolar disorders. Seek a knowledgeable experienced psychologist and psychotherapist. Utilize peer support. Get evaluated for cognitive impairment at the first signs of executive or intellectual impairment. Bipolar disorder is a chronic illness from which we can survive and even excel.
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.
Wednesday, November 18, 2009
Bipolar Visions: The Ravages of Bipolar Disorder and Co-occurring Addiction By Peter J. Dorsen, M.D., LADC
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.
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.
Tuesday, November 17, 2009
Bibliography from the 40th M.A.R.R.C.H. Annual Chemical Health Conference at St. Paul, MN (Oct. 27, 2009)
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
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
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.”
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.”
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