By Tim Kuss, LADC, LMFT
As we approach the winter holidays it’s good to remember that they can be difficult to negotiate for some of us.
I remember, for example, visiting my parent’s home in a small town for a few days around Christmas. I became delusional and found myself driving around town in the middle of the night. I eventually wound up at the power plant because there were people there.
I was into my old “There’s something special for me” thinking. They eventually figured out who I was and called my parents.
One of my theories about holiday stress is that we have such high expectations. When we were kids it was a magical, miraculous time. As adults we may become aware of the loss of that magic. Now, our losses and our lack of accomplishments may loom large.
It may be best to keep our expectations down. Just plan to have an OK time for the holidays. Aim for comfortable get-togethers with your family and friends.
Forget about big presents!
Survive. If anything better happens then you’re ahead.
It’s hard to be disappointed if you don’t set yourself up for it.
Sunday, December 12, 2010
Tuesday, November 2, 2010
Social Rhythm
By Tim Kuss, LADC, LMFT
It should come as no big surprise to those of us in recovery from chemical dependency that consistent, predictable contact with other people is a stabilizing force. For years as a counselor, I have been advising clients to find a “home” AA or NA group to attend on the same night at the same time every week and to meet with a sponsor for at least an hour a week outside of meetings. We have also recognized that support from spouses, parents, siblings and friends can be an important part of recovery. I have also advocated for finding “mentors”, respected “elders” like ministers, teachers, etc, not necessarily in recovery, to connect with regularly.
So when Ellen Frank suggested that social rhythm is important in managing bipolar disorder it seemed to make sense. As part of Interpersonal Social and Rhythm Therapy she suggests that we keep track of our contact with others, as well as other daily events. Her 5 item social metric asks people with bipolar disorder to track their time out of bed, first contact with another person, the start of work, school, or other activity, dinner time and bed time.
I have long recognized that structured, “meaningful” activity aids with stability, chemical or psychological. I have seen many clients start patterns of heavy drinking after retirement, while other elderly people seem to create a new structure in their lives that gives them things “to do”. Unfortunately, some clients with chemical and mental health problems are unable to work, or are, at least, temporarily out of work. I advise them to find volunteer work and to create a “busy” schedule at least 5 days a week, which can include social activities, like cards at the senior center, church activities, projects at home, visits to museums, libraries, etc. Most communities have community education programs that offer inexpensive classes. One of the main assets of a schedule could be spending time with and around other people.
Contact with others provides “grounding” and “reality testing”. It’s harder for our thinking to get off track if we are communicating with others. Also, we are more likely to experience a sense of well-being if we are in positive, supportive relationships. It is important for families to learn positive communication and conflict resolution skills. Sometimes family therapy is necessary for this. It is also possible for one person to learn better skills and to teach by example.
I think that individuals within a couple or family may each need their own support network to some degree. It is OK for men to go to a men’s group and to spend time with buddies and for women to have their own groups and friends It is also a good idea for the couple or family to have support as a unit. Churches, temples and synagogues used to provide predictable support for families. Unfortunately, we have increasingly busy lives and often do not think of the concepts of “self-care” and “nurturing”. Predictability and regularity count a lot in terms of mood stability.
So, the concept here is “Social rhythm”. The thing to think about is our amount, types and quality of human contact. If you experience episodes of mania or depression, whether mild or severe, it may be a good idea to look at your social rhythm and how it could be adjusted.
The first step in changing social rhythm is to notice our “routine” of social contact. When one is depressed it is generally a good idea to increase our contact with others. When one is manic it is a good idea to look at the quality of our connections with others and to be on the lookout for making too much of new relationships based on too little. The type of connection we need is consistent, predictable and nurturing.
It should come as no big surprise to those of us in recovery from chemical dependency that consistent, predictable contact with other people is a stabilizing force. For years as a counselor, I have been advising clients to find a “home” AA or NA group to attend on the same night at the same time every week and to meet with a sponsor for at least an hour a week outside of meetings. We have also recognized that support from spouses, parents, siblings and friends can be an important part of recovery. I have also advocated for finding “mentors”, respected “elders” like ministers, teachers, etc, not necessarily in recovery, to connect with regularly.
So when Ellen Frank suggested that social rhythm is important in managing bipolar disorder it seemed to make sense. As part of Interpersonal Social and Rhythm Therapy she suggests that we keep track of our contact with others, as well as other daily events. Her 5 item social metric asks people with bipolar disorder to track their time out of bed, first contact with another person, the start of work, school, or other activity, dinner time and bed time.
I have long recognized that structured, “meaningful” activity aids with stability, chemical or psychological. I have seen many clients start patterns of heavy drinking after retirement, while other elderly people seem to create a new structure in their lives that gives them things “to do”. Unfortunately, some clients with chemical and mental health problems are unable to work, or are, at least, temporarily out of work. I advise them to find volunteer work and to create a “busy” schedule at least 5 days a week, which can include social activities, like cards at the senior center, church activities, projects at home, visits to museums, libraries, etc. Most communities have community education programs that offer inexpensive classes. One of the main assets of a schedule could be spending time with and around other people.
Contact with others provides “grounding” and “reality testing”. It’s harder for our thinking to get off track if we are communicating with others. Also, we are more likely to experience a sense of well-being if we are in positive, supportive relationships. It is important for families to learn positive communication and conflict resolution skills. Sometimes family therapy is necessary for this. It is also possible for one person to learn better skills and to teach by example.
I think that individuals within a couple or family may each need their own support network to some degree. It is OK for men to go to a men’s group and to spend time with buddies and for women to have their own groups and friends It is also a good idea for the couple or family to have support as a unit. Churches, temples and synagogues used to provide predictable support for families. Unfortunately, we have increasingly busy lives and often do not think of the concepts of “self-care” and “nurturing”. Predictability and regularity count a lot in terms of mood stability.
So, the concept here is “Social rhythm”. The thing to think about is our amount, types and quality of human contact. If you experience episodes of mania or depression, whether mild or severe, it may be a good idea to look at your social rhythm and how it could be adjusted.
The first step in changing social rhythm is to notice our “routine” of social contact. When one is depressed it is generally a good idea to increase our contact with others. When one is manic it is a good idea to look at the quality of our connections with others and to be on the lookout for making too much of new relationships based on too little. The type of connection we need is consistent, predictable and nurturing.
Managing Anxiety
By Tim Kuss, LADC, LMFT
This assignment is for anyone who experiences anxiety, which includes worry and fear. You may or may not have a diagnosis of anxiety disorder.
1. Describe how you experience anxiety, fear or worry.
a. If you have fear, what are you afraid of?
b. If you worry, what do you worry about?
c. Obsessive compulsive behavior can be a sign of anxiety. If you have this behavior, what is it about?
d. Are there physical symptoms? How do you breath when anxious? What happens to your heart rate? Your blood pressure?
2. Dysfunctional behavior?
a. Did you use chemicals to feel better? If so, what kind of chemicals? What effect did they have? How did you feel when the chemicals wore off?
b. What other things did you do to try to feel better? Sex, gambling, spending? How did those things work?
3. Did you know that some medications can relieve anxiety?
a. Anti-depressant meds, specifically SSRI’s can help. Are you willing to try that?
b. Benzodiazepines, such as Valium, Xanax and Klonopin are NOT good ideas for people with chemical dependency.
4. Individual therapy could be helpful
a. If you are willing to try this, please ask the therapist if they have experience with working with people with anxiety.
b. Some group therapies, such as cognitive or rational-emotive therapy can help.
5. Even if you take meds and go to therapy, it’s still a good idea to learn other COPING SKILLS for managing anxiety
a. Mindfulness skills include deep breathing and progressive muscle relaxation, including imagery and affirmations.
b. Yoga, acupuncture, or meditation may also be helpful
c. Cognitive restructuring is another positive method. This means noticing your negative self-talk, and learning to challenge and change it.
d. Distraction can help. This means doing activities like tv, reading, video games, housework, walking, work, etc,
e. Have a support network and connect with them on a regular basis
For example, find at least one person who you can share your worries or fears with and talk with them at least once a week. You can tell them that you don’t need advice and just need someone to listen. Or you can ask for suggestions some times.
6. Be involved in healthy activities that help you prevent anxiety
a. exercise for at least 15 minutes 3 to 4 times a week.
b. maintain a healthy diet. See your doctor if you need a plan for this
c. sleep 6 to 10 hours a day, depending on personal need
d. Have a daily schedule go to bed and get up about the same time every day
eat meals about the same time every day
e. Do fun stuff every day. Set aside time to do fun stuff for 1 to 3 hours at a time every week.
f. Connect with people who care about you regularly. Put it on your schedule.
7. Take a daily inventory of your anxiety, fear and worry
a. Make a plan to use coping skills to manage each one.
Questions:
What new things did you learn about anxiety, fear and worry?
What coping skills and/or strategies do you plan to use in the next week?
What skills or strategies do you plan to improve, or to develop through practice?
Read pp 12-15: Overcoming Major Anxiety Disorders and Addiction by Ihson M. Solloum, MD, MPH and Dennis Daley, MSW to get more ideas.
This assignment is for anyone who experiences anxiety, which includes worry and fear. You may or may not have a diagnosis of anxiety disorder.
1. Describe how you experience anxiety, fear or worry.
a. If you have fear, what are you afraid of?
b. If you worry, what do you worry about?
c. Obsessive compulsive behavior can be a sign of anxiety. If you have this behavior, what is it about?
d. Are there physical symptoms? How do you breath when anxious? What happens to your heart rate? Your blood pressure?
2. Dysfunctional behavior?
a. Did you use chemicals to feel better? If so, what kind of chemicals? What effect did they have? How did you feel when the chemicals wore off?
b. What other things did you do to try to feel better? Sex, gambling, spending? How did those things work?
3. Did you know that some medications can relieve anxiety?
a. Anti-depressant meds, specifically SSRI’s can help. Are you willing to try that?
b. Benzodiazepines, such as Valium, Xanax and Klonopin are NOT good ideas for people with chemical dependency.
4. Individual therapy could be helpful
a. If you are willing to try this, please ask the therapist if they have experience with working with people with anxiety.
b. Some group therapies, such as cognitive or rational-emotive therapy can help.
5. Even if you take meds and go to therapy, it’s still a good idea to learn other COPING SKILLS for managing anxiety
a. Mindfulness skills include deep breathing and progressive muscle relaxation, including imagery and affirmations.
b. Yoga, acupuncture, or meditation may also be helpful
c. Cognitive restructuring is another positive method. This means noticing your negative self-talk, and learning to challenge and change it.
d. Distraction can help. This means doing activities like tv, reading, video games, housework, walking, work, etc,
e. Have a support network and connect with them on a regular basis
For example, find at least one person who you can share your worries or fears with and talk with them at least once a week. You can tell them that you don’t need advice and just need someone to listen. Or you can ask for suggestions some times.
6. Be involved in healthy activities that help you prevent anxiety
a. exercise for at least 15 minutes 3 to 4 times a week.
b. maintain a healthy diet. See your doctor if you need a plan for this
c. sleep 6 to 10 hours a day, depending on personal need
d. Have a daily schedule go to bed and get up about the same time every day
eat meals about the same time every day
e. Do fun stuff every day. Set aside time to do fun stuff for 1 to 3 hours at a time every week.
f. Connect with people who care about you regularly. Put it on your schedule.
7. Take a daily inventory of your anxiety, fear and worry
a. Make a plan to use coping skills to manage each one.
Questions:
What new things did you learn about anxiety, fear and worry?
What coping skills and/or strategies do you plan to use in the next week?
What skills or strategies do you plan to improve, or to develop through practice?
Read pp 12-15: Overcoming Major Anxiety Disorders and Addiction by Ihson M. Solloum, MD, MPH and Dennis Daley, MSW to get more ideas.
Understanding Depression
By Tim Kuss, LADC, LMFT
I am suggesting a bio-psycho-social approach to understanding and coping with depression. The biological component comes in as we have noticed that mood disorders, such as depression, bipolar disorder and anxiety disorder tend to be found in successive generations of a family. As with alcoholism, what is inherited is a genetic predisposition to mood disorders. That means, if you have a parent, grandparent or other family member with a mood disorder, you are more likely than others to have one. It might not even be the SAME mood disorder. For example, someone’s grandmother may have had Major Depressive Disorder (depression) and that person may have bipolar disorder. We have learned that people with depression and bipolar disorder have a chemical imbalance. Medications can allow our bodies to work properly and maintain the right balance of neurotransmitters.
SSRI’s and other chemicals work as antidepressants, while lithium and certain anticonvulsants work as mood stabilizers to help manage bipolar disorder. Taking medications consistently can help us avoid episodes of depression.
The biological approach for managing depression intersects with the behavioral approach in that behaviors such as regular exercise, proper nutrition and sleep hygiene help us to avoid or cope with episodes of depression. Exposure to the sun or artificial sunlight also helps our body relieve depression.
The best psychological approach for managing depression is Cognitive Behavioral Therapy(CBT). In their book, Depression:Causes and Treatment, Aaron Beck and Brad Alford state that major depression is the leading cause of disability worldwide. They note that studies have shown changes in thyroid hormone levels in response to cognitive therapy, showing that our bodies and minds are linked. They say that depression results in a complex pattern of deviation in feelings, thoughts and behavior.
Symptoms of depression include low mood, pessimism, self-criticism, agitation, problems with memory and concentration, and physical complaints such as pain. There may be a loss of gratification with activities that starts with a few areas and expands. Activities that involve responsibility, obligation or effort become less satisfying and there is greater satisfaction in passive pursuits, including recreation, relaxation and rest..
People with depression begin to distort reality, They become preoccupied with continuous, repetitive negative thoughts(perseveration). There is often a contrast between a depressed person’s image of themselves and the objective facts. They dwell on mistakes, imperfections and inabilities, convinced that others will reject them, and that they will lose jobs, relationships, and friendships. They continue to think in themes of deprivation and defectiveness
Depression seems to be a reversal of human nature, of the survival instinct to eat and sleep and the desire to experience pleasure. Others need to respond with concern, empathy and acceptance and to be aware of the client’s difficulty in concentration and in formulating thoughts. People with depression are hypersensitive to rejection and discouragement.
The cognitive approach to managing depression involves recognizing the negative thoughts or negative self-talk that continues and increases depression. We can learn to challenge the negative thinking and replace it with neutral or positive thinking. For example, if I notice that I’m not functioning as well as normally at work, I can encourage myself to do the best I can. Instead of thinking that “I can’t do anything right” or “I’m doing so badly, that I might as well quit”, I can realize that this thinking doesn’t help the situation, and pay more attention to what I am doing well and think about what I can do today to improve the situation.
The behavioral approach involves doing things that help relieve depression. A depressed person is likely to withdraw from emotional attachments and tends to isolate from others. We can notice this and purposely spend time with others. If necessary, we can ask others to just let us be there without demanding conversation or interaction. Depression includes lethargy, but it is better to be active. Daily rituals such as walking the dog, biking, walking or swimming several times a week can be helpful.
Routine and structure can provide relief from nagging negative thoughts and feelings, so it is best to go to work or school, or to do volunteer work, or be involved in group activities, like crafts or sports. A person with depression needs to “push the envelope” in terms of involvement and activity, striving to get beyond his or her comfort zone. It’s best to start with a few small steps and keep expanding.
There is no reason why we shouldn’t pay attention to our biology, our thoughts and our behavior during the same time frame. There is no shame in taking medication for depression. We wouldn’t hesitate to take an antibiotic regardless of what people might think of us. We need to pay attention to seasonal changes including the amount of sunlight we are getting, healthy sleep habits, proper nutrition and exercising. We need to avoid isolation and too much unstructured time. We need to adjust our thinking to encourage ourselves to do all of these healthy things. Depression IS treatable. We are the prime agents in our own recovery!
I am suggesting a bio-psycho-social approach to understanding and coping with depression. The biological component comes in as we have noticed that mood disorders, such as depression, bipolar disorder and anxiety disorder tend to be found in successive generations of a family. As with alcoholism, what is inherited is a genetic predisposition to mood disorders. That means, if you have a parent, grandparent or other family member with a mood disorder, you are more likely than others to have one. It might not even be the SAME mood disorder. For example, someone’s grandmother may have had Major Depressive Disorder (depression) and that person may have bipolar disorder. We have learned that people with depression and bipolar disorder have a chemical imbalance. Medications can allow our bodies to work properly and maintain the right balance of neurotransmitters.
SSRI’s and other chemicals work as antidepressants, while lithium and certain anticonvulsants work as mood stabilizers to help manage bipolar disorder. Taking medications consistently can help us avoid episodes of depression.
The biological approach for managing depression intersects with the behavioral approach in that behaviors such as regular exercise, proper nutrition and sleep hygiene help us to avoid or cope with episodes of depression. Exposure to the sun or artificial sunlight also helps our body relieve depression.
The best psychological approach for managing depression is Cognitive Behavioral Therapy(CBT). In their book, Depression:Causes and Treatment, Aaron Beck and Brad Alford state that major depression is the leading cause of disability worldwide. They note that studies have shown changes in thyroid hormone levels in response to cognitive therapy, showing that our bodies and minds are linked. They say that depression results in a complex pattern of deviation in feelings, thoughts and behavior.
Symptoms of depression include low mood, pessimism, self-criticism, agitation, problems with memory and concentration, and physical complaints such as pain. There may be a loss of gratification with activities that starts with a few areas and expands. Activities that involve responsibility, obligation or effort become less satisfying and there is greater satisfaction in passive pursuits, including recreation, relaxation and rest..
People with depression begin to distort reality, They become preoccupied with continuous, repetitive negative thoughts(perseveration). There is often a contrast between a depressed person’s image of themselves and the objective facts. They dwell on mistakes, imperfections and inabilities, convinced that others will reject them, and that they will lose jobs, relationships, and friendships. They continue to think in themes of deprivation and defectiveness
Depression seems to be a reversal of human nature, of the survival instinct to eat and sleep and the desire to experience pleasure. Others need to respond with concern, empathy and acceptance and to be aware of the client’s difficulty in concentration and in formulating thoughts. People with depression are hypersensitive to rejection and discouragement.
The cognitive approach to managing depression involves recognizing the negative thoughts or negative self-talk that continues and increases depression. We can learn to challenge the negative thinking and replace it with neutral or positive thinking. For example, if I notice that I’m not functioning as well as normally at work, I can encourage myself to do the best I can. Instead of thinking that “I can’t do anything right” or “I’m doing so badly, that I might as well quit”, I can realize that this thinking doesn’t help the situation, and pay more attention to what I am doing well and think about what I can do today to improve the situation.
The behavioral approach involves doing things that help relieve depression. A depressed person is likely to withdraw from emotional attachments and tends to isolate from others. We can notice this and purposely spend time with others. If necessary, we can ask others to just let us be there without demanding conversation or interaction. Depression includes lethargy, but it is better to be active. Daily rituals such as walking the dog, biking, walking or swimming several times a week can be helpful.
Routine and structure can provide relief from nagging negative thoughts and feelings, so it is best to go to work or school, or to do volunteer work, or be involved in group activities, like crafts or sports. A person with depression needs to “push the envelope” in terms of involvement and activity, striving to get beyond his or her comfort zone. It’s best to start with a few small steps and keep expanding.
There is no reason why we shouldn’t pay attention to our biology, our thoughts and our behavior during the same time frame. There is no shame in taking medication for depression. We wouldn’t hesitate to take an antibiotic regardless of what people might think of us. We need to pay attention to seasonal changes including the amount of sunlight we are getting, healthy sleep habits, proper nutrition and exercising. We need to avoid isolation and too much unstructured time. We need to adjust our thinking to encourage ourselves to do all of these healthy things. Depression IS treatable. We are the prime agents in our own recovery!
Managing Depression
By Tim Kuss, LADC, LMFT
Several things influence the development of depression. Some people inherit depression. This means that their body does not work properly and they will probably need to use medications to stop their depression. Things that happen to us also influence depression. People who have bad things happen to them as children may continue to feel sad about these things long after they have grown up. The good news is that we can move beyond these effects by changing our behaviors and our thoughts. Things that happen to us and around us today also influence depression. The good news is that we can learn to cope with life events in positive ways and reduce the sadness and other negative feelings we experience.
Let’s try this.
1. What is one thing that happened or is happening to you that you feel sad about?
2. What do you think about what happened.
3. How have you acted related to what happened?
4. What have been the consequences of your thoughts and actions?
5. What can you do about the situation?
6. How can you think differently about the situation?
Would you consider taking anti-depressant medication? Why?
Would you consider going to individual therapy?
Complete pages 12 to 17 and 20,22,23 from UNDERSTANDING DEPRESSION AND ADDICTION by Daley and Thase
What are 5 ways to improve your mood?
Coping with depression:
People with depression often don’t want to get out of bed. However, getting out of bed and getting active is healthy for us. We also tend to want to stay in the house. It is better to get out of the house. Fresh air and sunshine work against depression. Activity, including exercise and work raise the level of endorphins so that we feel better. We may not want to eat, but a healthy breakfast will give us energy. It is also a good idea to set short-term achievable goals. Having daily goals that are measurable and that we can accomplish will provide encouragement and raise self-esteem. Practicing morning rituals will give us a good start to our day. Our habits can provide good structure for those days when we have low mood and aren’t sure what we want to do or if we want to do anything. Washing your hands and face, brushing your teeth and styling your hair can all provide positive feelings, while lounging around unkempt can contribute to negative thoughts and feelings about yourself.
When depressed we tend to want to isolate. We might think that we don’t measure up to other people, or that they don’t have anything to offer us. In this case we need to challenge the negative thoughts and practice positive behavior. Feel free to comment with your own positive skills for managing depression.
Several things influence the development of depression. Some people inherit depression. This means that their body does not work properly and they will probably need to use medications to stop their depression. Things that happen to us also influence depression. People who have bad things happen to them as children may continue to feel sad about these things long after they have grown up. The good news is that we can move beyond these effects by changing our behaviors and our thoughts. Things that happen to us and around us today also influence depression. The good news is that we can learn to cope with life events in positive ways and reduce the sadness and other negative feelings we experience.
Let’s try this.
1. What is one thing that happened or is happening to you that you feel sad about?
2. What do you think about what happened.
3. How have you acted related to what happened?
4. What have been the consequences of your thoughts and actions?
5. What can you do about the situation?
6. How can you think differently about the situation?
Would you consider taking anti-depressant medication? Why?
Would you consider going to individual therapy?
Complete pages 12 to 17 and 20,22,23 from UNDERSTANDING DEPRESSION AND ADDICTION by Daley and Thase
What are 5 ways to improve your mood?
Coping with depression:
People with depression often don’t want to get out of bed. However, getting out of bed and getting active is healthy for us. We also tend to want to stay in the house. It is better to get out of the house. Fresh air and sunshine work against depression. Activity, including exercise and work raise the level of endorphins so that we feel better. We may not want to eat, but a healthy breakfast will give us energy. It is also a good idea to set short-term achievable goals. Having daily goals that are measurable and that we can accomplish will provide encouragement and raise self-esteem. Practicing morning rituals will give us a good start to our day. Our habits can provide good structure for those days when we have low mood and aren’t sure what we want to do or if we want to do anything. Washing your hands and face, brushing your teeth and styling your hair can all provide positive feelings, while lounging around unkempt can contribute to negative thoughts and feelings about yourself.
When depressed we tend to want to isolate. We might think that we don’t measure up to other people, or that they don’t have anything to offer us. In this case we need to challenge the negative thoughts and practice positive behavior. Feel free to comment with your own positive skills for managing depression.
A level playing field: an illusion?
by Peter J. Dorsen M.D., LADC
It’s been a fair amount of time since I have connected with the blog but am more than ready to do so. The last entry had to do with “ a level playing field,” and whether someone with bipolar disorder can ever return to a place they were at before they were diagnosed and adequately treated.
With a number of additional fiery accusations, I said categorically “yes.” But I have been mulling over my opinion almost continually since I entered my earlier opinion. Between then and now, I have experienced at least one bout of depression and may even have experienced at least one episode albeit brief of hypomania. I usually know about the depression. I actually get irritable. I discussed my emotional state with my psychiatrist and in a collaborative fashion, I began taking a higher dose of Depakote, the anti seizure medication for my bipolar 2 disorder that has served me well of late.
Things all settled back to emotions as usual and the constipation, probably the only physiological manifestation of my mental disarray, vaporized. My ability to deal with day-to-day challenges with my wife and her stepsons improved. Any issues with my sometimes testy students seemed to be of less consequence to them and to me. Perhaps I was showing more tolerance to everyday challenges on all fronts. I doubt this was La belle indifference but more that I was once again properly medicated.
I am not aloof how significant is my interaction with my loved ones or with the students whose tuition goes toward paying my salary. However, that I was once again subject to emotional “issues” even while properly medicated made me look more objectively at what I had written and almost believed as gospel. I don’t doubt that some of my opinions could well have been an element of denial:”I don’t really have a debilitating mental illness,” I insisted. How could I? It’s adequately treated and I am euthymic. Sure, in the same article, I had also taken a poke at psychiatrists in general as drug pushers perhaps even wagged dog-wise by a pharmaceutical industry anxious financially to get a return on their investment after developing all those designer psychotropics.
Recently, the mother of an often oppositional defiant young man still working through grief and PTSD after losing his father in his mid teens, told me an interesting story. Her son thinks anyone wanting to mentor him isn’t genuine. Likewise, he opines, any professional taking on the challenge wanting to guide him along “has to be” motivated by the financial aspect of such a relationship.
However, so much about our patient-therapist relationships get guarded by professionally mandated restraints. For instance, I cannot communicate with my psychiatrist by e-mail. I cannot talk to my psychiatrist directly. I must go through his nurse clinician if I have a problem or if I need medications earlier. This disturbs me. My psychotherapist, a well-meaning MSW therapist tried to categorically explain away this communication pattern as what happens when someone(me) is dealing with a system. My response was certainly testy, “ If we don’t question the system, we will be corrupted.”
There are certainly symptoms and signs that early mania or hypomania, the opposite emotional process to depression, is in motion: am I becoming hypermanic? Here is when taking an inventory by yourself or with the help of a loved one makes sense. How am I sleeping? Am I fairly abruptly needing dramatically less sleep? Am I more edgy with my wife or associates? Am I flying off the handle over seemingly smaller issues? There are co-occurring issues: did you resume drinking or drugging? Then there’s the angle of sexuality. Some is normal, inappropriately more is not.
This addition to the blog is not meant as an apology for what I have said previously but I want it to represent a dramatic reappraisal of how my disorder works. Bipolar disorder sneaks up on you. It wiles you into believing that you don’t own it. I am offering a different message today. We can hope for as level a playing field as compliance with effective medication will allow or by how much an uncontrollable and latent genie inside us will reemerge or fluctuate autonomously. Genuine cooperation with our treatment process may determine a pinnacle we can accomplish despite a chronic illness. I do not eliminate the value of questioning how care is delivered. The studies confirm that collaborative decisions about medications and psychotherapy improve outcome.
A “level playing field” may have some ruts and bumps as those of us with bipolar disorder reconnoiter our opportunities. So, I suppose, I must now say no to my earlier premise that now appears somewhat of an illusion. In my own case I sheepishly admit that all is not as smooth sailing in our perceived “recovery’ as I might have hoped. I have alluded to hints of reemerging depression. It is not unusual that mania and hypomania resurface. Perhaps, we can identify either end of the emotional yo-yo of our illness more quickly and with help collaboratively return to that illusory “level playing field” once again.
It’s been a fair amount of time since I have connected with the blog but am more than ready to do so. The last entry had to do with “ a level playing field,” and whether someone with bipolar disorder can ever return to a place they were at before they were diagnosed and adequately treated.
With a number of additional fiery accusations, I said categorically “yes.” But I have been mulling over my opinion almost continually since I entered my earlier opinion. Between then and now, I have experienced at least one bout of depression and may even have experienced at least one episode albeit brief of hypomania. I usually know about the depression. I actually get irritable. I discussed my emotional state with my psychiatrist and in a collaborative fashion, I began taking a higher dose of Depakote, the anti seizure medication for my bipolar 2 disorder that has served me well of late.
Things all settled back to emotions as usual and the constipation, probably the only physiological manifestation of my mental disarray, vaporized. My ability to deal with day-to-day challenges with my wife and her stepsons improved. Any issues with my sometimes testy students seemed to be of less consequence to them and to me. Perhaps I was showing more tolerance to everyday challenges on all fronts. I doubt this was La belle indifference but more that I was once again properly medicated.
I am not aloof how significant is my interaction with my loved ones or with the students whose tuition goes toward paying my salary. However, that I was once again subject to emotional “issues” even while properly medicated made me look more objectively at what I had written and almost believed as gospel. I don’t doubt that some of my opinions could well have been an element of denial:”I don’t really have a debilitating mental illness,” I insisted. How could I? It’s adequately treated and I am euthymic. Sure, in the same article, I had also taken a poke at psychiatrists in general as drug pushers perhaps even wagged dog-wise by a pharmaceutical industry anxious financially to get a return on their investment after developing all those designer psychotropics.
Recently, the mother of an often oppositional defiant young man still working through grief and PTSD after losing his father in his mid teens, told me an interesting story. Her son thinks anyone wanting to mentor him isn’t genuine. Likewise, he opines, any professional taking on the challenge wanting to guide him along “has to be” motivated by the financial aspect of such a relationship.
However, so much about our patient-therapist relationships get guarded by professionally mandated restraints. For instance, I cannot communicate with my psychiatrist by e-mail. I cannot talk to my psychiatrist directly. I must go through his nurse clinician if I have a problem or if I need medications earlier. This disturbs me. My psychotherapist, a well-meaning MSW therapist tried to categorically explain away this communication pattern as what happens when someone(me) is dealing with a system. My response was certainly testy, “ If we don’t question the system, we will be corrupted.”
There are certainly symptoms and signs that early mania or hypomania, the opposite emotional process to depression, is in motion: am I becoming hypermanic? Here is when taking an inventory by yourself or with the help of a loved one makes sense. How am I sleeping? Am I fairly abruptly needing dramatically less sleep? Am I more edgy with my wife or associates? Am I flying off the handle over seemingly smaller issues? There are co-occurring issues: did you resume drinking or drugging? Then there’s the angle of sexuality. Some is normal, inappropriately more is not.
This addition to the blog is not meant as an apology for what I have said previously but I want it to represent a dramatic reappraisal of how my disorder works. Bipolar disorder sneaks up on you. It wiles you into believing that you don’t own it. I am offering a different message today. We can hope for as level a playing field as compliance with effective medication will allow or by how much an uncontrollable and latent genie inside us will reemerge or fluctuate autonomously. Genuine cooperation with our treatment process may determine a pinnacle we can accomplish despite a chronic illness. I do not eliminate the value of questioning how care is delivered. The studies confirm that collaborative decisions about medications and psychotherapy improve outcome.
A “level playing field” may have some ruts and bumps as those of us with bipolar disorder reconnoiter our opportunities. So, I suppose, I must now say no to my earlier premise that now appears somewhat of an illusion. In my own case I sheepishly admit that all is not as smooth sailing in our perceived “recovery’ as I might have hoped. I have alluded to hints of reemerging depression. It is not unusual that mania and hypomania resurface. Perhaps, we can identify either end of the emotional yo-yo of our illness more quickly and with help collaboratively return to that illusory “level playing field” once again.
Thursday, September 23, 2010
Chemical use
One of the problems is that using will provide temporary relief from anxiety, depression and other uncomfortable feelings common to Bipolar Disorder and other mental health problems. However, the longer-term effect will be increased anxiety, depression,etc. Another problem is that chemical use unbalances our brain chemistry, so that each use becomes kindling leading to more symptoms, including in my case and others, an eventual psychotic break from reality. It is best for folks with bipolar disorder to abstain from all chemical use. It could mean no more psych wards, less anxiety and depression and an overall improvement in one's quality of life. It's NOT a death sentence. Life is perfectly enjoyable without chemical use.
Friday, July 16, 2010
Have Hope!
I am at work. As I look out my window I can see the large state hospital campus that I left as a patient in 1970, 40 years ago. The old buildings are still there, now leased by the county, and there is a big new "Treatment Center" in another direction. My friends and I picketed this building, which was the cafeteria, advocating for better conditions. My journey has taken me into many situations, and I have learned much along the way. I now work with people with dual disorders and their families. Today I became a Licensed Marital and Family Therapist, another path to walk on. I want everyone out there to know that your dreams ARE possible. you have a lot to contribute and WE NEED YOU! Lift your head up and continue on your journey. Bipolar Disorder and Chemical Dependency are treatable. Tim Kuss, LMFT,LADC
Monday, June 28, 2010
What Happened to My Denial
By Tim Kuss, LADC, LMFT
I’m talking about denial of bipolar disorder and the need to take medications daily.
I believe that failure to take meds is, ultimately a denial of bipolar disorder—mine in particular. It’s not that I never had denial. In 1974, I left a psychiatric ward on pass and signed myself into a long-term chemical dependency treatment. It was easier for me to admit chemical dependency than “mental illness”. I had been in a state hospital twice, on commitment, and while there, had learned that others had been there for 20-30 years or more.
Today, we don’t see a lot of lengthy mental health stays. But two 5-month stays back then scared the be Jesus out of me. Fortunately, my treatment center did not insist that I take those horrid anti-psychotics, which they had prescribed because I had been misdiagnosed with schizophrenia. At that point, I had 25 years of sobriety with no medications and no hospitalizations for addiction issues per se. However, I had had plenty of problems with hypomania over those years, resulting in divorce, breaking up with several partners, and losing several jobs.
When I was FINALLY diagnosed with Bipolar Disorder in 1999, I believed it, but did no truly understand it. I had taken myself off anti-psychotics (and anti-depressants) in the past, and eventually went off my mood-stabilizer. I was hospitalized again in 2002. This time I almost died. My mania had me running myself ragged physically and my blood pressure was dangerously high.
I have been “med compliant” now for 8 years. I think of it as an insurance policy. My body has aged and no longer can take the physical exertion of mania. I used to go days with little or no sleep, walk for miles for days on end, and eat very little food usually with no attention to its nutritional value. Plus, I never liked psychiatric units, or the loss of freedom.
My meds do not provide negative side effects. I read about possible negative effects today, but could find none for the dose I’m taking. So why should I have denial.
I work as a chemical dependency counselor. I have seen literally hundreds of clients hospitalized because they would not accept that their chemical use has contributed to psychosis (“going crazy”). I have also seen clients try to manage without medications. My freedom requires 2 small concessions: 1. don’t use; and 2.I take my meds.
I have a pretty good life. I think I’ll keep it.
I’m talking about denial of bipolar disorder and the need to take medications daily.
I believe that failure to take meds is, ultimately a denial of bipolar disorder—mine in particular. It’s not that I never had denial. In 1974, I left a psychiatric ward on pass and signed myself into a long-term chemical dependency treatment. It was easier for me to admit chemical dependency than “mental illness”. I had been in a state hospital twice, on commitment, and while there, had learned that others had been there for 20-30 years or more.
Today, we don’t see a lot of lengthy mental health stays. But two 5-month stays back then scared the be Jesus out of me. Fortunately, my treatment center did not insist that I take those horrid anti-psychotics, which they had prescribed because I had been misdiagnosed with schizophrenia. At that point, I had 25 years of sobriety with no medications and no hospitalizations for addiction issues per se. However, I had had plenty of problems with hypomania over those years, resulting in divorce, breaking up with several partners, and losing several jobs.
When I was FINALLY diagnosed with Bipolar Disorder in 1999, I believed it, but did no truly understand it. I had taken myself off anti-psychotics (and anti-depressants) in the past, and eventually went off my mood-stabilizer. I was hospitalized again in 2002. This time I almost died. My mania had me running myself ragged physically and my blood pressure was dangerously high.
I have been “med compliant” now for 8 years. I think of it as an insurance policy. My body has aged and no longer can take the physical exertion of mania. I used to go days with little or no sleep, walk for miles for days on end, and eat very little food usually with no attention to its nutritional value. Plus, I never liked psychiatric units, or the loss of freedom.
My meds do not provide negative side effects. I read about possible negative effects today, but could find none for the dose I’m taking. So why should I have denial.
I work as a chemical dependency counselor. I have seen literally hundreds of clients hospitalized because they would not accept that their chemical use has contributed to psychosis (“going crazy”). I have also seen clients try to manage without medications. My freedom requires 2 small concessions: 1. don’t use; and 2.I take my meds.
I have a pretty good life. I think I’ll keep it.
Friday, June 25, 2010
Doomed or Can We Reach a Level Playing Field?
My blogmate, Tim Kuss, recently emphasized accepting one's mental illness-in our case, this is bipolar disorder-just as much as building and maintaining sobriety. You know, it's worked for Tim, I daresay, and for me especially since we both have been clean and sober for an impressive amount of time, take our medications deliberatively, and “take an active role in the design and delivery" of our care.
I really love Mathew Mattson and Sue Bergeson of the Depression and Bipolar Support Alliance (DBSA)'s remonstration that "the ultimate goal of treatment should be to engender hope." However, sometimes I wonder how that can actualize if we realize that we will continue to always have a chronic illness that will be there to haunt us especially if we do not walk the straight and narrow.
Dr. Jeffrey L. Sussman, in The Primary Care Companion to the Journal of Clinical Psychiatry, waxes profound when he notes, " The goal of treatment (for bipolar disorder) has changed in recent years from one of symptom abatement to one of recovery; that is returning patients to their level of functioning prior to the onset of illness."
Mover and shaker psychiatrist, Dr. Nada Stotland, allude to "moving beyond symptomatic recovery to also encompass functional recovery" She advocates ways to make this happen: (1) She wants “ policy and system changes to facilitate recovery.”
(2) She asks for “ improved funding for recovery-oriented care.” (3) She wants “implementation of recovery-oriented, collaborative care models that bring together psychiatrists and primary care providers.” Lastly, (4) She wants the “dissemination of improved tools for monitoring changes in symptoms and level of functioning.
Mattson and Bergeson emphasize that “the ultimate goal of treatment must be recovery” and that “consumers should take an active role in the design and delivery of their own care"
I want to dig deeper because I am not convinced the majority of practicing clinicians buy into this view. Many behavioralists, I suspect, focus on the "flavors" of one or the other presentations of bipolar disorder: are you manic and depressed, just a little off the wall, or rapidly cycling between ups and downs? The DSM IV has a diagnosis that fits you.
There are plenty of naysayers who would suggest that there is a greater tendency to define and treat in this New Age of twenty-minute Psychiatric visits. Is there a fiscal relationship between the plethora of psychotropics on the market and how many the average bipolar patient now takes? Does the tail wag the dog? Has "pushing" psychotropics to whatever extent supplanted interactive psychiatry?
Is there a financial impropriety based on the incredible profits engendered by so many medications? Have psychiatrists literally been "bought out" by the mega pharmaceutical companies?
So what is the incentive that anyone with bipolar illness will actually ever "get better?" I am not advocating that the bipolar patient as soon as they feel good again stop taking their medications. Sussman advocates utilizing an effective treatment team. I heartily agree with him and feel, to the bottom of my soul, that collaboration between the patient and physician is crucial. Such an approach demands mutual communication between physician and someone with bipolar disorder. Also, collaboration between primary care providers and specialists (psychiatrists, psychotherapists) is proven to have better outcomes.
Those lucky enough to have been treated collaboratively admitted better attitude about taking their medications and how bad they felt. They also just functioned better. Here again, these innovative psychiatrists are directing our attention toward returning to a level playing field; that is, somewhere before we began our struggle. Is that possible?
We circle around to the question whether someone like myself with known bipolar disorder can ever function normally again? "But you demonstrate compromise of executive and cognitive function on psychometric testing," they may tell you. However, the same psychologist may have performed testing under less than ideal emotional circumstances or under stressful conditions possibly contaminating the results.
In summary, it is my opinion also that a bipolar patient, collaboratively with appropriate medications from a perceptive yet vigilant psychiatrist and a knowledgeable therapist with co-occurring issues in check (anxiety, alcohol and drugs) CAN return to a level playing field.
I really love Mathew Mattson and Sue Bergeson of the Depression and Bipolar Support Alliance (DBSA)'s remonstration that "the ultimate goal of treatment should be to engender hope." However, sometimes I wonder how that can actualize if we realize that we will continue to always have a chronic illness that will be there to haunt us especially if we do not walk the straight and narrow.
Dr. Jeffrey L. Sussman, in The Primary Care Companion to the Journal of Clinical Psychiatry, waxes profound when he notes, " The goal of treatment (for bipolar disorder) has changed in recent years from one of symptom abatement to one of recovery; that is returning patients to their level of functioning prior to the onset of illness."
Mover and shaker psychiatrist, Dr. Nada Stotland, allude to "moving beyond symptomatic recovery to also encompass functional recovery" She advocates ways to make this happen: (1) She wants “ policy and system changes to facilitate recovery.”
(2) She asks for “ improved funding for recovery-oriented care.” (3) She wants “implementation of recovery-oriented, collaborative care models that bring together psychiatrists and primary care providers.” Lastly, (4) She wants the “dissemination of improved tools for monitoring changes in symptoms and level of functioning.
Mattson and Bergeson emphasize that “the ultimate goal of treatment must be recovery” and that “consumers should take an active role in the design and delivery of their own care"
I want to dig deeper because I am not convinced the majority of practicing clinicians buy into this view. Many behavioralists, I suspect, focus on the "flavors" of one or the other presentations of bipolar disorder: are you manic and depressed, just a little off the wall, or rapidly cycling between ups and downs? The DSM IV has a diagnosis that fits you.
There are plenty of naysayers who would suggest that there is a greater tendency to define and treat in this New Age of twenty-minute Psychiatric visits. Is there a fiscal relationship between the plethora of psychotropics on the market and how many the average bipolar patient now takes? Does the tail wag the dog? Has "pushing" psychotropics to whatever extent supplanted interactive psychiatry?
Is there a financial impropriety based on the incredible profits engendered by so many medications? Have psychiatrists literally been "bought out" by the mega pharmaceutical companies?
So what is the incentive that anyone with bipolar illness will actually ever "get better?" I am not advocating that the bipolar patient as soon as they feel good again stop taking their medications. Sussman advocates utilizing an effective treatment team. I heartily agree with him and feel, to the bottom of my soul, that collaboration between the patient and physician is crucial. Such an approach demands mutual communication between physician and someone with bipolar disorder. Also, collaboration between primary care providers and specialists (psychiatrists, psychotherapists) is proven to have better outcomes.
Those lucky enough to have been treated collaboratively admitted better attitude about taking their medications and how bad they felt. They also just functioned better. Here again, these innovative psychiatrists are directing our attention toward returning to a level playing field; that is, somewhere before we began our struggle. Is that possible?
We circle around to the question whether someone like myself with known bipolar disorder can ever function normally again? "But you demonstrate compromise of executive and cognitive function on psychometric testing," they may tell you. However, the same psychologist may have performed testing under less than ideal emotional circumstances or under stressful conditions possibly contaminating the results.
In summary, it is my opinion also that a bipolar patient, collaboratively with appropriate medications from a perceptive yet vigilant psychiatrist and a knowledgeable therapist with co-occurring issues in check (anxiety, alcohol and drugs) CAN return to a level playing field.
Monday, May 3, 2010
Managing Depression
MANAGING DEPRESSION
Tim Kuss, LADC, LAMFT
I am suggesting a bio-psycho-social approach to understanding and coping with depression. The biological component comes in as we have noticed that mood disorders, such as depression, bipolar disorder and anxiety disorder tend to be found in successive generations of a family. As with alcoholism, what is inherited is a genetic predisposition to mood disorders. That means, if you have a parent, grandparent or other family member with a mood disorder, you are more likely than others to have one. It might not even be the SAME mood disorder. For example, someone’s grandmother may have had Major Depressive Disorder (depression) and that person may have Bipolar Disorder. We have learned that people with depression and Bipolar disorder have a chemical imbalance. Medications can allow our bodies to work properly and maintain the right balance of neurotransmitters. SSRI’s and other chemicals work as antidepressants, while Lithium and certain anticonvulsants work as mood stabilizers to help manage bipolar disorder. Taking medications consistently can help us to avoid episodes of depression.
The biological approach for managing depression intersects with the behavioral approach in that behaviors such as regular exercise, proper nutrition and sleep hygiene help us to avoid or cope with episodes of depression. Exposure to the sun or artificial sunlight also helps our body to relieve depression.
The best psychological approach for managing depression is Cognitive Behavioral Therapy. In their book, Depression:Causes and Treatment, Aaron Beck and Brad Alford state that major depression is the leading cause of disability worldwide. They note that studies have shown changes in thyroid hormone levels in response to cognitive therapy, showing that our bodies and minds are linked. They say that depression results in a complex pattern of deviation in feelings, thoughts and behavior.
Symptoms of depression include low mood, pessimism, self-criticism, agitation, problems with memory and concentration, and physical complaints, such as pain. There may be a loss of gratification with activities that starts with a few areas and expands. Activities that involve responsibility, obligation or effort become less satisfying and there is greater satisfaction in passive pursuits, including recreation, relaxation and rest..
People with depression begin to distort reality, They become preoccupied with continuous, repetitive negative thoughts. There is often a contrast between a depressed person’s image of themselves and the objective facts. They dwell on mistakes, imperfections and inabilities, convinced that others will reject them, and that they will lose jobs, relationships, and friendships. They continue to think in themes of deprivation and defectiveness
Depression seems to be a reversal of human nature, of the survival instinct to eat and sleep and the desire to experience pleasure. Others need to respond with concern, empathy and acceptance and to be aware of the client’s difficulty in concentration and in formulating thoughts. People with depression re hypersensitive to rejection and discouragement.
The cognitive approach to managing depression involves recognizing the negative thoughts, or negative self-talk that continues and increases depression. We can learn to challenge the negative thinking and replace it with neutral or positive thinking. For example, if I notice that I’m not functioning as well as normally at work, I can encourage myself to do the best I can. Instead of thinking that “I can’t do anything right” or “I’m doing so badly, that I might as well quit”, I can realize that this thinking doesn’t help the situation, and pay more attention to what I am doing well.
The behavioral approach involves doing things that help relieve depression. A depressed person is likely to withdraw from emotional attachments and tends to isolate from others. We can notice this and purposely spend time with others. If necessary, we can ask others to just let us be there without demanding conversation or interaction. Depression includes lethargy, but it is better to be active. Daily rituals such as walking the dog, and biking, walking or swimming several times a week can be helpful. Routine and structure can provide relief from nagging negative thoughts and feelings, so it is best to go to work or school, or to do volunteer work, or be involved in group activities, like crafting, or sports. A person with depression needs to “Push the envelope” in terms of involvement and activity, striving to get beyond one’s comfort zone. It’s best to start with a few small steps and keep expanding.
There is no reason why we pay attention to our biology, our thoughts and our behavior during the same time frame. There is no shame in taking medication for depression. Would we not take an antibiotic because of what people might think of us? We need to pay attention to seasonal changes, including the amount of sunlight we are getting, to healthy sleep habits, to proper nutrition and to exercise. We need to avoid isolation and too much unstructured time. We need to adjust our thinking to encourage ourselves to do all of these healthy things. Depression IS treatable. We are the prime agents in our own recovery!
Tim Kuss, LADC, LAMFT
I am suggesting a bio-psycho-social approach to understanding and coping with depression. The biological component comes in as we have noticed that mood disorders, such as depression, bipolar disorder and anxiety disorder tend to be found in successive generations of a family. As with alcoholism, what is inherited is a genetic predisposition to mood disorders. That means, if you have a parent, grandparent or other family member with a mood disorder, you are more likely than others to have one. It might not even be the SAME mood disorder. For example, someone’s grandmother may have had Major Depressive Disorder (depression) and that person may have Bipolar Disorder. We have learned that people with depression and Bipolar disorder have a chemical imbalance. Medications can allow our bodies to work properly and maintain the right balance of neurotransmitters. SSRI’s and other chemicals work as antidepressants, while Lithium and certain anticonvulsants work as mood stabilizers to help manage bipolar disorder. Taking medications consistently can help us to avoid episodes of depression.
The biological approach for managing depression intersects with the behavioral approach in that behaviors such as regular exercise, proper nutrition and sleep hygiene help us to avoid or cope with episodes of depression. Exposure to the sun or artificial sunlight also helps our body to relieve depression.
The best psychological approach for managing depression is Cognitive Behavioral Therapy. In their book, Depression:Causes and Treatment, Aaron Beck and Brad Alford state that major depression is the leading cause of disability worldwide. They note that studies have shown changes in thyroid hormone levels in response to cognitive therapy, showing that our bodies and minds are linked. They say that depression results in a complex pattern of deviation in feelings, thoughts and behavior.
Symptoms of depression include low mood, pessimism, self-criticism, agitation, problems with memory and concentration, and physical complaints, such as pain. There may be a loss of gratification with activities that starts with a few areas and expands. Activities that involve responsibility, obligation or effort become less satisfying and there is greater satisfaction in passive pursuits, including recreation, relaxation and rest..
People with depression begin to distort reality, They become preoccupied with continuous, repetitive negative thoughts. There is often a contrast between a depressed person’s image of themselves and the objective facts. They dwell on mistakes, imperfections and inabilities, convinced that others will reject them, and that they will lose jobs, relationships, and friendships. They continue to think in themes of deprivation and defectiveness
Depression seems to be a reversal of human nature, of the survival instinct to eat and sleep and the desire to experience pleasure. Others need to respond with concern, empathy and acceptance and to be aware of the client’s difficulty in concentration and in formulating thoughts. People with depression re hypersensitive to rejection and discouragement.
The cognitive approach to managing depression involves recognizing the negative thoughts, or negative self-talk that continues and increases depression. We can learn to challenge the negative thinking and replace it with neutral or positive thinking. For example, if I notice that I’m not functioning as well as normally at work, I can encourage myself to do the best I can. Instead of thinking that “I can’t do anything right” or “I’m doing so badly, that I might as well quit”, I can realize that this thinking doesn’t help the situation, and pay more attention to what I am doing well.
The behavioral approach involves doing things that help relieve depression. A depressed person is likely to withdraw from emotional attachments and tends to isolate from others. We can notice this and purposely spend time with others. If necessary, we can ask others to just let us be there without demanding conversation or interaction. Depression includes lethargy, but it is better to be active. Daily rituals such as walking the dog, and biking, walking or swimming several times a week can be helpful. Routine and structure can provide relief from nagging negative thoughts and feelings, so it is best to go to work or school, or to do volunteer work, or be involved in group activities, like crafting, or sports. A person with depression needs to “Push the envelope” in terms of involvement and activity, striving to get beyond one’s comfort zone. It’s best to start with a few small steps and keep expanding.
There is no reason why we pay attention to our biology, our thoughts and our behavior during the same time frame. There is no shame in taking medication for depression. Would we not take an antibiotic because of what people might think of us? We need to pay attention to seasonal changes, including the amount of sunlight we are getting, to healthy sleep habits, to proper nutrition and to exercise. We need to avoid isolation and too much unstructured time. We need to adjust our thinking to encourage ourselves to do all of these healthy things. Depression IS treatable. We are the prime agents in our own recovery!
Wednesday, April 7, 2010
“Recognition and treatment Strategies for Bipolar Disorder Across the Life Cycle,” Primary Psychiatry 17:2 (Suppl 3) adapted by Peter J. Dorsen, M.D., LADC
The series kicks off with Joseph F. Goldberg, M.D., director of the Affective Disorders program at Silver Hill Hospital in New Canaan, Connecticut, by defining the bipolar entity, “ not otherwise specified,” as sub-threshold mania or hypomania. This type of bipolar disorder had a prevalence rate of 2.4%. This “expert” also notes "approximately a doubling diagnosing bipolar disorder of any type with “greater screening and surveillance.” Also, approximately 2/3 of bipolar patients will identify their first mood symptoms before early adulthood (note a modal peak between 15 and 19).
Hirschfield et al in J Clin Psychiatry. 2003; 64(2): 161-174., has noted that 60% of patients with bipolar disorder were “misidentified with unipolar depression.” As much as 54% of postpartum women appeared to be experiencing unipolar depression but in fact had a history of bipolar disorder. The fact is that there are so many issues that can mimic bipolar presentation: anxiety, substance abuse, steroids, even anti-depressants They ALL can produce secondary manias. They remind us to also consider Cluster B personality disorder which can share with mania or hypomania features such as mood instability or impulsivity.
Eighty five to 90% of children with bipolar disorder also meet the DSM IV criteria for ADHD. Goldberg emphasizes “both the overdiagnosis and underdiagnosis in patients with suspected bipolar disorder.” He advises “examining…symptoms such as decreased need for sleep, increased psychomotor activity, and the cognitive-behavioral and language features that comprise the constellation of mania or hypomania.” Also, he cautions, family history can be “somewhat challenging as bipolar illness does not follow Mendelian inheritance.” Therefore, if a strong family history is not available, this is not a clear negative predictive value.
Charles Borden, an M.D. at the University of Texas, San Antonio Health Science Center, emphasizes that clinicians RARELY see bipolar patients who do not have an anxiety disorder. “If anxiety disorder is present, patients are more likely to have substance abuse disorders, other impulse control disorders, eating disorders, and other personality disorders.” Borden notes: “In particular, if the prevalence rates of all anxiety disorders are grouped together, they are almost as prevalent as bipolar disorder itself, and clinicians rarely see a patient with bipolar disorder who does not have an anxiety disorder.” (Perugi G et al The temporal relationship between anxiety disorder and hypomania: a retrospective examination of 63 panic, social phobic and obsessive-compulsive patients with comorbid bipolar disorder. J Affect Disord 2001; 67(1-3): 199-206).
One in five with major depressive disorder (MDD) has bipolar disorder. Prevalence studies in MDD show at least 20% of patients with depressive episodes have either type I or type II bipolar disorders. He suggests that clinicians perhaps may fail to elicit histories of hypomanic illness because they are not spontaneously reported.
Claudia Baldassano, M.D., from the University of Pennsylvania, reports a significant reduction in mortality ratios for patients actively in treatment (29.2 versus 6.4% from suicide). Judd et al noted bipolar patients were most likely to be symptomatic with depression. Unfortunately, despite this reality, “monotherapy” is twice as commonly prescribed as mood stabilizers. Aripiprazole (Abilify) “fails to show positive evidence” for bipolar disorder ( despite what seems like a major media campaign touting its benefits for depression).
From a personal perspective, I was relieved to learn that divalproex (Depakote) may be effective for bipolar depression symptoms. She also reports for maintenance therapy “less efficacy” but “better tolerability” for the mood stabilizers. She notes that lamotrigine (Lemictal) is “well-tolerated and that it does not cause weight gain.
Noreen Reilly-Harrington, Ph.D from Mass General Hosptial confirms again that “adjunctive psychological treatments can help reduce relapse and provide patients as well as their families with tools…” She notes that three forms of intensive intervention : (1) cognitive behavioral therapy (CBT), interpersonal and social rhythm therapy, and family-focused treatment, were favorably compared with brief three-session psychoeducational intervention(collaborative care).
She found that any of these three showed (1) Median time to recovery 110 days earlier; (2) Higher year-end recovery rates; and (3) More than one to 1.5 times likely to be clinically well during any study month. She did not report any significant differences between the three intensive treatments. It is interesting that CBT, established in the 1960’s, was primarily used for unipolar depression. However, its main focus still remains education and problem solving. CBT is also effective for co-morbid anxiety, panic disorder, OCD, and social anxiety.
Reilly-Harrington advocates regulating schedules and monitoring moods daily to recognize any early warning signs of relapse. “Patients… take part in the planning of their treatment plan and to exercise choice in control.” Mood charting allows patients to develop awareness about their illness. Such a routine allows successful tracking of medication doses and treatment compliance. We as patients with bipolar disorder are not known for our compliance. She advises regulating daily schedules of activity including sleep-wake cycles, meal times, and work schedules.
In summary, these articles further help emphasize the challenges of identifying bipolar disorder especially with the likelihood of co-occurring and co-morbid problems. Anxiety almost inevitably co-exists with bipolar disorder. These authors offer us appropriate, unique, and effective psychotropic treatment advice. Lastly, although medications remain “the mainstay” of treatment, psychosocial modalities unquestionably enhance and improve outcomes.
Hirschfield et al in J Clin Psychiatry. 2003; 64(2): 161-174., has noted that 60% of patients with bipolar disorder were “misidentified with unipolar depression.” As much as 54% of postpartum women appeared to be experiencing unipolar depression but in fact had a history of bipolar disorder. The fact is that there are so many issues that can mimic bipolar presentation: anxiety, substance abuse, steroids, even anti-depressants They ALL can produce secondary manias. They remind us to also consider Cluster B personality disorder which can share with mania or hypomania features such as mood instability or impulsivity.
Eighty five to 90% of children with bipolar disorder also meet the DSM IV criteria for ADHD. Goldberg emphasizes “both the overdiagnosis and underdiagnosis in patients with suspected bipolar disorder.” He advises “examining…symptoms such as decreased need for sleep, increased psychomotor activity, and the cognitive-behavioral and language features that comprise the constellation of mania or hypomania.” Also, he cautions, family history can be “somewhat challenging as bipolar illness does not follow Mendelian inheritance.” Therefore, if a strong family history is not available, this is not a clear negative predictive value.
Charles Borden, an M.D. at the University of Texas, San Antonio Health Science Center, emphasizes that clinicians RARELY see bipolar patients who do not have an anxiety disorder. “If anxiety disorder is present, patients are more likely to have substance abuse disorders, other impulse control disorders, eating disorders, and other personality disorders.” Borden notes: “In particular, if the prevalence rates of all anxiety disorders are grouped together, they are almost as prevalent as bipolar disorder itself, and clinicians rarely see a patient with bipolar disorder who does not have an anxiety disorder.” (Perugi G et al The temporal relationship between anxiety disorder and hypomania: a retrospective examination of 63 panic, social phobic and obsessive-compulsive patients with comorbid bipolar disorder. J Affect Disord 2001; 67(1-3): 199-206).
One in five with major depressive disorder (MDD) has bipolar disorder. Prevalence studies in MDD show at least 20% of patients with depressive episodes have either type I or type II bipolar disorders. He suggests that clinicians perhaps may fail to elicit histories of hypomanic illness because they are not spontaneously reported.
Claudia Baldassano, M.D., from the University of Pennsylvania, reports a significant reduction in mortality ratios for patients actively in treatment (29.2 versus 6.4% from suicide). Judd et al noted bipolar patients were most likely to be symptomatic with depression. Unfortunately, despite this reality, “monotherapy” is twice as commonly prescribed as mood stabilizers. Aripiprazole (Abilify) “fails to show positive evidence” for bipolar disorder ( despite what seems like a major media campaign touting its benefits for depression).
From a personal perspective, I was relieved to learn that divalproex (Depakote) may be effective for bipolar depression symptoms. She also reports for maintenance therapy “less efficacy” but “better tolerability” for the mood stabilizers. She notes that lamotrigine (Lemictal) is “well-tolerated and that it does not cause weight gain.
Noreen Reilly-Harrington, Ph.D from Mass General Hosptial confirms again that “adjunctive psychological treatments can help reduce relapse and provide patients as well as their families with tools…” She notes that three forms of intensive intervention : (1) cognitive behavioral therapy (CBT), interpersonal and social rhythm therapy, and family-focused treatment, were favorably compared with brief three-session psychoeducational intervention(collaborative care).
She found that any of these three showed (1) Median time to recovery 110 days earlier; (2) Higher year-end recovery rates; and (3) More than one to 1.5 times likely to be clinically well during any study month. She did not report any significant differences between the three intensive treatments. It is interesting that CBT, established in the 1960’s, was primarily used for unipolar depression. However, its main focus still remains education and problem solving. CBT is also effective for co-morbid anxiety, panic disorder, OCD, and social anxiety.
Reilly-Harrington advocates regulating schedules and monitoring moods daily to recognize any early warning signs of relapse. “Patients… take part in the planning of their treatment plan and to exercise choice in control.” Mood charting allows patients to develop awareness about their illness. Such a routine allows successful tracking of medication doses and treatment compliance. We as patients with bipolar disorder are not known for our compliance. She advises regulating daily schedules of activity including sleep-wake cycles, meal times, and work schedules.
In summary, these articles further help emphasize the challenges of identifying bipolar disorder especially with the likelihood of co-occurring and co-morbid problems. Anxiety almost inevitably co-exists with bipolar disorder. These authors offer us appropriate, unique, and effective psychotropic treatment advice. Lastly, although medications remain “the mainstay” of treatment, psychosocial modalities unquestionably enhance and improve outcomes.
Tuesday, March 23, 2010
More on Mania and Mortality
by Peter J. Dorsen M.D., LADC
Dylan Murray et al in Mania and Mortality: "Why the Excess Cardiovascular Risk in Bipolar Disorder?" From Current Psychiatry Reports 2009, 11: 475-480, raises more questions why individuals with bipolar disorder have twice the cardiovascular mortality as the general population(prevalence ratio of 1.6). For one thing, metabolic syndrome is more common in this population.
Just being manic increases your chances for such increased mortality. There is a significant history of sudden death from cardiovascular factors in manic individuals. Confounders include behavior, access to treatment, quality of health care, and underlying pathophysiology. I can relate because I have mentioned previously experiencing an MI requiring angioplasty and two stents three years ago. I did not have any of the criteria for metabolic syndrome that include abdominal obesity, diabetes, dyslipidemia or hypertension.
The authors point out that our U.S. population certainly has its share of both metabolic syndrome and diabetes. Certainly, other studies warn about the dangers as well with associated smoking, an elevated total cholesterol, with specifically a reduced high-density lipoprotein (the “good” cholesterol).
Because of such significant associations, the authors advocate screening bipolar disorder patients for diabetes and metabolic syndrome especially if they happen to be on second-generation antipsychotics. They warn that bipolar disorder appears to negatively affect fat metabolism in women. Bipolar I patients appear to be at higher risk for cardiovascular mortality than bipolar II individuals. They attribute such disparity to a higher incidence of mania in bipolar I disorder. There appears to be less likelihood that the manic patient will have a primary care physician.
There may well be barriers to optimal medical care. Such patients may have difficulties navigating through the health care system. Murray et al suggest better integrated health care. They are suggesting better lines of communication between psychiatrist and primary care giver. They warn as well about QTc prolongation (the repolarization phase of the cardiogram). Ray et al warn about sudden death among atypical antipsychotic users (N Engl J Med 2009, 360:225-235).
Perhaps increased mortality can be attributed to increased smoking, medication-related weight gain, or linking genetic risk or pathophysiologic processes of bipolar disorder to elevated cardiovascular risk. They even ruminate about an overactive inflammatory response in bipolar patients.
These authors note that less than half of psychiatrists actually are monitoring lipid levels or waist circumference. Anyone on second-generation antipsychotics deserves to be monitored for family history of diabetes, body mass-index, weight gain and triglyceride levels. They reflect on compliance as well related to “ limited insight, a negative view of medications, and substance abuse.” They allude to studying cardiovascular risk in youth with bipolar disorder thus eliminating confounding variables.
In their own words, “Further education may improve recognition and screening for traditional risk factors and may result in better cardiovascular outcomes for this at-risk population.”
Dylan Murray et al in Mania and Mortality: "Why the Excess Cardiovascular Risk in Bipolar Disorder?" From Current Psychiatry Reports 2009, 11: 475-480, raises more questions why individuals with bipolar disorder have twice the cardiovascular mortality as the general population(prevalence ratio of 1.6). For one thing, metabolic syndrome is more common in this population.
Just being manic increases your chances for such increased mortality. There is a significant history of sudden death from cardiovascular factors in manic individuals. Confounders include behavior, access to treatment, quality of health care, and underlying pathophysiology. I can relate because I have mentioned previously experiencing an MI requiring angioplasty and two stents three years ago. I did not have any of the criteria for metabolic syndrome that include abdominal obesity, diabetes, dyslipidemia or hypertension.
The authors point out that our U.S. population certainly has its share of both metabolic syndrome and diabetes. Certainly, other studies warn about the dangers as well with associated smoking, an elevated total cholesterol, with specifically a reduced high-density lipoprotein (the “good” cholesterol).
Because of such significant associations, the authors advocate screening bipolar disorder patients for diabetes and metabolic syndrome especially if they happen to be on second-generation antipsychotics. They warn that bipolar disorder appears to negatively affect fat metabolism in women. Bipolar I patients appear to be at higher risk for cardiovascular mortality than bipolar II individuals. They attribute such disparity to a higher incidence of mania in bipolar I disorder. There appears to be less likelihood that the manic patient will have a primary care physician.
There may well be barriers to optimal medical care. Such patients may have difficulties navigating through the health care system. Murray et al suggest better integrated health care. They are suggesting better lines of communication between psychiatrist and primary care giver. They warn as well about QTc prolongation (the repolarization phase of the cardiogram). Ray et al warn about sudden death among atypical antipsychotic users (N Engl J Med 2009, 360:225-235).
Perhaps increased mortality can be attributed to increased smoking, medication-related weight gain, or linking genetic risk or pathophysiologic processes of bipolar disorder to elevated cardiovascular risk. They even ruminate about an overactive inflammatory response in bipolar patients.
These authors note that less than half of psychiatrists actually are monitoring lipid levels or waist circumference. Anyone on second-generation antipsychotics deserves to be monitored for family history of diabetes, body mass-index, weight gain and triglyceride levels. They reflect on compliance as well related to “ limited insight, a negative view of medications, and substance abuse.” They allude to studying cardiovascular risk in youth with bipolar disorder thus eliminating confounding variables.
In their own words, “Further education may improve recognition and screening for traditional risk factors and may result in better cardiovascular outcomes for this at-risk population.”
Monday, March 15, 2010
Alzheimer's and Sleep
by Peter J. Dorsen M.D., LADC
Andrew McCaddon, M.D. and Peter R. Hudson, Ph.D. of North Wales U.K, note utiliizing plasma total homocysteine (tHcy) as a marker, B vitamins deficiencies were found to be highly prevalent in the elderly. These writers note reports of elevated levels of homocysteine in individuals with clinically and pathologically confirmed Alzheimer’s disease (AD). Neuroinflammatory oxidative stress occurs early in AD. Amyloid plaques and neurofibrillary tangles represent end-stage of such oxidative stress.
They note as well an accumulation of methylmalonic acid that appears to be associated with lower cognitive function scores. There is an association as well between elevated homocysteine (Hcy) levels and stroke. Folate supplements serve as affective stroke prevention. They note the association of high Hcy and brain atrophy reversible with high-dose B-vitamin supplementation.
They recommend a naturally occurring product, cerefolin. They also report the efficacy of high doses of ORAL vitamin B12 (1-2mg/day). They emphasize assessing folate, B12 and homocysteine levels in ALL dementia patients and TREATING those with abnormal findings. Especially important, is that clinicians screen EVERYONE presenting with cognitive impairment who has co-occurring vascular risks such as high blood pressure, elevated cholesterol, diabetes, who smokes, or high homocystein levels. McCaddon and Hudson offer some novel warnings about and treatments for AD.
Sleep Problems
John W. Winkelman, MD. Ph.D. in Primary Psychiatry 16: 12 (suppl 8), differentiates between insomnia and sleep deprivation (reduced opportunity to sleep –voluntary or imposed. He recommends that someone who has trouble sleeping keep a 1-2 week sleep diary. Winkelman stresses that a polysomnogram (PSG) is NOT recommended routinely for insomnia unless a clinician suspects sleep apnea, periodic limb movement disorder or narcolepsy ( falling to sleep anywhere anytime inappropriately).
Many with insomnia spend more and more time in bed trying to get adequate sleep but don’t. He cites one such patient in whom “sleeplessness and anxiety symptoms are locked in a vicious cycle…”
Andrew Krystal, M.D. in this same monograph addresses treatment. He recommends Cognitive-Behavioral Treatment (CBT) for insomnia. CBT deals with such crucial issues as sleep hygiene, stimulus control, sleep restriction, and cognitive therapy. Cognitive therapy addresses “the maladaptive thought and emotional processes that often occur.” Consider “problem solving” BEFORE bedtime and something relatively simple like progressive muscle relaxation (one of Tim’s favorites). CBT compared more favorably compared with progressive muscle relaxation and imagery.
Utilizing medications like the hypnotic Zolpidem seem to work best with CBT when medication treatment at, let’s, say six months moves to an as-needed regimen. Clinicians aim for the speed of onset of pharmacotherapy with the durability of CBT. Krystal recommends a taper at 2-3 months and ultimately deciding whether to stop the medication altogether based on how well someone does.
These investigators emphasize not to minimize the potential side effects of the benzodiazepines for cognitive or psychomotor impairment and abuse potential, They advise: "initiate periodic tapers." One group cited treated patients three nights a week according to the patients’ preference. They reduced cost and minimized adverse effects. M Vaughn McCall, MD. MS, addresses co-morbid insomnia. “Relentless insomnia may be a prelude to development of a classic mental disorder such as depression.” He notes that it is important to investigate for a primary sleep disorder “ if a depressed insomniac complains of both insomnia and sleepiness.” Insomniacs, he reports, DENY daytime sleepiness complaining instead of "tiredness and exhaustion."
Certainly, appropriate for insomnia AND depression are the SSRIs. Insomniacs and depressed persons may well demonstrate remission on these medications. However, a large number continue to experience insomnia. If this does not resolve, and especially if a patient has hypersomnia (sleeping all the time) in addition to insomnia, they advise other modalities that include CBT-I for making changes in sleep schedules (avoiding going to bed too early or staying there too long); and dealing with distorted ideas about sleep (bedtime anxiety or fearing that they will be unable to fall asleep).
Consider bedtime hypnotic therapy. Evidence-based statistics, at this point, supports adding a FDA –approved hypnotic RATHER than a sedating antidepressant like trazadone. They advise “high level oversight” when using “benzo’s” or non-benzodiazepine receptor agonists (NBBRA’s). Why? Suicide! Note too, that insomnia is an independent indicator for suicidal ideation, behavior or death in depressed patients. Especially dangerous is an overdose of an accumulation of hypnotics and alcohol. As a result, clinicians should prescribe only 1-2 weeks of theses medications.Depression and insomnia often co-occur.These investigators offer some helpful advice that can stabilize both successfully.
Alzheimer's
"Novel treatment options: cognitive decline in Alzheimer’s disease" (Primary Psychiatry 17:1 (suppl 1). As we age, are afflicted with bipolar disorder, and might require a panel of mood stabilizers and more, we certainly can experience a decline in mental function (executive/cognitive as well?). Thirty million individuals will have (some form of ) dementia in 2010!Andrew McCaddon, M.D. and Peter R. Hudson, Ph.D. of North Wales U.K, note utiliizing plasma total homocysteine (tHcy) as a marker, B vitamins deficiencies were found to be highly prevalent in the elderly. These writers note reports of elevated levels of homocysteine in individuals with clinically and pathologically confirmed Alzheimer’s disease (AD). Neuroinflammatory oxidative stress occurs early in AD. Amyloid plaques and neurofibrillary tangles represent end-stage of such oxidative stress.
They note as well an accumulation of methylmalonic acid that appears to be associated with lower cognitive function scores. There is an association as well between elevated homocysteine (Hcy) levels and stroke. Folate supplements serve as affective stroke prevention. They note the association of high Hcy and brain atrophy reversible with high-dose B-vitamin supplementation.
They recommend a naturally occurring product, cerefolin. They also report the efficacy of high doses of ORAL vitamin B12 (1-2mg/day). They emphasize assessing folate, B12 and homocysteine levels in ALL dementia patients and TREATING those with abnormal findings. Especially important, is that clinicians screen EVERYONE presenting with cognitive impairment who has co-occurring vascular risks such as high blood pressure, elevated cholesterol, diabetes, who smokes, or high homocystein levels. McCaddon and Hudson offer some novel warnings about and treatments for AD.
Sleep Problems
John W. Winkelman, MD. Ph.D. in Primary Psychiatry 16: 12 (suppl 8), differentiates between insomnia and sleep deprivation (reduced opportunity to sleep –voluntary or imposed. He recommends that someone who has trouble sleeping keep a 1-2 week sleep diary. Winkelman stresses that a polysomnogram (PSG) is NOT recommended routinely for insomnia unless a clinician suspects sleep apnea, periodic limb movement disorder or narcolepsy ( falling to sleep anywhere anytime inappropriately).
Many with insomnia spend more and more time in bed trying to get adequate sleep but don’t. He cites one such patient in whom “sleeplessness and anxiety symptoms are locked in a vicious cycle…”
Andrew Krystal, M.D. in this same monograph addresses treatment. He recommends Cognitive-Behavioral Treatment (CBT) for insomnia. CBT deals with such crucial issues as sleep hygiene, stimulus control, sleep restriction, and cognitive therapy. Cognitive therapy addresses “the maladaptive thought and emotional processes that often occur.” Consider “problem solving” BEFORE bedtime and something relatively simple like progressive muscle relaxation (one of Tim’s favorites). CBT compared more favorably compared with progressive muscle relaxation and imagery.
Utilizing medications like the hypnotic Zolpidem seem to work best with CBT when medication treatment at, let’s, say six months moves to an as-needed regimen. Clinicians aim for the speed of onset of pharmacotherapy with the durability of CBT. Krystal recommends a taper at 2-3 months and ultimately deciding whether to stop the medication altogether based on how well someone does.
These investigators emphasize not to minimize the potential side effects of the benzodiazepines for cognitive or psychomotor impairment and abuse potential, They advise: "initiate periodic tapers." One group cited treated patients three nights a week according to the patients’ preference. They reduced cost and minimized adverse effects. M Vaughn McCall, MD. MS, addresses co-morbid insomnia. “Relentless insomnia may be a prelude to development of a classic mental disorder such as depression.” He notes that it is important to investigate for a primary sleep disorder “ if a depressed insomniac complains of both insomnia and sleepiness.” Insomniacs, he reports, DENY daytime sleepiness complaining instead of "tiredness and exhaustion."
Certainly, appropriate for insomnia AND depression are the SSRIs. Insomniacs and depressed persons may well demonstrate remission on these medications. However, a large number continue to experience insomnia. If this does not resolve, and especially if a patient has hypersomnia (sleeping all the time) in addition to insomnia, they advise other modalities that include CBT-I for making changes in sleep schedules (avoiding going to bed too early or staying there too long); and dealing with distorted ideas about sleep (bedtime anxiety or fearing that they will be unable to fall asleep).
Consider bedtime hypnotic therapy. Evidence-based statistics, at this point, supports adding a FDA –approved hypnotic RATHER than a sedating antidepressant like trazadone. They advise “high level oversight” when using “benzo’s” or non-benzodiazepine receptor agonists (NBBRA’s). Why? Suicide! Note too, that insomnia is an independent indicator for suicidal ideation, behavior or death in depressed patients. Especially dangerous is an overdose of an accumulation of hypnotics and alcohol. As a result, clinicians should prescribe only 1-2 weeks of theses medications.Depression and insomnia often co-occur.These investigators offer some helpful advice that can stabilize both successfully.
Wednesday, March 3, 2010
Bipolar disorder and Medical Co-morbidities Peter J. Dorsen, M.D. LADC
by Peter J. Dorsen M.D., LADC
Three years ago, I experienced excruciating chest pain with exercise, ultimately underwent angiography, required two stents and angioplasty, and subsequently was found to have experienced a heart attack in the process.
I had been taking lithium for an extended period of time for my bipolar II disorder.
What I could not completely comprehend was why, if I was thin and exercised regularly, did I continue to run a modestly elevated total cholesterol as well as an ongoing upper limit normal LDL (the “bad” cholesterol) and, no matter how fit I thought I was, I could never elevate my HDL (the “good” cholesterol) to a favorable level. I had a significant family history of high cholesterol. I chose not to take a lipid-lowering drug like simvastatin for fear of liver injury. Doctors are the worst patients!
The good news is that I have fared well with a “clean” angiogram one year after my stents and an acceptable fairly recent maximal graduated stress test several months ago. Initially, I had an elevated blood pressure transiently but am now off all blood pressure medications. I have never had any of the other criteria for metabolic syndrome such as diabetes or centripetal obesity. Metabolic syndrome is excess fat in one’s abdomen with a reduced sensitivity to insulin’s effects (insulin resistance), a high blood sugar level, abnormal cholesterol levels, and high blood pressure. Some have referred to such an insulin resistance syndrome as “Syndrome X.”
My BMI and waist circumference have never been excessive. However, metabolic syndrome is especially prevalent in developed countries with over 40% of those over 50 having it. This syndrome has the “apple-shape” in men or post menopausal women versus the “pear-shape” more commonly seen in women as adiposity collecting around the hips.
Aripiprazole (Abilify) has been advertised on TV recently as an adjunctive medication for depression. According to Page CU Expert Opin Drug Saf. 2009 May; 8(3) 373-86, it does have FDA approval for treatment “as adjunctive therapy or monotherapy (manic or mixed episodes) as well as an augmentation therapy of major depressive disorder (MDD).” These reporters state that it has “favorable safety compared to other atypical antipsychotics” with “minimal propensity for weight gain and metabolic disruption.” However they report abnormal body movements(akathisia) “that may limit its clinical use…especially in bipolar disorder and MDD.” It is actually one of the newer “atypical” antipsychotics with all the provisos and considerations that go with that class of drugs.
When I went on the medication, I developed tardive dyskinesia (TD) meaning that my chin began twitching and I developed uncontrollable spastic movements in my right hand. Secondly, it is important that you alert your provider if you have ever had a history of heart failure, a heart attack, high or low blood pressure, or a stroke or seizures if you elect to take this drug. Caveat emptor, “may the buyer beware.” These are not necessarily benign medications!
Here’s an interesting one: there are somewhat anecdotal reports that ginseng of one variety or another, functioning as an anti-oxidant, can lower low density lipoproteins (LDL). Not only is it reputed that ginseng may lower blood sugar in Type II diabetes, but it can decrease the risk of heart disease, improve blood pressure, and decrease symptoms of coronary heart disease. So not try some of this herb?
Wildes et al in J Clin Psychiatry. 2006 Jun; 67(6): 904-15, reviewed 92 studies and found that “(studies) targeting physical inactivity and overeating in bipolar disorders are needed, as are better screening and treatment for binge eating.” The authors want to explain both ” the causes and consequences of obesity…”
McIntyre et al in Ann Clin Psychiatry. 2007 Oct-Dec, advise: “ A comprehensive management approach for depressive disorders should routinely include opportunistic screening and primary prevention strategies targeting metabolically mediated comorbitity (eg. Cardiovascular disease).” Also, they say “ explore innovative treatments for mood disorders which primarily target aberrant metabolic networks.” They go so far as to “propose the notion of ‘metabolic syndrome type II’ as a neuropsychiatric syndrome.”
In an older article, Morriss R, Mohammed FA J. Psychopharmacol. 2005 Nov;19(6 Suppl): 94-101 report that lifestyle, illness and treatment factors in people with bipolar disorder (BD) may confer additional risk of morbidity and mortality to the increasing rates of obesity, metabolic syndrome, diabetes mellitus and cardiovascular mortality in the general population.” They observe increased mortality from cardiovascular causes as well as morbidity from obesity and type 2 diabetes increased compared with the general population. They note an increased risk in people with bipolar disorder as well due to less exercise, poor diet, frequent depressive episodes, and co-morbidity with substance misuse.
Saravane D et al in Encephale. 2009 Sep; 35(4): 330-9 (in French), posit that bipolar disorder is associated with “undue medical morbidity and mortality…with a 15-30 year shorter lifetime…” This is, after all, the same population who have “higher rate of preventable risk factors such as smoking, addiction, poor diet , lack of exercise.” Treatment of such co-morbitities is crucial, they advise as significant “ for their psychosocial functioning and overall quality of life.” Detect medical illness at “the first episode of mental illness.” They admonish: “ identify…crucial modifiable risk factors, such as… obesity, dyslipidemia, diabetes, hypertension, and smoking.
This team relates such metabolic and cardiovascular risk factors in population with significant mental illness “to poverty and limited access to medical care but also to the use of psychotropic mediations.” They advise in the first three to four months of treatment that patients with severe mental illness obtain baseline weight, height, waist circumference, blood pressure, fasting plasma glucose, and a fasting lipid profile. Obtaining a BMI ( Body mass index) which is weight(kg) over height(meters) squared can be extremely helpful.
Getting a baseline EKG is essential if a patient is taking an atypical antipsychotic which can increase your QT interval (the repolarization phase of the cardiogram) and lead to fatal arrhythmias. We need to know about the cardiovascular and metabolic risks of our medications! Prescribing antipsychotics carries responsibility for monitoring metabolic abnormalities as well. An ideal world MUST BE coordination among psychiatrists, GP’s, endocrinologists, cardiologists, nurses, dietitions, our families and US.
It is crucial that clinicians stay vigilant for metabolic syndrome among their stable of bipolar patients. Individuals who develop this complication are susceptible to coronary artery disease ( like I was), high blood pressure, Type 2 diabetes, abnormal fats, fatty liver, gout, polycystic ovaries, and chronic kidney disease. Men with abdominal girth over 40 inches and women over 35 inches may have it.
As Tim has suggested, changes in diet accompanied by a commitment to regular exercise is crucial. Medications that increase the body’s sensitivity to elevated glucose like metformin, thiazolidine, or rosiglitazone WITH exercise can improve sugar utilization. If weight reduction and exercise totally fail and after appropriate screening, bariatric surgery can certainly be a viable alternative. But that subject is for another time and blog.
Three years ago, I experienced excruciating chest pain with exercise, ultimately underwent angiography, required two stents and angioplasty, and subsequently was found to have experienced a heart attack in the process.
I had been taking lithium for an extended period of time for my bipolar II disorder.
What I could not completely comprehend was why, if I was thin and exercised regularly, did I continue to run a modestly elevated total cholesterol as well as an ongoing upper limit normal LDL (the “bad” cholesterol) and, no matter how fit I thought I was, I could never elevate my HDL (the “good” cholesterol) to a favorable level. I had a significant family history of high cholesterol. I chose not to take a lipid-lowering drug like simvastatin for fear of liver injury. Doctors are the worst patients!
The good news is that I have fared well with a “clean” angiogram one year after my stents and an acceptable fairly recent maximal graduated stress test several months ago. Initially, I had an elevated blood pressure transiently but am now off all blood pressure medications. I have never had any of the other criteria for metabolic syndrome such as diabetes or centripetal obesity. Metabolic syndrome is excess fat in one’s abdomen with a reduced sensitivity to insulin’s effects (insulin resistance), a high blood sugar level, abnormal cholesterol levels, and high blood pressure. Some have referred to such an insulin resistance syndrome as “Syndrome X.”
My BMI and waist circumference have never been excessive. However, metabolic syndrome is especially prevalent in developed countries with over 40% of those over 50 having it. This syndrome has the “apple-shape” in men or post menopausal women versus the “pear-shape” more commonly seen in women as adiposity collecting around the hips.
Aripiprazole (Abilify) has been advertised on TV recently as an adjunctive medication for depression. According to Page CU Expert Opin Drug Saf. 2009 May; 8(3) 373-86, it does have FDA approval for treatment “as adjunctive therapy or monotherapy (manic or mixed episodes) as well as an augmentation therapy of major depressive disorder (MDD).” These reporters state that it has “favorable safety compared to other atypical antipsychotics” with “minimal propensity for weight gain and metabolic disruption.” However they report abnormal body movements(akathisia) “that may limit its clinical use…especially in bipolar disorder and MDD.” It is actually one of the newer “atypical” antipsychotics with all the provisos and considerations that go with that class of drugs.
When I went on the medication, I developed tardive dyskinesia (TD) meaning that my chin began twitching and I developed uncontrollable spastic movements in my right hand. Secondly, it is important that you alert your provider if you have ever had a history of heart failure, a heart attack, high or low blood pressure, or a stroke or seizures if you elect to take this drug. Caveat emptor, “may the buyer beware.” These are not necessarily benign medications!
Here’s an interesting one: there are somewhat anecdotal reports that ginseng of one variety or another, functioning as an anti-oxidant, can lower low density lipoproteins (LDL). Not only is it reputed that ginseng may lower blood sugar in Type II diabetes, but it can decrease the risk of heart disease, improve blood pressure, and decrease symptoms of coronary heart disease. So not try some of this herb?
Wildes et al in J Clin Psychiatry. 2006 Jun; 67(6): 904-15, reviewed 92 studies and found that “(studies) targeting physical inactivity and overeating in bipolar disorders are needed, as are better screening and treatment for binge eating.” The authors want to explain both ” the causes and consequences of obesity…”
McIntyre et al in Ann Clin Psychiatry. 2007 Oct-Dec, advise: “ A comprehensive management approach for depressive disorders should routinely include opportunistic screening and primary prevention strategies targeting metabolically mediated comorbitity (eg. Cardiovascular disease).” Also, they say “ explore innovative treatments for mood disorders which primarily target aberrant metabolic networks.” They go so far as to “propose the notion of ‘metabolic syndrome type II’ as a neuropsychiatric syndrome.”
In an older article, Morriss R, Mohammed FA J. Psychopharmacol. 2005 Nov;19(6 Suppl): 94-101 report that lifestyle, illness and treatment factors in people with bipolar disorder (BD) may confer additional risk of morbidity and mortality to the increasing rates of obesity, metabolic syndrome, diabetes mellitus and cardiovascular mortality in the general population.” They observe increased mortality from cardiovascular causes as well as morbidity from obesity and type 2 diabetes increased compared with the general population. They note an increased risk in people with bipolar disorder as well due to less exercise, poor diet, frequent depressive episodes, and co-morbidity with substance misuse.
Saravane D et al in Encephale. 2009 Sep; 35(4): 330-9 (in French), posit that bipolar disorder is associated with “undue medical morbidity and mortality…with a 15-30 year shorter lifetime…” This is, after all, the same population who have “higher rate of preventable risk factors such as smoking, addiction, poor diet , lack of exercise.” Treatment of such co-morbitities is crucial, they advise as significant “ for their psychosocial functioning and overall quality of life.” Detect medical illness at “the first episode of mental illness.” They admonish: “ identify…crucial modifiable risk factors, such as… obesity, dyslipidemia, diabetes, hypertension, and smoking.
This team relates such metabolic and cardiovascular risk factors in population with significant mental illness “to poverty and limited access to medical care but also to the use of psychotropic mediations.” They advise in the first three to four months of treatment that patients with severe mental illness obtain baseline weight, height, waist circumference, blood pressure, fasting plasma glucose, and a fasting lipid profile. Obtaining a BMI ( Body mass index) which is weight(kg) over height(meters) squared can be extremely helpful.
Getting a baseline EKG is essential if a patient is taking an atypical antipsychotic which can increase your QT interval (the repolarization phase of the cardiogram) and lead to fatal arrhythmias. We need to know about the cardiovascular and metabolic risks of our medications! Prescribing antipsychotics carries responsibility for monitoring metabolic abnormalities as well. An ideal world MUST BE coordination among psychiatrists, GP’s, endocrinologists, cardiologists, nurses, dietitions, our families and US.
It is crucial that clinicians stay vigilant for metabolic syndrome among their stable of bipolar patients. Individuals who develop this complication are susceptible to coronary artery disease ( like I was), high blood pressure, Type 2 diabetes, abnormal fats, fatty liver, gout, polycystic ovaries, and chronic kidney disease. Men with abdominal girth over 40 inches and women over 35 inches may have it.
As Tim has suggested, changes in diet accompanied by a commitment to regular exercise is crucial. Medications that increase the body’s sensitivity to elevated glucose like metformin, thiazolidine, or rosiglitazone WITH exercise can improve sugar utilization. If weight reduction and exercise totally fail and after appropriate screening, bariatric surgery can certainly be a viable alternative. But that subject is for another time and blog.
Friday, February 26, 2010
Bipolar disorder and Exercise
By Tim Kuss, LADC, LMFT
Research by Sylvia, et al suggests that outcomes are suboptimal for patients with bipolar disorder who are treated with pharmacotherapy ALONE. They say that exercise can improve acute and long-term outcomes. Jamie Blumenthal did a study of 150 participants with depression. One third were assigned to take Zoloft, 1/3 assigned to an exercise regimen, and 1/3 to both. At the 6 month follow-up, the exercise only group had a significantly lower relapse rate than the other two groups. In studying this topic, I found numerous personal endorsements of exercise by people with bipolar disorder. There are so many articles about this on the internet that I find it hard to say anything new on the topic.
I will say, however, that I personally get close, if not achieve, the three-times a week of recommended exercise. I walk my dog around our block almost every day, which takes us 20 minutes, walking briskly. I get to the gym two to three times a week, swim for 30 minutes, and am now also gradually increasing my time on the stationary bike. Outdoor exercise is still my favorite because I can get some light therapy from the sun as well. I enjoy flowers in the spring, animals, trees, creeks and other nature "eye-candy."
As with any other healthy goal, it is best to start small and gradually improve. I am quick to forgive myself for getting off schedule. However, I don’t forget about the "big" plan. Here’s where my manic grandiosity pays off as I believe that I have a lot of important stuff to do and can’t afford episodes that disable me. Besides, hospital wards are not much fun.
“Bipolar disorder self-care,” www.mhsanctuary.com
Raven, Robin, “How to exercise for bipolar disorder,” ehow.com
“Dreaded exercise”, McMan’s depression and bipolar web
Research by Sylvia, et al suggests that outcomes are suboptimal for patients with bipolar disorder who are treated with pharmacotherapy ALONE. They say that exercise can improve acute and long-term outcomes. Jamie Blumenthal did a study of 150 participants with depression. One third were assigned to take Zoloft, 1/3 assigned to an exercise regimen, and 1/3 to both. At the 6 month follow-up, the exercise only group had a significantly lower relapse rate than the other two groups. In studying this topic, I found numerous personal endorsements of exercise by people with bipolar disorder. There are so many articles about this on the internet that I find it hard to say anything new on the topic.
I will say, however, that I personally get close, if not achieve, the three-times a week of recommended exercise. I walk my dog around our block almost every day, which takes us 20 minutes, walking briskly. I get to the gym two to three times a week, swim for 30 minutes, and am now also gradually increasing my time on the stationary bike. Outdoor exercise is still my favorite because I can get some light therapy from the sun as well. I enjoy flowers in the spring, animals, trees, creeks and other nature "eye-candy."
As with any other healthy goal, it is best to start small and gradually improve. I am quick to forgive myself for getting off schedule. However, I don’t forget about the "big" plan. Here’s where my manic grandiosity pays off as I believe that I have a lot of important stuff to do and can’t afford episodes that disable me. Besides, hospital wards are not much fun.
“Bipolar disorder self-care,” www.mhsanctuary.com
Raven, Robin, “How to exercise for bipolar disorder,” ehow.com
“Dreaded exercise”, McMan’s depression and bipolar web
Healthy Diet for Bipolar Disorder
By Tim Kuss, LADC, LMFT
Diet in this case does not indicate a goal of weight loss, but rather a regimen that will promote physical health AND mood stability. However, besides promoting mood stability, these diet suggestions may also help to prevent stroke, heart problems, and diabetes.
Eat at least 3 meals a day. Six smaller meals are better. Try to have these meals about the same time daily. Breakfast is IMPORTANT!
Omega-3 fatty acids have been proven to help PREVENT manic episodes. For example, Northern European countries in which people eat larger quantities of fish, have lower rates of bipolar disorder and manic episodes. In our home, we try to have three meals of fish a week. Avoid breaded fish entrees. Broiled fish is best.
Tuna, salmon, and trout, high in omega-3’s, are excellent choices. We eat salmon 1-2 times weekly. Just microwave it and add a little lime or lemon juice, YUM!
Fish oil supplements are available in many health food stores, pharmacies, or vitamin stores. While you are at it, pick up a multivitamin to take daily. Look for a multivitamin that contains the daily requirements of B6 and B12.
Flax seed oil actually has a higher concentration of Omega-3’s than fish oil. Flax seed needs to be ground to avoid releasing “free radicals," so be cautious of commercial brands. Canola oil, olive oil, and sunflower oil also have omega-3’s.
Omega-3 is also found in beets
Folic acid in many multivitamins has been shown to relieve bipolar depression and mania. Folic acid is present in dried beans, peas, oranges, whole wheat products, broccoli, Brussel sprouts, and spinach.
Inosital is a B vitamin that is reputed to provide relief from depression, panic attacks, and obsessive compulsive disorder (OCD). It is found in oranges, nuts, seeds, bran cereals, and legumes.
Make sure that you eat the daily recommended 6 servings of fruits and vegetables. Leafy green vegetables such as spinach, are vitamin rich and good for your diet. Fresh fruit is great! Use it as a substitute for high calorie sugary deserts.
USE whole grains if possible. We enjoy whole grain pasta in spaghetti and there are many whole grain cereals. Use 1 or 2% milk.
Eggs, soy products, nuts, and seeds are protective and nutrient dense. Include them in your meal plans. For example, my wife has several salad recipes that include nuts. We put walnuts and brown sugar substitute in oatmeal. I am a Type II diabetic.
Cut down on red meat. Limit that to 1 to 3 times a week. Such alternatives as chicken, turkey or tuna are better for you. Avoid saturated fats, trans fats and simple carbohydrates(candy bars, rich deserts, ice cream).
Avoid fried foods as they increase omega-6, which competes with Omega-3.
Grapefruit juice may have negative interactions with some bipolar medications.
Reduce sugar intake as much as possible. Splenda, according to my review, seems to be the best sugar substitute (no indication of negative effects).
Avoid caffeine, alcohol, and drugs.
Bibliography:
Reese Heather, “A healthy diet: tips for individuals with bipolar disorder.” healthcentral.com
“Bipolar disorder self-care.” mhsanctuary.com
“Bipolar diet: “foods to avoid.” WebMD.com
“Diet and manic-depression.” Bipolar-Lives.com
“Managing bipolar disorder.” www.psychologytoday.com
Diet in this case does not indicate a goal of weight loss, but rather a regimen that will promote physical health AND mood stability. However, besides promoting mood stability, these diet suggestions may also help to prevent stroke, heart problems, and diabetes.
Eat at least 3 meals a day. Six smaller meals are better. Try to have these meals about the same time daily. Breakfast is IMPORTANT!
Omega-3 fatty acids have been proven to help PREVENT manic episodes. For example, Northern European countries in which people eat larger quantities of fish, have lower rates of bipolar disorder and manic episodes. In our home, we try to have three meals of fish a week. Avoid breaded fish entrees. Broiled fish is best.
Tuna, salmon, and trout, high in omega-3’s, are excellent choices. We eat salmon 1-2 times weekly. Just microwave it and add a little lime or lemon juice, YUM!
Fish oil supplements are available in many health food stores, pharmacies, or vitamin stores. While you are at it, pick up a multivitamin to take daily. Look for a multivitamin that contains the daily requirements of B6 and B12.
Flax seed oil actually has a higher concentration of Omega-3’s than fish oil. Flax seed needs to be ground to avoid releasing “free radicals," so be cautious of commercial brands. Canola oil, olive oil, and sunflower oil also have omega-3’s.
Omega-3 is also found in beets
Folic acid in many multivitamins has been shown to relieve bipolar depression and mania. Folic acid is present in dried beans, peas, oranges, whole wheat products, broccoli, Brussel sprouts, and spinach.
Inosital is a B vitamin that is reputed to provide relief from depression, panic attacks, and obsessive compulsive disorder (OCD). It is found in oranges, nuts, seeds, bran cereals, and legumes.
Make sure that you eat the daily recommended 6 servings of fruits and vegetables. Leafy green vegetables such as spinach, are vitamin rich and good for your diet. Fresh fruit is great! Use it as a substitute for high calorie sugary deserts.
USE whole grains if possible. We enjoy whole grain pasta in spaghetti and there are many whole grain cereals. Use 1 or 2% milk.
Eggs, soy products, nuts, and seeds are protective and nutrient dense. Include them in your meal plans. For example, my wife has several salad recipes that include nuts. We put walnuts and brown sugar substitute in oatmeal. I am a Type II diabetic.
Cut down on red meat. Limit that to 1 to 3 times a week. Such alternatives as chicken, turkey or tuna are better for you. Avoid saturated fats, trans fats and simple carbohydrates(candy bars, rich deserts, ice cream).
Avoid fried foods as they increase omega-6, which competes with Omega-3.
Grapefruit juice may have negative interactions with some bipolar medications.
Reduce sugar intake as much as possible. Splenda, according to my review, seems to be the best sugar substitute (no indication of negative effects).
Avoid caffeine, alcohol, and drugs.
Bibliography:
Reese Heather, “A healthy diet: tips for individuals with bipolar disorder.” healthcentral.com
“Bipolar disorder self-care.” mhsanctuary.com
“Bipolar diet: “foods to avoid.” WebMD.com
“Diet and manic-depression.” Bipolar-Lives.com
“Managing bipolar disorder.” www.psychologytoday.com
Wednesday, February 24, 2010
Sleep Hygiene #2
Here are some tips on getting the sleep you need:
1. Try to go to bed and get up about the same times every day. This will help you establish a rhythm and structure to your sleep pattern.
2. The ideal setting is a cool dark room. Also, reduce the noise level. Use ear plugs or eye shades if needed.
3. You can always put a CD on with mellow relaxing music.
4. I reommend that you learn and practice deep breathing, visualization, and progressive muscle relaxation. Many bookstores sell CD's that help guide you or make your own!
5. Avoid napping during the day.
6. Use your bed only for sleeping and sex. If you can't sleep, go into another room and read, or do something else relaxing and quiet
7. Too much light can keep you awake. Keep light levels low.
8. Avoid stimulating activities, including video games, internet surfing, or social networking close to bedtime
9. Exercise regularly, but not for 6 hours before bedtime, as it is stimulating.
10.Try to eat your heavy high protein meals earlier in the day. Breakfast is best.
11. Avoid caffeine in coffee, tea, and certain soft drinks, especially in the evening. Set limits!
12 Nicotine is stimulating. Don't smoke before bed or if you wake up.
13 Alcohol and other drugs may make you "pass out" but will contribute to disrupted sleep. Your balance and sleep cycle are endangered by chemical use.
14. Try changing your sleep position, like sleeping on your side rather than your back.
15 Yoga, tai chi and other disciplines can help you relax and sleep
16 Exercise for at least 20 minutes every other day
17 Try to have your meals at about the same times every day
18 Avoid rigid, rapid weight loss, use a slow, sensible plan!
19 Get enough calcium. Calcium and vitamin supplements can help
20 A glass of milk and a turkey sandwich could help
21 Have a pre-bedtime ritual, like washing, getting into pajamas, or reading a chapter in a book
22. Writing in a journal can help. Also, use a day planner so you worry less about getting to appointments. I also write "to do" lists before bedtime
23. Don't be afraid to ask your doctor for sleep meds. Use them "as needed"
24 Connect with people who love or support you on a regular basis
25. Use visualization to imagine that you are in a beautiful relaxing place
26. Accept your wakefulness when you have it. Relax, enjoy
27 Hide the bedroom clocks
28. Try a warm bath before bed
29 Affirm yourself. Make lists of your abilities, deeds, gratitude, etc before bedtime, and use them as part of your relaxation
I would like suggestions and feedback on this post. Tim Kuss, 2-24-10
1. Try to go to bed and get up about the same times every day. This will help you establish a rhythm and structure to your sleep pattern.
2. The ideal setting is a cool dark room. Also, reduce the noise level. Use ear plugs or eye shades if needed.
3. You can always put a CD on with mellow relaxing music.
4. I reommend that you learn and practice deep breathing, visualization, and progressive muscle relaxation. Many bookstores sell CD's that help guide you or make your own!
5. Avoid napping during the day.
6. Use your bed only for sleeping and sex. If you can't sleep, go into another room and read, or do something else relaxing and quiet
7. Too much light can keep you awake. Keep light levels low.
8. Avoid stimulating activities, including video games, internet surfing, or social networking close to bedtime
9. Exercise regularly, but not for 6 hours before bedtime, as it is stimulating.
10.Try to eat your heavy high protein meals earlier in the day. Breakfast is best.
11. Avoid caffeine in coffee, tea, and certain soft drinks, especially in the evening. Set limits!
12 Nicotine is stimulating. Don't smoke before bed or if you wake up.
13 Alcohol and other drugs may make you "pass out" but will contribute to disrupted sleep. Your balance and sleep cycle are endangered by chemical use.
14. Try changing your sleep position, like sleeping on your side rather than your back.
15 Yoga, tai chi and other disciplines can help you relax and sleep
16 Exercise for at least 20 minutes every other day
17 Try to have your meals at about the same times every day
18 Avoid rigid, rapid weight loss, use a slow, sensible plan!
19 Get enough calcium. Calcium and vitamin supplements can help
20 A glass of milk and a turkey sandwich could help
21 Have a pre-bedtime ritual, like washing, getting into pajamas, or reading a chapter in a book
22. Writing in a journal can help. Also, use a day planner so you worry less about getting to appointments. I also write "to do" lists before bedtime
23. Don't be afraid to ask your doctor for sleep meds. Use them "as needed"
24 Connect with people who love or support you on a regular basis
25. Use visualization to imagine that you are in a beautiful relaxing place
26. Accept your wakefulness when you have it. Relax, enjoy
27 Hide the bedroom clocks
28. Try a warm bath before bed
29 Affirm yourself. Make lists of your abilities, deeds, gratitude, etc before bedtime, and use them as part of your relaxation
I would like suggestions and feedback on this post. Tim Kuss, 2-24-10
Monday, February 22, 2010
Sleep Hygiene
I have Bipolar Disorder, type 1 and have experienced numerous problems in regulating sleep. I have learned by reading and personal experience to manage sleep better. Sleep and mania provide "Catch-22" situation. When one becomes more manic, one tends to sleep less and when one sleeps less, one becomes more manic. Several of my manic episodes started after several days of reduced sleep, for example, sleeping only 3 to 5 hours a day for 3 or more days. People with bipolar disorder tend not to feel the need for sleep. We get wrapped up in our various "meaningful" projects or our compulsions and lose track of how much sleep we are getting. Sleep is important to positive functioning. For example, during the Rapid Eye Movement (REM) stage of sleep, we dream and in dreaming process our daily experiences and prepare to face challenges. There are other advantages to the other 4 stages of sleep. Sleep is part of the natural "Circadian rhythm" of our body. If we don't get needed sleep, both our mental and physical health deteriorate. In this blog I hope to present positive ideas about how to practice positive "sleep hygiene." For starters, I am suggesting keeping a sleep log in which you enter the hours of sleep you get every night. It's also a good idea to track the time you go to bed and the time you get up as well as any interruptions, like my old trick of waking up at 3:00 AM. Fortunately, while we can't totally control waking up at night, but we can change what we do when we wake up. We CAN do things to manage our sleep/wake cycle. More to come. Tim
Sunday, February 21, 2010
Cognitive and Executive Dysfunction: Effect of Age and Medications
Issues about cognitive or executive dysfunction as well as general matters of intellectual deterioration with bipolar disorder continue to interest me. I am adding some fairly recent articles to the blog pertaining to such phenomena. Peter J. Dorsen, M.D., LADC
Neurocognition in bipolar disorders—a closer look at comorbidities and medications. Bulanza-Martinez V et al Eur. J Pharmacol. 2010 Jan 10; 626(1): 87-96.
Their research is of neuropsychological study in bipolar disorder associated with persistent neurocognitive impairments EVEN during periods of euthymia in the broad domains of attention, verbal memory, and executive function. They also showed that there was a poorer functional outcome among bipolar disorder patients. Cognitive dysfunction is gene-environmental, drug–induced cognitive adverse effects ie there are confounders. It is important to look at the contribution medications plus medical and psychiatric co-morbid conditions have on bipolar disorder.
The longitudinal course of cognition in older adults with bipolar disorder Gildengers AG et al Bipolar Disorder. 2009 Nov; 11(7): 744-52.
“…elders with bipolar disorder (BD) may be at increased risk for dementia…”
Findings: Subjects with BD performed significantly worse on the Dementia Rating Scale (DRS) compared to mentally healthy comparators. In their study, “older adults with BD had more cognitive dysfunction and more rapid cognitive decline than expected given their age and education.”
The consequences of such decline was decreased independence and increased reliance on family and community supports with EVEN potential placement in assisted living facilities.
Cognitive features in euthymic bipolar patients in old age Delaloye C et al Bipolar Disord. 2009 Nov; 11(7): 735-43. Their conclusion relates to the notion that cognitive changes observed in older BD patients is similar to that observed in younger BD cohorts. However, issues relating to processing speed and episodic memory are two CORE DEFICITS that appear to differ in elderly BD patients.
Identifying and treating cognitive impairment in bipolar disorder Bipolar Disord. 2009 Jun; 11 Suppl 2:123-137. Goldberg JF, Chengappa KN. These investigators found that circumscribed cognitive deficits may be both iatrogenic and intrinsic to bipolar disorder. They concluded that cognitive deficits involving attention, executive function, and verbal memory are evident across ALL PHASES OF BIPOLAR DISORDER.
Clinical predictors of functional outcome of bipolar patients in remission Rosa A et al Bipolar Disorders VII(4):401-409, showed that 60% of 71 euthymic patients had overall functional impairment.Bipolar patients showed a worse functioning in all areas of the Functioning Assessment Short test (FAST). Previous mixed episodes, current subclinical depressive symptoms, previous hospitalizations, and older age were identified as significant predictors of functional impairment.
In the J Clin Psychiatry. 2009 Jul; 70(7):1017-23., Martinez-Aram A et al emphasized : “a close relationship between poor treatment adherence and cognitive impairment, but the causal inferences of these findings are uncertain.” They conclude that such poor treatment adherence may worsen the course of bipolar disorder and so indirectly worsen cognitive performance (thus, more severe illness).
A comparison of cognitive functioning in medicated and non medicated subjects with bipolar depression Holmes MK et al Bipolar Disord. 2009 Nov; 10(7): 806-15. This study demonstrated deficits in affective processing in the medicated group. They saw more errors in the “happy” conditions, indicating a potential attentional bias in subjects with bipolar depression on mood-stabilizing medications.
Excellent quote: “The present study also implicates impairment in sustained attention for medicated subjects with bipolar disorder PARTICULARLY those with bipolar II.
Neurocognition in bipolar disorders—a closer look at comorbidities and medications. Bulanza-Martinez V et al Eur. J Pharmacol. 2010 Jan 10; 626(1): 87-96.
Their research is of neuropsychological study in bipolar disorder associated with persistent neurocognitive impairments EVEN during periods of euthymia in the broad domains of attention, verbal memory, and executive function. They also showed that there was a poorer functional outcome among bipolar disorder patients. Cognitive dysfunction is gene-environmental, drug–induced cognitive adverse effects ie there are confounders. It is important to look at the contribution medications plus medical and psychiatric co-morbid conditions have on bipolar disorder.
The longitudinal course of cognition in older adults with bipolar disorder Gildengers AG et al Bipolar Disorder. 2009 Nov; 11(7): 744-52.
“…elders with bipolar disorder (BD) may be at increased risk for dementia…”
Findings: Subjects with BD performed significantly worse on the Dementia Rating Scale (DRS) compared to mentally healthy comparators. In their study, “older adults with BD had more cognitive dysfunction and more rapid cognitive decline than expected given their age and education.”
The consequences of such decline was decreased independence and increased reliance on family and community supports with EVEN potential placement in assisted living facilities.
Cognitive features in euthymic bipolar patients in old age Delaloye C et al Bipolar Disord. 2009 Nov; 11(7): 735-43. Their conclusion relates to the notion that cognitive changes observed in older BD patients is similar to that observed in younger BD cohorts. However, issues relating to processing speed and episodic memory are two CORE DEFICITS that appear to differ in elderly BD patients.
Identifying and treating cognitive impairment in bipolar disorder Bipolar Disord. 2009 Jun; 11 Suppl 2:123-137. Goldberg JF, Chengappa KN. These investigators found that circumscribed cognitive deficits may be both iatrogenic and intrinsic to bipolar disorder. They concluded that cognitive deficits involving attention, executive function, and verbal memory are evident across ALL PHASES OF BIPOLAR DISORDER.
Clinical predictors of functional outcome of bipolar patients in remission Rosa A et al Bipolar Disorders VII(4):401-409, showed that 60% of 71 euthymic patients had overall functional impairment.Bipolar patients showed a worse functioning in all areas of the Functioning Assessment Short test (FAST). Previous mixed episodes, current subclinical depressive symptoms, previous hospitalizations, and older age were identified as significant predictors of functional impairment.
In the J Clin Psychiatry. 2009 Jul; 70(7):1017-23., Martinez-Aram A et al emphasized : “a close relationship between poor treatment adherence and cognitive impairment, but the causal inferences of these findings are uncertain.” They conclude that such poor treatment adherence may worsen the course of bipolar disorder and so indirectly worsen cognitive performance (thus, more severe illness).
A comparison of cognitive functioning in medicated and non medicated subjects with bipolar depression Holmes MK et al Bipolar Disord. 2009 Nov; 10(7): 806-15. This study demonstrated deficits in affective processing in the medicated group. They saw more errors in the “happy” conditions, indicating a potential attentional bias in subjects with bipolar depression on mood-stabilizing medications.
Excellent quote: “The present study also implicates impairment in sustained attention for medicated subjects with bipolar disorder PARTICULARLY those with bipolar II.
Thursday, February 11, 2010
High achievers more likely to be bipolar
MacCabe J, Lambe M, Sham P, Hultman C. Excellent school performance at age 16 and risk of adult bipolar disorder national cohort study. The British Journal of Psychiatry (2010) 196: 109-115.
This study revealed two interesting findings. In a joint study between investigators from Stockholm’s famous Karolinska Institute and London’s King’s College, the final exam results of 15-16 year-old pupils attending High Schools in Sweden from 1988 to 1977 were compared with hospital records of bipolar disorder admissions between the ages of 17 and 31.
The students with A-grade results had an almost four times greater chance for such admissions than average students. Variables such as income and education levels of parents were controlled. Males predominated.
Also, students with low exam grades had a greater risk for developing bipolar disorder than average pupils.
Once again and consistent with facts listed before in this blog, these scientists found the highest rate of bipolar disorder among those who excelled in the humanities such as literature or music, classically subjects most frequently associated with madness.
“….the scientists suggest there are two distinct groups of people with bipolar disorder: the high achievers who are aided by their manic stages, and low achievers who have poor motor skills, which may be caused by ‘subtle neurodevelopmental abnormalities’”. Submitted by Gary Jedynak
This study revealed two interesting findings. In a joint study between investigators from Stockholm’s famous Karolinska Institute and London’s King’s College, the final exam results of 15-16 year-old pupils attending High Schools in Sweden from 1988 to 1977 were compared with hospital records of bipolar disorder admissions between the ages of 17 and 31.
The students with A-grade results had an almost four times greater chance for such admissions than average students. Variables such as income and education levels of parents were controlled. Males predominated.
Also, students with low exam grades had a greater risk for developing bipolar disorder than average pupils.
Once again and consistent with facts listed before in this blog, these scientists found the highest rate of bipolar disorder among those who excelled in the humanities such as literature or music, classically subjects most frequently associated with madness.
“….the scientists suggest there are two distinct groups of people with bipolar disorder: the high achievers who are aided by their manic stages, and low achievers who have poor motor skills, which may be caused by ‘subtle neurodevelopmental abnormalities’”. Submitted by Gary Jedynak
Monday, February 8, 2010
Primary Psychiatry 16:12 (Suppl 10): Practical Management Strategies for Acute Mania and Mixed Episodes of bipolar disorder reviewed by Peter J. Dorsen, M.D., LADC
Article 1 Primary Psychiatry 16:12 (Suppl 10)
Goldberg, Joseph F. “Overall assessment of mixed episodes in bipolar disorder.”
Dr Goldberg is a clinical associate professor of psychiatry at The Mount Sinai School of Medicine
“…mixed episodes…often present with co morbid anxiety or substance misuse…”
Interesting comment: “Although DSM-IV recognizes mixed episodes as occurring ONLY(ed) bipolar I disorder…mixed polarity symptoms may be EQUALLY(ed) common in patients with bipolar II disorder.
He states: “syndromic mood states” are a constellation of signs and symptoms.
Think of mania or hypomania when there is “nocturnal hyperactivity.” Likewise, if the patient is “flooded with thoughts,” look for “accelerated thought processes.” Psychomotor agitation can also go hand in hand with self-destructive behavior.
Goldberg advises: utilizing a corroborative historian especially in adolescents or young adults. Why? A clinician may need all the help she can get to identify prior depression or manic/hypomanic events.
Ref: Birk et al “Bipolar mixed states: the diagnosis and clinical salience of bipolar mixed states. Aust NZ J Psychiatry.2005; 391. 215-221. Agitated depression may overlap with mixed episodes.
Differentiate between true anxiety, iatrogenic signs, akathisia, drug intoxication/withdrawal effects, psychomotor agitation, and acceleration suggestive of mania or hypomania. (a potpourri of possibilities).
Psychosis (delusions, hallucinations, or formal thought disorder) occur in a half or more of those with bipolar I!
Here’s a gem: “subsyndromal mania symptoms may be eclipsed by more prominent depressive features.” Such patients may demonstrate fewer mania symptoms than would meet the DSM-IV criteria for a full mixed episode, they may show distracted thinking, psychomotor agitation, flight of ideas, or racing thoughts.
Some resources: Clinical Monitoring Form (CMF; www.manicdepressive.org.)
Diagnosis of bipolar disorder is based on the comprehensive interview!
Another resource: Hirschfeld, RM et al. Development and validation of a screening instrument for bipolar spectrum disorder: the Mood Disorders Questionnaire. Am J. Psychiatry.2000; 157:1873-1875.
He debunks “mood destabilization.”
He adds: “…transmission of bipolar disorder is non-Mendelian, conferring only moderate importance to the categorical presence or absence of bipolar disorder in a first-degree relative.”
In a 15-year follow-up study of late adolescents hospitalized for unipolar depression, 45% met criteria for mania or hypomania!
Delineate identification of prominent mood disturbances in the absence of acute intoxication states. Look for loss of need for sleep, flight of ideas, or racing thoughts not “mood swings.”
Important factoids: “Age of onset, psychosis, high rate of recurrence with brief episodes, atypical depressive features, cognitive deficits, and family history…help differentiate unipolar from bipolar disorder….”
Article 2 (Primary Psychiatry 16: 12 ( Suppl 10)
Frye, Mark A, M.D. “Treatment guidelines for acute manic and mixed episodes of bipolar disorder.”
Doctor Frye is professor of psychiatry and director of the Mayo Mood Clinic and Research Program, Rochester, Minnesota.
“It is important to look at evidence-based data set to guide treatment selection for mood stabilization.”
Pearl: “ …rapid cycling, mixed mania, psychotic symptoms…influence medication selection.” ( bipolar disorder is highly co-morbid with Axis I, II, and III illnesses).
Pearl: …dysphoric mania predictive of nonresponse to lithium and better to divalproex.
Benzodiazepines CAN work: “…lorazepam and clonazepam can be successfully used as adjunctive anti manic agents to treat acute mania”
Lithium (narrow therapeutic index), valproate, carbamazepine for acute mania. Valproate and carbamazepine: mixed episodes and a growing small evidence-based potential for alcohol withdrawal symptoms or relapse
Dysphoric mood: Nay lithium, Yay divalproex.
Lamotrigene: Yay bipolar depression(FDA: maintainance); Nay Acute mania
Atypical antipsychotics: Acute, mixed episodes. However increased associated mortality
Co-morbidity: alcohol abuse/dependency: earlier onset, higher rates mixed, rapid cycling, impulsivity, aggressivity, suicidality, and treatment-emergent mania.
Article 3 ( Primary Psychiatry 16: 12 (Suppl 10)
Bowden, Charles L. “Maintenance treatment in bipolar disorder.”
Doctor Bowden is clinical professor of psychiatry and pharmacology at the University of Texas health Center, San Antonio.
Doctor Bowden advocates efficacy versus adverse effects. He stresses carefully evaluating the patient who frequently presents as depressed. Start with an anti manic drug. If the patient persists psychotic or develops manic symptoms, choose an atypical antipsychotic. He advocates lamotrigene or valproate rather than carbamazepine as they are better tolerated. If devalproex was the right drug for the acute problem, it also had better maintenance outcomes.
He realistically discusses the finding of “poor set-shifting, processing speed predicted by any antipsychotic use.” So the goal must be to achieve a good dose yet avoid cognitive dulling and psychomotor slowing.
He reports “poorer executive function on WCST categories in subgroups taking antipsychotics.”
Two articles address a matter very close to my heart and I will list them for your perusal:
Frangou S, et al. The Maudsley Bipolar Disorder Project: executive dysfunction in bipolar disorder I and its clinical correlates. Biol Psychiatry. 2005;58:859-864.
Altshuler LL, et al. Neurocognitive function in clinically stable men with bipolar I disorder or schizophrenia and normal control subjects. Biol Psychiatry. 2004;56:560-569.
Such issues of deteriorated cognitive function ( in this case related to antipsychotics) certainly can relate to “ unrealistic fear of side effects on the part of patients or the patient’s family.”
Bowden notes that outcomes are less positive if there is preexisting anxiety. He alludes to a new comprehensive scale, the Bipolar Inventory of Signs and Symptoms Scale (BISS).
Ed: His message is that it is not just mania or depression but also anxiety, irritability, or psychosis that is pivotal how this illness performs. This is why the majority of patients are treated with multiple medications during acute mania and maintenance care.
He cites Goldberg et al in their study, manic symptoms during depressive episodes in 1380 patients with bipolar disorder: findings from the STEP-BD. Am J Psychiatry. 2009;166: 173-181. More than 1000 entered the program depressed but more than 2/3 had clear manic symptoms especially distractability, activation, excessive energy, or risky-type behavior.
His summary: “All of the different features associated with bipolar disorder-depression, mania, irritability, anxiety and psychosis; cognitive symptomatology; and adverse effects from medications used to treat the disorder—makes for a complex challenge for the patient and the clinician.”
PS: Bowden warns: don’t forget “... attention over time to appropriate sleep hygiene practices.”
Article 4 (Primary Psychiatry 16:12 (Suppl 10)
Sajatovic, Martha. Medical comorbidity and recovery in individuals with bipolar disorder.
Doctor Sajatovik is Professor of psychiatry at Case Western University School of Medicine in Cleveland, Ohio.
She opines: “Medical conditions are the rule rather than the exception among individuals with bipolar disorder.”
The range for the co-occurrence of metabolic syndrome ranges from 20-50% or greater.
ED: This has always been one of my pet peeves: “Psychiatrists often tend to operate in a vacuum when they need to be in communication with primary care (givers) and colleagues.”
She warns us that there is actually a lot of medical co-morbidity in individuals with late-life bipolar disorder compared with rather low rates in the community. One such strong statistic is that bipolar disorder is present in 17% of geriatric patients presenting to psychiatric emergency departments (ed question: with metabolic syndrome?)
Although the incidence of adverse drug reactions in bipolar patients is actually low under forty, 20% of hospital admissions are due to adverse events over 80!
She warns: “ …illness does not go away or ‘burn out’ in late life.”
It is crucial to (1) Characterize the target symptoms; (2) Identify and characterize any medical co-morbidity (especially in the geriatric patient). (3) Treat (parsimonious and step-wise in the elderly). Nothing will remain static! (4) Review on an ongoing basis medications for their toxicity or withdrawal; (5) Incorporate nonpharmacologic interventions; (6) Have multidisciplinary coordination.
Goldberg, Joseph F. “Overall assessment of mixed episodes in bipolar disorder.”
Dr Goldberg is a clinical associate professor of psychiatry at The Mount Sinai School of Medicine
“…mixed episodes…often present with co morbid anxiety or substance misuse…”
Interesting comment: “Although DSM-IV recognizes mixed episodes as occurring ONLY(ed) bipolar I disorder…mixed polarity symptoms may be EQUALLY(ed) common in patients with bipolar II disorder.
He states: “syndromic mood states” are a constellation of signs and symptoms.
Think of mania or hypomania when there is “nocturnal hyperactivity.” Likewise, if the patient is “flooded with thoughts,” look for “accelerated thought processes.” Psychomotor agitation can also go hand in hand with self-destructive behavior.
Goldberg advises: utilizing a corroborative historian especially in adolescents or young adults. Why? A clinician may need all the help she can get to identify prior depression or manic/hypomanic events.
Ref: Birk et al “Bipolar mixed states: the diagnosis and clinical salience of bipolar mixed states. Aust NZ J Psychiatry.2005; 391. 215-221. Agitated depression may overlap with mixed episodes.
Differentiate between true anxiety, iatrogenic signs, akathisia, drug intoxication/withdrawal effects, psychomotor agitation, and acceleration suggestive of mania or hypomania. (a potpourri of possibilities).
Psychosis (delusions, hallucinations, or formal thought disorder) occur in a half or more of those with bipolar I!
Here’s a gem: “subsyndromal mania symptoms may be eclipsed by more prominent depressive features.” Such patients may demonstrate fewer mania symptoms than would meet the DSM-IV criteria for a full mixed episode, they may show distracted thinking, psychomotor agitation, flight of ideas, or racing thoughts.
Some resources: Clinical Monitoring Form (CMF; www.manicdepressive.org.)
Diagnosis of bipolar disorder is based on the comprehensive interview!
Another resource: Hirschfeld, RM et al. Development and validation of a screening instrument for bipolar spectrum disorder: the Mood Disorders Questionnaire. Am J. Psychiatry.2000; 157:1873-1875.
He debunks “mood destabilization.”
He adds: “…transmission of bipolar disorder is non-Mendelian, conferring only moderate importance to the categorical presence or absence of bipolar disorder in a first-degree relative.”
In a 15-year follow-up study of late adolescents hospitalized for unipolar depression, 45% met criteria for mania or hypomania!
Delineate identification of prominent mood disturbances in the absence of acute intoxication states. Look for loss of need for sleep, flight of ideas, or racing thoughts not “mood swings.”
Important factoids: “Age of onset, psychosis, high rate of recurrence with brief episodes, atypical depressive features, cognitive deficits, and family history…help differentiate unipolar from bipolar disorder….”
Article 2 (Primary Psychiatry 16: 12 ( Suppl 10)
Frye, Mark A, M.D. “Treatment guidelines for acute manic and mixed episodes of bipolar disorder.”
Doctor Frye is professor of psychiatry and director of the Mayo Mood Clinic and Research Program, Rochester, Minnesota.
“It is important to look at evidence-based data set to guide treatment selection for mood stabilization.”
Pearl: “ …rapid cycling, mixed mania, psychotic symptoms…influence medication selection.” ( bipolar disorder is highly co-morbid with Axis I, II, and III illnesses).
Pearl: …dysphoric mania predictive of nonresponse to lithium and better to divalproex.
Benzodiazepines CAN work: “…lorazepam and clonazepam can be successfully used as adjunctive anti manic agents to treat acute mania”
Lithium (narrow therapeutic index), valproate, carbamazepine for acute mania. Valproate and carbamazepine: mixed episodes and a growing small evidence-based potential for alcohol withdrawal symptoms or relapse
Dysphoric mood: Nay lithium, Yay divalproex.
Lamotrigene: Yay bipolar depression(FDA: maintainance); Nay Acute mania
Atypical antipsychotics: Acute, mixed episodes. However increased associated mortality
Co-morbidity: alcohol abuse/dependency: earlier onset, higher rates mixed, rapid cycling, impulsivity, aggressivity, suicidality, and treatment-emergent mania.
Article 3 ( Primary Psychiatry 16: 12 (Suppl 10)
Bowden, Charles L. “Maintenance treatment in bipolar disorder.”
Doctor Bowden is clinical professor of psychiatry and pharmacology at the University of Texas health Center, San Antonio.
Doctor Bowden advocates efficacy versus adverse effects. He stresses carefully evaluating the patient who frequently presents as depressed. Start with an anti manic drug. If the patient persists psychotic or develops manic symptoms, choose an atypical antipsychotic. He advocates lamotrigene or valproate rather than carbamazepine as they are better tolerated. If devalproex was the right drug for the acute problem, it also had better maintenance outcomes.
He realistically discusses the finding of “poor set-shifting, processing speed predicted by any antipsychotic use.” So the goal must be to achieve a good dose yet avoid cognitive dulling and psychomotor slowing.
He reports “poorer executive function on WCST categories in subgroups taking antipsychotics.”
Two articles address a matter very close to my heart and I will list them for your perusal:
Frangou S, et al. The Maudsley Bipolar Disorder Project: executive dysfunction in bipolar disorder I and its clinical correlates. Biol Psychiatry. 2005;58:859-864.
Altshuler LL, et al. Neurocognitive function in clinically stable men with bipolar I disorder or schizophrenia and normal control subjects. Biol Psychiatry. 2004;56:560-569.
Such issues of deteriorated cognitive function ( in this case related to antipsychotics) certainly can relate to “ unrealistic fear of side effects on the part of patients or the patient’s family.”
Bowden notes that outcomes are less positive if there is preexisting anxiety. He alludes to a new comprehensive scale, the Bipolar Inventory of Signs and Symptoms Scale (BISS).
Ed: His message is that it is not just mania or depression but also anxiety, irritability, or psychosis that is pivotal how this illness performs. This is why the majority of patients are treated with multiple medications during acute mania and maintenance care.
He cites Goldberg et al in their study, manic symptoms during depressive episodes in 1380 patients with bipolar disorder: findings from the STEP-BD. Am J Psychiatry. 2009;166: 173-181. More than 1000 entered the program depressed but more than 2/3 had clear manic symptoms especially distractability, activation, excessive energy, or risky-type behavior.
His summary: “All of the different features associated with bipolar disorder-depression, mania, irritability, anxiety and psychosis; cognitive symptomatology; and adverse effects from medications used to treat the disorder—makes for a complex challenge for the patient and the clinician.”
PS: Bowden warns: don’t forget “... attention over time to appropriate sleep hygiene practices.”
Article 4 (Primary Psychiatry 16:12 (Suppl 10)
Sajatovic, Martha. Medical comorbidity and recovery in individuals with bipolar disorder.
Doctor Sajatovik is Professor of psychiatry at Case Western University School of Medicine in Cleveland, Ohio.
She opines: “Medical conditions are the rule rather than the exception among individuals with bipolar disorder.”
The range for the co-occurrence of metabolic syndrome ranges from 20-50% or greater.
ED: This has always been one of my pet peeves: “Psychiatrists often tend to operate in a vacuum when they need to be in communication with primary care (givers) and colleagues.”
She warns us that there is actually a lot of medical co-morbidity in individuals with late-life bipolar disorder compared with rather low rates in the community. One such strong statistic is that bipolar disorder is present in 17% of geriatric patients presenting to psychiatric emergency departments (ed question: with metabolic syndrome?)
Although the incidence of adverse drug reactions in bipolar patients is actually low under forty, 20% of hospital admissions are due to adverse events over 80!
She warns: “ …illness does not go away or ‘burn out’ in late life.”
It is crucial to (1) Characterize the target symptoms; (2) Identify and characterize any medical co-morbidity (especially in the geriatric patient). (3) Treat (parsimonious and step-wise in the elderly). Nothing will remain static! (4) Review on an ongoing basis medications for their toxicity or withdrawal; (5) Incorporate nonpharmacologic interventions; (6) Have multidisciplinary coordination.
Thursday, February 4, 2010
surviving a manic episode
Unfortunately, I have experienced many hypomanic episodes that I did not recognize. Recently, however, I have survived two manic episodes, including delusional thinking. The biggest challenge seems to be in recognizing the symptoms of mania. I have had enough experience with my delusions that I recognized that my thinking was off track. A second positive factor is having a support network that you trust. I trusted my wife and my friend enough that I told them I was having an episode. My wife reminded me that sleep management is important to my stability. I contracted with her to stay off my computer(especially games and the internet!) and to read instead, We have also practiced meditative skills together and I agreed to go to the living room and listen to relaxing music while practicing deep breathing, progressive muscle relaxation and affirmations. It took about 3 days to get out of the woods the first time and about 24 hours the second time. Also, it helped to do some "normal" activities like walk around the block with my dog. watch movies, read, go shopping, read e-mail, etc. While I enjoyed my "'inspired" thoughts, I was also aware of the consequences of former manic episodes and was thus motivated to continue to challenge the delusional thoughts. I kept reminding myself of the "real" positives in my life. including my family, my career, my friends, my men's group, etc. This decreased my attraction to the promised benefits of my false reality. I hope that some others can use this information to survive manic episodes, Tim Kuss, 2-4-10
Tuesday, February 2, 2010
So what type of intelligence is best to have?
Submitted by “Jerry” Westcott who has consistently pointed out the similarities between his own ADHD and those with bipolar “cognitive” struggles.
Michael Bond, a London-based consultant to New Scientist, quotes Keith Stanovich, “ I.Q. isn’t everything. Notwithstanding that IQ tests determine…the academic and professional careers of millions in the U.S.) (The SAT’s for instance). In his book, What Intelligence Tests Miss(Yale University press, 2008), he claims standard IQ tests “measure only a limited part of cognitive functioning.” Stanovich and other reaearchers focus attention on cognitive faculties that go beyond intelligence. In fact, our brains use two different systems to process information. One is intuitive and spontaneous. The other is deliberative and reasoned.
Intelligence, as we know it, can be a poor predictor of “good thinking.” People with higher intelligence excel in certain situations like number ratios, probabilities, deductive reasoning, and the use of hindsight. However, correlation between intelligence and successful decision making is weak. Stanovich adds, “ intelligent people perform better only when you tell them what to do.”
Wandi Bruine de Bruin notes: “those who displayed better rational-thinking skills suffered significantly fewer negative events in their lives such as credit card debt, having an unplanned pregnancy, or being suspended from school.”
Interestingly, Baruch Fischhoff reports in the Journal of Behavioral Decision Making V 18, p1 that adolescents who scored higher on a test of decision-making competence drank less, took fewer drugs, and engaged in less risky behavior overall.” He notes that “irrational thinking (not IQ) may be more important than intelligence for positive life experiences.”
Unfortunately, to date, there is no “rationality- quotient (RQ) test.” Also, although IQ tests excel in measuring brainpower or for academic selection, “RQ tests” might be the way to select managers and leaders. The same researchers also warn that, unlike IQ tests, it may be easy to train people to do well on RQ tests; that is, “to ignore intuition and engage reasoning.” The affirmative, however, is “ that everyone can improve their rational thinking and decision-making skills.”
One conclusion that is possible from this information is that there can be special psychotherapists who may offer their skills correcting such conditions trauma-related cognitive-executive deficits or bipolar and ADHD “misfiring” that register on the RQ scale instead of the standard IQ scale. Food for thought anyway. Adapted by Peter J. Dorsen, M.D., LADC
Michael Bond, a London-based consultant to New Scientist, quotes Keith Stanovich, “ I.Q. isn’t everything. Notwithstanding that IQ tests determine…the academic and professional careers of millions in the U.S.) (The SAT’s for instance). In his book, What Intelligence Tests Miss(Yale University press, 2008), he claims standard IQ tests “measure only a limited part of cognitive functioning.” Stanovich and other reaearchers focus attention on cognitive faculties that go beyond intelligence. In fact, our brains use two different systems to process information. One is intuitive and spontaneous. The other is deliberative and reasoned.
Intelligence, as we know it, can be a poor predictor of “good thinking.” People with higher intelligence excel in certain situations like number ratios, probabilities, deductive reasoning, and the use of hindsight. However, correlation between intelligence and successful decision making is weak. Stanovich adds, “ intelligent people perform better only when you tell them what to do.”
Wandi Bruine de Bruin notes: “those who displayed better rational-thinking skills suffered significantly fewer negative events in their lives such as credit card debt, having an unplanned pregnancy, or being suspended from school.”
Interestingly, Baruch Fischhoff reports in the Journal of Behavioral Decision Making V 18, p1 that adolescents who scored higher on a test of decision-making competence drank less, took fewer drugs, and engaged in less risky behavior overall.” He notes that “irrational thinking (not IQ) may be more important than intelligence for positive life experiences.”
Unfortunately, to date, there is no “rationality- quotient (RQ) test.” Also, although IQ tests excel in measuring brainpower or for academic selection, “RQ tests” might be the way to select managers and leaders. The same researchers also warn that, unlike IQ tests, it may be easy to train people to do well on RQ tests; that is, “to ignore intuition and engage reasoning.” The affirmative, however, is “ that everyone can improve their rational thinking and decision-making skills.”
One conclusion that is possible from this information is that there can be special psychotherapists who may offer their skills correcting such conditions trauma-related cognitive-executive deficits or bipolar and ADHD “misfiring” that register on the RQ scale instead of the standard IQ scale. Food for thought anyway. Adapted by Peter J. Dorsen, M.D., LADC
Bipolar Visions/as adapted from the presentation to the M.A.R.R.C.H. 2009 fall conference
I have personally experienced Bipolar disorder, type I for the majority of my life. Age 20 is considered a “typical” age of onset and I experienced a series of manic episodes resulting in psychosis and hospitalization around that time. At age 26, I started my recovery from chemical dependency, but due to being misdiagnosed at least 4 times. I did not start my recovery from bipolar disorder until 8 years ago, in 2002.
My part of our presentation focuses largely on Bipolar Disorder, type I
Over two million Americans suffer from Bipolar Disorder. About 15 to 20% never get it treated. The risk of suicide is higher for bipolar disorder than for any other mental health diagnoses. Those if us who have it are also prone to taking a lot of dangerous risks, which could also contribute to high rates of death or serious injury.
Bipolar disorder is considered to be the result of differences in brain chemistry. Many of us have attempted to adjust our brain chemistry ourselves, by using alcohol or other drugs. resulting often in more harmful brain imbalances, leading to more negative consequences, including a higher incidence of mixed or rapid cycling.
Mania can disrupt our lives in several ways. For those of us with Bipolar Disorder, type 1, uninterrupted mania can lead to psychosis, including paranoia. rapid thinking, a decreased need for sleep, and delusions of power. Even “mild” hypomania can result in a tendency to be argumentative, agitated, and defiant, In Full-blown mania these qualities become more exaggerated. Our behavior can result in deterioration in our significant relationships,job loss or legal, or other social problems. When we come out of the mania, facing it’s consequences can contribute to a swing to depression.
Depressive episodes can also have consequences, since we tend to have low energy for jobs and relationships. We can also experience “mixed” states of combined mania and depression, In a mixed state, our rapid thoughts may be pessimistic. We might have grandiose ideas, but lack energy to act on them. We tend to be irritable and impatient with others, at times being disappointed with them and at other times devaluing ourselves.
We could experience months to years of “euthymia”. relatively “normal” mood and behavior, interspersed with days to weeks of mania, hypomania or depression. Stability in our moods and behavior is more likely when we abstain from alcohol and other drug. Practice of a “balanced” recovery program also promotes stability. I, for example, experienced a 5 year period of euthymia from 1978 to 1983. I did not use chemicals, attended AA up to 3 times a week, kept a good job, functioned well as a husband and father, exercised regularly, ate responsibly, and had a close circle of supportive friends. During this time, we had 3 foster children, and I was attending graduate classes weekly and was involved in local politics and community activities,
I did not use prior to my next episode, but found that poor choices led to a domino effect in the breakdown of the preventative factors I had built up. When we become manic, we begin to take risks, believing that nothing can hurt us. We are more likely to abuse chemicals. According to Burgess, between 60 to 80% of people with bipolar disorder experience alcoholism or other chemical dependency during their lives. It is generally believed that our chemical use is an attempt to self-medicate. We may distrust our doctors and believe that we can do a better job of managing our moods and behavior ourselves. Estroff and Collaprea reported that 58% of patients abused Cocaine while manic versus 30% who used it while depressed. We may use uppers such as Cocaine and Metamphtamine to intensify and/or to prolong the high, and are more likely to take risks when manic. It is estimated that 15 to 65% of those with bipolar disorder abuse marijuana. We tend to think that pot will bring us down from uncomfortable manic states and will soothe our agitation and anxiety. Clients also report that alcohol relieves irritability, restlessness and agitation associated with mania. We are more likely to use alcohol when depressed. One study found that 38 % of clients with bipolar disorder increased alcohol use when depressed versus 15% of clients with unipolar depression. Clients are also likely to use alcohol when they get worried about the sleep loss that accompanies mania. Unfortunately, chemical use tends to imbalance our body chemistry even more, leading to more sleep loss and more depression.
We really believe that chemical use helps us. Gavin and Kleber note that 80% of bipolar clients reported an “improvement” towards hypomania when using chemicals. Our perceptions of positive effects may prevent us from observing that we actually experience increased anxiety, depression,etc, following chemical use. I have been present when some clients realize this in treatment. This is a gutsy awareness, involving a challenge to the mythology promoted by peers and even poorly informed professionals.
The diagnosis of bipolar disorder is a challenge. A process known as differential diagnosis must be used to distinguish bipolar disorder from other conditions with similar symptoms. For example, i was misdiagnosed twice with schizophrenia. which shares an average age of onset of 30 with bipolar disorder. The psychosis of a manic state can be confused with the more permanent psychosis of schizophrenia. Unfortunately, the antipychotic medications used to treat schizophrenia may provide less than optimal effectiveness for bipolar disorder, especilly if they are not used in combination with a mood stabilizing medication.
I was also diagnosed with hyperthyroidism, which is metabolic illness that affects organ function in ways that are similar to bipolar disorder. Following my last manic episode, I was treated by a wise doctor, who insisted on tests to rule out other medical conditions that could produce the symptoms I was experiencing. There seems to be a high correlation between bipolar disorder and diabetes, which I also have.
Research shows that over 70 % of people with bipolar disorder were misdiagnosed more than 3 times. Peter believes that clinicians failed to link his cyclical depression to bipolar disorder, type II, a common error. Children seem to be often misdiagnosed with ADHD, Differential diagnosis is complicated by a high cooccurence of ADHD and bipolar disorder in children.
Chemical use can complicate proper diagnosis. Conditions such as drug-induced psychosis must be ruled out. Goodwin and Jamison note that substance abuse contributes to more severe episodes of bipolar disorder, including rapid cycling, mixed episodes and slower recovery. Many clinician prefer to observe a period of abstinence for a client before providing a definite diagnosis. Unfortunately, clients may not stop their chemical use long enough to rule out drug effects.
Abstinence is likely to be beneficial in treatment of any patient with bipolar disorder. Jamison reported that chemical use contributes to more severe pathology and less favorable outcomes. Clients with a genetic predisposition to bipolar disorder, determined by a family history of bipolar disorder, or other mood disorder, are likely to discover that chemical abuse precipitates mania and depression. While use of antidepressants can trigger a switch to mania, this is more likely when chemical use is a factor. Jamison cited research that showed that longer periods of marijuana use are related to longer periods of mania.
While many clients report that they use chemicals to cope with depression, studies show that they tend to abuse chemicals more frequently when manic, This may be related to our tendency for increased risk-taking behavior when manic. Another factor in destabilization is that alcohol and other drug use contributes to a disorganized lifestyle, including lack of daily routine and structure,including poor medication compliance.
Family dynamics related to bipolar disorder include use of denial in coping with anger and anxiety, unrealistic expectations for family members, and low self-esteem passed through the generations. Family members may build anger. People with bipolar disorder act very irrationally, causing consequences for the whole family and we become irritable and agitated, resulting in verbal or physical aggression against those close to us. Family members tend to take on guilt for their imagined contribution to the illness. They often grieve,like the client, for the loss of the healthy self, and/or loss of connection or predictability in the relationship. The family’s support network can be diminished as they experience blame by extended family members or friends and try to hide the extent of problems because they believe that they can’t explain them or others won’t understand.
When chemical abuse is present in a person with bipolar disorder, family members, like the client, can be in denial about it’s negative effects. They may, like the client. see a temporary positive effect from the client’s chemical use ot they may be using chemicals themselves to self-medicate the stress and anxiety they experience in dealing with a family member with bipolar disorder. As a result, family members may even encourage chemical use. Professionals who advocate abstinence may be perceived as lacking credibility in having “failed” the client and family in the past. It is also easy to discount the findings of researchers, locked up in their ivory towers. The solution may be psycho-education for the nuclear family, ass well as compassionate therapy to help the family cope with their feelings and build their courage and coping skills.
Schizoaffective disorder may be related to bipolar disorder and there exists the potential to learn how to treat it as we expand our ability to treat bipolar disorder. It is diagnosed as either depressed type or bipolar type, including symptoms of these mood disorders, as well as a “thought disorder” With SD psychosis can occur outside of episodes of depression or mania, with less visible, if any “triggers”preceding episodes.
Friends, family members and professionals who cope with clients with bipolar disorder are advised to distinguish the difference between the person and their behavior. We need to cope with our own feelings and practice proactive stress management. We need to avoid isolation by connecting with a positive support network. We participate with the client in nurturing a new “healthy” family system in which there is shared problem-solving and conflict resolution.
Families can enlist the help of a family focused therapist to identify difficulties or conflicts that produce client or family stress. The therapist can cue into crical, hostile and over-involved attitudes and behaviors in family members that contribute to client and family stress.
Anxiety frequently accompanies the cycles of mania, depression or mixed states. It has been observed that 39% of clients with bipolar disorder demonstrate symptoms of anxiety. This may manifest as agitation,accelerated thought processes, restlessness, social anxiety, irritability, or dysphoric mood. co-occurring anxiety disorders include Panic Disorder, Obsessive Compulsive Disorder, Post Traumatic Stress Disorder and phobias. Anxiety and bipolar disorder tend to be more severe when cooccurring. Bipolar individuals often experience trauma during episodes because of poor judgment and risk-taking.
We need to practice our recovery daily, including: a. taking medications consistently, b. abstinence from alcohol and other drugs, c. using positive coping skills. We can work with professionals who have dual training in chemical dependency and mental health. We can participate in mutual support and self-help with other clients and families in which bipolar disorder is present. Establishment of daily routines and a fairly consistent schedule can help to promote stability in our moods and our lives. It is important to practice positive sleep hygiene. We need a certain amount of REM (rapid eye movement) sleep every day, so that we can dream, successfully process our lives and problem solve.
When people use alcohol or other drugs to sleep, they usually just “pass out” zand do not achieve restful REM sleep. Although some of us will need to use prescribed sleep medications, it would be a good idea to also develop “sleep skills” to achieve sleep as well. For example, I have used “meditation” in the form of progressive muscle relaxation, imagery, and affirmations to get needed sleep. I is a good idea to get regular exercise, but if done too close to bedtime, exercise can be stimulating and promote wakefulness. Stimulating activity, like going on-line, television or stimulating reading can prolong wakefulness. It is best to avoid caffeine, nicotine and sugar, especiallt close to bedtime.
Healthy eating helps those with bd maintain balance. Fish or flaxseed oil supplements can provide omega-3 fatty acids. Protein is important in the morning, but can be too stimulating in the evening. We need 6 servings of fruits and vegetables daily. Leafy green vegetables like spinach and kale are especially good. Whole grains are also important.
20 minutes of aerobic level exercise every other day is the standard for everyone, but possibly more important for those with bd who wish to maintain balance. Periods of meditation are also helpful, even if we are sleeping well. Yoga, tai chi and acupuncture are all positive practices for bipolar disorder..
Professionals working with bipolar disorder may wish to access the website of Kathleen Sciacca. Her recent work shows how motivational interviewing can help individuals and families with mental illness. Dennis Daley has done extensive writing on chemical dependency and mental illlness. He and co-workers have prepared assignments in which clients can improve their awareness, their problem-solving and their recovery coping skills. We also suggest that you investigate the work of Ellen Frank and others with IPSRT(Interpersonal Social and Rhythm Therapy and the work of Basco and Rush with CBT(Cognitive Behavioral Therapy). We will soon be publishing our own workbook for use in treating bipolar disorder and chemical dependency.
I wish to remind you once again of our vision for bipolar disoder, one which we hope you will share. We believe that those of us in recovery from dual disorder have precious awarenesses and coping skills that can overcome the negative effects of our condition. Through sharing these and through mutual support we CAN live meaningful, productive and enriched lives! Tim Kuss 1-18-10
BIBLIOGRAPHY
Basco, Monica Ramirez and Rush, A. John, Cognitive Behavioral Therapy for Bipolar Disorder, Guilford Press, London, 2007
Burgess, Wes, The Bipolar Handboook, Penguin Group, New York, 2006
Candida, Frank, and Kraynik, Joseph, Bipolar Disorder for Dummies, Wiley Publishing Inc, Hoboken, New Jersey, 2005
Castle, Lana, Bipolar Disorder Demystified, Marlease and Company, New York, 2003
Daley, Dennis and Moss, Howard, Counseling Clients with Chemical Dependency and Mental Illness, Hazelden Publishing, Minneapolis, MN, 2002
Frank, Ellen, Treating Bipolar Disorder: A Clinician’s Guide to Interpersonal Social and Rhythm Therapy, Guilford Press, New York, 2005
Fawcett, Jan, Golden, Bernard and Rosenfeld, Nancy, New Hope for People with Bipolar Disorder, Three Rivers Press, New York, 2007
Goodwin, Frederick and Jamison, Kay, Manic Depressive Illness, Oxford University Press, Oxford. England,1990
Jamison, K. R, An Unquiet Mind, Vintage Books, New York, 1995
Johnson, Sheri and Leahy, Robert, Psychogical Treatment of Bipolar Disorder, Guilford Press, London, 2004
Mandimore, Francis, Bipolar Disorder, a Guide for Patients and their Families, John Hopkins Press, Baltimore, MD, 2006
Miklowitz, David and Goldstein, Michael, Bipolar Disorder: A Family Focused Treatment Approach, Guilford Press, New York, 1997
Miklowita, David, The Bipolar Disorder Survival Guide, Guilford Press, New York, 2002
Oliwenstein, Lori, Taming Bipolar Disorder, Alpha Books, New York, 2005
Web Resources
Depression and Bipolar Support Alliance, www.dbsalliance.org
Dual Recovery Anonymous, www.draonline.org
McMan’s Depression and Bipolar Web, www.McManweb.com
National Alliance for the Mentally Ill, www.nami.org
Sciacca, Kathleen, Dual Diagnosis Website, www.users.erols.com/ksciacca
Videos
“Understanding Bipolar Disorder and Addiction”, Hazelden, Minneapolis, MN. 1995
“Dark Glasses and Kadeiloscopes”, Depession and Bipolar Support Alliance, 2006
Subscribe to:
Posts (Atom)
Posts
