by Peter J. Dorsen, M.D., LADC
I thought this response to my challenges with Billy would be interesting counterpoint to my own thoughts on anger in someone with bipolar disorder.
Dr Gove Hambidge, an unique psychoanalyst who prefers to go in depth with his clients, emphasizes that it is crucial for Billy to "self discover." He further adds that there is implicit danger if you " give instructions"(as I seem to have done with Billy); that he "might think you incompetent." However, “preferably, if he discovers the fact( call it truth) himself, it becomes self-fulfilling."
In his opinion, however, in respect to a relationship between Billy’s explosive anger and his bipolar disorder, "they are always linked.” This “ social organization”, as it were, is part of him: anger-mania-hypomania.
"But Billy is a good learner." In answer to my question why Billy’s mother is calling canceling her son's appointment is that it could represent "a power struggle you are having (with the mother). " You are like a pair of boxers in the ring and she can win by canceling the appointment."
"Keep in mind, it's his job to discover. Be subtle. Empathize. Invite him to look at his behavior (like the incident hitting the door recently." Dr Hambidge added, " He's certainly pissed at his mother. It is for him to look and say "intolerable"-- that's why I recommend self-discovery."
"I suspect you have been suckered into the role of giving instruction. Instead, hand power over to the client/patient.
But the good thing, is that you are (now) more familiar with the family dynamics."
Sometimes, it just seems like such a painful way to learn!
Definitely insightul!
Sunday, May 29, 2011
Tuesday, May 24, 2011
Bipolar Visions: What About explosive Anger?
It has frequently come to my attention that people who happen to have bipolar disorder get “accused” more often than not of having a often inaccurate “bipolar moment.” However, I must be one of those splitters rather than lumpers and think such unfortunates have an independent entity called Intermittent Explosive Disorder(IED).
What I have consistently come to believe is that what we are witnessing, especially in someone diagnosed with bipolar disorder (especially Type 1 more frequently than Type 2), is what the Diagnostic and Statistical Manual of Mental Disorders (DSMIV) has categorized as 312.34, under the broad umbrella of impulse-control disorders(not elsewhere classified.
Here is a case from my practice:
Billy, age 17, enrolled in a special school and additionally carefully supervised there for his bipolar disorder(not otherwise specified, 296.80), is currently participating in a specially tailored weekly outpatient CD program with me, biofeedback and therapy from a mental health counselor, and obtains in-depth psychotherapy and medications(Depakote) from a psychiatrist. He has \demonstrated rapid alterations(over days) between manic and depressive symptoms that meet symptom threshold criteria but not minimal duration criteria for manic, hypomanic, or major depressive episodes.
Billy entered the legal system as a minor at 16 and received probation after totaling his parents’ car while under the influence and discovered carrying an illegal amount of marijuana a week later at school(a possession charge). He also has suffered chronically from anxiety and panic attacks for which his PMD prescribes a long acting anxiolytic(Valium) which is monitored. He endures an abusive dependent relationship with a schoolmate and accepts victimization.’
A week ago, his girlfriend called him out of class while he was on a short break enlisting another girl in a dialogue over a rumor that they were breaking up. He violently and uncontrollably punched the door behind the girl several times and immediately screamed four-letter epithets how she should stay the F out of his business. An xray was taken of his hand that was suspicious of a hairline fracture. In our conversation he admitted regret what he had done but said he could not control himself.. His girlfriend was suspended for 10 days for instigating the incident.
I believe this case is illustrative for demonstrating impulsive aggression (that) is unpremeditated and so characteristic of IED. Curiously, IED belongs to the larger family of Axis I impulse control disorders such as kleptomania, pyromania, and pathological gambling. By definition, it is a “disproportionate reaction to any provocation, real or perceived.” Keep in mind that, prior to the incident, my client was sitting quietly in chair in a “comfi” chair in a short break from a class movie.
It comes as no surprise to me that “the disorder itself is not easily characterized and often exhibits comorbidity with other mood disorders, particularly bipolar disorder or, as I am inclined to say, “true-true, but not related. Here’s where I’m in the “splitters” camp. I believe the two are separate entities.
The consistent pattern of this illness is that outbursts are brief( less than a half hour) and, certainly in our patient, often associated with panic and anxiety. There is an association as well with chest tightness, twitching and palpitations, somatic experiences. One of the comments my client volunteered was, “ I could never hit a woman.” She very quickly scurried off to class immediately after this encounter. He said he wished he had been capable of reacting differently. It was all so instantaneous. It was as if he had explained, “The Devil made me do it!”
Except for known and diagnosed bipolar disorder, my patient lacks other possibilities for his behavior: an antisocial personality disorder. He is not borderline, and does not have ADHD. I am unaware of prior brain injury and he has four months of sobriety from all illicit drugs verified by negative regular and random urine screens. He has had witnessed consumption of Depakote, his mood stabilizer, although admittedly he has not had a level drawn and has requested increasing his dose from 250 twice a day to 500mg twice a day. “I feel better on the higher dose.”
Certainly, there are some exotic theories for an etiology for IED such as a low brain serotonin turnover rate(low 5-HIAA) in the CSF as well as an increased insulin secretion. I am personally aware how volatile any of us can become with low blood sugar certainly a consequence of elevations of insulin.
It is important to address treatment issues for IED. In Billy’s case, we are utilizing the aforementioned interdisciplinary approach to our patient’s documented polysubstance addiction problems. Our method includes addressing mental and physical health issues. Unquestionably, a concern for family dynamics as well as Billy’s difficult dependent relationship with his girlfriend are important in our focus. We are treating him for bipolar disorder as well as endeavoring to find the best anxiolytic because so much of his challenge has been his own self-medicating with marijuana, MDX, alcohol, and opiates.
It is my opinion that Billy definitely has issues with bipolar disorder which we are in the process of stabilizing. We are working with his family as well as generating as much cooperation from Billy who I want to begin assuming more and more responsibility for his treatment as well as his behavior. As with other issues like cursing out his mother, I am trying to help Billy create better alternatives. Cognitive behavior therapy(CBT) is one of the mainstays of therapy. I like to think ours is eclectic and may as a result be even more successful. I am not so quick to incriminate Billy’s primary illness, bipolar disorder as what instigates his IED.
My plan is to approach Billy’s IED both independently and simultaneously with his bipolar disorder and addiction to relearn “uncontrollable” responses to frustration. I would like to see him divert impulsive and disproportionate rage reactions elsewhere or help him anticipate ways of avoiding potential trigger events like the one described he had at school.
In this event, I am attempting to assist Billy prepare by avoiding any potential for such an reoccurrence. I advised developing preventive skills. There is no way I can guarantee we can fully eliminate IED in our client. However, I believe it helps to view IED as an independent entity with its own combustion point that can be anticipated and hopefully modulated.
What I have consistently come to believe is that what we are witnessing, especially in someone diagnosed with bipolar disorder (especially Type 1 more frequently than Type 2), is what the Diagnostic and Statistical Manual of Mental Disorders (DSMIV) has categorized as 312.34, under the broad umbrella of impulse-control disorders(not elsewhere classified.
Here is a case from my practice:
Billy, age 17, enrolled in a special school and additionally carefully supervised there for his bipolar disorder(not otherwise specified, 296.80), is currently participating in a specially tailored weekly outpatient CD program with me, biofeedback and therapy from a mental health counselor, and obtains in-depth psychotherapy and medications(Depakote) from a psychiatrist. He has \demonstrated rapid alterations(over days) between manic and depressive symptoms that meet symptom threshold criteria but not minimal duration criteria for manic, hypomanic, or major depressive episodes.
Billy entered the legal system as a minor at 16 and received probation after totaling his parents’ car while under the influence and discovered carrying an illegal amount of marijuana a week later at school(a possession charge). He also has suffered chronically from anxiety and panic attacks for which his PMD prescribes a long acting anxiolytic(Valium) which is monitored. He endures an abusive dependent relationship with a schoolmate and accepts victimization.’
A week ago, his girlfriend called him out of class while he was on a short break enlisting another girl in a dialogue over a rumor that they were breaking up. He violently and uncontrollably punched the door behind the girl several times and immediately screamed four-letter epithets how she should stay the F out of his business. An xray was taken of his hand that was suspicious of a hairline fracture. In our conversation he admitted regret what he had done but said he could not control himself.. His girlfriend was suspended for 10 days for instigating the incident.
I believe this case is illustrative for demonstrating impulsive aggression (that) is unpremeditated and so characteristic of IED. Curiously, IED belongs to the larger family of Axis I impulse control disorders such as kleptomania, pyromania, and pathological gambling. By definition, it is a “disproportionate reaction to any provocation, real or perceived.” Keep in mind that, prior to the incident, my client was sitting quietly in chair in a “comfi” chair in a short break from a class movie.
It comes as no surprise to me that “the disorder itself is not easily characterized and often exhibits comorbidity with other mood disorders, particularly bipolar disorder or, as I am inclined to say, “true-true, but not related. Here’s where I’m in the “splitters” camp. I believe the two are separate entities.
The consistent pattern of this illness is that outbursts are brief( less than a half hour) and, certainly in our patient, often associated with panic and anxiety. There is an association as well with chest tightness, twitching and palpitations, somatic experiences. One of the comments my client volunteered was, “ I could never hit a woman.” She very quickly scurried off to class immediately after this encounter. He said he wished he had been capable of reacting differently. It was all so instantaneous. It was as if he had explained, “The Devil made me do it!”
Except for known and diagnosed bipolar disorder, my patient lacks other possibilities for his behavior: an antisocial personality disorder. He is not borderline, and does not have ADHD. I am unaware of prior brain injury and he has four months of sobriety from all illicit drugs verified by negative regular and random urine screens. He has had witnessed consumption of Depakote, his mood stabilizer, although admittedly he has not had a level drawn and has requested increasing his dose from 250 twice a day to 500mg twice a day. “I feel better on the higher dose.”
Certainly, there are some exotic theories for an etiology for IED such as a low brain serotonin turnover rate(low 5-HIAA) in the CSF as well as an increased insulin secretion. I am personally aware how volatile any of us can become with low blood sugar certainly a consequence of elevations of insulin.
It is important to address treatment issues for IED. In Billy’s case, we are utilizing the aforementioned interdisciplinary approach to our patient’s documented polysubstance addiction problems. Our method includes addressing mental and physical health issues. Unquestionably, a concern for family dynamics as well as Billy’s difficult dependent relationship with his girlfriend are important in our focus. We are treating him for bipolar disorder as well as endeavoring to find the best anxiolytic because so much of his challenge has been his own self-medicating with marijuana, MDX, alcohol, and opiates.
It is my opinion that Billy definitely has issues with bipolar disorder which we are in the process of stabilizing. We are working with his family as well as generating as much cooperation from Billy who I want to begin assuming more and more responsibility for his treatment as well as his behavior. As with other issues like cursing out his mother, I am trying to help Billy create better alternatives. Cognitive behavior therapy(CBT) is one of the mainstays of therapy. I like to think ours is eclectic and may as a result be even more successful. I am not so quick to incriminate Billy’s primary illness, bipolar disorder as what instigates his IED.
My plan is to approach Billy’s IED both independently and simultaneously with his bipolar disorder and addiction to relearn “uncontrollable” responses to frustration. I would like to see him divert impulsive and disproportionate rage reactions elsewhere or help him anticipate ways of avoiding potential trigger events like the one described he had at school.
In this event, I am attempting to assist Billy prepare by avoiding any potential for such an reoccurrence. I advised developing preventive skills. There is no way I can guarantee we can fully eliminate IED in our client. However, I believe it helps to view IED as an independent entity with its own combustion point that can be anticipated and hopefully modulated.
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