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

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

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

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.