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
Friday, February 26, 2010
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
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