The Bipolar Disorder Survival Guide: What You and Your Family Need to Know

•

Recognizing Early Warning Signs of Mania or Depression

•

Understanding Your Everyday Ups and Downs - and When It's Your Symptoms Talking

•

Working with Your Doctor

to Find the Right Medication and Therapy

•

Preventing Mood Swings from Ruling Your Life, and Staying on Track at Home and Work

DAVID J. MIKLOWITZ, PhD

T H E BIPOLAR B I P O L A R DISORDER D I S O R D E R SURVIVAL S THE GUIDE GUIDE

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THE

T

H

E

BIPOLAR DISORDER

BIPOLAR DISORDER

SURVIVAL GUIDE

SURVIVAL GUIDE What You Y o u and a n d Your Y o u r Family F a m i l y Need N e e d to t o Know K n o w W h a t

D A V I D J. J. MIKLOWITZ, M I K L O W I T Z , PHD PhD DAVID

�

T H E GUILFORD G U I L F O R D PRESS PRESS THE New York New York I/ London London

© Press © 2002 2002 The The Guilford Guilford Press A A Division Division of of Guilford Guilford Publications, Publications, Inc, Inc. 72 York, NY 72 Spring Spring Street, Street, New N e w York, N Y 10012 10012 www.guilford.com www.guiLford.com

All righlS All rightsreserved reserved

The in this thisvoLume volumeisis not intended a substitute The information information in not intended as aassubstitute for for consultation consultation with heaLthcare healthcare profesSionals. professionals. Each Each individual's individual's health concerns concerns should should be be evaluated evaluated by aa qualified qualified professional. health profeSSional. No part part of stored in a in a No of this thisbook bookmay maybe bereproduced, reproduced,translated, translated, stored retrieval system, or transmitted, transmitted, in any form or by any means, retrieval system. means, electronic, mechanical, microfilming, recording, recording, or electronic, mechanical, photocopying, photocopying, microfilming, otherwise, wrilten permission PubLisher. otherwise, without without written permission from from the the Publisher.

Printed inthe theUnited UnitedStates States of America Printed in of America This book book is isprinted printedononacid�free acid-free paper. paper. Last digit digitis is print number:9 9 88 Last print number: Library of Congress Congress Cataloging-in-Publication Cataloging-in-Publication Data Library of Data Miklowitz, Oavid David Jay, Jay, 1957Miklowitz:, J957guide: what you and your family k n o w /I The bipolar disorder survival guide: famiLy need to know J. Miklowitz. Miklowitz. David J. p. cm. cm. Includes bibliographical bibLiographical references and index. index. ISBN-10: \-57230-525-8 1-57230-525-8 ISBN-13: ISBN-13: 978-1-57230-525-0 (pbk.) (pbk.) ISBN-lO: ISBN-10: 1-57230-712-9 1-57230-712-9 I$BN-13: ISBN-13: 978-1-57230-712-4 (doth) (cloth) 15BN-1O: 1. Manic-depressive illness-Popular illness—Popular works. I. I. Title. 1. Title. RC516 .M554 20012001 RCS16 .M554 616.89'5—dc21 616.89'5-dc21 2001040937 2001040937

Contents Contents

vii vii

Preface Preface

PART I The Diagnosis Courseofof Bipolar Disorder PART I The Diagnosis and and (ourse Bipolar Disorder W h y Do D o II Need Need This This Book? Book? 11 Why

33

2 What What Bipolar Bipolar Disorder Disorder Looks Looks Lihe-to Like—to You, You, 2 to the the Doctors, Doctors, and and to to Everyone Everyone Else to Else

13 13

3 Into Into the the Doctor's Doctor's Court: Court: 3

30 30

What to to Expect Expect from from the the Diagnostic Diagnostic Process Process What

4 4 Is Is It It an an Illness Illness or or Is IsIt ItMe?: Me?: Tips on Coping with the Diagnosis Tips on Coping with the Diagnosis

54 54

PART PARTIIIICauses (ausesand and Treatments Treatments

73 73

5 Where Where Does Does Bipolar Bipolar Disorder Disorder Come Come From?: From?: 5 Genetics, Biology, Biology, and and Stress Genetics, Stress 6 What What Can Can Medication Medication and and Psychotherapy Psychotherapy Do D o Jar for Me? Me? 6

98 98

129 129

Coming to to Tenns Terms with with Your Your Medication Medication 77 Coming ,

vi vi

CContents ontents

PAR I I Self-Management P A R TT IIII Self-Management

8 8 How H o w Can C a n II Manage M a n a g e My M y Disorder?: Disorder?: Practical Practical Ways W a y s to to Maintain Maintain WeI/ness Wellness

151 151

9 What 9 W h a t Can C a n II Do D o If IfIITlI/nk Think I'm I'm Getting Getting Manic? Manic?

183 183

10 Think I'm 10 What W h a t Can C a n II Do D o If If II Think I'm Getting Getting Depressed? Depressed?

214 214

11 Dealing Dealing with with Suicidal Suicidal Thoughts Thoughts and and Feelings Feelings 11

238 238

12 12 Coping Coping Effectively Effectively in in the the Family Family and and Work W o r k Settings Settings

254 254

Resources Resources for for People People with with Bipolar Bipolar Disorder Disorder

290 290

References References

297 297

Index Index

311 311

About About the the Author Author

322 322

Preface Preface

I

I first first became became interested interested in in bipolar bipolar disorder disorder in in 1982 1982 when, w h e n , as as a a predoctoral predoctoral psychology psychology intern intern at at the the University University of of California, California, los Los Angeles Angeles ( U C L A ) Medical Medical Center, Center, II supervised supervised a a bipolar bipolar support group with a fellow (UCLA) support group with a fellow intern. intern. The T h e assignment assignment was was a a challenge, challenge, but but IIwas wasimmediately immediatelystruck struckby byhow how the the members m e m b e r s of of the the group-men g r o u p — m e n and and women w o m e n ranging ranging in in age age from from 19 to 5050— 19 to had discovered, discovered, quile quite independently, independently, how h o w to to deal deal with with their their illness. illness. They had had They had learned recur­ learned to to ask ask for for medical medical and and social social support support when w h e n the the early early signs signs of of recurrences first appeared, to rely on their significant others for emotional support, rences first appeared, to rely on their Significant others for emotional support, and lO to separate separate themselves themselves from from the the disorder disorder and and fight fight its its stigma. stigma.All Allof ofthem them and understood that that leading leading fulfilling fulfilling lives lives required required more more than than just just taking taking medicaunderstood medica­ tion. tion. T h e experience experience inspired inspired me m e to to choose choose a a PhD P h D dissertation dissertation on on this this disorder, disorder, The specifically about about family family relationships relationships among a m o n g late late adolescents adolescents and and young young specifically adults who w h o were were recently recently out out of of the the hospital. hospital. In In the the 15 15 years years since, since, I1 have have adults cared for, for, or orsupervised supervisedthe thecare careof, of,several severalhundred hundredpeople peoplewith withbipolar bipolar disorcared isor­ der and and their their families families in in the the context context of of my m y research research studies studies and and clinical clinical pracder prac­ tice. People People have have come c o m e to to my m y office office in in a a variety variety of of clinical clinical slates, states, each each person person tice. with his his or or her her own o w n unique unique expression expression of of the the disorder disorder and and unique unique beliefs beliefs with about h o w it it should should be be treated, treated,the thefactors factorsin inhis hisor orher hergenetic, genetic,biological, biological,oror about how family background background that that caused caused it, it,and andwhat whatititmeant meantfor forthe thefuture. future.Many M a n yhave have family had a a love-hate love-hate relationship relationship with with the the illness: illness: they theyhave havecherished cherished the theintensity intensity had of the the emotional emotional experiences experiences that that mania mania provides provides but but have have detested detested the the low low of periods, the the disorder's disorder's unpredictability, and the the emotional, emotional, practical, practical, and periods, unpredictability, and and fifi­ nancial damage damage done done lO to their their lives. lives. nancial

f

vii VII

viii viii

PPrelme reface

My long-term collaboration (1979-1997) with the Michael Goldstein, Goldstein, (1979-1997) with thelate late Michael My long-term collaboration P h D , of of UCLA U C L A resulted resulted in in the the development development of of family-focused family-focused therapy, therapy, an an edu­ eduPhD, cational intervention intervention that that assists assists people people with with the the disorder disorder and and their their family family cational m e m b e r s in in coping coping during during the the periods periods after after an an illness episode. My M y experimen­ experimenillness episode. members tal studies studies at at the the University University of of Colorado, Colorado, and and those those of of my my U C L A colleagues, tal UCLA colleagues, showed that that people w h o receive family-focused therapy therapy and and medication medication have have showed people who receive family-focused lower rates of relapse relapse and and less less severe severe symptoms symptoms than than people people who w h o receive receive indilower rates of indi­ vidual supportive supportive care care and and medication. medication. Their Their improvements improvements can can be be observed observed vidual for studies, funded for up u p to to two two years years after after they they begin begin family family treatment. treatment. These These studies, funded by by the Alliance for for Research the National National Institute Institute of of Mental Mental Health Health and and the the National National Alliance Research people. The on on Schizophrenia Schizophrenia and and Depression, Depression, have have included included more more than than 150 150 people. The participants retirees; from participants have have ranged ranged in in age age from from teenagers teenagers to to retirees; from people peopleexperi­ experiencing their their first manic or or depressive depressive episode episode to to those those who w h o have been ill ill for for enCing first manic have been most of their the disorder only occasional most of their lives; lives; from from people people for for whom w h o m the disorder poses poses only occasional life life problems problems to to those those who w h o are are chronically chronically in in and and out out of of hospitals; and people people hospitals; and in contexts. in a a wide wide variety variety of of living living situations situations and and family family contexts. II wrote wrote this this book book to to respond respond to to aa need need voiced voiced by by Virtually virtually everyone everyone with with whom w h o m II have have worked, worked,along alongwith with their theirfamily family members. members. People Peoplewith with the thedisor­ disorder wish wish for more understanding understanding from friends,and andcoworkers. coworkers.Their Their der for more from relatives, relatives, friends, family family members, want to toknow k n o w how h o w best bestto tohelp help their theirbipolar bipolar relative relative members, in in turn, turn, want without Both ask without becoming becoming angry, angry, controlling, controlling, or or overprotective. overprotective. Both ask the the core core question this attempts to to answer: answer: How H o w can can people people with the disorder disorder question this book book attempts with the achieve beuer better m o o d stability stability and and lead lead more more fulfil fulfilling lives, while whiletaking takingmedi­ mediachieve mood ling lives, cation and and dealing dealing with with the the realities the illness illness imposes? imposes? cation realities the It is is my m y strong strong belief belief that h o do do best best with with the disorder are are those those It that people people w who the disorder w h o have learned to to recognize recognize triggers triggers for for their their mood m o o d cycles cycles and and h o w to to mini­ minihave learned how who mize the the impact impact of of these triggers. They They are arepeople peoplewho w h o stay stayclose closeto totheir theirrec­ recthese triggers. mize o m m e n d e d medication medication regimens regimens and and have have good good relationships relationships with with their their phy­ phyommended sicians. They They have have regular therapists or or go go to to support support groups. groups. They They have have sicians. regular therapiSts learned as as much m u c h as as they they can about the the illness, illness,go goto toconferences conferenceswhere where the thelat­ latlearned can about est findings findings about about the the disorder disorder are are presented, presented, talk talk with with orhers others who w h o have have the the est illness, and and read read books books and and anicles articles concerning concerning the the latest latest treatments. treatments. They They illness, have to accept accept the the disorder disorder but but do do not not unnecessarily unnecessarily limit limit their their perlearned to per­ have learned sonal goals goals because because of of it. it. sonal At that that bipolar bipolar support support group group years years ago, ago, II was was impressed impressed by by the themembers' members' At ability other as themselves. One ability and and willingness willingness to to take take care care of of each each other as well well as as themselves. One group hospital inpatient inpatient unit tell group member m e m b e r regularly regularly made m a d e trips trips to to the the local local hospital unit to to tell patients with the the disorder disorder about about the the advantages advantages of of obtaining obtaining medical medical and and patients with psychosocial treatment treatment at at the the U C L A Affective Affective Disorders Disorders Clinic. Clinic. When W h e n aamem­ mempsychOSOcial UCLA ber of of the the group group started started to to cycle cycle into into an an episode, episode, others others were were quickly quickly able able to to ber

Pre/oce Preface

ix IX

recognize recognize the the early early warning warning signs signs and and offer offer assistance. assistance. Members Members were were some­ sometimes blunt with said. times blunt with each each other other but but would would say say things things that that needed needed to to be be said. I'd as that that I'd like like to to think think of of this this book book as as performing performing the the same same function function as support support group. group. It It is is my m y sincere sincere hope hope that that after after reading reading it, it,you you will willfeel feelless less alone available, alone in in your your struggles, struggles, realize realize that that there there are are effective effective treatments treatments available, and have at your fingertips strategies to prevent mood swings from and have at your fingertips strategies to prevent mood swings from ruling ruhng your your life. life. I Ihope hopethis thisbook bookwill willtell tellyou youthe thethings thingsthat thatneed need to tobe besaid saidand and that your benefit, that you'll you'll use use them them to to your benefit, even even if if you you don't don't always always want want to to hear hear them. con­ them. Most Most of of all, all, II hope hope you you and and your your family family members members will will become become convinced vinced that that you you can can lead lead aa full full life life and and achieve achievemany many of ofyour yourpersonal personalgoals goals despite having having the the disorder. despite disorder.

A A Word Word of of Thanks Thanks

Many deserve heartfelt appreciation for supporting me in writ Many people people deserve mymy heartfelt appreciation for supporting me in writing thisbook. book.IIfeel feelespecially especially grateful m ycollaborators, collaborators, Ellen Frank, PhD, grateful toto my Ellen Frank, PhD, andand this David Kupfer, Kupfer, MD, M D , of of the the University University of of Pittsburgh Pittsburgh School School of of Medicine, for David Medicine, for their their encouragement their clinical clinical wisdom wisdom and and their encouragement of of my m y research. research. The The illness illness management management tools tools outlined outlined in in this this book-education, book—education, relapse relapse prevention, efprevention, ef­ fective communication communication and and problem problem solVing, solving, relying relyingon onsocial socialsupports, supports,and and fective social rhythm rhythm stabilization-in stabilization—in many many ways ways reflect reflect aa synthesiS synthesis of of familyfamily­ social focused therapy therapy principles principles and and their their interpersonal interpersonal therapy therapy approach approach to helpfocused to help­ ing people people cope cope more more effectively effectively with with bipolar bipolar disorder. ing disorder. Many teachers teachers and and close close colleagues colleagues have have been been inspirational inspirational throughout throughout Many m y career and have strongly influenced how I think about clinical problems: my career and have strongly influenced how I think about clinical problems: Michael Goldstein, Goldstein, PhD, PhD,Ian IanFalloon, Falloon, M D Keith , Keith Nuechterlein, PhD, Raymond Michael MD, Nuechterlein, PhD, Raymond Knight,PhD, PhD,Connie ConnieHammen, H a m m e n ,PhD, PhD,W. W .Edward EdwardCraighead, Craighead,PhD, PhD, Gary Sachs, Knight, Gary Sachs, M D , Michael Michael Thase, Thase, MD, M D , Steve Steve Carter, Carter, PhD, PhD, Lyman Lyman Wynne, Wynne, M D , Robert MD, MD, Robert Liberman, MD, M D ,Michael MichaelGitlin, Gitlin,MD, M D ,and andKay Kayjamison, Jamison, PhD. M ygraduate graduate stuLiberman, PhD. My stu­ dents and and postdoctoral postdoctoral fellows fellows at at the theUniverSity Universityof ofColorado Colorado are areoften oftenthe thefirst first dents to suggest suggestclinical clinicalstrategies strategiesfor for working with individuals families, and their to working with individuals oror families, and their research has has often often influenced influenced the the direction direction of of my m y own. own. They They have research have included included Elizabeth George, George, PhD, PhD, Teri Teri Simoneau, Simoneau, PhD, PhD, Dawn D a w n Taylor, Taylor, PhD, PhD, Jeff Elizabeth Jeff Richards, M A , Tina Goldstein, M A , Natalie Sachs-Ericsson, PhD, Jennifer MA, Tina Goldstein, MA, Natalie Sachs-Ericsson. PhD, jennifer Richards, Wendel, MA, M A , Kristin Kristin Powell, Powell, PhD, PhD,and andApama AparnaKalbag, Kalbag,PhD. PhD.Colleagues Colleagueswith with Wendel, w h o m II collaborated collaborated at at UCLA U C L A hold hold aa special special place place in in my m y hean, heart, including whom including Margaret Rea, Rea, PhD, PhD,Angus Angus Strachan, Strachan,PhD, PhD,Martha MarthaTompson, Tompson,PhD, PhD, JimMinlZ, Mintz, jim Margaret PhD, Amy A m y Weisman, Weisman, PhD, PhD, and and Sun Sun Hwang. Hwang. PhD, would like like to to extend extend special special appreciation appreciation to to several several friends friends and and col1I would col-

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leagues whocommented commentedonon early drafts of the manuscript and, in many ca leagues who early drafts of the manuscript and, in many cases, suggested additional additional material: material: Lori Altshuler, MD M D and and Richard RichardSuddath, Suddath,MD MD Lori Altshuler, suggested (notably for for their their help help with with the the medication medication chapters), chapters), Sheri Sheri johnson, Johnson, PhD, PhD, (notably Joseph Goldberg, Goldberg, MD, M D , Greg Greg Carey, Carey, PhD, PhD, Daniel Daniel Barth, Barth, PhD, PhD, and Robert joseph and Robert Spencer, Spencer, PhD. PhD. Many thanks thanks go go to to members members of of my m y family-Mary family—Mary Yaeger, Yaeger, my m y daughter daughter Many whom have Ariana, and and my m y brother, brother, Paul Paul Miklowitz, Miklowitz, and and his his family-all family—all of of w h o m have Ariana, brought me m e great great joy reminded me m e that that life life is is not not just about work. My brought joy and and reminded just about work. My a mother, mother, Gloria Gloria MiklowilZ, Miklowitz, who has published published over over 50 50 books, has been been a who has books, has source of of inspiration inspiration during during the the often often difficult difficult process process of of writing writing this source this book. book. The The memory memory of of my m y father, father,julius JuliusMiklowitz, Miklowitz,aaprofessor professorwho w h o taught taughtme m e the the value of research, research,hard hardwork, work,and anda a lifof e of learning, guided e throughout value of life learning, hashas guided me mthroughout my m y academic academic life. life. Finally, would like liketo toexpress expressmy m y sincere sinceregratitude gratitudeto totwo twoof ofthe themost most Finally, tIwould talented, patient, and knowledgeable universe-Kitty Moore talented, patient, and knowledgeable editors editors in in the the universe—Kitty Moore and Chris and Chris Benton Benton of of The The Guilford Guilford Press. Press.Their Theirimprint imprintappears appearsthroughout throughoutthe the book. Without Without their theirencouragement, encouragement,tenacity, tenacity,and and support, this project would book. support, this project would never never have have come come to to fruition. fruition. have enjoyed enjoyed writing writing this this book book and and wish wish you you success success in in your your personal personal II have journey bipolar disorder. disorder. journey through through the the ups ups and and downs downs of of bipolar DAVID J. Miklowitz, PhD

DAVID J. MIKLOWITZ, PhD

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The Dia T h e D i ag g nosis n o s i s and Course a n d C o u r s e o f B i p o l a r D i s o r d e r of Bipolar Disorder

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1

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o I I Need N e e d T h i s Book? B o o k ? Why DDo This

W h y

•T To understand the the symptoms, symptoms,diagnosis, diagnosis,and andcauses causesoof your o understand f yOUT bipolar bipolar disorder disorder • To To learn learn about about effective effectivemedical medical and and psychological psychological treatments treatments • • To To learn learn self-management self-management techniques techniques to to help help you you deal deal with with mood mood • cycles cycles • To To improve improve your your functioning functioning in in family family and and work work settings settings • •

Martha, 34, 34, ended ended up up in in the the hospital hospital after after storming storming out out of of the the house, house, in in Martha, which she she lived lived with with her her husband husband and and tWo two school-age school-age children, children, and and which spending aa disastrous disastrous night nightin inaatown townover overtwo twohours hoursaway. away.Her Herproblems, problems, spending however, had had started started about about two two weeks weeks earlier, earlier,when whenshe shebecame becameunusu­ unusuhowever, ally irritable irritable with with her her husband, husband, Eric, Eric, "slamming "slamming about about the the house,n house," as as he he ally described it, it, and andbecoming becomingeasily easilyprovoked provokedby bythe theminor minor infractions infractionsof of described their children. children.She Shethen thenbegan beganto tosleep sleepless lessand andless less and was increasingly and was increasingly their preoccupied with with many many ideas ideas for for aa new new "dot-com" "dot-com" business business she she planned planned preoccupied to start. start.Despite Despitethis thisintense intensefocus, focus,Martha Marthaseemed seemedvery veryeasily easily distracted. to distracted. She also also began began speaking speaking very very rapidly. rapidly. She Her problems problems came came to to aa head head when when she she left leftthe thehouse houseininaafury furyshortly shortly Her after dinner dinner one one night night and and impulSively impulsively took took aa bus bus to to aa gambling gambling casino casino after about 100 100 miles miles away. away. By By her her account, account, she shemet metaaman m a n atataabar barthe thesame same about night and and went went to to bed bed with with him. him. The The next next morning morning she she called called her her hus­ husnight band, crying, and explained what had happened. Needless to say, he was to say, he was band, crying, and explained what had happened. Needless 3

4 4

THE COURSE Of OF BII'()�R DISORDER THEDIAGNOSIS DIAGNOSISAND AND COURSE BIPOI AR DISORDER

quite angry and and drove to the casino to to pick herher up. HeHe arrived quite angry drove to the casino pick up. arrivedatalthe the agreed-upon place and time, only to find that Martha w a s not there, so he there, so he agreed-upon place and time, only to find that Martha was not returned h o m e — w h e r e he he found founci his his wife, wife, disheveled, disheveled,sleep sleepdeprived, deprived,and and returned home-where angry. After Aftersobbing sobbing for forseveral severalhours, hours,she she finally finallyagreed agreed to togo gowith with him h i mto to angry. be evaluated at at a a local local hospitaL hospital. She Shewas was admitted admitted to tothe theinpatient inpatientunit unitand and be evaluated given a a diagnosis diagnosis of of bipolar bipolar disorder, disorder,manic manic phase. phase. given Bipolar disorder is is a amood disorder atleast least one every every 70 70 Bipolar disorder mood disorderthat thataffects affects at one in in people and and puts puts them them at at high high risk risk for for the the kinds kinds of of problems problems in in their their family, family, people social, and with bipolar aTe social, and work w o r k lives lives that that Martha Martha suffered. suffered. People People with bipolar disorder disorder are also also at at high high risk risk for for physical physical problems, problems,alcohol alcohol and andsubstance substance use usedisorders, disorders, and even suicide. there is psy­ and even suicide. Fortunately, Fortunately, there is much m u c h hope. hope. With With medications, medications, psychotherapy, the chotherapy, and and self-management self-management techniques, techniques, it's it's pOSSible possible to to control control the rapid shifts in in mood m o o d from manic highs highs to to severe severe depreSSive depressive lows lows (called rapid shifts from manic (called "mood from occurring, de­ " m o o d disorder disorder episodes"), episodes"), prevent prevent future future episodes episodes from occurring, decrease the crease the impact of "environmental triggers," and and cope cope effectively effectively so so that impact of ""environmental [riggers," that you enjoy a full life. you can can enjoy a full life. Whether Whether you you have have already already been been diagnosed diagnosed with with bipolar bipolar disorder, disorder, think think you might illness, or you might have have this this illness, orare areconcerned concerned about about someone someone who w h ohas hasit, it,this this book you understand understand the it effectively. book will will help help you the disorder disorder and and learn learn to to manage manage it effectively. In the chapters you'll up-to-date information the nature of In the follOwing following chapters you'll find find up-to-date information on on the nature of the the disorder, disorder, its its causes, medical and and psychological psychological treatments, treatments, and and the the life­ lifecauses, medical style changes changes you you can m a k e to to help help manage manage the the disorder. disorder. T h e information information style can make The should be be relevant relevant to to you you whether whether you you have have been been treated treated on on an an inpatient inpatient basis, basis, should like Martha, Martha, or or on on an outpatient basis, basis, which which is is becoming becoming more and more more like an outpatient more and common. common.

Understanding the the Fads Facts about about Bipolar Bipolar Disorder: Disorder: Its Its Symptoms, Symptoms, Causes, Causes, Understanding Treatment, and Self-Management Treatment, and Self.Management The The inpatient who saw Martha diagnosed diagnosedher her as bipolar inpatientphysician physician who saw Martha as bipolar very very quickly and recommended a regime of mood stabilizing medication ( l ithof mood stabiliZing quickly and recommended a regime medication (lith­ ium) and and an an antipsychotic antipsychotic medication medication (Haldot). (Haldol). After After only only a a few few days days it it ium) was was clear clear that that she she was was responding responding well. well. But Butwhen when her herdoctor doctormade made plans plans to discharge discharge her, her, Martha Martha confronted confronted him him with with a a litany litany of of questions questions and and to worries worries she she had had about about everything everything that that was washappening happening to to her. her.Why W h y was wasshe she being being given given "this "this death death sentence" sentence" (her (her diagnosis) diagnosis) and and "drugged "druggedand anddis­ disposed of being labeled of posed of so so quickly"? quickly"? Why W h y was was she she being labeled manic, manic, when when most most of what she what she had had done, done, she she felt, felt,could couldbe beattribUled attributedto toher herpersonality personalityor orin­ interpersonal terpersonal style? style? "I've "I've always always been been assertive," assertive," she shecomplained complainedto toher herdocdoc-

Why Why Do Do I INeed NeeThis d ThBook? is Book?

S 5

husband, and almost everyoneelse else she she saw. tor,tor, herher husband, and almost everyone saw. "Since "Sincewhen when isisevery­ everything with sympathy sympathy but thing II do do a a mental mental illness?" illness?" Her Her doctor doctor responded responded with but offered offered insufficiem insufficient information information to to satisfy satisfy Martha. Martha. Under Under considerable considerable pressure pressure to to get get people people in in and and out out of of the the hospital hospital quickly, quickly, he he left lefther herwith withaa regimen what had had haphap­ regimen of of medications medications to to take take but but little litde understanding understanding of of what pened to to her or what to expect expect once once she she got got home. home. pened her or what to If you were Martha's position, in likelihood youyou would findfind the hos­ If you were in in Martha's position, in all all likelihood would the hospital my experience, pital experience experience as as confusing confusing and and frustrating frustrating as as she she did. did. In In m y experience, people bipolar disorder for people with with bipolar disorder and and their their family family members m e m b e r s usually usually are are hungry hungry for

information about about the the disorder, disorder, particularly particularlyduring duringor orafter afteraamanic manic or ordepres­ depresinformation sive sive episode. episode. Of O f course, course, people peoplewith withthe thedisorder disorderhave have an an easier easiertime timeassimilat­ assimilating ing information information about about it it once once they they are are over over the the worst worst of of their their symptoms. symptoms. But But even have benebene­ even during during the the hospitalization, hospitalization, Martha Martha and and her her husband husband would would have fited fited a a great great deal deal from from some s o m e basic basic facts: facts: how h o w her herdoctors doctorsknew k n e w she shehad had the theill­ illness, ness, how h o w the the symptoms symptoms are are experienced experienced by by the the person person with the disorder with the disorder verver­ sus would have sus everyone everyone else, else, and and the the course course of of the the illness illness over over time. time. They They would have benefited benefited from from knowing knowing what what to to expect expect after after she she was was discharged discharged from from the the hos­ hos-

pital, including includingher her risks risksof ofcycling cyclingimo intonew n e w episodes. episodes.Without Without this thisinforma­ informapital, tion, it it was was difficult difficultfor forMartha Martha to toput put her her experiences experiences in in context. context.As A s aa result, result, tion, she began to wis­ she began to doubt doubt the the accuracy accuracy of of the the diagnosis diagnosis and, and, by by extension, extension, the the wis-

d o m of of complying complying with with her her prescribed prescribed treatments. treatments. dom A major major assumption assumption of of this this book book is is that that understanding understanding the thefacts facts about about your your A disorder will help help you you accept accept it it and and live livewith withit. it.Important Importantquestions questionsthat thatofoften len disorder will go unanswered mental health health providers providers simply simply don't don't have time ingo unanswered because because mental have time in­ clude: clude:

• What are the of bipolar disorder? are symptoms the symptoms of bipolar disorder? • What •

• Who W h o am a m II apart apart from from my m y disorder? disorder?

•

• Where W h e r e did did the the illness illness come c o m e from? from?

•

• How H o w do do II know k n o w when w h e n I'm I'm becoming becoming ill? ill?

•

• What W h a t triggers triggers my m y mood m o o d cycles? cycles? • What W h a t can can II do do to to minimize minimize my m y chances chances of of becoming becoming ill illagain? again?

•

• How H o w do do II explain explain the the illness illness to to other other people? people?

• •

• What W h a t can can II expect expect from from my m y future? future?

helpshelps you to pre­ Being able able to toput putyour yourillness illness an informational context you to preBeing in in an informational context

vent or or at at least least minimize minimize the the damage damage associated associated with future recurrences vent with future recurrences of of the long-term fufu­ the disorder disorder and and set set appropriate appropriate goals goals for for your your immediate immediate and and long-term ture. ture.

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THE THE DIAGNOSIS DIAGNOSIS AND AND COURSE COURSE OF OF BIPOlAR BIPOIAR DISORDER DISORDER

Adjustingtotothe the Aftermath of Episode an Episode Adjusting Aft.rmoth of on Martha leftleft thethe hospital for hthiumand andHaldol Haldol and Manha hospitalwith withprescriptions prescriptions for lithium and anan appointment to to see see a a new n e w doctor doctor two two weeks weeks later. later. Upon U p o n discharge dischargeshe shehad had appointment agreed to to follow follow the the recommendations recommendations of of the the inpatient inpatient staff staff to to continue continue agreed taking her her medications, medications, but but she she knew k n e w little about what what the the medications medications taking little about were doing doing or or exactly exactly what what was was being being medicated. medicated. She She felt felt shaky, shaky, agitated, agitated, were and irritable. irritable, and andbecame became mentally mentallyconfused. confused.These Theseuncomfortable uncomfortablesensa­ sensaand tions were were largely largely the the result result of of continuing continuing symptoms symptoms of of her her disorder, disorder, but but tions in the the absence absence of of any any information information to to the the contrary, contrary, Martha assumed her her in Martha assumed confusion confusion was was due due entirely entirely to to the the lithium. lithium. felt She then then noticed noticed her her mood m o o d start start to to drop. drop, gradually gradually at at first. first. She She felt She numb, n u m b , disinterested disinterested in in things, things, tired, tired, and and unable unable to tosleep sleepeven even though thoughshe she desperately desperately wanted wanted to. to. She She began began to to spend spend more more time time during during the the day day "sleep "sleep bingeing" bingeing" to to try try to to catch catch up u p from from the the night night before. before. She She awoke awoke in inthe the afternoon responsibili­ afternoon feeling feeling worse worse and and having having difficulty difficulty with with her her usual usual responsibilities, such ties, such as as making making dinner dinner or or helping the children children do do their their homework. homework. helping the The idea her mind The idea of of committing committing suicide suicide crossed crossed her mind for for the the first first time. time. She She felt guilty about the impact of her disorder on her children and wondered felt guilty about the impact of her disorder on her children and wondered whether they be better better off off without without her. whether they would would be her. Martha Martha developed developed an an upper upper respiratory respiratory infection, infection, which which kept kept her herup up late at late at night night coughing. coughing. Compounding C o m p o u n d i n g this this stress, stress, the theneighbors neighborswere werehav­ having work w o r k done done on on their their house, house, and and she she was was awakened awakened from from her fitful sleep sleep ing her fitful by noise noise early early in in the the morning. morning. Her Her sleep sleep became became more more and and more more inconsisby inconsis­ tent, and and her herdaily dailyand and nightly nightlyroutines-when routines—^whenshe shewent went to tobed bed and and when when tent, she w o k e u p — b e g a n to change from day to day. she woke up--began to change from day to day. About a a week after being being discharged discharged from from the hospital, Martha's Martha's About week after the hospital, m o o d escalated escalated upward upward again. again. Her Her thoughts thoughts began began to to race, and she shestarted started mood race, and de· to think think again again about about the the dot-com dot-com business. business. Then, Then, in in what what she she later later delO scribed as as a a "nash," "flash," she she decided decided that that all all of of her her problems-not problems—not just just the the scribed mental confusion but but also also her cycling m o o d , her her sleep sleep disturbance, disturbance, and and mental confusion her cycling mood, her lethargy—were caused caused by by the the lithium. lithium. Without checking with with a a phy­ phyWithout checking her lethargy-were sician or or telling telling anyone, anyone, she she lowered lowered her her lithium lithium dosage. dosage. When W h e n she she saw saw sician be­ no apparent apparent negative negative results, results, she discontinued it it altogether. altogether. Martha Martha beno she discontinued came severely severely irritable irritable again, again, began to sleep sleep less less and and less, less, and and finally came began to finally ended up up back in the the hospital only three weeks after after her her discharge. ended back in hospital only three weeks discharge. Martha's story is is all common. Because of the thedisorder disorder was Martha'S SlOry all too too common. Becausethe the nature nature of was not explained fully fully to to her, her, she she thought thought of of the the episode episode as as a a son sort of of "nervous "nervous not explained breakdown" requiring requiring only only temporary temporary medication. medication. She She did did not not understand understand breakdown" illness could that the the illness could be be recurrent. recurrent. In In Chapters Chapters 2, 2, 3, 3, and and 4, 4, you you will will become become that familiar varifamiliar with with the the expected expected course course of of bipolar bipolar disorder disorder over over lime time and and the the vari-

Why Why Do Do I INeed NeeThis d ThBook? is Book?

7 7

ous This knowledge cancan help youyou stickstick ous forms forms that thatmood mood recurrences recurrencescan cantake. take. This knowledge help to to a a treatment treatment and and self-management self-management plan plan that that may m a y help help stave stave off off recurrences. recurrences. Martha would have benefited from Martha also also would have benefited from knowledge knowledge of of the the factors factors that that we we believe bipolar disorder: believe cause cause the the cycling cycling of of bipolar disorder: a a complex complex interplay interplay of of genetic genetic background, individual background, individual biochemisLTY, biochemistry, and and life life stress, stress, as as discussed discussed in in Chapter Chapter 5. who with guilt guilt and 5. Many M a n y people people w h o have have bipolar bipolar disorder disorder burden burden themselves themselves with and by psypsy� self-blame because they believe their mood m o o d disorder disorder is is caused caused solely self-blame because they believe their solely by chological chological factors factors or or even even sheer sheer weakness weakness of of character. character. Martha Martha could could have have avoided bipolar disorder is associated associated avoided such such self-blame self-blame if if she she had had known k n o w n that that bipolar disorder is biochemical imbalances imbalances of brain neurotransmitters dra­ with with biochemical of brain neurotransmitters that that accelerate accelerate dramatic matic mood m o o d shifts. shifts. Her Her experiences experienceswould would have havemade m a d e more more sense senseto toher her in inthe the context of of her her family family tree: tree: her her mother mother had had depression depression and and her her paternal paternal grandcontext grand­ father was hospitalized once once for for "mental "mental anguish" anguish" and and "exhaustion." "exhaustion." father was hospitalized K n o w i n g about about the the biological causes of of your your disorder disorder will will also also clarify clarify why why Knowing biological causes consistency good mood sta­ consistency with with your your medications medications is is essential essential to to maintaining maintaining good m o o d stability. Martha Martha knew k n e w that that she she needed needed to to take take medication, medication, but but not not why. Chapwhy. Chap­ bility. ters 6 6 and and 7 7 deal deal with with medication medication treatments treatments for for bipolar disorder. There There are bipolar disorder. are ters m a n y drugs drugs available available nowadays, nowadays, in in various various combinations combinations and and dosages. dosages. Doc­ Docmany which treatments to tors tors have have to to be be constantly constantly updated updated on on which treatments to to recommend r e c o m m e n d to which patients, since the accepted accepted treatment treatment guidelines guidelines for for this this disorder disorder which patients, since the change so so rapidly. rapidly. You Y o u will will feel feel more more effective effective in in managing managing your your disorder disorder if change if you can can openly openly communicate communicate with with your your physician physician about about which which medications medications you are most most effective effective for for you, you, their their side side effects, effects, and andthe themixed mixed emotions emotions you you may may are feel feel about about taking taking them. them. Self-Management Self-ManagementStrategies Strategies

Beyond Beyond taking taking medications medications and and meeting meeting with with a a psychiatrist, psychiatrist, there there are are good good and bad ways learning to to and bad ways to to manage manage your your disorder. disorder. Self-management Self-management involves involves learning recognize your own your hfe life acac­ recognize your o w n individual individual triggers triggers for for episodes episodes and and adjusting adjusting your that cordingly. This This book book will will teach teach you you a a number n u m b e r of of self-management self-management tools tools that cordingly. will probably probably increase stable. For will increase the the amount amount of of time time that that your your moods m o o d s remain remain stable. For example, would have stay­ example, Martha Martha would have benefited benefited from from sleep-wake sleep-wake monitoring monitoring or or staying ing on on a a regular regular daily daily and and nightly nightly routine, routine, including including going going to to bed bed and and waking waking at ategies described at the the same same time, time, sLT strategies described in inChapter Chapter 88 (Frank (Frank et etal., al.,1994). 1994).Like­ Likea v.rise, wise, keeping keeping a a mood m o o d chart chart (discussed (discussed in in Chapter Chapter 8) 8) would would have have provided provided a and hhow these structure structure for for tracking tracking her her day-to-day day-to-day changes changes in in emotions emotions and o w these changes vary with with fl uctuations in re­ changes vary fluctuations in sleep, sleep, consistency consistency with with her her medication medication regime, gime, and and stressful stressful events events (Leverich (Leverich & & Post, Post, 1998; 1998; Sachs, Sachs, 1993, 1993, 1996). 1996). Recall Recall that infection and that Martha'S Martha's worsening worsening mood m o o d was was precipitated precipitated by by a a respiratory respiratory infection and

8 8

THE (QURSE OF Of BIP!m THEDlAGHOSIS DIAGNOSISAND AND COURSE BIPOIDISORDER AR DISORDER

the appearance appearance ofofneighborhood neighborhoodnoise, noise, which were stressful and disrupted her the stressful and disrupted her which were sleep-wake patterns. patterns. In In addition addition to to recognizing recognizing these these events events as as triggers, triggers,Mar­ Marsleep-wake tha and and her her husband husband could could have have developed developed a a list list of of early early warning signs that that warning signs tha would alert alert them them to to the the possibility possibility of of a e w episode episode of of mania. In Martha's Martha's would a n new mania. In

a case, these signs included included irritability irritability and and a a sudden in developing developing a case, these signs sudden interest interest in business. Chapter business. Chapter 9 9 provides provides a a comprehensive comprehensive overview overview of of possible possible early early warning warning signs signs of of mania. mania. W h e n Manha Martha first first slarted started becoming becoming depressed, depressed, certain certain behavioral behavioral stratestrate­ When gies might might have have kept kept her her from from sinking sinking further, further, including including behavior activation gies behavior activation exercises 10. exercises and and cognitive cognitive restructuring restructuring techniques, techniques, introduced introduced in in Chapter Chapter 10.

She would have by knOWing She would have felt felt supported supported by knowing that that suicidal suicidal thoughts thoughts and and feelings-a bipolar syndrome-can be combated feelings—a common c o m m o n component component of of the the bipolar s y n d r o m e — c a n be combated through prevention strategies rela� through prevention strategies involving involving the the support support of of close close friends friends and and relatives, tives, counseling, counseling, and and medications, medications, as as described described in in Chapter Chapter 11. 11.

Coping ectively in the and Work Sellings Coping Eff Effectively in Family the Family and Work Settings Martha spent more days thehospital hospital but bUl this Martha spent fivefive more days in in the thislime timewas wasdischarged discharged with a clearer follow-up met the would see as with a clearer follow-up plan. plan. She She met the phYSician physician who w h o would see her her as an monitor her blood serum serum levels. an outpatient outpatient to to monitor her medications medications and and blood levels. The The in­ inpatient work patient social social w o r k team team also also helped helped arrange arrange an an outpatient outpatient appointment appointment with a psychologist psychologist who w h o speCialized specialized in in the the treatment treatment of of mood m o o d disorders. with a disorders. This time, time, she about the the hospitalization hospitalization experience experience but was This she felt felt better better about but was quite wary of what would happen once she was back at home. quite wary of what would happen once she was back at home. After her her discharge, discharge, Martha Martha spoke spoke with with close close friends friends about about what had After what had happened. They were things like like ""I guess everyI guess every­ were sympathetic sympathetic but but said said things happened. They body's a little manic-depressive" and and "Maybe "Maybe you just working working body's a little bit bit manic-depressive" you were were just too hard." W h e n she she disclosed to one one friend that she she was taking lithium, too hard." When disclosed to friend that was taking lithium, the friend friend said, "Don't get addicted." Although Although she she knew k n e w her her friends friends were were the said, "Don't get addicted." trying to to be supportive, these these messages confused her. her. Was W a s she she really really i ll or or trying be supportive, messages confused ill just going through a a tough tough time? time? Were W e r e her her problems really an an illness illness or or just going through problems really just an an extreme extreme of of her her personality? Hadn't the the physicians told her her that that personality? Hadn't physicians told just medications were meant to to be taken over over the the long long term? term? medications were meant be taken Martha's husband, husband, Eric, Eric, seemed seemed unsure unsure of of how h o w to to relate relate to to her. her. He He Martha's genuinely cared about her and wanted to help but frequently became incared about her and wanted to help but frequently genuinely became in­ trusive whether she trusive about about issues issues such such as as whether she had had taken taken her her medications. medications. He He pointed for­ pointed out out minor minor shifts shifts in in her her emotional emotional reactions reactions to to things, things, which which fornow relabeled as merly but which which he merly would would have have escaped escaped his his notice notice but he n o w relabeled as "your "your rapid rapid cycling." cycling." Martha, Martha, in in turn, turn, felt felt she she was was being being told told she she was was "no "no longer longer allowed to reactions." She can't allowed to have have normal normal emotional emotional reactions." She told told him, him, "You "You can't just hand hand me me a a tray tray of of lithium lithium every every time time 1I laugh laugh too tooloud loud or orcry cryduring during aa just movie." movie."

Why D NeeThis d ThBook? is Book? Why Doo I INeed

I} 9

At other times Eric became angry and criticized her At other times Eric became angry and criticized her for forthe thedeteriora­ deterioration in in her her care care of of the the children. tion children. Indeed, Indeed, she she didn't didn't have have enough enough energy energy to to take them various activities activiti.es or get them school on on time. time. She take them to to their their various or get them to to school She didn't feel feel up up to didn't to the the social demands of social demands of being being a a parent. parent. "You uYou aren't aren't trying trying hard enough," said. "'You've got to buck up up and and beat beal this this thing." thing." At At hard enough," Eric Eric said. "You've got to buck other times times he he would would tell other tell her her she she shouldn't shouldn't take take on on too too much m u c h responsibil­ responsibility because because of her illness. illness. Martha became confused what her her hushus­ ity of her Martha became confused about about what band expected her. What understood was was that most people people band expected of of her. W h a t neither neither understood that most need a low-key, low-demand low-demand period period of a hospitalizahospitaliza­ need a low-key, of convalescence convalescence after after a tion so that disorder. tion so that they they can can fully fully recover recover from from their their episode episode of of bipolar bipolar disorder. Her children eyed Martha expecting her her to Her children eyed Martha with with suspicion, suspicion, expecting to burst burst into into irritable tirades, asshe shehad had done done prior priorto tothe thehospitalization. hospitalization.She Shebegan began to to irritable tirades, as feel that that her her family family was ganging up u p on on her. her. The T h e family family stress stress during during the feel was ganging the aftermath her episode contributed to desire to to withwith­ aftermath of of her episode contributed to her her depression depression and and desire draw. draw. Martha return to Martha tried tried to to return to her her part-time part-time computer computer programming programming job job but unable to at work, work, but felt felt unable to handle handle the the long long commute. commute. When W h e n she she arrived arrived at used to to k know well she stared at at the the computer computer screen. screen. "The "The programs programs II used n o w well she stared now seem like her boss n o w seem like gobbledygook," gobbledygook," she she complained. complained. She She finally finally told told her boss about at first first but about her her psychiatric psychiatric hospitalizations. hospitalizations. He H e seemed seemed sympathetic sympathetic at but soon began began pressuring her to to return return to to her her prior prior level level of of functioning. functioning. She She soon pressuring her felt felt uncomfortable uncomfortable around around her her coworkers, coworkers,who w h o seemed seemed edgy edgy and and avoidant avoidant as they they "handled "handled me m e with with kid kid gloves." gloves." The The shiflS shifts in in work w o r k schedules, as schedules, which had had been a regular regular part part of of her her job job before, before, started started to to feel feel like they been a like they which were swings. were contributing contributing to to her her mood m o o d swings.

Martha had had significant significant problems problems reestablishing reestablishing herself herself in in her her home, h o m e , work, work, Martha and community community following following her her hospitalization. hospitahzation. People People who w h o develop develop other other and chronic medical medical illnesses, illnesses, such suchas asdiabetes, diabetes,cardiac cardiacdisorders, disorders,multiple multiplesclero­ sclerochronic sis, sis,or orhypertension, hypertension,also alsohave havetrouble troublerelating relatingto totheir theirpartner, partner,children, children, other other family your everyday family members, members, friends, friends, and and coworkers. coworkers. When W h e n you you reenter reenter your everyday world world following following aa bipolar bipolar episode, episode, even even well-intentioned well-intentioned family family members members don't don't know k n o w how h o w to to interpret interpret the the changes changes in in your your behavior behavior (for (for example, example, your your

irritabihty or or lack lack of of motivation). motivation). They They often often mistakenly mistakenly think think that that you you are are irritability acting acting this this wayan w a y on purpose purpose and and could could control control these these behaviors behaviors if ifyou you only only tried tried harder. harder. As A s aa result, result, they they become become critical, critical, evaluative, evaluative, and and judgmental. judgmental. They They may m a y also also mistakenly mistakenly think think you you can't can't take take care care of of yourself yourself and and try try to to do do things things for for you you that that you you are are more m o r e than than capable capable of of doing doing yourself. yourself. For For example, example, they they may m a y try try to to actively actively manage manage your your time, time, direct direct your your career career moves, moves, telephone telephone your your doctors doctors with with information information about about you, you, or or become become vigilant vigilant about about even even the the state. most most minor minor changes changes in in your your emotional emotional state. In In the the workplace workplace you you may m a y find find your your employer employer initially initially sympathetiC sympathetic but but

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THE DIAGNOSIS DIAGNOSISAND ANDCOURSE COURSE BIPOLDISORDER AR DISORDER TNE Of OF BIPO�R

impatient.Your Yourcoworkers coworkersmay maybe beguarded, guarded, suspicious, or even scared. impatient. suspicious, or even scared. In ad­In addition, you m a y feel feel that that you can't concentrate concentrate as as well on the the job as you you did did dition, you may you can't well on job as before you ill. These Thesedifficulties difficultiesare areall allaapart partof ofthe theconvalescent convalescentpe­ pebefore you became became ill. riod that that follows follows an an episode. episode. In In all all likelihood, likelihood, your concentration problems problems riod your concentration will diminish once once your m o o d becomes stable. But Butititcan canbe bequite quiteupsetting upsettingto to will diminish your mood becomes stable. feel like likeyou're you're not not functioning functioning at atthe the level levelat atwhich whichyou youknow k n o w you're you'recapable. capable. feel As you are probably probably aware, aware, bipolar disorder carries carries a a social stigma not not as­ asAs you are bipolar disorder social stigma sociated with medical medical illnesses. Even though though bipolar bipolar disorder is clearly clearly a a dissociated with illnesses. Even disorder is dis­ order of of the the brain, and its genetic and and biological biologicalunderpinnings underpinnings are are well welldocu­ docuorder brain, and its genetic mented, it it is is still still treated a "mental "mental illness." illness." Many M a n y people people still erroneously mented, treated as as a still erroneously you may believe believe it it is is related related to to your your personal choices or or morals. morals. As As a a result, result, you may personal choices

feel alienated alienated from from others others w h e n they they find find out out about feel when about your your disorder. disorder. O n the the hopeful hopeful side, side, there there is is much m u c h you you can to educate educate your your family, family, (0coOn can do do to wor/lers, friends about nature of workers, and and friends about the the nature ofyour your illness. illness. Cenainly, Certainly,people peoplewill willre­ respond to your disorder disorder in ways that you will will find but their spond to your in ways that you find uncomfortable, uncomfortable, but their re­ reactions will will vary, vary, at at least least in with how you present present it actions in part, part, with h o w you it to to them. them. One One objective of objective of this this book book is isto tofamiliarize familiarizeyou youwith withthe therole roleof offamily familyand andother otherso­ so-

cial factors in in contributing contributing to, to, or orameliorating, ameliorating,the the cycling cyclingof ofyour yourbipolar bipolardis­ discial factors order. is devoted ways of the order. Chapter Chapter 12 12 is devoted to to explOring exploring ways of coping coping effectively effectively in in the family family and and workplace. workplace. You'll You'll learn h o w to to talk talk to to your family, friends, friends,and andco­ colearn how your family, workers about your disorder know you and don't workers about your disorder so so that that they they k n o w how h o w best best to to help help you and don't

perpetuate their misconceptions misconceptions with (as was the case case for for Martha). Martha). You'll You'll perpetuate their with you you (as was the learn specific specific strategies strategies for for communicating communicating effectively effectively with family so so that learn with your your family that disagreements about about the the disorder disorder don't don't escalate escalate into unproductive and and stressdisagreemems into unproductive stress­ ful arguments. arguments. ful

Martha: Epilogue Epilogue Martha: Martha's first two hospitalizations wasquite quite difficult, firstyear yearafter after her her two hospitalizations was difficult, but but Martha's n o w , several several years later, she sheisisdoing doingmuch m u c hbetter. better.She She found a psychiatrist now, years later, found a psychiatrist with h o m she she feels feels comfonable. comfortable. She She is taking a a regimen regimen of of lithium, lithium, with w whom is taking divalproex sodium (DepakOle), (Depakote), and and a a thyrOid thyroid supplement. Her mood m o o d and and divalproex sodium supplemem. Her behavior still shift shiftup up and and down, d o w n ,but buther hersymptoms symptoms are areno no longer longerincapac­ incapacbehavior still itating. For example, example, she she reacts strongly to to disagreements disagreements v^dth her hus­ husreacts strongly with her itating. For band and has periods periods of feeling d o w n or or unmotivated. part due due to band and still still has of feeling down unmOlivated. In to In part of m mood stabiliZing medications, her to commit commit to to a a program program of o o d stabilizing her willingness willingness La medications, she received initially. initially. she has has not not needed needed the the intensive intensive inpatient inpatient treatment treatment she she received Martha and Eric see Martha and Eric have have improved improved their their relationship. relationship. They They regularly regularly see a a marital marital therapist, therapist, who w h o has hashelped helpedthem them distinguish distinguishhow h o w the thedisorder disorderaf­ affects relationship, how fects their their relationship, h o w conflicts conflictsin intheir theirrelationship relationshipaffect affectthe thedisordisor-

Why Why 00 DoI INeed NeeThis d ThBook? is Book?

II 11

what problems theirfamily family life life are unrelated to her To� der,der, andand what problems in in their are unrelated to illness. her illness. Together gether they they have have developed developed a a list list of of the the signs signs of of her her oncoming oncoming episodes episodes and her and what what steps steps to to take take when w h e n these these signs signs appear appear (for (for example, example, calling calling her physician hospitalization). Her physician for for an an emergency emergency appointment appointment to to prevent prevent hospitalization). Her children have have become b e c o m e more more accepting accepting of of her her moodiness, moodiness, and and she she has has bechildren be­ come in the c o m e more m o r e enthusiastic enthusiastic about about parenting. parenting. She She has has had had frustrations frustrations in the workplace, and just not a nine-tonine-lO­ workplace, and finally finally came came to to the the conclusion conclusion that that ''I'm "I'm just not a fiver." her stress stress fiver." She She decided decided to to try try freelance freelance work, work, which which has has reduced reduced her and given given her predictable hours. and her predictable hours. Martha bener understanding understanding of and how to Martha now n o w has has a a better of the the disorder disorder and h o w to manage has learned to manage it. it. For For example, example, by by keeping keeping a a mood m o o d chart chart she she has learned to distinguish-for her everyevery­ distinguish—for herself herself as as well well as as for for other other people-between people—between her day, normal normal mood m o o d swings swings and and the the more more dramatic dramatic mood m o o d swings swings of day, of her her bibi­ polar polar illness. illness. She She has has learned learned to to maintain maintain a a regular regular sleep-wake sleep-wake cycle. cycle. She She recognizes key to to meeting recognizes that that keeping keeping her her disorder disorder well well controlled controlled is is the the key meeting her own o w n expectations expectations of of herself. herself. She She is is now n o w more more comfortable comfortable trusting her trusting and enlisting enlisting the the support support of of her her husband husband and and friends friends w h e n she feels deand when she feels de¥ pressed suicidal. pressed or or suicidal. Martha bm also also feels that Martha recognizes recognizes that that her her disorder disorder is is recurrent, recurrent, but feels that she she is is more m o r e in incontrol controlof ofher her fate. fate.In Insumming s u m m i n gup upher herdeveloping developingability abilityto to cope disorder, she cope with with the the disorder, shesaid, said,"I've "I'velearned learnedtotoaccept acceptthat thatI've I'vegot gotsome­ something biochemical that of w who thing biochemical that goes goes haywire, haywire, but but it's it's not not the the sum s u m total total of h o II am. If If1Icould could change change one one thing thing about about myself, myself,it'd it'dbe beother otherpeople's people'smoods moods am. and h o w they they affect affect me, m e , even even when w h e n it's it's their their problem problem and and not and how not mine." mine." Above all, all, this book isisabout you'vejust just been diagnosed with this book abouthope. hope. If If you've been diagnosed with bi­ biAbove polar disorder, disorder, or or even even if if you you have have had had many m a n y episodes, episodes, you have polar you probably probably have fears about about what what the the future future holds. holds. Martha's Martha's story-while story—while perhaps perhaps representafears representa­ tive of of only only one one fonn form of of the the disorder disorder and and one one type type of of life life situation-captures situation—captures tive

some s o m e of of the the ways ways that that people people learn learn to to live live with with bipolar bipolar illness. illness. A A diagnosis diagnosisof of aspirations. bipolar disorder disorder doesn't doesn't have have to to mean m e a n giving giving up up your your hopes hopes and and aspirations. bipolar A s you you will will soon see, you you can can come c o m e to to terms terms with the disorder disorder and and develop develop As soon see, with the

skills skills for for coping coping with with it it and and still still experience experience life hfe to to its its fullest. fullest.

H o w This This Book B o o k Is Is Organized Organized How This book book is dividedinto intothree three sections. In remaining the remaining chapters of This is divided sections. In the chapters (2-4)(2-4) of this this section, section, "The "The Diagnosis Diagnosis and and Course Course of of Bipolar Bipolar Disorder," Disorder," you'll you'll learn learn about the the symptoms symptoms and and recurrent recurrent nature nature of of the the disorder disorder from from your w n vanyour o own van­ about tage tage point point as as well well as as that that of of your relatives and and the the physician physician w h o makes the di­ diyour relatives who makes the

agnosiS. agnosis. You'll You'llbecome become familiar familiarwith with what what behaviors behaviorsare areconsidered considered to tobe be withwith-

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THE OF OF BIPOlAR THE DIAGNOSIS DIAGNOSISAND ANDCOURSE COURSE BIPOIDISORDER AR DISORDER

in the the bipolar bipolar spectrum spectrum and and what process. in what to lO expect expect from from the the diagnostic diagnostic process. Chapter 4 4 offers offers you you tips tips on on how h o w to to cope the diagnosis diagnosis and and addresses addresses the the Chapter cope with with the question question many m a n y people people ask ask themselves: themselves: "Is "Is it an illness illness or or is is it it m e?" il an me?"

In Part Part II, II, "Causes "Causes and and Treatments," Treatments," Chapter Chapter 5 5 provides provides an an overview overview of In of the You'll the genetic, genetic, biological, biological,and andenvironmental environmentaldeterminants determinantsofofthe thedisorder. disorder. You'll

c o m e to to see see how h o w the the disorder disorder is is not not just just about about biology biology or or just just about about environcome environ­ ment but an interaction interaction of of the the two. two. Chapler Chapter 6 6 is devoted to to medications medications for ment but an is devoted for treating treating the the biological aspects of of the the disorder disorder (mood (mood stabilizers, stabilizers, antidepres­ antidepresbiological aspects sants, sants, amipsychorics, antipsychotics,and andnewer, newer,nontraditional nontraditionalagenlS), agents),including includingtheir theireffec­ effectiveness, we work, and psy­ tiveness, how how w e think think they they work, and their their side side effects; effects; and and the the role role of of psy-

chotherapy in helping helping you you cope cope more more effectively m o o d swings chotherapy in effectively with with mood swings and and their their triggers. Chapter Chapter 7 7 deals deals with the issue issue of of accepting accepting and and coming coming to to terms terms with with the with triggers. a long-term program program of of medication. medication. For For people people with with bipolar bipolar disorder-and disorder—and a long-term m a n y other other recurrent illnesses—taking medications regularly and and for for the the long many recurrent illnesses-taking medications regularly long term poses poses many m a n y emotional emotional and practical challenges. challenges. In In this this chapter chapter you'll term and practical you'll learn why medications consistently why some of of learn w h y taking taking medications consistently is is so so important important and and w h y some

the medications (for don't the common c o m m o n arguments arguments for for discontinuing discontinuing medications (for example, example, "} "I don't need to medications w when feel well") well") are are erroneous. erroneous. need to take take medications h e n II feel

Part Ill, III, "Self�Managemem," "Self-Management," SLarts starts with to manage the disorder disorder by by Part with ways ways to manage the strategies for cycle "Maimaining "Maintaining Wellness" Wellness" (Chapter (Chapter 8), 8), strategies for derailing derailing the the upward upward cycle

9), and how into mania (Chapter (Chapter 9), into mania and h o w to to recognize recognize and and handle handle depression depression (Chap­ (Chapter 10). 10). II devote devote a special chapter chapter to to dealing dealing with suicidal thoughts thoughts and and feela special with suicidal feel­ ter ings (Chapter (Chapter 11), 11), which, for m a n y people people with disorder, is isaaconstant constant ings which, for many with bipolar bipolar disorder, source of pain pain (see, (see, for for example, example, Kay Kay Jamison's Jamison's excellent excellent book Night Falls Falls source of book Night Fast: Understanding Understanding Suicide). Suicide). You'll You'll learn learn ways to get get help help from from others when Fast: ways to others when you're suicidal and things you can do do to to manage these feelings feelings on on your your you're suicidal and some some things you can manage these o w n . The The last last chapter, chapter, "Coping "Coping Effectively Effectively in in the the Family Family and and Work W o r k Settings," own. Senings,n talks about about handling handling the the family, social,and andwork workstress stressthat thatusually usuallyaccompa­ accompatalks family, social, nies the the postillness postillness phases phases of of the the disorder as well h o w to to educate educate others others nies disorder as well as as how about the challenges challenges you about the you face. face.

2 2

What W h a t Bipolar B i p o l a r Disorder D i s o r d e r Looks L o o k s Like­ Liket o You, Y o u , to t o the t h e Doctors, Doctors, to and a n d to t o Everyone E v e r y o n e Else Else

T

hough bipolar disorder is isvery verydifficult difficulttotodiagnose, diagnose,the the "textbook" bipolar disorder "textbook" I hough

descriptions of of it it make make ititsound soundlike likeitit shouldn't hard. After all, what descriptions shouldn't bebe soso hard. After all, what could be be more more dramatic dramatic than than shifting shifting between between extraordinarily extraordinarily manic manic behavior, could behavior, feeling on on top top of of the the world world and supercharged with energy, LO to feeling feeling dede­ feeling and supercharged with energy, pressed, pressed, withdrawn, withdrawn,and and suicidal? suicidal?

Consider aa surprising surprising fact: fact:On O n average, average,there thereisis eight-year lag between Consider anan eight-year lag between a first firstepisode episodeof ofdepression depressionor ormanic manicsymptoms symptomsand andthe thefirst first time the disorder a time the disorder

is diagnosed diagnosed and and treated treated (Goodwin (Goodwin & & Jamison, Jamison, 1990; 1990; Lewis, Lewis, 2000). Why 2000). Why is

should it it take takeso solong longfor foraaperson personwith withthe thedisorder disorderto tocome come to tothe theattention attention should of of the the mental mental health health profession? profession? In In pan, part, the theanswer answerisisbecause becausethe thebehaviors behaviors

that we w e summarize summarize with with the theterm term bipolar bipolardisorder disordercan can look look qUite quitedifferenr, different,de­ dethat pending on on your your perspective. perspective. But Buteven evenwhen when people peopleagree agreeon on how how aaperson's person's pending behavior deviates from from normal, normal, they theycan canhave havevery verydifferent differentbeliefs beliefsabout aboutwhat what behavior deviates causes the the person personto tobe bethis thisway. way.Consider ConsiderLauren, Lauren, w h ohas has bipolar disorder: causes who bipolar disorder:

Lauren, a 28-year-old of three, three, describes herself as an "exercise Lauren, a 28-year-old mother mother of describes herself as an "exercise junkie." In junkie." In the the past past three three weeks, weeks,aatypical typicalday daywenrlike went likethis: this: Once she got Once she got the kids kids off offto toschool, school,she sherushed rushedtotothe thegym, gym,where whereshe she workedout out onanan worked on the exercise bicycle for a quick yogurt exercise bicycle for up up to to two two hours. hours. Then, Then, she she grabbed grabbed a quick yogurt and went hiking her kids kids and went hiking for for most most of of the the afternoon. afternoon. She She would would pick pick up up her from school, make dinner for them, from school, make dinner for them,and and spend the majority the evening spend the majority ofof the evening 13

13

14 14

IHE THE DIAGNOSIS DIAGNOSISAND AND[QURSE COURSE BIPOIA R DISORDER OFOF BIPOlAR DISORDER

on the But she psychiatrist until, by the by the on stairmaster. the stainnaster. But shedid didnot notconsult consult her her psychiatrist until, end of of the the second second week, week, she she had become exhausted exhausted and and unable unable to to funcend func­ had become tion. At At this thispoint point she she left leftthe thechildren children with with their theirgrandparents grandparents and and spent spent tion. several days days sleeping. sleeping. She She admitted admitted to to having having had had several cycles like like these. these. several several cycles Now Now consider how Lauren, her mother, and herand doctor describe her describe her consider how Lauren, her mother, her doctor behavior. Lauren Lauren summarizes summarizes her her problems problems as as the the result result of of being overcommitbehavior. being overcommit­ ted. "It's "It's incredibly incredibly difficult difficult to to take take care care of of three three kids, kids, maintain maintain a a household, household, ted. little help, and and try try to to stay stay healthy," healthy," she she argues. argues. "My " M y ex-husband ex-husband is of very help,and and is of very little II don't don't have have many m a n y friends friends who w h o can can help help out. out. Sometimes Sometimes II push push myself myself too too

hard, but bounce back." Her mother mother feels hard, but II always always bounce back." Her feels that that she she is is "irresponsible "irresponsible and self-centered," would would "rather kids," and self-centered," "rather be be exercising exercising than than taking taking care care of of her her kids," and questions whether geuing enough struc­ and questions whether her her children children are are getting enough guidance guidance and and structure. bipolar II disorder. ture. Lauren's Lauren's doctor doctor has has diagnosed diagnosed her her as as having having bipolar II disorder. Who is right? her environ­ W h o is right? Lauren Lauren thinks thinks her her behavior behavior is is a a function function of of her environment. behaviors as driven by her personality ment. Her Her mother mother describes describes the the same same behaviors as driven by her personality attributes. Her psychiatrist thinks she has has a biologically based based mood disorder. attributes. Her psychiatrist thinks she a biologically m o o d disorder. These Lauren, because because they to These different different perspectives perspectives pose pose a a problem problem for for Lauren, they lead lead to very dirrerent feels that very different remedies remedies for for the the situation. situation. Lauren Lauren feels that others others need need to to be be more supportive. needs to become more responsi­ more supportive. Her Her mother mother thinks thinks Lauren Lauren needs to become more responsible. Her doctor thinks mood stabiliZing medication. medication. ble. Her doctor thinks Lauren Lauren needs needs to to take take a am o o d stabilizing Almost every Almost every patient patient II have have worked worked with with describes describeshis hisor orher herbehavior behavior dif­ differently from from the the way way a or family family member m e m b e r would. Consider Brent, Brent, who who ferently a doctor doctor or would. Consider has been having having trouble trouble holding jobs. H e says says he is depressed depressed but butfeels feelsmost mostof of has been holding jobs. He he is

itt is i due to to being unable to to deal deal with with his his hypercritical hypercritical boss. boss. As As a a result, result, he he is due being unable thinks he needs work environment. thinks he needs to to switch switch jobs jobs and and nnd find a a more more permissive permissive work environment. His wife, Alice, thinks thinks he he is is manic manic and and irritable, irritable, not not depressed, and that that he he His wife, Alice, depressed, and needs long-term long-term psychotherapy psychotherapy to to deal his problems problems with needs deal with with his with male male authority aUlhority figures. She She also thinks he drinks too too much m u c h and and needs needs to to attend attend Alcoholics Alcoholics figures. also thinks he drinks A n o n y m o u s meetings. meetings. Brent's Brent's doctor doctor thinks thinks he a postmanic depressive Anonymous he is is in in a postmanic depressive phase and from a a combination combination of of medication medication and couples therphase and would would benefit benefit from and couples ther­ apy. apy. Psychiatrists and psychologislS psychologists usually usually think think of of bipolar disorder as as a a set set of of Psychiatrists and bipolar disorder symptoms, which must be be present present in in clusters clusters (that (that is, is, more more than than one one at at a symptoms, which must a time) and and last for a a certain certain length of time, time, usually usually in in"episodes" "episodes"that thathave have aabe­ betime) last for length of ginning a phase in which and a ginning phase, phase, a phase in which symptoms symptoms are are at at their their worst, worst, and a recovery recovery

described in phase. The The traditional traditional approach approach to to psychiatric psychiatric diagnOSis diagnosis described in Chapter Chapter phase. 3 follows follows this this line line of of reasoning. reasoning. In In contrast, contrast,people people with with the the illness illness often often pre­ pre3 fer bipolar disorder disorder as fer to to think think of of bipolar as a a series series of of life life experiences, experiences, with with the theactual actual symptoms symptoms being being of of secondary secondary importance importance to to the the factors factors that that provoked provoked them. them. Family significant others different perspective altoFamily members members or or significant others may m a y have have a a different perspective alto-

What Bipolar Bipolar Disorder Disorderlooks LoobUke Like Whot

15 lS

gether, perhaps onethat thatemphasizes emphasizes the patient'spersonality personalityor orthat that views viewsthe the gether, perhaps one the patient's deviant behavior behavior in historical perspective perspective (for always b been deviant in historical (for example, example, "She's "She's always een moody"). different, there there is is a a degree validity to to all m o o d y " ) . Although A l t h o u g h often often quite quite different, degree of of validity all

three points points of view. three of view. In this you'll gain gain a the different people take In this chapter chapter you'll a sense sense of of the different perspectives perspectives people take

in understanding o o d swings a n d how h o w these these different perspectives in understanding bipolar bipolar mmood swings and different perspectives can lead to very different different feelings about w which should bbe under­ can lead to very feelings about h i c h treatments treatments should e undertaken. perspectives include include the standpoint, as as described described b by pa­ taken. These T h e s e perspectives the personal personal standpoint, y patients who disorder; the viewpOint, which usually means tients w h o have have the the disorder; the observers' observers' viewpoint, w h i c h usually means parents, spouses, or viewpoint. Questions to parents, spouses, or close close friends; friends; and a n d the the doctor's doctor's viewpoint. Questions to pose to yourself when reading this are: pose to yourself w h e n reading this chapter chapter are: How do I experience in my mood? • How• do I experience svvangs swings in my mood? •

• Are A r e they they similar similar to to the the ways w a y s others others with with bipolar bipolar disorder disorder experience experience them? them?

•

How H o w do do IIundersland understand my m y own own behavior? behavior?

•

How H o w is is my m y understanding understanding different differentfrom from the the way way others others perceive perceive me? me?

• • • • • •

How H o w do do IIsee see myself myself differently differently from from the the way way my m y doctor doctor sees sees me? me?

What kinds kinds of ofproblems problems arise arise from from these these differences differences in in perceptions? perceptions? What

Understanding these varying you, whether Understanding these varying perspectives perspectives willwill be ofbe useofto use you,to whether you are are on on your first episode episodeor orhave havehad hadmany many episodes, episodes,ininthat thatyou youwill will gain you your first gain some clarity clarity on on how h o w your your own own experiences experiences may may differ differ from from those those of of people some people without bipolar bipolar disorder. disorder.You Youmay mayalso alsocome cometo tosee seewhy why others othersin inyour yourfamily family without or work/social work/social environment environment think think you you need need treatment, treatment,even evenififyou youdon't don'tagree agree or with with them. them.

Nuts and and Boils: Bolts: Whal What Is Is Bipolar Bipolar Disorder? Disorder? Nuls

Let's begin by defining the syndrome ofdisorder. bipolarItsdisorder. Its key chara Let's begin by defining the syndrome of bipolar key characteristic is extreme extreme mood mood swings, swings,from frommanic manichighs highsto tosevere severedepressions. depressions.ItItisiscalled calleda a is mood disorder disorder because because it itprofoundly profoundlyaffects affectsa aperson's person'sexperiences experiencesofofemotion emotion mood and "affect" "affect" (the (the way way he he or or she she conveys conveys emotions emotions to to others). others).I I called bipolar bipolar and ttisis called because the the mood mood swings swings occur occur between between two two poles-high poles—high and and low-as low—as opop­ because posed to to unipolar unipolar disorder, disorder,where wheremood mood swings swingsoccur occuralong alongonly onlyone onepole­ pole— posed the the lows. lows.

In the the manic manic "high" "high" state, state,people peopleexperience experiencedifferent differentcombinations combinationsof ofthe the In following: following: elated elated or or euphoric euphoric mood mood (excessive (excessive happiness happiness or or expansiveness), expansiveness),

irritable mood mood (excessive (excessive anger anger and and touchiness), touchiness), aa decreased decreased need need for for sleep, sleep, irritable grandiosity grandiosity or or an an inflated inflated sense sense of of themselves themselves and and their their abilities, abilities, increased increased

16 16

TNE DIAGNOSIS OfOF BIPOlAR DISOROER THE DIAGNOSISANO ANDCOURSE COURSE BIPOUR DISORDER

talkativeness, racing thoughts or jumping from one idea another, an intalkativeness, racing thoughts or jumping from one idea to to another, an in­ crease in in activ activity and energy energy levels, levels, changes changes in in thinking, thinking, auention, attention, and and percrease ity and per­ ception, and and impulsive, impulsive,reckless recklessbehavior. behavior.These Theseepisodes episodesalternate alternatewith withinter­ interception, vals in in which which a a person person becomes becomes depressed, depressed, sad, sad, blue, blue,or or"down "downin inthe thedumps," dumps," vals loses interest interest in in things things he he or or she she ordinarily ordinarily en enjoys, loses weight weight and and appetite, loses appetite, joys, loses feels fatigued, fatigued, has has difficulty difficulty sleeping, sleeping, feels guilty and and bad bad about about himhim- or or herher­ feels feels guilty self, has hastrouble troubleconcentrating concentrating or ormaking making decisions, decisions,and and often oftenfeels feelslike likecom­ comself, mitting suicide. suicide. mitting to Episodes of of either either mania mania or or depression depression can can last last anywhere anywhere from from days days to Episodes months. months. Some S o m e people people (about (about 40% 4 0 % by by some some estimates; estimates; Calabrese Calabrese et et a1., al., 1996) 1996) don't don't experience experience depressions depressions and and manias manias in in alternating alternating fashion. fashion. Instead, Instead, they they experience what we which I I'll experience them them simuhaneously, simultaneously, in in what w e call call "mixed "mixed episodes,n episodes," which 'll talk talk about about in in the the next next chapter. chapter.

Episodes of of bipolar bipolar disorder disorder do do not develop overnight, overnight, and and how h o w severe severe Episodes not develop the varies greatly the manias manias or or depressions depressions get get varies greatly from from person person to to person. person. Many M a n y peo� peo-

ple accelerate into into mania mania in in stages. stages. Drs. Drs. Gabrielle Gabrielle Carlson Carlson and and Frederick Frederick pie accelerate the early feel Goodwin G o o d w i n (1973) (1973) observed observed that that in in the early stages stages of of mania, mania, people people feel "wired" race with "wired" or or charged charged up up and and their their thoughts thoughts race with numerous numerous ideas. ideas. They They start mildly irritable ("hypo­ start needing needing less less and and less less sleep sleep and and feel feel giddy giddy or or mildly irritable ("hypo-

mania"). Later they they accelerate accelerate into into a a full-blown full-blown mania, mania, marked marked by by euphoria, euphoria, mania"). Later impulsive behaviors frenetic periods of impulsive behaviors such such as as spending spending sprees, sprees, and and intense, intense, frenetic periods of

activity. In In the the most advanced stages, stages, the the person person can can develop develop mental activity. most advanced mental confuconfu­ sion, delusions delusions (beliefs (beliefs that that are are irrational), irrational), hallucinations hallucinations (hearing (hearing voices voices or or sion, seeing things), things), and and severe severe anxiety. anxiety. Not Not everyone everyone experiences experiences these these stages, stages, and and seeing many m a n y people people receive receive treatment treatment before before they get to to the the most most advanced advanced stage. they gel stage.

People also also spiral spiral into into depression depression gradually, gradually, although although its its stages stages are are less People less clear-cut. For Forsome, some,severe severedepressions depressionsarise arisewhen w h e n they theywere wereotherwise otherwisefeeling feeling c1ear-cUl. well. In In others, others, major depression develops develops on on top of ongOing, ongoing, milder milder depresdepres­ well. major depression top of sions (see Chapter 10). sions called called "dysthymias" "dysthymias" (see Chapter 10).

The periods periods in in between between manic manic and and depressive depressive episodes episodes are are symptom-free symptom-free The in some some people. people. For For olhers, others, there there are are symptoms symptoms left over from from the the episodes, in left over episodes, such as as sleep sleep disturbance, disturbance, ongOing ongoing irritability, irritability, or or dysthymiC dysthymic or or hypomanic hypomanic such disorders. disorders. Most Most people people experience experience problems problems in in their social and and work work life life be­ betheir social

cause of the the illness illness (Coryell (Coryell et et aI., al., 1993; 1993; Goldberg al., 1995). 1995). cause of Goldberg et et al., Between 0.8% 0.8% and and 1.6% 1.6% of of the the general general population population has has "bipolar "bipolar I" I" disorder, Between disorder, marked mania. About marked by by swings swings from from extreme extreme depression depression to to extreme extreme mania. About 0.5% 0.5% (1 (1

in 200) 200) has has "bipolar "bipolar II" 11" disorder, disorder, in in which which people people vary severely dein vary from from severely de­ pressed to to hypomanic, hypomanic, a a milder milder form form of of mania mania (Kessler (Kessler e ett aI., al., 1994; 1994; Regier Regier et pressed et al., New bipolar disorder young chilchil­ al., 1990). 1990). N e w cases cases of of bipolar disorder have have been been recognized recognized in in young

dren and and in in the the elderly, elderly, but butthe thetypical typicalage ageat atfirst firstonset onsetis isbetween between I15 and 19 19 dren S and (Goodwin in (Goodwin & & jamison, Jamison, 1990). 1990). It It is is generally generally treated treated with with a a range range of of drugs drugs in combination with psychotherapy: combination with psychotherapy:

What polar DDisorder isorder looks Loob Uke Like WhatBiBipolar

17 17

•• Mood stabilizers (for example, lithium carbonate, Depakote, or Teg-or TegMood stabilizers (for example, lithium carbonate, Depakote, retol) retol) Antidepressants (for (for eexample, Paxil or or Wellbutrin) Wellbulrin) •• Antidepressants x a m p l e , Paxil

•• Antipsychotics x a m p l e , Zyprexa Antipsychotics (for (for eexample, Zyprexa or or Seroquel), Seroquel), and/or and/or •• Antianxiety Antianxiety agents agents (for (for eexample, x a m p l e , Klonopin Klonopin or or Ativan). Ativan).

DiKeren! Perspectives Perspedives oon Depression Different n MMania a n i a aand n d Depression As associated with bipolar mood disorder can be experiAs noted, nOled,the thesymptoms symptoms associated with bipolar mood disorder can be experi­ enced y the y aan n observer, n d bby y qUite differently differently bby the person person with with the the disorder, disorder, bby observer, aand enced quite aa physician. h e disorder ood a n d behavior. o u r moods moods and behavior. YYour physician. T The disorder primarily primarily affects affects mmood cannot e observed y others, o u will cannot always always bbe observed bby others, although although yyou will usually usually be be aware aware of of them. o u mmay a y not them. Likewise, Likewise, yyou not always always be be aware aware of of your your behavior behavior or or its its impact impact oon n others, others, while while others others (family, (family, friends, friends, or or doctors) doctors) are are acutely acutely aware aware of of it. it. WWhen h e n people n d evaluate a m e set experiences people look look at at a and evaluate the the s same set of of behaviors behaviors or or experienc�s through o u can o w mmuch u c h rroom o o m there different lenses, lenses, y you can imagine imagine h how there is is for for interthrough different inter­ pretation pretation and a n d misinterpretation. misinterpretation.

Y ou m ay b e quite quite articulate in describing describing what what y o u are are feeling feehng a n d thinkYou may be articulate in you and think­ ing. WWhen h e n in a mmanic a n i c phase, phase, your thoughts flow rapidly and a n d life exotic ing. in a your thoughts now rapidly life feels feels exotic a n d wonderful. wonderful. You Y o u may m a y speak speak more m o r e than than usual usual and a n d more m o r e freely freely reveal reveal your your and inner thoughts. thoughts. An A n observer, observer, such s u c h as as a a family family member, m e m b e r , usually usually focuses focuses on on inner y o u r behavior, behavior, which w h i c h he h e or or she she may m a y describe describe as as too too outspoken, outspoken, boisterous, boisterous, your verbally hostile, hostile, dangerous dangerous to to yourself yourself or or others, others, or or impulSive impulsive in in ways w a y s that that verbally negatively affect affect others others (for (for example, example, spending spending or or investing investing your your money m o n e y sud­ sudnegatively denly). Your Y o u r doctor doctor is is usually usually attuned attuned to to whether w h e t h e r your your mood m o o d and a n d behavior behavior are are denly). significant departures departures from f r o m your y o u r normal n o r m a l states, states, taking taking into into account account such such Significant things as as whether w h e t h e r the the symptoms s y m p t o m s have have lasted lasted for for aa period period of of time, time, how h o w intense intense things they are, are, and a n d whether w h e t h e r they they cause cause impainnent impairment in in your your functioning. functioning. they In the the follOwing following sections, sections,IIwill will describe describe mania m a n i a and a n d depression depression from from these these In three perspectives. perspectives. II will will focus focus on o n the the personal personal experiences experiences that that really really define define three episodes of ofbipolar bipolar disorder, disorder,which w h i c h are are summarized s u m m a r i z e d in in the the sidebar sidebar on o n page page 18. 18. episodes

Roller Coaster CODster Mood MoodStates S'D'es Roller "How can can I ever make make plans plans or count anything or anybody? I never "How 1 ever or on count on anything or anybody? I never k n o w how h o w I'm I'm going going to to feel. feel.IIcan can be b e up u p and a n d happy h a p p y and a n d full fullof ofideas, ideas,but but know then the the littlest htUest things things set set me m e off. off.I'll I'lldrink drink aa cup c u p of of tea tea and a n d it it doesn't doesn't then m a t c h my m y expectation expectation of of how h o w hot hot ititshould should be, be,and a n d I'll I'lljust just react-I'll react—I'll match cuss,scream-I'm s c r e a m — I ' m bitterly bitterlyvolatile volatile . .. .I'm I'm afraid afraid of ofmy m y own o w n moods." moods." cuss, — A 3D-year-old 30-year-old woman w o m a n with with bipolar bipolar IIdisorder disorder -A

18 18

IHE THE DIAGNOSIS DIAGNOSIS AND AND (QURSE COURSE OF OF BIPOlAR BIPOIAR DISORDER DISORDER

Experiences of of Manic M a n i c and a n d Depressive Episodes Experiences Depressive Episodes •

• Roller-coaster Roller-coaster moodstates states (euphoria, irritability, depression) mood (euphoria, irritability, depression)

•

• Changes Changes in in energy energy or or activity activity levels levels

•

• Changes Changes in in thinking thinking and and perception perception

•

• Suicidal Suicidal thoughts thoughts

•

• Sleep Sleep problems problems

•

• lmpulsive Impulsive or or self-destructive self-destructive behavior behavior

voLatile, unpre­ Most people Most people with with bipolar bipolar disorder disorder describe describe their their moods m o o d s as as volatile, unpredictable, Mood bi­ dictable, "all "all over over the the map," map," or or "like "like a a seesaw." seesaw." M o o d states states accompanying accompanying bipolar polar disorder can be be irritable irritable (during (during either either depression depression or or mania), mania), euphoric, euphoric, disorder can elevated de­ elevated or or excessively excessively giddy giddy (during (during mania), mania), or or extremely extremely sad sad (during (during de-

pression). pression). You Y o u may m a y agree agree that thatyou you have have variable variablemood m o o d states, states,but butyour yourexplanation explanationfor for these these mood m o o d states states may m a y be be quite quitedifferent differentthan thanthose thoseof ofyour yourdoctor, doctor,family family memmem­ bers, bers, or orfriends. friends.People Peoplewith withbipolar bipolardisorder disorderoften oftenget getangry angrywhen w h e ntheir theirdoctors doctors bring bring out out a a list listof ofsymptoms symptoms and andask askthem them how h o w many m a n y they theyhave havehad had and andfor forhow how

long. They They find find themselves themselves reluctantly reluctantly agreeing agreeing that that they they suffer suffer from from irritable long. irritable m o o d s but but also also know k n o w the thetriggers triggersfor forthese thesemoods m o o d sthat thatother other people m a ynot notsee. see. people may moods "When I'mI'm mad, nobody better get feellike like crushing every"When mad, nobody better getin inmy myface. face. I I feel crushing every­ thing and and everybody. everybody. Every little thing thing will will provoke provoke me. m e . II hate hate everything Every little every­ body, hate my m y life hfe and and want want to to kill kill myself myself in in some some really dramatic way. way. really dramatic body, II hate It's like a sharp-edged, sharp-edged, pointed pointed anger, anger, like like a a burning burning feeling." It's like a feeling."

— A 23-year-old 23-year-old woman w o m a n with with bipolar bipolar II U disorder disorder -A

Family members, members, when when describing theemotional emotional volatility of bipolar their bipolar sibFamily descriping the volatility of their sib­ ling, ling, child, child, or or parent, parent, tend tend to to emphaSize emphasize the the int intimidation they feel feel in in the the face imidation they face

of sudden sudden outbursts outbursts that that they they don't don't feel provoked. Consider Consider this this inter­ interof feel they've they've provoked. change between Kirsten, age age 2 21, and her her mother, mother, after after Kirsten Kirsten had had railed railed at 1 , and between Kirsten, at change her mother mother just just minutes minutes earlier. her earlier. Kirsten: wanna come with you. you. 1Ican canhandle handleit.it. comeback backand andlive live with KIRSTEN: II wanna Mother: But But you're you're not not in in a a good good place place right right now. n o w . Look Look how h o w angry angry you you just just MOTHER: got. g01.

What ipolar D isorder loo Loob Like WhatBBipolar Disorder ks like

19 19

Kirsten: youyou toldtold me Ime wasn't readyready to take care care of myself! Of course I KIRSTEN:ButBut I wasn't to take of myseH! Of course I exploded! exploded! MMOTHER: o t h e r : AAnd n d you're e , aand nd you're not. not. II can can tell tell because because you're you're overreacting overreacting to to mme, that e you're that tells tells mme you're probably probably not not better better yet. yet.

It's o u r mmood o o d swings n illness, It's hard hard to to think think of ofyyour swings as as evidence evidence of ofaan illness, especially especially wwhen h e n every o u have e e m s perfectly every emotional emotional reaction reaction yyou have sseems perfectly justifiable, justifiable, given given what's a p p e n e d to o u . TTo o Kirsten, e e m e d perfectly what's just just hhappened to yyou. Kirsten, her her angry angry outburst outburst sseemed perfectly justified, o t h e r hhad a d questioned e r mmother other justified, because because her her mmother questioned her her competency. competency. HHer kknows n o w s wwhat h a t her h e n she's n d sees her daughter daughter is is like like wwhen she's well well aand sees her her irritability irritability as as aa departure ffrom this norm. departure r o m this norm.

In a n i c experience In contrast, contrast, the the elated, elated, euphoric euphoric periods periods of of the the mmanic experience feel feel exex­ ceptionally o o d to a y JJamison a m i s o n has ceptionally ggood to the the person person with with the the disorder. disorder. KKay has written written exex­ tensively o n d r o u s feelings a c c o m p a n y mmanic a n i c episodes tensively about about the the w wondrous feelings that that can can accompany episodes aand n d hhow o w the the desire desire to to sustain sustain these these feelings feelings can can lead lead aa person person to to resist resist taking taking medication a m i s o n et o t all 1979; Jamison, Jamison, 1995). 1995). NNot all people people with with bipolar bipolar medication Q Oamison et al., al., 1979; disorder o o d s as disorder experience experience their their high high m moods as euphoria, euphoria, however. however. For For example, example, Beth, 2 , described described her m o o d during m a n i c episodes episodes as sudden 42, her mood during manic as "the "the sudden Beth, age age 4 awareness I'm not not depressed awareness that that I'm depressed anymore." anymore."

T o others, others, y o u r euphoria euphoria or or high high mood m o o d may m a y seem s e e m strange strange or clownish, To your or clownish, a n d they they may m a y not not share share it it with with you, y o u ,but but they they are are unlikely unhkely to to be be as as disturbed disturbed by by and it as as they they are are by b y your y o u r irritability. irritabihty. To T o your your relatives, relatives, especially especially those those wwho h o have have it g o n e through through one o n e or or more m o r e previous previous episodes episodes with with you, y o u , euphoric euphoric m o o d is is wor­ worgone mood risome to to the the extent extent that that it it heralds heralds the the development development of ofaa full-blown full-blown manic m a n i c epi­ epirisome sode. sode. N o w consider consider how h o w you y o u experience experience depression. depression. Would W o u l d you y o u describe describe it it as as Now

a n intense intense sadness sadness an

a n u m b i n gfeeling feehng. . ... a feehng beingremoved r e m o v e dfrom from .. . . a numbing . a feeling ofof being

others .... a lack lack of of interest interest in in things things you y o u ordinarily ordinarily enjoy? enjoy? One O n e man m a n put put it others . . a it bluntly: "My " M y depressions depressions eat eat me m e alive. alive. 1I feel feel like like I'm I'm in in aa tank tank that that separates separates bluntly: m e from f r o m other other people. people. It's It's all all just just hopelessness, hopelessness, and a n d II don't don't see see any any future future for for me myself. " myself." In contrast, contrast, aa family family member, m e m b e r , friend, friend, or or lover lover might m i g h t see see your your depression depression In

as self-inflicted. self-inflicted.People People who who as

are close close to to you y o u might m i g h t feel feelsympathetic sympathetic at at first firstbut but are

then gel get irritated irritated and a n d annoyed. annoyed. They T h e y may m a y think think you're you're not not tryi.ng trying hard hard enough enough then or could could "'make " m a k e this this all all go g o away a w a y if ifyou y o u had h a d the the right right mental mental altitude." attitude." or W h a t does does the the doctor doctor look look for? for? To T o determine determine whether w h e t h e r the the diagnosis diagnosis is is What correct (if (ifyou y o u are are being being diagnosed diagnosed for for the the first first time), time), or or whether whether you y o u are are ex­ excorrect periencing aa recurrence recurrence of of the the disorder disorder (if (if you've you've been b e e n diagnosed diagnosed before) before), periencing , y o u r doctor doctor will will evaluate evaluate whether w h e t h e r your your mood m o o d Slates states are are different, different,in in terms terms of of your degree or or intensity, intensity, from f r o m those those of of "normal" "normal" people. people. Do D o your your moodsmoods— degree

20 20

THE DIAGNOSIS DIAGNOSISAND ANDCOURSE COURSE BIPOLDlSOROER AR DISORDER Of OF BIPOlAR THE

euphoric, irritable, or depressed—get of hand of hand for for euphoric, irritable, or depressed-get outout of hand andand staystay out out of hand days at time? Do D o your your mood m o o d swings swings cause cause problems problems in in your your social, social, work, work, days at aa time? and/or family family life? hfe? The T h e questions questions listed hsted in in the the sidebar sidebar on on this this page page will will figure figure andlor prominently in in your your doctor's evaluation of of whether your m o o d states are prominently doctor's evaluation whether your mood states are problematic perspective. problematic from from a a clinical clinical perspective.

ChDng.s in L•••Levels ,s Changes in En.rgy EnergyDna andActi.ity Activity If someone asked your symptoms, symptoms, you you might on If someone asked you you to to describe describe your might not not focus focus on your mood m o o d fluctuations. fluctuations. In Infact, fact,many m a n ypeople peoplewho w h oare areasked askedabout abouttheir theirmood mood your states instead. states answer answer with with descriptions descriptions of of their energy and and activity activity levels levels instead. their energy They're They're more more conscious conscious of of what what they they do do or or don't don't do do than than of of how h o w they they feel. feel. They focus focus on on the the great great increases increases in in energy energy that that they they experience experience during during the the They manic the decreases the manic or or mixed mixed phases phases or or the decreases in in energy energy they they experience experience during during the depressive depressive phases. phases. One O n e way w a y to to understand understand these these fluctuations fluctuations is is to tothink think of ofbipolar bipolardisorder disorderas as aa dysregulation dysregulation of of drive drive states states as as well well as as of of mood. m o o d . Changes Changes in in nonnal normal motiva­ motivational drives, such tional drives, such as as eating, eating, sleeping, sleeping, sex, interacting with with others, and sex, interacting others, and The achievement are are part part and and parcel parcel of of the the bipolar bipolar pendulum. pendulum. T h e nonnal normal drives drives achievement

Questions a a Doctor Doctor Might M i g h t Ask Ask Questions to Distinguish M o o d Swings Swings to Distinguish Bipolar Bipolar Mood

from f r o m Nonnal N o r m a l Mood M o o d Variability Variability • Do your family • Do your mood moodswings swingscause causeproblems problemsin in your your social social ororfamily

life? life? •

• Do D o your your mood m o o d swings swings lead lead to to decreases decreases in in your your work work productivity that that last last more more than than a a few few days? days? productivity

• Do D o your your mood m o o d states states last last for for days days at at aa time time with with lillie little relief, relief,or or •

do do they they change change when w h e n something something good happens? good happens? •

• Do D o other other people people notice notice and and comment c o m m e n t when w h e n your your mood m o o d shifts? shifts?

•

• Do D o your your mood m o o d changes changes go go along along with with noticeable noticeable changes changes in in

•

•

thinking, perceiving, perceiving, sleeping, sleeping, and/or and/or energy energy or or activity activity levels? thinking, levels? D o your your mood m o o d swings swings ever ever get get so so out out of ofhand hand that that the the police police Do have to to be be called called or or a a hospitalization hospitalization becomes becomes necessary? necessary? have

If youranswer answertotomost mostofof these questions is then yes, itthen it is likely that If your these questiOns is yes, is likely that

your range. your mood m o o d swings swings go go beyond beyond the the nonnal normal range.

Whol What Bipolor BipolarDisorder Disorderlooks Looblike Like

2121

that ourbehavior behavior become intensified in mania and diminished that guide guide our become intensified in mania and diminished in de- in de­ pression. pression. These T h e s e changes changes in in drive drive states, states, of of course, course, can can have have a a tremendous t r e m e n d o u s im­ im-

pact on o n one's one's daily daily life life and a n d productivity. productivity. pact feellike like I1 have motorattached. attached.Everything Everything moving slowly, "I" }feel have aa motor is is moving too too slowly, and and II want w a n t to to go, go, go, go, go. go. 1I feel feel like like one o n e of of those those toys toys that that somebody s o m e b o d y winds w i n d s up up

a n d sends sends spinning spinning or or doing doing cartwheels cartwheels or or whatever whatever ... . . a nto d stop to stop feels and . and feels like being being in in a a cage." cage." like — A 38-year-old 38-year-old woman w o m a n with with bipolar bipolar I disorder I disorder -A Consider the increases in energy level that accompany manic episodes. Consider the increases in energy level that accompany manic episodes.

For Lauren, Lauren, this this surge surge took took the the form f o r m of of an a n intense intense drive drive to to accomplish accomplish a a par­ parFor ticular activity activity (exercising (exercising and a n d getting getting in in shape). shape). For For another another patiem, patient, Cynthia, Cynthia, ticular it took took the the form f o r m of of a a strong strong desire desire for for social social contact contact and a n d stimulation. stimulation. When When it manic, whom m a n i c , she she would w o u l d call call people people all all over over the the coumry country w h o m she she hadn't hadn't spoken s p o k e n to to in years, doublein years, double- and a n d triple-schedule triple-schedule her her social social calendar, calendar, and a n d become b e c o m e bored bored qUickly quickly with with the the company c o m p a n y of of others. others. jolene's Jolene's took took on on a a sexual sexual quality: quality: Accu­ Accumulating mulating as as many m a n y sexual sexual partners partners as as possible possible felt felt to to her her like like a a physical physical need. need. the nursing Ted T e d felt felt the the drive drive in in relation relation to to food: food: "They " T h e y I[the nursing staff staff at at the the hospital] hospital] put it." put this this entire entire chicken chicken in in front front of of me m e and a n d I, I, like, like, inhaled inhaled it." Quite Quite often, often, increases increases in in activity activity are are accompanied a c c o m p a n i e d by b y grandiose grandiose behavior. behavior.

This is is behavior behavior that that most m o s t people people would w o u l d consider consider dangerous, dangerous, "over "over the the top," This top," unrealistic, and a n d associated associated with with inflated inflated (sometimes (sometimes delusional) delusional) beliefs about unrealistic, beliefs about one's powers p o w e r s or or abilities. one's abilities. "I"Iwalked into a real fancy restaurant withwith my mother and started jump- jump­ walked into a real fancy restauram my mother and started ing around a r o u n d and a n d running, running, and a n d there there were w e r e these these chandeliers chandeliers on o n the the ceiling. ceiling. ing II thought thought II was w a s Superman S u p e r m a n or or something, something, and a n d II leapt leapt up u p to to grab grab omo onto one one of it." of them t h e m and a n d started started swinging swinging on o n it."

— A 21-year-old 21-year-old man m a n with with bipolar bipolar I disorder -A I disorder

Grandiose usually go go along withwith highhigh or euphoric feelings, but not Grandiosebehaviors behaviors usually along or euphoric feelings, but not invariably. You Y o u may m a y experience experience an a n inflated inflated sense sense of of self-confidence self-confidence and a n d then then invariably. feel impatient impatient and a n d irritable irritable because because others others seem s e e m slow slow to to go g o along along with your feel with your ideas or or plans. plans. Grandiose Grandiose behavior behavior is is detrimental detrimental not not only only because because of of its its assoideas asso­ ciated health health risks risks but but also also because because it it leads leads to to feelings feelings of of shame, s h a m e , which w h i c h can can ciated c o m p o u n d your y o u r depression depression in in the the aftermath aftermath of of a a manic m a n i c episode. episode. In In the the case case of of compound the young y o u n g man m a n just just quoted, quoted, the the police police were w e r e called called in, in, a a scuffle scuffle ensued, and a a ensued, and the hospitalization followed. followed. Although A l t h o u g h he h e later later related related the the incident incident with a degree degree with a hospitalization of of bravado, bravado, he h e admitted admitted to to feeling feeling quite quite embarrassed embarrassed by b y his his public public behavior. behavior.

F o r every every example e x a m p l e already already given, given, you y o u can can imagine imagine what what a a coumercounterFor

22 22

THE BIPOlAR Of OF COURSE THEDIAGNOSIS DIAGNOSISAND AND COURSE BIPOLDISORDER AR DISORDER

example would would look likeduring duringthe the depressed phase. In depression, you may you may In depression, phase. depressed look like example become unusually slowed d o w n , like you're "moving through molasses." The become unusually slowed down, like you're " moving through molasses." The most mundane m u n d a n e of of tasks tasks feels feels like like it it requires requires tremendous tremendous effort. effort.Your Your appetite appetite most is usually diminished. Typically, the last thing a depressed person wants is is usually diminished. Typically, the last thing a depressed person wants is sex, and and exercise exercise has has even even less less appeal. appeal. Socializing Socializing seems seems like like an an unpleasant unpleasant sex, chore and and requires requires too too much m u c h concentration concentration and and mental mental energy. energy. chore W h e n drive drive states states are are heightened heightened in in hypomania hypomania and and mania, mania, important important When things can be accomplished and significant plans for personal advancement can things can be accomplished and significant plans for personal advancement can be pul put into into place. place. UnfoTlunately, Unfortunately, the the depressive depressive aftermath aftermath of of these these heightened heightened be drive stales states can canmake m a k e the theplans plansseem seem difficult difficultor oreven evenimpossible impossibleto toaccomplish. accomplish. drive The inability inability to to carry carry out out plans plans that that were were hatched hatched while while manic manic can can become become a a The source source of of despair despair while while depressed. depressed. A A 19-year-old 19-year-old bipolar bipolar man m a n described described the the fly high switch switch from from mania mania to to depression depression like like this: this: "I'm "I'm like like aa porpoise. porpoise. IIfly highup upin in the air airand and then then IIyell, yell, 'I'm going d o w nagain!' again!' A n then d then 1 go underneath wa­wathethe underneath I go And down going 'I'm {he ter, ter, and and all allthe theair, air,sunshine, sunshine, andthe theocean oceanbreeze breezejust just vanish." vanish." and What See? Others See? Do Others Whot Do

Her older disorder. of bipolar episodes several had had Carol, aa 20-year-old, Carol, 20-year-old, had had several episodes of bipolar disorder. Her older behavior this her manic, sister sister described described her manic, activated activated behavior this way: way: 1O support, we all thatthat projects in these "She these creative creative projects we want all want to support, involved in geLSinvolved "Shegets like hand-painting hand-painting dishes dishes or or making making soap soap sculptures sculptures and and trying trying to to sell sell like them. But But then then she she seems seems to to take take it it tOo too far. far. She She tries tries to to sell sell them on the the them on them. W e b , and and then she gets gets all u p and and frantic frantic and and starts starts staying staying up up all all riled up all riled then she Web, night on on the computer—and then then she she crashes crashes and and all all the projects get night get the projects the computer-and dumped." dumped." The The rapid changes in energy andand activity accompany highs lows and lows highs and that accompany activitythat in energy changes rapid

behavior are often a a source source of conflicts. T o obselVers, observers, your activated behavior your activated To family conflicts. of family are often while a y look attractive or especiallyififyou youwere were while manic first, especially at first, encouraging at or encouraging look attractive may manic m formerly and more more more and become more you become as you charm as its charm loses its itt loses But i depressed. But formerly depressed. manic W h a t obob­ purposeless. What and purposeless. frenetic and look frenetic to look begins to behavior begins your behavior and your manic and

of servers (for example, feeling of the feeling is the of is unaware of usually unaware are usually members) are family members) example. family selVers (for friends may or friends members Family m experiencing. Family purposefulness a y be e m b e r s or may be experiencing. you mmay that you purposefulness that con­ of conbecome angry angry about about your "driven" quality lack of apparent lack and apparent quality and agitated, "driven" your agitated, become cern e m b e r s become worried become worried family mmembers Slates, family manic states, extreme manic the extreme In the others. In for others. cern for that a y become your with your frustrated with become frustrated they mmay parallel, they In paraUel, yourself. In hurt yourself. will hurt you wiU that you inactivity during depressed phases and give you "pep talks" that can contribinactivity during depressed phases and give you "pep talks" that can contrib­ ute inadequacy. or inadequacy. gUilt or of guilt feelings of your feelings to your ute to T o a doctor, your increases in actiVity activity are are the the surest surest clue clue that thathypomania hypomania To a doctor, your increases in

polar DDisoil isordleer r looks Loob Uke Like WhotBiBipolor

23 23

or hashas setset in,in, but he he or or sheshe will probably looklook for evidence that that your your mania but will probably for evidence ormania fact behavior h e mmere e r e fact behavior is is consistently consistently activated activated across across different different situations. situations. TThe to that o u hhave a v e taken n extra o r k projects n o u g h to thatyyou taken oon extra wwork projectsis isnot not usually usually eenough topoint pointto

mmania. a n i a . S$0 o yyour o u r doctor a y ask o u hhow o w mmany a n y telephone ade, doctor mmay ask yyou telephone calls calls you've you've mmade, hhow o w many o w much h o w many many many hours hours you've you've worked, worked, hhow much sleep sleep you've you've gotten, gotten, how social h o w much much sex sex activity activity and and drive drive you've social engagements engagements you've you've arranged, arranged, how you've had. e or o w you had. HHe or she she may may also also base basejudgments judgments about about your your state state on on hhow you behave behave in it sstill, till, whether whether you you answer answer ques­ quesin the the interview interview room: room: whether whether you you can can ssit tions tions rapidly rapidly or or interrupt interrupt aa lot, lot. or or whether whether you you wring wring your your hands, hands, pick pick at at things, your physician physician will will look look for for �psycho­ "psychothings, or or constantly constantly fidget. fidget. Likewise, Likewise, your motor motor retardation" retardation" (being (being slowed slowed down down in in your your physical physical movements) movements) and and blunted facial facial expressions expressions during during depressions. depressions. blunted

A toyou, you, the theincreases increasesin inenergy energy and and A key key point point to to remember remember here here is is that, that, to activity activity that that accompany accompany manic manic episodes episodes may may feel feel good, good, productive, productive, and and purpur­ poseful. To others, others,including includingyour yourdoctor, doctor, they may seen pointless, unreposeful. To they may bebe seen asas pOintless, unre­ ahstic, orsigns signsof ofaadeveloping developingillness. iUness.These Thesedifferent differentperceptions perceptionswill willcause cause alistic, or conflict between you you and and them, them,but butit's it'simportant importantto tobe beopen opento totheir theirperspec­ perspecconflict between tives while also your own. own. tives while also explaining explaining your

Changes Thinkingand and Perception Changes ininThinking Perception "My"My mindmind feels feels like I'm oneinofone those of the city thatcity are that are likeinI'm of postcards those postcards of the taken at at night. night, with with the the camera c a m e r a moving. m o v i n g . Lights Lights feel feel like like they they have have tails, taken tails, the whole w h o l e world w o r l d is is zooming-l z o o m i n g — I love love it. it. My M y mind m i n d is is 50 so fuU full of of thoughts thoughts the that that IIfeel feel like like I'm I'mgoing going to to burst." burst." — A 26-year-old 26-year-old woman w o m a n with with bipolar bipolar II disorder disorder -A

Manic Manic and depressive moods almost always involve changes in yourchanges in your and depressive moods almost always involve thinking. During D u r i n g mania m a n i a this this involves involves the thespeeding speeding up u p of ofmental mental functions functions thinking. (racing thoughts) thoughts) and a n dthe the verbal verbal expression expression of ofone o n e thought thought after after another another in (racing in rapid-fire fashion fashion (flight (flight of ofideas). ideas).Many M a n y experience experience the the world world differently: differently: col­ colrapid-fire ors become b e c o m e brighter brighter and a n dsounds s o u n d sbecome b e c o m eintolerably intolerablyloud. loud.Mental Mentalconfusion confusion ors can accompany a c c o m p a n y the the most m o s t advanced advanced stages stages of of mania: mania: The T h e world world begins begins to tofeel feel can like like aaFerris Ferris wheel w h e e l that that is isspinning spinning out out of ofcomrol. control. D u r i n g mania, m a n i a ,your y o u r memory m e m o r y can can seem s e e m extra extracrisp crispand a n d dear, clear,you y o u feel feelbril­ brilDuring

liantly sharp, sharp,one o n eidea idea can can be b eeasily easily related related to toanother, another, and a n dyou y o ucan c a nrecall recall liantly events in invivid vivid detail. detail.However, H o w e v e r , this thisapparent apparent improvement i m p r o v e m e n t in in memory m e m o r y is isof­ ofevents tenillusory; illusory;people people experiencing experiencing mania m a n i a think thinkthey theyremember r e m e m b e r better betterthan than they they ten actually do. d o .In Infact, fact,attention attention and a n dconcentration concentration can can become b e c o m e quite quite impaired impaired actually duringmania. m a n i a .You Y o u cannot cannotkeep k e e pyour y o u rmind m i n d on o nanyone any o n ething thingat ataatime timebecause because during

24 24

THE THE DIAGNOSIS DIAGNOSISAND ANDCOURSE COURSE BIPOLADISORDER R DISORDER OFOF BIPO�R

your mind mind is istrying trying process too many things at Your once.attention Your attention can be­ can beyour to to process too many things at once. c o m e easily easily distracted distracted by by mundane m u n d a n e things things like like random random noises, noises, the the facial facial ex­ excome pressions of of others, others, or or the the feeling feeling of of your your clothing clothing against against your your skin. skin. pressions A s mania mania spirals spirals upward, upward, your your thoughts thoughts can can become increasingly jumbled jumbled As become increasingly and even even incoherent. incoherent. Others Others LO to whom w h o m you you speak speak may m a y be be unable unable LO to understand understand and you. They They will will probably probably try try to to keep keep you you focused focused and and ask ask you you to to slow slow down. down. you. Y o u will will probably probably find find these these interactions interactions annoying annoying and and have have the the reaction reaction that that You others seem seem slow, slow, dumb, d u m b , and and unimeresting. uninteresting. others Some S o m e people develop hallucinations hallucinations (perceptual (perceptual experiences experiences thal that are are not not people develop real) and and delusions delusions (unrealistic, (unrealistic, mistaken mistaken beliefs) beliefs) during during mania. mania. "Grandiose "Grandiose real) tal­ delusions" are are especially especially common, c o m m o n , such such as as thinking thinking you you are are exceptionally exceptionally taldelusions" ented ented in in an an arena arena in in which which you you have have had had no no formal formal training, training, believing believing you you have like you know are have exceptionally exceptionally high high intelligence, intelligence, feeling feeling like you k n o w what what others others are thinking, believing believing you you have havespecial specialpowers, powers,or or thinking thinkingyou you are areaamajor major pub­ pubthinking, lic lic figure figure or or even even God: God:

[As II was thisthis ideaidea in my that that I should " "[As was cycling cycling into intomania], mania],I got I got in head my head I should knew. As that throw throw a a party party for for everyone everyone II knew. As the the days days wore wore on, on, II believed believed that all to all my m y doctors-everyone doctors—everyone who w h o had had ever ever treated treated me-were m e — w e r e going going to come. Before long, long, II thought thought Bruce Bruce Springsteen Springsteen was was coming, coming, and and 50 so was was come. Before Michael Jackson, Jackson, and the voice voice of of God G o d telling telling me, m e , 'Go 'Go to to Dennis Dennis Michael and I I heard heard the [ex-boyfriend]; he he wants wants you." lex-boyfriend]; you." — A 119-year-old bipolar woman woman 9-year-old bipolar -A Delusions and hallucinations hallucinations particularly to significant others, who Delusions and areare particularly scaryscary to Significant others, who view them them as as the most concrete concrete sign sign of of "craziness." "craziness." Doctors Doctors will will be be especially especially view the most attuned to to these these symptoms symptoms and and will will also also be be on on the the lookout lookout for for less less dramatic dramatic attuned psy­ signs of of distorted distorted thinking. thinking. Consider Consider the the follOwing following interchange interchange between between a a psysigns chologist and and a a 20-year-old 20-year-old man man w h o was was coming coming off off the the crest crest of of his his manic manic chologist who high. The m a n sal sat with with a a law law book book in in his his lap, arguing that that he he could could pass pass the high. The man lap, arguing the bar without without going going to to law school and would sue anyone w h o challenged challenged him: him: and would sue anyone who law school bar Doctor: any unusual unusual thoughts thoughtsoror experiences Have you you had had any experiences thisthis week?week? DOCTOR: Have past past Patient: No, N o , not not really. PATIENT: really. DOCTOR: Doctor: Any A n y feelings feelings like like you you have have special special powers powers or or that that you're you're a a famous famous

person? Last person? Last week week you you were were thinking thinking a a lot lot about about God G o d and and having­ having— Patient: (jllterrupts) {interrupts) Well, that was was last last week! week! (laughs) {laughs) No, N o , II don't don't think Well, that of think of PATIENT:

myself that way, teacher. myself that way, but but I'm I'm more more like hke a a young young god, god, kind kind of of like like a a teacher. {giggles) II think think II have have a a lot lot to to offer offer others. (giggles) others.

What polar DDisorder isorder Looks Loob like Like WhatBiBipolar

25 2S

The client waswas still delusional. HisHis thinking frequently got him Theabove above client still delusional. thinking frequently got into him into trouble h o wwere e r e mostly troublewith with others, others, especially especiallyhis hisparents, parents, wwho mostlyconcerned concerned about about his h e y wwere e r e angered y his imhisinability inability to tohold holdaajob. job. TThey angered bby hisunrealistic unrealisticbeliefs beliefsin in hhim­ self n d his c h e m e s for self aand his elaborate elaborate sschemes for fighting fighting the the educational educational system. system. In n even n e thing. ou In contrast, contrast, during during depression depression it's it's hard hard to to focus focus oon even oone thing. YYou will o w n of will experience experience the the slowing slowing ddown of mental mental functions functions as as aa difficulty difficulty in in concon­ centrating a k i n g simple e e m drab. centrating or or mmaking simple decisions. decisions. Colors Colors sseem drab. Disturbances Disturbances of of mmemory e m o r y are o m m o n : YYou o u mmay a y have umbers are ccommon: have difficulty difficulty recalling recalling telephone telephone nnumbers yyou o u use e m e m b e r i n g appointments, use regularly, regularly, rremembering appointments, or or following follOwing aa television television propro­ ggram r a m because memory. because of of trouble trouble holding holding events events in in your your memory. Ruminations, h i c h aa person nd Ruminations, in in wwhich person thinks thinks about about aa certain certain event event again again aand again, c c o m p a n i m e n t to again, are are aa frequent frequent aaccompaniment to depression. depression. Ruminations Ruminalions during during the the depressive o r example, ecame depressive phase phase are are often often self-recriminating. self-recriminating. FFor example, Margie Margie bbecame preoccupied W a s Paul h e n II didn't preoccupied with with the the thought thought " "Was Paul [her (her boss] boss] insulted insulted wwhen didn't sit i m at a m e r o n described: W h e n II w as sit next next to to hhim at the the meeting?" meeting?" Simflarly, Similarly, CCameron described: ""When was mmanic a n i c I1 jokingly y friend a s 'hot,' n d II couldn't jokingly asked asked mmy friend if if his his wife wife wwas 'hot,' aand couldn't stop stop thinking o w stupid a s wwhen h e n II got got depressed." thinking about about hhow stupid that that wwas depressed." Depressive Depressive ruru­ minations frequently guilt or or shame, s h a m e , or or feeling feeling worthless, minations frequently include indude guilt worthless, hopeless, hopeless, or helpless. helpless. T h e y can can b e c o m e all-encompassing aU-encompassing a n d affect one's day-to-day day-to-day or They become and affect one's functioning. When W h e n Patrice Patrice b e c a m e depressed, she found found herself herself �rehearsing "rehearsing functioning. became depressed, she

like a mantra" m a n t r a " statements statements hlike k e "I "I suck suck ... . 1 I hate hate myself myself . .. . I'm I'msuch sucha a like a

bitch. " bitch."

SuicidD/ Thoughts Thoughts Suicidal Ruminations often often take take the the form f o r m of of suicidal suicidal preoccupatio preoccupations—thoughts about Ruminations ns-thoughts about the various various ways w a y s one o n e could could kill kiU oneself. oneself. These These ruminations ruminations are are most m o s t common common the during depressive depressive or or mixed m i x e d episodes episodes but but can can also also be b e present present during during mania. mania. during D e p e n d i n g on o n how h o w desperate desperate aa person person feels. feels, he h e or or she she may m a y act act on o n these these Depending thoughts thoughts or or impulses, impulses, often often with with dire dire consequences. consequences.

Friends and a n d family family members m e m b e r s will will be b e particularly particularly upset upset and a n d scared scared by b y your your Friends suicidal thoughts, thoughts, if if voiced voiced to to them, t h e m , and and w will d o their their best best [0 to help help you y o u deal deal suicidal i ll do with them, t h e m , although although they they may m a y not not know k n o w what w h a t to to say say or or do. do.Your Y o u r therapist therapist or or with physician is is also also likely hkely to to ask ask about about them t h e m (for (for example, example, "Are "Are you y o u having having any any physician thoughts of of hurting hurting or or killing killing yourself, yourself, as as many m a n y people people do d o when w h e n they're they're thoughts down?").H Ifyou y o u have have never never had h a d suicidal suicidal thoughts thoughts before before and a n d have have them t h e m now, now, down?"). y o u may m a y feel feelafraid afraidto toshare share them. them.You Y o u may m a y fear fearthat thatthe thephysician physician will will hospi­ hospiyou talize you y o u immediately. immediately. This This is is certainly certainly one o n e lreatment treatment option, option, but but not not the the talize only one. one.Others Others may m a y include include psychotherapy, psychotherapy, modifications modifications of of your your medica­ medicaonly tion regime, regime, and/or and/or various various forms forms of of communilY c o m m u n i t y or or family family suppon. support. tion T a k e the the chance chance of of discussing discussing these these feelings feelings wilh with your your physician physician or or Take

26 26

THE Of OF BIPO�R THE DIAGNOSIS DIAGNOSISAND ANDCOURSE COURSE BIPOLDISORDER AR DISORDER

therapist—you may some of thoughts dissipate dissipateafter after you've therapist-you mayfind find that that some of these these thoughts you've shared them them with with someone someone else. else. You Y o u may m a y also alsolearn learnthat thatmental mentalhealth healthprofes­ professhared sionals are are more more helpful helpful at at such such times times than than you you would expected. II will will sionals would have have expected. discuss suicidal suicidal feelings feelings and and actions actions in in more more detail detail in in Chapter Chapter 111. discuss 1.

Sleep Sleep Disturbances Disturbances Virtuallyall all peoplewith with bipolar disorder experience disturbances of sleep Virtually people bipolar disorder experience disturbances of sleep to during their their mood m o o d swings. swings. When W h e n you manic, you m a y feel feel no no need need to during you get get manic, you may sleep. Sleeping Sleeping feels feels like like a a waste of lime, time, especially especially w h e n so so many m a n y things things can can sleep. waste of when gel accomplished in middle of During depression, get accomplished in the the middle of the the night! night! During depression, sleep sleepcan canfeel feel like like the the only only thing thing that that is is welcomed. welcomed.When W h e n you you are are depressed, depressed,you you may m a y sleep sleep many hours than than usual usual (for 16 hours hours aa day) un­ m a n y more more hours (for example, example, 16 day) and and become become unproductive the home productive and and unable unable to to function function outside outside of of the h o m e (hypersomnia). (hypersomnia). Alter­ Alterlie natively you a y have have insomnia insomnia and find that that sleep sleep eludes Y o u may m a y lie natively you mmay and find eludes you. you. You awake at and turning, turning, thinking the same awake at night night tOSSing tossing and thinking aboUl about the same problems problems over over and over again. again. Sleep Sleep can can feel feel frustratingly frustratingly out out of of your and over your reach. reach. Are Are sleep sleep problems problems a a symptom s y m p t o m of of bipolar bipolar disorder, disorder, or or do do they they actually actually cause appears that both symptom cause. cause problems problems in in mood? m o o d ? It It appears that they they are are both symptom and and cause. Most not, have have changes mood when Most people, people, bipolar bipolar or or not, changes in in m ood w h e n they they have have trouble trouble sleeping, vulnerable to the sleeping, bUl but bipolar bipolar people people are are particularly particularly vulnerable to changes changes in in the sleep-wake cycle cycle (for (for example, example, W e h r et et al., al., 1987; 1987; Ehlers Ehlers et et al., 1993). I'll I'll say say al., 1993). sleep-wake Wehr more about sleep disruptions disruptions and and mood m o o d states states in Chapter 5. more about sleep in Chapter 5. will probably you aboUl Your doctor doctor will probably ask ask you about sleep sleep disturbances, disturbances, with with empha­ emphaYour sis on on whether problem is is falling falling asleep, asleep, waking up in in the the middle middle of of the sis whether the the problem waking up the night, or or waking up too too early. H e or or she she may m a y ask ask you to keep keep track track of of your your night, waking up early. He you to sleep you have have trouble troublerecalling recalling the thenature nature of ofyour your disturbances. disturbances.If Ifyou youhave have sleep if if you spouse, he he or or she she may m a y be be affected affected by by your your sleep sleep patterns-when patterns—when one one person person aa spouse, can't sleep, sleep, others others often often can't can't as as well! Your own o w n irritability, aswell wellas asthat thatof of can't well! Your irritability, as sleep your family family members, members, can be a a function of lack of sleep sleep or or inconsistent your can be function of lack of inconsistent sleep habits. habits.

Impulsive, SeH.Destrudive, Self-Destructive, or orAddictive AddictiveBehaviors Behaviors Impulsive,

you start start totofeel manic? What do do when when you feel manic? Whenyou youare are loaded do you youusually usually do What When loaded with energy, energy, you you may m a y feel feellike likeyou you have have to tohave have an an outlet. outlet.Ordinary Ordinary life lifemoves moves with slowly. Perhaps when people get too slowly. Perhaps as as a a result, result, w h e n people get manic, manic, they they often often lose lose their too their inhibitions inhibitions and and behave behave impulSively. impulsively. Many M a n y of of these these impulsive impulsive behaviors behaviors can can be be threatening threatening to to one's one's life life or or health, health, such such as as driving driving recklessly recklessly on on the the freeway, freeway, performing different performing daredevil daredevil acts, acts, or or haVing having unprotected unprotected sex sex with with many m a n y different

Vo/hOI WhatBipolar BipolarDisorder Disorderlnoh LoobUke Like

2727

partners. 1) was a major impulsivebehavior behavior (Chapter partners. Martha's Martha's impulsive (Chapter 1) was a major cause cause of theof the marital problems p r o b l e m s she she had h a d after after her her manic m a n i c episode. episode. marital Some S o m e people people make m a k e unwise u n w i s e decisions, decisions, like like spending spending a a lot lot of of money money indiscriminantly. indiscriminantly. Kevin Kevin was w a s 34 3 4 and a n d lived lived with with his his father. father. When W h e n manic, manic, he he convinced in­ convinced his his father father to to liquidate liquidate part part of of his his IRA I R A account, account, which w h i c h Kevin Kevin invested His vested wildly wildly in in various various commodities. commodities. Most M o s t of of the the money m o n e y disappeared. disappeared. His family, family, understandably, understandably, was w a s livid livid with with him; h i m ; his his older older brothers brothers refused refused to to talk talk to him h i m anymore. a n y m o r e . Prior Prior to to this this incident, incident, Kevin Kevin had h a d been b e e n making m a k i n g plans plans to to move move to on his own. But his father insisted he pay the money back before he agreed out o n his o w n . B u t his father insisted h e p a y the m o n e y back before h e agreed out to help help finance finance Kevin's Kevin's attempts attempts to to b e c o m e independent. independent. to become Carl, improve­ Carl, age age 40, 40, spent spent tremendous tremendous amounts amounts of of money money on on home home improvements. bathroom f ixtures, and ments. He He installed installed elaborate elaborate fireplaces, fireplaces, impractical impractical bathroom fixtures, and eye-catching but gaudy paintings. paintings. His His partner, partner, Roberta, Roberta, with with whom w h o m he he eye-catching but gaudy cohabitated, finances, cohabitated, became became increasingly increasingly frustrated frustrated about about their their dwindling dwindling finances, and their their conOicrs conflicts intensified. intensified. In InRoberta's Roberta'sview, view,Carl Carlwas wasunwilling unwillingto torecog­ recogand nize his his mania mania as as the the source source of of the the problem. problem. nize Self-destructive behavior can Self-destructive behavior can take take many many forms. forms. Many Many people peopletum turnto toalco­ alcohol hol or or drugs drugs during during manic manic episodes. episodes.Substance Substanceuse useproblems problemsand andaddictive addictivebe­ behaviors haviors are are not not essential essential symptoms symptoms of of bipolar bipolar disorder, disorder, but butthey theycan canbecome become intertwined with mood way that worsens intertwined with mood disorder disorder symptoms symptoms in in such such aa way that each each worsens the other. other. Alcohol Alcoholisisoften oftensought soughtas asaameans meansof ofbringing bringingoneself oneselfdown down from from the the high and quelling quelling the the anxiety, anxiety, confusion, confusion,and andsleep sleepdisturbance disturbancethat that the high state state and typically go go with with il. it. Some Some use use cocaine, cocaine, amphetamine, amphetamine, or or even even marijuana typically marijuana to to heighten and depres­ heighten and intensify intensify the the euphoric euphoric experiences experiences of of mania. mania. During During a a depression, alcohol alcohol or or drugs drugs are are usually craved as as a a means means of of dulling dulling the the pain, or sion, usually craved pain, or what w e call call self-medicating. self-medicating.More Morethan thanany anyother otherassociated associatedcondition, condition,drug drug what we and alcohol alcohol abuse abuse makes the course course of of your disorder much and makes the your bipolar bipolar disorder much worse worse (for (for example, Tohen Tohen et etal., al.,1990; 1990;Strakowski Strakowskietetal., al., 2000). Mark described role 2000). Mark described thethe role example, alcohol played played in his depressions depressions as as follows: follows: alcohol in his "When I'm me isislike· likea security "When I'mdown, down,drinking drinking for for me a security blanket.blanket. When I'mWhen I'm feeling m y worst, the bottle is there there in in the the closet, closet, like likean an old oldfriend. friend.I I feeling my worst, the bottle is don't think think about about what it's doing doing to to m y body, only that that I numb don't what it's my body, only I need need to to numb myself out. out. Sometimes, justknOwing knowing there's there'saa bottle bottlein in the the cabinet cabinet is is myself Sometimes, just enough to to make make m e feel justcan't can'tstop stopmyself. myself.}Ikeep keep blowing blowing enough me feel better. better. II just it. " it."

Another personwith with bipolar disorder, Thad, clear on why he dr Another person bipolar disorder, Thad, was lesswas clearless on why he drank when manic. While While in inthe the hospital, hospital,he hesummarized summarizeditit like this: "I don't "} don't when he he was was manic. like this: know what iittisiswith it'sitnot funny, but but when­ know what withme m eand andbooze booze(smiling). {smiling).I know I know 's not funny, whenever II get get that that way way [high, [high, manic], ever manic],IIjust justseem seemtotoneed needtototie tieone oneon." on."

28 28

THE DIAGNOSIS DIAGNOSISAND ANDCOURSE COURSE BIPOIDISORDER AR DISORDER THE OF OF BIPOlAR

Family members may be more by your alcohol use Family members may be bothered more bothered bydrug yourand drug and alcohol use than your your mood m o o d swings. swings. They They may m a y even even define define your your problems problems as as alcoholalcohol- or or than to drug-related and and reject reject the the bipolar bipolar diagnosis, diagnosis, thinking thinking it it is is a a way w a y for for you you to drug-related justify continuing continuing to to drink. drink. They They may m a y be be incorrect incorrect aboUl about this, this, but butyour yourdoctor doctor justify will need need to to conduct conduct a a thorough thorough diagnostic diagnostic assessment assessment to to be be sure sure (see (see will Chapler Chapter 3). 3). Your Your doctor doctor will will probably probably be be skeptical skeptical of of the the bipolar bipolar diagnosis diagnosis unless unless there is is concrete concrete evidence evidence that that your your m o o d swings swings occur occur when w h e n you you do do not use there mood not use drugs drugs or or alcohol. alcohol. Jeff, Jeff,for forexample, example,had hadhad hadseveral severalmanic manicepisodes episodesbefore beforehe he justified. developed developed problems problems with alcohol, and and the the bipolar bipolar diagnosis diagnosis seemed seemed justified. with alcohol, On O n [he the other other hand, hand, Kate's Kate's alcohol alcohol problems problems developed developed well well before before there there was was any character­ any evidence evidence of of mood m o o d swings, swings, and and her her mood m o o d episodes-allhough episodes—although characterized typical bipolar bipolar symptoms ized by by typical symptoms such such as as irritability, irritability, sleep sleepdismrbance, disturbance,leth­ lethargy, argy, suicidality, suicidality, and and impulsiveness-were impulsiveness—were eventually eventuallyattributed attributed to tothe theeffects effects of alcohol alcohol intoxification. of intoxification.

Summary: S u m m a r y : Dillerent Different Perspectives Perspectives As seen, people withwith bipolar disorder have dis­ As you you already alreadyknow know or or have havejust just seen, people bipolar disorder have distinct their m mood states tinct experiences experiences that that comprise comprise their o o d disorder. disorder. Varying Varying emotional emotional states and and changes changes in in energy, energy, judgment, judgment,thinking, thinking,and and sleep sleep characterize characterize the theswings swings between the the poles. poles. Family Family members members or or Significant significant others others are are not not likely likely to to unbetween un­ derstand these widely widelyfluctuating experiences (unless (unless they they have have bipolar bipolar disorderstand these fluctuating experiences disor­ der themselves) and are are likely likely to to focus focus on on how h o w your behavior affects affects them them and and der themselves) and your behavior other family family members. members. Most Most psychiatrists psychiatrists will will be be Jess less interested interested in in the the mean­ meanother ing of of these these experiences experiences to to you you than than in in the the symptoms symptoms you've you've had had that that are are coning con� sistent or or inconsistent inconsistent with with the the bipolar bipolar diagnOSiS, diagnosis, or or that that point point 10 to specific specific sistent treatments (see (see Chapter Chapter 6). 6). treatments These different different perspectives perspectives may m a y be be a a source source of of frustration frustration for for yOll, you, be­ beThese cause you you may m a y feel feel like like others others don't don't understand understand you you or or aren't aren't interested interested in cause in your Likewise,your yourfamily familymembers, members,and andperhaps perhapsyour yourdoctor, doctor, will your inner inner life. life. Likewise, will be frustrated if you seem seem to to be be oblivious oblivious to to or or unconcerned unconcerned about about the the effects effects be frustrated if you of of your behavior on on others. others. These These disparate disparate perceptions perceptions can can be be a a source of your behavior source of conflicts over over the the treatment treatment plan: plan: Y o u may m a y feel feel that that you've conflicts You you've had had profound profound exex­ periences, but only seem seem interested interested in in labeling labeling you you as as a a sick sick person. person. periences, but others others only M a n y people bipolar disorder, disorder, out of frustralion frustration over over these these issues, issues, reject reject Many people with with bipolar au{ of the notion notion that that they they are are having having symptoms symptoms and and also also reject reject the the diagnosis diagnosis and and its the its associated treatments treatments (see (see Chapters Chapters 3 3 and and 4). Others are are fortunate fortunate enough enough to associated 4). Others to be able able to communicate effectively effectively with with their their doctor doctor and and family family members, members, to communicate be w h o correspondingly correspondingly make m a k e attempts attempts to to understand understand these these private private experiences. who experiences.

What ipolar Disorder DisorderLoo Loob Like What BBipolar ks like

29 29

Thehope, hope,ofofcourse, course,isis that that you will find find aa treatment that will will stabilize The you will treatment regime regime that stabilize yyour o u r mmood o o d without without minimizing minimizing the the significance significance that that these these personal personal experiexperi­

ences have have held held for for yyou. ences ou. step WWhether h e t h e r yyou o u are are having o u r first h a d mmany, a n y , the having yyour first episode episode or or have have had the first first step

in obtaining optimal optimal treatment treatment for for yourself yourself is is to to get get aa proper proper diagnosis. diagnosis. in obtaining

Chapter 33 deals deals v^dth with this this very very important important issue issue bby answering the the following following Chapter y answering questions: questions: • How• is the is disorder actually diagnosed by mental health health professionals? diagnosed by mental professionals? How the disorder actually •• What W h a t symptoms s y m p t o m s and a n d behaviors behaviors do d o doctors doctors look look for? for? •

• What W h a t can can you y o u expect expect during during the the diagnostic diagnostic process? process? • How • H o w will will your y o u r doctor doctor elicit elicitinformation information from f r o m you y o u to to determine determine the the diag­ diag-

nosis? nosis? issue of of "bor­ Indescribing describingthe thediagnostic diagnostiCcriteria, criteria, I'll In Lfltouch touch on on the the important important issue "border der conditions": conditions": • How•doHow you do knowyou if know you have bipolar some othersome psy- other psy­ if you havedisorder bipolar versus disorder versus

chiatric chiatric illness? illness? • Does D o e s the the diagnosis diagnosis give give aa reasonable reasonable explanation explanation for for your your behavior? behavior? • •

• If If not, not, are are there there other other diagnoses diagnoses that that fit fityou y o u better? better?

3 3

Into the Doctor's Court Into

the

D o c t o r ' s

C o u r t

W H A T TO T O EXPECT EXPECT WHAT

FROM DIAGNOSTIC F R O M THE THE D I A G N O S T I C PROCESS PROCESS

Y

ou're not not alone alone in in feeling feeling that that mania mania and and depression depression are are very very per­ perou're I o sonal and and intense intense experiences. experiences. Nor Nor are are you you alone alone if if you you are are wary wary of of any any sonal Y

stranger's ability ability lO to understand understand what what you're going through, no matter how you're going through, no matler how stranger's highly qualified as a a medical medical professional. professional. Many Many people peopleexperiencing experiencingbipolar bipolar qualified as highly symptoms postpone seeing a a doctor for as as long long as as possible possible because they al­ alsymptoms postpone seeing doctor for because they ready feel misunderstood. Olhers Others receive receive a a diagnosis diagnosis but but reject reject it it ready feel thoroughly thoroughly misunderstood. out of of hand. hand. Still Still others others grudgingly grudgingly accept accept a a diagnosis diagnosis of of bipolar bipolar disorder disorder but but out re­ then express express their their resistance resistance by by refusing to comply comply with with their their treatment treatment rethen refUSing to

gime. IIf you fit fitinto intoany anyof ofthese thesecategories, categories,I hope I hope you'll reconsider the benef you you'll reconsider the bene­ gime. fits of of a a professional filS profesSional diagnosis. diagnosis. N o diagnostiC diagnostic label label can can completely completely capture capture your your unique unique situation. situation. In In fact, fact, No you may m a y feel feel onended offended by by the the diagnostic diagnostic label label because because it it is isincomplete, incomplete,imper­ imperyou sonal, or or simply simply doesn't doesn'tdo dojustice justice to toyour your lire lifeexperiences. experiences.But Butthese theselabels labelsdo do sonal, serve a a purpose. purpose. First, First,using usingstandardized standardizedlabels labelsallows allowsclinicians cliniciansto tocommuni­ communiserve cate with with each each other. other. If IfIIrerer referaaclient clientof ofmine minetotoanother anothermental mentalhealth healthprofes­ profescate sional and say say that that "she "she has has bipolar bipolar II disorder, disorder, mixed mixed episode, episode, with with mood­ moodsional and incongruent psychotic psychotic features," features," there there is is a a high high likelihood likehhood that that this this other other incongruent doctor will wifl know k n o w what what to to expect. expect. This This common c o m m o n language language serves serves you you well well doctor should you switch switch doctors, doctors, as as so so many m a n y of of us us do do today. today. Second, Second, an an accurate accurate di­ dishould you agnosis is is importaOl important to to selecting selecting the the right right treatment. treatment. If you are are misdiagnosed misdiagnosed If you agnosis as having having depreSSion depression alone, alone, for for example, your doctor doctor might might recommend recommend a example, your a as 30 30

Intothe theDoctor's Doctor'sCourt: Court: What to Expect the Diagnostic Process Into Whotto Expect fromfrom the Diagnostic Process

31 31

standard antidepressant medication (for example, Prozac, Zoloft, Paxil, or standard antidepressant medication (for example, Prozac, Zoloft, Paxil, or If you Wellbutrin) W e l l b u t r i n ) without without a a mood m o o d stabilizer stabilizer like like lithium lithium (see (see Chapter C h a p t e r 6). 6 ) . If y o u are are actually actually bipolar, bipolar, this this treatment treatment regime r e g i m e could c o u l d make m a k e you y o u swing s w i n g into into mania. mania. Likewise, is attention L i k e w i s e , if if you y o u were w e r e diagnosed d i a g n o s e d as as bipolar bipolar when w h e n the the real real problem p r o b l e m is attention

deficit disorder, disorder, you y o u might m i g h t not n o t benefit benefit from f r o m the the mood m o o d stabilizer stabilizer regime r e g i m e yyou ou deficit would label helps helps doctors would be be given. given. Notice, Notice, then, then, how h o w an an accurate accurate diagnostic diagnostic label doctors treat the symptoms treat the the whole whole syndrome syndrome that that is is affecting affecting you you rather rather than than just just the symptoms

you are are reponing reporting right right now. now. you Diagnoses Diagnoses also also help help you you prepare prepare for for the the challenges challenges the the future future might might hold. hold.

Your doctor doctor will will use use the the diagnosis diagnosis to to formulate formulate your your prognosis. prognosis. Will Will you have Your you have another will you you know another episode? episode? Will Will you you be be able able to to go go back back to to work? work? How H o w will know

w h e n you're you're getting getting sick sick again? again? Knowing Knowing that that you you have have bipolar bipolar disorder disorder when makes you you and and your your doctor doctor privy privy to to all all of of the the information information that that researchers researchers and and makes clinicians clinicians have have gathered gathered from from the the experiences experiences of of thousands thousands of of people people like like you. you.

For example, example, you you can can expect expect to to have have another another episode episode soon soon if if you you don't don't take For take medication, and go­ medication, and you you may m a y need need to to wait wait for for a a while while after after an an episode episode before before go-

ing back back to to work w o r k full full time. time. Fortifying Fortifying yourself yourself with with this this information information makes t ing makes iit easier easier to to manage manage your your life life and and minimizes minimizes the the disabilities disabilities that that bipolar bipolar disorder disorder

can cause. can cause.

The Crileria Criteria for for a a Diagnosis Diagnosis of of Bipolar Bipolar Disorder Disorder The

Psychiatrists and psychologists onfourth the fourth of the Diagnostic an Psychiatrists and psychologists rely rely on the editionedition of the Diagnostic and Statistical Manual Manual o of Mental Disorders Disorders to to make m a k e diagnoses diagnoses (DSM-IV; (DSM-IV; American American Statistical f Mental Psychiatric Association, Association, 1994a, 1994a, 2000). 2000). Note Note the the term term "manual" "manual" in in the A Psychiatric the title: title: A clinician should should be be able able to to pick pick up u p the the manual manual and and decide decide whether whether a a patient clinician patient meets the the criteria criteria for for a a specific specific psychiatriC psychiatric illness. illness. Applying Applying these these diagnostic diagnostic meets criteria reliably reliably (that (that is, is, being being able able to to tell tell one one disorder disorder from from another) another) cannot cannot criteria be done done quickly quickly or or haphazardly: haphazardly: it it requires requires considerable considerable training, training, experience, experience, be and profesSionaL and skill skill on on the the part part of of the the mental mental health health professional.

T h e first first edition edition of of the the DSM D S M was was published published in in 1952; 1952; other other editions editions were were The published in in 1968, 1968, 1980, 1980, 1987, 1987, and and finally, finally, 1994 (with a a text text revision revision in published 1994 (with in 2000). Each Each version version has has been been informed informed by by the the research research and and observations observations of of 2000). m a n y investigators investigators and and clinicians clinicians and and by by experiences experiences elicited elicited from from numerous numerous many patients with with psychiatric psychiatric disorders. disorders. No N o diagnostic diagnostic manual manual is is perfect, perfect, and and not patients not everyone everyone agrees agrees with with the the premises premises of of the the DSM-IV D S M - I V (e.g., (e.g., Carson, Carson,1991). 1991).In Inmy my opinion, opinion, the the DSM-IV D S M - I V is is an an extremely extremely useful useful manual, manual, and and no no other other diagnostic diagnostic system reasonable alternative. alternative. system exists exists that that provides provides a a reasonable

Your doctor doctor will will first first identify identify which which symptoms symptoms you you have have (for (for example, example, Your sleep sleep disturbance, disturbance, irritability), irritability), how h o w severe severethese thesesymptoms symptoms are, are,and and how h o w long long

32 32

BIPOlAR Of OF COURSf THf THEDIAGNOSIS DIAGNOSISAND AND COURSE BIPOLDlSORDfR AR DISORDER

they have have lasted. lasted. From F r o m YOUT your particular particular pattern pattern of of symptoms, symptoms, he he or or she she will will they then determine determine if if the the diagnosis diagnosis of of bipolar bipolar disorder--as disorder—as outlined outlined in in the the DSM­ DSMthen IV—fits you. you. If Ifititdoes, does,your yourdoctor doctor will then concernedwith with whichkind kindofof bebeconcerned then will IV-fits which bipolar disorder disorder you you have: have: is isititbipolar bipolartype typeI Ioror II? o you have rapid cycling? cycling? DoD you II? bipolar have rapid

Bipolar II Disorder Disorder Bipolar

disorder The The sidebar on this page describes describesthe themajor majorsubtypes subtypesofofbipolar bipolar disorder this page sidebar on listed listed in in the the DSM-IV. DSM-IV. For For bipolar bipolar II disorder, disorder, you you must must have have had had at at least least one one symp­ associated other three and mood elated with episode, mixed or manic manic or mixed episode, with elated m o o d and three other associated symptoms toms of of mania mania (grandiose (grandiose thinking, thinking, decreased decreased need need for for sleep, sleep, pressured pressured speech, speech, increased increased activity activity or or energy energy level, level, racing racingthoughts, thoughts,flight flight ideas, disdis­ ofofideas, tractibility, tractibility,or orimpulsive impulsivebehavior) behavior)that thatlasted lastedaaweek w e e kor ormore moreandlor and/orrequired required that that you you be be hospitalized. hospitalized. If If your your mood m o o d was was irritable irritable and and not not elated, elated, four four or or more m o r e associated associated symptoms symptoms are are required. required. Note Note how h o w these these symptoms symptoms capture capture subjective experiences the the essence essence of of the the subjective experiences of of mania mania described described in in Chapter Chapter 2: 2: the the roller-coaster roller-coaster mood m o o d states, states,increases increasesin inactivity activityand and drive, drive,changes changesininthinking thinking behaviors. and and perception, perception, and and impulsive impulsive or or self-destructive self-destructive behaviors.

The D S M - I V Subtypes Subtypes of of Bipolar Bipolar Disorder Disorder DSM-IV The Bipolar IIdisorder disorder Bipolar • At• least oneone lifetime manic or mixed disorder disorder or mixed of manic episode of lifetimeepisode At least • Although Although not not required required for for the the diagnOSiS, diagnosis, at at least least one one lifetime lifetime episode of of major depressive disorder disorder major depreSSive episode

•

Bipolar disorder Bipolar 11IIdisorder • At• least oneone lifetime hypomanic disorder disorder of hypomanic episode of lifetimeepisode At least • At least least one one lifetime lifetime episode episode of of major major depresSive depressive disorder disorder • At Bipolar disorderwith with rapid cycling cycling rapid Bipolar disorder • Meets criteria for or bipolar bipolarII II disorder disorder I or bipolar I forbipolar criteria • Meets • Four or or more more episodes episodes of of major major depressive depressive disorder, disorder, manic manic • Four disorder, mixed disorder, one any one in any disorder in hypomanic disorder or hypomanic disorder, or disorder, mixed year year

Inlo Court: Whol to Expe
33 33

You may find yourself negatively to how reductionistic You may find yourself reactingreacting negatively to how reductionistic the symp- [he symp­ t o m labels labels are: are: what w h a t you y o u see see as as clear clear insights insights and a n d the the energy energy to to get get important important tom things are things done d o n e may m a y be b e labeled labeled by b y the the DSM-IV D S M - I V as as grandiosity. grandiosity. Your Y o u r reactions reactions are certainly certainly understandable. understandable. These T h e s e symptom s y m p t o m labels labels are are shorthand s h o r t h a n d for for very very com­ complex plex life hfe experiences experiences and a n d mood m o o d states, states, much m u c h like like the the diagnostic diagnostic label label itself. itself. The T h e DSM-IV D S M - I V requires requires at at least least one one week w e e k of of manic manic symptoms symptoms for for bipolar bipolar II disorder, disorder, unless unless hospitalization hospitalization was was necessary, necessary, in in which which case case there there is is no no time time requirement. There must also be evidence that you showed deterioration requirement. There must also be evidence that you showed deterioration in in your your work w o r k or or family family life life (for (for example, example, major major family family arguments, arguments, loss loss of of your your job, job, etc.). etc.). In In most most cases, cases,aabipolar bipolarIIperson personwill willalso alsohave havehad, had,at atsome some point pointin in hfe, life,aaminimum m i n i m u m two-week two-week period periodwith withfive fiveor ormore more symptoms symptoms of ofmajor major de­ depressive pressive illness illness (depressed (depressed mood, m o o d , loss loss of of interests, interests,weight weightloss lossor oraachange change in in appetite, appetite, loss loss of of energy energy or or fatigue, fatigue, motor motor agitation agitationor orretardation, retardation,loss lossofofcon­ concentration, centration, feelings feelings of of worthlessness, worthlessness, insomnia insomnia or or hypersomnia, hypersomnia, suicidal suicidal thoughts thoughts or or actions) actions) and and during during which which there there was was aa deterioration deterioration in in everyday everyday functioning. functioning. People de­ People with with bipolar bipolar II disorder disorder can can experience experience episodes episodes of of mania mania and and depression depres­ pression in in different different sequences. sequences. Some S o m e people people have have manias manias followed followed by by depressions ("euthymic" sions followed followed by by periods periods in in which which their their mood m o o d returns returns to to nonnal normal ("euthymic" mood). m o o d ) . Other Other people people have have depressions depressions followed followed by by manias, manias, which which are are then then followed states, which followed by by euthymic euthymic mood. m o o d . Other Other people people have have '"rapid ''rapid cycling" cycling" states, which I'll talk talk about about m o r e later. I'll more later. If you you have have had had a a manic manic episode episode but but no no depressions, depressions, your your doctor doctorwill willstill still If diagnose you you with with bipolar disorder. This This is is because because he he or or she she assumes assumes that that aa diagnose bipolar II disorder. depression will will eventually eventually occur occur if if the the disorder disorder is is not not treated treated adequately. adequately. As A s II depression mentioned in in Chapter Chapter 2, 2, people people diagnosed diagnosed with with bipolar bipolar I disorder can can also I disorder also mentioned have mixed mixed episodes, episodes, or or what what some some physicians physicians refer refer to to as as "dysphoric "dysphoric mania." have mania." This This means means that that you you have have met the criteria criteria for for major major depressive depressive disorder disorder and and met the mania nearly nearly every every day day for for at at least least a a week. week. Some S o m e people people describe describe mixed mania mania mixed mania as the the �tired "tired but but wired" wired" feeling. feeling. You Y o u can can feel feel extraordinarily extraordinarily pessimistic and as pessimistic and hopeless, fatigued, fatigued, and and unable unable to to concentrate, concentrate, but butstill stillfeel feel"revved," "revved,"anxious, anxious, hopeless, irritable,driven, driven,and andsleep sleepdeprived, deprived, with your thoughts movingvery very rapidly. irritable, with your thoughts moving rapidly. Bipolar Bipo'.rII /I Disorder Disorder In bipolar II disorder, a a person person alternates alternates between between major major depressive depressive episodes In bipolar II disorder, episodes and hypomanias. Hypomanias are are milder forms of of mania a y not and hypomanias. Hypomanias milder forms mania that that mmay not last last as as long as full manias i n i m u m requirement for the the diagnosis long is four four days), days), as full manias (the (the mminimum requirement for diagnosis is but the the n u m b e r of of symptoms is the the same (that is, is, three three if the m o o d is but number symptoms required required is same (that if the mood is elated, four o o d is hypomania experience elated, four if if the the m mood is irritable). irritable). People People with with hypomania experience the the first ofthe the three threestages stages of ofmania mania described described in in Chapter Chapter 2, 2, but but they they do do not not go go hebefirst of

34 34

THE BIPO�R THE DIAGNOSIS DIAGNOSISAND ANDCOURSE COURSEOFOF BIPOIADISORDER R DISORDER

yond this: they have sleep problems, irritability, increased activity, yond this: they have sleep problems, irritability. increased activity, and an in­ and an i flatedsense senseof ofthemselves, themselves,but butnot nottotothe thedangerous dangerouslevels levelsof ofthe thefully fullymanic manic flated person. Generally, Generally, hypomanic hypomanic episodes episodes do do not not cause cause big big problems problems in in your your person. work, family, family, or or social socialfife, but you you may m a y still stillexperience experience some some interpersonal interpersonal work, life, but difficulties when w h e n in in this this state state (for (for example, more arguments arguments with with your spouse difficulties example, more your spouse or kids). kids). Hypomanias Hypomanias do do not not require require hospitalization. hospitalization. or Hypomanic episodes episodes can can be be quite quite enjoyable enjoyable to to the the person person experiencing experiencing Hypomanic them. In In general, general, others others will will be be baffled baffled and and put put off off by by your your energetic, them. energetic, hypersexual, and and driven driven quality quality when w h e n hypomanic hypomanic (for (for example, they may m a y tell hypersexual, example, they tell you to "chill "chill out"). out"). Your Your significant others may m a y also also be be relieved relieved by by what what they you to significanl others they perceive to to be be the the disappearance disappearance of of the depressive states states that preceded perceive the depresSive that often often preceded disorder: the energized energized one. one. Consider Consider Heather, Heather, who w h o had had bipolar bipolar II II disorder: the

Heather, She described Heather, age age 36,36, was a a professional conferencecoordinator. coordinator. She described was professional conference herself When herself as as almost almost always always depressed. depressed. W h e n she she went went through through her her divorce, divorce, contact with her contact with her soon-to-be�ex-husband soon-to-be-ex-husband "felt "felt like likeaadrug drug IIneeded-it needed—itwas was the only me at that the only thing thing [hat that kept kept m e alive." alive." She She became became suicidal suicidal at that time. time. But But soon soon after, after, she shebegan beganplanning planningaaconference conferencefor foraagroup group of ofarchitects, architects,and and started dating dating one one of of them. them. The and the the new n e w relationship relationship "wired "wired started The work work and me ... II got so me... got my m y energy energy back. back. II SlOpped stopped sleeping sleeping and and staying staying in in my m y condo condo so much m u c h of of the the time time .. .. went went walking walking my m y dog dog at at 2 2 A.M. A.M. People People told told me m e II seemed seemed much m u c h better, better, like likeIIhad had my m y oid oldself selfback, back,but but IIknew k n e w IIwas was going going overboard. " overboard." KeepKeep in mind whatwhat different diagnostic may mean your treat­ treatin mind different diagnostiC subtypes subtypes may meanfor for your

ment. ment. If If you you have II instead of bipolar bipolar II disorder, your illness illnessis isproba­ probahave bipolar bipolar II instead of disorder, your and bly less severe. But But you you still still need need to tobe be careful: careful:hypomanias, hypomanias,while while fun andex­ exbly less severe. fun citing, can can herald herald the the development development of of a a severe severe depresSion, depression, or or even even of of rapid rapid citing, cycling, especially especially if if you are not protected by mood-stabilizing medications. cycling, you are nOl protected by mood-stabilizing medications. Rapid Cycling Rapid Cye/ing Rapid cycling can canaccompany accompany either eitherbipolar bipolar ordisorder. II disorder. In cycling, rapid cycling, Rapid cycling I orI II In rapid

people people quickly quickly switch switch back back and and forth forth from from mania mania or or hypomania hypomania or or mixed mixed disdis­ order to to depression, depression, with with four four or or more more distinct distinct episodes episodes in in a a single single year. year. In In order other words, words, you you have have many m a n y episodes episodes in in a a short short period period of of time. time. Some S o m e people people other have �ultra-radian "ultra-radian cycling," cycling," which which means means switching switching from from one one mood m o o d pole pole to to have the other within a single 24-hour period. the other within a Single 24-hour period. If you you have have rapid rapid cycling, cycling, you you may m a y have have to to go go through through quite quite a a bit bit of of [rial trial If and error with your medications until you find something that works. Your and error with your medications until you find something that works. Your doctor may m a y want want to to rule rule Oul out other other factors factors thal that may m a y contribUle contribute to to your mood doctor your mood

Into the the Docto(s Doctor's (ouII: Court: Whot WhattotoExpect Expectfrom fromthe theDiagnostic Diagnostic Process Process Into

lS 35

ap� swings, swings, like like thyroid thyroid abnormalities. abnormalities. The The good good news news is is that that rapid rapid cycling cycling apdo not pears pears to to be be a a time�limited time-limited phenomenon p h e n o m e n o n (Coryell (Coryell et et al., al., 1992): 1992): People People do not rapidly cycle cycle their their whole whole lives. lives. I'll I'll talk talkmore moreabout aboutfrequent frequentcycling cyclingin inChapter Chapter rapidly 6 on on drug drug treatments. treatments. 6

The Progression Progression of of Bipolar Bipolar Episodes Episodes The

Many Many people—including been diagnosed diagnosed with withbipolar bipolar people-includingthose thosewho whohave havenot not yet yet been disorder the diagnostic disorder and and those those who w h o have have but but are are in in doubt doubt about about it-find it—find the diagnostic criteria criteriajust justdiscussed discussed confusing. confusing.Many M a n y clinicians cliniciansdo do as aswell! well!You Y o u may m a y wonder wonder whether diag� whether having having only only one one or or two two of of these these symptoms symptoms qualifies qualifies you you for for the the diagnosis nosis or or what what it it means means if if you you had had one one symptom s y m p t o m in in January, January, none none in in February February and March. March, and and a a different different symptom s y m p t o m in in July. July. and One in O n e of of the the keys keys to to making making the the diagnosis diagnosis of of bipolar bipolar disorder disorder is is to to think think in terms terms of of clusters clusters of of symptoms symptoms that that cycle cycle together together in in episodes. episodes. There There must must be be evidence evidence that that you you have have had had time�limited time-limited periods periods of of mood m o o d disorder disorder that that alter­ alternate with periods of functioning fairly normally or that alternate with internate with periods of functioning fairly normally or that alternate with inter­ vals vals in in which which you you experience experience the the opposite opposite pole pole of of the the illness illness (for (for example, example, manic inter­ manic episodes episodes that that are are followed followed by by depressive depressive episodes). episodes). Episodes Episodes are are intervals when w h e n your your mood, m o o d , activity activity level. level,thinking thinkingpatterns, patterns,and andsleep sleepall all changeatat vals change the same same time. time. An A n episode episode (see (see the the figure figure on on this this page) page) generally generally has has a the a prodromal phase phase (a (a period period of of symptom s y m p t o m buildup), buildup), an an active active phase phase (a period of prodromal (a period of severe (the symptoms severe depression depression or or manic manic symptoms), symptoms), and and a a recovery recovery phase phase (the symptoms are abating abating but but are are not not quite quite gone gone yet). yet). Consider, Consider, Tom, Tom, a a 46-year-old 46-year-old bipolar bipolar are patient: patient:

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SEVER SEVERE

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MODERATE MODERATE--

ACTIVE PHASE

MILD ^/IILD-•

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RECOVERY PHASE

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TIME TIME

The phases phases of of a a manic manic episode. The episode.

36 36

THE mURSE OF OF 8IPO�R THE DIAGNOSIS DIAGNOSISAND AND COURSE BIPOLDISORDER AR DISORDER

Tom Tom described both both depressive episodes andand mixed episodes. his described depressive episodes mixed episodes.AsAs hisdede­ pression developed developed over over several several weeks, he experienced experienced sadness sadness and and loss loss of weeks, he of pression interests in his usual activities, but a mild paranoia with anxiety also deinterests in his usual activities, but a mild paranoia with anxiety also de­ veloped. H e began began to to feel feel that that no no one one in in his his family was on on his his side side and and veloped. He family was that they they were were talking talking about about him him behind behind his his back. back. As A s he he progressed progressed into into a thal a mixed episode, his his depression depression worsened worsened and and so so did did his his anxiety anxiety and and parapara­ mixed episode, noia, but but he he also alsodeveloped developed an an irritability irritabilityand and anger anger that thathe he expressed expressed in­ innoia, appropriately. In In one one case, case, he hebroke brokesome some dishes; dishes;in inanother, another,hehekicked kickedinin appropriately. a door. door. His His family family members m e m b e r s became became scared scared of of him. him. His His sleep sleep deteriorated, deteriorated, a and and his his thoughts thoughts look took on on a a rapid, rapid, ruminating ruminating quality quality ("I ("I think think about about death and death and that that there's there's no no future--doesn'l future—doesn't seem seem like like there's there's anything anything II or or anybody can can do"). do"). These These periods periods usually usually lasted lasted at least a a week w e e k but but often anybody at least often longer. longer. As As he he recovered recovered from from his his mixed mixed episode-usually episode—usually after after his his medi­ medication been increased increased or cation dosage dosage had had been or a a new n e w medication medication added-he a d d e d — h e would would feel less less hopeless, hopeless, his his thoughts thoughts would would slow slow down, d o w n , and and he he became feel became easier easier for for others others to to communicate communicate with. with. Nonetheless, Nonetheless, he he cominued continued to to feel feel anx� anxious, sad, sad, and and easily easily irritated irritated by by others. others. He H e began began to to see see how h o w his his behavior behavior ious, and that affected his his family family and that at at least least some some of of his his paranoid paranoid feelings feelings were were un­ unaffected founded. founded. Notice how,how, in Tom's case, episodeprogressed progressedinin stages. Different Notice in Tom's case,a asingle Single episode stages. Different

symptoms symptoms (his (his hopelessness hopelessness and and paranoia) paranoia) changed changed more more rapidly rapidly than than others others (his sadness sadness and and anger), anger). The The length length of of bipolar bipolar episodes episodes varies varies from from person person to (his to person. person. It may m a y not not always always be be possible possible to to tell tell when w h e n you you are are finished finished with with an an epiIt epi­ sode or or developing developing a a new n e w one, one. If If you you have have had had aa number n u m b e r of ofepisodes episodes already, already, sode you probably probably are are more more attuned attuned than than most most people people to to what what it it feels feelslike like to tobe be ill ill you versus well. well. But Butif ifyou're you'reon onyour yourfirst firstepisode, episode, you m a be y be unclear when versus you may unclear asas toto when you're back back to to normal or what itfeels feelslike liketo tobe begetting gettingsick sickagain. again.As Asyou'll you'll see you're normal or what it see w h e n we w e discuss self-management techniques, techniques, knowing knowing your your prodromal prodromal when discuss self-managemem symptoms (the (the signs signs that that an an episode episode of of mania mania or or depresSion depression has has begun) and symptoms begun) and w h e n to to get get emergency emergency treatmem treatment helps protect you you against against further further escalation escalation when helps protect of the the disorder. disorder. of

Diagnostic Self-Evaluation Self-Evaluation as as a a Starting Starting Point Point or or a a Backup Backup Check Check Diagnostic

The self-administered self-administered checklist follows is a starting point in determinin checklist that that follows is a starting point in determining The whether your your diagnosis diagnosis is iscorrect. correct.IfIf youhave have never seen a psychiatrist but think you never seen a psychiatrist but think whether you might might need need to, to, the thechecklist checklistwill willorient orientyou you to tothe thekinds kindsof ofsymptoms symptoms your your you doctor will will ask ask about. about.IfIfyou've you'vealready alreadyreceived receivedthe the diagnosisof of bipolar disorder diagnosis bipolar disorder doctor

Intothe theDoctoi's Doctor's(our!: Court: What to Expect the Diagnostic Into Whot to Expect from from fhe Djagnos�c ProcessProcess

37 37

and are ofof it, provides your with a backup check. The The and are suspicious suspicious it, the thelist list provides yourdoctor doctor with a backup check. checklist checklist is is not not a a diagnostic diagnostic instrument: instrument: just just because b e c a u s e you y o u endorse e n d o r s e the the items items does does not not mean m e a n that that you you have have the the disorder, disorder, only onlythat thatyou've you'vehad had symptoms symptoms of ofmania mania and and depression depression that that you you and and your your doctor doctor will will want want to todiscuss. discuss.likewise, Likewise,ififnone none of the the symptoms symptoms sounds sounds familiar, famihar, you you may m a y still stillhave havethe thedisorder disorderbut butyou youand and of your doctor doctor will will want want to to discuss discuss other other diagnoses diagnoses as as well. well. your In with your In filling filling out out the the checklist, checklist, and and in in discussing discussing the the symptoms symptoms with your physician, the same physician, keep keep in in mind m i n d that that these these symptoms symptoms must must co-occur co-occur during during the same period period of of time. time. If If you you had had sad sad mood m o o d at at one one time time in in your your life, life,racing racingthoughts thoughtsat at another, same thing as another, and and insomnia insomnia during during another another period, period, that that is is not not the the same thing as having epi­ having an an episode episode of of major major depressive depressive illness illness or or a a manic manic or or hypomanic hypomanic episode. sode.

What W h a t the the Dodor Doctor Will Will Want W a n t to to Know: K n o w : Steps Steps toward toward Diagnosis Diagnosis and Treatment Treatment and Many M a n y of of my m y patients patients have have come c o m e to to me m e feeling feeling that that their their initial initial diagnosis diagnosis was was m a d e too hastily. Either they become victims of the managed care rush made too hastily. Either they become victims of the managed care rush to to make m a k e diagnostic diagnostic and and treatment treatment decisions decisions or or they they were were never never asked asked about about eleele­ ments of of their their life life story story that, that, to to them, them, seemed seemed critical critical to to an an understanding understanding of ments of their mood m o o d problems. problems. their Whether you you have have already already been been diagnosed diagnosed and and wish wish to to review review whether whether Whether your your case case has has been been handled handled correctly, correctly,or oryou you are arepreparing preparingfor foryour yourfirst firstevalu­ evaluation, understanding understanding the the sequence sequence of of steps steps in in the the diagnostic diagnostic and and treatment treatment ation, process process will will help. help. These These steps steps include include the the diagnostic diagnostic referral, referral, reviewing reviewing your your prior medical medical records, records, and and the the diagnostic diagnostic interview. interview. prior A s II review review the the steps steps in in the the diagnostic diagnostic process, process, keep keep in in mind mind that that your your As doctor will will base base your your diagnosis diagnosis largely largely on on the the symptoms symptoms you you have have recently doctor recently exex­ perienced. How H o w you you developed developed these these symptoms symptoms (also (also called called the the etiology etiology of perienced. of your disorder) disorder) is isreally reallyaadifferent differentquestion. question.You Y o u may m a y feel feelthat thatthese thesesymptoms symptoms your are are not not the the product product of of a a biochemical biochemical imbalance imbalance as as much m u c h as as current current stressors stressors (for example, example, having having jusl just broken broken off off a a relationship) relationship) or or childhood childhood issues issues (e.g., (for (e.g., traumatic events events such such as as abuse). abuse). If If your your doctor doctor is is doing doing his his or or her her job, he or or traumatic job, he she she will will address address these these psychological psychological issues issues with with you you later later in in treatment, treatment, after after establishing the the diagnosis diagnosis and and after after the the two two of of you you have have agreed agreed on on a a medica­ medicaestablishing tion treatment treatment plan. plan. If If your your doctor doctor does does not not do do psychotherapy, psychotherapy, you you may m a y want want tion to ask ask him h i m or or her her for for a a referral referral so so that that you you receive receive simultaneous simultaneous treatment treatment to with a a therapist. with therapiSt.

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THE THE DIAGNOSIS DIAGNOSIS AHO AND[QURSE COURSEOF OFBlfQlAR BIPOIARDISORDER DISORDER

B I P O L A R SYMPTOMS: SYMPTOMS: A A SELF·ADMINISTERED SELF-ADIWINISTERED CHECKLIST CHECKLIST BIPOLAR

DEPRESSION

DEPRESSION^

1

Has there thereever everbeen been a period of time lasting two or weeks moreyou when younot were not your a period of time lasting two weeks moreor when were your Has usual usual self self and and you you experienced experienced five five or or more more of of the the following: following:

Yes Yes

No No

Felt sad, sad, blue, blue,or or down d o w n in inthe the dumps? dumps? Felt Were Were uninterested uninterested in in things? things?

Lost or or gained gained more more than than 5 % of of your body weight? weight? 5% your body Lost Slept Slept too too little little or or too too much? much?

Were slowed slowed down d o w n or or sped sped up up in in your your movements? movements? Were Felt Felt fatigued fatigued or or low low in in energy? energy? Felt Felt worthless worthless or or very very guilty guilty about about things? things? Were Were unable unable to to concentrate concentrate or or make make decisions? decisions?

Thought about about killing killing yourself yourself or or making making plans plans to to do do so? so? Thought

2 M A N I A OR O R HYPOMANIA HYPOMANIA^ MANIA

Has there therebeen beena aperiod period time when were usual self and you: Has of of lime when youyou were not not youryour usual self and you: Yes Yes Felt so so good good or or so so hyper hyper that that other other people people thought thought you you were were Feh not your your normal normal self self or or you you were were so so hyper hyper that that you you got got into not into trouble? trouble?

Were so so irritable irritable that that you you shouted shouted at at people people or or started started fights fights Were or or arguments? arguments?

Felt much m u c h more more self-confident self-confident than than usual? usual? Felt Got much m u c h less less sleep sleep than than usual usual and and found found you you didn't didn't really really miss miss Got it? it?

Were much m u c h more more talkative talkative or or spoke spoke much m u c h faster faster than than usual? usual? Were Had thoughts thoughts racing racing through through your your head head or or couldn't couldn't slow slow down down Had your mind? mind? your Were so so easily easily distracted distracted by by things things around around you you that that you you had had Were trouble concentrating concentrating or or staying staying on on track? track? trouble Had much m u c h more more energy energy than than usual? usual? Had Were Were much m u c h more more active active or or did did many many more more things things than than usual? usual?

Were much m u c h more more social social or or outgoing outgoing than than usual; usual; for for example. example, Were telephoning friends friends in in the the middle middle of of the the night? telephoning night?

No No

Into the the DodGr's Doctor's (ourt: Court: Whol What to to �ped Expect hom from the the Diogllostic Diagnostic Process Process 11110

Yes Yes

339 9

No No

Were W e r e much m u c h more m o r e interested interested in in sex sex than than usual? usual? Did Did things things that that were were unusual unusual for for you you or or that that other other people people might might

have thought thought were were excessive, excessive, foolish, foolish, or or risky? risky? have Spent Spent excessive excessive money m o n e y thal that got got you you or or your your family family into into trouble? trouble? If you yes to than one oneof of the the above, above' have several If you checked checked yes to more more than have several of these these ever ever happened happened during during the the same same period of time? time? of period of How to work; H o w much m u c h of of aa problem problem did did any any of of these these cause cause you-like you—like being being unable unable to work; having having family. family, money, m o n e y , or or legal legal troubles; troubles; getting getting into into arguments arguments or or fight? fight? Please Please check check

one response response only. only. one ___

___

No problemMinor problem Minor problem No problem Moderate problem

Serious problem problem Serious

Moderate problem

_ _ _

_ _ _

lAdapted fromfrom the criteria for major depressive anddepressive manic episodes ofthe DSM-LYTat Rt:vision Adapted by bypermission permission the criteria for major and manic episodes of the DSM-IV-T (American tion. (American Psychiatric Psychiatric Association, Association,2000). 2000).Copyright Copyright2000 2000by bythe theAmerican AmericanPsychiatric PsychiatricAssocia Association. lAdapted ­ Adapted by by pennission permission from from Hirschfeld Hirschfeld et et al. al. (2000). (2000). Copyright Copyright 2000 2000 by by the the American American Psychiatric Psychiatric Associa Association. tion.

Step ,7: The Diagn051 Diagnostic Referral Step : The ic Referral

The first step in getting a diagnosis proper diagnosis is right to find theIf you right docto The first step in getting a proper is to find the doctor. have private private insurance, insurance, you you may may be beable ableto tosee seesomeone someonewho w h o specializes specializesin in have mood disorders. disorders.If Ifititisisunclear unclearwhether whetheraadoctor doctorisisaaspecialist, specialist,you youshould shouldfeel feel mood free to toask. ask. You You can canalso alsoobtain obtaininformation informationabout aboutwho w h o in in your your area areatreats treatsper­ perfree sons with with mood mood disorders disorders from from the the American American Psychiatric Psychiatric Association's Association's referral referral sons line (888-35-PSYCH) (888-35-PSYCH) or or from from the the books books in in the the "How "How to to Find Find the the Best Doctors" line Best Doctors" series series (for (for example, example, Connolly, Connolly, 2000). 2000). If you you have have aa managed managed care care plan plan or or no no insurance, insurance,you youmay may not nothave haveaalot lot If of choice choice about about whom w h o m you you see. see. Hopefully, Hopefully,your yourplan planwill willdirect directyou youtoto menof aa men­ tal health healthprofessional professionalwho w h o has hasat atleast leastsome some experience experience in inmood mood disorders. disorders. tal But this this may may reqUire require some some detective detective work work on on your your part part. Nancy, Nancy,for forexample, example, But thought she might have bipolar disorder and wanted to see a psychiatrist but thought she might have bipolar disorder and wanted to see a psychiatrist but was confused confused by by the the number number of of doctors doctors listed Hsted in in the the Yellow Yellow Pages Pages who w h o purwas pur­ portedly treated treated mood mood problems. problems. She She called called several several but butcould couldreach reachonly only their their portedly receptionists,who w h o gave gaveher herinformation informationlike Hke"Dr. "Dr. seesmainly mainly receptionists, sees adults" or or "she "she has has aa general general psychiatry psychiatry practice." practice." She She finally finally discussed discussed the adults" the matter with with her her general general practitioner, practitioner, who w h o referred referred her her to to aa psychiatrist matter psychiatrist in in town who w h o was was covered covered by by her her insurance insurance plan plan and and was was known known to to have have expertown exper­ tise mood disorders. disorders. tise in in the the treatment treatment of of mood

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lHE OF OF BIPO�R THE DIAGNOSIS DIAGNOSISANO ANDCOURSE COURSE BIPOIDISORDER AR DISORDER

In today's managed carecare system, your initial evaluation may may In laday's managed system, your initialdiagnostic diagnostic evaluation not be be done done by by a a psychiatrist. psychiatrist. Many M a n y insurance insurance plans plans have have an an intake intake worker worker not w h o determines determines the the need need for for follow-up follow-up psychiatric psychiatric care. care. However, However, this this does does who not mean m e a n your your care care will will be be inferior. inferior. Memal Mental health health professionals professionals from from other other not disciplines (e.g., (e.g., psychology, psychology,social socialwork, work,nursing) nursing)are areoften oftenwell-trained well-trained in in disciplines diagnostic methods. methods. There There is is a a good good chance chance that that this this intake intake worker worker will will refer diagnostic refer you you to to a a psychiatrist, psychiatrist, if ifthere thereisisany anysuspicion suspicionthat thatyou youhave havebipolar bipolardisorder, disorder,

and he he or or she she will will almost almost certainly certainly do do so so if ifyou you have have had had prior prior mood m o o d disorder disorder and episodes. this initial evaluation was adequate oror led to to episodes. But But if ifyou youdon't don'tfeel feelthat that this initial evaluation was adequate led appropriate appropriate follow-up follow-up care, care, be be assertive assertivewith with your your health healthcare careprogram program in inask� asking appointmems. ing for for follow�up follow-up appointments.

Step 2: Records Step 2:Reviewing ReviewingYour Your Records The doctor you do The doctor you do see see will will probably probably want want to to review review any any prior prior medical medical records records that previ� that other other doctors doctors have have wriUen written about about you. you. The The records records usually usually contain contain previous (which may may previ­ ous diagnoses diagnoses (which m a y or or m a y not not include include bipolar bipolar disorder), disorder), your your previous responded and ous medications medications (including (including how h o w well well you you responded and if if you you experienced experienced

side effects effects from from them) them),, and and relevant relevant information information about your medical, social, side about your medical, social, and family family history. and history. Your Your doctor doctor will will ask ask you you to to sign sign a a "release "release of of information" information" form, form, which which al­ al-

lows him him or or her her to to gain gain access access to to these these records. records. Of Of course, course, you you can can refuse refuse to lows to sign this release, release,but butrefusing refusingis isnot notininyour yourbest bestinterest. interest.Even Even you feel your sign this if if you feel your previous psychiatric psychiatric care care was was flawed, it will will help your new n e w doctor doctor [0 to know know previous flawed, it help your about these theseflaws, as well well as as what what treatmems treatments were were tried tried and and why w h y they they were were about flaws, as discontinued. Your Your doctor doctor will will not not necessarily necessarily recommend recommend the the same same treatdiscontinued. treat­ ments as as you've you've had had in in the the past. ments past. If this thisis isyour yourfirst firstvisit visit mentalhealth healthprofeSSional, professional, you may not have If toto aa mental you may not have prior medical medical records. records. If you have have had had other other psychiatric psychiatric consultations, consultations, you you prior If you m a y wonder wonder why w h y your your new n e w doctor doctor needs needs to to conduct conduct a a new n e w diagnostic diagnostic evaluamay evalua� tion and and can't can't simply simply review review your your medical medical records. records. There There are are many m a n y reasons reasons tion w h y medical medical charts charts are are inadequate inadequate for for determining determining your your diagnosis, diagnosis, treatment, treatment, why or prognosis. prognosis. First, First, medical medicalcharts chartsare areoften oftensketchy. sketchy.They They contain containcomments comments or like "patiem "patient complains complains of of depression" depression" without specifying the the severity severity of of this like without specifying this depression, whether whether other other symptoms symptoms co-occurred, co-occurred, or or whether whether the the depression depression depreSSion, occurred in in discrete discrete episodes. episodes. Chan Chart notes are often often written written by by professionals professionals occurred notes are focused on on other other aspects aspects of of your your medical medical or or psychiatric psychiatric history (for example, example, focused his[Ory (for bipolar an endocrinologist endocrinologist evaluating evaluating thyroid thyroid functioning) functioning) rather rather than than your your bipolar an

disorder. So So think think of of the the prior prior medical medical records records as as supplemental supplemental information information disorder. that may m a y help help your doctor clari clarify the diagnOSiS. diagnosis. The The majority of his his or or her her fy the majority of that your doc[Or judgments judgments will will come c o m e from from the the face�to-face face-to-face diagnostic diagnostic interview. interview.

Into the the Doctor's Doctor's Court: What to to Expect Expect from the Diagnostic Into (ourt: Whot from the Diogoostic Process Process

441 1

Step 3:3:Whal Expecl from from the Oiagno,'ic Inlerview Interview Sfep What10 to Expect the Diagnostic

The diagnosis of bipolar disorder is established through a clinical interview, in The diagnosis of bipolar disorder is established through a clinical int which be asked asked whether you have certain symptoms which you you will will be whether you have experienced experienced certain symptoms over period of If your your doctor doctor conducts inter­ over a a given given period of time. time. If conducts a a comprehensive comprehensive interview, view, he heor orshe shewill willask asknot notonly onlyabout aboutyour yourmood mooddisorder disordersymptoms symptomsbut butalso also whether you had psychotic whether you have have ever ever had psychotic symptoms symptoms (for (for example, example, hallucinations), haUucinations), drug drug or or alcohol alcohol abuse, abuse, anxiety anxietysymptoms, symptoms,eating eatingdisorder disordersymplOms, symptoms,or orother other problems. problems. Filling Filling out out the the self-administered self-administered checklist checklist from from the the last last section sectionmay may help help your the your doctor doctor obtain obtain some some of of this this information information more more efficiently. efficiently. Because Because the checklist parallel some your checklist is is based based on on the the DSM-IV. DSM-IV, it it may may parallel some of of the the questions questions your doctor doctor will will ask. ask. You You can cangive giveitit to to him him or orher herat at the the beginning beginningof of the the first firstinter­ interview symptoms that that view as as a a way way of of ensuring ensuring that that he he or or she she follows follows up up on on certain certain symptoms may concern you. may concern you. During this interview, During this interview, your yourdoclOr doctorwill willprobably probablywant wantto toknow know not notonly only which symptoms symptoms you've you've experienced experienced but also which which symptoms symptoms typically typically go which but also go together with together with other other ones ones (that (that is, is, in in discrete discrete episodes), episodes), the the severity severity of of these these symptoms, mind for symptoms, and and their their duration. duration. Your Your doclOr doctor has has a a threshold threshold in in mind for how how severe and and how how impairing impairing aa symptom symptom must must be be before before it it is is considered considered part severe part of of the For example, the bipolar bipolar syndrome. syndrome. For example, when when asking askingabout about"loss "lossof ofenergy energy or orfa­ fatigue," your yourdoctor doctorwill willwant want(0to know knowsuch suchthings thingsasas whether whetheryou've you'vebeen beenun­ untigue," able to to go go to to work work because because of of fatigue, fatigue, or or whether whether you you have have trouble trouble doing able doing housework. When W h e n asking asking about about insomnia, insomnia, he heor orshe shemay may want want to toknow know how how housework. many nighlS nights of of the the week week you you have have trouble trouble sleeping sleeping and and whether whether your your lack many lack of of sleep impairs impairs your your ability ability to to drive, drive, concentrate concentrate at at work, work, play play sports, sports, or orcon­ consleep duct any any of of your your usual usual activities. activities.In Inmany manyways waysbipolar bipolarsymptoms symptomsare are just justex­ exduct aggerations of normal mental, behavioral, and emotional processes, and some aggerations of normal mental, behavioral, and emotional processes, and some degree of of variability variabiHty in in mood, mood, sleep, sleep,or oractivity activitylevel levelisispart partofofthe the human humancon­ condegree dition. Your Yourdoctor doctorhas hasto toestablish estabHshwhether whetheryour yoursymptoms symptomsmeet meetaacriterion criterion dition. of of severity severity or or impairment. impairment. Interviews can can be be quite quite subjective, subjective,and andthere thereisis always alwaysthe thepossibility possibilitythat that Interviews the the way way your your doctor doctor asks asks you you the the questions, questions, and and the the way way you you answer answer them, them, will final diagnosis. win affect affect the thefinal diagnosis.Consider Consider the the following following interchange interchange that that oc­ occurred curred between between aa doctor doctor and and aa person person with with bipolar bipolar disorder. disorder. Notice Notice that that this this doctor probes probes carefully carefully for for certain certain symptoms, symptoms, and and the the patient, patient, correspond­ corresponddoctor ingly, ingly,gives givesuseful usefulexamples examplesof ofhis hisexperiences experiencesand andbehavior. behavior.

very happy or happy or Doctor: Did you youever ever have a week-long period you felt very DOCTOR: Did have a week-long period when when you felt very very irritable? irritable? Patient: No, No, not not really. PATIENT: really.

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THE THE DIAGNOSIS DIAGNOSIS AND ANDCOURSE COURSEOF OFBIPOlAR BIPOIARDISORDER DISORDER

Doctor: when you you feltfelt very grouchy or easily provoked? DOCTOR:OrOr when very grouchy or easily provoked? Patient: No. No. PATIENT: DOCTOR: Doctor: How H o w about about feeling feeling charged charged up up and and full full of of energy? energy?

Patient: Yes. PATIENT: Yes. DOCTOR: like? Doctor: What W h a t was was that that like?

Patient: Well, Well,in inMarch March IIwas wasrunning runningat atfull fulltilt, tilt, full like, all sorts of ideas. PATIENT: full of,of, like, all sorts of ideas. thought II could could develop develop aa weather weather monilOring monitoring system system that that could could be be op­ opII thought erated from y basement. basement. erated from m my Doctor: How H o w were were you you sleeping sleeping at at the the t time? DOCTOR: ime? PATIENT: Patient: Not Not at at alll all! [I didn't didn't need need to, to, and and II got got resentful resentful when w h e n people people told told me m e II

should. should. DOCTOR: Doctor: Resentful? Resentful? Tell Tell me m e more. more. PATIENT: Patient: Well, Well,nobody nobody appreciated appreciatedwhat what IIwas was trying trying1O todo. do. Everybody Everybody seemed seemed

like they they were were moving moving slowly. slowly. One O n e time, time, II practically practically bit this guy's guy's head head like bit this off off for for knocking knocking on on my m y door door when w h e n II was was in in the the middle middle of of a a project. project. And A n d II yelled at at my m y kids kids a a bunch bunch of of times times because because they they kept kept interrupting interrupting me. me. yelled

otherother has found evidence of of irritable moodmood and and In thisexample, example,the thedoctor doctor has found evidence irritable In this history. Had this probprob­ manic symptoms in in this this patient's patient's history. H a d the the doctor doctor not not done done this manic symptoms ing, evidence of of this bipolar syndrome syndrome might might not not have have emerged. emerged. ing, evidence this bipolar The diagnostic diagnostic interview interview will will take take at at least least an an hour or two. two. If If you you have have a The hour or a particularly complicated complicated set set of of symptoms, symptoms, your your doctor doctor may m a y request request several several particularly sessions to to be be reasonably sure of of the the diagnosis. diagnosis. A A long interview can can be be tesessions reasonably sure long interview te­ dious, especially especially if if you've you've been been through one before, before, but but you'll you'll find find that that your your dious, through one will and the doctor's time has been been well well spent. spent. The information you provide will and the doctor's time has The information you provide better inform a a careful careful diagnosis, diagnosis, which will almost almost certainly certainly translate translate into inform which will into better treatment. treatment

Does the the Diagnosis Diagnosis Fit? Fit? Could Could Vou You Have Have Another Another Disorder Disorder Instead? Instead? Does Whether you your first first problemswith withdepression depression mania, youare are having haVing your problems or or mania, andand Whether will possibly even if you have had numerous episodes of m o o d disorder, you will even if you have had numerous episodes of mood disorder, you possibly probably want to to discuss discuss the the accuracy accuracy of of the the diagnosis diagnosis with your doctor. doctor. Does Does with your probably want the diagnosis give a reasonable explanation for the kinds of problems you've you've the diagnosis give a reasonable explanation for the kinds of problems had with other had with with your your mood m o o d states, states, behavior, behavior, and and relationships relationships with other people? people? mood Could you have another disorder instead? Y o u m a y wonder whether the mood another disorder instead? You may wonder whether the Could you have

4). swings you experience experience are really a a part part of of your your personality personahty (see (see Chapter Chapter 4). are really swings you Y o u may m a y believe beheve that that you you have have a a different different psychiatric psychiatric disorder disorder or or no no disorder disorder You

Intothe theDocto(s Doctor'sCoUr!: Court: WhatExpect to Expect the Diagnostic Process Into Whotto homfrom the DiognOSli( Process

43 43

at all. may believe, rightfully, that another psychi­ at all.Alternatively, Alternatively, you you may believe, rightfully, that youyou havehave another psychiatric disorder disorder in in addition addition to to bipolar bipolar disorder. disorder. atric Bipolar Bipolar disorder disorder can c a n be b e difficult difficult to to tell tell apart apart from f r o m other other disorders disorders that that share of share features features in in common c o m m o n with w i t h it. it. In In this this section, section, II discuss discuss the the problem p r o b l e m of misdiagnosis. misdiagnosis. II also also discuss discuss the the disorders disorders that that are are orten often confused c o n f u s e d with w i t h bipolar bipolar disorder disorder and a n d how h o w they they differ differ from f r o m it. it. Sometimes S o m e t i m e s these these disorders disorders are are diagnosed diagnosed alongside of of bipolar bipolar disorder disorder ("comorbidity"). ("comorbidity"). alongSide What You Think ThinkYou've You^veBeen BeenMisdiagnosed? Misdiagnosed? Wha'Can Can You You Do Do if if You

There are are many reasons why bipolar disorder bebe hard to distinguish from from There many reasons why bipolar disordercan can hard to distinguish other other disorders. disorders. First, First, moods m o o d s can can vary vary for for any any number n u m b e r of of reasons, reasons, which which can can include of the include hormones, hormones, personal personal stress, stress, personality personahty disturbances, disturbances, diseases diseases of the brain, or or ingestion ingestion of of drugs drugs or or alcohol. alcohol. Second, Second, people people with with the the disorder disorder often brain, often have histo­ have trouble trouble describing describing their their mood m o o d states states to to others others and and giving giving accurate accurate histories ries of of their their disorder. disorder. Third, Third, mental mental health health profeSSionals professionals are are not not always always ade­ adequately quately trained trained to to recognize recognize the the more more subtle subtle forms forms of of the the disorder disorder (for (for exam­ example, ple, mixed mixed states, states, rapid rapid cycling, cycling, mild mild depressions, depressions, hypomania). hypomania). Diagnostic criteria Diagnostic confusion confusion can can also also occur occur because because of of the the diagnostic diagnostic criteria themselves. disorder. themselves. Certain Certain symptoms symptoms are are characteristic characteristic of of more more than than one one disorder. Psychotic experiences experiences (for (for example, example, grandiose grandiose delusions) delusions) can can occur occur in in other other PsychotiC disorders, such such as asschizophrenia. schizophrenia.Problems Problemswith withdistractibility distractibilityoccur occur in inmania mania disorders, and in in auention-deficitlhyperactivity attention-deficit/hyperactivity disorder disorder (ADHD). ( A D H D ) . Sleep Sleep disturbance disturbance and and and irritability can can occur occur in in recurrent recurrent depreSSion depression and and anxiety anxiety disorders disorders as as well irritability well as as bipolar bipolar disorder. disorder. Lastly, Lastly, mood m o o d variability variabilityis isaakey keyfeature featureof ofborderline borderlineperson­ personality ality disorder. disorder. Try to to be be as as patient patient as as you you can can with with the the diagnostic diagnostic process. process. The The common common Try use of of the the DSM-IV D S M - I V together together with with improved improved training training in in the the recognition recognition of of use m o o d disorders disorders make m a k e diagnosis diagnosis more more reliable reliable than than it it used used to to be. be. Nonetheless, Nonetheless, mood errors inevitably inevitably occur. occur. Your Your phYSician physician may m a y need need to toobserve observeyou you during during an an ep­ eperrors isode and once you have recovered to be sure of your diagnosis. If you have isode and once you have recovered to be sure of your diagnosis. If you have strong doubts doubts about about the the diagnosiS diagnosis you you have have been been given, given, getting gettingaasecond second opin­ opinstrong ion idea. ion is is a a good good idea. If you you do do seek seek a a second second opinion, opinion, be beprepared prepared to tobe beasked asked some some of ofthe thesame same If questions about about your your symptoms symptoms that that you you were were asked asked the the first first time. Tell the questions time. Tell the n e w psychiatrist psychiatrist why w h y you you think think you you have have some s o m e disorder disorder other other than than bipolar bipolar new and, speCifically, specifically, why w h y you you don't don'tthink thinkthe thediagnostic diagnosticcriteria criteriafor forbipolar bipolardisor­ disorand, der derfit. Alternatively, if if you you think think that that bipolar bipolar is is the the correct correct diagnOSiS diagnosis but but fit. Alternatively, you've been been diagnosed diagnosed with with something something else, else, tell tell the the new n e w physician physician w h y you you you've why believe this. Bring along a close family m e m b e r , significant other, or trusted this. Bring along a close family member, significant other, or believe trusted life friend. This This person person can can offer offer a a different different perspective perspective on on your your symptoms symptoms and and life friend.

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THE DIAGNOSIS DIAGNOSISAND ANDCOURSE COURSEOfOF BIPOIA R DISORDER THE BIPOlAR DISORDER

experiences,which whichmay may be bequite quite useful to mental the mental health professional who experiences, useful to the health professional who makes the makes the diagnosis. diagnosis. Relate Most Most of of all, all,it's it'simportant importanttotowork workcollaboratively collaborativelywith withyOUT yourdoctor. doctor. Relate accu­ what you you can can about about your your history and report report events events and and symptoms symptoms as as accuwhat history and rately as as possible, possible, even even if ifwhat whatyou youare arereponing reportingisissometimes sometimesembarrassing embarrassingoror rately painful painful to to talk talk about. about. Try Try to to see see things things from from the the doctor's doctor's perspective. perspective. If If the the

doctor bipolar, what doctor thinks thinks you you are are bipolar, whatis isthe therationale rationalebehind behindthat thatopinion? opinion?What What diagnostic criteria criteria does does the the doctor doctor think think apply apply to to you? Is he he or orshe she considering considering diagnostic you? Is other other diagnoses, diagnoses, and and if if not, not,why w h y not? not?

Comorbid Disorders Disorders (omorbid

The to the of twoof or two more The term term "comorbidity" "comorbidity"refers refers to co-occurrence the co-occurrence orpsychiatric more psychiatric disorders Many disorders in in the the same same person. person. M a n y people people have have more more than than one one DSM-IV D S M - I V psy­ psychiatric disorder. disorder. In In fact, fact, two two carefully carefullydesigned designednational nationalsurveys surveysof ofpsychiat­ psychiatchiatric ric disorders in the general population-the National Comorbidity Survey ric disorders in the general population—the National Comorbidity Survey and and the Epidemiologic Epidemiologic Catchment Catchment Area Area study-concluded study—concluded that that 56--60% 5 6 - 6 0 % of of people people the with one psychiatric psychiatric disorder disorder report two or or more more disorders (Kessler et et aI., al., repon two disorders (Kessler with one 1994; 1994; Robins Robins et et al., al., 1991). 1991). In In clinical clinical practice, practice,people peopleare areoften oftengiven givenmultiple multiple diagnoses, sometimes because diagnoses, sometimes because they they have have more more than than one one disorder disorder and and some­ sometimes because because the the clinician clinician isn't isn't sure sure which which diagnosis diagnosis best applies and and theretimes best applies there­ fore diagnoses more than one. fore diagnoses more than one. W h a t does does a a person person with with two two or or more more comorbid comorbid disorders disorders look look like? like? Con­ ConWhat sider Elena, a 49-year-old w o m a n w h o has been diagnosed with bipolar II dissider Elena, a 49-year-old woman who has been diagnosed with bipolar II dis­ order and ADHD. order and ADHD. hadhad Elena had had several long-lasting episodes, during which several long-lasting depressive depreSSive episodes, during which sheshe Elena had difficulty holding holding a a job. job.Her Her hypomanic hypomanic periods periods were were characterized characterized by by had difficulty Chris, irritability, racing thoughts, and and sleep sleep disturbance. disturbance. Her Her husband, husband, Chris, racing thoughts, irritability, that was understanding understanding of of her depression but but became became enraged enraged at at the the fact fact that was her depression w h e n he he tried tried to to talk talk to to her about her her job job situation, situation, Elena's Elena's eyes eyes would would her about when that glaze over and she she seemed seemed not not to to be be listening. listening. Chris Chris also also complained complained that glaze over and she made made a a lot lot of of careless careless mistakes: mistakes: When W h e n she she sent senther herresume resume to toprospec­ prospecshe tiveemployers, employers,there therewas wasoften oftenaapage pagemissing missingor orthe theprinting printingwas wasslanted. slanted. tive She also also frequently forgot appointments appointments with with her her doctors. doctors. Her Her forgetfulShe frequently forgot forgetful­ ness and and inattention inattention seemed seemed to to characterize characterize her behavior most most of of the her behavior ness the time, even even w h e n she she wasn't depressed. when wasn't depressed. time,

In Elena's case, the codiagnosis of disorder bipolar with disorder with ADHD led her physicia In Elena's case, the codiagnosis of bipolar ADHD led her physician to recommend recommend a a regimen regimen that that included included a am o o d stabilizer stabUizer and and dextroampheta dextroampheta-­ mood to mine (Adderall), (Adderafl), a a drug drug deSigned designed to to improve improve attention attention and and concentration. concentration. mine

Into Intothe the Doctor's Dodo(sCourt: Court:What Whotto toExpect Expectfrom homthe theDiagnostic DiagnosticProcess PIOCes:5

4 45 5

Psychiatric Disorders Disorders Often Often CConfused with Bipolar Bipolar Disorder Disorder Psychiatric o n f u s e d with Attention-deficitlhyperactivity disorder (ADHD) •• Attention-deficit/hyperactivity disorder (ADHD) Borderline personality • • Borderline personality

•• Cyclothymic Cyclothymic disorder disorder •• Schizophrenia Schizophrenia or or schizoaffective schizoaffective disorder disorder • Recurrent • Recurrent major major depreSSive depressive disorder disorder • Substance-induced • Substance-induced mood m o o d disorder disorder

T h e sidebar n this disorders that thatare areoften often comorbid comorbid with with bipo­ bipoThe sidebar o on this page page lists lists disorders lar confused with with it diagnostically. A D H D , borderline lar disorder disorder or or confused it diagnostically. ADHD, borderline personality personality disorder, and and cyclothymic cyclothymic disorder disorder can can all allbe be codiagnosed codiagnosed with with bipolar bipolar disor­ disordisorder, der. others require the clinician der. The T h e others require that that the clinician make make a a decision decision between between these these diagdiag­ noses disorder. noses and and bipolar bipolar disorder.

Attention-Deficit/Hyperactivity Disorder (ADHD) Attention-Deficit/Hyperactivity Disorder (ADHD) Do you have have any any of of the the following Do you followingproblems? problems? • Difficulty paying attentionto to details? details? • Difficulty paying attention •

• Making Making careless carelessmistakes mistakes in inwork w o r k or or other other activities? activities?

•

• Trouble Trouble listening listening to to others? others?

•

• Problems Problems with with organization? organization?

•

• Distraction? Distraction? • Forgetfulness? Forgetfulness?

•

ADHDADHD is a childhood-onset disorder characterized bybydifficulty attending is a childhood-onset disorder characterized difficulty attending

to tasks. tasks.A A child child who w h o has has ADHD A D H D with with hype�ctivity hyperactivity or or impulsivity impulsivity will will fidget, fidget, to blurt out out answers answers to to questions, questions,have havedifficulty difficultyremaining remainingseated. seated,and andtalk talkex­ exblurt cessively (American (American Psychiatric Psychiatric Association, Association, 1994;;1, 1994a, 2000). 2000). Notice Notice how h o w simi­ simicessively larthese these symptoms s y m p t o m s are are to to mania! mania! Distinguishing Distinguishing childhood-onset childhood-onset bipolar bipolar dis­ dislar order from from ADHD, A D H D , or or distingui�hing distinguishing adult adult bipolar bipolar disorder disorder from from the the order continuation of ofan an ADHD A D H D first firstdiagnosed diagnosed in in childhood, childhood,is isextremely extremely difficult. difficult. continuation A n d it itis ispossible possible to tohave have both. both.Some S o m e studies studieshave have found found that thatas asmany m a n y as as 90% 90% And ofchildren childrenand and 30% 3 0 % of ofadolescents adolescentswith vidthbipolar bipolardisorder disorder also also have have ADHD, A D H D , al­ alof though though not not everyone everyone agrees agrees on on this this(Geller (Geller &: & Luby. Luby, 1997). 1997).

Distinguishingbipolar bipolardisorder disorderfrom fromADHD A D H D is isimportant, important,because becausethe thepri­ priDistinguishing mary drugs drugs for for treating treating ADHD A D H D are are stimulants stimulants such such as as methylphenidate methylphenidate mary

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THE OF OF BIPO�R THE DIAGNOSIS DIAGNOSISAND ANDCOURSE COURSE BIPOLDISORDER AR DISORDER

(Ritalin) Adderall. These drugs areusually not usually towith people with bipolar (Ritalin) oror Adderall. These drugs are not given togiven people bipolar disorder unless unless accompanied by a a mood m o o d stabilizing stabilizing agent agent like like lithium lithium or or disorder accompanied by Depakote. You'll You'll learn learn more more about about these medications in in Chapter Chapter 6. 6. Ritalin, these medications Ritalin, Depakote. like many m a n y stimulating stimulating drugs, drugs, can can increase increase the the chances chances of of developing developing a a manic manic like

53). or hypomantc episode the case or hypomanic episode (see (see the case study study on on page page 53).

There is currently a a trend trend among a m o n g mental mental health health professionals professionals to to coThere is currently co� diagnose diagnose bipolar bipolar disorder disorder and and ADHD, A D H D , particularly particularly in in children. children. There There are are no no separate separate diagnostic diagnostic criteria criteria for for bipolar bipolar disorder disorder in children, and, and, unfortuin children. unfortu· naleiy, both, nately, this this trend trend sometimes sometimes leads leads to to imprecision. imprecision. It possible lO to have have both, It is is possible

and many m a n y people people do, do, but but there there are are also also ways ways to to tell tell them them apart. and apart. First, First, the thecognitive cognitiveproblems problems associated associatedwith withADHD A D H D do do not notchange changemuch much from from day day to to day day or or week week to to week, the person person is is taking taking Ritalin or a a simi­ simiweek, unless unless the Ritalin or lar constant problems lar drug. drug. People People with with ADHD A D H D have have fairly fairly constant problems with with attention, attention, dis­ distractibility, tractibility,and and organization, organization,regardless regardlessof oftheir theirmood m o o d state. state.In Incontrast, contrast,peo­ people ple with with bipolar bipolar disorder disorder may m a y become become impulsive impulsive and and have have difficulty difficulty attending, attending, but mixed, or epi­ but mainly mainly when w h e n they they are are in in the the midst midst of of a a manic, manic, mixed, or depressed depressed episode. For sode. For example, example, Teri, Teri, age age37, 37,worked worked successfully successfullyas asaagraphic graphicartist artistduring during her her periods periods of of mood m o o d stability. stability. Only Onlywhen w h e n she shewas wasdepressed depressedwas wasshe sheunable unableto to concentrate layouts. concentrate on on her her design design layouts. In In addition, addition, ADHD A D H D is isnot not accompanied accompanied by by the theextreme extreme highs highsand and lows lowsof of mood m o o d states states that that are are the the hallmark hallmark of of bipolar bipolar disorder. disorder. It It is isnot nottypical typicalfor forpeo­ peo-

ple with A D H D to to experience experience elated elated highs, goal-directed behavior, with ADHD highs, goal-directed behavior, hyperhyper­ ple sexuality, sexuality, decreased decreased need need for for sleep, sleep, or or grandiOSity grandiosity (Geller (Geller el et al., al., 1998), 1998), or or to to

experience deep deep depressions depressions alternating alternating with with periods periods of of stable stable mood. mood. experience A D H D is is usually usually associated associated with with difficulty difficulty in in school school settings. settings. When W h e n you you ADHD were school, were were you you fairly fairlyconSistently consistently able ableto tokeep keep your your mind mind on on class class were in in school, activities? Have Have you you generally functioned well well in in tasks tasks that that require require concentra­ concentraactivities? generally functioned tion and and effort effort since since then? then? If If the the answer answer to to both both of of these these is is yes, it is isunlikely unlikely tion yes, it that you have have ADHD, A D H D , although although a a thorough thorough answer answer to to this this question question requires requires that you cognitive testing. testing. If you think think you you might might have have A D H D , raise the possibility cognitive If you ADHD, raise the pOSSibility with your your doctor and ask ask for for a a separate separate evaluation evaluation of of that that condition. condition. In In addi­ addiwith doctor and tion to to medications medications for for A D H D , there m a y be be �cognitive "cognitive rehabilitation" rehabilitation" protion ADHD, there may pro­ grams in in your your area area that that you you can can enroll enroll in to help help you you develop develop strategies strategies for for im­ imgrams in to proving your your attention attention and and concentration. concentration. proving Borderline Personality Disorder Borderline Personality Disorder Do Do you you have have .. .. • Difficulty defining who you you are are or orwho who you you want want lO to be? be? • Difficulty definingfor for yourself yourself who •

• A A history history of of very very intense intense and and unstable unstable relationships relationships with with people? people?

Into Proces5 the Diagnostic homfrom Whotto Intothe theDocto(s Doctor'sCourt: Court: What Expect to Expect the Diagnostic Process

47 47

• A history of making efforts to efforts keep people from abandoning or abandoning or people from to keep great making of great • A history leaving you? leaving you? •

• Difficulty Difficulty controlling controUing angry angry outbursts? outbursts?

•

•A A history history of ofimpulsive impulsive or or reckless recklessbehavior behavior in in sex, sex,spending spending money, money, or or eating? eating?

•

•A A history history of ofself�destructive self-destructive acts acts (for (for example, example,self�cutting)? self-cutting)?

in thinking, disturbance long�lasting patterns arelong-lasting disorders Personality Personality disorders are patternsofof disturbance in thinking, perceiving, perceiving, emotional emotional response, response, interpersonal interpersonal functioning, functioning, and and impulse impulse con� control. trol. The The hallmarks hallmarks of of borderline borderline personality personality disorder disorder are are instability instability in in mood, mood, relationships, relationships, and and one's one'ssense senseof ofself selfor oridentity. identity.People Peoplewith withborderline borderlinedisor� disorder der feel feel chronically chronically empty empty and and bored, bored, have have terrible terrible trouble trouble being being alone, alone, and and re� frequently frequently make m a k e suicidal suicidal gestures gestures or or threats. threats. They They tend tend to to have have remarkably remarkably rere� active active moods m o o d s and and qUickly quickly become become intensely intensely sad, sad, anxious, anxious, or or irritable irritable in in relast sponse sponse to to events events involving involving close close relationships. relationships. These These mood m o o d states states tend tend to to last for only only aa few few hours hours or, or, at atmost, most,aafew fewdays days(American (American Psychiatric PsychiatricAssociation, Association, for 1994a, 1994a, 2000). 2000). Borderline Borderline personality personahty disorder disorder generally generally continues continues throughout throughout adulthood, unless unless the the individual individual seeks seeks treatment. treatment. adulthood, did, she did, a day. times a 10 times to 10 upto boyfriendup herboyfriend calledher Carla, Carla, age age 27,27. called day. When When she she couldn't if she she she often often raged raged at at him h i m for for "not "not being being there there for for her" her" and, and, if couldn't reach him, him, accused accused him him of of being being w with another woman. woman. W h e n alone, alone, she she When ith another reach would feel feel like like she she was was disappearing, disappearing, and and feel feel intolerable intolerable cravings cravings to to would smoke, eat, eat, drink drink alcohol, alcohol, vomit, vomit, or or cut cut herself herself with with glass. glass. She to tried to She tried smoke, hurt herself herself in in minor minor ways ways several several times, times, but but never never severely severely enough enough to hurt to threaten her her life. life. These Theseproblems problemshad had continued continued for forseveral severalyears, years,despite despite threaten the fact fact that she was was in in psychotherapy psychotherapy and and had had tried tried various various forms forms of antithe of anti� that she depressant medication. medication. depressant There are are several parallels disorder, parpar� bipolar disorder, and bipolar borderline and betweenborderline parallelsbetween several There ticularly the the rapid rapid cycling but there are also also discernible discernible differences. differences. In In there are forms, but cycling forms, ticularly borderline the changing m o o d states states are are usually usually very very short-lived and short�lived and changing mood disorder the borderline disorder a reaction reaction to to being being rejected rejected or or even even just just slighted slighted by by people people with with w h o m the the per� perwhom a son son is affiliated.In Infact, fact,the the disturbances people with borderline personality is affiliated. personality borderline with people inin disturbances are are most most visible visible w h e n one one observes observes their their romantic relationships. They to tend to They tend romantic relationships. when idealize and devalue those those with h o m they close, and and they they go go to to become close, they become whom with w then devalue and then idealize great lengths great lengths to to avoid avoid being being what experience as as abandoned. abandoned. they experience what they People borderline personality disorder do depressed and of� and ofbecome depressed do become personality disorder with borderline People with ten full criteria criteria for for a a major episode at o m e point their in their point in some at s depreSSive episode major depressive meet full ten meet lives. But they they do do not notdevelop develop the the full fullmanic manic or ormixed mixed affective affectivesyndrome syndrome un� unlives. But less also have have a bipolar disorder. Between 1 0 % and and 4 0 % of with people with of people 40% 10% disorder. Between a bipolar they also less they

THE DIAGNOSIS DIAGNOSISAND ANDCOURSE COURSEOFOFBIPOlAR BIPOLAR DISORDER DISORDER THE

48 48

personality for a borderline criteria diagnostic the the meet also bipolar bipolardisorder disorder also meet diagnostic criteria for a borderline personality 1995). al., et Peselow 1996; aI., eL George 1995; al., et (Carpenter et al., 1995; George et al., 1996; Peselow et al, 1995). (Carpenter Why W h y is is it it important important to to know k n o w if ifyou you have have borderline borderline personality personality as as well well as as (or instead instead 00 of) bipolar bipolar disorder? disorder? Currently, Currently, there there arc are no no agreed-on agreed-on gUidelines guidelines (or for the the drug drug treatment treatment of of people people with with borderline borderline personality personality or or those those with with for both borderline borderline and and bipolar bipolar disorders. disorders. It It is is generally generally believed believed that that people people with with both both disorders disorders are are more more "treatment "treatment refractory" refractory" or or have have morc more trouble trouble respond­ respondboth ing or or adhering adhering to to mood m o o d stabilizing stabilizing drugs drugs (American (American Psychiatric Psychiatric Association, Association, ing 1994b). 1994b). If If you you are are having having trouble trouble finding finding the the right right combination combination of of medica­ medications,and and ififsome someof ofthe thepreceding precedingfeatures featuresfit fityou, you,ititisispossible possibleyou youhave havethis this tions, complicating condition. condition. In In these these cases, cases, it it is is especially especially important important for for you you to to complicating consider psychotherapy psychotherapy in in addition addition to to medication. medication. The The form form of of therapy therapy that that consider has the the most most research research support support for for borderline borderline personality personality disorder disorder is is ··dialecti­ "dialectihas cal cal behavior behavior therapy," therapy," a a form form of of cognitive-behavioral cognitive-behavioral therapy, therapy, in in both both group group and and individual individual settings, settings, developed developed by by Marsha Marsha Linehan Linehan (1993). (1993). Cyclothymic Disorder Cyclothymic Disorder Do have .. .. you have Do you • Short periods of of feeling irritable, excited? excited? and and active, irritable, feelingactive, periods • Short •

• ShOT[ Short periods periods of of feeling feeling mildly mildly depressed? depressed?

•

•A A tendency tendency to to alternate alternate back back and and forth forth between between the the two? two?

To make matters eveneven more complicated, you can have a afluctuating form fluctuating form have can you complicated, more matters To make of mood m o o d disorder disorder marked marked by by short short periods periods of hypomania alternating alternating with with of hypomania of short, mild mild periods periods of of depression. depression. To T o have cyclothymic disorder, disorder, you must you must have cyclothymic short, have alternated alternated between between high high and and low low periods for at at least consecutive two consecutive least two periods for have years and and never be without without mood m o o d disorder disorder symptoms symptoms for for more more than two than two never be years months at a time time (American (American Psychiatric Association, 1994a, o w is is 2000). HHow 1994a, 2000). Psychiatric Association, at a months this disorder? Consider vignette: follOwing vignette: the following Consider the 1I disorder? bipolar II from bipolar different from this different Katherine was was a 30-year-old woman who, since adolescence, since who, woman a 30-year-old Katherine experi­ hadexperiadolescence,had enced a pattern of alternating between she which she in which periods in three-day periods between three-day of alternating a panern enced cried a lot and felt sad and less interested in things, foflowed by another cried a lot and felt sad and less interested in things, followed by another three-day she would feel irritable, energetic, and irritable, energetic, would feel which she in which period in three-day period talk­ and talkative. either her her depressive for either hospitalized for been hospitalized never been had never She had ative. She or depressive or hypomanic concemrate, to concentrate, unable to suicidal, unable been suicidal, she been had she nor had symptoms, nor hypomanic symptoms, or comsometimes com­ boyfriend sometimes Her boyfriend weight. Her of weight. amounts of significam amounts lost significant or lost plained diffi­ more diffiwas more it was Although it ragefulness. Although and ragefulness. moodiness and her moodiness about her plained about cult h e n she be­ lost aa job never lost had never she had depressed, she was depressed, she was work wwhen to work her to for her cult for job because it. of it. cause of

Intothe theDoctor's Doctor'sCourt: Court: What Expect Diagnostic Process Into Whot to to hpect homfrom the the Djognos�( Process

49 49

Katherine received a diagnosis of cyclothymic rather disorthan bipolar disor� Katherine received a diagnosis of cyclothymic rather than bipolar der. Had H a d her h e r depressions depressions been b e e n worse w o r s e and/or and/or required required hospitalization, hospitalization, h e r diag­ diagder. her nosis nosis would w o u l d be b e changed c h a n g e d to to bipolar bipolar II II disorder disorder with w i t h cyclothymic c y c l o t h y m i c disorder. disorder. OOne ne can be diagnosed with both! be diagnosed with both! can The T h e psychiatrist psychiatrist Hagop H a g o p Akiskal Akiskal from from the the University University of of California, California, San San Diego Diego School School of of Medicine, Medicine, views viewscyclothymia cyclothymia as asaadisturbance disturbance of oftemperament temperament that predisposes predisposes people people to to bipolar bipolar disorder disorder (Akiskal, (Akiskal, 1996; 1996; see see also also Chapter Chapter that 4). 4). In In fact, fact,cyclothymia cyclothymiahas hasaalot lotin incommon c o m m o n with withbipolar bipolar1Iand and II IIdisorders, disorders,inin terms is terms of of ilS its pattern pattern of of inheritance inheritance and and ilS its presumed presumed biology. biology. Cyclothymia Cyclothymia is listed listed in in the the DSM�lV D S M - I V as as a a mild mild form form of of bipolar bipolar disorder. disorder. About About one one in in every every three people people with with cyclothymia cyclothymia progresses progresses to to bipolar bipolar 1I or or II II disorder disorder (that (that is, is, three they develop develop full-blown full-blown manic manic episodes, episodes, longer longerhypomanias, hypomanias,or ormajor major depres­ depresthey sive episodes) over periods of two to three years (Akiskal et aI., 1977). sive episodes) over periods of two to three years (Akiskal et al., 1977). There There are are very very few few studies studies on on the the ideal ideal treatmenlS treatments for for bipolar bipolar II II disorder disorder versus similar versus cyclothymia. cyclothymia. As As a a result, result, psychiatrislS psychiatrists tend tend to to treat treat them them in in a a similar way, way, with with mood m o o d stabilizers stabilizers like like lithium lithium or or Depakote. Depakote. Nonetheless, Nonetheless, people people with with cyclothymia can can sometimes sometimes function function without medication because their disorwithout medication because their disor­ cyclothymia der der is is generally generally less less severe severe and and less less impairing. impairing. For For some, some, the the label label cyclothymia cyclothymia feels less less frightening frightening than than bipolar bipolar 11 II disorder, disorder, even even though though they they have many feels have many similar features. similar features. Schizophrenia Schizophrenia If you are areaaperson personwith withschizophrenia, schizophrenia, will experience of fol­ the folIf you youyou will experience somesome of the

lowing lowing symptoms: symptoms: • Delusions, suchsuch as a as feeling of being followed, a belief that your • Delusions, a feeling of being followed, a belief that your

•

•

•

•

•

•

•

•

thoughts are are being being controlled controlled by by an an outside outside force, force, or or a a belief belief that that some­ somethoughts one one (or (or some s o m e organization) organization) wanlS wants to to hun hurt you you Hallucinations,in in which which you you hear hear aa voice voice or or see see aa vision vision Hallucinations, Lack of of motivation, motivation, apathy, apathy, and and disinterest disinterest in in seeing seeing anyone anyone lack Loss of of or or "blunting" "blunting" of of emotions emotions Loss Very jumbled jumbled or or confused confused communication communication and and thinking thinking Very

It can be quite difficult distinguishbipolar bipolar disorder from schizophreIt can be qUite difficult to to distinguish disorder from schizophre­ nia, especially especially when when a a person person is isfirst seeking treatment treatment or or has has his his or or her her first first nia, first seeking hospitalization. People People with with schizophrenia schizophrenia do do not not have have multiple multiple personalities, hospitalization. personalities, as is is commonly c o m m o n l y believed. believed. Instead, Instead, they they have have delusions delusions (mistaken, as (mistaken, unrealistic unrealistic behefs) or or hallucinations hallucinations (sensory (sensory experiences, experiences, like like voices, voices, without a real without a real beliefs) stimulus). stimulus). They They can can experience experience severe severe depressions, depressions, but but often often their their biggest biggest affect). problem is is being being cut cut off off from from their their emotions emotions (flatness (flatness or or blunting blunting of of affect). problem

50 SO

COURSE Of OF BIPOlAR THEDlAGHOSIS DIAGNOSISANO AND COURSE BIPOIOISORDER AR DISORDER lHE

People with withbipolar bipolar disorder have delusions and hallucinations; these People disorder can can also also have delusions these and hallucinations; are typically typically (but (but not not invariably) invariably) of of aa manic, manic, grandiose grandiose type type (for (for example, example, "I "I are have have a a finely-tuned finely-tuned extrasensory extrasensory perception") perception") or or of of aa depressive depressive sort sort (for (for ex­ example, ample, "The "The devil devil tells tells me m e II am a m to to be be punished punished for for my m y bad bad deeds"). deeds"). According to to DSM-IV D S M - I V criteria, criteria,you youhave havebipolar bipolardisorder disorderinstead insteadof ofschizo­ schizoAccording phrenia swings emotion phrenia if, if,during duringyour yourepisodes, episodes,you youexperience experiencesevere severe swingsofof emotionand and energy or or activity activity levels, levels,and andYOUT yourdelusions delusionsor orhallucinations hallucinations(if (ifthey theyoccur occuratat energy all) all)do donot notappear appearumil untilafter afterthe theonset onsetof ofyour yourmood m o o d swings. swings.IfIfyour yourdelusions delusions and and hallucinations hallucinations develop develop before before your your mood m o o d swings swings and/or and/or persist persist after after your your depressive depressive or or manic manic symptoms symptoms clear clear up, up, you you would would more more likely likely be be diagnosed diagnosed with JJective disorder, with schizophrenia schizophrenia or or schizoa schizoaffective disorder, a a blend blend of of the the schizophrenia schizophrenia and mood m o o d disorder disorder categories. and categories. These distinctions distinctions are are very very important important in in relation relation to to your your prognosis. prognosis. The The These long-term long-term outcome outcome of of schizophrenia-in schizophrenia—in terms terms of of number number of of hospitalizations, hospitalizations, ability ability to to work, work, and and other other quality-of-life quality-of-life indicators-is indicators—is worse worse than than for for bipolar bipolar or or schizoaffective schizoaffective disorder disorder (Grossman (Grossman et et al., al., 1991). 1991). It's It's also alsoan an important importantdis­ distinction with schizophrenia tinction for for treatment, treatment, because because people people with schizophrenia require require a a different different line is line of of medications medications than than people people with with bipolar bipolar disorder. disorder. If If your your diagnosis diagnosis is schizophrenia your physician probably recrec­ schizophrenia or or schizoaffective schizoaffective disorder, disorder, your physician will will probably ommend ris­ o m m e n d drugs drugs like like olanzapine olanzapine (Zyprexa), (Zyprexa), c10zaril Clozaril (Clozapine), (Clozapine), and and risperidone (Risperdal) (Risperdal) (see (see also also Chapter Chapter 6). 6). These These are are novel novel antipsychotic antipsychotic peridone drugs with properties. If If the the doctor doctor feels feels your bipolar diagdrugs with mood-stabilizing mood-stabilizing properties. your bipolar diag­ nosis is is accurate accurate but but that thatyou you have have psychotic psychotic symptoms symptoms or orsevere severeagitation, agitation,he he nosis or she m a y recommend one of these drugs along with a m o o d stabilizing agent or she may recommend one of these drugs along with a mood stabilizing agent like lithium, lithium, Depakote, Depakote,or orTegretol. Tegretol.Consider Consider the theexperiences experiencesof ofKurt, Kurt,age age19: 19: like KurtKurt believed there was a a"gang thatroamed roamed the theplanet planet and spebelieved there was "gangof of nine" nine" that and spe­ cifically was looking for him. H e described his "self as a "sheU" that was cifically was looking for him. He described his " self" as a "shell" that was gradually deteriorating deteriorating and and would eventually be be taken over by this gang. gradually would eventually taken over by this gang. W h e n he he began began to be preoccupied preoccupied with with the of nine, he would would beWhen to be the gang gang of nine, he be­ come up, irritable, irritable, easily easilyprovoked provoked to totears, tears,speak speaka amile mflea aminute, minute, come revved revved up, and SLOp stop sleeping. sleeping. He H e was was hospitalized hospitalized because because his and his thinking thinking became became inin­ creasingly bizarre bizarre and his parents became afraid afraid of him. When W h e n his creaSingly and his parents became of him. his older older brother visited the hospital, hospital, Kurt Kurt ran to him, him, threw his arms arms brother visited him him in in the ran up up to threw his around him, and screamed, "Thanks for saving me!" me!" After around him, began began crying, crying, and screamed, "Thanks for saving After hospital Haldol (an antipsychotic medication), calmed hospital treatment treatment with with Haldol (an antipsychotic medication), he he calmed d o w n conSiderably considerably and down and began began sleeping sleeping again. again. But But he he continued continued to to believe believe a gang was was follOWing following him him and and that its members members were were waiting waiting for forhim him to tobe be a gang that its discharged discharged from from the the hospital. hospitaL

Notice thatKurt's Kurt's primary disturbance is in his thinking Notice that primary disturbance is in his thinking processesprocesses rather thanrather than his e continued delusional behefs afmood. H He continued to to be be preoccupied preoccupied with with his his delusional his mood. beliefs even even af-

Into the the Doctor's Doctor's (ourt: Court: Whot What to to Expect Expect from from the the Diognostic Diagnostic Process Process Into

5S1I

ler sleep problems improved. He Hewas wasgiven giventhe the diagnosis diagnosis of of ter his hismood mood and and sleep problems improved. schizoaffective distinctions are are schizoaffective instead instead of of bipolar bipolar disorder. disorder. These These diagnostic diagnostic distinctions Often, among a m o n g the the most most difficult difficult to to make m a k e reliably reliably (Pope (Pope &: & Lipinski, Lipinski, 1978). 1978). Often, people people with with these these unclear unclear patterns patterns of of symptoms symptoms have have to to be be observed observed across across several their diagnosis several episodes, episodes, and and try try many m a n y different different medications, medications, before before their diagnosis becomes clear. becomes clear. Recurrent Major Major Depressive Depressive Disorder Rew"ent Disorder Have you severe periods periodsof ofdepression depression that have come and gone, Have you had had major, major, severe that have come and gone, but distin­ but no no obvious obvious signs signs of of mania mania or or hypomania? hypomania? It It may m a y seem seem simple simple to to distinguish people people with with only only recurrent recurrent depressions depressions from from those those who w h o have have both gUish both dede­ pressions pressions and and manias, manias, but but it it is is actually actually quite quite difficult. difficult.The Themost mostcommon c o m m o n situ­ situation ation is is a a person person who w h o has has had had repeated repeated episodes episodes of of major major depreSSion, depression, and and then then develops and "ready to develops a a brief brief period period (a (a few few days) days) of of feeling feeling "wired," "wired," "up," "up," and "ready to take take on o n the the world." world." Is Is this this bipolar bipolar II II disorder? disorder? Or O r simply simply the the "high" "high" most most of of us us would would feel feel after after coming coming out out of of a a long long depreSSion? depression? A A true true hypomanic hypomanic episode episode involves involves an an observable observable change change in in functioning functioning from a a prior prior mood m o o d state. state. A A hypomanic hypomanic person personsleeps sleepsless, less,feels feelsmildly mildlyor ormod­ modfrom erately elated elated or or irritable, irritable,and andhas hasracing racingthoughts thoughtsor orbecomes becomes talkative. talkative.IfIfthis this erately state state lasts lasts for for days days at at a a time, time, and and others others have have commemed commented on on it, it, a a hypomanic hypomanic episode (and (and bipolar bipolar disorder) disorder) is is suspected. suspected. In In comrast, contrast, a a person person who w h o simply simply episode feels good good after after being being depressed, depressed, but but who w h o has has few few or or none none of of the the other sympother symp­ feels toms in in the the hypomanic hypomanic cluster, cluster, is is probably probably a a patient patient with with "unipolar "unipolar deprestoms depres­ sion." A A history history of of bipolar disorder in in your your family family provides provides additional additional evision." bipolar disorder evi­ dence for the bipolar over the unipolar diagnosis. A s mentioned earlier, dence for the bipolar over the unipolar diagnOSiS. As mentioned earlier, ifif your doctor doctor cannot cannot be be certain certain if if you you have have unipolar unipolar depression depression or or bipolar bipolar your disorder, he he or or she she will will probably probably recommend r e c o m m e n d that that you you take take a am o o d stabilizer disorder, mood stabilizer before before introdUcing introducing an an antidepressant. antidepressant. Substance-Induced Mood Disorder Substonce-Indured Mood Disorder Are all allofofthe the following true Are following true for for you?you? • You havehave had had an episode of depression or or mania • You an episode of depreSSion mania •

• These These symptoms symptoms developed developed after after you you took took aa street street drug, drug, drank drank aa large large

quantity of of alcohol alcohol over over several several days days or or weeks, weeks, or or began began taking taking an an antiquantity anti­ depressant or or some s o m e other other medication medication that that affects affects moods moods depressant • Your Your mood m o o d symptoms symptoms subsided subsided shortly shortly after afteryou you stopped stopped drinking drinking the the • alcohol alcohol or or taking taking the the drug drug • You Y o u have have not not had had previous previous manic manic or or depressive depressive episodes, episodes,except except those those • brought on on by by alcohol alcohol or or drugs drugs brought

THEDIAGNOSIS DIAGNOSISAND AND COURSE BIPOLDISORDER AR DISORDER THE COURSE OF OF BIPOlAR

52 52

Manic and depressive symptoms can be mimicked by certain drugsdrugs of Manic and depressive symptoms can be mimicked by certain of abuse. Cocaine, Cocaine, amphetamine amphetamine ("speed"), ("speed"), heroin, heroin, and and LSD L S D have have all all been been abuse. k n o w n to to create create manic-like manic-like Slates, states, often often with with accompanying accompanying psychosis. psychosis. Am­ Amknown phetamine, in in panicular, particular,has hasbeen beenknown k n o w n to toproduce produceirritable, irritable,hyperactivated, hyperactivated, phetamine, delusional delusional states. states. It It is isunlikely unlikely that thatalcohol alcoholabuse abuse or ordependence dependence will willdirectly directly cause depres­ cause aa manic manic episode, episode, but but it it can can certainly certainly contribute contribute lO to a a spiraling spiraling depression. sion. The The DSM·IV D S M - I V distinguishes distinguishes mood m o o d disorders disorders that that are are a a function function of of certain certain substances substances from from those those that that are are due due to to a a person's person's inherent inherent phYSiology. physiology. Mood Mood

disorders that that are are the the direct direct function function of of substances substances are are usually usually short-lived, short-lived,dis­ disdisorders appearing are appearing more more qUickly quickly than than non�substance�related non-substance-related mood m o o d disorders, disorders, and and are usually usually treated treated through through detoxification detoxification and and chemical chemical dependency dependency program. program.

Sometimes they they abate abate without without treatment. treatment. However, However, substances substances can can contribute contribute Sometimes to the the onset onset of of the the first first episode episode of of bipolar disorder, which which then then takes takes on on a a to bipolar disorder, course not uncommon bipolar persons LOto say that their first course of of its itsown. own.ItItisis not u n c o m m o nfor for bipolar persons say that their first manic manic episode episode began shortly after after they they began began experimenting experimenting with with drugs. began shortly drugs. As As II talked talkedabout aboutin inChapter Chapter 2, 2,you youcan canhave haveboth bothaamood m o o dand andaasubstance substance use use disorder, disorder, with withone one influencing influencingthe thecourse courseof ofthe theother. other.Mood M o o d swings swingsmake make you likely to you more more likely to take take drugs drugs or or alcohol, alcohol, and and drugs drugs or or alcohol alcohol can can worsen worsen your mood al­ your m o o d swings. swings. About About 60% 6 0 % of of people people with with bipolar bipolar disorder disorder have have had had an an alcohol cohol or or substance substance use use disorder disorder at at some some point point in in Iife-a life—a rate rate that that is is much much

higher than than the the general general population population rate rate of of 10-20% 1 0 - 2 0 % (Regier (Regier et et al., al., 1990; 1990; Sonne Sonne higher

& Brady, Brady, 1999). 1999). So, So,even even if ifyou you originally originallysought soughttreatment treatmentfor foraamood m o o d prob­ prob&

lem, your your docLOr doctor may m a y still still diagnose diagnoseyou you with with aasubstance substanceor oralcohol alcoholuse usedisor­ disorlem, der and and recommend recommend that that you you take take part part in in a a 12-step 12-step program program (for (for example, example. Al­ Alder coholics Anonymous) A n o n y m o u s ) or or an an individual therapy deSigned designed to help you you coholics individual therapy to help overcome chemical chemical dependency overcome dependency problems. problems. Your doctor doctor will probably assess assess the the sequence sequence of of your your m o o d symptoms symptoms will probably mood Your and and drinking drinking or or drug drug use: use: Do D o you you usually usually get depressed and and then then drink? drink? Does Does get depressed

i everhappen happen that thatyou you drink drink and and then then get getdepressed? depressed? Do D o you you use use cocaine cocaineor or itt ever marijuana and then get manic, or is i t the reverse? Usually, he or she wiU not marijuana and then get manic, or is it the reverse? Usually, he or she will not be to tell teh for for sure ifyou you have have both both aa bipolar bipolar and and aa substance substance abuse abuse prob­ probbe able able to sure if lem until you have remained sober or or drug-free for a a period of time. time. Again, lem until you have remained sober drug-free for period of Again, your others m a y be be of here. For your close close relatives relatives and and significant significant others may of help help here. For example, example, your spouse spouse m a y be able to h o w and and when w h e n your behavior started started to to shift shift your may be able to recafl recall how your behavior in relation relation to w h e n you took certain in to when you took certain substances. substances. A n important case of m o o d disorder mania, hypoAn important case of substance-induced substance-induced mood disorder is is mania, hypo­ mania, cycling that in mania, or or rapid rapid cycling that develops develops after after taking taking antidepressants. antidepressants. Karine, Karine, in the example below, strongly mimicked a mixed the example below, showed showed symptoms symptoms that that strongly mimicked a mixed epiepi­ sode, but sode, but her her symptoms symptoms remined remitted once once the the antidepressant antidepressant was was withdrawn. withdrawn.The The

DSM-IV one DSM-IV requires requires that that the the bipolar bipolar syndrome syndrome not not be be diagnosed diagnosed until until at at least least one

Into Intothe the Doctor'� Doctor's(ourt: Court:Whot What toto Expect Expect 110m from the the Oiognosti( Diagnostic PrO(e5S Process

5533

by an­ provocation withoUl manic, manic, mixed, mixed,or orhypomanic hypomanic episode episodehas hasoccurred occurred without provocation by antidepressants tidepressants or or other other substances. substances. If If you you do do become become manic manic or or hypomanic hypomanic be­ because cause of of antidepressants, antidepressants,you youmay m a y indeed indeedhave havebipolar bipolardisorder, disorder,but butmore moreevi­ evidence will will be be required. required. dence about anxious depressed severely Karine, Karine, age age 48, 48, had had beenbeen severely depressed and and anxious for for about a a m o n t h after after the the death death of of her her father. father. She She had had never never had had a a manic manic or or a a month hypomanic hypomanic episode. episode. Her Her physician physician had had put put her her on on an an antidepressant, antidepressant, but but it itdid did not not make m a k e her her depression depression better; better; in in fact, fact,her heranxiety anxietygot gotworse. worse.Her Her physician then then gave gave her her aa different different kind kind of of antidepressant. antidepressant. physician "At "At first, first, 1I felt felt greaL. great. II could could focus focus on on things things like like never never before. before. II no no longer longer needed needed cigarettes cigarettes to to keep keep my m y mind mind on on my m y work. work. But But then then my m y mood mood started started to to go go up u p and and down d o w n like like a a seesaw. seesaw. My M y sleep sleep gOt got worse worse and and worse-I worse—I woke w o k e up u p almost almost every every hour. hour. II felt felt wired, wired, but but then then my m y depression depression came came back. back. II started started feeling feeling really really irritable irritable and and worried, worried, and and II couldn't couldn't stop stop my my ruminations, ruminations, which which were were like like a a tape tape playing playing at at 78 78 rpms. rpms. II had had to to take take it." A m b i e n (a (a sleep sleep medication) medication) nearly nearly every every night. night. II couldn't couldn't stand stand it." Ambien Her physician physician took took her her off off of of the the antidepressant antidepressant gradually. gradually. Her Her mood mood Her milder a to returned then but weeks few a for fluctuate to continued continued tofluctuatefor a few weeks but then returned to a milder state state of of depression. depression. She She was was eventually eventually treated treated successfully successfully with with oxcarbazepine oxcarbazepine (Trileptal, (Trileptal, an an anticonvulsive anticonvulsive agent agent like like Tegretol) Tegretol) and and psychotherapy. psychotherapy. Her Her dis­ mood rapid rapid cycling cycling was was considered considered an an instance instance of of substance-induced substance-induced m o o d disbereave­ order, order, although although she she was was also also believed believed to to have have �uncomplicated "uncomplicated bereavement," a a form form of of major major depression that is is a a reaction reaction to to a a loss loss experience. experience. depression that ment," She was was never never given given the the diagnosis diagnosis of of bipolar bipolar disorder. disorder. She *

*

*

II hope hope you you can can see see now n o w how h o w important important it itis is to to obtain obtain aa proper proper diagnosis diagnosis and and to to rule rule out out competitive competitive diagnoses. Knowing the the diagnostic criteria for bifor bi­ diagnostic criteria diagnoses. Knowing polar disorder disorder and and h o w these these symptoms symptoms manifest manifest themselves themselves within and polar you and within you how others others is is empowering. empowering. As A s you'll you'll see awarenessof ofthe thesymptoms symptoms that thatyou you later, awareness see later, typically typically experience experience w h e n developing bipolar episodes will go a long w a y in when developing bipolar episodes will go a long way in helping you to prevent prevent these these episodes episodes from from spiraling spiraling out out of control. of control. you to helping In the In the next chapter, I'll I'll discuss discuss the have in to adjusting to in adjusting people have problems people the problems next chapter, or coping with bipolar disorder. S o m e deny deny the the reality the of the reality of disorder. Some of bipolar diagnosis of the diagnosis with the or coping disorder and just exaggerations per­ their perof their exaggerations of are just symptoms are their symptoms that their believe that and believe disorder sonality. Some sonality. S o m e overcommit overcommit to and unnecessarily limit to limit try to unnecessarily try diagnosis and the diagnosis to the their career and aspirations, and and others othersreluctantly reluctantlyagree agree to to the the diag­ diagpersonal aspirations, and personal their career nosis nosis but continue living illness-free. No N o one one likes likesto to were illness-free. they were as ifif they lives as their lives living their but continue believe that have a they have that they believe treat­ long-term treatrequires long-term that requires disorder that psychiatric disorder a psychiatric ment. o m i n g to process. emotional process. difficult emotional is aa difficult diagnosis is the diagnosis accept the to accept Coming ment. C

4

4

Is I s It It an a n Illness I l l n e s s or o r Is I s It It Me? M e ? TIPS T I P S ON O N COPING C O P I N G WITH W I T H THE T H E DIAGNOSIS DIAGNOSIS

I

In n Chapter Chapter 33 we w e discussed discussed the the rather rather dry dry (though (though useful) useful)DSM-IV DSM-IV diagnostic criteria. criteria. What What these thesecriteria criteriado donot notaddress addressor orconvey conveyisisthe theemo­ emodiagnostic tional impact impact of of learning learning you you have have bipolar bipolar disorder disorder and and acknowledging acknowledging ilS its re­ retional ality. Most Mostof ofmy m y patienLS patientsgo gothrough throughpainful painfulstruggles strugglesin incoming coming to toterms terms ality. with this this diagnosis. diagnosis. Initially, Initially, they theyexperience experienceanger, anger,fear, fear, sadness, guilt, disapwith sadness, guilt, disap­ pointment, and and hopelessness. hopelessness. These These are are not cycles but poimment, not manic-depressive manic-depressive cycles bUl rather a a process of forming forming a a new n e w sense sense of of who w h o they are, aanew n e wself-image self-imagethat that rather process of they are, may incorporates having having biological biological imbalances imbalances that that affect affect their their moods. moods. It It m ay incorporates or sound like like I'm I'm talking talking about about people people who w h o have have had had only only one one or or two two manic manic or sound depressed episodes episodes and and are are surprised surprised by by the the diagnosis, diagnosis, but but rYe I'vealso alsoseen seenthese these depressed reactions in in people people who w h o have have been hospitalized for for the the disorder disorder numerous numerous been hospitalized reactions times. times. hav­ W h y is is the the process process of of acceplance acceptance so so painful? painful? Coming C o m i n g to to terms terms with with havWhy ing the disorder disorder may m a y mean m e a n admitting admitting to to a a new n e w role role for for yourself yourself in in your your family, family, ing the to in the the workforce, workforce, or or in in your personal relationships. relationships. It It may m a y require require you you to your personal in m a k e some decisions about about restructuring restructuring your your life life and and priorities, priorities, which which may may some decisions make m e a n viewing viewing yourself yourself differently. differently. For example, Esteban, Esteban, age age 25, 25, gave gave up u p his his For example, mean apartment and and returned returned to to live live with his parents parents after afterhis hishospitalization. hospitalization.He He apanment with his then had had to to deal deal with with their their hypervigilance hypervigilance and and increased increased attempts attempts to to control control then his behavior, behavior, which which made m a d e him himfeel feellike likehe hewas wasaachild childagain. again.Rob, Rob,age age38, 38,had had his was been quite quite successful successful in his work as a a civil civil engineer. engineer. After After his diagnosis was in his work as his diagnosis been revealed, he he found that people people at at work work seemed seemed afraid afraid of him. He H e attributed attributed revealed, found that of him. losing his his job to the the disclosure disclosure of of his his illness. Nancy, age age 44, 44, noted noted that that after job to illness. Nancy, lOSing after 54 54

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SS 55

learning of telling mmany of her it, at at least least oone learning of hher e r diagnosis diagnosis and a n d telling a n y of h e r friends friends about a b o u t it, ne "dumped m me 1 was imagine the the "dumped e because because I was too too 'high 'high maintenance.' maintenance.' "" You Y o u can can imagine there are to acknowledg­ pain pain and and confusion confusion you you might might feel feel when w h e n there are such such costs costs to acknowledging the the disorder. ing disorder.

What's Unique What's Unique about about Bipolar Bipolar Disorder? Disorder? People who have to medical diagnoses such as diabetes or hyperten­ People who have to live livewith with medical diagnoses such as diabetes or hypertension sion go go through through similar similar emotions emotions in in coping coping with with their their diagnoses. diagnoses. Nobody Nobody likes to to believe believe they they have have a a long-term long-term illness illness that that requires requires regular regular treatment. likes treatment. But But bipolar bipolar disorder disorder has has its its own o w n particularities. particularities. As A s IImentioned mentioned in inChapter Chapter 2, 2, bipolar ups and bipolar disorder disorder can can be be difficult difficult to to distinguish distinguish from from the the normal normal ups and downs downs of of human h u m a n life. life. You Y o u may m a y have have always always been been moody m o o d y or or temperamental temperamental and believe believe that that your your manic manic or or depreSSive depressive periods periods are are just just exaggerations exaggerations of and of your moodiness. How your natural natural moodiness. H o w do do you you know k n o w what what is is really really your your illness illness and and self" or what is is your your ""self or your your personality personality (your (your habits, habits, attitudes, attitudes,and andstyles stylesof ofre­ rewhat lating yourself lating to to others; others; the the way w a y you you are are most most of of the the time)? time)? How H o w do do you you train train yourself to to know k n o w the the difference difference between between you you when w h e n you're you're well well and and you you when w h e n you're ill, you're ill, and not not fool fool yourself yourself into into thinking thinking that changes in in mood, m o o d , energy, energy, or or activity and that changes activity are are just just "how " h o w I've I've always always been"? been"? On a a practical practical level, level, the theability abilityto torecognize recognizethese thesedifferences differencesbetween betweenper­ perOn sonality traits traits and and disorder disorder symptoms symptoms is is important important so so that that you you and and others others sonality k n o w when w h e n emergency emergency procedures procedures need need to to be be undertaken. undertaken. On O n an an emotional emotional know level, understanding understanding these these distinctions distinctions can can contribute contribute to to a a more more stable stable sense sense level, of who w h o you you are. are. Maureen, Maureen, for for example, example, knew k n e w she she had had always always been been extraverted extraverted of but but realized reahzed she she needed needed to to visit visit her her doctor doctor when w h e n she she began began staying staying up u p late late to to caU people-all people—aU over over the the country-to country—to whom w h o m she she hadn't hadn't spoken spoken in in years. years. The The call requirement of of an an increased increased dosage dosage of of lithium lithium did did not not interfere interfere with with her her aprequirement ap­ preciation preciation of of others. others. T h e reaction reaction of of many m a n y of of my m y clients clients upon u p o n learning learning of of the the diagnosis diagnosis is is dis­ disThe beliefor ordenial, denial,which whichisisonly onlynatural. natural.After After aU, they havetoto revisetheir their image belief all, they have revise image of of themselves, themselves, which which is is painful painful and and difficult difficult to to do. do. Others, Others, especially especially those those who w h o were were diagnosed diagnosed some s o m e time time ago, ago, come c o m e to to believe believe they they have have the the disorder disorder but continue continue to to lead lead their their lives lives as as if if they they did did not. not. You Y o u can can imagine imagine why w h y people people but would react react this this way; way; in in fact, fact,you youmay m a y even evenrecognize recognizethese thesereactions reactionsin inyour­ yourwould self. self. Nevertheless, Nevertheless,these thesestyles stylesof ofcoping copingcan cancause causetrouble troublefor foryou, you,especially especially if they they lead lead to to your your refusal refusal to to take take medications medications that that would would help help you you or or to to en­ enif gaging in in high-risk high-risk activities activities (for (for example, example, staying staying up u p all allnight, night,getting getting drunk drunk gaging frequently) illness. frequently) that that can can worsen worsen your your illness. For example, example, Antonio, Antonio, age age 35, 35, behaved behaved in in self-destructive self-destructive ways ways to to cope cope For

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THE OF OF BIPOlAR THEDIAGNOSIS DIAGNOSISAND ANDCOURSE COURSE BIPOIDISORDER AR DISORDER

with his confusion confusionand andpain. pain.HeHewent wentoff off medications to to tryprove to prove to with his hishis medications to try to others that that he wasn't sick, sick, but butthen thenrelapsed relapsed and and ended ended up up back back in inthe thepsychi­ psychiothers he wasn't atrist's office, office, with with more more medication medication being being recommended. recommended. Rosa, Rosa,who w h o had had re­ reatrist's ceived her her diagnosis diagnosis years years ago, ago, of often turned to to alcohol alcohol when w h e n she she experienced experienced ceived len turned the the shame, shame, social social stigma, stigma, and and hopelessness hopelessness she she felt felt the the diagnosis diagnosis conferred conferred on on her. her. After they they have have lived lived with with the the disorder disorder for for a a while, while, some some people people begin begin After thinking of themselves as if they were nothing more than a diagnostic label or thinking of themselves as if they were nothing more than a diagnostic label or set of of dysfunctional dysfunctional molecules. molecules. They They start start automatically automatically attributing attributing all all of of aa set their personal personal problems problems to to the illness, even eventhose thoseproblems problems that thatpeople peoplewith­ withtheir the illness, out for out bipolar bipolar disorder disorder routinely routinely experience. experience. They They usually usually accept accept the the need need for medications medications but but unnecessarily unnecessarily limit limit themselves themselves and and avoid avoid taking taking advantage advantage of of opportunities handle. opportunities that that they they actually actually could could handle. By By the the end end of of this this chapter chapter you you will will have have a a greater greater sense sense of of the the various various emotional feel emotional reactions reactions people people have have upon upon learning learning of of the the diagnosis. diagnosis. You'll You'll feel empowered knOwing knowing that that your o w n emotional emotional reactions reactions are are shared shared by others empowered your own by others and that admitting up hopes and as� and that admitting to to the the diagnosis diagnosis doesn't doesn't mean m e a n giving giving u p your your hopes and aspirations. pirations. The The chapter chapterends endswith withsuggestions suggestionsfor forcoping coping with with the thedifficult difficultpro­ process is something that cess of of coming coming to to terms terms with with the the illness. illness. Bipolar Bipolar disorder disorder is something that you but it it is are. you have, have, but is not not who w h o you you are. The Emotional Emotional Fall-Out Fail-Out 01 of the the Diagnosis Diagnosis The Most thepeople peoplewho whoconsult consult havebeen beentold told someone some time Most of of the memehave by by someone at at some time that they they have have bipolar disorder, even even if ifthey theydon't don'tbelieve beheveititthemselves. themselves. When bipolar disorder, When that a w e actually actually sit sit d o w n and and begin begin discussing discussing the the disorder, disorder, they they experience experience a we down wide range range of of emotions, emotions, including including bewilderment, bewilderment, anxiety, anxiety, and and anger. anger. Some Some wide people feel feel relief: rehef: learning that you you have have a a psychiatric psychiatric disorder disorder that that has has a people learning that a name, and and that that explains explains a a great great deal deal of of what what has has happened happened to to you, you, can can help help alname, al­ leviate your your feelings feelings of of gUilt guilt or or self-blame. self-blame. More More often. often, however, however,the thediagnosis diagnosis leviate raises more more questions questions than than it it answers-most answers—most of of which concern what what the the furaises which concern fu­ ture holds holds for for you you and and those those close close to to you. ture you. W h e n you youfirst learned that that you you had had the the disorder, disorder, you you may m a y have have asked asked first learned When yourself questions questions like like the the following: following: yourself

Why Why me? me? W h y is is this this happening happening now? now? Why A m II "only "only bipolar" bipolar" now, now, or or do do II still stiUhave have aaseparate separateidentity? identity? Am Where do do 1I stop stopand and the thedisorder disorderbegin? begin? Where

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myperiods prior periods of high energy, creativity, and accomplishment WereWere my prior of high energy, creativity, and accomplishment n o t h i n g more m o r e than than signs signs of of an a n illness? illness? nothing How think I'm I'm H o w much m u c h mood m o o d variability variability am a m II "allowed" "allowed" before before people people think getting sick sick again? again? getting How H o w responsible responsible am a m II for for my m y own o w n behavior? behavior? Will II have have a a normal normal life life and and achieve achieve my m y goals? goals? Will

if you've disorder, youyou maymay stillstill ask ask Even if you'vehad hadnumerous numerous episodes episodes of ofbipolar bipolar disorder, Even yourself that yourself these these questions. questions. It's It's natural natural to to do do so, so, and and healthy-to healthy—to the the extent extent that struggling goals. struggling with with these these questions questions helps helps you you clarify clarify your your feelings feelings and and goals. parents) If If any any dose close family family members m e m b e r s (for (for example, example, your your spouse spouse or or parents) learned learned of of your your diagnosis diagnosis at at the the same same time time as as you you did, did, they they probably probably had had ques­ questions directly tions of of their their own. o w n . They They may m a y not not have have voiced voiced these these questions questions to to you you directly because because they they understood understood that that hearing hearing their their worries worries might might be be painful painful for for you you and because they and because they didn't didn't wish wish to to cause cause family family conflict. conflict. For For example, example, Kyana's Kyana's ill and never parents worried worried that that she she would would always always be be tagged tagged as as mentally mentally i ll and never parents have have a a normal normal life. life. They They worried worriedthat thatthey theywould would have haveto totake takecare careof ofher her for for the the rest rest of of their their lives lives and and that that their their hopes hopes and and dreams dreams for for her her had had been been dashed. dashed. Greg's wife wife wondered wondered if if she she had had married married the the wrong wrong man m a n and and whether she Greg's whether she should should leave leave the the relationship. relationship. None N o n e of of these these family family members members raised raised their their wor­ worries until until they they began began talking talking openly openly about about the the disorder disorder with with Kyana Kyana or or Greg. Greg. ries O n the the positive positive side, side, learning learning more more about about the the disorder disorder was was comforting comforting to On to Kyana, Greg, Greg, and and their their families, families, because because they they learned learned together together that thatthe theprog­ progKyana, nosis nosis was was not not as as poor poor as as they they had had feared. feared.

'It's No Big Big Deal": Deal": Rejecting RejectingororUnderidentilying Underidentifying with Diagnosis "It's No with thethe Diagnosis "I"1want back to to the theplace place where I used to live in Miami, back before wantto to go go back where I used to live in Miami, back before all this this mess mess started. started. Who W h o knows? M a y b e the the apartment apartment II lived lived in is still still all knows? Maybe in is available. People People liked Hked me m e there. there. II had had so so many m a n y friends. friends. I sometimes available. I sometimes think if if II go go back back there, there, I'll I'll find find the the old old me m e sunning sunning herseU herself under some think under some big tree." big old old palm palm tree." — A 26-year-old 26-year-old woman w o m a n who w h o had had just just been been hospitalized hospitalized -A for her her second second manic manic episode Jor episode Perhaps you remember remember the timesomeone someone told toldyou youthat that youhad had bipolar Perhaps you the first first time you bipolar disorder. Did Did any any of of the the reactions reactions in in the the sidebar sidebar on on page page 58 58 describe describe how h o w you you disorder. felt felt then then or or now? now? Consider the the first first reaction reactionof ofrejecting rejectingthe thediagnosis diagnosisoutright. outright.Did Did you you (or (or Consider

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THE DIAGHOSIS DIAGNOSIS AHO AND COURSE COURSE Of OF BIPOlAR BIPOIAR DISORDER DISORDER THE

Common C o m m o n Reactions Reactions to to Being Being Told Told O n e Has H a s Bipolar Bipolar Disorder Disorder One •

• "The "The diagnosis diagnosisisis wrong: wayother for other to to peoplepeople a waya for just just it'sit's WTong: explain away away my m y experiences" experiences" [re [rejecting the diagnosis] diagnosis] jecting the explain

•

• ''I'm "I'mjust just aa moody m o o d y person" person" (underidentification [underidentification with with the the diagnosis: giving giving some some credence credence (0 to it it but but making making few, few, if if any, any, diagnosis:

lifestyle lifestyle adaptations] adaptations] •

• "My " M y illness illness is iseverything, everything,and and IIhave have no no control control over over my my behavior" (overidentification [overidentification with with the the diagnosis: diagnosis: rethinking rethinking yOUT your behavior" life problems problems and and beginning beginning to to blame blame all, all, or or most most of of them, them, on on life the disorder, disorder, or or unnecessarily unnecessarily limiting limiting your your aspirations aspirations because because the

J of of the the illness illness]

do do you you now) n o w ) believe believe that that the the diagnosis diagnosis was was all all just just a a misunderstanding misunderstanding of of your your and weren't trying to behavior? behavior? Did Did you you think think others others were were just just trying to rein rein you you in in and weren't in· interested terested in in your your private private experiences? experiences? Did Did you you get get confused confused about about whether whether your medication was was meant meant to to treat treat your m o o d swings swings or or whether whether it caused it caused your mood your medication them in in the the first firstplace? place?Were W e r e you you convinced convinced that thatthe thediagnosis diagnosiswas was wrong wrong and and them that "alternative "alternative treatments" treatments" were were the answer? the answer? that Carter, age age 49, 49, re rejected the diagnosis, refused to to see see his his doctor, doctor, and re­ and rediagnosis, refused jected the Carter, fused to to take medication. This This obstinancy obstinancy usually surfaced when w h e n he he was was usually surfaced take medication. fused manic, but also dug heels w h e n he had few few or or n o symptoms symptoms of of the the no he had when his heels in his dug in he also but he manic, disorder. He H e believed believed that that whatever whatever problems problems arose arose could could be be controlled controlled by by disorder. diet (particularly (particularly by his sugar sugar intake) intake) and acupuncture treatments. treatments. and acupuncture limiting his by Hmiting diet H e argued his behavior-no behavior—no matter h o w dangerous dangerous or or bizarre it had had bizarre it matter how that his argued that He b e e n — w a s just just being e blamed blamed his his He misinterpreted. H and misinterpreted. misunderstood and being misunderstood been-was behavior people he provoked him-typically, him—typically, family family mem­ memhad provoked thought had he thought on people behavior on bers, employers, or or romantic romantic partners. the few in which which he he did did times in few times During the partners. During bers, employers,

his ill­ agree to to take mistakenly concluded caused his illhad caused it had that it concluded that he mistakenly medication, he take medication, agree ness o o d s were e Depakote, o w they swing they swing now and n Depakote, and me gave m they gave until they fine until were fine moods ("My m ness ("My all over the place"). all over the place"). As I in Chapter you will wiU certainly certainly want want to to explore explore with with your your As 3, you Chapter 3, discussed in I discussed doctor h y he the diagnosis appHes to h y other possiother possi­ why and w you, and to you, diagnosis applies thinks the she thinks or she he or why doctor w ble diagnoses out. Second and there there helpful, and often helpful, are often opinions are Second opinions ruled out. being ruled are being diagnoses are ble is substitute for learning as as m u c h as symptoms of of the the the symptoms about the can about you can as you much for learning no substitute is no disorder, medications, and strateself-management strateand self-management various medications, of various purposes of the purposes disorder, the

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59 59

gies. But rejecting isisa adangerous stance to take, because, as in as in rejectingthe thediagnosis diagnosis dangerous stance to take, because, gies. But

Carter's of treatments bee life-saving. Carter's case, case, it it can c a n lead lead to to the the rejection rejection of treatments that that may m a yb life-saving. People People who w h o take take this this stance stance often often go g o through t h r o u g h several several episodes episodes and a n d hospitaliza­ hospitalizations tions before before they they admit a d m i t that that anything anything is is wrong, w r o n g , and a n d even e v e n then then may m a y distrust distrust the the diagnosis, the the doctors, doctors, and a n d the the medication. medication. diagnosis, the Now N o w consider consider the the second s e c o n d reaction, reaction, what w h a t II call call underidentifying underidentifying wwith i t h the diagnosis. diagnosis. Underidentification Underidentification is is a a very very common c o m m o n reaction reaction style, style, and, a n d , for for many many people, to being people, is is a a stage stage in in coming c o m i n g to to accept accept haVing having an a n illness. illness. It It is is similar similar to being re­ "in "in denial," denial," which w h i c h is is not n o t the the same s a m e thing thing as as rejecting rejecting the the diagnOSiS. diagnosis. Denial Denial refers fers to to the the process process of of aVOiding avoiding emotionally emotionally painful painful problems p r o b l e m s by b y pushing p u s h i n g them them out of of conscious conscious awareness. awareness. Being Being told told that that you y o u have h a v e an a nillness illness that that will will recur recur out a n d that that requires requires rethinking rethinking your y o u r life life goals goals is is extraordinarily extraordinarily painful. painful. Who W h o and wouldn't want w a n t to to push p u s h away a w a y their their emotional emotional reactions reactions to to this this nnews e w s and a n d try try to wouldn't to k e e p living living their their life hfe as as if if the the diagnOSiS diagnosis were w e r e not n o t true? true? keep People by People who w h o learn learn that that they they have h a v e other other medical medical diagnoses diagnoses also also react react b y underidentifying. underidentifying. For F o r example, e x a m p l e , people people who w h o have h a v e had h a d hean heart attacks attacks may m a y ac­ acknowledge yet go on k n o w l e d g e to to others others thal that they they need n e e d to to make m a k e lifestyle lifestyle adaptations adaptations yet go o n smoking, People with s m o k i n g , exercising exercising little little or or not n o t at at all, all, and a n d sleeping sleeping irregularly. irregularly. People with diabetes diabetes or or hypertension hypertension can c a n also also superficially superficially acknowledge a c k n o w l e d g e their their diagnoses diagnoses but but go g o on o n eating eating sugary sugary or or salty salty foods. foods. Ellen her Ellen Frank F r a n k and and h e r colleagues colleagues (1994) ( 1 9 9 4 ) at at the the University University of of Piltsburgh Pittsburgh have t e r m e d the e m o t i o n a l issues underlying the denial of bipolar disorder have termed the emotional issues underlying the denial of bipolar disorder "grieving the the lost lost healthy healthy self." self." People People with w i t h bipolar bipolar disorder disorder were w e r e often often very very "grieving energetiC, energetic, popular, popular, bright, bright, and a n d creative creative before they became b e c a m e ill. T h e n , once once before they ill. Then, their their illness illness is is diagnosed diagnosed and a n d people people around a r o u n d them t h e m start start treating treating tthem h e m like like aa "mental patient," patient," they they become b e c o m e resentful resentful and a n d start start yearning yearning for for who w h o they they used used "mental to be. T h e y may m a y think think that that if if they they go g o on o n acting acting as as if if nothing nothing has h a s changed, c h a n g e d , their their to be. They old self self will will come c o m e back, back, like like a a long long lost lost friend-the friend—the way w a y the the w o m a n quoted quoted old woman earlier dreamed dreamed of of finding finding her her old old self self back back in in Miami. Miami. Underlying Underlying these these reac­ reacearlier tions are are deep deep feelings feelings of of loss loss over over the the dramatic dramatic changes changes the the illness has tions illness has brought. brought. If you're you're just just now n o w being being diagnosed diagnosed for for the the first first time, time, it's it's normal normal to in a If to be be in a certain amount amount of of denial. denial. But Buteven evenif ifyou you have havehad had the thediagnosis diagnosisfor forsome some time time certain and and feel feel you've you've accepted accepted its its reality, reality, you you may m a y be beable ableto torecall recalltimes timeswhen w h e n you you were were in in denial denial about about it. it. When W h e n you you have have been been hypomanic hypomanic or or manic, manic, have you have you found yourself yourself doubting doubting whether whether the the illness illness was was real? real? Perhaps Perhaps thinking thinking that found that the the diagnosiS diagnosis has has been been a a mistake mistake all all along? along? Perhaps Perhaps "testing" "testing" the the diagnosis diagnosis by by staying out out all all night, night, drinking drinkingaalot lotof ofalcohol alcoholor ortaking takingstreet streetdrugs? drugs? Have Have you you staying found yourself yourself "forgetting" "forgetting" to to take take your your lithium, lithium, Depakote, Depakote, or or Tegretol? Tegretol? Have Have found you believed you could take your medication without any supervision (regucould take your medication without any supervision (regu­ you believed you lar doctor's doctor's appOintments appointments to to discuss discuss side side effects effects and and monitor monitor your your blood blood levlar lev-

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THE OF OF BIP()�R IHEOIAGNOSIS DIAGNOSISAND ANDCOURSE COURSE BIPOLDISORDER AR DISORDER

with bipo­ els)? Inconsistency els)? Inconsistency with medication big problem people with bipowith medication is a is big aproblem amongamong people lar lar disorder, disorder, with with more more than than 50% 5 0 % discontinuing discontinuing their their drug drug regimen regimen at at some some time their lives time in in their lives (Goodwin (Goodwin & & Jamison, Jamison, 1990). 1990). Frequently, Frequently, when w h e n people people

don't don't take take their their medications medications it itis isbecause becausethey theyare aremanic, manic,hypomanic, hypomanic,or orother­ otherChapter 7). 7). wise in in denial denial about about their their illness illness (see (see Chapter wise

"If I'm I'm Bipolar, Bipolar, So So Is Is Everybody Everybody Else" Else" "If "My mother reallygets getson onmymy case about medications, about "My mother really case about my my medications, about my my

visits to to my m y doctor, doctor, about about the the men m e n I'm I'm going going out out with, with, my m y job, job, my my visits sleep—you name n a m e it. it. She's She's always always asking asking me m e if if I've I've been been drinking. drinking. She She sleep-you goes try to out. She's dis­ goes behind behind my m y back back to to try to find find out. She's always always been been critical critical and and dis-

approving of of m e . II think think she's she's the the one one who's who's bipolar." approving me. bipolar."

-A — A 29-year-old 29-year-old woman w o m a n with with bipolar bipolar II II disorder disorder and and alcoholism alcoholism Sometimes people disorder say it's because confused Sometimes people who who denydeny the the disorder say it's becausethey're they're confused

about where m o o d variation ends and and bipolar illness begins. Perhaps abom where normal normal mood variation ends bipolar illness begins. Perhaps you've wondered wondered at at times times whether whether your your emotional emotional reactions to events events or or situa­ situayou've reactions to tions are are really really any any different different from from other other people's. people's. Have Have you you found found yourself yourself tions thinking or or saying, saying, "People "People around around me m e have have it, it, but but they they just just don't don't know k n o w iit t thinking yet"? are yet"? You Y o u are are rnosl most like1y likely to to think think this this way w a y when w h e n your your relatives relatives or or friends friends are

getting increasingly increasingly angry angry or or overcontrolling, overcontroUing, accusing accusing you you of of being being sick sick even even getting w h e n you're you're in in remission remission and and having fairly ordinary ordinary ups and downs. downs. when having fairly ups and You may m a y be be right right that that others others around around you you are are moody. moody. We W e do do know k n o w that that bi­ biYou polar disorder disorder runs runs in in families families (see (see Chapter Chapter 5) 5) and and that that bipolar bipolar people people tend tend to to polar find mates mates who w h o themselves themselves have have mood m o o d disorders, disorders, (called (called ""assortative mating";; find assortative mating"

1983), So Gershon, Gershon, 1990; 1990; Merikangas Merikangas et et aL, al., 1983). So it's it's not notimpossible impossiblethat thatolhers othersin in your family family context context have have the the disorder disorder or or a a mild mild fonn form of of it. it. Of Ofcourse, course,ifif you your you oror asked them them why w h y they're they're so so moody, moody, they they might might say say they're they're only only reacting reacting to to II asked your behavior. behavior. In In turn, turn, you you may m a y think think that thatyour yourbehavior behavioroccurs occursin inreaction reactionto to your their moods. moods. their Being aware aware of of the the moodiness moodiness of of your your close close relatives relatives or or friends friends is is not notnec­ necBeing essarily a a bad bad thing. thing. You Y o u can can learn learn to to avoid avoid doing doing the the things things that that provoke provoke essarily them and, and, even even better, better, help help them them find sources of of help help (for them find appropriate appropriate sources (for example, a a support group). Remember R e m e m b e r that that their o o dfluctuations a y occur example, support group). their m mood nuctuations mmay occur because of of matters matters that that have have nothing nothing to to do do with with you. you. Chapter Chapter 12, 12, on on commu­ commubecause nicating with with family family members, members, should should help help you you with with some some of of these these issues. nicating issues, Simply having having moods m o o d s that that shift shift doesn't doesn't make m a k e one one bipolar bipolar (recall the dis­ disSimply (recall the But if cussion of of symptom symptom thresholds thresholds in in making making the the diagnosis diagnosis in in Chapter Chapter 3), 3). But if cussion

you find find yourself yourself seeing seeing bipolar bipolar disorder disorder in in everyone everyone else, else, the the issue issue is is probaprobayou

IIss ItItononlI100ss IllnessOf or It Me? Is ItIsMe?

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bly the diagnostic criteria. Rather, the issue bly not not that thatyou're you'remisunderstanding misunderstanding the diagnostic criteria. Rather, the issue is o t wwanting a n t i n g to d m i t t i n g that and probably nnot to feel feel alone alone or or isolated. isolated. AAdmitting that you're you're ill ill and is probably different r o m others nd c an b e quite o w e v e r , as different f from others is is stigmatizing stigmatizing a and can be qUite painful. painful. HHowever, as we'll c k n o w l e d g i n g the a n also e eempowering mpowering a n d does­ doeswe'll see see later, later, a acknowledging the disorder disorder ccan also b be and n't e a n that o u know k n o w it, a s to n't mmean that life, life, as as y you it, h has to stop. stop.

TThe h e Personality-versus-Disorder Problem Personolity-versus-Disorder Problem "I"Ifeel likeeverything everythingI do I do is now somehowconnected connectedtotomy my being beingsick. sick. feel like is now somehow If it's because I'm depressed. If I'm I'm happy, happy, it's it's because because I'm I'm manic; manic; if if I'm I'm sad, sad, it's because I'm depressed. don't want want to to think think that that every every time time II have have an an emotion, emotion, every every time time II get get II don't angry at at somebody, somebody, it's because I'm ill. Some S o m e of of my m y feelings feelings are justified. angry it's because I'm ill. are justified. People say I'm a different different person person every day, but that's m e ! I've I've never been People say I'm a every day, but that's me! never been a stable stable person." person." a — A 25-year-old 25-year-old woman woman w h o had had a a manic -A who manic episode episode followed by by a a six-month six-month depression followed depression Having a sense of how youryour personality, habits, differ from Having a sense of how personality, habits, and and attitudes attitudes differ from your symptoms symptoms is is an an important important part part of of learning learning to to accept accept the the disorder. Most your disorder. Most people want want to to feel feel that that they they have have a a sense sense of of self self that that is is separate separate from from their their people

symptoms and and biochemical biochemical imbalances. imbalances. They They especially especially feel feel this this way w a y if ifthey've they've symptoms

been led led to to believe, believe, by by their their doctors doctors or or by by anyone anyone else, else, that that their their illness is a been illness is a "Hfe sentence." sentence." Defining Defining yourself yourself in in terms terms of of a a set set of of stable stable personality personality traits "life traits that have have been been with with you you through through most most of of your your life lifemay m a y make m a k e you you feel feelless lessvul­ vulthat nerable to to the the kinds kinds of of connicts conflicts the the young young woman w o m a n just just quoted quoted is is experiencing. experiencing. nerable Another reason reason to to distinguish distinguish between between your your personality personality and and your your disorder disorder Another is that that it it will will help help you you determine determine when w h e n you you are are truly truly beginning beginning a a new n e w episode episode is

rather than than just just going going through through a a rough rough time. For example, example, if if you you are are extrarather time. For extra­

verted by by nature, nature, socializing socializing aa great great deal deal in in one one weekend weekend may m a y be be less less signifi­ signifiverted cant in in determining determining whether whether you you are are having having a a mood m o o d episode episode than than changes changes in in cant your sleep sleep patterns, patterns, increases increases in in your your irritability, irritabihty, or orfluctuations in your your en­ enyour fluctuations in ergy levels. levels. In In contrast, contrast, increases increases in in your your SOCializing sociaHzing may m a y be be quite quite useful useful as as a a ergy sign of of aa developing developing episode episode if if you you are are habitually habitually an an introverted introverted person. person. sign Bipolar Disorder and Temperament Bipolar Disorder and Temperamen' Y o u may m a y believe-and b e l i e v e — a n d others others who w h o imeract interact with w i t h you y o u may m a y believe-that believe—that your your You s y m p t o m s of of mania m a n i a are are just just your y o u r exuberant, exuberant, optimistic, optimistic, high-energy high-energy self; self; that that symptoms y o u r depression depression is is just just your y o u r tendency t e n d e n c y to to slide slide into into pessimism p e s s i m i s m or or overreact overreact to your to disappointments; or or that that your y o u r mixed m i x e d episodes episodes or or rapid rapid cycling cycling reflect reflect your your disappointments;

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THE THE DIAGNDSIS DIAGNOSISAND AND(DURIE COURSEDFOFBIPDIAR BIPOLARDISORDER DISORDER

natural InIn that peo­ naturalmoodiness moodiness or or"dark "darktemperament." temperament." fact, is evidence that fact, therethere is evidence disturbances" ple ple with with bipolar bipolar disorder disorder have have mood m o o d swings swings or or "temperamental "temperamental disturbances" that that date date way w a y back back to to childhood. childhood. A A questionnaire questionnaire given given to to members m e m b e r s of of the the Na­ National bipo­ tional Depressive Depressive and and Manic-Depressive Manic-Depressive Association Association revealed revealed that that many m a n y bipolar people report having depressive and hypomanic periods even w h e n they Lar people report having depresSive and hypomanic periods even when they were children, children, well well before before anyone anyone diagnosed diagnosed them (Lish et et aI., al., 1994). 1994). were them (Lish O n e of of the the more more creative creative thinkers thinkers in in our our field, field, Hagop HagopAkiskal, Akiskal,has hasan anin­ inOne teresting teresting slant slant on on the the whole whole question. question. He H e believes believes that that the the behaviors, behaviors, habits, habits, and and attitudes attitudes we w e often often refer refer to to as as a a bipolar bipolar client's client's personality personality are are really really mild mild forms of of m o o d disorder, disorder, or or the the bipolar bipolar disorder disorder in in its its early early stages stages of of develop­ developforms mood ment. He ment. H e describes describes four four temperamental temperamental disturbances that he he believes believes predisdisturbances that predis­ pose pose people people to to bipolar bipolar disorder disorder (see (see the the sidebar sidebar on on this this page). page).He H e presents presentsevi­ evidence that people people with with these these temperaments, temperaments, even even if if they they have have never never had had a dence that a major major depressive, depressive, hypomanic, hypomanic, mixed, mixed, or or manic manic episode, episode, often often have have a a family family history the illness illness history of of bipolar bipolar disorder disorder and and are are vulnerable vulnerable to to developing developing the (Akiskal, 1996). 1996). (Akiskal, Why W h y is is it it important important for for you you to to examine examine whether whether one one of of these these tempera­ temperaments ments applies applies to to you? you? Because Because if if you you have have them, them, you're you're at at risk risk for for a a worsening worsening of For example, of your your disorder disorder if if you you are are not not getting getting proper proper treatment. treatment. For example, if if you you had or cyclothymia in adolescence, you are for developing had dysthymia dysthymia or cyclothymia in adolescence, you are at at risk risk for developing bipolar depressive episodes episodes earlier earlier rather rather than than later later (Akiskal (Akiskal et et a1., al., 1977; 1977; Klein Klein bipolar depressive & Depue, Depue, 1984; 1984; Cassano Cassano et et aI., al., 1992). 1992). Lithium Lithium can can be be used used to to treat treat cyclo­ cyclo&: thymia as as well well as as bipolar bipolar disorder. disorder. If If you you had had dysthymia dysthymia or or hyperthymia hyperthymia as as a a thymia child or or adolescent, adolescent, you you are areat atrisk riskfor fordeveloping developing hypomanic hypomanic episodes, episodes,espe­ espechild cially if if you you take take an an antidepressant antidepressant medication medication and and are are not simultaneously cially not simu lt�neously

Akiskal's Akiskal's Four F o u r Temperamental T e m p e r a m e n t a l Disturbances Disturbances •

• Hyperthymic: Hyperthymic:chronically chronically cheerful, overly optimistic, exuberant, cheerful, overly optimistic, exuberant,

extraverted, stimulus stimulus seeking, seeking, overconfident, overconfident, meddlesome meddlesome extraverted, • Cyclothymic: Cyclothymic: Frequent Frequent mood m o o d shifts shifts from from unexplained unexplained tearfulness tearfulness • to giddiness, giddiness, with with variable variablesleeping sleepingpatterns patternsand and changing changing levels levels to of self-esteem of self-esteem • • DysthymiC: Dysthymic: chronically chronically sad, sad, tearful, tearful,joyless, joyless,lacking lackingin inenergy energy • Depressive mixed: Simultaneously anxious, speedy, irritable, • Depressive mixed: simultaneously anxious, speedy, irritable, restless, and and sad, sad,with with fatigue fatigueand and insomnia insomnia restless, Source: Akiskal Akiskal (1996) (1996) SOUTce;

peo-

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taking stabilizer such as lithium (Akiskal, 1996; 1996; AkiskalAkiskal & Akiskal, taking aa mood mood stabilizer such as lithium (Akiskal, &: Akiskal, 1992). If have any a y still 1992). If you you have any of of the the four four temperaments, temperaments, you you m may still experience experience mood variability even once you you return return to to your your "baseline" a manic manic or or dede­ m o o d variability even once "baseline" after after a pressive episode. episode. The notion is is that that these these temperaments are relatively relatively concon­ pressive T h e notion temperaments are a biologically biologically based based vulnerability vulnerability to to your your disorder. disorder. They stant and and reflect reflect a They come come stant the before the onset the disorder and remain the worst worst of onset of of the disorder and remain present present even even after after the of the before the

symptoms have ceased. symptoms have ceased. So, in in one So, one sense, sense, when w h e n people people with with bipolar bipolardisorder disorder say say that thatthey they have have al­ almoody, right. But ways been m o o d y , they're they're right. But the thekey key point pointis isthat thatyour your moodiness moodiness may may ways been reflect imbalances underlying underlying the than characcharac­ reflect the the biochemical biochemical imbalances the disorder disorder rather rather than ter like personality personality traits ter or or personality. personality. What W h a t can can look look like traits can can really ongoing really be be ongOing symptoms your disorder require more more aggressive medical or or psychopsycho­ symptoms of of your disorder that that require aggressive medical

logical treatment. logical treatment.

Self-AdministeredChecklist Checklist AA Self-Administered It isperhaps perhapsimpossible impossibletototell tellfully fullywhat whatisisyour yourpersonality personalityand andwhat whatisis your It is your disorder, disorder, particularly particularly if if you've you've had had aa number n u m b e r of ofepisodes episodes and and you've you've become become accustomed accustomed to to the the wide wide mood m o o d swings swings and and the the changes changes in in energy energy and and behavior behavior that with them. thinking about that go go with them. The T h e following following exercise exercise may m a y clarify clarify your your thinking about these to these matters. matters. In In filling filling out out this this exercise, exercise, compare compare your your personality personality traits traits to

the symptoms symptoms you you have have when w h e n you you get get manic manic or or depressed. depressed. Under Under "personalthe "personal­ ity," try try to to think think of of the the way w a y you you are are most most of of the the time, time, not not just just when w h e n you're you're ity," having cycles. having mood m o o d cycles.

Does your your personality personality consist consist of of a a group group of of traits traits that that"hang "hang together" together"(for (for Does example, sociable, sociable, optimistic, optimistic, affectionate, affectionate, open)? open)? See See if if you you can can distinguish distinguish example, the cluster cluster of of traits traits that thatdescribe describeyou you throughout throughoutyour your life lifefrom fromthose thosethat thattyp­ typthe ify the the way w a y you you ify

feel,think, think,or orbehave behavewhen w h e n you youare aremanic manicor ordepressed. depressed.How How feel,

do do you you usually usually relate relate to to other other people, people, and and does does this this change change when w h e n you you get get into into

high or or low low mood m o o d states? states? When W h e n you're you're racing racing and and charged charged up, up, are are you you really high really "affectionate and and open" open" or or just just physical physical with with many m a n y different different people people and and talk"affectionate talk­ ative across across the the board? board? Would W o u l d people people describe describe you you as as boisterous, boisterous, assertive, assertive, or or ative energetic even even when w h e n you're you're not not cycling cycHng into into aa manic manic episode? episode? Are Are you you pessienergetiC pessi­ mistic mistic and and withdrawn withdrawn when w h e n you're you're not not feeling feeling depressed? depressed?

Ifyou're you'renot notsure sureabout aboutwhether whetheryou you have have certain certainpersonality personality traits, traits,check check If with others others to to see see if if they they would would describe describe you you with with these these trait trait terms. terms. Fre­ Frewith

quently, those those close close to to you you will will have have different different ideas ideas than than you you do do about about what what quently, your personality personality is is like like and and how h o w it it differs differs from from your your mood m o o d disorder disorder symp­ sympyour toms. Of O f course, course, you you may m a y feel feel uncomfortable uncomfortable approaching approaching certain certain close close relatoms. rela­ tives with with these these questions, questions,especially especially if ifyou you feel feelthese thesefamily familymembers m e m b e r s have havean an tives agenda, such such as as getting getting you you to to take take more more medication. medication. For For now, n o w , try try to to select select agenda,

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THE DIAGNOSIS DIAGNOSIS AND AND COUR
WHAT'S WHAT'S ME M E AND A N D WHAT'S WHAT'S MY M Y ILLNESS? ILLNESS? Check as as many many o off the the following following as as apply. apply. Check Your Your personality personality traits traits

Your manic manic or or depressive depressive symptoms symptoms Your __

Euphoric Euphoric

__

Depressed Depressed

Assertive Assertive

_

Sleeping too too much much Sleeping

__

Open Open

__

Sleeping Sleeping 100 too linle little

__

Optimistic Optimistic

__

Racing thoughts thoughts Racing

Reliable Reliable

Grandiose Grandiose

Conscientious Conscientious __

Dependable Dependable

Loss of of interest Loss interest

Indecisive Indecisive

Sociable _ _ _ Sociable Withdrawn Withdrawn Ambitious Ambitious Aloof Aloof Critical Critical Intellectual Intellectual Affectionate Aff ectionate Spirited Spirited Passive Passive Talkative Talkative Seeking novelty Seeking novelty Spontaneous Spontaneous Boisterous Boisterous Fearful Fearful Pessimistic Pessimist ic Erratic Erratic Rebellious Rebellious

__

__

__

__

Full of of energy energy Full

__

Doing things Doing too too many many things

__

Highly distractible Highly distractible

__

Feeling suicidal Feeling suicidal

__

More More easily easily fatigued fatigued

Unable to to concentrate Unable concentrate Irritable Irritable __ __

__

__

__ __ __ __ __

Feeling Feeling worthless worthless Taking hig Taking big or or unusual unusual risks risks Wired Wired Highly Highly anxious anxious Slowed Slowed down down Sped up up Sped Overly goal-driven goal-driven Overly Aggressive impulses impulses Aggressive Hopeless Hopeless Unusually passive Unusually passive

someone you you think think is is not not invested invested in in (he the outcome outcome of of the the discussion discussion (that (that is, is, someone whether you you conclude conclude that that certain certain behaviors behaviors are are your your illness illness rather rather than than your your whether personality, or or vice vice versa). versa). A A close, close, trusted trusted rriend friend may m a y be be a a good choice. Per� Perpersonality, good choice.

haps so haps rrame frame the the question question like like this: this: ''I'm "I'm trying trying to to figure figure out out why w h y I've I've had had so m a n y mood m o o d changes. changes. II want want to to know k n o w whether whether I've I've really really changed changed or whether or whether many I've always always been been like like this. this. Can C a n you you help m e with with a a simple I've help me simple exercise?" exercise?"

"Won't Bipolar Bipolar Disorder Disorder Change Change My M y Personality?" "Won't Personality?" Theflip side of of this this Mpersonality "personality versus versus disorder" disorder" question question is whether one one or The flip side is whether or more episodes episodes of of mania mania or or depression depression can can actually actually change change your your personality personahty or more or

Illnesor s Is orIIIsMe? It Me? IsIsItItanonIllness

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character. Thisisisa avery verycomplicated complicated question. some research evi­ character. This question. There There is someisresearch evid e n c e that that very very painful painful events events can c a n change c h a n g e the the fundamental f u n d a m e n t a l character character of of a a per­ perdence s o n (the (the "scar "scar hypothesis"; hypothesis"; see see Just Just et et al., al., 2001). 2 0 0 1 ) . Many M a n y people, people, particularly particularly son those ex­ those who w h o have h a v e had h a d many m a n y bipolar bipolar episodes, episodes, feel feel that that the the disorder disorder and a n d the the experiences painful life life periences of of hospitalization, hospitahzation, medications, medications, psychotherapy, psychotherapy, and a n d painful events just been events have have fundamentally fundamentally changed changed who w h o they they are. are. People People who w h o have have just been diagnosed may m a y not not worry worry so so much m u c h that that their their personality personahty will wiH be be changed changed by by diagnosed the the diagnosis diagnosis as as that that people people will wfll relate relate to to them them differently differently because because of of it-and it—and that they they may m a y start start acting acting differently differently as as a a result. that result. Certainly, not been Certainly, a a longstanding longstanding mood m o o d disorder-especially disorder—especially if if it it has has not been rreated--can treated—can profoundly profoundly affect affect your your attitudes, attitudes, habits, habits,and and styles stylesof ofrelating relatingto to others. per­ others. It It can can also also require require lifestyle lifestyle changes changes that that are are a a lot lot like like changes changes in in personality. But But if if you you were were really really free free of of your your mood m o o d disorder disorder symptoms symptoms for for a a sonality. before the long period period of of time, time, would would you you go go back back to to being being the the way w a y you you were were before the long illness began? began? illness We in a per­ W e really really don't don't know k n o w whether whether there there are are fundamental fundamental changes changes in a perthat what son's character character as as a a result result of of long-term long-term bipolar bipolar illness. illness. It It is is possible possible that what son's look like changes in personality (for example, becoming less sociable, acting look like changes in personality (for example, becoming less sociable, acting more really more aggresSively) aggressively) following following repeated repeated episodes episodes of of bipolar bipolar disorder disorder are are really just "subsyndromal symptoms"-depressive symptoms"—depressive or or man manic symptoms that not just "subsyndromal ic symptoms that have have not fully disappeared disappeared after after the the last last major major episode. episode. But But no no one one doubts doubts that that the the exfully ex­ perience of of bipolar bipolar mood m o o d swings swings is is very very profound profound and and can can change change the the way w a y you you perience view view yourself yourself and and those those around around you. you.

"I Am My as a a Coping Coping Style "I Am MyDisorder": Disorder": Overidentifying Overidenlilying as Style "I've become very having another another episode. episode.I keep I keep thinking "I've become very worried worried about about having thinking that even even the the smallest smallest thing thing will will push push me m e over over the the edge-a e d g e — a glass glass of of wine, that wine, traveling, eating eating a a rich rich dessert, dessert, even even just just going going to to the the store. store. M y husband husband traveling, My wants me m e to to do do more, more, like like go go with with him h i m to to restaurants restaurants or or shows, shows, but I'm hut I'm wants afraid going going out out will will make m a k e me m e manic. manic. I'm I'm now n o w leading leading a a pretty pretty sheltered sheltered afraid life, life, IIguess." guess." — A 58-year-old 58-year-old woman w o m a n iin a depressed depressed phase phase o of bipolar II disorder disorder -A na f bipolar Some Some peoplepeople deal with thewith emotional pain of the disorder giving themdeal the emotional pain of theby disorder by giving them­ selves over over to to it. it. They T h e y "overidentify" "overidentify" with w i t h the the illness, illness,viewing viewing all allof of their their prob­ probselves lems, lems, eemotional m o t i o n a l reactions, reactions, viewpoints, viev^qjoints, attitudes, attitudes, and a n d habits habits as as pan part of of their their disorder. disorder. If If your y o u r last last period period of of illness illness was w a squite quite traumatic traumatic for for you y o u (for (for exam­ example, ple, your y o u r life life or or health health was w a s threatened, threatened, you y o u experienced experienced public public shame s h a m e or or hu­ humiliation, miliation, or or you y o u lost lost a a great great deal deal of of money m o n e y or orstatus), status), you y o umay m a y have h a v e become become

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OFOF BIP{)�R DISORDER THE THE DIAGNOSIS DIAGNOSISAND ANDCOURSE COURSE BIPOIA R DISORDER

on your fearful disorder's overand you, and severe placedrestrictions severe restrictions on you fearful ofof thethe disorder's powerpower over you, placed life not delife as as a a way w a y of of warding warding off off future future damage. damage. If If this this coping coping style style does does not de­ scribe you you n o w , perhaps you can can recall of time h e n it it did. did. scribe now, perhaps you recall periods periods of time w when There are are many m a n y reasons reasons for for overidentifying overidentifying with with the the illness. illness. First, First, you you There may m a y have have received received inaccurate inaccurate information information from from your your dOClOTS doctors or or other other mental mental health sources. You Y o u may m a y have have been been told told that that your your illness illness is is quite quite grave, grave, that that health sources. you shouldn't shouldn't have have children, children, that that you you can't can't expect expect a a satisfying satisfying career, career, that thatyou you you may of Lime in hospitals, m a y end end up up spending spending a a considerable considerable amount amount of time in hospitals, that that your your marital problems will worsen, worsen, and and that that there there is is liule little you you can can do do to to control control marital problems will your raging raging biochemical biochemical imbalances. imbalances. If you've been been given given this this kind kind of of inforyour If you've infor­ mation, it's it'snot notsurprising surprisingthat thatyou you would would give giveup up control controlto tothis thisaffliction afflictionthat that mation, destroys everything-or everything—or so so you've you've been been told. destroys told. Being given given this this kind kind of of "life "life sentence" sentence"by by your your doctor doctormay m a y make m a k e you you stan start Being reinterpreting your your life life in inthe thecontext contextof ofthe thelabel. label.You Y o umay m a ystart startthinking thinkingback back reinterpreting on normal normal developmental developmental experiences experiences you you had had (for (for example, example, being being upset upset on about with your girlfriend) and about breaking breaking up up with your high high school school boyfriend boyfriend or or girlfriend) andlabeling labeling them them as as yOUT your first first bipolar bipolarepisode. episode.You You may m a y start startto to think think that thatyou you can canaccom­ accomplish "All I am andand I can't change. It's It's plish little littlewith withyOUT your life, life,belieVing, believing, "All I ais m bipolar, is bipolar, I can't change. all all biochemical biochemical and and II can't can't take take responsibility for myself." myself." This This way w a y of of thinkresponsibility for think­ ing work, withdraw ing may m a y lead lead you you to to avoid avoid going going back back to to work, withdraw from from social social relation­ relationships, and and rely rely more more and and more more on on the the caretaking caretaking of of your your family family members. ships, members. In case case it it isn't isn'tobvious, obvious,IIdisagree disagreewith with this thisway w a y of ofcharacterizing characterizing bipolar bipolar In disorder. Many-in M a n y — i n fact, fact, m o s t — o f my m y patients patients are are productive productive people who disorder. most-of people who have successful interpersonal interpersonal relationships. relationships. They adjusted to to the the neceshave successful They have have adjusted neces­ sity of of taking taking medication, medication, but but they don't feel feel controlled controlled by by their illness or or its its sity they don't their illness treatments. They They have havedeveloped developed strategies strategiesfor formanaging managing their theirstress stresslevels levelsbut but treatments. don't completely completely avoid avoid challenging chahenging situations situations either. either. II have have been amazed by by don't been amazed how m a n y of of my m y mOSt most severely severely i ll clients clientscall callme m e years yearslater laterto totell tellme m e they've they've how many ill gotten married, married, had had kids, kids, and/or and/or started started an an eXCiting exciting new n e w job. job. But But without without gotten knowing the the future, future, some some people people "overarm" "overarm" themselves themselvesand and go go too toofar farin inny­ tryknOWing ing to to protect protect themselves themselves from from the the world. world. ing You may m a y find that you're you're more more likely Hkely to to underidentify underidentify with with the the disorder disorder Vou find that w h e n in in the the manic manic pole of the the illness, illness, whereas whereas you you may m a y overidentify overidentify with with it it pole of when w h e n experiencing experiencing the the depressive depressive pole. pole. This is, in part, because depression This is, in part, when because depression dampens your motivation to to initiate initiate certain certain activities, activities, like like work, dampens yOUT motivation work, socializing, socializing, or sexual sexual contract. contract. Vou You may m a y have have subtle subde problems problems in in memory m e m o r y or or concentra­ concentraor tion as aswell, well,rendering rendering the theworld world aa confUSing, confusing,blurry blurry place place that thatdemands demands lOa too tion much. The The illness illness can can seem seem like like an an incredible incredible burden burden that that erases erases any any hopes hopes for for much. the future. future. W h e n you you feel feel this this way, way, you you may, may, understandably, understandably, begin begin to to merge merge the When the illness with your sense of of who w h o you you are are and and w h o you you will wiH become. become. the illness with your sense who

IsIs lIon It anIllness Illnesor s Is orItIMe? s It Me?

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If you have have symptoms of depression, it's important not to takenot on more If you symptoms of depression, it's important to take on more

than don't than you you can can handle, handle, and and to to "stick "stick to to your your guns" guns" about about what what you you do do and and don't feel able to do (even w h e n others want you to do more). But remember feel able to do (even when others want you to do more). But remember also also that that your your depression depression is is likely likely to togo go away, away,with with the theproper proper combination combination of ofmed� medtime. So, a ication, psychotherapy, psychotherapy, family family and and friendship friendship support, support, and and time. So, it's it's a ication, good idea idea to to set set some s o m e limited limited goals goals for for what what you you can can accomplish accomplish even even while while good you're certain you're depressed, depressed, to to help help you you become become more m o r e energized. energized. Maintaining Maintaining a a certain level of of "behavioral "behavioral activation" activation" can can protect protect you you against against a a worsening worsening mood mood level state (see (see Chapter Chapter 10). state 10). "What Way for "WhalIs Is the Ihe Best Besl Way for Me Meto 10 Think Think about aboul the lhe Diagnosis?" Diagnosis?"

Getting into about whether Getting into debates debates with with yourself yourselfororothers others about whetheryour yourbehavior behavior stems from from your your personality personality or or your your disorder disorder can can be be quite quite discouraging. discouraging. You'll You'll stems find yourself yourself intensely intensely disagreeing disagreeing with with your your friends friends or or family family m e m b e r s about about find members whether re� whether you you really really have have changed changed or or whether whether you're you're just just being being yourself yourself and and reacting who ex� acting to to circumstances. circumstances. Alternatively, Alternatively, you you may m a y disagree disagree with with others others w h o expecl pect you you to to be be "up "up and and rolling" rolling" when w h e n you you feel feel like like you're you're not not back back to to full full ca� capacity. But Butififunderidentifying underidentifyingand and overidentifying overidentifyingare areboth bothproblematic, problematic,what what pacity. the is is a a helpful helpful view? view? Is Is there there an an accurate accurate and and empowering empowering way w a y to to think think about about the disorder? Keep Keep in in mind m i n d several several "mantras" "mantras" about about the the diagnosis diagnosis of of bipolar bipolar disordisorder? disor� def. der. 1. Bipolar disorder is not is a life sentence. As I've As discussed, underiden-underiden­ disorder nor a life sentence. I've discussed, 1. Bipolar tifying and a n d overidentifying overidentifying are are based b a s e d in in painful painful experiences experiences from f r o m the the past past aand nd tifying understandable fears fears and a n d uncertaimies uncertainties about a b o u t the the future. future. But B u t having having a a bipolar bipolar understandable illness doesn't doesn't mean m e a n you y o u have h a v e to to give give up u p your y o u r identity, h o p e s , and a n d aspirations. illness identity, hopes, aspirations. Try to to think think of of bipolar bipolar disorder disorder in in the the same s a m e way w a y you y o u would w o u l d think think of diabetes Try of diabetes or high high blood b l o o d pressure. pressure. That T h a t is, is, you y o u have have a a chronic chronic medical medical illness iUness that or that rere� quires you y o u to to take take medication medication regularly. regularly. Taking T a k i n g medication medication over over the term quires the long long term m a r k e d l y reduces reduces the the chances c h a n c e s that that your y o u r illness illness will w i H interfere interfere with with your y o u r life. Hfe. markedly T h e r e are are also also certain certain lifestyle lifestyle adaptations adaptations you y o u will w i U need n e e d to tomake m a k e (such (such as as vis� visThere iting regularly regularly with with a a psychiatrist psychiatrist or or therapist, therapist, arranging arranging blood b l o o d tests, tests, keeping keeping iting y o u r sleep-wake s l e e p - w a k e cycles cycles regulated, regulated, moderating m o d e r a t i n g your y o u r exposure e x p o s u r e to to stress, stress, choos� choosyour ing ing work w o r k thal that helps helps you y o u maintain maintain a a stable stable mood). m o o d ) . None N o n e of of these these changes, changes, h o w e v e r , requires requires that that you y o u give give up u p your y o u r life life goals, goals, including including having having a a success­ successhowever, ful career, career, maintaining maintaining good g o o d friendships friendships and a n d family family relationships, relationships, having having ro� roful mance, m a n c e , or or getting getting married married and a n d having h a v i n g children. children. 2. Many M a n y creative, creative, productive productive people people have have lived lived with with this this illness. illness. Bipolar Bipolar disdis� 2.

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THE OfOF BIPOlAR DISORDER THE DiAGNOSIS DIAGNOSISAND ANDCOURSE COURSE BIPOIA R DISORDER

to upside it: peo­ to it: pe order is a very small set of illnesses that maythat order isone oneofof a very small set of illnesses have an havemay an upside ple ple who w h o have have it it are are often often highly highly productive productive and and creative. creative. This This is is because, because, in in episodes of part, when w h e n you're you're not not actively actively cycling cycling in in and and out out of of episodes of the the disorder, disorder, part, your your innate innate mental mental capabilities, capabilities, imagination, imagination, artistic artistic talents, talents, and and personality personality dis­ strengths her book strengths come c o m e to to the the fore. fore. In In her book Touched Touched with with Fire, Fire, Kay Kay Jamison Jamison dis-

cusses the the link link between between manic-depression manic-depression and and artistic artistic creativity. creativity. In In reading reading cusses her work, work, you you will discover that that you you are are not not alone alone in in your your struggles. struggles. Some S o m e of her will discover of the most most influential influential people people in in art, art, literature, literature, business, business, and and politics politics have have had had the the pieces of the disorder disorder and and have have produced produced pieces of work work that that have have had had lasting lasting effects effects on on

our society. OUf society.

3. 3. Try Try to to maintain maintain a a healthy healthy sense sense of of who who you you are are and and think think about about how how your your reflect personality personality strengths strengths can can be he drawn drawn on on in in dealing dealing with with the the illness. illness. As A s you you reflect on on who w h o you you were were before before you you were were diagnosed diagnosed (and (and after after completing completing the the check­ checklist personality list in in the the exercise), exercise), you you will will probably probably recall recall many m a n y of of your your personality

strengths. Perhaps Perhaps you you are are assertive, assertive, sociable, sociable,or orintellectual. intellectual.How H o wcan canyou yoube be strengths. appropriately assertive assertive in in gett getting proper medical medical treatment? treatment? Can C a n you you use use your your appropriately ing proper natural your friends, and neighbors natural sociability sociability to to call call on on your friends, family, family, and neighbors lO to help help you you

through rough rough times? times? Can Can you your natural natural intellectual intellectual inclinations inclinations to through you use use your to read up up on on and and learn learn as as much m u c h as as you can about about your your illness? illness? DOing Doing so so may may read you can generate a a feeling feeling of of continuity continuity between between who w h o you used to to be be and and who w h o you you are are generate you used now. now. 4. The The way way you you fed feel right right now now is is nor notnecessarily necessarilythe theway way you youwillf will feel three 4. ul ininthree months, six six months, months, or oraa year. year.You Youmay m a ybe befeeling feelingbad badabout aboutyour yourdiagnosis diagnosisand and months, unable to to function function at at the level that that you you know k n o w you're you're capable capable of. of. This Thisrough roughpe­ peunable the level riod may m a y make m a k e you you feel feel like like you you have have to to give give up up control control to to your your family, family, your your riod doctors, and, and,worst worstof ofall, all, your illness—a prospect that feels highly distasteful. doctors, your illness-a prospect that feels highly distasteful. But in in all all likelihood, likelihood, with with proper proper treatment, treatment, you you will will return return to to a a state state that that is is But

close to to where where you used to to be, be, or or at at least leastthat thatis ismore moremanageable manageable(see (seeChapter Chapter close you used 6 on on medication medication treatment). treatment). In In the the same same way w a y that that someone someone who w h o has has had had aa bad bad 6 viralflu has to to stay stay in in bed bed for foranother another few few days days after after the theworst worst symptoms symptoms have have flu has viral to cleared, you a y need need a a period period of of convalescence convalescence before before you can get get back back to you m may you can cleared,

your ordinary ordinary routines routines and functioning. your and functioning. 5. There There are are things things you you can can do do in in addition addition to to taking taking medications to control control 5. medications to the cycling cycling o of your mood mood states. states. Coming Coming to to terms terms with with the the diagnosis diagnosis of of bipo­ bipof your the lar disorder disorder also also means means learning learning certain certain strategies strategies for for mood m o o d regulation. regulation. Later lar Later chapters (8-1 (8-11) describe these these in in more more detail. detail. Knowing Knowing the the practical practical selfchapters 1) describe self­ management strategies strategies will keep you you from from feeling feeling victimized victimized by by the the disormanagement will keep disor­ der. der. *

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Illnesor s Is orItIMe? s It Me? IsIsItItonanIllness

Hopefully, thechapters last chapters haveyou given youofa sense of the challenges Hopefully, the last have given a sense the challenges the

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the disorder can c a n bring bring to to your y o u r self-image, a n d how, h o w , when w h e n you're you're challenged challenged in self-image, and in disorder in this way, w a y , it it is is natural natural to to want w a n t to to reinterpret reinterpret the the evenLS events that that have h a v e occurred occurred in this w a y s that that feel feel more m o r e acceptable. acceptable. Your Y o u r reactions reactions to to the the illness illness label label are are shared shared ways by by others others with with the the disorder. disorder.You Y o u may m a y be be able ableto tomake m a k e even even more more sense sense of ofyour your disorder when w h e n you you think think aboUl about the the biological imbalances of of the the brain brain that that credisorder biological imbalances cre­ your ate different different mood m o o d states, states, and and how h o w certain certainstressful stressfulcircumstances circumstancesin in your life life ate dis­ can trigger trigger these these imbalances. imbalances. Becoming Becoming familiar familiar with with the the causes causes of of bipolar can bipolar disorder will will help help assure assure that that you you ask ask for, for, and and get, get, the the right right treatmenLS. treatments. order

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Causes and Treatments C a u s e s a n d T r e a t m e n t s

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Where W h e r e Does D o e s Bipolar B i p o l a r Disorder Disorder C o m e From? F r o m ? Come GENETICS, G E N E T I C S , BIOLOGY, B I O L O G Y , AND A N D STRESS STRESS

Stacy,38, 38,had hadtwo twoyoung youngdaughters daughtersand andworked workedpart partlime timefor foran anaccount� accountStacy, ing firm. firm. She She had had carried carried the the bipolar bipolar II diagnosis diagnosis for for at atleast least I15 years and and S years iog took Depakote Depakote on on a a regular regular basis. basis. Although Although she she agreed agreed that that she'd she'd had had se­ setook vere mood m o o d swings, swings, her her interpretations interpretations of of their their causes causes tended tended toward toward the vere the psychological rather rather than than the the biological. biological. She She often often doubted doubted that that she she had had psychological bipolar disorder: disorder: She She was was scientifically scientifically trained trained and and fell felt that that the the absence bipolar absence of of a definitive definitive biological biological test test meant meant that that the the diagnosis diagnosis should should remain remain in a in doubt. Her psychiatrist frequently frequently reminded reminded her her of of her her family family history: history: Her Her doubt. Her psychiatrist uncle had had been been diagnosed diagnosed with with bipolar bipolar illness illness and and alcoholism. alcoholism, and and her uncle her mother suffered suffered from from major major periods periods of of depression. depression. Bm But she she remained remained unmother un­ convinced and and continued continued to to wonder wonder whether whether she she really really needed needed medica­ medicaconvinced tion. tion. After After all, all, she she had had been been feeling feeling fine fine for for more more than than a a year. year. She She toyed toyed with the the idea idea of of discontinuing discontinuing her her Depakote Depakote but but was was talked talked out of it, time with out of it, time and time again, by her psychiatrist. and time again, by her psychiatrist. Over the the course course of ofaayear, year,Stacy Stacywenl went through through aaseries seriesof oflife lifechanges, changes, Over including divorcing divorcing her her husband. husband. Other Other than than some s o m e mild mild depression, depression, she she including m a d e it it through through the the initial initial marital marital separation separation reasonably reasonably well. It wasn't wasn't made well. 1t until she she and and her her children children had had to to undergo undergo a a child child custody custody evaluation evaluation that until that she began began to to show s h o w symptoms symptoms of of mania. mania. As A s the the evaluation evaluation proceeded, proceeded, she she she found that calls from her lawyer m a d e her spring into action: She would that calls from her lawyer made her spring into action: She would found rush off off to to the the library library and and copy copy every every legal legal precedent precedent that that was was even even rerush re73

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CAUSESAND ANDTREATMENTS TREATMENTS CAUSES

mOlely pertinent her case, call call friends motely pertinent to to her case, friends the country ask them all all overover the country to asktothem to to speak speak to to lawyers lawyers they they knew, knew, and and fax fax numerous numerous documents documents to to her her law­ lawyer's and and doclor's doctor's offices. offices. She She often often called called her her estranged estranged husband husband and and yer's screamed screamed threats threats into into the the phone. phone. Her Her lawyer lawyer assured assured her her that that the the divorce divorce and and custody custody agreement agreement would would be be comfortable comfortable for for her her and and her her children, children, but his his assurances assurances did did liale little to to SlOp stop her her from from working working harder harder and and harder harder but and less. and sleeping sleeping less less and and less. When W h e n her her psychiatrist psychiatrist suggested suggested to to her her that that she she was was getting getting manic, manic, she shrugged shrugged and and said said ""probably," adding that that she she needed needed to to spend spend every every she probably, " adding minute preparing preparing for for her her upcoming upcoming court court dale. date. As A s her her mania mania escalated, escalated, minute her her doctor doctor convinced convinced her her to to ny try an an increased increased dosage dosage of of Depakote Depakote and and to to add add a a major major tranquilizer tranquilizer (Zyprexa) (Zyprexa).. She She reluctantly reluctantly agreed agreed to to these these modi­ modifications fications but but still still maintained maintained that that her her problems problems were were stress-related. stress-related. The The divorce divorce and and custody custody arrangement arrangement were were eventually eventually settled settled out out of of court court (and (and in in Stacy's Stacy's favor) favor).. Perhaps Perhaps due due to to the the additional additional medication medication and and the the removal removal of of this this life life stressor, stressor,her hermania maniagradually graduallyremitted remittedand anda amajor major crisis was was averted. averted. crisis questions plague virtually everyone diagnosed with bipolar Two Two majormajor questions plague virtually everyone diagnosed with bipolar disorder: disorder: "How " H o w did did II get getthis?" this?"and and "What "What triggers triggersan an episode episode of ofmania mania or orde­ de-

pression?" As As you you read read this this chapter, chapter, you'll you'll make m a k e distinctions distinctions between between factors pression?" factors that cause onset of of the disorder and that affect affect the course of of the that cause the the onset the disorder and factors factors that the course the disorder once once it it is ismanifest. manifest.These Thesefactors factorsare arenot notnecessarily necessarilythe thesame. same.Alter­ Alterdisorder natively, the same factors m a y carry carry different different weight the onset than in natively, the same factors may weight in in the onset than in the the

course of of the the disorder. disorder. Specifically, theinitial initialcause cause of ofthe thedisorder disorderis isstrongly strongly Specifically, the course

influenced by (having a a family family history history of of bipolar disorder or or at at influenced by genetic genetic factors factors (having bipolar disorder least depreSSive depressive illness). illness). In contrast, n e w episodes episodes that that develop develop after the first least In contrast, new after the first one appear to heavily influenced influenced by by environmental environmental stress, stress, sleep sleepdisruption, disruption, to be be heavily one appear other alcohol and substance abuse, noncompliance with drug treatments, and and substance abuse, noncompliance with drug treatmenlS, and other alcohol genetic, biological, or environmental environmental factors. genetic, biological, or factors. If you have havehad had the thedisorder disorderfor forquite quitesome sometime, time,you youmay m a ybe beaware awarethat thatyour your If you m o o d swings basis. You You may m a y also alsobe beaware aware that thatbipo­ biposwings have have a a strong strong biochemical biochemical basis. mood lar disorder runs runs in in families. famihes.You Youmay m a y know k n o wseveral severalother otherpeople peoplein inyour yourfamily family lar disorder disorder tree w h o have have had had it itor orversions versionsof ofit. it.IfIf you learning about bipolar disorder you areare learning about bipolar tree who

for you may m a y not not have have been been told told that that the the cycling cycling of of the the disorder disorderis is first time, time, you for the the first and influenced influenced by by disturbances disturbances in in the the activity activity of of receptors receptors on on your your nerve nerve cells cells and and the the production production or or breakdown breakdown of of certain certain neurotransmitters, neurotransmitters, hormones, hormones, and

other Medications are aredesigned designed to tocorrect correct these theseimbal­ imbalother chemicals chemicals in in your your brain. brain. Medications ances. Ineither eithercase, case,ititisis useful k n oabout w about the genetic and biological origins useful toto know the genetic and biological origins ances. In of disorder,because becausethis thisknowledge knowledgewill wiHhelp helpyou youaccept acceptthe theillness illnessand andedu­ eduof the the disorder, cate you about about what what you you are are going going through through (see (seealso alsoChapter Chapter12). 12). cate others others close close to to you Also, Also, knowing knOWing about about the the biological biological bases bases of of your your disorder disorder wiH will probably probably make make taking medications feel more reasonable to you. taking medications feel more reasonable to you.

Where Does DoesBipolar BipolarDisorder Disorder Come From? Where (orne From?

7575

But genetics and biology aregoing not going to be the story. whole As story. As Stacy's But genetics and biology are not to be the whole Stacy's

case reflects, reflects, a a major major life Hfe stressor, stressor, such such as as going going through through a a divorce, divorce, can can serve serve case as as a a catalyst catalyst for for the the cycling cycling of of mood m o o d states. states. Everybody E v e r y b o d y gets gets mad, m a d , sad, sad, or or happy, happy,

depending on o n the the nature nature of of the the things things that that happen h a p p e n to to them. them. People People with depending with bipobipo­ lar disorder, disorder, because because of of the the nature nature of of their their biology, biology, can can develop develop extreme extreme lar moodiness m o o d i n e s s in in reaction reaction to to events events in in their their environment. environment. We W e don't don't know k n o w whether whether

stress causes causes people people to to have have bipolar disorder in in the thefirst place, but fairly stress bipolar disorder first place, but we're we're fairly certain that that it it makes m a k e s the the course course of of the the illness illness worse w o r s e in in people people wwho h o already already certain have it. have it.

Vulnerability Vulnerability and a n d Stress Stress needn't think bipolar disorder �only brain disease"oror"only "only psy­ We think ofofbipolar disorder asas"only a abrain disease" a apsyWeneedn't chological be both influences the chological problem." problem." It It can can be both of of these these things, things, and a n d each each influences the

other. Most M o s t professionals think of of the the cycling cycling of of bipolar disorder—and, for other. profeSSionals think bipolar disorder-and, for that matter, matter, the the waxing w a x i n g and and w a n i n g of of most m o s t illnesses-as illnesses—as reflecting reflecting a a complex complex that waning interplay between interplay b e t w e e n biological biological agents agents (for (for example, example, reductions reductions in in the the activity activity of of dopamine your brain), psychological d o p a m i n e in in y o u r brain), psychological agents agents (for (for example, example, your your expectations expectations about whether pos­ about things), things), and a n d stress stress agents agents (things (things that that bring bring about about changes, changes, whether pos-

itive or or negative, negative, such such as as transitions transitions in in your job or or living living situation, situation, financial financial itive your job problems, family family conflicts, conflicts, or or a a new n e w romantic romantic relationship). relationship). Think T h i n k of of it problems, it this this way: Y o u have have underlying underlying biochemical biochemical disturbances disturbances ("vulnerabilities") ("vulnerabilities") with with way: You w h i c h you y o u may m a y have have b e e n born. born. These These disturbances disturbances can can include include your which been your brain's brain's over- or or underproduction underproduction of of neurotransmitters neurotransmitters (such (such as as norepinephrine, norepinephrine, overdopamine, d o p a m i n e , or or serotonin) serotonin) and a n d abnormality abnormality in in the the structure structure or or function function of of

your nerve nerve cell cell receptors. receptors. Much M u c h of of the the time time these these disturbances disturbances are are "dormant" "dormant" your and still and have have little little effect effect on o n your your day-to-day day-to-day functioning, functioning, though though they they still

m a k e yyou o u more m o r e susceptible susceptible to to experiencing experiencing bipolar episodes. W h e n stressors stressors make bipolar episodes. When reach a a certain certain level, level, these these biological vulnerabilities or or predispositions predispositions get exreach biological vulnerabilities get ex­ pressed as as the the symptoms s y m p t o m s you're you're already already familiar familiar with—irritable o o d , racing racing pressed with-irritable m mood, thoughts, thoughts, paralyzing paralyzing sadness, sadness, and/or and/or sleep sleep disturbance. disturbance. In In other other wwords, o r d s , your your

biological predispositions predispositions affect affect your your psychological psychological and a n d emotional emotional reactions reactions biological to stress stress (and (and in in all all likelihood, likelihood, vice vice versa). versa). Likewise, Likewise, when w h e n the the stress to stress agent agent is is r e m o v e d , your y o u r biochemical imbalances may may b e c o m e dormant d o r m a n t again again (as (as hapremoved, biochemical imbalances become hap­ pened p e n e d for for Stacy). Stacy).

S o m e psychiatriSts psychiatrists and a n d psychologists psychologists use use a a vulnerability-stress vulnerability-stress model model Some

(Zubin & & Spring, Spring, 1977) 1 9 7 7 ) to to explain explain a a person's person's bipolar s y m p t o m s . Look L o o k at at the the bipolar symptoms. (Zubin

graph on o n page page 76. 76. If If y o u are are born b o r n with a great great deal deal of of genetiC genetic vulnerability­ vulnerability— you with a graph for example, e x a m p l e , the the disorder disorder is is present present across across multiple multiple past past generations generations of of your your for f a m i l y — a relatively relatively minor m i n o r stressor stressor (for (for example, example, a a change change in family-a in your your job job shift shift hours) may b e enough e n o u g h to to elicit elicit your your bipolar s y m p t o m s . If If you y o u have less gehours) may be bipolar symptoms. have less ge-

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CAUSES AND ANDTREATMENTS TREATMENTS CAUSES

Maximum ,--Maximum

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Threshold-...ThresholdWellness WeI/ness

Minimum Minimum

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Vulnerability Vulnerability A wellness. A vulnerability-suess vulnerability-stress model for for understanding understanding periods periods of of illness illness and and wellness. Copyrigh.t ical Association. Association. Adapted Copyright by by the the American American Psycholog Psychological Adaptedby bypennission permissionfrom from Zubin Zubin and and Spring Spring (1977). (1977).

netic vulnerability vulnerability (for (for example, example, only only one o n e extended extended relative, relative, like likean a nuncle, uncle,had had netic bipolar disorder, disorder, or or a a few few relatives relatives had h a d depression, depression, but but no n o one o n e was w a s bipolar), bipolar), it it bipolar m a y take take a a relatively relatively severe severe stressor stressor (for (for example, example, the death of of a a parent) parent) to may the death to evoke your your bipolar bipolar symptoms. symptoms. evoke In this this chapter, chapter, you'll you'll see see examples examples of of what w h a t is is meant m e a n t by b y genetic genetic and a n dbio­ bioIn logical vulnerability vulnerability and and a a way w a y to to determine determine whether whether your your family family tree tree puts puts you logical you at greater greater or or lesser lesser risk. risk. You'll You'll also also see see examples examples of of the the kinds kinds of stressors that at of stressors that have been been shown s h o w n in in research research studies studies to to b important in triggering mood m o o d cyhave bee important in triggering cy­ cling. Recognizing Recognizing that you m a y be be biologically biologically and a n d genetically genetically vulnerable vulnerable and cling. that you may and that certain factors factors are are stressful stressful for for y o u is the first first step step in in learning learning skills skills for for you is [he that certain m a n a g i n g your disorder. B y the chapter's end, y o u should have a general idea managing your disorder. By [he chapler's end, you should have a general idea and of h o w geneticS genetics and a n d biology biology answer answer the the question question "How " H o w did did 1I get get this?" this?" and of how h o w these these factors factors combine c o m b i n e with with stress stress to to bring bring about about new n e w episodes episodes (recur­ (recurhow rences) of your your bipolar bipolar disorder. disorder. Later Later chapters provide practical practical suggestions suggestions rences) of chapters provide for minimizing minimizing the the impact impact of of stressful stressful events events or or circumstances. circumstances. for

''How Did Did II Get G e t This?": This?": The T h e Role Role of of Genetics Genetics "How W e have have known k n o w n for for many m a n y years years that that psychiatric psychiatric disorders disorders are are genetically genetically heri­ heriWe table table and a n d run r u n in in families. famihes. In the 1960s 1960s and a n d 1970s, 1970s, studies studies of of schizophrenic schizophrenic pa­ paIn the tients who w h o had h a d been adopted away a w a y from from their their natural natural parents parents showed s h o w e d that tients been adopted that

Where From? Where Does DoesBipolar BipolarDisorder Disorde(orne r Come From?

7777

schizophrenia occurred higher than average rates thebiological biologicalrelatives relatives schizophrenia occurred atathigher than average rates ininthe of of the the patients, patients, even even when w h e n these these relatives relatives had h a d played played no n o role role in in raising raising the the patients patients (Heston, (Heston, 1966; 1966; Kety, Kety, 1983; 1983; Rosenthal, Rosenthal, 1970). 1970). ldemical Identical twin twin studies studies have also also supported supported the the idea idea that that genes genes can can predispose predispose aa person person lO to develop­ develophave ing ing schizophrenia, schizophrenia, probably probably in in combination combination with with environmental environmental triggers triggers (Gottesman, (re­ (Gottesman, 1991). 1 9 9 1 ) . Genetic Genetic studies studies of of persons persons with with bipolar bipolar disorder disorder (reviewed in in the the next next section) section) have have led led lO to similar similar conclusions conclusions (Gershon, (Gershon, 1990). 1990). viewed As initial A s we w e discussed discussed in in Chapter Chapter 3, 3, family family history history is is often often aa part part of of the the initial diagnostic diagnostic evaluation. evaluation. Stacy, Stacy, as as it it turned turned out, out, had had a a mother m o t h e r and a n d an a n uncle uncle who who s h o w e d signs signs of of mood m o o d disorder, disorder, although although it it was w a s only only her her uncle uncle who w h o had h a d bipo­ biposhowed lar lar disorder. disorder. It It is is not not unusual unusual for for bipolar bipolar disorder disorder to to "co-segregate" "co-segregate" or or be b e asso­ associated ciated in in family family trees trees with with other other kinds kinds of of mood m o o d disorders, disorders, particularly particularly various various forms of of depression depression (Gershon, (Gershon, 1990, 1 9 9 0 , Nurnberger Nurnberger &. & Gershon, G e r s h o n , 1992) 1 9 9 2 ) .. fonos How H o w do d o we w e know k n o w that that bipolar bipolar disorder disorder runs runs in in families? families? Geneticists Geneticists usu­ usually studies, ally establish establish that that an a n illness illness is is heritable heritable through through family family studies, studies, twin twin studies, and and adoption adoption studies. studies. II discuss discuss each each of of these these briefly briefly and a n d offer offer additional additional sources for for reading reading more m o r e about about these these topics. topics. sources Family^ Twin, ond and Adoption Adoption Studies Fomily, Twin, Studi.s Family people whowho havehave an illness and and then then find find out out Familyhistory historystudies studiesexamine examine people an illness w h o in in their their family family ··pedigree'· "pedigree" or or family family tree tree also also has has the the disorder disorder or or some some who form of of it it (recall (recall from f r o m earlier earlier chapters chapters that that bipolar bipolar disorder disorder can quite fonn can look look quite variable). We W e know k n o w that w h e n one o n e person person has has the the disorder, disorder, often often a a brother, brother, variable). that when sister, sister, parent, parent,or or aunt aunt or or uncle uncle will willalso alsohave have it. it.We W e also alsoknow k n o w that thatsome s o m erela­ relatives of of bipolar bipolar people people will will have have other m o o d disorders, disorders, such such as as major deprestives other mood major depres­ sive sive disorder disorder or or dysthymic dysthymic disorder disorder (long-term, (long-term, mild mild depression). depression). TThey h e y may may also be be affected affected by b y alcoholism, alcoholism, drug drug abuse, abuse, panic panic or or other other anxiety anxiety symplOms, symptoms, also or or an a n eating eating disorder disorder (for (for example, example, obeSity obesity with with binge binge eating), eating), wwhich, h i c h , while while not not mood m o o d disorders disorders themselves, themselves, are are problems problems that that co-occur with a n d some­ someco-occur with and times times mask m a s k underlying underlying depresSive depressive or or manic m a n i c symptoms. s y m p t o m s . The T h e figure pictures figure pictures Stacy's family family pedigree. pedigree. The T h e circles circles represent represent women, w o m e n , and a n d the the squares squares repreStacy's repre­ sent men. sent m e n . Notice Notice that that s o m e of of her relatives had h a d mmood o o d disorders disorders and and s o m e did did some her relatives some not. not. T h e rate rate of of m o o d disorder disorder (major (major depression, depression, dysthymia, dysthymia, or or bipolar The mood bipolar disordisor­ der) der) among a m o n g first-degree first-degree relatives relatives (siblings, (siblings, parents, parents, and a n d children) children) of bipolar of bipolar persons averages averages about 2 0 % . T h a t is, o n e of every five first-degree relatives of persons about 20%. That is, one of every five first-degree relatives of a bipolar bipolar person person has has a a mood m o o d disorder. disorder. On O n average, average, about about 8% 8 % of of a person's firsta a person's first­ degree relatives have bipolar disorder, and a n d about about 12% 1 2 % have have major depressive degree relatives have bipolar disorder, major depressive episodes without a n i a or or h y p o m a n i a . TThese h e s e nnumbers u m b e r s are Some without mmania hypomania. are averages: averages: Some episodes people have have mmany more relatives wwho people any m o r e relatives h o have have mmood o o d disorders disorders aand n d ssome o m e have have

78 78

CAUSES AND AND TREATMENTS TREATMENTS CAUSES

,,,64 (major depres&lor1)

.,, age 66 66

Brolher. Brother, oge age 41 41

Uncle, age 65 (bipolar disorder, alcohol dependence)

Mother,

Father, Fatlier,

Uncle, Uncle, age age 71 71

s...", '" 3B (bipolat Ihorder)

Sister,

.ge 34

Stacy's family family pedigree. Stacy's pedigree.

fewer. Also, Also, these these numbers numbers are are "age-corrected," "age-corrected," meaning meaning that that older older firstfewer. first­ degree relatives, relatives,because becausethey theyhave havehad had more more time timeto todevelop developaamood m o o d disorder, disorder, degree weight in rela­ are given given more more weight in the the calculations calculations than than are are younger younger first-degree first-degree relaare would like slUdies, tives. If If you you would like to to read read funher further about about these these family family history history studies, tives. check check out out two two excellent excellent chapters chapters authored authored or or coauthored coauthored by by Eliot Eliot Gershon Gershon

(1990; Nurnberger Nurnberger & & Gershon, Gershon, 1992). 1992). (1990;

Another way w a y (0 to establish establish heritability heritability is is to to ask ask [his this question: question: When W h e n one one Another identical twin twin has has the disorder, what what is is the probability (percentage) (percentage) that that the identical the disorder, the probability the other idemicai identical lwin twin has has it it also? also? Identical Identical twins, twins, as as you you probably probably know, know, share share other 1 0 0 % of of their their genes. genes. Fraternal Fraternal twins twins (from (from two two different different eggs) eggs) share share only only 50% 50% 100% of their their genes, genes, just justlike likebrothers brothersand and sisters. sisters.IfIfwe w ethink thinkaadisorder disorderisisheritable, heritable, of w e would would expect expect that that the the identical twin pairs pairs will will have have higher higher "concordance" we identical twin "concordance" or agreement agreement rates-when rates—^when one one twin twin is is bipolar, bipolar, the theother othershould should be bealso---than also—than or fraternal twin twin pairs. fraternal pairs. O n e review review of of the the genetic genetic literature found that that concordance rates for for bi­ biOne literature found concordance rates polar disorder disorder among a m o n g identical identical twins averaged 5 7 % and and between between fraternal 57% fraternal polar twins averaged twins, 4 % (Aida, (Alda, 1997). 1997). Stated Stated another another way, w h e n one one identical identical twin twin has has bi­ bitwins, 1 14% way, when polar disorder, disorder, there thereis ismOfe more than thanaaone-in-two one-in-twochance chance that thatthe theother otheridentical identical polar a twin does does also. also. When When a a fraternal fraternal twin twin has has bipolar bipolar disorder, disorder, there there is is about about a twin dis­ one-in-seven chance chance that that his or her her twin twin has has it it. This This suggests suggests that that bipolar bipolar disone-in-seven his or

order has has a a strong strong genetic genetic component. component. If If the the illness Ulness were entirely genetic, genetic, the the order were entirely identical twin twin rate rate would would be be 100%. 100%. Because Because it it is is only only 57%, 5 7 % , we w e know k n o w there there idemical must be be nongenetic, nongenetic, environmental environmental causes causes as as well, well, and and these these are are discussed discussed must later in the the chapter chapter (DeRubeis (DeRubeis et et ai., al., 1998). 1998). later in Twin studies studies have have been been criticized criticized because because identical twins tend tend to to be be Twin identical twins treated as as more alike by by their their parents parents than do fraternal fraternal twins. twins. If If environmental environmental treated more alike than do

Where Does DoesBipolar BipolarDisorder DisorderCome Come From? Where From?

7979

factors do identical and and fraterfrater­ factors do play play aa role, role,Lhen then the thedifferences differencesfound found between between identical envi­ nal twins twins cannot cannot necessarily necessarily be b e attributed attributed 10 to genetics. genetics. To T o eliminate ehminate the the envinal ronmental been ronmental factor, factor, researchers researchers look look for for identical identical twins twins who w h o have have b e e n raised raised separately. Few F e w studies studies have have been b e e n done d o n e on o n this this topic topic because because they are very very separately. they are hard binh in in hard to to do. do. Two T w o such such studies studies found found that that identical identical twins twins raised raised from f r o m birth two t w o different different households households had h a d concordance concordance rates rates for for major major mood m o o d disorders disorders

that that were w e r e similar similar 10 to the the rates rates for for identical identical twins twins raised raised in in the the same s a m e household household (McGuffin &: & Katz, Katz, 1989; 1989; Price, Price, 1968). 1968). (McGuffin Finally, geneticists can find families Finally, geneticists can find out out if if bipolar bipolar disorder disorder runs runs in in families through adoption adoption studies. studies. Adoption Adoption studies studies are are another another way w a y to to begin 10 sepasepa­ through begin to or rate "nature "nature from from nurture" nurture" by by examining examining whether whether the the biological biological parents parents or rate Siblings siblings of of bipolar bipolar adoptees adoptees are are themselves themselves ill, ill,even evenififthey theynever nevershared sharedan anen­ environment researchers, Mendlewicz vironment with with the the bipolar bipolar adoptee. adoptee. Two T w o researchers, Mendlewicz and and Rainer Rainer (1977), who had been (1977), examined examined the the biological biological relatives relatives of of bipolar bipolar people people w h o had been adopted. (bipo­ adopted. These These biological biological relatives relatives had had the the same same rate rate of of mood m o o d disorder disorder (bipolar or or major major depressive depressive illness) illness) as as the the biological biological relatives relatives of of bipolar bipolar persons persons lar of these who w h o had had not not been been adopted adopted (about (about 26%). 2 6 % ) . The T h e adoptive adoptive parenlS parents of these bipolar bipolar persons persons did did not not show show a a higher higher than than average average rate rate of of mood m o o d disorder. disorder. Once Once again, again, ititseems seems that thatbipolar bipolardisorder disorderruns runsin infamilies, families,even evenwhen w h e nscientislS scientistsare are able able 10 to rule rule out, out, or or at at least limit, the the influences influences of of the the person's person's upbringing. least limit, upbringing.

WhatExactly Exactly Is Is Inhe,ited? What Inherited? Weknow know inheriting bipolar disorder as simple as inheriting We thatthat inheriting bipolar disorder can'tcan't be asbe simple as inheriting b r o w n hair hair or or blue blue eyes. eyes. Too T o o many m a n y people people with with bipolar bipolar disorder disorder have have no no brown m o o d disorder disorder in in their their families, families, or or the the last last time time it it occurred occurred in in the family w as mood the family was several generations generations ago. ago. This This means m e a n s that that the the way w a y the the disorder disorder is is inherited several inherited has has to to be b e more m o r e complicated. complicated. It It may m a y be b e that that the the tendency tendency to to become b e c o m e "emotionally "emotionally dysregulated"—extremely moody-runs m o o d y — r u n s in in families. families. It It may m a y be b e that people indysregulated"-extremely that people in­ herit herit a a mild mild form f o r m of of bipolar bipolar disorder disorder (for (for example, example, bipolar bipolar II II disorder) disorder) or or perper­ haps haps just just a a moody m o o d y temperament, t e m p e r a m e n t , but but develop develop the the full full bipolar bipolar condition condition only only if if other predisposing predisposing conditions conditions occur. occur. Some S o m e of of these these conditions conditions may m a y include include other inheriting genes genes for for bipolar bipolar disorder disorder from f r o m both both sides sides of of the the family, family, being being "in "in inheriting utero" when w h e n the the mother m o t h e r contracted contracted a a virus, virus, undergOing undergoing a a difficult, difficult, compli­ compliutero" cated birth, birth, taking taking street street drugs drugs when w h e n growing growing u p , sustaining sustaining a a head head injury, cated up, injury, or or some s o m e traumatic traumatic environmental environmental circumstance. circumstance. T h e hypotheSiS hypothesis that that a a person's person's genetiC genetic inheritance inheritance interacts interacts with with specific specific The environmental conditions conditions to to produce p r o d u c e bipolar bipolar disorder disorder is is just just that, that,aa hypothe­ hypotheenvironmental sis. To T o test test this this hypotheSiS hypothesis in in a a research research study, study, we w e would w o u l d have have to to determine determine sis. whether children children born b o r n wiLh with a a genetic genetic history history of of bipolar bipolar disorder disorder and a n d affected affected whether b y these these predispOSing predisposing environmental environmental conditions conditions are are more m o r e likely likely to to develop develop hibiby

CAUSES CAUSESAND ANDIREAIMENIS TREATMENTS

80 80

polar disorder disorderinin adulthood than children a similar genetic who polar adulthood than children withwith a similar genetic historyhistory who have have not not been been affected affected by by these these environmental environmental conditions. conditions. These These long-term long-term

studies, which which would would take takemany m a n y years yearsto tocomplete complete and and are areextremely extremely difficult difficult studies, to execute, execute, have have not been done. done. to not been Current Current advances advances in in modern modern genetics genetics now n o w allow allow researchers researchers to to examine examine regions locale genes disorder. regions of of the the chromosomes chromosomes in in an an attempt attempt to to locate genes for for bipolar bipolar disorder. To T o date, date, no no Single singlegene gene of oflarge largeeffect effecthas has been been found, found,leading leading researchers researchersto to suspect many with quite the suspect that that m a n y genes---each genes—each with quite small small effect-contribute effect—contribute lO to the genetic re· genetic vulnerability vulnerability to to bipolar bipolar disorder. disorder. Several Several investigations investigations have have re-

ported a a vulnerability vulnerability gene gene on on chromosome chromosome 18 18 (for (for example, example, the the research research of of ported MacKinnon MacKinnon and and associates, associates, 1998), 1998), but but pinpointing pinpointing the the exact exact gene gene has has been been elusive. elusive. At At this thisstage, stage,there thereis isaalot lotwe w e don't don'tknow k n o w about abouthow h o w bipolar bipolardisorder disorder

is inherited, inherited,but butscientists scientistsare areworking workingvery veryhard hardtotosolve solvethe thepuzzle. puzzle.Once Oncethe the is genes genes are are located, located, more more accurate accuratediagnoses diagnoses and and better bettertreatments treatmentsare arelikely likelyto to follow. follow.

" D o II Have Have a a Genetic Genetic Vulnerability?": Vulnerability?": Examining Examining Your Your Own O w n Pedigree Pedigree "Do Before we thethe issue of what the genetic data might formean yourfor ownyour own Before we gel getinto into issue of what the genetic datamean might

life, let's let'stake takeaalook lookat atwhether whetherbipolar bipolardisorder disorderruns runsin inyour yourfamily. family.Are Areyou you life, genetically predisposed predisposed to to the disorder? In In part part II of this exercise, exercise, fiH of this fill out out the the genetically the disorder? table on on page page 81 81 to to the best of your knowledge. knowledge. Confine Confine yourself yourself to your own own table the best of your to your children, your your Siblings siblings(note (notein inthe thetable tableif ifthe theperson personisisa a full sibling half children, full sibling oror aa half sibling), your parents, parents, grandparents, grandparents, aunts, aunts, and and uncles. uncles. Leave out cousins, Sibling) , your Leave out cousins, to nephews and and nieces nieces (the (the information information people have on on these these relatives relatives tends tends to nephews people have

be unreliable). unreliable). Consult Consult your your relatives relatives if if you you want want more more information. information. II have have be filled the first four lines from Stacy's family examples. fill ed inin the first four lines from Stacy's family asas examples. Next, place a a star star nexL next LO to anyone anyone you think may m a y have have had had (or (or still stiU has) has):: Next, place you think bipolar 1. FuH bipolar I or bipolar oreven evena a mflder form bipolar 1. Full bipolar I or bipolarII II disorder, disorder, or milder form of of

disorder, such such as as cyclothymia cyclothymia (mild (mild and and short short depressed depressed periods periods that that disorder, alternate with with short short hypomanic hypomanic periods) periods) alternate 2. Major Major depressive depressive episodes episodes or or long-term periods of of milder milder depression depression 2. long+term periods (dysthymia) (dysthymia) 3. Any A n y other other psychiatric psychiatric problem problem that that is is not not a a mood m o o d disorder disorder but but that 3. that prob+ m a y be be masking masking changes changes in in mood m o o d (for (for example, example, drinking drinking or or drug drug probmay

lems, panic panic aLtacks, attacks, or or eating eating disorders) disorders) lerns, Answers to followingquestions questionswill will give clues asyour to your relative's Answers to the the following give youyou clues as to relative's health or illness: health or illness:

Where From? Where Does Does Bipolar Bipolar Disorder Disorder (orne Come From?

81 81

COLLECTING COLLECTING INFORMATION INFORMATION TO TO DRAW D R A W YOUR YOUR PEDIGREE PEDIGREE Name N a m e of of relative reljitive

Relationshi p to Oll Relationship toy you Father Father

3. Mark Mark 3. 4. Valerie Valerie 4.

H o w did did be/she he/she die? How die? Heart attack attack Heart

Brother Brother

66 66 64 64 41 1 4

Sister Sister

344 3

(Still alive) alive) (Still

Mother Mother

(Still alive) alive)* (Still *

(Still alive) alive) (Still

_ _ _

fi 6. 7. 7 8 8. Q 9. in 10.

(or at at (or death) death)

1. Roben Robert 1. 2. Isabelle Isabelle 2.

5.

A ge now Age now

_ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _

•

How H o w did did the the relative relative die die (if (if deceased)? deceased)? Was W a s it it an a n accident, accident, suicide, suicide, or oran an

•

Was time, or he or W a s the the person person ever ever unable unable to to work w o r k for for a a period period of of time, or did did h e or

illness? illness? she she constantly constantly switch switch jobs? jobs? •

D i d he h e or or she she jump j u m p from f r o m one o n emarriage marriage or or relationship relationship to to another? another? Did

•

A r e there there family family stories stories about about the the person person being being drunk, d r u n k , hurting hurting himh i m - or Are or herself or or others, others, or or having having a a "nervous "nervous breakdown"? breakdown"? herself

•

A r e there there stories stories about about how h o w this this relative relative was wasa a recluse, recluse, shutting shutting h i m - or Are himor herself away a w a y in in a a room r o o m for for days days at at a a time? time? herself

•

D i d he h e or or she she ever ever take take medication? medication? What W h a t kind? kind? Did

•

W a s the the relative relative ever ever in in a a psychiatric psychiatric hospital? hospital? Was

N o w assemble assemble your y o u r information information into into the the pedigree. pedigree. Again. Again, circles circles refer refer to Now to female relatives relatives and a n d squares squares to to males. males. Fill Fill in in the the circle circle or or square square of of any a n y relative relative female y o u think think may m a y have h a v e had h a d bipolar bipolar disorder. disorder. Fill FiU in in only only half half of circle or you of the the circle or

square if if the the person person had h a d major m a j o r depression, depression, dysthymia, dysthymia, cyclothymia, cyclothymia, or or any a n y of square of the other other problems p r o b l e m s mentioned m e n t i o n e d that that can c a n mask mask a a mood m o o d disorder disorder (for (for example, example, the alcoholism, drug d r u g abuse, abuse, eating eating disorders). disorders). Put P u t an a n "s" " S " above above anyone a n y o n e who w h o com­ comalcoholism,

mitted suicide. suicide. Put Put a a question question mark m a r k in in the the circles circles or or squares squares of of any a n y relatives relatives mitted you're you're not not sure sure about. about.

N e x t , examine e x a m i n e the the pedigree pedigree (paying (paying particular particular attention attention to to the the solid soHd a nd Next, and half-solid circles circles or or squares) squares) and a n d ask ask yourself yourself the the following foUowing questions: questions: How How half-solid m a n y of of your y o u r relatives relatives have h a v e bipolar bipolar disorder? disorder? If If none, n o n e , are are there there m e m b e r s in many members in had your your family family tree tree who w h o are/were are/were depressed, depressed, alcoholic, alcoholic, drug-addicted drug-addicted or or have have h ad

CAUSES CAUSES AND AND TREATMENTS TREATMENTS

82 82

( Aunt J

Uncle

^ ( Sister )

Grandfather

Grandmother Grandmother

Grandlather Grandfather

A ^ . f Aunt J

Brother

Dad D,d

Sister

IWom )

Uncle

Brother

M E -,- Spouse ME

Daughter!

Son

(Daughter)

Grandmolhef

Aunt )

Uncle

Son

Locating relatives with with mood m o o d disorders disorders in in your your family family pedigree. locating relatives pedigree.

an eating eating disorder? disorder? If If so, so, consider consider whether whether the the alcoholism, alcoholism, eating eating problem, problem, or or an panic symptoms symptoms may m a y have have hidden hidden an an underlying underlying depressed depressed or or bipolar bipolar condipanic condi­ tion. For For example, example, if if the the person person had had bursts bursts of of rage rage even even w h e n not not drunk, drunk, and and tion. when became withdrawn withdrawn for for periods periods of of lime time even even when w h e n "on "on the the wagon," wagon," he he or or she she became m a y have have had had an an underlying underlying mood m o o d disorder disorder as as well well as as alcoholism. alcoholism. may Disorders like alcoholism or or drug drug abuse abuse lend tend lO to affect affect males males more more than than fe­ feDisorders like alcoholism males, whereas whereas major major depressive depressive episodes episodes afrecl affectmore more females females than than males males (for (for males, example, Kessler Kessler et et al., al., 1994). 1994). Does Does this this pattern pattern help you determine determine whether whether example, help you the male male versus versus the the female female relatives relatives in in your your family family tree had psychiatric psychiatric condithe tree had condi­ tions? Did any any relative relative spend in a a psychiatric psychiatric hospital hospital or or take take psychiatric psychiatric tions? Did spend time time in medications for for a a long long period period of of time? Did anyone anyone commit commit suicide? suicide? Although Although medications time? Did w e cannot n o w for for sure, sure, there there is is a a possibility possibility that that a a suicidal suicidal relative relative had had a we cannot k know a m o o d disorder disorder and/or and/or an an alcohol alcohol or or substance substance dependence dependence disorder. disorder. mood a If you you have have children, children, you you may m a y know k n o w whether whether one one or or more more of of them them has has a H psychiatric disorder disorder and and can can fill fill in in those those circles circles or or squares. squares. Of Of course, course, your your psychiatric children may m a y not not yet yet have reached an an age age when w h e n the disorder is is recognized­ recognized— children have reached the disorder bipolar disorder can be be diagnosed diagnosed at at any any age, age, but most frequently frequently starts starts be­ bebipolar disorder can but most tween ages ages J15 and 19. 19. Be Be sure sure to to fill fillin inany any psychiatric psychiatricinformation information relevant relevantto to tween 5 and your children's mother mother (if (if you you are are their their father) father) or or father (if you you are are their your children's father (if their mother), and and draw draw in "tree branches" branches" to to any any affected affected or or unaffected unaffected relatives relatives in in mOlher), in "tree his or or her her family family of of origin. origin. As As you know, i is possible possible that your children children inhis you know, itt is that your in­ herited mood m o o d disorders disorders from the other other parent's parent's side side of of the the family, family, or or from from herited from the both family. both sides sides of of the the family.

Where Does Does Bipolor Bipolar Disorder Disorder (orne Come From? From? Where

883 3

"What Does the the Genetic Mean lorfor Me?" "What Does GeneticEvidence Evidence Mean Me?'' P,actical lmplications of Genetics Practical Implications of Genetics

to It not yetyet possible to assign a number to a person's geneticgenetic vulnerability It isis not possible to assign a number to a person's vulnerability to bipolar n general bipolar disorder. disorder. Instead, Instead, vulnerability vulnerability is is usually usually described described iin general terms terms like to like "low," "low," "medium," "medium," or or "high." "high." One O n e way w a y of of assessing assessing your your family family tree tree is is to ask first-degree relatives ask whether whether the the number n u m b e r of of late-teenage late-teenage or or adult adultfirst-degree relatives in in your your pedigree 8% (20% pedigree who w h o have have bipolar bipolar disorder disorder exceeds exceeds the the average average rate rate o off 8 % ( 2 0 % if if you you include dolted� with include persons persons with with depressive depressive disorders). disorders). If If your your family family tree tree is is ""dotted" with

people who w h o have have bipolar bipolar disorder disorder or or some s o m e other other mood m o o d disorder disorder (more (more people people people are if bipolar are affected affected than than unaffected), unaffected), your your vulnerability vulnerability is is high. high. Likewise, Likewise, if bipolar disorder disorder or or other other mood m o o d disorders disorders are are present present in in several several generations generations (for (for exam­ example, ple, in in your your Siblings, siblings, parents, parents,and andgrandparents), grandparents),then thenyour yourgenetic geneticvulnerabil­ vulnerabil-

ity is is higher higher than than for for a a person person with with bipolar bipolar disorder disorder in in only only one one generation. generation. If If ity only and no only one one of of your your first-degree first-degree relatives relatives had had a a mild mild dysthymiC dysthymic depreSSion depression and no one the low one had had bipolar bipolar disorder, disorder, your your genetic genetic vulnerability vulnerability is is probably probably on on the low

end of of the the continuum. continuum. end Now, N o w , what what do do you you do do with with the the information information if if you you have have concluded concluded that that bi­ bi-

polar disorder, disorder, or or at at least least depreSSion, depression, runs runs in in your your family? family? Genetic Genetic evidence evidence polar has that the has practical practical implications implications for for your your life. life. First, First,the thefact fact that thedisorder disorderruns runsinin

your family family should should make m a k e you you feel feel less less ashamed ashamed of of having having the the illness. illness. None N o n e of your of us us can can control the genes genes with with which which we w e come c o m e into into this this world. world. As A s you'll see in control the you'll see in

later chapters, chapters, there there are are things things you you can can do do to to control control the the cycling cycling of of your your disordisor­ later der. But But getting getting the the disorder disorder in in the the first first place placeis is heavily heavily influenced influenced by by your your ge­ geder. netic makeup. makeup. We W e don't don't know k n o w how h o w to to engineer engineer the the environment environment to to prevent prevent netic the original original onset onset of of the the disorder. disorder. In In other other words, words, it isn't your your fault—a the it isn't fault-a fact fact that your your family family members m e m b e r s may m a y also also need need to to hear hear (see (see Chapter Chapter 12). 12). As that As the the fafa­ ther of of one one young young man m a n with with bipolar bipolar disorder disorder put put it, it, "For "For a a long long time time we we ther thought he he was was just just a a screw-up. screw-up. He H e seemed seemed able able to to screw screw up u p everything. everything. But But thought eventually we w e realized realized there there was was an an illness, illness, and and that thatthere therewas was something something re­ reeventually ally wrong wrong with his brain. brain. He H e had had a a real real problem problem that that had had a a chemical ally with his chemical basis, basis, and and it it was was probably probably something something he he got got from from me m e or or from from my m y wife's wife's side side of of the the family. family. He H e wasn't wasn't doing doing all all that that stuff stuff to to hurt hurt us. us. That's That's when when w e came came to some we to some understandings understandings as as a a family." family."

Having a a family family history history of of bipolar bipolar disorder disorder may m a y also also help help confirm confirm your your Having diagnosis, if if you you still still have have doubts doubts (see (see also also Chapter Chapter 3). 3). If If bipolar bipolar disorder disorder diagnosiS, clearly runs runs in in your your family, family, this this fact fact will will sway sway your your doctor doctor toward toward a a bipolar clearly bipolar diagnosis rather rather than, than, say, say, attention-deficitlhyperactivity attention-deficit/hyperactivity disorder, disorder, depression, depression, diagnOSiS or schizophrenia. schizophrenia. A A family family history history of of bipolar bipolar disorder disorder is is not not a a conclusive conclusive piece or piece of evidence, evidence, but but it it provides provides one one piece piece of of the the diagnostic diagnostic puzzle. puzzle. of

84 84

CAUSESAND ANDTREATMENTS TREATMENTS CAUSES

youyou have mood is not saythat that genetic genetic evidence thethe keykey to why ThisThis is not to to say evidenceisis to why have mood swings. swings. We W e believe believe genetics genetics play play a a big big role role in in who w h o has has bipolar bipolar disorder, disorder, hut butwe we know oc­ k n o w that that genetics genetics alone alone do do not not explain explain when w h e n and and why w h y your your mood m o o d swings svnngs occur. Even Even if if bipolar bipolardisorder disorder TUns runs in inyour your family, family,you youprobably probablyfeel feelthat thatyour your cur. mood m o o d swings swings are are a a product product of of more more than than just just your your genes genes or or some some chemicals chemicals in in your your brain brain that that have have gone gone haywire. haywire. Stacy Stacy certainly certainly felt felt this thisway. way.That's That'swhy w h yit's it's very prob­ very important important lO to think think of of genetics genetics as as providing providing only only a a background background for for problems you may m a y have have in in regulating your emotions, emotions, thinking, and activity activity levels. levels. lems you regulating your thinking, and It's I t's the the same same way w a y with high blood certainly runs runs in in families, families, but but with high blood pressure: pressure: It It certainly not family ends pres­ not everyone everyone in in a a genetically genetically susceptible susceptible family ends up up with with high high blood blood pressure, sure, and and certainly certainlynot noteveryone everyone with with aa family family history history of ofhean heartdisease diseaseends endsup up dying dying of of a a heart attack. What W h a t people people eat, eat, whether whether they smoke, their heart attack. they smoke, their weight, weight, their their levels levels of of stress, stress, and and aawhole whole host hostof ofother otherfactors factorscome c o m e imo intoplay. play.Again, Again, there there is is an an imponam important distinction distinction to tobe be made m a d e between between the theoriginal originalcauses causesof ofthe the disorder and and triggers triggers of of episodes. disorder episodes. ''What IfI Don', I Don't Have a Family History the Disorder?'' "Wha' If Have a Family His'ory 01 'heof Disorder?"

Somepeople people with with bipolar examine their family pedigrees and see Some bipolardisorder disorder examine their family pedigrees andnosee no evidence of any evidence of any illness, illness, mood m o o d or orotherwise. otherwise.This This isisunusual, unusual,but but ititdoes doeshap­ happen. The thing to yourself is pen. The thing to ask ask yourself is whether whether you you know k n o w enough enough about about the thepeople people in your your pedigree pedigree to to say say that that they they had had no no illness. Could the the "exhaustion" "exhaustion" that in illness. Could that your mother mother describes describes about about her her own o w n mother mother have have reflected reflected a a depression? depression? If your If your grandfather grandfather is is described described as as"dominating," "dominating," "angry," "angry,"or or "aggressive," "aggressive,"could could your he have also been been manic? manic? If If not, not,could could bipolar bipolar illness illness have have occurred occurred in in some­ somehe have also one several several generations generations back? back? one Often, your your older older relatives relatives will will know k n o w more more about about your your family family pedigree pedigree Often, than you do, in which case you can enlist their help in filling out your than you do, in which case you can enlist their help in filling out your pedipedi­ gree chart. chart. Your Your parents, parents, if they are are alive, alive, will almost cenainly certainly know k n o w more more gree if they will almost about the the lives lives of of their their parents, parents, Siblings, siblings, and and other otherrelatives. relatives.Consider Consider asking asking about your doctor to to perform perform a a family family history history interview interview with with one one or or more more of of your your your doctor relatives, if such an evaluation was not done as part of your initial evaluation relatives, if such an evaluation was not done as pan of your initial evaluation (see Chapter Chapter 3). 3). (see Nonetheless, you you may m a y not not be be able able to to identify identify any any relatives relatives in in your your pediNonetheless, pedi­ gree who w h o have have had had mood m o o d disorders. disorders. We W e believe believethere thereare areother other triggers triggersfor forthe the gree onset of bipolar disorder, disorder,but butwe w e aren't aren'tcertain certainwhat whatthese theseare. are.It's It'pOSSible s possible that onset of bipolar that prolonged drug drug abuse abuse can can bring bring on on bipolar bipolar disorder disorder in in some some people. A n injury injury prolonged people. An to the the head head or or a a neurological neurological illness illness such such as as encephalitis encephahtis or or muhiple multiple sclerosis sclerosis to can bring bring on on mood m o o d swings swings that that look just like like those those of of bipolar bipolar disorder. disorder. Per­ Percan look just haps we w e will will find find that that the the onset onset of of bipolar bipolar disorder disorder can can be be attributed attributed in in some some haps people people to to complications complications that occurred during during their their birth or to to viruses viruses their that occurred binh or their

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mothers contracted during pregnancy, as been has been for schizophrenia mothers contracted during pregnancy, as has found found for schizophrenia (for (for more m o r e information information about about this this possibility, possibility, see see an a n excellent excellent review review of of the the schizophrenia literature by is schizophrenia Hterature b y Barbara Barbara Cornblatt Cornblatt and a n d her her associates associates (1999). (1999). It It is unlikely unlikely that that environmental environmental stress stress or or traumatic traumatic experiences experiences alone alone can can make make a a person develop bipolar disorder if he or she has no genetic predisposition, but person develop bipolar disorder if h e or she has n o genetic predisposition, but this topic topic has has never never been b e e n studied. studied. this Even still E v e n if if your your disorder disorder doesn't doesn't have have an a n obvious obvious genetic genetic basis, basis, you y o u may m a y still respond to to the the medications medications that that are are used used to to treat treat bipolar bipolar disorder disorder (see (see Chapter Chapter respond 6), just just as as environmental environmental stress stress can can cause cause a a headache headache that that aspirin aspirin can can alleviate. aHeviate. 6), Some S o m e studies studies indicate indicate that that if ifyou y o u have have aa high high prevalence prevalence of ofbipolar bipolar disorder disorder in in your family family tree, tree, you y o u may m a y respond respond better better to to lithium lithium than if you y o u have a low low your than if have a et al., 1993; prevalence prevalence (Abou-Saleh (Abou-Saleh &: & Coppen, C o p p e n , 1986; 1986; Aida Alda el et al., al, 1997; 1997; Grof Grof et al., 1993; Maj anti­ M a j et et al., al., 1984; 1 9 8 4 ; Prien Prien et et al., al., 1973). 1973). You Y o u may m a y respond respond better better to to anticonvulsants convulsants (for (for example, example, Tegretol) Tegretol) than than to to lithium lithium if if you y o u have have little little or or no no family is not not strong family history history (Post (Post et et al., al., 1987). 1987). But But the the evidence evidence for for this this is strong enough of knowl­ e n o u g h to to gUide guide our our choice choice of of treatments. treatments. Given G i v e n our our current current state state of knowledge, your your physician physician will will probably probably place place greater greater emphasis emphasis on o n your your current current and and edge, past her drug drug treattreat­ past symptoms s y m p t o m s and a n d pattern pattern of of mood m o o d cycling cycling in in making m a k i n g his his or or her ment m e n t recommendations, r e c o m m e n d a t i o n s , rather rather than than on o n your your family family history. history. "What Children?" "Wh.,about .boulHaving Having Chiltlren?" As you have of of passing thethe As indicated indicated above, above,if if you havebipolar bipolardisorder, disorder,your yourchances chances passing disorder on o n to to your y o u r kids kids average average about about 8% 8 % (20% ( 2 0 % if if you y o u include include major major depres­ depresdisorder sion). These These probabilities probabilities are are relatively relatively low l o w and a n d are are comparable comparable to to other other psy­ psysion). chiatric disorders. disorders. For For example, example, if if you y o u have have schizophrenia, schizophrenia, your your chances chances of of chiatric passing it it on o n to to your y o u r children children are are about about 13% 1 3 % (Gottesman, (Gottesman, 1991). 1991). So, So, the the odds odds passing are in in your your and a n d your your child's child's favor. favor. Of O f course, course, the the question question of of whether whether to have are to have children goes goes well well beyond b e y o n d statistics. statistics. Whether W h e t h e r you y o u are areaawoman w o m a n or or aa man, m a n ,your your children answer answer to to this this question question should should be be based based on o n considerations considerations such such as as whether whether you y o u are are clinically clinically stable stable enough e n o u g h to to take take care care of of a a child, child, whether whether y o u are are physiyou physi­ cally cally healthy healthy in in other other ways, w a y s , and, and, where w h e r e applicable, applicable, whether w h e t h e r you y o u are are satisfied satisfied with with your your relationship relationship with vdth your y o u r partner. partner.

Genes AreNot NolDestiny Desliny Genes Are Despite the the relatively that bipolar Despite relatively small small chance chance that bipolar disorder disorder will willbe be passed passed geneti­ genetically from from parent parent to to child, child, many m a n y people people feel feel doomed d o o m e d by b y the the evidence evidence that that they they cally m a y have have those those genes. genes. They T h e y assume a s s u m e that that having having the the associated associated genes genes means means may that they they and a n d their their children children have have nothing nothing to to look look forward forward to to but but a of mood mood a lot lot of that cycling, doctors, medications, a n d hospitals. cycling, doctors, medications, and hospitals.

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by by means Being geneticallyprone proneororvulnerable Being genetically disordermeans meansthat, that, means vulnerable to to aadisorder of of your your biology, biology, you you aTe are more more likely likely to to get get an an illness illness than than someone someone withom without not the the same same genetic genetic susceptibility. susceptibility. But But being being genetically genetically vulnerable vulnerable does does not m e a n that that you you will will necessarily necessarily get get ill ill within within aa certain certainstretch stretch of oftime; time;ititdoes does mean not tell the timing not tell you you the the probability probability or or the timing of of your your recurrences. recurrences. It It also also does does not not m e a n that that there there is is nothing nothing you you can can do do to to control control your your cycling. cycling. High High blood blood mean pressure, pressure, high high cholesterol. cholesterol, and and diabetes diabetes are are all all heritable, heritable, but but exercise, exercise, diet, diet, and appropriate appropriate medications medications go go a a long long way w a y in in controlling controlling these these diseases. diseases. Like­ Likeand wise, wise, lifestyle lifestylemanagement management and and medications medicationsare arecrilicai criticallo tocontrolling controllingepisodes episodes of bipolar bipolar illness illness (see (see Chapters Chapters 6-10). 6-10). of Being genetically genetically susceptible susceptible doesn't doesn't mean m e a n that that your your first-degree relatives, Being first-degree relatives, including your your children, children, will will necessarily necessarily get get the the illness, illness, even even if if they they are are at at a including a higher trans­ higher than than average average statistical statistical risk. risk. Illnesses Illnesses skip skip generations generations or or can can be be transmitted to to your your children children in in a a milder milder form. Nonetheless, ififyou youdo dohave haveaafamily family mitted form. Nonetheless, history of and you history of bipolar bipolar disorder disorder and you also also have have children, children, you you may m a y be be concerned concerned about how protect them. There are or about h o w you you can can protect them. There are ways ways to to determine determine whether whether one one or more of of your your children children are are showing showing signs signs of disturbance that that suggest suggest the beginmore of disturbance the begin­ nings bipolar disorder. nings of of bipolar disorder. These These can can include include irritability, irritability, aggreSSiveness, aggressiveness,sleep sleep disturbance, night terrors, terrors, school problems, inappropriate disturbance, night school problems, inappropriate sexuality, sexuality, drug drug or or alcohol lethargy, or alcohol abuse, abuse, extreme extreme and and rapid rapid switches switches in in mood, m o o d , sadness, sadness, lethargy, or withdrawal from from others. others. There There are are steps steps you you can can take to gel get your your child child treatwithdrawal take to treat­ ment if these signs are present, even if you're not really sure that he or she has ment if these signs are present, even if you're not really sure that he or she has bipolar disorder. disorder. If Ifyou'd you'd like liketo tolearn learnmore more about aboutbipolar bipolar disorder disorder in inchildren, children, bipolar I ' d suggest reading The Bipolar Child by Demitri and Janice Papolos (1999). I'd suggest reading The Bipolar Child by Demitri and Janice Papolos (1999).

W h a t Is Is a a Biochemical Biochemical Imbalance? Imbalance? What Stacy had had been been told told that that her her illness illness was was probably probably biochemical. However, Stacy biochemical. However, no linkage ever been been m a d e for for her between her biochemistry and and her her no linkage had had ever made her between her biochemistry medications. She She understood that haVing having a a biochemical biochemical imbalance imbalance meant meant understood that medications. that her her illness illness was was not not fuHy fully under her control, control, but butshe shewas was unclear unclearwhat what that under her else it it meant. meant. Was W a s the the biochemical biochemical imbalance imbalance something something that that could could be be else measured? Why W h y was was there there no no blood blood test test for for it? W a s the the imbalance imbalance there measured? it? Was there only when w h e n she she was was manic manic or or depressed? depressed? What W h a t were medications doing doing only were the the medications to it? it? Were W e r e the the medications medications creating creating a a different different kind kind of biochemical im­ imto of biochemical frustrated balance? Could Could the imbalance be be corrected corrected by by diet? diet? She She became became frustrated balance? the imbalance that her her doctor doctor didn't didn't give give clear clear answers answers to to these these questions, questions, even even though though that being he seemed seemed quite quite knowledgeable knowledgeable otherwise. otherwise. She She felt felt that that she she was was being he asked to to accept accept a a lot lot of of things on faith, faith, and and her her scientific scientific background background asked things on m a d e her feel doubtful. made her feel doubtful.

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Bio'ogico' BiologicalV.'nerobili/i.s Vulnerabilities dis­ Given that genetic background influences the onset of bipolar Given that genetic backgroundsosostrongly strongly influences the onset of bipolar disAs order, surely surely anatomical anatomical and/or and/or physiological physiological faclOrs factors play play a a role role as well. A s I1 order, as well. discussed discussed in in the the preceding preceding sections, sections, aabiological biologicalvulnerability vulnerabilitycan can be be dormant dormant and and then then become b e c o m e activated activated by by a a trigger, trigger, such suchas asenvironmental environmental stress stressor ordrug drug abuse. much trickier, abuse. Defining Defining the the nature nature of of this this biological biological predisposition predisposition is is m u c h trickier, however. imbalance in the however. If If you you have have been been lOld told that that you you have have a a "biochemical "biochemical imbalance in the brain," an­ brain," you you may m a y feel feel that that this this explanation explanation raises raises as as many m a n y questions questions as as it it answers, as as it it did did for for Stacy. swers, Stacy. You Y o u may m a y find find you're you're more more willing willing to to accept accept the the neceSSity necessity of of a a medication medication regime vulnerability regime if if you you understand understand what what your your doctors doctors mean m e a n by by a a biological biological vulnerability or biochemical biochemical imbalance. imbalance. They They are are usually usually referring referring to to something something that that is is part or part of you you even even when w h e n you're you're not not having having any any symptoms. symptoms. To T o use use the the blood blood pressure pressure of analogy, analogy, people people with with hypertension hypertension always always have have a a vulnerability vulnerability to to an an attack attack of of high blood blood pressure, pressure, even even when w h e n they're they're doing doing fine. fine. Their Their system system is such that is such that high their stress-free their blood blood pressure pressure is is above above normal normal even even when w h e n they they are are relatively relatively stress-free and eating well, and stress causes their blood pressure lo rise even higher. and eating well, and stress causes their blood pressure to rise even higher. Likewise, we w e think think that thatin inbipolar bipolardisorder, disorder,certain certainchemicals chemicals or or molecules molecules in in Likewise, the loO high the brain-notably brain—notably neurotransmitters-are neurotransmitters—are produced produced at at levels levels that that are are too high or or too too low. low. The T h e cells' cells' receptors receptorsfor forthese theseneurotransmitters-along neurotransmitters—along with with vari­ various enzymes enzymes or or neurohormones-may n e u r o h o r m o n e s — m a y be be altered altered in in their their molecular molecular structure structure ous and function. function. In In bipolar bipolar disorder, disorder, biological biological vulnerabilities vulnerabilities involving involving these and these chemicals may m a y be be evoked evoked by by stress stress agents agents (for (for example, example, a a sudden sudden change change such such chemicals as loss loss of of a a job), job), alcohol alcohol or or street street drugs, drugs, or or for for some some people, people, antidepressants antidepressants as (see Chapter Chapter 6). 6). When When a a stressor stressor brings brings vulnerabilities vulnerabilities to to the the foreground, (see foreground, the the symptoms symptoms of of bipolar bipolar disorder disorder are are most most likely likely to to appear. appear. T o gel get technical technical for for a a moment, m o m e n t , we w e strongly strongly suspect suspect that that people people with To with bipobipo­ lar lar disorder disorder have have disturbances disturbances in in the the production production and and catabolism catabolism (chemical (chemical breakdown) of of the the neurotransmitters neurotransmitters norepinephrine, norepinephrine, dopamine, dopamine, acetylchobreakdown) acetylcho­ line,serolOnin, serotonin,and and GABA G A B A (gamma-aminobutyric (gamma-aminobutyric acid). acid).We W e believe believethat thatsome some line, of these these neurotransmitters neurotransmitters are are overover- or or underproduced underproduced during during different different phases phases of of of the the illness, illness, then then not not broken broken down d o w n quickly quickly enough, enough, or or broken broken down d o w n too loO quickly. We W e also also know k n o w that that people people with with bipolar bipolar disorder disorder and and unipolar unipolar depresquickly. depres­ sion have have an an abnormal abnormal production production of of hormones (for example, example, glucocorticoids glucocorticoids sion hormones (for such as as cortisol) Cortisol) produced produced by by the the adrenal adrenal glands glands when when a a person person is is under under such stress. Long-term Long-term stress stress and and glucocorticOid glucocorticoid overproduction overproduction may m a y damage damage or or stress. destroy cells cells in in the the hippocampus, hippocampus, a a brain brain structure structure that that is is an an important important com­ comdestroy ponent ponent of of the the limbic limbic system, system, which which regulates regulates emotional emotional states, states, sleep, sleep, and and arousal arousal (Sapolsky, (Sapolsky, 2000; 2000; Manji, Manji, 2001). 2001). Measuring biochemical biochemical imbalances imbalances gives gives us us incomplete incomplete information. information. For For Measuring

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example, many people with have lowlow levels of the example, many people with bipolar bipolardisorder disorder have levels ofmetabolite the metabolite (the (the breakdown breakdown product) product) of of norepinephrine norepinephrine when w h e n they they are are in in the the depressed depressed phase phase and and higher higher levels levels when w h e n in in the the manic phase (Manji (Manji & & POlLer, Potter, 1997; 1997; manic phase Man ji, 2001). Manji, 2001). Generally Generally in in these these studies, studies, levels levelsof ofthe thebreakdown breakdown product productin inaa bipolar person's bipolar person's urine, urine, blood, blood,or orcerebrospinal cerebrospinalfluid fluid(which (which requires requiresaaspinal spinal tell us tap) tap) are are measured. measured. Such Such procedures procedures may m a y tell us that thatsomething something is iswrong wrong in inthe the production production of of norepinephrine, norepinephrine, but but we w e don't don'thave have the theprecision precision to topoint point to tothe the area neural cir� area in in the the brain brain where where this this misfiring misfiring is is occurring. occurring. Eventually, Eventually, the the ""neural circuits" (brain pathways) most most associated associatedwith withbipolar bipolarsymptoms symptoms may m a y be be identi­ identicuits" (brain pathways) fied, fied, perhaps perhaps through through brain brain imaging imaging techniques techniques such such as as fMRls fMRIs (functional (functional magnetic resonance imaging) help us magnetic resonance imaging).. Identifying Identifying these these brain brain circuits circuits may m a y help us rec+ recognize ognize persons persons at at risk risk for for the the disorder, disorder, even evenwhen w h e n they theyare aresymptom+free, symptom-free,and and hopefully develop treatments. hopefully develop more more effective effective treatments. New N e w research research with with bipolar bipolar persons persons has has found found problems problems in in their their second second messenger (also k known messenger systems systems (also n o w n as as "Signal "signal transducers"), transducers"), which which are are molecules molecules inside brain brain nerve nerve cells. cells. When W h e n one one nerve nerve cell cell "fires," "fires," it it sends sends neurotransinside neurotrans+ millers (the mitters (the "first "first messengers") messengers") to to the the next next nerve nerve cell. cell.Then Thenaasecond secondmessen­ messenger ger system the second second nerve nerve cell cell that that the the first cell has has fired. fired. In In system informs informs the first nerve nerve cell other words, second whether a other words, second messengers messengers help help to to determine determine whether a cell cell communi­ communicates messages to same cell to nearby of cates messages to other other parts parts of of the the same cell and and to nearby cells. cells. One O n e part part of the the second second messenger messenger system, system, called called G-proleins G-proteins (guanine (guanine nucleotide-binding nucleotide-binding proteins), may m a y be be present present at at abnormally abnormally high high levels levels in in the the blood blood platelets platelets of proteins), of people with bipolar bipolar disorder, disorder, even even when w h e n they they are are free free of symptoms (Mitchell (MitcheU people with of symptoms et al., al., 1997). 1997). Lithium Lithium probably probably changes changes G-protein (Avissar et et al, G-protein function function (Avissar al., et 1988; ]ope, Jope, 1999; 1999; Risby Risby et et aI., al., 1991). 1991). Lithium Lithium and and Depakote Depakote also also slow slow down down 1988; of activity of of the protein kinase kinase C C signaling signaling cascade, cascade, an an important important mediator mediator of activity the protein signals within within the the cells cells when w h e n their their receptors receptors are are stimulated stimulated by by neuroSignals neuro­ transmitters (Manji, (Manji, 2001). 2001). This This exciting exciting research research suggests suggests that that changes changes in transmitters in second messenger messenger systems systems may m a y constitute constitute one one form form of of biological biological vulnerability vulnerabihty second to bipolar bipolar disorder--one disorder—one that that m a y be be partially correctable by by medications. to may partially correctable medications. The Lackof ofa aDefinitive Definitive The Lack Te.t Test ,

Despite this this promising research, is no definitive or genetic t Despite promising research, therethere is no definitive biologicalbiological or genetiC test for chemical imbalances imbalances in in bipolar bipolar disorder. disorder. Most Most professionals, professionals, patients, patients,and and for chemical families wish there were, were, because because that that would would make m a k e diagnOSiS diagnosis and and treatment treatment families wish there planning m u c h easier. easier. Most Most of ofus usbelieve beheve that thatsuch suchaatest testwill wiHbe befound foundeventu­ eventuplanning much ally, but for n o w i t ' s a long w a y off. ally, but for now it's a long way off. The absence absence of a definitive definitive test test makes makes it iteasy easy to to forget forgetthat that you you have have aa bio­ bioThe of a chemical imbalance and even easier to believe that you never had one in chemical imbalance and even easier to believe that you never had one in the the first place. place. Notice Notice that that Stacy, Stacy, w h o had been free of symptoms symptoms for for quite quite some some first who had been free of time, started started to towonder wonder whether whether she she really reallyhad had aabiological biologicalpredisposition. predisposition.ItIt Lime, is is

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understandable have this question. Could or depressive understandable totohave this question. Could youryour manicmanic or depressive epi- epi­ sodes cir­ sodes have have been b e e n one-time one-time occurrences occurrences that that were w e r e set set off off by b y unpleasant unpleasant life life circumstances? cumstances? Many M a n y people people start start to to believe believe that that "I "I had h a d this this illness illness once, once, but but now for a n o w it's it's under u n d e r my m y control," control," especially especially when w h e n they've they've been b e e n well well for a while. while. But But bipolar bipolar symptoms s y m p t o m s have have a a way w a y of of recurring recurring when w h e n you y o u least least expect expect them. them. We W e believe believe this this is is because because biological biological vulnerabilities vulnerabilities are are still still present, present, even even when when your symptoms s y m p t o m s are are controlled controlled by b y medications medications and a n d psychotherapy. psychotherapy. your

WhatTurns Turns a Biological Vulnerability an Episode? What a Biological Vulnerability intointo an Episode? Learningthat thatyou you probably a biological imbalance, although Learning probably havehave a biological imbalance, although perhapsperhaps frightening, frightening, should should help help to to arm a r m you y o u against against recurrences recurrences of of your your illness. illness. Like Like the diabetic diabetic who w h o knows k n o w s he h e or or she she must m u s t avoid avoid ice ice cream, cream, or or the the person person with with the high high blood blood pressure pressure who w h o must m u s t avoid avoid extreme extreme distress distress and a n d be be sure sure to to exercise, exercise, y o u can can exert exert a a degree degree of of control control over over your your bipolar bipolar disorder disorder b y learning learning to to you by avoid triggers triggers that influence the the expression expression of of your your chemical chemical imbalance. imbalance. avoid that influence When trig­ W h e n people people who w h o do d o not not have have biochemical biochemical imbalances imbalances experience experience these these triggers lev­ gers (for (for example, example, they they take take drugs drugs or or alcohol alcohol or or intentionally intentionally rake take on o n high high levels the degree els of of stress), stress), they they may m a y experience experience changes changes in in mood m o o d but but not not to to the degree that that characterizes a a person person with with bipolar bipolar disorder. disorder. characterizes S o m e triggers triggers may m a y directly directly impinge impinge on on a a person's person's chemical chemical imbalances imbalances Some and a n d set set them t h e m off, off, kind kind of of like like lighting lighting a a fuse fuse connecting connecting a a string string of of firecrack­ firecrackers. For For example, example, LSD L S D stimulates stimulates the the action action of of certain certain serotonin serotonin receptors receptors in in ers. the the brain, brain, which w h i c h produces produces other other biochemical biochemical events events that that will will increase increase your your risk of developing a m a n i c episode. Studies of laboratory animals as well as risk of developing a manic episode. Studies of laboratory animals as well as humans that amphetamine h u m a n s find find that a m p h e t a m i n e (speed) (speed) stimulates stimulates the the release release and a n d prolongs prolongs the the activity activity of of dopamine d o p a m i n e in in the the brain, brain, which w h i c h can can also also result result in in a a Slate state of of high high arousal, paranoid paranoid thinking, thinking, irritability, irritability, and a n d increases increases in in energy energy or or m o t o r activarousal, motor activ­ ity. Caffeine Caffeine usage usage blocks blocks a a receptor receptor for for the the neurotransmitter neurotransmitter adenosine, adenosine, ity. w h i c h may m a y result result in in greater greater release release of of dopamine, d o p a m i n e , norepinephrine, norepinephrine, and a n d acetylwhich acetyl­ choline. choline. Alcohol Alcohol inhibits inhibits the the activity activity of of your your central central nervous nervous system system (for (for ex­ example, ample, it it increases increases the the effects effects of of the the inhibitory inhibitory neurotransmiLter neurotransmitter GABA G A B A on o n its its receptors) and, and, like like caffeine caffeine and a n d other other substances, substances, interferes interferes with with your sleepreceptors) your sleep­ w a k e rhythms. rhythms. When W h e n you y o u stop stop drinking, drinking, your your brain brain circuits circuits become become m o r e ex­ exwake more citable, citable, much m u c h like like they they do d o in in mania. mania. Environmental stress can a u g m e n t your your biochemical biochemical imbalances, imbalances, but the Environmental stress can augment but the m e c h a n i s m s by b y which w h i c h this this happens h a p p e n s are are not not well well understood understood b y scientists. mechanisms by scientists. Stress cannot cannot be b e avoided avoided in in the the same s a m e way w a y that that alcohol alcohol or or drugs drugs can can be be Stress avoided, but but knowing k n o w i n g what w h a t kinds kinds of of stress stress agents agents will will be be particularly particularly trouble­ troubleavoided, s o m e wiD will help help you y o u know k n o w when w h e n you y o u are are most m o s t at at risk risk for for bipolar bipolar recurrences recurrences some a n d plan plan preventively preventively in in the the ways w a y s that that are are covered covered in in the the next next few few chapters. chapters. and

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Stress and Bipolar Bipolar Episodes Episodes Stress and Can disorder be be caused caused by by environmental environmental factors, factors, such a highly Can bipolar bipolar disorder such as as a highly

conflictive a adifficult job, oror conflictive marriage, marriage, problems problemswith with parents, parents,life lifechanges, changes, difficult job, be­being abused abused as as a a child? child? These These are are extremely extremely important important questions questions that that arc are not not ing fully fully answerable. answerable. As As II mentioned mentioned earlier, earlier,most mostofofus usdoubt doubtthat thatenvironmental environmental factors alone alone can can cause cause bipolar bipolar disorder disorder without without the the contributing contributing influences influences of of factors genetics genetics and and biology. biology. However, However,we w e are arereasonably reasonablycenain certainthat thatstress stressaffeclS affectsthe the course of your illness, or increases the chances that you will have an course of your illness, or increases the chances that you will have anepisode episode of mania mania or or depression if you you already already have have bipolar bipolar disorder. disorder. Your Your level level of of of depreSSion if stress stress may m a y also also affect affect how h o w long long it it lakes takesyou you to toget getover overaabipolar bipolarepisode. episode.That That is, is, the the level level and and type type of of stress stress you you experience experience is is a a "prognostic "prognostic factor" factor" that that helps within a helps determine determine your your likelihood likelihood of of getting getting better better or or worse worse within a certain certain lime time frame. frame. Psychiatrists Psychiatrists and and psychologists psychologists are are interested interested in in knOwing knowing about about the help them the role role of of stress stress in in your your life life because because it it can can help them in in treatment treatment planning, planning, therapy to such such as as deciding deciding what what type type of of therapy to recommend recommend to to you. you. What W h a t kinds kinds of of environmental environmental stress stress are are particularly particularly impacting? impacting? If If you you have have bipolar bipolar disorder, disorder, encountering encountering a a major major life life change-whether change—^whether positive positive or or negative-increases negative—increases your your likelihood likelihood of of having having a a bipolar bipolar recurrence. recurrence. Stacy's Stacy's di­ divorce had had relatively relatively little little immediate immediate effect effect on on her her mood m o o d state, state, but but the the child vorce child custody evaluation evaluation played played a a major role in in her manic episode. episode. Other Other kinds of custody major role her manic kinds of stress include include sleep-wake sleep-wake cycle cycle disruptions disruptions and and conflicts conflicts with with Significant significant othstress oth­ ers. I'll I'll be be talking talking about about each each of of these and giving giving examples. examples. I 'll also also discuss discuss ers. these and I'll some of of the current lhinking thinking about about mechanisms mechanisms by by which which biochemical biochemical imbalsome the currenl imbal­ ances might might be be affected affected by by stress. ances stress.

Mojor Life Major LifeChanges Changes Changes are are a a part andand sometimes they are are quite welcome. SomeSome of of Changes part of oflife, life, sometimes they quite welcome. them are positive and and some some quite quite negative. negative. Examples Examples of of positive positive life life changes changes them are positive include getting getting married, married, having having a a child, child, buying an e w house, house, making making money money include buying a new

include from an an investment, investment, or or getting getting a a job promotion. Negative Negative life life changes changes include from job promotion. the death death of of a a loved loved one, one, the the loss of a a relationship, relationship, the theloss lossof ofaajob, job,aacar caracci­ accithe loss of family dent, or or the the development development of of a a medical medical illness illness in in yourself yourself or or another another family dent, member. member. Manic and and depressive depressive episodes episodes often often follow follow major major life life changes, changes,both bothposi­ posiManic tive and negative. negative. Sheri Johnson, PhD, PhD, a a psychology psychology professor professor at at the the Univer­ Univertive and Sheri Johnson, sity of of Miami, Miami, has has written written extenSively extensively about about life life events eventsin inbipolar bipolardisorder disorder(for (for Sity example,Johnson Johnson & 62 Roberts, Roberts, 1995). 1995). She She points points out out that that it itisisnot notalways alwaysclear clear example, whether life life events events are are a a cause cause or or an an effect effect of of the the mood m o o d episode. episode. A A client client with with whether

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bipolar disorder, Patrick, Patrick, age age 36, 36, provides providesananillustration. illustration. When When bipolar disorder, he he waswas cy- cy­ cling cling into into mania, m a n i a , he h e would w o u l d become b e c o m e overconfident overconfident and a n d frequently frequently "tell "teH off' off" his his employers. employers. He H e often often lost lost jobs jobs as as aa result. resuh. When W h e n discussing discussing his his history, history, he he would w o u l d argue argue that that his his pattern pattern was w a s to to lose lose jobs jobs and a n d then then become b e c o m e manic-when manic—when the the reality reality was w a s probably probably the the other other way w a y around. around. But But even even when w h e n considering considering only only events events that that couldn't couldn't have have been b e e n brought brought about about by b y the the illness illness itself itself (for (for ex­ example, ample, the the death death of of aa parent; parent;losing losing one's one's job job at at aa plant plant [hat that closed closed down), d o w n ) , re­ researchers searchers still still find find that that life life events events play play aa role role in in the the onset onset of of manic m a n i c and a n d depres­ depressive episodes episodes Oohnson (Johnson &: & Roberts, Roberts, 1995). 1995). sive All A H of of us us are are emotionally emotionally affected affected by b y stress, stress, but but not not everyone everyone has has the the se­ severe vere mood m o o d swings swings that that bipolar bipolar people people have have when w h e n under u n d e r stress. stress. Are A r e people people with bipolar bipolar disorder disorder somehow s o m e h o w more m o r e sensitive sensitive to to life life events? events? Johnson J o h n s o n and a n d her her with colleagues coHeagues (2000) (2000) point point out out that that the the kinds kinds of of events events that that precede precede manic m a n i c epi­ episodes sodes are are often often goalgoal- or or achievement-oriented. achievement-oriented. Examples E x a m p l e s of of these these kinds kinds of of events invest­ events include include job job promotions, promotions, new n e w romantic romantic relationships, relationships, financial financial investments, ments, and a n d athletic athletic successes. successes. She S h e and a n d her her colleagues coHeagues think think that that these these kinds kinds of of events events activate activate aa circuit circuit in in the the brain brain known k n o w n as as the the behavioral behavioral activation activation system, system, which re­ w h i c h regulates regulates the the activity activity of of the the brain brain when w h e n "cues" "cues" or or stimuli stimuli indicating indicating reward w a r d are are present present (for (for example, example, investments investments that that Signal signal the the pOSSibility possibility of of great great financial financial gain). gain). In In contrast, contrast, other other kinds kinds of of events events cause cause people people to to shut shut down down and a n d withdraw, withdraw, as as they they do d o when w h e n they they get get depressed. depressed. These These events, events, which w h i c h usu­ usually involve involve loss, grief, or or rejection, rejection, may m a y activate activate a a different different set set of of neural neural cirally loss, grief, cir­ cuits, called called the the behavioral behavioral inhibition inhibition system. system. This This system system motivates motivates the person the person cuits, to avoid stimuli that signal p u n i s h m e n t . For example, the loss of a relationto avoid stimuli that Signal punishment. For example, the loss of a relation­ ship may may m ake a a person person withdraw w i t h d r a w from f r o m others others as as a a way w a y of of avoiding avoiding further further reship make re­ jection. jection. T h e behavioral behavioral activation activation and a n d inhibition inhibition systems systems probably probably involve dopaThe involve dopa­ m i n e and a n d serotonin serotonin activity, h i c h , as as mentioned m e n t i o n e d earlier, earlier, may m a y bbe e abnormal a b n o r m a l in mine activity, wwhich, in the brains brains of of people with bipolar bipolar disorder. disorder. People might the people with People with with bipolar bipolar disorder disorder might therefore b e m o r e biologically sensitive to to events events that that are are goal-oriented goal-oriented or or therefore be more biologically sensitive loss/rejection-oriented. Johnson's hypothesis a n intriguing intriguing one, one, a n d she has loss/rejection-oriented. Johnson's hypotheSiS is is an and she has supported y shOwing s h o w i n g that, m o n g people supported it it in in her her research research bby that, aamong people with with bipolar bipolar II disorder, m a n i c episodes episodes are are often y events events that that stimulate disorder, manic often preceded preceded bby stimulate goalgoal­ directedness o h n s o n et 2000). directedness QOohnson et al., al., 2000). Stressful Events: E.amining Examining Your Your History Slressful Events: Hislary Have your previous events played playedaa role role in in your previous episodes? episodes?IfIf you youhave havehad had Havestressful stressful events mmore o r e than n e clear-cut o u mmay a y find than oone clear-cut episode, episode, yyou find the the following following exercise exercise useful. useful. Fill o r e of a n i c / h y p o m a n i c or dates of of three three or or mmore of your your previous previous mmanic!hypomanic or dede­ Fill out out the the dates pressive n d see o u can h e t h e r life pressive episodes episodes aand see if if yyou can determine determine wwhether life events events occurred occurred

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WHAT W H A T ROLE ROLE HAS HAS STRESS STRESS PLAYED PLAYED IN IN YOUR Y O U R ILLNESS? ILLNESS? ApprOximate dale Approximate date of pisode of eepisode

T ype of pisode Type of eepisode

(or (or your your age age at at the the

(manic, (manic, hypomanic, hypomanic,

time) time)

depressed, depressed, mixed) mixed)

Stressful Stressfulevents events(describe) (describe)

before (or (or during) during) any any or or all all of of them. them. If If yOUT your previous previous episodes episodes have have been been before mainly mixed, mixed, indicate indicate this this in in the table so so that that you you can can keep them separate separate mainly the table keep them know w h e n evaluating evaluating the the exercise. exercise. Currently, Currently, we w e don't don't k n o w whether whether mixed mixed epi­ epiwhen

sodes have have different different environmental environmental stress stress triggers triggers from from manic or depreSSive depressive sodes manic or episodes. episodes. Include Include major major events events (for (for example, example, a a move m o v e to to a a new n e w state, state, new n e w romantic romantic

relationships or or relationship relationship breakups, breakups, car car accidents, accidents, job job changes, changes,deaths deaths in in relationships the family) family) as aswell wellas asevents eventsthat, that,by bycomparison, comparison,are areless lesssevere severeorordisruptive disruptive the (for example, example, buying a new n e w pet, pet, getting getting the theflu, taking aa vacation, vacation, changing changing (for buying a flu, taking your job hours). hours). Include Include both both positive positive and and negative negative life life events. events. your job Try take a Try to to take a somewhat somewhat removed removed stance stance when w h e n examining examining the the role role of of life Hfe

stress in in your o w n illness. illness. Are Areparticular particulartypes typesof ofevents eventsconsistently consistentlyrelated relatedto to stress yOUT own yOUT Has an your episodes? episodes? Has an event event involving involving loss loss or or grief grief ever ever preceded preceded one one or or more more

of your your depressive depressive episodes? episodes? H o w many m a n y of of your your prior prior manic manic or or mixed mixed epiof How epi­

sodes were related sodes were related to to romantic romantic relationships, relationships, even evenif ifpositive positive(such (suchas, as,fmding finding

a new n e w partner)? partner)? Do D o events events that that involve involve achievement achievement (for (for example, example, an an increase increase a in your w o r k aSSignments) assignments) often often precede precede your or hypomanic episodes? in your work your manic manic or hypomanic episodes? How might have changes in H o w many m a n y of of these these events events might have resulted resulted in in changes in when w h e n or or how how

WRere From? Where Does DoesBipolar BipolarDisorder Disorde(orne r Come From?

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much you generally, do do these events occur independently of your much youslept? slept?More More generally, these events occur independemly of your mood m o o d disorder? disorder? Or O r does does your your manic m a n i c or or depressive depressive behavior behavior play play a a significant significant role in in causing causing these these events? events? role Don't Don't be be disappoimed disappointed if if you y o u have have difficulty difficulty answering answering these these questions. questions. M a n y people people with with bipolar bipolar disorder disorder have have trouble trouble recalling recalling when w h e n their their episodes episodes Many started started and a n d ended e n d e d and a n d when w h e n certain certain stressful stressful events events occurred. occurred. If If you y o u are are hav­ having ing trouble, trouble, try try consulting consulting aa family family member m e m b e r or or your your doctor doctor if if he h e or or she she has has seen you through several episodes. Take him or her through the exercise and seen y o u through several episodes. T a k e h i m or her through the exercise a n d see if if he h e or or she she can can help help jog jog your y o u r memory m e m o r y about about when w h e n certain certain events events oc­ ocsee curred, curred, whether w h e t h e r these these events events came c a m e before before or or after after an a n episode, episode, and a n d what w h a t type type of of episode you y o u had. had. episode The T h e temporal temporal relationship relationship between between a a life life event event and and a a resulting resulting mood m o o d state state can be be quite quite complicated. complicated. For For example, example, Annie, Annie, a a 27-year-old, 27-year-old, become b e c o m e mildly mildly can depressed depressed after after she she broke broke up u p with with her her live-in live-in girlfriend girlfriend but but did did not not develop develop a a full full bipolar bipolar depression. depression. However, H o w e v e r , when w h e n her her physician physician staned started her her on on a a regime regime of of antidepressam antidepressant medication, medication, she she developed developed aa mixed m i x e d episode. episode. In In this this case, case, the the environmental stressor stressor (the (the relationship relationship ending) ending) was w a s related related to to the the outcome outcome environmental (the (the mixed m i x e d episode) episode) only only through through the the avenue avenue of of aa change change in in her her medication. medication. R e m e m b e r that that discovering discovering aa linkage linkage between b e t w e e n life life events events and a n d your your mood mood Remember disorder episodes episodes does does not not mean m e a n that that you y o u are are somehow s o m e h o w at at fault fault for for causing causing disorder your your own o w n illness. illness. Many M a n y life life events events are are unavoidable. unavoidable. Some S o m e of of these these events events can can b e c o m e more m o r e likely to occur occur when w h e n you y o u get get manic m a n i c or or depressed, depressed, but but that become likely to that still still doesn't mean m e a n you y o u are are fully fully in in control control of of their their occurrence. occurrence. For For example, example, you you doesn't may m a y have have lost lost certain certain jobs jobs once once your y o u r mood m o o d cycled cycled into into irritability irritability or or depres­ depression, but but that that doesn't doesn't m e a n you y o u should should have have been b e e n able able to to control control these these mood mood sion, mean states or or their their effects effects on o n others, others, particularly particularly without without having having any any tools tools to d o so. states to do so. rhe Cycle Cycle TIre Role Role of of the the Sleep-Wake Sleep-Woke W e ' v e already already talked talked about about one o n e mechanism m e c h a n i s m by b y which w h i c h stress stress can can affect bipolar We've affect bipolar s y m p t o m s — t h e behavioral behavioral activation activation and a n d inhibition inhibition systems. systems. Another Another mecha­ mechasymptoms-the nism is is sleep. sleep. If If you you r e m e m b e r back back to to your your first first episode episode or or any any other epinism remember other epi­ sodes, sodes, you y o u will will probably probably agree agree that that sleep sleep played played some s o m e role role in in them. them. Perhaps Perhaps it it is is simply simply that that when w h e n you y o u were w e r e manic m a n i c you y o u slept slept less, less, and a n d when w h e n you y o u were w e r e dede­ pressed you y o u slept slept more. m o r e . But But changes changes in in sleeping sleeping and a n d waking w a k i n g are are important important in pressed in another way. w a y . Researchers Researchers believe that bipolar bipolar people people are are very very sensitive sensitive to to even even another believe that m i n o r changes changes in h y t h m s , such as when w h e n they g o to when in sleep-wake sleep---wake rrhythms, such as they go to bed, bed, �hen minor they actually actually faU fall asleep, asleep, and a n d when w h e n they they w a k e up u p (Wehr ( W e h r et et al. al. 1 9 8 7 ; FFrank r a n k et they wake 1987; et al, 2 0 0 0 ; Malkoff-Schwartz et al., 1998). If so, events that change your sleep2000; Malkoff-Schwartz et al., 1998). If so, events that change your sleep-­ aI., w a k e cycle also affect affect your your m o o d . Stacy Stacy became b e c a m e quite quite manic m a n i c wwhen h e n she wake cycle will will also mood. she bebe­ gan g a n the the child child custody custody proceedings, proceedings, possibly possibly because the preparations preparations were were because the

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manic stressful and forced her her to stay later night.atDarryl, age 24, became stressful and forced to up stay up at later night. Darryl, age 24, became mani shortly later shortly after after his his graduate graduate school school finals, finals, during during which which he he had had stayed stayed up u p later and later. losing and later. Losingeven evenaasingle singlenight's night'ssleep sleepcan canprecipitate precipitateaamanic manic episode episodein in people with bipolar disorder who w h o have have otherwise otherwise been been stable stable (Malkoff­ (Malkoffpeople with bipolar disorder Schwartz Schwartz et et aI., al., 1998). 1998). In In parallel, parallel, sleep sleep deprivation deprivation can can improve improve the the mood mood 1998; of briefly (Barbini of a a person person with with depression, depression, although although only only briefly (Barbini et et aI., al., 1998; Liebenluft Liebenlufi &:. & Wehr, W e h r , 1992). 1992). What Affects Sleep-Wake Regularity?: Socialand Zeitgebers What Affects OurOur Sleell-Woke Regularity?, Sodol Zeitgebers Zeitstorers and Zeitstorers Unless you speak speak German, German, you've you've probably probablynever neverheard heard these terms before— Unless you these terms hefore­

nor y hypothesis of nor had had II until until II started started reading reading about about the the social social rhythm rhythm stabilit stability hypothesis of Cindy Ehlers Ehlers and and her her associates associates at at the the University University of of Pittsburgh Pittsburgh Medical Medical Center Center Cindy (Ehlers et al., 1988; Ehlers et al., 1993). This model helps us understand (Ehlers et al., 1988; Ehlers et al., 1993). This model helps us understand why why lire cycles. life events events might might affect affect bipolar bipolar people's people's mood m o o d cycles. Ehlers' theory theorystates statesthat thatthe thecore coreproblem problem in inbipolar bipolardisorder disorderis isone one of ofin­ inEhlers' stability. Usually, Usually,people peoplemaintain maintainregular regularpatterns patternsof ofdaily dailyactivity activityand andsocial social stability. stimulation, such as they get gel up stimulation, such as when w h e n they they go go to to bed, bed, when w h e n they up and and go go to to work, work, how h o w many m a n y people people they they ordinarily ordinarily socialize socialize with, with, or or where where they they go go after after work. work. These "social "social rhythms" rhythms" are important in in maintaining maintaining OUT our "circadian "circadian rhythms," These are important rhythms," which are are the the more more biologically biologically driven driven cycles cycles such such as as when w h e n you you actually actually faU which fall asleep, the the production production of of hormones hormones like like melatonin melatonin (which (which is is produced produced when when asleep, you are are approaching approaching sleep), sleep), or or your pattern of of rapid eye movement m o v e m e n t activity you your pattern rapid eye activity during sleep. during sleep. Social rhythms rhythms stay stay stable, stable, in inpart, part,because becauseofofsocial socialZeitgebers, Zeitgebers, which are Social which are persons or or events events that that function function as as an an external external time time clock clock to regulate your your hab­ habpersons to regulate its. Yourdog dogcan canbe beaasocial socialZeitgeber Zeitgeberififshe sheor orhe heneeds needstotobe bewalked walkedatata acer­ cerits. Your plays tain time of the morning. morning. If you have have aaspouse, spouse,he heor orshe shealmost almostcertainly certainly plays of the If you tain time a role role in in organizing organizing your your eating eating and and sleeping sleeping schedules schedules and and probably probably affects affects a h o w much m u c h stimulation stimulation you you have have from from other other people people during during the day. If If you you how the day. were to to split split up up with your spouse, spouse, or or even even if if he or she she were to go go away away for for a with your he or were to a were job period of of time, time, your your daily daily and and nightly nightly routines routines would would be be disrupted. disrupted. Your Your job period also keeps keeps you you on on a a regular regular routine. also routine. de­ In contrast, contrast, a a social social Zeitstorer Zeitstorer (time (time disturber) disturber) is is a a person person or or a a social social deIn m a n d that that throws throws everything everything off off balance. balance. When W h e n you you start start a a new n e w relationship, mand relationship, your patterns of sleeping, sleeping, waking, waking,and and SOCializing socializingchange. change.The The same same thing thingwill will your patterns of happen if if you have a a baby. baby. In In these these cases, cases, the e w romantic romantic partner partner or or your your happen you have the n new baby is is a a Zeitstorer. Zeitstorer. If If you you take take on employment that that has has constantly constantly shifting baby on employment shifting work hours or requires requires that that you you travel travel across across different different time time zones, zones, your your social social work hours or and circadian circadian rhythms rhythms will will be be disrupted disrupted conSiderably. considerably. and W h a t does does all all of ofthis thismean m e a n for foraaperson person with with bipolar bipolardisorder? disorder? Events Events that that What

From? Whefe WhereDoes DoesBipolar BipolarDisorda DisordeCome r Come From?

9595

re­ ZeitstorersororreintroducingZeitstorers byintroducing eitherby rhythms,either social rhythms, changesininsocial bring bring about about changes moving m o v i n g Zeilgebers, Zeitgebers, alter alter circadian circadian rhythms. rhythms. You Y o u are are particularly particularly vulnerable vulnerable to to life aa manic m a n i c episode episode after after you y o u have have experienced experienced aa social social rhythm-disrupting rhythm-disrupting life event (for (for example, e x a m p l e , Malkoff-Schwartz Malkoff-Schwartz et et al., al., 1998). 1998). event Let Let me m e give give you y o u an a n example. example. Debra, Debra, aa 36-year-old 36-year-old woman w o m a n with with bipolar bipolar II II disorder, disorder, lived lived with with her her husband, h u s b a n d , Barry. Barry. During During aa therapy therapy session session with with the the couple, couple, Debra D e b r a complained complained that that Barry Barry had h a d changed changed the the schedule schedule for for feeding feeding their their two t w o cats. cats. He H e had h a d begun b e g u n feeding feeding them t h e m both both in in the the morning m o r n i n g instead instead of of the the evening, evening, and a n d as as aa result result one o n e or or both both of of the the cats cats were w e r e coming c o m i n g into into the the couple's couple's room r o o m in in the the middle middle of of the the night, night, crying crying for for food. food. Debra Debra wanted w a n t e d to to feed feed the the cats cats before before she she and a n d Barry Barry went w e n t to to bed, bed, but but he h e refused, refused, saying saying it it would w o u l d make m a k e the the irri­ cats cats overweight. overweight. After After three three consecutive consecutive nights nights of of poor poor sleep, sleep, she she became b e c a m e irritable, table, experienced experienced mental mental confusion confusion at at work, w o r k , and a n d developed developed racing racing thoughts. thoughts. Finally, Finally, Barry Barry agreed agreed to to the the new n e w evening evening feeding feeding schedule, schedule, which w h i c h alleviated alleviated the the problem p r o b l e m with with the the cats. cats. As A s Debra D e b r a got got back back on o n aa regular regular sleep-wake sleep-wake cycle cycle and experienced experienced several several nights nights of of restorative restorative sleep, sleep, her her hypomania h y p o m a n i a started started to to and settle settle down. d o w n . In In Debra's Debra's case, case, a a major major episode episode was w a s averted averted by b y reestablishing reestablishing routines that that had h a d been b e e n disrupted disrupted by b y aa relatively relatively minor m i n o r event. event. routines Miriam, Miriam, a a 47-year-old 47-year-old woman w o m a n with with bipolar bipolar II disorder, disorder, reported reported that that she she developed manic m a n i c or or mixed m i x e d symptoms s y m p t o m s the the morning m o r n i n g or or afternoon afternoon after after drinking drinking developed me to clear entirely wasn't II quantities. small alcohol, even if only in small quantities. It wasn't entirely clear to m e why why a a alcohol, even if only in small amount a m o u n t of of alcohol alcohol would w o u l d make m a k e her her manic m a n i c until until II considered considered her her sleep sleep small cycle: alcohol alcohol was w a s acting acting as as a a disruptive disruptive Zeitstorer. Zeitstorer. She S h e had h a d much m u c h more m o r e diffidiffi­ cycle: culty falling asleep after after drinking. drinking. Once O n c e she she stopped stopped drinking drinking (or (or limited limited herher­ falling asleep culty self to to one o n e beer, beer, usually c o n s u m e d early early in in an a n evening), evening), she she had h a d less less trouble trouble usually consumed self sleeping and a n d fewer fewer shifts shifts in in her her mood m o o d states. sleeping stales. In Chapter a y s to Maintain Wellness," Wellness," I'll I'll tell o u about about aa tell yyou to Maintain "Practical WWays 8, "Practical Chapter 8, In m e t h o d for for keeping keeping y o u r social social routines even wh w h �n 2n events conspire events conspire regulated even routines regulated your method to to change change t h e m (the h y t h m stability stability method; method; F r a n k et et al., 0 0 0 ) . This This al., 22000). Frank social rrhythm (the social them self-monitoring technique o u keep ood a n d sleep-wake cy­ sleep-wake cyand your mmood keep your help yyou can help technique can self-monitoring cles stable. stable. cles Conflicts with Significant SignificantOthers Others Conflicts with

So far, routine. The yourroutine. in your So we've talked talked about about single events and and changes changes in life events Single life far, we've The other o with ongoing relationships. relationships. Chapter Chapter other major your ongOing with your to ddo has to stress has of stress type of major type 12 family mmembers, e m b e r s , so mention brief mention only brief it only give it I'll give so I'll with family dealing with to dealing devoted to is devoted 12 is here. o evidence examhere. There (for exam­ relationships (for family relationships in family disturbances in that disturbances evidence that is nno There is ple, o o r parenting h e n yyou o u wwere e r e aa child) first the first in the disorder in bipolar disorder cause bipolar child) cause parenting wwhen ple, ppoor place. likeli­ your likeliincrease your can increase situations can marital situations or marital family or high-conflict family But high-conflict place. But hhood o o d of o u have it. have it. once yyou disorder once bipolar disorder of bipolar recurrence of having aa recurrence of having

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I conducted my dissertation topicatat UCLA with withmy my for­ formy dissertationresearch researchon onthis this topic UCLA I conducted mer mentor, mentor, Michael Michael Goldstein Goldstein (Miklowitz (Miklowitz et et aI., al., 1988). 1988). In In this this study, study, we we mer worked worked with with bipolar bipolar II manic manic adults adults who w h o lived lived primarily primarily with with their their parenlS. parents. We W e examined examined the the level level of of conflict conflict between between these these patients patients and and their their parents parents while surpris­ while the the patients patients were were in in the the hospital hospital and and once once they they got got out. out. Not Not surprisingly, ingly, those those who w h o returned returned to to high-conflict high-conflict families families had had mOTe more manic manic and and de­ depressive pressive episodes episodes (recurrences) (recurrences) within within nine nine months months after after their their hospitalization hospitalization than than those those who w h o returned returned to to low-conflict low-conflict families. families. Though T h o u g h all all of of the the people people in in our our study study were were hospitalized, hospitalized, many m a n y people people with with bipolar bipolar disorder disorder never never enter enter a a hospital. be­ hospital. Nevertheless, Nevertheless, other other researchers researchers have have found found similar similar associations associations between family family relationships relationships and and the the outcome outcome of of bipolar bipolar disorder, disorder, whether whether or or tween not not the the patients patients had had been been hospitalized hospitalized (O'Connell (O'Connell et et al., al., 1991; 1991; Priebe Priebe et et al., al., 1989; Honig Honig el et aI., al., 1997). 1997). 1989; We bi­ W e don't don't know k n o w exactly exactly why w h y conflict-ridden conflict-ridden family family environments environments make m a k e bipolar polar people people more more recurrence-prone recurrence-prone (though (though it it makes makes sense), sense), but butwe w e do do know know that disor­ that family family environments environments affect affect the the course course of of many m a n y other other psychiatric psychiatric disorders, including including schizophrenia, schizophrenia, depreSSion, depression, alcoholism, alcoholism, and and eating eating disorders disorders ders, (Butzlaff & & Hooley, Hooley, 1998). 1998). We W e also also suspect suspect that that i is not not only only conflicts conflicts with with (Butzlaff itt is family of your family members members or or a a spouse spouse that that can can affect affect the the cycling cycling of your disorder disorder but but also also conflicts conflicts with with other other Significant significant people people in in your your life, life,such suchas asyour youremployer, employer, coworkers, wilh her coworkers, or or friends. friends. In In Stacy's Stacy's case, case, her her conflicts conflicts with her ex-husband ex-husband may may have played played a a role in her her escalating escalating mania. mania. H a d she she been been able able to to sit sit down d o w n with with have role in Had him and and work work things things out out with with civility, civility, her her chances chances of of staying staying stable stable might might him have been better. But But she she really really didn't didn't have have that that option. have been beuer. option. For n o w , let's simply recognize that family and interpersonalconflicts conflictscan can now, lel's simply recognize that family and interpersonal For be risk risk factors in the the course course of illness. Begin be factors in of your your illness. Begin thinking thinking about about what what role role family or marital marital conflict conflict has in your disorder. Do D o your episodes typifamily or has played played in your disorder. your episodes typi­ cally coincide with significant family family or or marital marital arguments? arguments? Do D o these cally coincide with Significant these conflicts conflicts to c o m e before before the the episode, episode, after after the the episode episode has has begun, or is is it it impossible impossible to come begun, or epi­ tell? a n y of of my m y clients clients say say that before their their epitell? M Many that the the family family conflicts conflicts came came before sodes; say that that the the conflicts conflicts arise arise once they've become become manic, manic, mixed, or sodes; others others say once they've mixed, or depressed—but also also make m a k e it harder to to get get better. S o m e report report that family condepressed-but it harder better. Some that family con­ flicts that havebeen beenthere there alongget get worsewhen w h e nthey they becomeill,iH, that flicts that have allaHalong worse become ororthat "buried" issues c o m e out out in members. W h e n you "buried" issues come in their their dealings dealings with with family family members. When you are becoming ifl, it can be difficult to "edit" the things you want to say to your are becoming ill, it can be difficult to "edit" the things you want to say to your family a y have members, and and these these family family members members mmay have similar similar difficulties in family members, difficulties in their communication with you (see Chapter 12). their communication with you (see Chapter 12). WWhen h e n thinking to avoid their thinking through through these these issues, issues, try try 1O avoid blaming blaming others others for for their role in your illness—in most cases family members are trying their best to role in your illness-in most cases family members are trying their best to be be helpful n o w what helpful and and often often don't don't kknow what to lO do do or or say. say. As As you'H you'll see see in in Chapter Chapter 12, 12,

Where From? Where Does Does Bipolor BipolarDisorder Disorde(orne r Come From?

9797

there andbad bad ways deal with your family members regarding is­ there are are good good and ways to to deal with your family members regarding issues is an im­ sues surrounding surrounding your your disorder. disorder. Managing M a n a g i n g your your family family relationships relationships is a n important element element of of maintaining maintaining wellness. wellness. portant *

*

*

Bipolar to Bipolar disorder disorder does does not not have have clear-cut clear-cut causes, causes, but but we w e know k n o w enough e n o u g h to say say that that it it involves involves biological biological brain brain imbalances imbalances that that are are partly partly under u n d e r genetic genetic controL kinds of of control. These T h e s e biological biological vulnerabilities vulnerabilities can can be b e set set off off by b y various various kinds stressors, stressors, conflicts, conflicts, or or life life changes, changes, whether w h e t h e r positive positive or or negative. negative. Stacy's Stacy's expe­ experiences riences with with life life stress, stress, family family conflict, conflict, and a n d sleep-wake sleep-wake disturbances disturbances may m a y mir­ mirror some s o m e of of your your own. own. ror Medications imbalances. Medications are are deSigned designed to to correct correct the the underlying underlying biological biological imbalances. The next next chapter chapter describes describes the the available available medications, medications, what what we w e think think they they do, do, The their treatment. their side side effects, effects, and and the the role role of of psychotherapy psychotherapy as as an an adjunctive adjunctive treatment. tech­ Later chapters chapters describe describe lifestyle lifestyle management management techniques. techniques. Usually Usually these these techLater niques are are recommended r e c o m m e n d e d alongSide alongside medication medication as as a a way w a y of of improving improving your your niques ability ability (Q to cope cope with with stress. stress. As A syou you read readon, on,try tryto tothink thinkof ofbiology biologyand and environ­ environment as interacting with each other—you'll have an easier time making ment as interacting with each other-you'll have an easier time making choices choices about about treatments treatments if if you you can can keep keep these these mult multiple causes of of bipolar iple causes bipolar disdis­ order order in in mind. mind.

6

6

a n MMedication e d i c a t i o n WhatC Can a and n d P Psychotherapy s y c h o t h e r a p y D Do o f for o r MMe? e ? W h a t

W

time firfirst-line st-line w . e ehave haveknown knownfor fora along long timethat thatmedication medicationisisthe the treatment for bipolar disorder. e know treatment for bipolar disorder.WWe knowthat thataaperson personwith withbipolar bipolardisorder disorder remains well longer i f he or she takes medication regularly. But remains well longer if he or she lakes medication regularly. Butwe wealso alsoknow know that medication requires careful monitoring by you and your physician and that medication requires careful monitoring by you and your phYSician and sometimes demands that you tolerate unpleasant side sometimes demands that you tolerate unpleasant sideeffects. effects. People have strong feelings about taking mood stabilizing medications People have strong feelings ahoUl taking mood stabilizing medications and sometimes don't take them even when they would clearly benefit—often and sometimes don't take them even when they would clearly benefit-often because lack information about the medications and their side becausethey they lack information about the medications and their sideeffects. effects. The overview of the medications used to treat bipolar disorder presented in in The overview of the medications used to treat bipolar disorder presented this chapter will allow you toto take onon a much more powerful role inindealing dealing [his chapler will allow you take a much more powerful role with your disorder. Knowing what these medications do, which side effects with your disorder. Knowing what these medications do, which sideeffects are common and which are rare, and how you can deal with them, as well as are common and which are rare, and how you can deal with them, as well as what the most recent research teltells ls ususabout the most recent research aboutthe the"track "trackrecord" record"ofofthese thesemedimedi­ what cations, will help you plan your medication regimen with your doctor and cations, will help you plan your medication regimen with your doctor and manage i t over time. manage it over time. I strongly believe that are I strongly believe thatpeople peoplewith withbipolar bipolardisorder disorderdo dobest bestwhen whenthey theyare taking medications and simultaneously working with a therapist. Although taking medications and Simultaneously working with a therapist. Although psychotherapy isisnot psychotherapy nota asubstitute substitutefor formedication, medication,there thereare arethings thingsyou youcan canacac­ complish in therapy that won't be accomplished by medication. For this rea­ complish in therapy that won't be accomplished by medication. For thisreason I Ialso alsotalk talkabout aboutthe therole roleofofpsychotherapy psychotherapyas asan anadjunct adjuncttotomedication medicationin in son this chapter. this chapter. 9898

Whot What (on Can Medication Medication and andPsycholheropy PsychotherapyDo DoforforMe? Me?

9999

Knowing the about facts about medication is a crucial foundation for adhering Knowing the facts medication is a crucial foundation for adhering to to a a medication medication regimen. regimen. The T h e reasons reasons that that people people with with bipolar bipolar disorder disorder commonly c o m m o n l y refuse refuse to to take take medication medication range range from f r o m suffering suffering uncomfortable uncomfortable side side effects effects to to having having trouble trouble remembering r e m e m b e r i n g to to take take the the medication, medication, disagree­ disagreeing with the diagnosis, disHking having one's m o o d s controlled, or having ing with the diagnosis, disliking having one's moods controlled, or having strong these factors strong feelings feelings about about what w h a t the the medication medication represents. represents. Any A n y of of these factors can lead lead to to a a patient's refusal to to take take medication medication consistently consistently or or at at all. all. Be­ Becan patient's refusal cause cause it it is is so so important important to to take take medication medication consistently, consistently, I've I've devoted devoted Chap­ Chapter 7 7 to to exploring exploring the the factors factors that that impede impede a a person's person's adherence adherence with with a a given given ter medication regimen. regimen. medication

"What Can Can Medication Medication Do Do for for Me?" Me?" "What

You'll recall from earlier chapters that bipolar a relapse! You'll recall from earlier chapters that disorder bipolar follows disorder follows a rel remission remission course. course. Research Research by by Michael Michael Gitlin Gitlin and and his his colleagues colleagues at at UCLA UCLA found that that aa person person who w h o has has had had aa manic manic or or depreSSive depressive episode episode has has a a6 0% found 60% chance of of having having another another one one within within two two years yearsand and aa 73% 7 3 % chance chance over over an an av­ avchance erage aL, 1995). erage of of four four and and aa third third years years (Gitlin (Gitlin et et al, 1995). Likewise, Likewise, the theNational NationalIn­ InstitUle stitute of of Mental Mental Health Health Collaborative Collaborative Program Program on on the the Psychobiology Psychobiology of of De­ Depression of pression found found that that 81-91% 81-91% of of people people with with manic manic or or mixed mixed episodes episodes of bipolar disorder disorder had had recurrences recurrences within within five five years years(Keller (Kelleret etaI., al.,1993). 1993). Many bipolar Many people people have have significant significant symptoms symptoms even even when when they they aren't aren't having having major major epiepi­ sodes (Harrow (Harrow et al, 1990; 1990; Gitlin Gitlinet etaI., al,1995). 1995). sodes et aL, The good good news news is is that that virtually virtuallyeveryone everyonesuffering sufferingfrom from the thedisorder disorderfinds finds The that medication medicationmakes makes recurrences recurrencesless lesslikely. likely. Across a numberofof studies, that Across a number studies, thethe average relapse relapse rate rate on on lithium lithium is is 34% 3 4 % over over periods periods of of treatment treatment ranging ranging from from average five months months to to40 40months. months.The The relapse relapserate rateis is81% 8 1 %on onplacebo placebo pills pills(Goodwin (Goodwin five & Jamison, Jamison, 1990)! 1990)! &:. Even more more important, important,long-term long-termtreatment treatmentwith withmood mood stabilizing stabilizingmedica­ medicaEven tions (notably (notably lithium) lithium) decreases decreases the the chances chances that that any any person person with tions with bipolar bipolar disorder will will commit commit suicide suicide (Baldessarini (Baldessarini et et aL, al, 1999; 1999; Tondo Tondo et al, 1998). disorder et aL, 1998). One One only only has has to to read read autobiographical autobiographical accounts accounts of ofpeople people with with bipolar bipolar or or de­ depressive pressive disorders disorders to to know know the the pOSitive positive impact impact that that medication medication has has had had on on their their lives, lives,including includingthe theremoval removalofofsuicidal suicidal thoughts, impulses, attempts thoughts, impulses, andand attempts (for example, example,]amison, Jamison,1995; 1995;Wurtzel, Wurtzel,1994; 1994;Solomon, Solomon,200l). 2001).Sadly, Sadly,many manyof of (for the people people who w h o committed committed suicide suicide had had little little or orno noaccess accessto topsychiatric psychiatrictreat­ treatthe ment. They They did did not not receive receive the the appropriate appropriate medicat medication or psychiatric psychiatric care, care, or or ment. ion or their illnesses illnesses were were not not even even detected detected by by mental mental health health profeSSionals professionals in in the the their first place place Oamison, (Jamison,2000a; 2000a;Jamison, Jamison,2000a, 2000a,b).b). first

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CAUSES AND TREATMENTS TREATMENTS CAUSES AND

Acute versus Acute versus Preventative PreventativeTreatment Treatment For the medication treatment, think of your as having For the purposes purposesofof medication treatment, think of disorder your disorder as an having an �acute phase" (treating an an existing "acute phase" (treating episode) and and aa "maintenance "maintenance phase" phase" existing Ulness illness episode) (preventing future future episodes). episodes). The medication you you take take during during the the two two phases phases (preventing The medication may be different. different. Your m a y be Your regime regime during during the theacute acute phase phase is islikely likelyto toinvolve involve more more medications at at higher dosages than than your your regime regime during the maintenance medications higher dosages during the maintenance phase. phase. The phase involves bringing you you d o w n from severe manic high or The acute acute phase involves bringing down from a a severe manic high or up from a depreSSive low. low. Acute Acute phase usually done done on on an inten­ up from a depressive phase treatment treatment is is usually an intensive sive outpatient through regular psychiatry appoimments, appointments, or or through through inoutpatient basis basis through regular psychiatry in­ patient hospitalization. On average, the the acute phase of patient hospitalization. O n average, acute phase up to of treatment treatment lasts lasts up to three months, although although nowadays nowadays only only about a week (if any) any) would would be be three months, about a week of of this this (if spent in the hospital. hospital. The length of of the acute phase phase m a y be shorter or or longer, spent in the The length the acute may be shorter longer, depending your response medications. depending on on your response to to the the medications. In contrast, contrast, the maintenance phase phase involves involves keeping keeping you you well well and and preIn the maintenance pre­ venting you you from from developing developing more severe symptoms. symptoms. This is also called "proventing more severe This is also called " pro­ phylactic" (preventative) (preventative) treatment. treatment. The The maintenance maintenance phase phase does does not not have have a phylactic" a prescribed length, although prescribed length, althoughsome some doctors doctorssay saythat thatat atleast leastsix sixmonths months of ofstable stable medication is is necessary necessary after after the the acute acute phase phase to to help help prevent prevent recurrences recurrences of of medication et aI., the disorder disorder (Fawcett (Fawcett et al, 2000). 2000). As A s you'll you'll see see in in Chapter Chapter 7. 7, many m a n y people people the take their their medications medications during during the the acute acute phase phase but but mistakenly mistakenly want want to to drop drop take them during during the the maintenance maintenance phase, phase, thinking thinking they they no no longer longer need need them. them. The The them result is is often often that that they they have have rapid rapid recurrences recurrences of of the the disorder, disorder, even even though though result they were were better better at at the the point point when w h e n they they discontinued discontinued the they the medications. medications. The two two graphs graphs on on page page 101 101 show show how h o w acute acute and and maintenance maintenance treatment treatment The works. Two T w o patterns patterns are are described described in in each: each: one one in in which which a a bipolar bipolar person person works. takes medication medication (solid (solid line), line), and and one one in in which which he he or or she she does does not not (dOlled (dotted takes line). In In the the first first figure, figure, Alben, Albert, aa 32-year-old 32-year-old with with bipolar bipolar II disorder, disorder, devel­ develline). oped a a severe severe manic manic episode. episode.Just Justbefore beforethe themania mania would would have havecrested, crested,he hebe­ beoped gan taking taking two two medications, medications, lithium lithium and and an an antipsychotic antipsychotic drug. drug. The The dotted dotted gan line shows shows what what would would likely likely have have happened happened if ifhe he hadn't hadn'ttaken takenmedications medicationsat at line that point point in in time. time. that The The second second figure figure shows shows what what Albert's Albert's longer-term longer-term course course of of illness illness looked like like with with medications, medications, and and what what it it would would have have looked looked like like without without looked them. Notice Notice that that for for Alben, Albert, medications medications do do not not eliminate eliminate his his mood m o o d cycling, cycling, them. but they they do do slow slow it it down d o w n and and prevent prevent full full recurrences. recurrences.The Theperiods periodsofofwellness wellness but between are longer, longer,his hisepisodes episodesare areshaner shorterand andless lesssevere, severe, and his symptoms between are and his symptoms episodes are are milder. milder. Thus, Thus, in in the the best-case best-case scenario, scenario, aa medication medication regime regime episodes should do do three three things things for for you: you: should

101 101

What (on lor Me? Con Medimtion Medication and and Psychotherapy Psychotherapy Do Do for Me?

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Albert's longer-tenn longer-term mood m o o d cycling, cycling, as asititwould wouldappear appearon onappropriate appropriatemedications medications(solid (solidlines) lines)and andoff off Albert's medications medications (dotted (dotted lines). lines).

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CAUSES AND CAUSES ANDIREAIMENIS TREATMENTS

1. Control and and helphelp resolve anan episode developed; resolve episodethat that has has already already developed; 1 . Control do occur; occur; 2. episodes and 2. Delay Delay future future episodes and minimize minimize the the severity severity of of those those that that do 3. 3. Reduce Reduce the the severity severity of of the the symptoms symptoms you you experience experience between between episodes. episodes. More globally, globally, when you you can can expect to be to be More whenyour yoursymptoms symptoms are arewell-controlled, well-controlled, expect

more control of and have easier time goals. Havmore in in cootTol of your your life life and have an an easier time pursuing pursuing your your goals. Hav­ ing more more control control increases the chances chances that you'll be be able able to to function function beueT ing increases the that you'H better at at work and and in in your your family family and and social work social life. life.

"Do II Have Have to to lake Take Medication Medication Forever?" ''Do Forever?" This is isa aquestion question manypeople peoplewith with bipolar illness ask. Itunderstand­ is an understandThis many bipolar illness ask. It is an able and and very important question. question. As As you you know k n o w from from Chapter Chapter 5, 5,bipolar bipolardisor­ disorable very important der is is associated with underlying biological imbalances the activity activity der associated with underlying biological imbalances involving involving the

of brain brain neurotransmitters and their their associated signaling systems. These im­ imof neurotransmitters and associated Signaling systems. These balances are believe that that medications medications help balances are inherited inherited in in many m a n y cases. cases. We W e also also believe help

correct biochemical biochemical imbalances in some some of of the the ways ways described described below. below. For For this correct imbalances in this reason, most most people people with with bipolar bipolar disorder disorder must must take take medication medication indefinitely, reason, indefinitely, especially especially if if the the diagnosis diagnosis seems seems definite, definite, if if they they have have had had more more than than one one

major episode, and and if if they they have have aa family family history history of ofbipolar bipolar illness. illness.Much M u c h like like major episode, diabetes or or high high blood blood pressure, pressure, bipolar bipolardisorder disorder involves involvesbiological biologicalvulnera­ vulneradiabetes bilities that require treatment. bilities that require long-term long-term treatment.

There are are exceptions exceptions lO to this this rule, such as as if if a a woman w o m a n wants wants to to become become rule, such There pregnant (mood (mood stabilizers stabilizers can can increase increase the the risk risk to to the the fetus fetus of of hean heart and and cenpregnant cen­ tral nervous nervous system system defects). defects). In In the the case case of of pregnancy, pregnancy, the the solution solution is is usually usually tral to gradually gradually discontinue discontinue medication medication prior prior to to conception conception and and then then reintroduce reintroduce to it later later in in (or (or after) after) the the pregnancy, pregnancy, or or find find a a different different class class of of medication medication it rather than than stopping stopping altogether altogether (Cohen (Cohen et et aL, al, 1994; 1994; Kahn K a h n et et al., al, 2000). 2000). ¥ou You rather m a y also also have have to to stop stop medication medication if ifyou you develop develop aamedical medicalcondition condition that thatpre­ premay vents you you from from taking taking mood m o o d stabilizers stabilizers (for (for example, example, certain certain diseases diseases of of the the vents liver or or kidney). kidney). Fortunately, Fortunately, your your mood m o o d stabilizing stabilizing medications medications are are not not ad­ adliver

dictive or or habit-forming: habit-forming:You You will willnot notcrave cravethem them when w h e n they theyare arewithdrawn. withdrawn. dictive

Ifyou you have have had had only only one one episode, episode,your your doctor doctor may m a y recommend recommend that thatyou you If take medication medication for for one one year year and and then then reassess reassess your your need need for for it. it.But Butthat thatrec­ rectake ommendation will will vary vary from from doctor doctor to to doctor doctor and and will will depend depend on on how h o w stable stable ommendation ,

your mood m o o d remains remains over over the the year. year. It's It'saagood goodidea ideato toask askyour yourdoctor doctorhow h o w long long your he he or or she she expects expects you you to to be be taking taking medicines. medicines.

Needless to to say, say, accepting accepting aa long-term long-term drug drug regime regime is is aa very very Significant significant Needless decision. I'll I'llsay saymore more about aboutthe theemotional emotionalSignificance significanceof oftaking takingmedications medications decision.

WhatCon CanMedication Medicationand andP�(hotheropy PsychotherapyDoDo or Me? Whot lor fMe?

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in Chapter Chapter 7.7.For Fornow, now, let's let'sfocus focus on on thethe mechanics mechanics of medications: of medications: which which in effects, ones ones you y o u are are likely likely to to be b e prescribed, prescribed, in in what w h a t dosages, dosages, their their likely likely side side effects, a n d how h o w long long before before they they take take effect. and effect.

What W h a t Is Is a a Mood M o o d Stabilizer? Stabilizer? Mood stabilizers are given during duringthe theacute acutephase phase and continued Mood stabilizers are usually usually given and continued dur-dur­ ing ing the the maintenance m a i n t e n a n c e phase phase of of treatment. treatment. To T o be b e defined defined as as a a mood m o o d stabilizer, stabilizer, a a medication has has to to be b e effective effective in in treating treating manic, m a n i c , mixed, m i x e d , or or depressive depressive episodes episodes medication of bipolar bipolar disorder, disorder, andlor and/or must m u s t prevent prevent new n e w episodes episodes during during long-term long-term main­ mainof tenance. tenance. Some S o m e mood m o o d stabilizers stabilizers do d o both. both. The T h e medication medication must m u s t not not worsen w o r s e n the the bipolar bipolar disorder disorder or or cause cause rapid rapid cycling cycling (four (four or or more m o r e episodes episodes in in one o n e year; year; see see Chapter Chapter 3). 3 ) . As A s you'll you'll soon s o o n see, see, antidepressants antidepressants like like fiuoxetine fluoxetine (Prozac) (Prozac) are are not not considered considered mood m o o d stabilizers stabilizers because because they they impact impact only only depreSSion, depression, not not mania, mania, a n d because because they they can can cause cause rapid rapid cycling. cycling. N o t e that that medications medications have have at at least least and Note two names: names: a a generic generic name n a m e that that reflects reflects their their chemistry chemistry (which (which I'll I'll give give first) two first) followed by by a a specific specific brand b r a n d name n a m e created created by b y the the pharmaceutical pharmaceutical company company followed that that developed developed the the generic generic drug d r u g for for commercial c o m m e r c i a l use use (given (given in in parentheses). parentheses). Doctors and a n d pharmacies pharmacies usually usually refer refer to to drugs drugs by b y their their brand brand name. n a m e . The T h e main main Doctors m o o d stabilizers stabilizers in in use use today today are are lithium lithium carbonate carbonate and a n d the the anticonvulsants: mood anticonvulsants: typically, divalproex divalproex sodium sodium (Depakole) (Depakote) or or carbamazepine carbamazepine (TegretoI). (Tegretol). Certain Certain typically, n e w e r agents---for agents—for example, e x a m p l e , lamotrigine (Lamictal), topiramale topiramate (Topamax) ( T o p a m a x ) ,, newer lamotrigine (LamictaI), and gabapentin gabapentin (Neurontin)-although ( N e u r o n t i n ) — a l t h o u g h less less proven, proven, benefit benefit some s o m e people. people. and Y o u r mood m o o d stabilizing stabilizing medications medications are are likely likely to to change change over over time, time, both both in in Your type and a n d in in dosage. dosage. The T h e need n e e d to to change c h a n g e medications medications doesn't doesn't mean m e a n you're you're get­ gettype ting ting worse. worse. Typically, Typically, no n o Single single medication medication works w o r k s to to alleviate sympalleviate bipolar bipolar symp­ t o m s over over the the person's person's entire entire lifespan. Hfespan. It's It's also also likely likelythat thatyou'll you'll be b e treated treated with with toms m o r e than than one o n e mood m o o d stabilizing stabilizing medication medication at at some s o m e point point or or perhaps perhaps even even on on more an an ongOing ongoing basis basis (for (for example, e x a m p l e , lithium lithium and a n d Depakote D e p a k o t e together). together). Many M a n y people people with bipolar bipolar disorder disorder experience experience an a n additive additive therapeutic therapeutic benefit benefit f r o m taking taking with from m o r e than than one o n e mood m o o d stabilizer. stabihzer. Perhaps Perhaps this this is is because because agents agents like Hke H t h i u m and and lithium more Depakote Depakote have h a v e different different but b u t complementary c o m p l e m e n t a r y effects effects on o n brain brain mechanisms, mechanisms, such as as the the protein protein kinase kinase C C signaling signaling pathway p a t h w a y (Manji, (Manji, 2001; 2 0 0 1 ; see see Chapter Chapter 5). 5). such Taking more m o r e than than one o n e medication medication doesn't doesn't mean m e a n that that you y o u are than Taking are sicker sicker than the the next next person person with with bipolar bipolar disorder-it disorder—it just just may m a y mean m e a n that that your y o u r unique unique physiology doesn't doesn't respond respond as as well as that that person's person's to to an a n individual individual com­ comphysiology well as p o u n d . People People vary vary in in their their response response to to medications medications in in part part because because of of their their pound. patterns of of symptoms, s y m p t o m s , such s u c h as as whether w h e t h e r they they have have pure pure manic m a n i c highs versus patterns highs versus mixed m i x e d episodes. episodes.

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CAUSES CAUSESANO ANDIREAIMENIS TREATMENTS

Types of Stabilizers Types of Mood Mood Stabilizers LithiumCarbonate Carbonate Lithium

The most well well known mood stabilizer is which dispensed The most known mood stabilizer is lithium, lithium, whichisis dispensed under under brand names names like like Eskalith, Eskahth, Lithobid, Lithobid, Lithonate. Lithonate, or or Cibalith-S. Cibalith-S. A A naturally naturally ocbrand oc­ curring find in first curring element element that that you'll you'll find in the the periodic periodic table, table, lithium lithium was was the the first medication proven proven to to stabilize stabilize mood m o o d in in bipolar bipolar disorder disorder and and also also to to prevent prevent medication manic or or depressive depressive episodes episodes from from returning. returning. Although Although various variousforms forms of of"lith­ "lithmanic ium overexcite­ ium bromide" bromide" were were used used during during the the late late 18005 1800s to to quell quell agitation agitation or or overexcitement, the the discovery discovery of of lithium lithium as as a a treatment treatment for for bipolar bipolar disorder disorder is is usually ment, usually anribuled attributed to to John John Cade Cade (1949). (1949). Cade Cade was was an an Australian Australian phYSician physician who w h o theo­ theorized what was rized that that there there were were toxic toxic compounds compounds in in the the urine urine of of patients patients with with what was then called called manic-depressive manic-depressive illness. illness. He H e happened happened upon u p o n lithium lithium by by accident. then accident. His experiment experiment involved involved injecting injecting uric uric acid mixed with with lithium lithium into into the His acid mixed the bloodstream bloodstream of of guinea guinea pigs. pigs. Injection Injection with with lithium lithium calmed calmed down d o w n the the guinea guinea pigs pigs and and made m a d e them them less less active. active. Cade Cade then then thought thought to to try try lithium lithium with with one one of of his most severely ill ill manic manic patients, patients,a aS 51-year-old m a n .The Thepatient patientresponded responded most severely l·year-old man. his very rst time very well well and and for for the the fi first time was was able able to to function function outside outside of of a a hospital. hospital. This This story fact that pa­ story of of sciemific scientific serendipity serendipity is is somewhat somewhat tempered tempered by by the the fact that this this patient later, tient took took himself himself off off the the medication, medication, against against medical medical advice advice six six months months later, perhaps foreshadowing foreshadowing the the wide-ranging wide-ranging problem problem of of med\cation medication nonad­ nonadperhaps herence by by people people treated treated for for bipolar bipolar disorder. disorder. Nonetheless, Nonetheless, lithium lithiumcame came into into herence general use use in in the the 1960s 1960s and and has has been been used used regularly regularly in in the the United United States States since since general 1970, to to the the great great benefit benefit of of many m a n y people people with with the the illness. 1970, illness. Lithium is is usually usually given given in in 300300- or or 4S0.milligram 450-milligram (mg) (mg) tablets, tablets, and and peo­ peoLithium ple usually usually take take between between one one and and eight eight of of these these per per day day (300-2400 (300-2400 mg). m g ) . Some Some ple people take take their lithium in in divided divided doses, doses, several several times times a a day, day, and and some some only only their lithium people once—this is is one one of of the the decisions decisions you your doctor doctor can a k e when w h e n trying once-this you and and your can m make trying to figure figure out out how h o w best best to to control control your your side side effects. effects.A A correct correctdosage dosageis isone onethat that to brings your blood blood level level into "therapeutic range." range." The The therapeutic therapeutic range range your your brings your into aa "therapeutic doctor targets targets for for you you during during treatment treatment of of your your acute acute episode episode may m a y be be higher higher doctor than the the one one he he or or she she targets targets during during your your ongoing ongoing maintenance maintenance treatment, than treatment, which is is usually usually between between 0.8 0.8 and and 11.2 millequivalents per liter liter (a (a chemical chemical which . 2 mill equivalents per measure of of lithium Hthium concentration concentration in in the the blood). Children with with bipolar bipolar disormeasure blood). Children disor­ of der or or persons persons over over the the age age of of 65 65 can can often often be maintained on on lower lower dosages dosages of der be maintained lithium and and still still show show good good responses. lithium responses. H o w well well does does lithium Hthium work? work? Studies Studies indicate indicate that that 60-70% 6 0 - 7 0 % of of people people with with How bipolar disorder disorder show show a a remission remission of of symptoms symptoms when w h e n treated treated with with lithium lithium bipolar (Goldberg, 2000; 2000; Goodwin Goodwin & & lis, Zis, 1979). 1979). Even Even at at appropriate appropriate blood blood levels, (Goldberg, levels, however, people people can can have have "breakthrough" "breakthrough" episodes episodes of of mania or depression. however, mania or depression.

What What(on Con Medication Medication and and Psychotherapy Psychotherapy Do Do for for Me? Me?

lOS 105

Lithium doesa abetter betterjob jobofofpreventing preventing manic episodes controlling Lithium does manic episodes and and controlling manicmanic symptoms s y m p t o m s than than it it does d o e s preventing preventing depreSSive depressive episodes, episodes, but b u tit itcan c a nstill stiH be b e effec­ effec1996; Prien et et tive tive as as an a n antidepressant antidepressant when w h e n used used alone alone (Keck ( K e c k &: & McElroy, McElroy, 1 9 9 6 ; Prien al, 1984; 1984; Zornberg Zornberg & & Pope, Pope, 1993). 1993). aI., When W h e n you y o u begin begin taking taking lithium, lithium, you y o uwon't won't feel feel its itsbenefit benefit right right away. a w a y . It Itwill will probably probably take take at at least least a a week w e e k and a n d often often a a few f e w weeks w e e k s before before you y o u start start seeing seeing iim­ mp r o v e m e n t in in your y o u r manic m a n i c or or depressive depressive symptoms. symptoms. provement The that go T h e table table on o n this this page p a g e lists lists the the symptoms s y m p t o m s and a n d course course patterns patterns that go a less along along with with a a good g o o d response response to to lithium, lithium, and a n d the the factors factors that that go g o along along with with a less favorable favorable response response to to lithium lithium and and a a better better response response to to the the anticonvulsants anticonvulsants factors, (Depakote (Depakote and a n d TegretoD. Tegretol). It It is is useful useful for for you y o u lO to know k n o w about about these these factors, w h i c h function function as as predictors. predictors. They T h e y may m a y help help explain explain why w h y your y o u r doctor has rec­ recwhich doctor has ommended o m m e n d e d anticonvulsants anticonvulsants over over lithium, lithium, or or the the reverse. reverse. In In general, general, the the more more your illness illness reflects reflects the the "textbook" "textbook" description description of of bipolar bipolar disorder disorder (euphoric, (euphoric, your grandiose, grandiose, manic m a n i c highs highs followed followed by b y deep d e e p depreSSions, depressions, combined c o m b i n e d with with a a family family history the history of of bipolar bipolar disorder disorder in in one o n e or or more m o r e of of your y o u r first-degree first-degree relatives), relatives), the more m o r e likely likely you y o u are are to to respond respond to to lithium. lithium. The T h e more m o r e "atypical" "atypical" your y o u r disorder disorder is is (for (for example, e x a m p l e , characterized characterized by b y mixed m i x e d episodes, episodes, psychosis, psychosis,or orrapid rapid cycling), cycling), the more m o r e likely likely you y o u will will do d o better better on o n the the anticonvulsams. anticonvulsants. the We and W e don't don't know k n o w exactly exactly why w h y lithium lithium is is effective effective in in controlling controlling manic manic a nd (to (to a a lesser lesser extent) extent) depreSSive depressive episodes, episodes, but b u t we w e suspect suspect it it has has effects effects on o n the the underlying biological biological vulnerabilities vulnerabilities discussed discussed in in Chapter Chapter 5. 5. You'll You'll recall recall that that underlying c o m p o n e n t s of of the the second s e c o n d messenger m e s s e n g e r system system (for (for example, e x a m p l e , calcium, calcium, protein protein componems Predictors of Response to Lithium Anticonvulsants Predictors of Response to Lithium vc:rsus versus Anticonvulsants A good good response response to to lithium lithium A

good response response to to amiconvuisants anticonvulsants A good

"Pure," euphoric euphoric manias manias ·Pure."

Mixed episodes episodes (depression (depression and mania Mixed combined) combined)

A cycling cycling pattern pattern marked marked by by manias manias followed A

cycling pattern pattern marked marked A cycling

by by depressions, depressions, followed followedby bynonnal normalmood mood

followed followedby bymanias manias

by depressions by

periods periods

High prevalence of bipolar disorder in in the the High

No (or (or low) low) prevalence prevalence of of bipolar bipolar disorder in in No

family tree tree family

(he the family family tree tree

Absence of of rapid rapid cycling cycling Absence

Rapid cycling cycling (four (four or or more more episodes/year) Rapid episodes/year)

A good good respo� response to to lithium lithium previously previously A

Very severe severe manias manias wilh with psychosis psychosis (delusions/ (delusions/ Very hallucinations) hallucinations)

Fewer, rather ratherthan thanmore, more,previous previousepisodes episodesofof Fewer,

Co.occuning bstance abuse Co-occurringsusubstance abuseororanxiety anxiety

illness iUness

disorders disorders

Clear-cut episodes episodes with with relatively symptom-free

Mania symptoms that that occur occur after after aa Mani a symptoms

intervals in in between between intervals

neurological neurological illness illness or orbrain braininjury injury

Sources: Calabr� Calabrese et et al. al. (1996); (1996); Grof Grof et et a1. al. (1993): (1993); McDonald McDonald (2000). (2000). Sources:

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CAUSES CAUSESAND ANDIREAIMENIS TREATMENTS

kinase communicating kinase C) C) are are responsible responsiblefor for communicatingchemical chemicalmessages messagestotovarious various parts of parts of the the cell, cell,such suchas asthe thecell cellnucleus, nucleus,which which determines determineswhen w h e n aacell cellcom­ communicates municates messages messages to to other other cells. cells. Through Through its its effects effects on on signal signal transduction transduction pathways, lithium lithium may m a y affect affect whether whether chemical chemical messages messages are are sent sent from from the the pathways, brain to to parts parts of of the the body body or or from from one one pan part of of the the brain brain to to another. another. brain Side of Lilhium SideEffects Effects of Lithium W h e n you you take take any any medication, medication, it's it's important important to toknow k n o w its itspossible possibleside sideeffects effects When so that changes so that changes in in your your body body will will not not come c o m e as as a a surprise surprise to to you, you, and and you'll you'H them LO your doctor. know k n o w La to report report them to your doctor. All All mood m o o d stabilizing stabilizing agents agents have have some some side side effects. effects. In Infact, fact,be beskeptical skepticalofof"namral" "natural"oror"homeopathic" "homeopathic"mood m o o dremedies remedies that presumably presumably have have no no adverse adverse effects. effects. There Thereis isno noevidence evidencethat thatany anynatural natural that substance is is both both free free of of side side effects effects and and effective as a a m o o d stabilizer. substance effective as mood stabilizer. Your Your doctor doctor will will usually usually include include any any side side effects effects you you repon report as as an an impor­ important source of of information information for for planning planning your your treatment. treatment. Side Side effects effects can can often tant source often be a be controlled controlled in in some some of of the the ways ways described described below. below. In In Chapter Chapter 7 7 you'll you'll find find a side-effect side-effect recording recording sheet sheet that that will will help help you you communicate communicate with with your your doctor doctor about complications complications associated associated with your medication. medication. about with your People effects People with with bipolar bipolar illness illness generally generally have have some some predictable predictable side side effects with lithium, lithium, but butwhich which ones onesaaperson persondevelops developsand and their theirseverity severityvary varyaagreat great with deal from from person person to to person. person. Common C o m m o n side side effects effects of lithium include include thirst, thirst,re­ redeal of lithium in taining water, frequent urination, fatigue, diarrhea, and/or a metallic taste in taining water, frequent urination, fatigue, diarrhea, andlor a metallic taste the mouth. mouth. More side effects effects include include weight weight gain, gain, mental mental slugthe More troublesome troublesome side slug­ gishness or or problems problems with with memory, memory, shaky shaky hands, development or orflareup of gishness hands, development fiareup of skin conditions conditions (such (such as as acne acne or or psoriasis), psoriasis), andlor and/or stomach stomach discomfort or discomfort or skin pain. S o m e people also develop hypothyroidism, a condition in which the thypain. Some people also develop hypothyroidism, a condition in which the thy­ roid gland gland does does not produce enough enough hormone. hormone. Kidney Kidney functioning functioning (the (the ability abihty roid not produce of the the kidney kidney to clear substances substances like like urea urea or or creatinine creatinine out of the the blood) can of to clear out of blood) can also be affected if lithium is is taken taken over over a a long long period period of of time. also be affected if lithium time. The side effects of lithium can be related to the dosage you take. take. Many Many The side effects of lithium can be related to the dosage you doctors adopt adopt the the "start "start low, low, go go slow" slow" approach approach in which you start the the medi­ medidoctors in which you stan cation on a low dosage and gradually increase to the therapeutic dosage, as aa cation on a low dosage and gradually increase to the therapeutic dosage, as w a y of of keeping keeping your your side side effects effects in in check. check. If Ifyou you are arealready already being being maintained maintained way on a a cenain certain dosage dosage of of lithium lithium but have unpleasant unpleasant side side effects, effects, your your doctor doctor on but have m a y decide decide to to reduce reduce your dosage, although although this this carries the risk risk of of making may your dosage, carries the making the the medication less less effective effective for for you. you. In In other other words, words, treatment treatment with with lithium Hthium can can medication be a a bit bit of a balancing balancing act act in in which which you and your your doctor doctor collaborate collaborate to to find find the be of a you and the blood level that stabilizes stabilizes your your mood m o o d (for (for example, example, keeps keepsyou you episode-free episode-freefor for blood level that at least a a year) year) but butalso alsoallows allowsyou you to tofunction functionwith with the theleast leastannoying annoyingside sideef­ efat least fects (for (for example, example, not not haVing having to deal with with slowed-down slowed-down thinking). thinking). fects to deal

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Other effects require creative solutions: frequent urination, Other side side effects require more more creative solutions: frequent urination, for for example, day of sev­ e x a m p l e , can c a n be b e reduced reduced by b y taking taking lithium lithium once o n c e during during the the d a y instead instead of sev-

eral times times a a day; day; thirst thirst can can be b e controlled controlled by b y drinking drinking more m o r e water, water, c h e w i n g on on eral chewing ice chips, chips, or or using using sugarless sugarless cough c o u g h drops. drops. Stomach S t o m a c h irritation irritation can can bbe e helped by ice helped by taking lithium lithium after after a a full full meal. meal. In In other other cases, cases, your y o u r side side effects effects may m a y require require taking additional additional medications, medications, such s u c h as as thyroid thyroid supplements supplements (for (for example, e x a m p l e , levo­ levothyrOXine thyroxine (Synthroid)) [Synthroid]) or or beta-blockers beta-blockers for for hand h a n d tremors tremors (for (for example, example, propranolol lith­ propranolol [Inderal)). [Inderal]). Kidney K i d n e y functioning functioning is is usually usually monitored monitored during during Hthium i u m treatment treatment through through a a variety variety of of blood blood tests tests (for (for example, e x a m p l e , your y o u r creatinine creatinine

level)., level)

Lilhium Blood Lithium BloodTests Testsand andToxicity Toxidty People must have their blood drawn regularly to make sure People who whotake takelithium lithium must have their blood drawn regularly to make

sure

they are are getting getting a a proper proper dosage. dosage. If If you y o u are are starting starting lithium lithium for for the the first first time time they and are are being being stabilized stabilized from from a a manic m a n i c or or depressive depressive episode, episode, you y o u will will probably probably and have one have to to get get your y o u r blood blood tested tested every every week w e e k or or two t w o for for the the first first o n e or or two two

m o n t h s of of treatment, treatment, then then every every month m o n t h for for about about three three months. m o n t h s . If If all all has has gone gone months well it tested well up u p to to that that pOint, point, your y o u r doctor doctor will will probably probably recommend r e c o m m e n d you y o u get get it tested

every three three months m o n t h s or or so. so. The T h e purpose purpose is is to to make m a k e sure sure you y o u have have the the proper proper every level level of of lithium lithium in in your y o u r bloodstream. bloodstream. Generally, Generally, your your physician physician will will check check

your blood blood level level about about 10-14 1 0 - 1 4 hours hours after after your your last last lithium lithium dosage. dosage. your Getting your y o u r blood blood tested tested regularly regularly helps helps prevent prevent lithium lithium toxicity. toxicity, in in Getting w h i c h your y o u r body b o d y accumulates accumulates lithium lithium at at very very high high levels. levels. The T h e signs signs of which of toxicity toxicity include p r o b l e m s with balance and a n d coordination, coordination, severe severe diarrhea, diarrhea, abdominal abdominal include problems with balance discomfort, blurry blurry vision, vision, slurring slurring of of speech, speech, extreme extreme shakiness shakiness of of the the hands, hands, discomfort, severe nausea nausea or or vomiting, vomiting, and a n d mental mental confusion confusion or or disorientation. disorientation. Because Because severe this toxic toxic state state is is extremely extremely dangerous dangerous and a n d even even potentially deadly, it it is importhis potentially deadly, is impor­ tant to to know k n o w the the signs (and infonn inform your y o u r dose close relatives relatives as as well) well) so that y o u can can tant signs (and so that you get in in to to see see your y o u r doctor doctor as as soon soon as as possible, possible, to to have have your y o u r blood blood level checked level checked get and cases to a n d in in most m o s t cases to have have your y o u r lithium lithium adjusted adjusted or or stopped stopped temporarily. temporarily. Y o u r lithium lithium blood blood levels levels can can increase increase in in reaction reaction to to dehydration dehydration or or from from Your taking over-the-counter over-the-counter medications medications such s u c h as as ibuprofen. ibuprofen. Your Y o u r levels levels can also taking can also be too too low l o w or or even even non nontherapeutic, especially if if you y o u are are getting getting an a n inadequate inadequate be therapeutic, especially dosage or or have h a v e been b e e n Laking taking the the medication medication inconSistently. inconsistently. It is helpful helpful 10 to dosage It is k n o w these these facts facts and a n d to to become b e c o m e familiar familiar with with the the blood blood level level scale scale so so that that you you know can become b e c o m e an a n active active participant participant in in your y o u r lithium lithium treatment. treatment. Ask A s k your your doctor doctor can which w h i c h blood blood level level he h e or or she she is is targeting targeting for for you, y o u , so so that that you'll you'll know k n o w when when

your levels levels are are getting getting too too low l o w or or too too high. high. If If you y o u decide decide to to see see another another doctor, doctor, your h e or or she she will will want w a n t to to know k n o w what w h a t therapeutic therapeutic blood blood levels levels you y o u are are currently currently he maintaining, and a n d which w h i c h levels have been b e e n problematic problematic for for you y o u in in the past. levels have the past. maintaining,

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stuck withwith a nee­ You You may may find find blood testing difficult: No one one likes likes stuck a neeblood testing difficult: No to to be be dle, dle, and and having one's blood blood tested tested can can remind remind you you of of being being ill. ill.But Butititisisaavery very having one's important aspect aspect of of your your care. care. If If you you find find it it particularly particularly unpleasant, unpleasant, discuss discuss it it important with with your your doctor. doctor. He H e or or she she may m a y choose choose to to put put you you on on a a mood m o o d stabilizer stabilizer that that requires less testing. requires less frequent frequent blood blood testing. Divalproex Sodium Oi ••lproex Sodium

Divalproex or valproic Divalproex sodium, sodium, which which is is also also called called valproate valproate or valproic acid acid (brand (brand names Depakote and Depakene), is an anticonvulsant medication that has names Depakote and Depakene), is an anticonvulsant medication that has been used used for for decades decades to to treat treat epilepsy epflepsy and and other other seizure seizure disorders disorders (Kahn (Kahn et been el also aL, al, 2000). 2000). For For reasons reasons that that aren't aren't entirely entirely clear, clear, some some anticonvulsams anticonvulsants also have stabilizing properties. Divalproex is have mood m o o d stabilizing properties. Divalproex is a a fatty fatty acid acid that that is is similar similar to to other Divalproex proba� other compounds compounds found found in in animal animal fats fats and and vegetable vegetable oils. oils. Divalproex probably kinase bly works works in in several several ways, ways, including including reducing reducing activity activity of of the the protein protein kinase C pathway pathway and and enhancing enhancing the the action action of of the the inhibitory inhibitory neurotransmilter neurotransmitter C GABA G A B A (Manji, (Manji, 2001; 2001; Goldberg, Goldberg, 2000). 2000). Low L o w levels levels of of GABA G A B A have have been been found found in in blood blood samples samples and and spinal spinal fluids of people with depression depression (Petty (Petty &: & fluids of people with Sherman, Sherman, 1984). 1984). Charles Bowden, Bowden, a a researcher researcher at at the the University University of of Texas Texas Health Health Science Science Charles Center Antonio, and Center in in San San Antonio, and his hisassociates associateshave have found found that thatdivalproex divalproexis isat atleast least as efrective effective as as lithium in controlling controlling episodes episodes of of mania and may m a y be be even even better as lithium in mania and better than lithium lithium in in controlling mixed manic manic episodes episodes (Bowden (Bowden et et aI., al, 1994, 1994, 2000; 2000; than controlling mixed Swann et et aI., al, 1997). 1997). Divalproex Divalproex is is also also reasonably reasonably effective effective in treating bipolar Swann in treating bipolar for depressions, although although many m a n y experts experts view view it it as as a a second second choice choice to to lithium depressions, lithium for this purpose (Kahn (Kahn et al, 2001). 2001). The evidence for for its its effectiveness effectiveness in in preventThe evidence prevent� et aI., this purpose ing future future episodes episodes of of bipolar bipolar disorder disorder is is based based largely largely on on physicians' physicians' opinions opinions ing rather than than the the outcomes outcomes of of long�term long-term research research studies. studies. Nonetheless, Nonetheless, dival� divalrather proex has come come into into wide wide use use as as a a long�term long-term preventative preventative agent, agent, much m u c h like proex has like lithium. lithium. There are are at at least least three three reasons reasons why w h y your your physician physician might might give give you you There divalproex rather than lithium (see the table on page 105). First, if you have divalproex rather than lithium (see the table on page 105). First, if you have mixed episodes episodes or or rapid rapid cycling, cycling, i m a y be be more more effective effective for for you. you. Second, Second, it it mixed itt may seems to to work work a a bit bit more more quickly, quickly, even evenwithin withinas asfew fewas asthree threeto tofive fivedays daysafter after seems usually the onset of a a major major manic manic episode. episode. Unlike Unlike lithium, lithium, your your dosage dosage can can usually the onset of be raised raised rather rather quickly quickly without without severe side effects. effects. Third, Third, there is evidence evidence be severe side there is that people people have have less less severe severe side side effects effects with with divalproex divalproex than than with with lithium lithium that (Bowden, 1996; 1996; Weiss Weiss et et al., al, 1998). 1998). These These advantages advantages must be weighed weighed (Bowden, must be against the the greater greater abundance abundance of of supportive supportive research research on on lithium, lithium, perhaps perhaps beagainst be­ cause it it has has been been around for longer. cause around for longer.

what (on ConMedication Medicationond andPsychotherapy PsychotherapyDoDoforfo r Me? What Me?

109109

People usually are given divalproex in 250-into250500-mg they and they People usually are given divalproex to tablets, 500-mg and tablets, typically ,500 mg is a typically take take from f r o m 11,500 m g to to 3,000 3,000 mg m g per per day. day. Three T h r e e times times a a day day is a typi­ typical cal dosing dosing pattern. pattern. Your Y o u r doctor doctor will will want w a n t to to achieve achieve a a therapeutic therapeutic serum s e r u m level level which per milliliter w h i c h is is usually usually between b e t w e e n 45 4 5 and a n d 125 1 2 5 micrograms m i c r o g r a m s per milliliter (the (the measure measure used lithium, regreg­ used to to indicate indicate divalproex divalproex concentration concentration in in the the blood). blood). As A s with with lithium, ular ular blood blood tests tests can c a n tell tell you y o u and a n d your y o u r doctor doctor whether w h e t h e r you y o u are are geuing getting the the proper proper dosage dosage of of divalproex. divalproex.

Side Efterts 01 Divalproex Side Effects of Divalproex Because divalproexisisbroken broken down by the liver, develop an elevation Because divalproex down by the liver, youyou cancan develop an elevation in in liver liver enzymes, e n z y m e s , which, w h i c h , in in rare rare instances, instances, can can lead lead to to liver liver inflammation. inflammation. Divalproex Divalproex can can also also affect affect the the production production of of blood blood platelets. platelets. For F o r this this reason, reason, at your doctor doctor should should conduct conduct liver liver enzyme e n z y m e tests tests and a n d blood blood platelet platelet counts counts at your regular regular intervals intervals (Kahn ( K a h n et et aL, al, 2000). 2 0 0 0 ) . When W h e n you y o u start start taking taking divalproex, divalproex, you you may have a m a y feel feel nauseous, nauseous, sleepy sleepy or or sedated, sedated, or or have h a v e indigestion, indigestion, and a n d you you m a y have a may h a n d tremor tremor (as (as can can occur occur with with lithium). lithium). These T h e s e side side effects effects usually usually disappear disappear hand relatively relatively soon. soon. Some S o m e people people also also develop develop hair hair loss loss or or hair hair thinning. thinning. More More worrisome w o r r i s o m e is is significant significant weight weight gain, gain, which w h i c h can can contribute contribute to to other other medical medical problems (for e x a m p l e , high blood pressure, heart disease, or diabetes). Genproblems (for example, high blood pressure, hean disease, or diabetes). Gen­ erally, erally, your y o u r doctor doctor will will treat treat these these side side effects effects by b y changing changing the the schedule schedule of of your pills pills or or adjusting adjusting your y o u r dosage dosage (for (for example, e x a m p l e , dropping dropping the the dosage dosage may may your help you y o u feel feel less less sedated). sedated). Your Y o u r doctor doctor may m a y also also recommend r e c o m m e n d certain certain drugs drugs as as help adjuncts to to divalproex, divalproex, such s u c h as as ranitidine ranitidine (Zantac) (Zantac) for for nausea, nausea, or or vitamins vitamins adjuncts containing selenium selenium and a n d zinc zinc for for preventing preventing hair hair loss. loss. containing N e w formulations formulations of of divalproex divalproex help help people people who w h o are are very very sensitive sensitive to to the the New side effects effects of of the the 500-mg 5 0 0 - m g tablets. tablets. Depakote D e p a k o t e 125-mg 1 2 5 - m g sprinkles-a sprinkles—a popular popular alside al­ ternative for for children children and a n d many m a n y adul a d u lts---c t s — ca an n be b e put put on o n food food to to reduce reduce stomach stomach ternative irritation. There T h e r e is is also also an a n extended-release extended-release 500-mg 5 0 0 - m g tablet tablet (Depakote (Depakote ER) E R ) that that irritation. may m a y be b e less less likely likely to to cause cause stomach s t o m a c h distress distress or or significant significant weight weight gain. gain. T h e r e is a concern that w o m e n w h o take divalproex can develop a n illness There is a concern that women who take divalproex can develop an illness called polycystic ovary disease, disease, in in which w h i c h noncancerous cysts develop o n the the called polycystic ovary noncancerous cysts develop on ovaries. But B u t the the jury jury is is still still out out on o n whether w h e t h e r this this is is a a significant significant problem; studovaries. problem; stud­ ies now n o w in in progress progress may m a y help help to to answer a n s w e r this this question question (Sachs, (Sachs, 1998). 1998). ies T h e anticonvulsants anticonvulsants like like divalproex divalproex and a n d carbamazepine carbamazepine often often "interact" The "interact" with other other medications, medications, meaning m e a n i n g that that side side effects effects or or medical medical complications complications with can occur occur when w h e n these these drugs drugs are are used used together together with with other other drugs. drugs. For F o r this can this reason, you y o u should should be b e sure sure to to tell tell your y o u r physician, physician, especially especially if h e or or she she is if he is reason, n e w to to you, y o u , about about any a n y other other drugs drugs you y o u are are taking taking for for any a n y other other medical medical new conditions. conditions.

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CAUSES CAUSES AND AND TREATMENIS TREATMENTS

Carbamazepine Ca,lIomalepine

less popular three" mood stabilizers is carbamazepine (Teg­ (TegThe popular of ofthe the"big "big three" mood stabilizers is carbamazepine The less retol, CarbatTol, Carbatrol or or Atretol). Atretol). Carbamazepine Carbamazepine was was quite quite popular as a a treatment treatment retal, popular as in it can in the the 19805, 1980s, especially especially when w h e n used used in in combination combination with with lithium. lithium. But But it can be be difficult lO to find the appropriate appropriate dose with carbamazepine. carbamazepine, and and difficult difficultside sideef­ efdifficult find the dose with fects can which don't with divalproex. Nonetheless, fects can occur, occur, some some of of which don't occur occur with divalproex. Nonetheless, some doctors doctors will will recommend recommend carbamazepine carbamazepine if if you you have have a a difficult difficult time time with with some the the side side effects effects of of divalproex. divalproex. Like Like divalproex, divalproex, carbamazepine carbamazepine is is an an anticonvulsant anticonvulsant used used to to treat treat seizure seizure as well well as as mood m o o d disorders. disorders. There There is is a a substantial substantial amount amount of of research research supportas support­ mania (Ketter ing ing its its effectiveness effectiveness in in the the treatment treatment of of acute acute mania (Ketter et et al., al, 1998). 1998). About as as many m a n y people people with bipolar disorder disorder respond respond to carbamazepine as as to About with bipolar lO carbamazepine to lithium lithium (two-thirds), (two-thirds), but but different different kinds kinds of of people people may m a y respond respond to to these these two two medications. work well medications. Like Like divalproex, divalproex, carbamazepine carbamazepine seems seems 1O to work well for for people people with bipolar bipolar disorder disorder who w h o don't respond well well to lithium, including those with with with don't respond to lithium, including those mixed episodes, mixed episodes, rapid rapid cycling, cycling,or orpsychotic psychoticmanias manias(Post (PostetetaI., al,1987). 1987).Among Among people who to people w h o don't don't respond respond 1O to lithium, lithium, about about one-third one-third will will respond respond to carbamazepine within within a a month. month. Although seems to to work work better better for for manic manic carbamazepine Although i itt seems symplOms three people symptoms than than depressive depressive symptoms, symptoms, about about one one in in three people who w h o have have not not benefited from from other other treatments treatments for for depression depression will respond well to carbabenefited will respond well to carba­ mazepine (Post (Post et et al.. al, 1986). 1986). mazepine Carbamazepine probably probably works works by by affecting affecting the the movements movements of of sodium sodium Carbamazepine and calcium calcium ions ions across across the the membranes membranes of of the the nerve cells. This Thisnow flowof ofions ionsaf­ afand nerve cells. fects whether cells cellsfire fireorornot-whether not—whetherthe theelectrical electricalchanges changesoccur occurthat that aHow fects whether allow cells to communicate with with other other cells. cells. By By adjusting adjusting the the flow of these these ions, cells to communicate now of ions, carbamazepine probably probably slows slows down d o w n the the rate rate at at which which cells cells fire fire and and therefore carbamazepine therefore the overall overall rate rate of activity or or eXcitability excitability of of nerve nerve pathways. pathways. the of activity Your doctor will will probably probably start start you you on on a a dosage dosage of of 200-400 200-400 mg m g per per day day Your doctor and it by and increase increase it by 200 200 mg m g (one (one tablet) tablet) every everytwo twoto tofour fourdays. days.Typical Typicaldosages dosages are are between between 400 400 mg m g and and 11,600 m g per day, given given in in 200 200-mg tablets. As As with with ,600 mg per day, mg tablets. lithium or or divalproex, divalproex, your your physician physician will probably start start low low and and go go slowly lithium will probably slowly upward to to minimize minimize your your side side effects. effects. However, However, unlike unlike these these other other medica­ medicaupward tions,carbamazepine carbamazepinedoes doesnot nothave havea aspecific specificblood bloodlevel levelthat thatwe w eknow k n o wwill wiH tions, give you you the the best response. Usually, Usually, your your doctor doctor will choose your dosage best response. will choose your dosage give based on on balancing balancing its its effectiveness effectiveness for for your your mood m o o d stability stabHity against against its its side side ef­ efbased fects, rather ratherthan thanyour your blood blood levels levels(Ketter (Ketteret etaI., al, 1998). 1998).Typical Typicalblood blood levels levels fects, for people w h o take carbamazepine are between 4 and 12 micrograms per milfor people who take carbamazepine are between 4 and 12 micrograms per mil­ Hliter (Goldberg, 2000). 2000). Because Because the the liver liver breaks breaks down d o w n carbamazepine carbamazepine more more liliter (Goldberg, quickly over time, time, your yourdoctor doctor may m a y have have to toincrease increaseyour your dosage dosageafter afterthe thefirst first qUickly over -

What What(on CanMedicotion Medicationand andPsydJotheropy PsychotherapyDo DofOIforMe? Me?

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four to of of treatment—and periodically thereafter—to maintainmaintain a a thereafter-to periodically treatment-and weeks six weeks to six four therapeutic level level. therapeutic Side Effects Carbamazepine Corbomozepine 01 of Side Efferts

nausea, and are sedation, of carbamazepine side effects common most The The most common side effects of carbamazepine are sedation, nausea, and mild m H d memory m e m o r y impairment i m p a i r m e n t (for (for example, e x a m p l e , difficulty difficulty finding finding words). w o r d s ) . These T h e s e side side effects effects are are usually usually related related to to the the dose dose you y o u take take and a n d often often disappear disappear after after a a few few weeks w e e k s or or months m o n t h s of of treatment. treatment. Some S o m e people people experience experience blurry blurry vision, vision, consti­ constipation, pation, or or loss loss of of muscle m u s c l e coordination. coordination. There T h e r e is is less less of of aa problem p r o b l e m with with weight weight gain gain on o n carbamazepine, carbamazepine, which w h i c h is is why w h y some s o m e people people prefer prefer it. it. Usually, Usually, your your doctor will will treat treat side side effects effects by b y adjusting adjusting your y o u r dosage. dosage. doctor People People taking taking carbamazepine, carbamazepine, even even more m o r e ohen often than than for for divalproex, divalproex, can can develop develop a a mild mild elevation elevation in in liver liver enzymes, e n z y m e s , which w h i c h can can be b e identified identified through through regular regular liver liver function function tests. tests. Your Y o u r doctor doctor will will probably probably discontinue discontinue your your carbamazepine carbamazepine if if you y o u develop develop signs signs of of hepatitis, hepatitis, such such as as feeling feeling sluggish, sluggish, stomach s t o m a c h pain, pain, or or other other gastrointestinal gastrointestinal problems. problems. About A b o u t 10-15% 1 0 - 1 5 % of of people people de­ develop skin skin rashes. rashes. This This side side effect effect should should be be reported reported to to your y o u r doctor doctor immedi­ immedivelop ately ately because because it it can can progress progress into into a a serious, serious, potentially potentially life-threatening life-threatening skin skin condition called called Stevens-johnson Stevens-Johnson syndrome s y n d r o m e (a (a blistering blistering or or burning burning of of the the condition skin tissue tissue or or lining lining of of the the mucous m u c o u s membranes) m e m b r a n e s ) .. skin The T h e most m o s t serious serious side side effect effect of of carbamazepine carbamazepine is is a a bone b o n e marrow m a r r o w reaction reaction called agranulocytosis, agranulocytosis, which w h i c h is isquite quiterare, rare,affecting affectingabout aboutone o n ein inevery every100,000 100,000 called persons. It It involves involves aa dramatic dramatic drop d r o p in in white white blood blood cells. cells.Your Y o u rdoctor doctorshould shouldbe be persons. monitoring your y o u r blood blood count c o u n t regularly regularly to to detect detect the the beginning beginning of of this this condition. condition. monitoring Let your y o u r doctor doctor know k n o w if ifyou y o u develop develop aa fever, fever,infection, infection,sore sorethroat, throat,sores soresinin your your Let m o u t h , or or easy easy bruising bruising or or bleeding, bleeding, all all of of which w h i c h can can be b e signs signs of of a ad r o p in y o ur mouth, drop in your white blood blood count c o u n t (Ketter (Ketter et et al, 1 9 9 8 ) . None N o n e of of these these adverse adverse reactions reactions is, b y it­ itwhite is, by aL, 1998). self, reason reason to torule ruleout outcarbamazepine carbamazepine at atthe theoutset, outset,espeCially especiallybecause because it itcan canbe be self, prevented through through regular regular monitoring monitoring by b y your y o u r doctor. doctor. prevented A new n e w medication medication that that is is chemically chemically related related to to carbamazapine, carbamazapine, called called A oxcarbazepine (Trileptal), (Trileptal), has has recently recently c o m e on o n the the scene. scene. Its Its side side effects in­ effects income oxcarbazepine clude fatigue fatigue and and a a possible decrease in in s o d i u m levels, levels, but is easier take to take easier to it is but it sodium possible decrease clude than carbamazepine a n d does does not carry the the ssame a m e risk risk of of liver liver or dysblood dys­ or blood not carry and than carbamazepine function. function. M o r e research o n Trileptal Trileptal is is needed n e e d e d to to see see if if it will wwork o r k as well as as well it will research on More as carbamazepine in in controlling m o o d disorder disorder symptoms. symptoms. controlling mood carbamazepine T h e table o n page 2 summarizes s u m m a r i z e s some s o m e of of the the information information you've just you've just page 11 11 2 table on The read. Y o u may m a y want w a n t to it from f r o m time time to to time, to see see if y o u r side side effects effects read. You if your time, to refer to to refer 1O it for aany n y given listed and a n d if o u r dosages dosages if yyour those listed with those consistent with are consistent medication are given medication for a n d blood levels are are within range. expected range. the expected within the blood levels and

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CAUSES CAUSES AND AND lREA1MEN1S TREATMENTS

M o o d Stabilizing Agents Mood Drug Drug

Dosage

Blood level

Common ide effects Common s side

Lithium Lithium

300....2,400 300-2,400 mg mg

0.8-1.2 mEqIL mEq/L 0.8-\2

• Weight gain • Fatigue, Fatigue, sedation sedation

per day day

•

• • •

• • • •

Divalproex sodium D ivalproex sodium

1,500-3,000 1,500-3,000

45-125 meg! 45-125 meg/

(Depakole) (Depakote)

mg m g per per day day

ml ml

• • • •

• • • •

•

Carbamazepine Carbamazepint

400-1600 mg mg

(Tegretol) (Tegretol)

per per day day

4-12 mcg/ml mcg/ml t-12

Stomach Stomach irritation, irritation, diarrhea diarrhea Thirst Thirst and and frequem frequent urination urination Melallic Metallic taste taste in in mouth mouth

Hand tremor

Hand tremor Thyroid dysfunction Acne or psoriasis Acne or psoriasis Menial sluggishness or memory Mental sluggishness or memory problems problems Kidney clearance problems Kidney clearance problems Nausea, stomach stomach pain Faligue, Fatigue, sedalion sedation Hand Hand Iremor tremor Hai r loss, Hair loss, curlier curlierhair hair Dizziness Dizziness Headaches Headaches Weight Weight gain gain Elevated liver enzymes Elevated liver enzymes Drop in platelet count Drop in platelet count Thyroid dysfunction

• Fatigue, Fatigue, sedation sedation • Nausea, Nausea, stomach stomach pain pain • Mild iimpairment pairmem Mild memory memory m • •

• • •

•

• •

Const ipation Constipation

Diuiness, Dizziness, lightheadedness lightheadedness Blurred Blurred vision vision

IWh

Rash Problems with physical coordination, unsu�adinc.ss unsteadiness Elevaled liver enzymes Elevated liver enzymes Drop in white blood cell count Drop in white blood cell count Drop in sodium levels Drop in sodium levels

Problems with physical coordinalion,

Note. mEqIl. mEq/L,millequivalcnts millequivalentsper perliter; liter;mcglm mcg/ml, micrograms milliliter. 1 wish Altshuler, D, NOIe. l. micrograms perper milliliter. I wish \0 thto anthank k loriLori Altshuler. MD. M and

GaT)' Gary Sachs. Sachs, MD. M D ,for forproviding providingthe themedicol medicalinformation informationfor forthi.� thistable_ table.

and

Afeiver MMood o o d St.bilizers Stabilizers Newer One welcome the past pastfew few years been the increased availability One welcomeadvance advance in in the years hashas been the increased availability of these new of alternatives alternatives to to traditional traditional mood m o o d stabilizers. stabilizers. Most Most of of these n e w drugs drugs are are anticonvulsants like divalproex or or carbamazepine, carbamazepine, but but they they vary vary in in terms terms of amiconvulsants like divalproex of their side-effect side-effect profiles profiles and and how h o w effective effective they they are are for for the the manic versus the the their manic versus depressive pole pole of of the the disorder. disorder. They They are are mostly mostly used in combination combination with with the depressive used in the traditional mood m o o d stabilizers stabilizers to to create create a a stronger stronger response response (in (in terms of mood mood traditional terms of stability), rather than substituting for them. stability), rather than substituting for them. O n e new n e w option option is is lamotrigine lamotrigine (Lamictal). (Lamictal). The The limited limited research research on on One de­ lamotrigine indicates that i is reasonably reasonably effective, effective, especially especially for for bipolar bipolar delamolrigine indicates that itt is pressions pressions and and rapid rapid cycling. cycling. The The response response rates rates for for people people during during bipolar debipolar de-

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seven-week in one pills placebo than lamotrigine forlamotrigine higher werehigher pressionswere pressions for than forfor placebo piHs in one seven-week study, study, especially especially when w h e n the the dosage dosage was w a s 200 2 0 0mg m g per perday d a y(Calabrese (Calabrese et etal., al, 1999). 1999). Lamotrigine Lamotrigine may m a y successfully successfully treat treat people people with with manic m a n i c or or mixed m i x e d episodes episodes who who

haven't responded r e s p o n d e d well w e H to to other other medications, medications, either either when w h e n used used by b y itself itself or or in in haven't combination with with other other mood m o o d stabilizers stabilizers (Goldberg, (Goldberg, 2000). 2000). combination There T h e r e are are some s o m e concerns concerns about about this this drug d r u g because, because, as as with with carbamazepine, carbamazepine, about about 6-10% 6 - 1 0 % of of people people develop develop aa skin skin rash rash within within two t w o to to eight eight weeks w e e k s of of treat­ treatment. m e n t . This This usually usually mild mild rash rash can, can, in in rare rare instances instances (about (about 0.3%), 0 . 3 % ) , lead lead to to more more Johnson syndrome serious serious skin skin conditions, conditions, such s u c h as as StevensStevens-Johnson s y n d r o m e (described (described ear­ ear(to lier). lier). Your Y o u r doctor doctor can c a n try try to to prevent prevent rashes rashes by b y increasing increasing your y o u r dosage dosage (to bring bring you y o u up u p to to aa therapeutic therapeutic level) level) very very slowly. slowly. Otherwise, Otherwise, lamotrigine's lamotrigine's side side

effects are are relatively relatively mild mild and a n d usually usually transient, transient, and a n d can c a n include include problems problems effects with with physical physical coordination, coordination, dizziness, dizziness, vision, vision, nausea, nausea, vomiting, vomiting, and a n d head­ head-

aches (Currier (Currier & & Goodnick, Goodnick, 1998; 1998; Kahn K a h n et et aI., al, 2000). 2000). aches

that An A n even even newer newer agent, agent, topiramate topiramate (Topamax), (Topamax), is is an an anticonvulsant anticonvulsant that appears appears to to be be helpful helpful in in alleviating alleviating the the manic manic side side of of the the illness, illness, at atleast leastwhen when combined with other combined with other mood m o o d stabilizers, stabilizers, but butpOSSibly possibly even even by by itself. itsellIt Itmay m a y be be

useful useful for for people people with with rapid rapid cycling cycling (McElroy (McElroy & & Keck, Keck, 2000). 2000). Unlike Unlike most most other gain. For weight gain. weight loss t can other mood m o o d stabilizers, stabilizers, iit can cause cause weight loss rather rather than than weight For this this reason, reason, many m a n y people to substitute it for for lithium lithium or or divalproex, divalproex, but but substitute it want to people want

there is is not not enough enough research research on on it it yet yet to to justify justify this this substitution. substitution. This Thisdrug drug has has there side effects in in some s o m e people, people, such such as as blurred blurred vision or eye eye pain, pain, concentration concentration vision or side effects or memory m e m o r y problems problems (for (for example, trouble finding finding words), tingling feelings feelings in or in words), tingling example, trouble the hands hands or or face, face, fatigue, fatigue,feeling feelingslowed sloweddown, d o w n ,tremors, tremors, nausea, and dizziness dizziness and nausea, the (Chengappa et et al, 1999; Marcotte, Marcotte, 1998). 1998). aL, 1999; (Chengappa S o m e physicians physicians like like to to recommend recommend a a drug drug called called gabapentin gabapentin (Neu(Neu­ Some rontin),, which has become popular because it can can be be combined combined with other with other because it become popular which has rontin) m o o d stabilizers without the the negative negative effects effects or or interactions interactions that that have be to be have to stabilizers without mood considered considered w h e n adding adding drugs drugs like like carbamazepine. carbamazepine. But the research on research on But the when

gabapentin does does not not consistently consistently support its effects effects as as a a m o o d stabilizer. In stabilizer. In mood suppon its gabapentin fact, fact, in in a a large study of of people people with bipolar disorder h o were tradi­ taking tradiwere taking who disorder w with bipolar large study

tional m o o d stabilizers adding gabapentin gabapentin was was no no better­ better— well, adding doing well, not doing but not stabilizers but mood tio!.1al mania (Pande in treating placebo tablets less effective�than and perhaps effective—than placebo tablets in treating mania (Pande even less perhaps even and

et al, 2000). Other research that gabapentin at least least modestly et aL, ef­ modestly efis at gabapentin is indicates that research indicates 2000). Other fective antidepressant during (Young et 1997). aL, 1997). et al, depressions (Young bipolar depressions during bipolar an antidepressant as an fective as Gabapentin m a y be most useful the anxiety anxiety and and panic panic symptoms symptoms treating the in treating useful in be most may Gabapentin

that o o d swings (McElroy & & Keck, Keck, 2000). most Its most 2000). Its swings (McElroy mood bipolar m accompany bipolar often accompany that often c o m m o n side people, some people, in some and, in dizziness, and, oversedation, dizziness, include oversedation, effects include side effects common

overactivation 1997). Schaffer, 1997). & Schaffer, (Schaffer & overactivation (Schaffer

N o n e of of these these newer the proven track records stan­ the stanof the records of proven track has the medications has newer medications None agents these agents discuss these to discuss want to may you m stabilizers. But mood dard o o d stabilizers. But you a y want three" m "big three" dard "big

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CAUSES CAUSESAND ANDTRfATMENTS TREATMENTS

mood with are are having unpleasam reactions to the standard with your your doclor, doctor,if you if you having unpleasant reactions to the standard mood stabilizers stabilizers or or if if they they are arenot not working working as as well wellas asthey they should should in instabilizing stabilizingyour your moods. moods.

''Add-On" Medications: Antidepressants, Antidepressants, Antipsychotics, Antipsychotics, "Add-On" Medications:

and and Other Otiier Agents Agents Mood are often given with medications whose primary purpose Moodstabilizers stabilizers are often given with medications whose primary purpose is is to combat combat a a particular symptom, such such as as anxiety, anxiety, insomnia, agitation, or orpsy­ psyto panicular symptom, insomnia, agitation, chosis. regimen will make mOTe sense chosis. The The different different medications medications in in your your regimen will m a k e more sense if ifyou you think think of of each each of of them them as as belonging belonging to to a a certain certain class class (for (for example, example, amidepres­ antidepressams) sants) and and having having a a unique unique purpose purpose (for (for example, example, improving sleep). improving sleep).

Antidepressants Antidepress.nts

areare generally more more effective in preventing the manic the manic Standard mood stabilizers stabilizers generally effective in preventing Standard mood pole the illness. some point pole than than the the depressive depressive pole pole of of the illness. For For this this reason, reason, at at some point your doctor your mood stabi­ your doctor may m a y discuss discuss with with you you the the option option of of combining combining your m o o d stabilizer with lizer with an an antidepressant antidepressant medication. medication.You Y o u have have probably probably heard heard much m u c h in inthe the past years about the type of of antidepressants antidepressants called called the the selective selective serotonin serotonin past years about the type reuptake inhibitors inhibitors (SSRls). (SSRIs). These These include include fluoxetine (Prozac), sertraline reuptahe fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil),, fluvoxamine fluvoxamine (Luvox), (Luvox), and and citalopram citalopram (Celexa). (Celexa). (Zolofl), paroxetine (Paxil) A n older older line line of of antidepressants, antidepressants, called called the the tricydics, tricyclics, include include imipramine imipramine An (Tofranil), amitriptyline amitriptyline (Elavin, (Elavil), nortriptyhne nortriptyline (Pamelor), (Pamelor), and and deSipramine desipramine (Tofranil), (Norpramin). Still Still another class, called called the the monamine oxidase inhibitors (Norpramin). another class, monamine oxidase inhibitors (MAOIs), tranylcypromine (Pamale) set (MAOIs), include include tranylcypromine (Parnate) and and phenelzine phenelzine (Nardil). (Nardil). A A set of novel novel antidepressants antidepressants is is also also available, available, including including venlafaxine venlafaxine (Effexor), of (Effexor), bupropion (Wellbutrin), (Wellbutrin), trazodone trazodone (Desyrel), (Desyrel), nefazadone nefazadone (Serzone), (Serzone), and and bupropion mirtazapine (Remeron). (Remeron). mirtazapine of These agents agents can can be be effective effective in in alleviating alleviating the the unpleasant unpleasant symptoms symptoms of These bipolar bipolar depression, depression, such such as as sadness, sadness, loss loss of of interests, interests, insomnia, insomnia, fatigue, fatigue, and and suicidal feelings. feelings. Some S o m e are are more effective than than others, others, and and some some have have more more suicidal more effective easily tolerated tolerated side side effects. effects. Unfortunately, Unfortunately, they they all all have have a a major major side side e effect in easily ffect in bipolar disorder: disorder: They They can on hypomanic, hypomanic, manic, manic, or mixed affective bipolar can bring bring on or mixed affective states and and can can cause cause rapid rapid cycling. cycling. For this reason, reason, antidepressants antidepressants are are usually usually For this states recommended only only when w h e n necessary, necessary, and and then thenonly onlyin incombination combination with withmood mood recommended stabilizers. These These necessary necessary conditions conditions include going for for at at least least 1-2 1-2 months months stabilizers. include going with a a severe severe and and persistem persistent depression depression that that has has not not responded to mood mood with responded well well to stabilizers alone, alone, haVing having severe severedepressive depressive symptoms symptoms with with few few or orno no accompa­ accompastabilizers nying nying manic manic of of hypomanic hypomanic symptOms symptoms (e.g., (e.g., aadecreased decreased need need for forsleep, sleep,racing racing

What(on ConMedico�on Medicationand andPsychotherapy PsychotherapyDoDoforfo r Me? What Me?

115115

thoughts), and andhaving having severe suicidalimpulses impulses (Dubovsky &:. Buzan, If thoughts), severe suicidal (Dubovsky & Buzan, 1999).1999). If and you y o u do d o take take antidepressants, antidepressants, you'll you'H have have to to be b e monitored monitored carefully carefully a n d proba­ probably will will need n e e d to to see see your y o u r doctor doctor more m o r e often. often. bly

You not be Y o u should should not he taking taking an a n antidepressant antidepressant by by itself, itself, without without aa mood m o o d stabi­ stabiin­ lizer. Doing Doing so so will will greatly greatly increase increase the the chances chances of of developing developing mania mania or or inlizer. creased de­ creased mood m o o d cycling. cycling. The T h e mood m o o d stabilizer/antidepressant stabiHzer/antidepressant combination combination decreases this risk but doesn't erase it. creases this risk but doesn't erase it. Most antidepres­ Most psychiatrists psychiatrists do do recommend r e c o m m e n d that that their their patients patients try try an an antidepressant at at some s o m e point in their their illness. illness. Some S o m e antidepressants antidepressants seem seem safer safer than than sant point in others in in terms terms of of their their likelihood likelihood of of provoking provoking manic manic or or rapid cycling others rapid cycling states. tree" that that states. It It is is useful useful for for you you to to know k n o w about about the the medical medical "decision "decision tree" physicians to you, physicians sometimes sometimes follow follow in in recommending recommending antidepressants antidepressants to you, so so that his his or or her her recommendations recommendations don't don't seem seem random random or or haphazard. haphazard. A panel that A panel of experts experts (Frances (Frances et et aI., al, 1996) 1996) has has recommended recommended that that when w h e n bipolar bipolar people people of have have severe severe depressions, depressions, it's it's often often best best if if they they start start with with the the drug drug Well­ Wellbutrin, which seems to have a lower risk of inducing mania (for example, which seems to have a lower risk of indUcing mania (for example, butrin, Sachs Sachs el et aI., al, 1994), 1994), or or with with one one of of the the selective selective serotonin serotonin inhibitor inhibitor drugs drugs (for example, example, Paxil) Paxil) or or the the novel novel antidepressant Effexor. (for antidepressant Effexor. had bad side If If you you have have not not responded responded well well to to these these medications medications or or have have had bad side effects, effects, your your doctor doctor may m a y recommend recommend a a monoamine m o n o a m i n e oxidase oxidase inhibitor. inhibitor. Many Many people people do do quite quite well well on on MAOIs, M A O I s , but but they they are are difficult difficult to to take take in in that that they they rere­ quire you you to to avoid avoid foods foods that that are are high high in in the the amino amino acid acid tyramine tyramine (for (for exam­ examquire ple, aged aged cheeses, cheeses, sausage, sausage, chianti chianti wines). wines). The The tricyclics tricyclics are are usually usually recom­ recomple, mended last last because because of oftheir theirside sideeffects, effects,and andare areusually usuallyavoided avoidedaltogether altogetherin in mended people who w h o have have experienced experienced mania mania or or hypomania hypomania while while on on antidepressants antidepressants people (Goldberg & & Kocsis, Kocsis, 1999). 1999). (Goldberg About one one in in three three people people develop develop sexual sexual side side effects effects on on SSRIs SSRIs or or MAO M A O I Is. s. About These can can include include a a lower lower sex sex drive drive and and ""ejaculatory delay' (difficulty (difficulty reachThese ejaculatory delay" reach­ ing ing orgasm). orgasm). If If these these side side effects effects become become Significant, significant, your yourdoctor doctor may m a y recom­ recommend a a different different antidepressant antidepressant or or advise advise you you to to take take breaks breaks from from the mend the medicamedica­ tion. For Forsome s o m e people, people,sexual sexualside sideeffects effectsare arereason reasonenough enoughtotostop stoptaking takingthe the tion. antidepressant, but but as as with with any any side side effect, effect, you you should should discuss discussthis thiswith withyour your antidepressant, physician before before discontinuing discontinuing the the drug. drug. Going Going off off an an antidepressam antidepressant qUickly quickly physician has been been known k n o w n to to increase increase a a person's person's risk risk of of developing developing mania mania or or rapid rapid cyhas cy­ cling. Other Other side side effects effects of of antidepressants antidepressants can can include include weight weight gain, cling. gain, insomnia, insomnia, headaches, headaches, and and daytime daytime sedation. sedation.

Antipsychotic Antipsychotic Medic./ions Medications T h e notion notion of of taking taking an a n antipsychotic antipsychotic medication medication is is scary scary to to many m a n y people people be­ beThe cause they they equate equate the the use use of ofthese these drugs drugs with with having having severe severe delusions, delusions,halluci­ hallucicause nations, and a n d even even schizophrenia. schizophrenia. Antipsychotic Antipsychotic medications medications are are not not to to be be nations,

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CAUSESAND ANDIREAIMEHIS TREATMENTS CAUSES

but they have broader applicability than just treatmen( taken lightly, but they have broader applicability than the just the treatment of taken lightly, of schizophrenia. schizophrenia. Antipsychotics Antipsychotics are are used used in in bipolar bipolar disorder disorder for for several several purposes. purposes. First, First, some people people with bipolar disorder disorder do do have have severe severe disturbances disturbances in in thinking thinking some with bipolar and that are traditional and perception perception (psychosis) (psychosis) that are not not fully fully controlled controlled by by the the traditional m o o d stabilizers. stabilizers. For Forexample, example,during during the theperiod period in inwhich which they theyare areescalating escalating mood into manic episode into mania mania or or during during the the manic episode itself, itself,they theymay m a y hear heartheir theirname n a m ebeing being called called or or music music being being played played (even (even though though no no one one else else is is around), around), see see move­ movement OUl of the corner of their eyes (even though nothing is there) , or believe ment out of the corner of their eyes (even though nothing is there), or believe they they are are being being followed. followed. These These symptoms symptoms can can be be alleviated alleviated by by antipsychotic antipsychotic medicines. Second, Second, antipsychotic medicines. antipsychotic drugs, drugs, particularly particularly the thenewer newer ones onesknown k n o w n as as the the the atypical atypical antipsychotics, antipsychotics, have have antimanic antimanic properties. properties. They They may m a y augment augment the effects effects of of traditional traditional mood m o o d stabilizers stabilizers and and can can even even be be substituted substituted if you if you haven't fairly haven't responded responded well well to to lithium lithium or or the the anticonvulsants. anticonvulsants. They They work work fairly rapidly rapidly in in stabiliZing stabilizing an an acute acute manic manic or or mixed mixed episode episode and and are are sometimes sometimes recrec� o m m e n d e d for for rapid rapid cycling. cycling. Lastly, Lastly, anti antipsychotics can be be used used as astranquiliz­ tranquilizommended psychotics can ers, relieve anxiety, anxiety, restlessness, restlessness, or words, ers, to to relieve or problems problems with with sleep. sleep. In In other other words, your your doctor doctor may m a y recommend recommend these these medications medications even even if ifhe he or orshe she doesn't doesn'tthink think you are psychotic. you are psychotic. Ten anti­ Ten years years ago, ago, doctors doctors were were recommending recommending a a traditional traditional line line of of antipsychOlics that you chlorpromazine (Thorazine) psychotics that you may m a y have have heard heard of, of, such such as as chlorpromazine (Thorazine) and haloperidol haloperidol (Haldol). (Haldol). These These drugs drugs have severe long-term side effects, effects, in­ inand have severe long-term side cluding a a serious serious motor motor movement m o v e m e n t disorder disorder called called tardive tardive dyskinesia. dyskinesia. The The cluding newer atypical atypical antipsychotics antipsychotics have have less less severe severe side side effects effects and and appear appear to to be be newer less likely likely to to cause cause tardive tardive dyskinesia. dyskinesia. The The newer newer drugs drugs include include clozapine clozapine less (Clozaril), risperidone risperidone (Risperdal), (Risperdal), olanzapine olanzapine (Zyprexa), (Zyprexa), quetiapine quetiapine (Sero(Clozaril), (Sero­ quel), and ziprasidone ziprasidone (Zeldox, (Zeldox, Geodon). Geodon). It's It'snot notclear clearyet yetwhether whether these theseatyp­ atypquel) , and ical antipsychotics antipsychotics qualify quahfy as as mood m o o d stabilizers stabilizers (that (that is, is, whether whether they they control control ical acute episodes, episodes, decrease decrease the the vulnerability vulnerabihty to to future future episodes, episodes, and and do do not not acute worsen the the course course of of illness) or whether they just just have have short*term, short-term, sedating sedating worsen illness) or whether they effects on on existing manic or or mixed mixed episodes. effects existing manic episodes. Clozapine used used to to be be the the most most widely widely preSCribed prescribed novel novel antipsychotic, but Clozapine antipsychotic, but (less m a n y doctors doctors no no longer longer recommend recommend it it because because aasmall s m a H number number of ofpeople people (less many the than 1%) develop develop agranulocytosis agranulocytosis (definition (definition on on page Currently, the than 1%) page 1111). 1 l ). Currently, most popular popular of of these drugs is is probably probably olanzapine, olanzapine,which whichhas hasFood Foodand andDrug Drug most these drugs Administration approval for the treatment of of mania. mania. A A study study done done by by Mauricio Mauricio Administration approval for the treatment al., Tohen and and his his associates associates of of the the Lilly Lilly Research Research Laboratories Laboratories (Tohen (Tohen et et al, Tohen 1999) found found that that over over a a four-week four-week period, period,acutely acutelymanic manic or ormixed mixed episode episodepa* pa1999) tientsrecovered recoveredmore moreqUickly quicklyand andmore morefully fullyon onolanzapine olanzapinethan thanthey theydid didon on tients placebo pills. pills. Olanzapine Olanzapine did did have have more more side side effects effects than than placebo, placebo, including including placebo greater weight weight gain gain and and feeling feeling sleepy sleepy or or sleeping sleeping too too much. much. greater

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by your youdoctor, are recommended medications If these If these medications are recommended to you byto your it doctor, doesn't it doesn't necessarily necessarily mean m e a n that that your y o u r illness illness is is getting getting worse. worse. It It may m a y mean m e a n that that your your pro­ profile fileof ofsymptoms s y m p t o m s (for (forexample, e x a m p l e ,agitation, agitation,thinking thinkingdisturbances, disturbances,restlessness, restlessness, rapid cycling) cycling) will will respond respond better better to to these these medications medications than than to to mood m o o d stabiliz­ stabiHzrapid ers ers alone. alone. Often, Often, antipsychotic antipsychotic medications medications are are given given for for aa period period of of time time and and then discontinued discontinued gradually gradually once o n c e aa person person has has stabilized. stabilized. then

Options Other ant/ Benzot/iazepines, Thyroit/ Supplements, Thyroid Supplements, Benzodiazepines, and Other Options as adjuncts other medications Your recommend severalseveral other medications as adjuncts to your to your recommend may doctormay Yourdoctor mood m o o d stabilizers. stabilizers. For F o r example, e x a m p l e , it it is is not not unusual unusual for for doctors doctors to to recommend recommend thyroid thyroid supplements supplements such s u c h as as Synthroid. Synthroid. Certain Certain mood m o o d stabilizers, stabilizers, such s u c h as as lith­ Hthium, i u m , tend tend to to suppress suppress thyroid thyroid hormones. h o r m o n e s . This This is is usefuho useful to know k n o w if ifyou y o u are are feel­ feeling ing fatigued fatigued or or slowed slowed down d o w n on o n lithium-a l i t h i u m — a thyroid thyroid supplement s u p p l e m e n t may m a y help help bring you y o u back b a c k to to a a normal n o r m a l energy energy level. level. You Y o u may m a y benefit benefit from f r o m thyroid thyroid supple­ supplebring ments be can they because result test thyroid normal a have you if even m e n t s even if y o u h a v e a n o r m a l thyroid test result because they can be help­ helpful in in treating treating depression depression or or rapid rapid cycling c y c H n g (Bauer (Bauer & & Whybrow, W h y b r o w , 1990). 1 9 9 0 ) . Discuss Discuss ful this option option with with your y o u r doctor, doctor, particularly particularly if ifyou y o u are are female: female:Women W o m e n are are partic­ particthis ularly prone p r o n e to to hypothyroidism. hypothyroidism. ularly Many M a n y people people with with bipolar bipolar disorder disorder also also take take one o n e of of the the benzodiazepines, benzodiazepines, a a class of of drug d r u g that that may m a y calm c a l m you y o u down, d o w n , help help manage m a n a g e anxiety anxiety or or panic panic symp­ sympclass toms, toms, and a n d help help with with sleep. sleep. Remember R e m e m b e r Valium? V a l i u m ? Drugs D r u g s like like diazepam d i a z e p a m (Valium) (Valium) and and alprazolam alprazolam (Xanax) ( X a n a x ) were w e r e prescribed prescribed quite quite readily readily in in the the 1970s 1970s as as a a way w a y of of managing m a n a g i n g stress stress and a n d tension. tension. Other Other drugs drugs in in this this class class include include clonazepam clonazepam (Klonopin) and a n d lorazepam lorazepam (Ativan). (Ativan). These T h e s e drugs drugs need n e e d to to be b e taken taken with cau­ with cau(Klonopin) tion, tion, however, h o w e v e r , because because unlike unlike the the other other drugs drugs discussed discussed so so far, the ben­ benfar, the zodiazepines can b e addictive. People m a y n e e d higher a n d higher dosages zodiazepines can be addictive. People may need higher and higher dosages over have withover time time to the s a m e effects effects (they (they develop develop tolerance) tolerance) and a n d can can have same get the to get with­ drawal drawal ssymptoms y m p t o m s when w h e n stopping stopping them-including t h e m — i n c l u d i n g seizures. seizures. But o u are are if yyou But if if or if night, or at night, asleep at to sleep having having considerable considerable pproblems r o b l e m s getting getting to sleep or or staying staying asleep you y o u feel feel chronically chronically anxious anxious during during the the day, day, these these medications medications mmay a y help ou. help yyou. Your Y o u r doctor doctor may m a y also also r ecommend a a benzodiazepine benzodiazepine instead instead of n atypical atypical of aan recommend antipsychotic to to help help quell quell yyour o u r mmanic a n i c or or mixed m i x e d symptoms. symptoms. antipsychotic A A number n u m b e r of of other other alternative alternative medications medications have have come c o m e on o n the the scene the in the scene in past few studies. evaluated in being evaluated of being the process years and past few years a n d are are in in the process of in research research studies. tiagabine example, agents. FFor these agents. enthusiasm for Physicians Physicians vary vary in in their their enthusiasm for these or e x a m p l e , tiagabine (Gabitril),, aan n agent agent that reuptake of A B A into into the is celis, is nerve cells, the nerve of GGABA the reuptake inhibits the that inhibits (Gabitril) used used bby y s o m e doctors cycling. It c o m e into into wwide i d e use be­ use benot come has not It has rapid cycling. treat rapid to treat doctors to some cause of supportive evidence for its effectiveness. its effectiveness. evidence for of supportive lack of the lack of the cause O n e increasingly alternative is omega-3 fatty (fish plan (fish acid plan fatty acid the omega-3 is the popular alternative increaSingly popular One to mmany exciting to is exciting oil is oil). h e use a n y people is a a "natural" "natural" subsubit is because it people because fish oil of fish use of oil). TThe

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stance. hashas been found in onc to do to bener than placebo tablets intablets pro­ stance.ItIt been found in study one study do better than placebo in pro longing periods periods of longing of wellness wellness among a m o n g people people with with bipolar bipolar disorder disorder who w h o were were also also getting also a getting mood m o o d stabilizers stabilizers (Stoll (StoH el et al., al, 1999). 1999). There There is is also a class class of of drugs drugs the known k n o w n as as calcium calcium channel channel blockers. blockers. Although Although these these are are mainly mainly used used for for the treatment have mood-stabilizmood-stabiliz­ treatment of of heart heart diseases diseases and and blood blood pressure, pressure, they they may m a y have ing include verapamil ing properties. properties. These These drugs drugs include verapamil (Calan, (Calan, Isoptin), Isoptin), nimoclipine nimodipine treat­ (Nimotop), (Nimotop), and and other other agents. agents. They They are are sometimes for treatsometimes recommended recommended for ment-resistant mania mania but only rarely rarely given given their their questionable questionable efficacy. ment-resistant but only efficacy. More More research research is is needed needed on on all allof ofthese theseagents. agents.Right Rightnow, n o w ,they theyare arerecom­ recommended mainly as as add-cns add-ons to to traditional m o o d stabilizers stabilizers or or as as alternatives alternatives for for mended mainly traditional mood who tolerate the ion people w h o can't can't tolerate the side side effects effects of of any any of of the the first-line first-line medicat medication people choices. choices.

and Isn't It? Electroconvulsive Therapy: Therapy: What W h a t Is Is and Isn't True True about about It? Ele
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pose, giventhe therapid rapid effects medications the atypical antipsy­ pose, given effects of of medications such such as theasatypical antipsychotics. chotics. What first you W h a t happens h a p p e n s during during ECT? E C T ? Typically, Typically,first y o u stop stop taking taking your your regular regular medications, are medications, including including lithium lithium or or amiconvulsams. anticonvulsants. Once O n c e these these drugs drugs are washed w a s h e d out out of ofyour y o u r system system (which ( w h i c h can c a ntake take aa week w e e k or ortwo), t w o ) , an a n appointment appointment is is scheduled. this session, (for exam­ scheduled. During D u r i n g this session, you y o u are are given given a a general general anesthetic anesthetic (for example, re­ ple, sodium s o d i u m pemothal) pentothal) and a n d another another medication medication (succinyl (succinyl choline) choline) to to help help relax your y o u r muscles muscles and a n d prevent prevent a a full full body b o d y seizure. seizure. These T h e s e drugs drugs will will m a k e yyou ou lax make unconscious while while you y o u are are undergoing undergoing the the treatment. treatment. The T h e doctor doctor then then admin­ adminunconscious isters isters an a n electrical electrical pulse pulse that that creates creates a a mild mild seizure seizure in in your your brain. brain. Usually, Usually, be­ between week tween 4 4 and a n d 1122 treatments treatments are are needed, needed, or or up u p to to three three limes times a aw e e k for for about about one month. one month. The theory theory behind behind ECT E C T is is that that this this pulse pulse and and resulting resulting seizure "jumpThe seizure "jump­ starts" the the brain's brain's production production of of neurotransmitters. neurotransmitters. It It may m a y also also temporarily temporarily restarts" re­ duce duce the the activity activity of of the the fromal frontal lobe lobe of of the the brain, brain, which which is isthought thought to tobe be impor­ important in in modulating modulating mood m o o d states states (Sackheim (Sackheim et et aI., al, 1992). 1992). Because E C T is Because ECT is genergener­ tant ally usually ally not not considered considered a a maintenance maintenance (preventative) (preventative) treatmem, treatment, you you will will usually continue with with your your mood m o o d stabilizer, stabilizer,antidepressant, antidepressant,or orantipsychotic antipsychoticregimen regimen continue after the the course course of of ECT E C T is is over. over. after Because Because of of the the difficult difficult and and turbulent turbulent history history of of ECT, E C T , people people with with bipolar bipolar disorder it even disorder and and their their family family members m e m b e r s often often don't don't want want to to consider consider it even in in the the most dire dire of of circumstances. circumstances. This This is is unfortunate unfortunate because because ECT E C T is is life-saving most life-saving in in many m a n y cases. cases. It It can can pull pull people people out out of of serious serious depressions depressions from from which they which they might might have have otherwise otherwise committed committed suicide. suicide. M a n y physicians physicians recommend r e c o m m e n d ECT E C T only only reluctantly reluctantly because because one one of of its Many its side side effects is is a a loss loss of of memory. m e m o r y . The T h e memory m e m o r y loss loss is is usually usually most most noticeable noticeable for effects for events that that occurred occurred during during the the treatmem treatment itself itself (that (thatis, is,during duringthe thefour fourweeks weeks events or or so so when w h e n the the treatments treatments were were given) given).. But But some s o m e people people also also forget forget events events that occurred occurred prior prior to to the the ECT E C T procedure. procedure. This This is is probably probably because because E C T can can that EeT affect affect the the transfer transfer of of information information usually usually held held in in short-term short-term memory m e m o r y (the (the kind kind of of memory m e m o r y that that encodes encodes and and holds holds information information in in your your mind for a period mind for a brief brief period of of time, time, such such as as when w h e n you you first first hear hear people's people's names names and and phone phone numbers) numbers) to to long-term long-term memory m e m o r y storage. storage. It It is is not not clear clear that that memories memories are are lost lost for for good, good, however. In fact, memories for events that occurred before the E C T usually however. In fact, memories for events that occurred before the EeT usually come c o m e back back several several momhs months after after the the treatment treatment (Mondimore, (Mondimore, 1999; Squire et 1999; Squire et al., al, 1981). 1981). It It appears appears that that about about two-thirds two-thirds of of people people who w h o receive receive E C T experiECT experi­ ence problems problems in in memory m e m o r y functioning, functioning, but but the the problems problems seem to be tempoence seem to be tempo­ rary time. rary and and usually usually disappear disappear with with time. Nowadays, EeT E C T is is a a safe safe and and effective effective treatment treatment that that is is fairly fairly routine routine in in its its Nowadays, administration. It It can can be be done done on on an an outpatiem outpatient basis. basis. Because Because of of its its side side efadministration. ef­ fects and and high high economic economic cost, cost, ititis istypically typicallyconsidered consideredwhen w h e n aaperson person has has not not fects

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responded adequately or antidepressants and isand incapaci­ responded adequately to tomood mood stabilizers stabilizers or antidepressants is incapacitated tated by by depresSion, depression, psychosis, psychosis, or or sUicidality. suicidality. It It is is also also considered considered for for women women who w h o arc are pregnant pregnant and and severely severely depressed depressed or or manic. manic. Most Most mood m o o d stabilizers stabilizers and and antidepressants antidepressants carry carry some some risk risk of of harm harm to to the the unborn unborn baby, baby, but but ECT E C T docs doesnot not when w h e n administered administered under under standard standard medical medical conditions. conditions. ECT E C T will will not not be be done done against your your wishes. any psychiatric treatment, receiving receivingECT E C T is isbased basedon on against wishes. Like Like any psychiatriC treatment, aa joint joint decision decision between between you you and and your your doctor. doctor. A n ahernative alternative to to ECT, E C T , called called rapid rapid transcranial transcranial magnetiC magnetic stimulation, stimulation, has has An recently [0 recently been been developed. developed. The The procedure procedure is is a a simpler simpler and and less less invasive invasive way way to stimulate the cerebral cortex. cortex. It does not not require require you you to have general general anesthestimulate the cerebral It does (0 have anesthe­ and has relatively minimal cognitive side effects (George et al., 1997). BU[ sia and has relatively minimal cognitive side effects (George et al, 1997). But sia it does not not appear who not it does appear to to be be as as effective effective as as ECT E C T for for depressed depressed people people w h o are are not responding responding to to antidepressant antidepressant medications. medications. Perhaps Perhaps as as a a result, result, transcranial transcranial magnetic into wide wide use use in magnetic stimulation stimulation has has not not yet yet come c o m e into in clinical clinical practice practice (Nahas (Nahas et et aI., al, 1999; 1999; Thase Thase &: & Sachs, Sachs, 2000). 2000).

Light Light Treatment Treatment You may thatyour yourmoods moods vary varyconSiderably considerably with season You mayhave have noticed noticed that with thethe season of of the the year. year. Some S o m e people people do do have have seasonal seasonal bipolar bipolar disorders, disorders, which which usually usually means they they have have mania mania or or hypomania in the the spring spring or or summer s u m m e r and and depression depression means hypomania in in the fall or or winter. winter. It It may m a y be be that that changes changes in in exposure to light light during during the the in the fall exposure to different seasons seasons mediate mediate changes changes in in people's people's mood m o o d states. states. Sitting Sitting in in front front of different of full-spectrum bright white lights for half an hour to two hours per day can full-spectrum bright white lights for half an hour to two hours per day can improve mood m o o d and and selVe serve as as an an alternative alternative to to traditional traditional antidepressant antidepressant medi­ mediimprove cations for some (Terman & Terman, 1999). But like the antidepressants, cations for some (Terman &. Terman, 1999). But like the antidepressants, light treatment treatment can can lead lead to to switches switches into into mania mania or or hypomania hypomania or or interfere interfere with with light your sleep. Its recommended use in bipolar depressions is not clear because your sleep. Its recommended use in bipolar depressions is not clear because no systematic, systematic, controlled controlledstudies studieshave have been been done done among a m o n g bipolar bipolarpeople peopletaking taking no de­ your m o o d stabilizers (Thase & Sachs, 2000). Nonetheless, if you think your demood stabilizers (Thase &. Sachs, 2000). Nonetheless, if you think pressions have have seasonal seasonal triggers, triggers, discuss discussthis thisalternative alternativewith withyour yourphysician. physician. pressions

"Do Need P.y,hotherapy?" " D o II Need Psychotherapy?" andand cannot imagine imagine leading leading aanormal "I"I cannot normal life life without both taking Hthium without both taking lithium having had had the the benefits benefits of of psychotherapy psychotherapy.. ... . . ineffably, psychotherapy . ineffably, psychotherapy having heals. It makes makes some some sense sense of of the the confusion, confusion, reins reins in in the the terrifying terrifying heals. It thoughts and and feelings, feeHngs, returns returns some some control control and and hope hope and and possibility possibihty of thoughts of learning from from it it all. all. .. .. It It is is where where II have have believed-or believed-or have have learned learned to learning to

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believe-that I might someday to contend all ofNothis. beheve—that I might someday be ablebe to able contend with allwith of this. pillNo pill can likewise, can help help me m e deal deal with with the the problem p r o b l e m of of not not wanting wanting to to take take pills; pHls; likewise, no depres­ n o amount a m o u n t of of psychotherapy psychotherapy alone alone can can prevent prevent my m y manias m a n i a s and a n d depressions. II need n e e d both." both." sions. — J a m i s o n (1995, (1995, pp. 88-89) -Jamison pp. 88-89)

doctors will recommend that you combine medical treatment Many Many doctors will recommend that you combine your medicalyour treatment with some s o m e form f o r m of of psychotherapy. psychotherapy. For F o r example, e x a m p l e , Clarence, Clarence, a a 19-year-old 19-year-old man man with who w h o had h a d been b e e n hospitalized hospitalized during during a a manic m a n i c episode episode (see (see more m o r e details details in in Chap­ Chapter ter 7), 7 ) , came c a m e to to some s o m e important important decisions decisions about about his his illness illness and a n d his his need need for for medication medication as as a a result result of of psychotherapy. psychotherapy. He H e originally originally refused refused medication, medication, but but through through the the support support of of his his therapist therapist he h e eventually eventually agreed agreed to to a a trial trial of of lithium. lithium. In turn, turn, his his combination combination of of psychotherapy psychotherapy and a n d lithium lithium helped helped him h i m recover recover In from a a relatively relatively intractable intractable illness. from illness. Learning Learning to to accept accept medication medication is is only only one o n e reason reason to to seek seek psychotherapy. psychotherapy. Many M a n y people people with with bipolar bipolar disorder disorder say say that that therapy therapy is is an a n essential essential part part of of their their recovery can't cure recovery from f r o m episodes, episodes, on on a a par par with with medication. medication. Psychotherapy Psychotherapy can't cure you y o u of of bipolar bipolar disorder, disorder, nor nor is is it it a a substitute substitute for for medication. medication. Nonetheless, Nonetheless, psy­ psychotherapy can can help help you y o u learn learn to to recognize recognize the the triggers triggers for for your your m o o d swings swings chotherapy mood and a n d what w h a t to to do d o about about t h e m . If If you y o u can can afford afford it, it, and a n d if if you y o u can can find find a a good good them. therapist in in your y o u r community c o m m u n i t y who w h o knows k n o w s about about bipolar bipolar disorder, disorder, II would would therapist highly sat­ highly recommend r e c o m m e n d that that you y o u pursue pursue it. it. In In my m y experience, experience, most m o s t people people are are satisfied with weekly, weekly, hour-long hour-long visits visits to to an a n individual, individual, couple, couple, family, family, or group s i fied with or group therapist. therapist.

WhyTry TtyPsychotherapy? Psychotherapy? Why There There are are several several compelling compelling reasons reasons to to seek seek psychotherapy psychotherapy (see (see the the sidebar sidebar o n page page 122). 122). A A major m a j o r reason reason is is to to get get some s o m e guidance guidance in in managing m a n a g i n g yyour o u r disor­ disoron der. der. You Y o u may m a y want w a n t to to discuss discuss the the role role of of stressful stressful events events in in eliciting eliciting your your mood m o o d cycling, cycling, the the way w a y you y o u feel feel "set "set off' o f f by b y certain certain interactions interactions with with your your spouse or or other other family family members, m e m b e r s , your y o u r difficulties difficulties accepting accepting the the illness iHness or or its spouse its stigma, stigma, or or your y o u r ambivalence ambivalence about about medications. medications. You Y o u may m a y wish w i s h to discuss the the to discuss impact that that your y o u r illness illness is is haVing having on o n your y o u r work w o r k life, life, social sociallife, life,or or family family rela­ relaimpact tionships, tionships, or or how h o w to to talk talk about about it it with with other other people. people.These T h e s e are are all allgood g o o d reasons reasons to to seek seek therapy therapy to to help help you y o u cope cope with with and a n d manage m a n a g e your y o u r disorder. disorder. Y o u may m a y also also wish w i s h to to try try therapy therapy in in order order to to address address longstanding longstanding per­ perYou sonal problems p r o b l e m s that that may m a y be b e unrelated unrelated to to your y o u r disorder disorder or or that that seem s e e m to consonal to con­ tinue, whether w h e t h e r your y o u r mood m o o d is is stable stable or or not. not. These T h e s e issues issues are are probably probably not being tinue, not being addressed in in your y o u r medication medication monitoring monitoring sessions sessions with with your y o u r psychiatrist. psychiatrist. For For addressed example, some s o m e people people with with bipolar bipolar disorder disorder feel feel that that they've they've never never had had a a sucsueexample,

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The jectives of T h e Ob Objectives of Psychotherapy Psychotherapy for for Persons Persons with with Bipolar Bipolar Disorder Disorder •

sense of past episodes of of • To To help help you you make make sense ofyour your current currentoror past episodes

•

•

•

•

•

•

•

•

•

•

•

•

illness illness To T o discuss discuss long-term long-term planning, planning,given given your your vulnerability vulnerability [0 to future future episodes episodes T o help help you you accept accept and and adapt adapt to to aa long-tenn long-term medication medication regimen regimen To To identify and develop strategies for coping with stress T o identify and develop strategies for coping with stress To T o improve improve your your functioning functioning in in school school or or the the workplace workplace To T o deal deal with with the the social social stigma stigma of of the the disorder disorder To T o improve improve family family or or maritaVromantic marital/romantic relationships relationships

cessful abused as to cessful romantic romantic relationship. relationship. Some S o m e have have been been abused as children children and and need need to talk about about past past traumatic traumatic experiences. experiences. Some S o m e feel feel chronically chronically suicidal, suicidal, even even talk when w h e n they they are are not not in in an an episode episode of of depression. depression. Some S o m e experienced experienced painful painful childhood losses (for childhood losses (for example, example, the the suicide suicide of of a a parent) parent) and and need need to tomake m a k e sense sense of their their feelings feelings of of abandonment abandonment and and rejection. rejection. Even Even if ifthese thesepsychological psychologicalis­ isof sues are are not cause of of your your bipolar bipolar disorder, disorder, they they may m a y become become more more sues not aa primary primary cause salient to to you you when w h e n your your mood m o o d cycles. cycles. Gaining Gaining insight insight into into the the nature nature of of these these salient conflicts and and developing developing skills skills for for coping coping with them have the potential potential to conflicts with them have the to m a k e you you less less vulnerable vulnerable to to new new m o o d episodes. make mood episodes. from Esther, a 27-year-old with bipolar alsosuffered suffered from Esther, a 27-year-oldwoman woman with bipolarII11 disorder, disorder, also obsessive-compulsive symptoms, symptoms, which which had had become become bad bad enough enough that that she she obsessive--compulsive had quit quit her job as as a a court court reporter. reporter. She She was was bothered bothered by by intrusive had her job intrusive thoughts that that she she might might stab stab her her husband, husband, Carl, Carl, also also age age 27. 27. These These thoughts thoughts were were especially especially disturbing disturbing to to her her because because "I "I deeply deeply love love him him ... thoughts ... he's the the best best lhing thing that's that's ever ever happened happened to to me, m e , maybe m a y b e the the only only really really good good he's thing." W h e n she she had had these these violent violent thoughts, thoughts, she sfie often often cycled cycled into into dething." When de­ pressive, suicidal suicidal episodes. episodes. She consistent in in taking taking her regimen of She was was consistem her regimen of pressive, Depakote and Zoloft (an SSRI antidepressant), but her thoughts caused Depakote and Zoloft (an SSRI antidepressant), but her thoughts caused her Significant significant distress. distress. Carl Carl was was aware aware of of her her impulses impulses but but said said he he wasn't wasn't her worried about about them. them. She She had had never never acted acted on on them, them, and and "besides, "besides, I'd I'drather rather worried she had had fantasies about killing killing me m e than than somebody somebody off off the the street." she fantasies about street." During a a course course of of interpersonally interpersonally oriented oriented therapy therapy (see (see next next secDuring sec­ for tion), Esther Esther came came to to realize realize that that she she was was quite quite angry angry at at her her husband husband for tion), what she she termed termed his his "treating "treating me m e like Hke his his little Htde doll." doH." She She recounted recounted how how what her various various attempts attempts at at independence independence were were met met with with vitriolic vitriolic tirades tirades from from her

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Carl,Carl, in which he would assert assert "being "being the boss." In one In particularly emo- emo­ in which he would the boss." one particularly tional session she she reahzed realized that that her her violent violent thoughts thoughts usually usually appeared appeared tional session within within a a few f e w hours h o u r s of of having having a a frustrating frustrating discussion discussion with with Carl Carl regarding regarding her desire desire to to get get a a job job or or go g o back b a c k to to school. school. Later Later in in therapy, therapy, she she became became her more to be m o r e comfortable comfortable with with the the idea idea that that she she had h a d legitimate legitimate reasons reasons to b e an­ anher interinter­ gry gry with with Carl Carl and a n d decided decided to to work w o r k on o n her her assertiveness assertiveness skills skHls in in her actions with w i t h him. h i m . Whereas W h e r e a s Carl Carl continued continued to to oppose o p p o s e her her working w o r k i n g full fuH actions he did finally agree to support her applying for a part-time job at a time, h e did finally agree to support her applying for a part-time job at a time, health club club and a n d enrolling enroHing in in an a n evening evening course. course. Her H e r violent violent thoughts thoughts grad­ gradhealth ually receded. receded. ually Esther's problems with her husband did not stem directly her from bipo- her bipo­ Esther's problems with her husband did not stem from directly lar disorder, disorder, although although they they contributed contributed to to her her cycling cycling patterns. patterns. Notice that her her lar Notice that improvement i m p r o v e m e n t stemmed s t e m m e d from f r o m two t w o factors: factors: her her inSight insight into into the the reasons reasons behind behind

her violent violent thoughts, thoughts, and a n d her her decision decision to to do do something something differently differently in her relain her rela­ her tionship. effec­ tionship. Most M o s t therapists therapists nowadays n o w a d a y s believe believe that that psychotherapy psychotherapy is is most m o s t effec-

tive when w h e n people people combine c o m b i n e inSight insight with with learning learning the the needed n e e d e d skills skills for for changing changing tive their thinking thinking patterns patterns or or behaviors. their behaviors.

Choosingthe IheRight RighITherapy Theropy Choosing Like comes in different sizes, shapes, andand dosages. Like medication, medication,psychotherapy psychotherapy comes in different sizes, shapes, dosages. D e p e n d i n g on o n your y o u r community, c o m m u n i t y , you y o u may m a y be b e able able to to locate locate professionals professionals who who Depending practice individual individual therapy therapy from from a a number n u m b e r of of different different theoretical theoretical viev^^points. practice viewpoints. You Y o u may m a y also also have h a v e access access to to family family therapy, therapy, couple couple therapy, therapy, or or self-help self-help limited to to the groups. If If you y o u live live in in a a rural rural or or mountain m o u n t a i n setting, setting, you y o u may m a y be b e limited the groups.

orientation and a n d type type of of practice practice available available in in your y o u r immediate i m m e d i a t e locale. locale. orientation A l m o s t all all therapy therapy goes goes better better if if you're you're with with a a therapist therapist whom whom y o u reAlmost you re­ spect and a n d trust, trust, with with whom w h o m you y o u have have a a good g o o d relationship, relationship, and a n d who w h o you y o u feel spect feel genUinely genuinely cares cares about a b o u t you. y o u . But B u t it it is is also important to to find find a a therapist who also important therapist who

understands the the syndrome s y n d r o m e of of bipolar bipolar disorder. disorder. Avoid A v o i d being being in the position position understands in the of of educating educating your y o u r therapist therapist about a b o u t your y o u r bipolar bipolar symptoms, s y m p t o m s , or or having having him h i m or or

her label label your y o u r behavior behavior as as "acting "acting out" out" or or "low "low self-esteem" self-esteem" when w h e n the the real her real issues issues have h a v e to to do d o with with unresolved unresolved manic m a n i c or or depressive depressive symptoms. s y m p t o m s . Good Good questions questions to to ask ask your y o u r intended intended therapist therapist include include whether w h e t h e r her her or or she she (1) (1)

w o r k s regularly regularly with with persons persons with with bipolar bipolar disorder, disorder, (2) (2) will will integrate integrate his his or or works her her knowledge k n o w l e d g e of of the the disorder disorder into into the the treatment, treatment, and a n d in in what w h a t ways, w a y s , (3) (3) places places importance importance on o n understanding understanding the the illness illness and a n d its its effects effects on o n your y o u r relarela­

tionships, (4) (4) will will communicate c o m m u n i c a t e regularly regularly with with the the physician physician who w h o is is manag­ managtionships, ing ing your y o u r medications medications and a n d develop develop an a n integrated integrated treatmeOl treatment plan, plan, and a n d (5) (5) will will

focus on o n the the present present as as well as the the past. Y o u also also should ask h o w long your focus well as past. You should ask how long your

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therapy is to last, although your therapist may notmay be not ablebe to able give you therapy islikely likely to last, although your therapist to give you a for a precise precise answer. answer. It It is is reasonable reasonable to to expect expect weekly weekly or or biweekly biweekly sessions sessions for about six six months months 1O to a a year year after after an an illness illness episode, episode, with with an an agreement agreement to about to evaluate your your progress progress from from time time to to time. evaluate time. Avoid agreeing agreeing to to open-ended, open-ended, long-term long-term contracts contracts with with no no clearly clearly articu­ articuAvoid lated lated goals. goals. Avoid Avoid therapy therapy approaches approaches in in which which all all disorders-whether disorders—whether bipobipo­ lar anxiety problems, lar disorder, disorder, depression, depression, anxiety problems, or or substance/alcohol substance/alcohol abuse-are abuse—are ascribed ascribed to to traumatic traumatic "repressed "repressed memories" memories" (that (that is, is, memories memories of of negative negative childhood experiences experiences that that are are buried buried and and presumably presumably must be uncovered). uncovered). childhood must be Despite been around Despite the the fact fact that that these these treatments treatments have have been around for for some some time, time, they they are unproven by and have have not are largely largely unproven by research research and not been been evaluated evaluated systematically systematically in more, they tend to deny the in bipolar bipolar disorder. disorder. What's What's more, they tend to downplay downplay or or even even deny the im­ importance of of the the biological biological and genetic origins of the the disorder disorder and and the the need need for portance and genetiC origins of for medication. medication. This This is is not not to to say say that that examining examining painful painful childhood childhood events events will wiU not itt should be done fa acknowl­ not help help you, you, but but i should be done in in the the context context o of a tlierapy therapy tliat that acknowledges edges the the biological biological bases bases of ofyour your disorder, disorder,educates educatesyou youabout abouthow howtotocope copewith withit,it, and and deals deals wit with present di difficulties as well as past. Ii present fficulties as well as past. In In the the next next section, section, IItalk talkabout aboutdifferent differentkinds kindsof ofindividual individualpsychothera­ psychotherapy that available in purposes, py that may m a y be be available in your your community, community, their their assumptions assumptions and and purposes, and research research evidence evidence for for their their effectiveness effectiveness in in stabilizing stabilizing the the cycles cycles of of your your and bipolar disorder disorder w h e n combined combined with with medication. medication. bipolar when Individual Psychotherapy Individual Psychotherapy Individual therapyis is most often recommendedonce onceyou youhave havestaned started to reto re· Individual therapy most often recommended cover from from an an episode episode of bipolar disorder. disorder. Therapy Therapy is primarily a a maintenance maintenance cover of bipolar is primarily treatment rather than than an an acute acute episode episode treatment. treatment. When W h e n you you are arebeginning beginning to to treatment rather stabihze on your medication, medication, you you may m a y still still have have Significant significant mood m o o d symptoms, symptoms, stabilize on your disturbances in in your your thinking thinking patterns, patterns, and and behavior behavior patterns patterns that can interdisturbances that can inter· fere with with your your long.term long-term stability. stability. Consider Consider finding a psychotherapist psychotherapist who who fere finding a can work work with with you you cognitively cognitively or or interpersonally. interpersonally. These Theseare arethe the two two types typesof ofin· incan dividual therapy therapy that that have the most most research research support support in in terms of improving improving dividual have the terms of the course of bipolar bipolar disorder disorder when w h e n given given alongSide alongside medications medications (Miklowitz (Miklowitz the course of & Craighead, Craighead, 2001; 2001; Craighead Craighead & & MiklowilZ, Miklowitz, 2000). 2000). & Cognitive-behavioral therapy (CBT), a a treatment treatment designed designed by by Aaron Aaron Beck, Beck, Cognitive·behavioral therapy (CBT), M D , is is perhaps perhaps the the most most well·established well-established psychotherapy psychotherapy for for depreSSion depression (Beck (Beck MD, et aI., al, 1979; 1979; DeRubeis et aI., al, 1998). 1998). There are few few published published studies studies of of CBT C B T for There are et DeRubeis et for bipolar persons, persons, but but the the few that do do exist exist find that people people who w h o do do CBT C B T while while bipolar few that find that on medication medication have fewer relapses relapses of of their their disorder disorder (Cochran, (Cochran, 1984; 1984; Perry Perry et on have fewer et al, 1999; 1999; Lam L a m e1 et aI., al, 2000). 2000). If If your your therapist therapistspecializes speciahzesin in CST, C B T ,he he or orshe shewill wiU al.,

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encourage you focus patterns of negative thinking about yourself, encourage you to to focus on on patterns of negative thinking about yourself, your your

world, and a n d your y o u r future. future. By B y keeping keeping a a daily daily thought thought record record (see (see Chapter Chapter 110), 0), world, y o u can c a n learn learn to to identify identify your y o u r assumptions assumptions about about certain certain critical critical events, events, par­ paryou ticularly ticularlyany a n y self-defeating self-defeatingstatements-"hot s t a t e m e n t s — " h o tcognitions"-that cognitions"—thatspontaneously spontaneously

arise in in reaction reaction to to these these events events (for (for example, e x a m p l e , "I "1 lost lost my m y job job because because I'm I'm just just arise you not capable capable of of holding holding one"). o n e " ) . Your Y o u r CBT C B T therapist therapist will w i H encourage encourage y o u to to recog­ recognot

nize the the impact i m p a c t of of such s u c h assumptions assumptions on o n your y o u r mood m o o d states states and a n d to c o n d u c t "ex­ "exnize to conduct perimentsn periments" in in your y o u r day-to-day day-to-day life life to to detennine determine if if your y o u r assumptions assumptions are are valid. vahd.

A s therapy therapy proceeds, proceeds, he h e or or she she will will encourage encourage you y o u to to consider consider more m o r e adaptive adaptive As and a n d balanced balanced interpretations interpretations of of events events and a n d record record these these new n e w cognitions cognitions on on re­ your your thought thought record record (for (for example, e x a m p l e , "Maybe " M a y b e 1I lost lost this this job job because because II was w a s still stHl re-

covering from f r o m my m y depression depression and a n d couldn't couldn't function function at at the the level level II know k n o w I'm I'm cacovering ca­ pable of," of," or or "This "This last last job job taught taught me m e that that II need n e e d to to work w o r k in in an a n environment environment pable that that will w i H allow allow me m e to to stay stay stable stable and a n d still stiH use use my m y skills"). skills"). Chapter Chapter 10 1 0 offers offers a a more m o r e thorough t h o r o u g h discussion discussion of of the the CBT C B T approach a p p r o a c h and and a a selection selection of of cognitive cognitive

restructuring exercises exercises you y o u can c a n try try out out on o n your y o u r own. own. restructuring A second second individual individual approach a p p r o a c h is is interpersonal interpersonal therapy. therapy. This This therapy therapy is A is geared playing in geared toward t o w a r d helping helping you y o u understand understand the the role role that that your y o u r illness illness is is playing in your your close close relationships relationships or or work w o r k life, life, and a n d in in turn, turn, how h o w your y o u r relationships relationships or or work to work w o r k life life is is affecting affecting your y o u r bipolar bipolar disorder. disorder. This This therapy therapy was w a s shown s h o w n to work as as well well as as cognitive-behavioral cognitive-behavioral therapy therapy in in a a large large study study of of major m a j o r depreSSive depressive

disorder (Elkin (Elkin et et aI., a l , 1995; 1 9 9 5 ; Weissman W e i s s m a n et et aI., al, 2000). 2 0 0 0 ) . Interpersonal Interpersonal therapists therapists disorder encourage you y o u to to focus focus on on a a particular particular interpersonal interpersonal problem p r o b l e m in y o u r life and encourage in your life and consider consider how h o w it it relates relates to to your y o u r mood m o o d disorder. disorder. For F o r example, e x a m p l e , some s o m e people people dede­

velop a a manic m a n i c or or depreSSive depressive episode episode after after a a loss loss or or grief grief experience experience (e.g., (e.g., the the velop death of of a a parent) parent);; some s o m e after after a a life life transition transition such s u c h as as lOSing losing a a job job or or a a divorce; divorce; death some s o m e after after significant significant disputes disputes with with family family members m e m b e r s or or panners; partners; and a n d some s o m e afaf­ ter ter a a series series of of ongOing o n g o i n g problems p r o b l e m s in in maintaining maintaining relationships relationships with with other other peo­ peo-

ple. Interpersonal Interpersonal therapy therapy focuses focuses on o n your y o u r habits habits in in close close relationships relationships and and ple. how h o w to to alter alter them t h e m to to help help stabilize stabilize your y o u r mood. mood. A A new n e w fonn f o r m of of interpersonal interpersonal therapy, therapy, called called interpersonal interpersonal and and social social

rhythm therapy therapy (IPSRT; (IPSRT; Frank F r a n k et et aI., al, 1994; 1 9 9 4 ; Frank F r a n k et et al., al, 2000), 2 0 0 0 ) , includes includes a new a new rhythm element: element: monitoring monitoring y o u r sleep-wake sleep-wake rhythms, r h y t h m s , patterns patterns of of daily daily activity, activity, and and your

levels of of daily daily social social stimulation stimulation (for (for example, e x a m p l e , the the amount a m o u n t of of highhigh- versus versus levels low-intensity contact contact you y o u have h a v e with with friends friends or or family family members). m e m b e r s ) . This This method method low-intensity is is discussed discussed further further in in Chapter Chapter 8 8 (in (in particular, particular, see see the the self-rated self-rated Social Social Rhythm R h y t h m Metric). Metric). Working W o r k i n g with with a a therapist therapist who w h o specializes specializes in in this this interperinterper­

sonal model m o d e l may m a y be b e qUite quite helpful helpful to to you y o u in in implementing i m p l e m e n t i n g sleep-wake sleep-wake and and sonal other strategies strategies for for stabilizing stabUizing social social rhythms. r h y t h m s . In In one o n e carefully carefully designed designed study, study, other I P S R T was w a s shown s h o w n to to decrease decrease the the amount a m o u n t of of time time that that people people with with bipolar bipolar disIPSRT dis-

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order stable episodes andand to increase order spem spentin indepressive depressive episodes to increase time in mood stable mood their their time in 1999; Frank et al., 1999). states (Frank, states (Frank, 1999; Frank et al, 1999).

FGmily Family Gnd andCouple CoupleThe'G Therapy PY Sometimes bipolar bipolar disorder best treated in a family or couple context.context. Sometimes disorderis is best treated in a family or couple The The advantage advantage of of therapy therapy with with your your close close relatives relatives is is that that they they can can be be educated educated about your about your disorder disorder and and taught taught coping coping skills skills for for managing managing stress stress at at the the same same time often have have significant time as as you. you. People People with with bipolar bipolar disorder disorder often significant family family or or rela­ relationship problems problems (see (see Chapter Chapter 5). 5). Family treatments can can provide provide ways ways of of im­ imFamily treatments tionship proving proving your your communication communication with with your your spouse, spouse, parents, parents,or or kids kids (see (seethe thecom­ communication 12). munication strategies strategies described described in in Chapter Chapter 12). The family!couple family/couple approach approach that that II developed developed with with Michael Michael Goldstein, The Goldstein, PhD, PhD, called called family-focused family-focused therapy therapy (FFT), (FFT), is is a a nine�month-long nine-month-long educational educational therapy. therapy. In In FFT, FFT, bipolar bipolar persons persons and and their their spouses spouses or or parents parents are are acquainted acquainted with the with the facts facts about about the the disorder: disorder: its its symptoms, symptoms, causes, causes, prognosis, prognosis, and and treat­ treatment. Later stages of F F T focus focus on on family family or or couple couple communication communication and and probment. Later stages of FFT prob­ lem-solving lem-solving strategies, strategies, including including how h o w to tolisten, listen,negotiate, negotiate,and and solve solveconflicts conflicts (to therapy, see book by (to learn learn more more about about this this therapy, see the the book by Miklowitz Miklowitz & & Goldstein, Goldstein, 1997). disor­ 1997). In In two two different different studies studies we w e have have found found that that people people with with bipolar bipolar disorder der who w h o get get medication medication and and take part in in FFT F F T have better outcomes outcomes of of their have better their lake pan disorder over the the oneone- to to two-year two-year period period follOWing following an an episode episode than than those those disorder over who w h o get get medication medication and and supportive supportive individual individual therapy therapy or or case case management management (Miklowitz et et aL, al, 2000; 2000; Rea Rea et et al., al, 2001). 2001). (Miklowitz Cognitive, interpersonal, interpersonal, and and family family educational educational treatments treatments may m a y be be hard hard Cognitive, to find find in your community, community, but but look look for for them them anyway. anyway. Check Check out out lhe the website website to in your for the the Systematic Systematic Treatmem Treatment Enhancement Enhancement Program Program for for Bipolar for Bipolar Disorder, Disorder, which which includes referral information information for for sites sites around the coumry country that that offer includes referral around the offer these specialty specialty therapies therapies in the context context of of a a National National Institute Institute of of Mental Mental these in the Health-sponsored program program (www.stepbd.org). Health-sponsored (www.stepbd.org). Self-HelpG,oups Groups Sell-Help Many Manypeople peoplebenefit benefit from from support support groups groups(Bauer (Bauer62&McBride, McBride,1996). 1996).InIn groups, people people with with bipolar bipolar disorder disorder get get together together and and discuss discuss their their feelings, groups, feelings, attitudes, and and experiences experiencesrelated relatedto tothe thedisorder. disorder.Many M a n y people peoplefeel feelthat thatolhers others attitudes, them and with bipolar disorder disorder are are the the only ones who w h o can can truly truly undersland understand them and with bipolar only ones give them them viable viable solutions. solutions. People People in in bipolar bipolar support support groups groups lalk talk about about medi­ medigive cations they've they've tried and which have worked, worked, which which therapies therapies they've they've had, had, cations tried and which have h o w they they have have dealt dealt with with problems the work, work, family, orsocial socialsettings, settings,and and how problems in in the family, or what they they do do to to prevem prevent themselves themselves from from getting getting ill iH again. what again.

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Ofmore the than more than 2,000 respondents to the NationalandDepressive and Of the 2,000 respondents to the National Depressive Manic M a n i c Depressive Depressive Association Association (NDMDA) ( N D M D A ) Support Support Group G r o u p Compliance C o m p l i a n c e Survey Survey (1998; Lewis, Lewis, 2000)-all 2 0 0 0 ) — a H of of whom w h o m had had been been active active in in local local NDMDA N D M D A groupsgroups— (1998; 95% them become to 9 5 % said said that that their their group group experience experience helped helped them become more more willing wilHng to their side take take medication, medication, communicate communicate with with their their doctors, doctors, and and cope cope with with their side ef­ effects. used to fects. II used to run run a a support support group group for for people people with with bipolar bipolar disorder disorder and and was was continually continually impressed impressed with with how h o w effective effective the the members m e m b e r s were were at at helping helping each each other. other. Sometimes profession­ Sometimes these these groups groups have have leaders leaders who w h o are are mental mental health health professionals, dis­ als, and and sometimes sometimes they they are are leaderless leaderless and and contain contain only only people people with with the the disorder in a order ("mutual ("mutual support support groups"). groups"). Not Not everyone everyone feels feels comfortable comfortable in a group group sening, if setting, however. however. If If you you have have doubts, doubts, try try going going for for one one session session and and see see if you can relate to the other people in the group. Can you imagine feeling you can relate to the other people in the group. C a n you imagine feeling supported supported and and understood understood by by them them when w h e n talking talking about about your your own o w n problems? problems? Do D o they they seem seem to to have have had had the the kinds kinds of of life life difficulties difficulties or or illness illness manage­ management problems problems you've you've had? had? To T o see see if if there there are are groups groups available available in in your your ment community, town, community, try try calling calling the the local local mental mental health health center center in in your your city city or or town, local local psychiatrists psychiatrists who w h o specialize specialize in in mood m o o d disorders, disorders, or or the the phone phone numbers numbers listed in in the the next next paragraph. paragraph. listed Family SupportG,OUpS Groups Family Support

Your spouse Your parents may may also also want want to toanend attenda support a support group. They may spouse or or parents group. They may benefit from from a a group group in in which which they they can can commiserate commiserate with with other other relatives relatives of benefit of persons with with bipolar bipolar disorder. disorder. Good G o o d options options for for your your relatives relatives include include the persons the DeDe­ pression and and Bipolar Bipolar Support Support Alliance Alliance (800-826-3632; (800-826-3632; www.ndmda.org), www.ndmda.org), the pression the National Alliance Alliance for for the the Mentally Mentally III 111 (800-950-NAMI; (800-950-NAMI;www www.nami.org), orthe the .namLorg), or National Child and and Adolescent Adolescent Bipolar Bipolar Foundation Foundation (847-256-8525; (847-256-8525; www.bpkids.org). www.bpkids.org). Child These organizations organizations usually usually proVide provide informative informative lectures, lectures, group group discussions, discussions, These and and educational educational materials materials for for relatives. relatives. Try not not to to be be anxious anxious about about your your spouse's spouse's or or your your parent's parent's desire desire to to join Try join such such a a group. group. You Y o u may m a y fear fear that that these these groups groups will will be be composed composed of of angry angry relarela­ tives who w h o will will badmouth badmouth you you and and encourage encourage your your relatives relatives to to give give up up and and tives leave. In In my m y experience, experience, this this is is not not the the case. case. Rather, Rather, these these groups groups provide provide use­ useleave. ful ful information information and and support support and and help help relatives relatives feel feel less less isolated isolated in in their their atat­ tempts are uncomfort­ tempts to to understand understand and and cope cope with with bipolar bipolar disorder. disorder. If If you you are uncomfortable, ask ask your your relative relative to to take take you you with with them. them. In In most most cases, cases, these these groups groups are able, are usually, open to to persons persons with with the the disorder disorder as as well well as as their their relatives. relatives. And, And, usually, open they're free. they're free. *

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As you thereare arenumerous numeroustreatments treatments for for bipolar None As you can can see,see, there bipolardisorder. disorder. None of these these treatments treatments is is perfect, perfect,but butmany m a n ycan caneffectively effectivelytreat treatyour youracute acutesymp­ sympof toms toms and, and, in in all all likelihood, likelihood, even even out out the the course course of of your your illness illness over over time. time. Adding psychotherapy psychotherapy or or support support groups groups to to your your medication medication regimen regimen helps helps Adding ensure that that your your "person" is treated treated as as well as your your disorder, disorder, and and that thatyou you de­ deensure "person" is well as velop strategies triggers. velop strategies for for coping coping with with stress stress triggers. with aa number Y o u and and your your doctor doctor may m a y need need to to experiment experiment with number of of different different You medication is effective medication and and therapy therapy options options before before you you find find a a combination combination that that is effective and also also minimizes minimizes your your side side effects. effects. This Thistrial trialand and error errorprocess processmay m a y be befrus­ frusand trating at times. times. There is every every reason reason to to be be hopeful hopeful that, that, with with time, time,you you will wiU trating at There is find a a regimen regimen that that is is optimal optimal for for you. you. Of Of course, course, committing committing to to a a long-term long-term find program of of medication medication is is an an important important personal personal decision. decision. You Y o u may m a y have have sigprogram sig­ nificant any of of these nificant doubts doubts about about whether whether you you should should take take any these medications. medications, even even if if you you are are suffering suffering from from mood m o o d swings swings that that interfere interfere with with your your functioning. functioning. These reactions reactions are are understandable. understandable. But h e n people people with bipolar disorder disorder These But w when with bipolar stop taking medication, particularly particularly if if they they do do so so abruptly, abruptly, they they often often end end up up stop taking medication, relapsing and relapsing and worse worse off off than than they they were were before before they they stopped. stopped. To T o hear hear more more about how h o w patients patients have resolved this dilemma, read read on: on: Chapter Chapter 7 7 is is devoted devoted about have resolved this dilemma, to in coming coming to to the the issues issues involved involved in to accept accept a a long-term long-term program program of of medication. medication.

7 7

C o m i n g to t o Terms T e r m s Coming w i t h Your Y o u r Medication Medication with

"Accusing quality. "Accusing me m e of of mania, mania, my m y elder elder sister's sister's voice voice has has an an odd odd manic manic quality. 'Are coo­ 'Are you you taking taking your your medicine?' medicine?' A A low low controlled controlled mania, mania, the the kind kind of of control in in furious furious questions questions addressed addressed to to children, children, such such as as 'Will 'Will you trol you get get d o w n from from there?' there?' ... .. . down "As if if by by going going off offlithium lithium IIcould could erase erase the the past, past,could could prove prove it ithad had MAs never happened, happened, could could triumph triumph over over and and contradict contradict my m y diagnoses; diagnoses; this this never w a y II would would be be right right and and they they would would be be wrong. had always always been been the way wrong. It It had the other way; way; they they were were right right and and II was was wrong. wrong. Of O f course courseIIhad had only only to to take take other the lithium lithium in in order order to to be be accepted accepted back back .... on lithium lithium II would would he be 'all all the . . on right'. ... .But . But a m never all right, in remission. If I could right' I amI never all right, just just in remission. If I could win win this this gamble.. ...." gamble —Millet (1990, (1990, p. 32) -Millet p. 32) .

The nature nature of ofbipolar bipolar disorder is such that when even you whenfeel youbetter, feel better, The disorder is such that even you still you still have an an underlying underlying biological biological predisposition predisposition to to the the illness. illness.This Thispredisposition predisposition have requires you you to to take take medication medication even even when w h e n you're you're feeling feeling well. well. Often, Often, though, though, requires when w h e n you you feel feel beuer, better, you you will will be be tempted tempted to to stop stop your your medication, medication, because because you won't won't see see the the need need for for it. it. That's That's an an understandable understandable reaction. reaction. Unfortu­ Unfortuyou nately, stopping stopping your your medications medications against against medical medical advice-and advice—and sometimes sometimes nately, even just taking inadequate dosages or missing dosages regularly—puts you at laking inadequate dosages or missing dosages regularly-pulS you at even just m u c h higher higher risk risk of of having having aa recurrence recurrence of of your your bipolar bipolar disorder. disorder. aa much 129 129

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their medi­ In my people are to consider considerstopping stopping their mediIn experience, my experience, people aremost mostlikely likely to cations cations once once they they have have recovered recovered from from a a manic or depressive depressive episode. episode. During During manic or this they m may in control this phase phase they a y feel feel good good or or even even hypomanic, hypomanic, but but are are more more in control of of theiT height of feels their moods m o o d s than than during during the the height of theiT their illness. illness. Taking Taking medication medication feels like are especially true of like spoiling spoiling a a good good party. party. These These reactions reactions are especially true of younger younger peopeo­ ple who some­ ple w h o have have had had only only a a few few episodes. episodes. Inconsistency Inconsistency with with medication medication sometimes times stems stems from from feelings feelings of of "youthful "youthful invulnerability" invulnerability" or or just just plain denial of plain denial of the disorder. disorder. But But II have have also worked with middle-aged and and older older adults adults who who the also worked with middle-aged have many and still have had had many, many, m a n y bipolar bipolar episodes episodes and still doubt doubt that thatthey theyneed need medica­ medication, they do they tion, even even if if they do acknowledge acknowledge having having the the disorder. disorder. Understandably, Understandably, they want to to know k n o w what life would would be be like without the the pills. want what life like without pills. In to In the the last last chapter, chapter, II talked talked about about the the various various drug drug treatments treatments available available to people with with bipolar bipolar disorder. disorder. In this chapter, chapter, II talk talk about about the the various various reasons reasons people In this that people people with with bipolar bipolar disorder disorder give give for for discontinuing discontinuing their their drug drug regimens. that regimens. Many reasons have those M a n y of of these these reasons have been been offered offered by by my m y own o w n clients, clients, including including those who but question the medicamedica­ w h o have have been been stable stable for for quite quite some some time time but question whether whether the tion is tion is really really working. working. Sometimes Sometimes the the issues issues surrounding surrounding inconsistency inconsistency or or "nonconcordance" "nonconcordance" are are related related to to feelings feelings or or beliefs beliefs about about the the disorder, disorder, such suchas as disagreeing the pleasure the high disagreeing with with the the diagnosis diagnosis or or missing missing the pleasure of of the high periods. periods. in­ InconSistency can also consistency can also be be a a response response to to unpleasant unpleasant side side effects effects (for (for example, example, weight gain weight gain on on divalproex), divalproex), difficulty difficultyrelating relatingto toaaparticular particularphYSician, physician,or ordis­ dislike like of of having having one's one's blood blood drawn. drawn. Sometimes Sometimes people people just just forget forget to to take take their their medicine. People also go off medication because of practical matters like medicine. People also go off medication because of practical matters like prepre· scriptions that that lapse lapse (and (and difficulties difficulties getting getting a an e w appointment) appointment) and and the the high high scriptions new costs of paying for for medication medication (for (for example, example. Keck Keck et al, 1997; 1997; Lewis, Lewis, 2000). 2000). costs of paying et aI., In this this chapter, chapter, II suggest suggest some some tips tips for for making making medication medication feel feel more more acIn ac­ physi­ ceptable to you, as well as ideas for discussing side effects with your physiceptable to you, as well as ideas for discussing side effects with your cian. Y o u may m a y recognize recognize your your own o w n experiences experiences in in the the illustrations illustrations of cian. You of issues issues that people commonly struggle with w h e n trying to accept a long-term pro­ that people commonly struggle with when ttying to accept a long-term program of of medication. medication. gram

What Medication Concordance? W h a t Is Is Medication Concordance? "Concordance" medication isis congruence between "Concordance'· with with medication "a "a congruence between thethe planplan mademade withwith the physician physician and and the the plan plan carried carried out out by by the patient" (Sachs, (Sachs, 2000). 2000). the the patiem" "Nonconcordance" means means that that you you have have nOI not followed foHowed the the physician's physician's recom­ recom"Nonconcordance" mendations in in taking taking your your medication medication or or have have stopped stopped altogether, altogether, against againsthis his mendations or her her advice. advice. But people can become nonconcordant nonconcordant in in any any number number of of ways. ways. or But people can become For example, some some people people take take their their medications medications correctly correctly for for several several weeks weeks For example, and then then stop stop all aH of of them abruptly. Some S o m e stop stop only only one one medication medication in a "cock"cockand them abruptly. in a

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tail" theyare areon onHthium, lithium, Depakote, Zyprexa, and decide taU" of of medications: medications: they Depakote, and and Zyprexa, and decide to to discominue discontinue everything everything but b u t the the Depakote D e p a k o t e (and (and sometimes s o m e t i m e s even even take take a a higher higher dosage dosage of of this this medication medication than than prescribed). prescribed). Other O t h e r people people drop drop their their dosages of dosages or or take take medications medications intermittemly intermittently (for (for example, e x a m p l e , take take only only half half of their their recommended r e c o m m e n d e d Tegretol Tegretol tablets, tablets, miss miss their theirevening evening dosages, dosages,skip skipSaturday Saturday nights). nights). For F o r others, others, nonconcordance n o n c o n c o r d a n c e takes takes the the form f o r m of of substituting substituting unproven unproven remedies remedies (for (for example, e x a m p l e , medicinal medicinal herbs herbs like like Sl. St. John's John's won w o r t or orkava kava kava) kava) for for mood m o o d stabilizers, stabilizers, or or trying trying to to use use alcohol alcohol or or marijuana marijuana to to control control their their mood mood states. states. in Why W h y the the term term concordance? concordance! Many M a n y alternative alternative terms terms have have been b e e n proposed proposed in the medical medical literature, literature, the the most m o s t common c o m m o n of of which w h i c h are are adherence adherence and a n d compli­ complithe ance. ance. In In my m y experience, experience, persons persons with with bipolar bipolar disorder disorder don't don't usually usually like H k e either either of those those terms. terms. Nonadherence Nonadherence either either feels feels critical critical or or judgmental judgmental or or is is associated associated of in the the mind m i n d with with tape tape or or glue. glue. It It implies implies that that the the person person with with the the disorder disorder is in is s i the unwilling unwilling or or unable unable to to stick stick to to an a n agreed-upon agreed-upon program. program. Even E v e n worse w o r s e is the term noncompliance, noncompliance, which w h i c h implies implies a a paternalistic paternalistic stance: stance: The T h e client client with with bibi­ term polar polar disorder disorder is is not not going going along along with with what w h a t others others insist insist that that he h e or or she she must m u s t do. do. II prefer prefer the the term term concordance concordance because because it itunderlines underlines the theimportance importance of of the the alliance alliance between b e t w e e n the the physician physician and a n d the the person person with with bipolar bipolar disorder. disorder. Stopping Stopping medications medications or or taking taking them t h e m inconsistently inconsistently can can often often be b e attributed, attributed, in in pan, part, to to the purposes of various medi­ the phYSiCian, physician, who w h o may m a y not not have h a v e articulated articulated the the purposes of the the various medications in in the the regimen, regimen, may m a y not n o t have have alerted alerted you y o u to to the the possible possible side side effects, cations effects, or may m a y not n o t have h a v e been b e e n understanding, understanding, respectful, respectful, or or communicated communicated a sense of or a sense of caring for for your y o u r individuality. individuality. caring

H o w (ommon C o m m o n Is Is Nonconcordance? Nonconcordance? How Frequently, peoplewith withbipolar bipolardisorder disorder discontinue their medication. Frequently, people discontinue their medication. Esti­ Estimates vary, but to be than half with mates vary, but the the consensus consensus seems seems to be that that more more than half of of those those with bipolar disorder quit quit taking at some some point bipolar disorder taking their their medications medications at point in in their their lives lives (Colom et et aI., al, 2000). study by by Stephen Stephen Strakowski and colleagues colleagues at (Colom 2000). A A study Strakowski and at the the University of Cincinnati College College of of Medicine (1998) found found that that 5 9 % of University of Cincinnati Medicine (1998) 59% of papa­ tients tients with with m o o d disorder disorder were mood were "partially "partially nonadherent" nonadherent" (took Ctook medications medications inin­ consistently) or "fully "fully nonadherent" (quit taking taking them them altogether) consistently) or nonadherent" (quit altogether) during during the the year year after after their episode. Y o u are become their first first hospitalized hospitalized episode. You are more more likely likely to to become nonconcordaot if nonconcordant younger rather rather than than older, older, severely severely iill ll with if you you are are male, male, younger with mood m o o d disorder, recently hospitalized, hospitalized,prone pronetotoalcohol alcoholor orsubstance substanceabuse abusedis­ disdisorder, recently orders, and lack lack a a supportive a spouse, spouse, or on orders, and supportive family family structure, structure, a or friends friends to to rely rely on (Colom al, 2000; oodwin & Jamison, 1990). 1990). &. Jamison, (Colom et et aI., 2000; G Goodwin Not to the rate of examNot all all medications medications lead lead to the same same rate of nonconcordance. nonconcordance. For For exam-

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withwith of people 21%21% only pie, pie,Roger RogerWeiss Weissand andcolleagues colleagues (1998) found that only of people that found (1998) the all it with consistent were lithium taking were who disorder bipolar bipolar disorder w h o were taking lithium were consistent with it all the lime. time. The The rate rate was was 50% 5 0 % among a m o n g people people taking taking Depakote, Depakote, possibly possibly because because its its side side ef­ effects are are easier easier to to tolerate. tolerate. fects People People with with bipolar bipolar disorder disorder are are not not the the only only ones ones who w h o have have trouble trouble ac­ accepting cepting aa long-term long-term program program of of medication. medication. Those Those with with diabetes, diabetes, hean heart dis­ disease,hypertenSion, hypertension,glaucoma, glaucoma,or orany anyother otherchronic chronic medical medicalcondition conditionthat thatre­ reease, quires quires ongOing ongoing medication medication are are up up against against the the same same challenge challenge you you are. are. People People are are even even inconsistent inconsistent with with taking taking antibiotics antibiotics and and birth birth control control pills! pills! You're You'renOl not alone alone in in this this type type of of struggle. struggle.

W h a t Are Are the the (onsequences Consequences of of Nonconcordance? Nonconcordance? What

being being withoutwithout to take told told often areare People with People with bipolar bipolardisorder disorder often to medication take medication given compelling compelling reasons reasons for for doing doing so so or or a a full full understanding understanding of of what what might might given happen happen if if they they don't. don't. The The main main t'eason reason that that sLopping stopping your medication is is inad­ inadyouI' medication visable visable is is that that it it is is associated associated with with a a high high risk risk of of t'ecurrence recurrence (for (for example, example, It also et al., Strober Strober el et aI., al, 1990; 1990; Keck Keck et al, 1998). 1998). It also gt'eatly greatly increases increases the therisk riskof ofsui­ suicide. In In fact, fact, not nottaking takingmedications, medications,as aspreSCribed, prescribed,isisthe thegreatest greatestSingle singlefactot' factor cide. et people have contributing to to when when and and how how often often bipolat' bipolar people have t'ecurrences recurrences (Colom (Colom et contributing al, 2000). 2000). As As stated stated by by Jamison Jamison (1995), (1995), "That "That lI owed owed my m y life life lO to pills pills was was not, not, al., ne­ however, obvious lO to me m e for for a a long long time; time; my m y lack lack of of judgement judgement about about the the nehowever, obvious cessity to to take take lithium lithium proved proved to to be be an an exceedingly exceedingly costly (p. 89). 89). one" (p. costly one" cessity W h e n medications are discontinued discontinued very very abruptly abruptly (which (which is is usually usually the the medications are When case), case), the chances of of relapsing--or relapsing—or of of committing committing suicide-are suicide—are higher higher than than the chances 1993; w h e n medications medications are discontinued slowly slowly (for example, Suppes Suppes et al, 1993; et aI., (for example, are discontinued when Tondo &: & Baldessarini, will take take a a while while before before your your medication medication It will 2000). It Baldessarini, 2000). Tondo reaches a a stable stable blood level if you stop stop suddenly suddenly and and then then restart. restart. If If you you take take reaches if you blood level medication inconsistently, end up levels blood levels inadequate blood with inadequate up with also end can also you can inconSistently. you medication that same negative negative results. results. the same to the lead to that lead get M a n y people people want go on thinking that they get if they that if holidays," thinking "drug holidays," on "drug lO go want to Many worse, go back and return Hke normal-just like to normal—just return to drug and the drug on the back on always go can always they can worse, they that. Because the theconsequences consequences of ofdiscontinuing discontinuing medication medication is isnot not always always im­ imthat. Because mediate is, you you can can feel feelbetter, better,temporarily, temporarily,after afterstopping stopping your your medica­ medica(that is, mediate (that tion), you may m a y feel feel that thatyou you are are "in "in the the clear" clear"and and can can go go on on living livingyOUT your life Hfe tion), you without the to the due to be due can be feelings can good feelings your good Unfortunately, your medication. Unfortunately, without medication. hypomania This withdrawn. This is withdrawn. medication is after medication shortly after develops shortly often develops that often hypomania that hypomania stage in in the the evolution evolution of ofaa serious serious manic manic episode. episode. first stage the first often the is often hypomania is If you go go off off aa drug drug such such as as lithium lithium and and then then have have aa relapse relapse of of yOUT your illness, illness, If you there eH w h e n you resume you resume when as wwell respond as won't respond you won't that you possibility that real possibihty very real a very is a there is

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taking it (Post, canlead leadtotoa a taking it (Post, 1993). 1993). In In fact, fact,starting startingand and stopping stopping medication medication can pattern pattern of of continuous continuous cycling cycling in in which w h i c h illness illness episodes episodes beget beget other other illness illness epi­ episodes, periods of sodes, and a n d the the periods of feeling feeling well w e H between b e t w e e n periods periods of of illness illness get get shorter shorter and a n d shorter shorter (the (the "kindling "kindling effect"; effect"; Post, Post, 1992). 1992). On O n the the positive positive side, side, getting getting medical medical treatment treatment early early in in the the course course of of your y o u r disorder disorder (that (that is, is, when w h e n it it is first is first diagnosed), it can cy­ diagnosed), and a n d staying staying with with it c a n prevent prevent these these patterns patterns of of continuous continuous cycling. cling.

Why W h y Do D o People P e o p l e Stop Stop Taking Taking Their Their Medicotion­ Medication— and Why W h y Should Should You You Resist Resist Doing Doing So? So? and Clarence, a 19-year-old man, had hisfirst first manic Clarence, a 19-year-old man, had his manic episode episode while while aastudent student at at a a West W e s t Coast Coast state state university. university. He H e became became belligerent, belligerent, inappropriately inappropriately sexual, sexual, giddy, giddy, and and grandiose, grandiose, claiming claiming that that his his artwork artwork and and writing writing were were soon soon to to make m a k e him h i m millions. millions. His His thoughts thoughts raced raced and and he he became became hyperverbal. hyperverbal He H e was was given given lithium lithium and and an an antipsychotic antipsychotic medication medication while while an an inpatient inpatient at at the the university's university's hospital. hospital. He H e showed showed a a partial partial response response but but was was still stillhypomanic hypomanic when w h e n he hereturned returnedto tohis hisparents' parents'house houseafter afterdropping dropping out without telling his out of of school. school. He H e abruptly abruptly stopped stopped his his medications medications without telling his parents. lethargy, parents. He H e sank sank into into a a deep deep depression, depression, marked marked by by insomnia, insomnia, lethargy, slowed thinking, thinking, suicidality, suicidality, and and thoughts thoughts such such as as "I suck .... don't deslowed "I suck . . II don't de­ serve to to live live ... .. I've . I've done nothing anyone in this universe." e eventuserve done nothing forfor anyone in this universe." HeHeventu­ ally agreed agreed to to see see a a therapist, therapist, rather ratherthan thanaapsychiatrist, psychiatrist,under underthe theproviso proviso ally that ""whoever he is is needs needs to to know k n o w that that I'm I'm philosophically philosophically and and spiritually that whoever he spiritually opposed opposed to to medications medications of of any any sort." sort." Clarence did did not not rule rule out out the the pOSSibility possibility that that he he had had bipolar bipolar disorder. Clarence disorder. He H e made m a d e it it clear, clear, however, however,that thatthe thetherapist therapistshould shouldaddress addressClarence's Clarence'sin­ individual struggles with identity, sexuality, moral values, and family reladividual struggles with identity, sexuality, moral values, and family rela­ tionships, rather rather than than treating treating him him as as a a umanic--depressive "manic-depressive case." case." The The tionships, therapist spent spent a a number n u m b e r of of sessions sessions developing developing an an alliance alliance with Clarence therapist with Clarence and helping helping him him understand understand the the onset onset of of the the depreSSion depression from from two two stand­ standand points: its its psychosocial psychosocial triggers triggers (events (events in in college, college,such suchas asrejection rejectionby by his his points: girlfriend) and and its its biological and genetiC genetic bases, bases, including including a a history of suihistory of sui­ girlfriend) biological and cide and and bipolar bipolar disorder disorder in in his his maternal maternal grandfather. grandfather. The The therapist therapist did did cide not challenge challenge the the idea that Clarence's Clarence's depreSSion depression was was ""existential and not idea that existential and spiritual" but but gradually gradually introduced introduced the the notion notion that that it it might might have have a a chemi­ chemispiritualn cal basis basis as as well. well. His His father father and and stepmother stepmother were were brought brought in for conjoint conjoint cal in for educational sessions where the treatment options were discussed and educational sessions where the treatment options were discussed and Clarence explained explained his his position. position. Over Over the the next next two two months, months, Clarence's Clarence's Clarence m o o d improved improved somewhat, somewhat, but but he he remained remained moderately moderately depressed and depressed and mood complained complained of of insomnia. insomnia. After he he and and Clarence Clarence had had developed developed a a solid solid alliance, alliance, the thetherapist therapistrereAfter

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forfor an an introduced the the idea of of trying agreed to to retry retryit it introduced idea tryinglithium. lithium. Clarence Clarence agreed agreed-upon interval interval (three (three months). months). The The therapist therapist referred referred Clarence Clarence to to a agreed-upon a psychiatrist,who w h o took took time timeto todevelop developaarapport rapportwith withhim him and andlisten listento tohis his psychiatrist, story. story. The Thepsychiatrist psychiatristrecommended recommended he he try trylithium lithiumat at1,200 1,200 mg. m g .Clarence Clarence responded quickly: His His depression depression lifted, lifted, his his suicidal thoughts disapresponded quickly: suicidal thoughts disap­ peared, peared, and and his his sleep sleep improved. improved. After After six six months months of of twice twice weekly weekly individual individual plus plus family family therapy, therapy, and and college. regular maintenance maintenance lithium lithium treatment, treatment, he he decided decided to to return return lO to college. regular H e remained remained on on medication medication once once back back in in college, college,where wherehis histreatment treatmentwas was He managed the student the managed by by a a psychiatrist psychiatrist at at the student health health service. service. Contact Contact with with the therapist several several years later revealed revealed that that his m o o d disorder disorder was was stable, stable,he he therapist years later his mood remained in in school, school, and and he he was was still still taking taking lithium. lithium. remained Accepting a program of of medication tototreat bipolardisorder disorder a long-term Accepting a program medication treat bipolar is ais long-term commitment and and thus thus a a very very important important personal personal decision. decision. Naturally Naturally you you will wiU commitment have questions. questions. If If you you have havejust justbeen been diagnosed diagnosed with with bipolar bipolar disorder disorder or orare areat at have an its course, regi­ an early early point point in in its course, questions questions about about committing committing to to a a medication medication regimen they were were for But you m e n may m a y be be particularly particularly salient salient for for you, you, as as they for Clarence. Clarence. But you m a y have strong feelings feelings about about medication, medication, even even if if you you have been taking may have strong have been taking m o o d stabilizers stabilizers for for a a long long time. time. In In this section, 1I discuss discuss some some of of the reasons the reasons mood this section, people stop taking their medications, con­ people stop taking their medications, and and some some counterargumems counterarguments to to consider, if if you you find find yourself yourself agreeing agreeing with with these these reasons. reasons. sider, "I Miss MissMy My High HighPeriods" Periods" UI "Does know when wet?Hypomania Hypomania felt feltgood goodtoto me. I felt "Doesa afish fish know whenit's it's wet? me. I felt like Ilike I was finally finally getling getting there there in in my m y life. life. ItItdidn't didn'tfeel feelat atall alllike likethere therewas wasany­ anywas thing wrong wrong to to me, m e , it it felt feltgreat, great,and andI'd I'dbeen beenfeeling feelingbad badfor forso solong. long.So SoI I thing went off offmy m y medication, medication,and andthen thenI Istarted startedgetting gettinghigher higherand andhigher. higher. Peowent Peo­ ple told told me m e to to go go back back on, on, but but it it felt feltpatronizing. patronizing.I Iresented resentedtheir theirlack lackof of ple recognition that that II was was accomplishing accomplishing things. things. II told told them, them, 'You 'You don't don't un­ unrecognition derstand, you've you've got got me m e in in a a box, box, you're you're sticking sticking me m e in in one one of of your your catederstand, cate­ gories.' But then thenIIcycled cycledinto intoaa depression depressionand and got gotsuicidal. suicidal.IIwent went back back gOries." But to my m y doc doc and-wouldn't and—wouldn't you you know k n o w it?—back on lithium." Hthium." to it?-back on — A 38-year-old m a n with bipolar II disorder, disorder, -A 38-year-old man with bipolar cycle reviewing his most recent recent mood mood cycle reviewing his most Kay Kay Jamison makes clear, from her research asher herpersonal personal expeJamison makes clear, from her researchas as well well as expe­ riences with with bipolar bipolar disorder, disorder, that that many m a n y people people enjoy enjoy their their high high periods riences periods Qamison, 1995; 1995; Jamison Jamison el etal., al, 1979). 1979). The The highs, highs,especially especially if ifthey theyare areaccom­ accomOamison, panied by by euphoria euphoria and and grandiosity, grandiosity, feel feel quite quite good. good. W h e n in in this this state state you you panied When

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feel driven,onontoptOp things, cheerful, invulnerable. feel productive, productive, driven, of of things, cheerful, andand invulnerable. Who Who wouldn't wouldn't enjoy enjoy this this state, state, and a n d why w h y spoil spoil it it with with medication? medication? One people fall O n e of of my m y c1iems clients compared c o m p a r e d mania m a n i a to to being being in in love. love. When W h e n people fall in in love, love, it it can c a n resemble resemble mania: mania: You Y o u feel feel giddy, giddy, happy, h a p p y , and a n d driven, driven, and a n d you y o u sleep sleep less; you feel more confident, attractive, and sexual; you want to talk to more less; y o u feel m o r e confident, attractive, a n d sexual; y o u w a n t to talk to m o r e people people and a n d do d o more m o r e things. things. My M y client client said, said, "If "If you y o u were w e r e in in love, love, and a n d someone someone would came c a m e along along with with a a tablet tablet that that would w o u l d cure cure you y o u of of the the feeling, feeling, where where w o u l d you you tell that that person person to to go?" go?" teU Not N o t everyone everyone experiences experiences mania m a n i a as as a a happy h a p p y state. state. It It can can also also be be a a wired, wired, pressured, pressured, irritable irritable state. state. But B u t even even when w h e n people people experience experience mania m a n i a negatively, negatively, they they resem resent the the idea idea that that their their moods m o o d s are are under u n d e r the the control control of of a a substance. substance. As As I've said said in in earlier earlier chapters, chapters, no n o one o n e likes likes the the feeling feeling of of being being under u n d e r the control I've the control of another another person person or or thing, thing, and a n d in in my m y experience experience people people with with bipolar bipolar disorder disorder of are are particularly particularly sensitive sensitive to to this this issue. issue. They T h e y often often have have a a 10veJhate love/hate relationship relationship with moods: fluctuate so with their their m o o d s : They T h e y hate hate the the fact fact that that their their moods m o o d s fluctuate so wildly, wildly, and and particularly central to particularly resent resent the the lows, lows, but but mood m o o d variations variations are are also also central to who w h o they they are life. are and a n d how h o w they they experience experience life. There There is is no n o mincing m i n c i n g words w o r d s about about it: it: Medication Medication does does take take away a w a y the the high high periods. periods. When W h e n people people take take lithium, lithium, Depakote, Depakote, or or TegretOl, Tegretol, their their moods m o o d s are are more m o r e stable. stable. Some S o m e people people complain complain that that they they are are too too stable. stable. Stability Stability puts puts you you in the the driver's driver's seat seat and a n d gives gives you y o u more m o r e control control over over your y o u r fate fate than than the the illusion illusion in of control control that that mania m a n i a gives gives you. y o u . But But stability stability also m e a n s giving giving u p the the intensity intensity of also means up of the roller-coaster ride that bipolar disorder provides. In other w o r d s taking of the roller-coaster ride that bipolar disorder provides. In other words,, taking medication can mean m e a n increased increased stability stability at at the the cost cost of of the the exciting, exciting, positive positive medication can features features of of the the disorder. disorder. Nonetheless, the the excitemem excitement and a n d drama d r a m a of of the the high high periods periods often often bring bring Nonetheless, debilitating depressions depressions in in their their wake. w a k e . The T h e 38-year�0Id 38-year-old man m a n just just quoted expedebilitating quoted expe� rienced an a n almost almost immediate i m m e d i a t e crash crash after after his his mania m a n i a crested. crested. This This is also true true if is also rienced if y o u have h a v e the the bipolar bipolar II II form f o r m of of the the disorder: disorder: Even E v e n if if your y o u r hypomania h y p o m a n i a is is not not you particularly destructive destructive in in itself, itself,preventing preventing hypomanic h y p o m a n i c episodes episodes can can help help pre­ preparticularly vent the the severe severe depressions depressions that that often often follow follow (see (see also also Chapter Chapter 99). ). vent "I Now, So Do Do I Need Medicine?" "/ Feel F••/ Fine Fin. Now, $0Why Why Medicin.?" / N.ed M a n y people people with with bipolar bipolar disorder disorder realize realize that that they they need n e e d medication medication when when Many they're cycling cycling into into an a n episode, episode, but but don't don't see see the the need n e e d for for prophylaxis-the prophylaxis—the they're use of of medication medication when w h e n they're they're healthy to prevent prevent future future episodes episodes (Colom ( C o l o m et healthy to et use al, 2000). 2 0 0 0 ) . When W h e n their their manic m a n i c or or depreSSive depressive episode episode has has resolved, resolved, they wonder, aL, they wonder, " W h y should should II keep k e e p taking taking medication medication and a n d dealing d e a H n g with with the the side side effects?" "Why effects?" S o m e people people think think of of mood m o o d stabilizers stabilizers in in the the same s a m e way w a y they they m i g h t think think of of Some might painkillers: You Y o u take take them t h e m only only when w h e n you're you're hurting, hurting, and a n d you y o u stop stop taking taking painkillers:

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once the h'sIt's the same them the pain paindisappears. disappears. the same usethey're when they're on them once logic logic peoplepeople use when on diets. met their diets. Once Once they they have have met their initial initial goal goal of of losing, losing, say, say,15 15 pounds, pounds,they theysee see no reason reason to to continue continue dieting, dieting, even even though though continuing continuing to diet is is the key to no to diet the key to weight weight maintenance. maintenance. This confusion confusion is is understandable, understandable, but but remember remember onc one of of the the key key points points in This in Chapters pre­ Chapters 5 5 and and 6: 6: People People with with bipolar bipolar disorder disorder have have underlying underlying chemical chemical prepre­ dispoSitions them to dispositions that that require require them to take take medicine medicine on on an an ongoing ongoing basis basis for for preventative purposes. purposes. There There is is no no guarantee guarantee that thatyou'll you'llbe befree freeof ofepisodes episodeseven evenifif ventative you take m mood psychotics. SUl you do do take o o d stabilizers, stabilizers, antidepressants, antidepressants,andlor and/oranti antipsychotics. Butthe the less severe chances that that you'll you'H remain remain well well over over long long periods periods and and have have less severe epichances epi­ sodes are greatly improved. sodes are greatly improved. "Medication TakesAway AwayMy My Creativity" Creativit/' "Medication rake, O n e of most fascinating fascinating aspects aspects of bipolar disorder disorder is is its its association association with with One of the the most of bipolar artistic creativity. creativity. Many M a n y famous famousartists, artists,writers. writers, poets, and musicians probably artistic poets, and musicians probably had bipolar disorder disorder or or a a variant variant of of it. it. Examples Examples may m a y include include Sylvia Sylvia Plath, had bipolar Plath, Anne Sexton, Roben Lowell, Ernest Delmore Schwartz. A n n e Sexton, Robert Lowell, Ernest Hemingway, Hemingway, Delmore Schwartz, Vincent Vincent van Gogh, Gogh, and and Ludwig Ludwig van van Beethoven. Beethoven. Jamison Jamison (1993) (1993)has has written writtenextensively extensively van about this issue issue in in her her book book Touched Touched with with Fire: Fire: Manic�Depressive Manic-Depressive Illness Illness and and about this the Artistic ArtisticTemperament. Temperament.IIcan canalso alsorecommend recommend aathorough thoroughreview reviewof ofthe thestud­ studthe ies in in this this area area by by Teresa Teresa Carreno Carreno and and Paul Paul Goodnick Goodnick of of the the UniverSity University of of Mi­ Miies ami School School of of Medicine Medicine (1998). (1998). ami The link link with with creativity creativity can can put put the the person person with with bipolar bipolar disorder disorder in in a The a bind. What W h a t if if you you pride pride yourself yourself on on your your writing, writing, artistic artistic talent, talent, or or musical musical bind. ability, and and fear fear that that taking medication will destroy your your product? product? If ability, taking medication will destroy If having having m o o d swings swings can can improve improve the quality of your art art by by investing investing it it with with emotion emotion mood the quality of your and passion, passion, why w h y take takethese theseaway? away? Benson Benson (1975) (1975)reported reported that thatof of12 12patiems patients and w h o stopped their lithium, one-third did so because they thought i t damaged one-third did so because they who stopped their lithium, thought it damaged their creativity. their creatiVity. Does mood m o o d stabilizing stabilizing medication medication actually actually interfere interfere with with creativity? creativity? We We Does can certainly certainly point point to to people people like like Kay Kay Jamison, Jamison, who w h o has has produced produced excellent excellent can writing even even when w h e n taking taking lithium. lithium. W h a t does does the the broader broader research research say say about about writing What this topic? topic? Not m a n y research research studies studies have have been done, and and most most are are case case stud­ studthis Not many been done, effect ies that have examined examined a a select select group of artistic artistic people people to to observe observe what ies that have group of what effect lithium had had on on their work. None N o n e of of these studies on on creat creativity involve people people lithium their work. these studies ivity involve on Depakote or Tegretol, so w e don't k n o w if those medications are better or on Depakote or Tegretol, so we don't know if those medications are better or worse. worse. MarshaH and and colleagues coHeagues (1970) (1970) found found that that of of six six recognized recognized artists artists and and Marshall businessmen who w h o had had bipolar bipolar disorder, disorder, five five reported reported higher higher productivity productivity and and businessmen better quality quality of of work work output output while while on on lithium lithium than than while while not not on on it. it.In InMogens Mogens better

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Schou's (1979)report report anisLS writers with bipolar disorder, 12 re­ Schou's (1979) onon 24 24 artists andand writers with bipolar disorder, 12 reported ported that that the the drug d r u g improved i m p r o v e d their their creativity creativity and a n d productivity, productivity, 6 6 said said it it de­ decreased prevented all all creased their their productivity, productivity, and and 6 6 said said it it had h a d no n o effect. effect. Lithium Lithium prevented

24 2 4 people people from f r o m developing developing recurrences recurrences of of their their bipolar bipolar disorder. disorder. Do D o people people with w i t h bipolar bipolar disorder disorder become b e c o m e more m o r e creative creative when w h e n they they stop stop their their medication? medication? The T h e literature literature does does not not provide provide a a clear clear answer a n s w e r to to this this ques­ question, tion, at at least least where w h e r e lithium H t h i u m is is concerned. concerned. Shaw S h a w and a n d associates associates (1986) (1986) found found that that bipolar bipolar people people did did better better in in "associational "associational processing" processing" (prodUCing (producing a a cre­ creative it. Kocsis Kocsis and asso­ ative stream stream of of ideas) ideas) when w h e n they they were w e r e off off lithium lithium than than on o n it. a n d assoon ciates ciates (1993) ( 1 9 9 3 ) tested tested 46 4 6 people people with with bipolar bipolar disorder disorder who w h o were were o n long-term long-term lithium lithium treatment treatment and a n d who w h o were w e r e discontinued discontinued from f r o m it it in in the the context context of of their their study. study. They T h e y found f o u n d that that patients' patients' scores scores on o n memory, m e m o r y , associative associative productivity, productivity, and lithium. T The a n d motor m o t o r speed speed (finger (finger lapping) tapping) improved i m p r o v e d once o n c e they they went w e n t off off lithium. he people who the people who w h o improved i m p r o v e d the the most m o s t on o n these these measures m e a s u r e s were w e r e those those w h o had h a d the highest the drug, drug, sug­ highest levels levels of of lithium lithium in in their their bloodstream bloodstream before before going going off off the suggesting gesting that that higher higher dosages dosages may m a y lead lead to to more m o r e interference interference with with menlal mental func­ func-

tioning. tioning. First, What W h a t do d o these these findings findings mean m e a n for for people people who w h o have h a v e anistic artistic talent? talent? First, lithium but it it isn't lithium can can have h a v e effecLS effects on o n your y o u r cognitive cognitive or or motor m o t o r performance, performance, but isn't at at all be all certain certain that that it it interferes interferes with with your y o u r creativity. creativity. In In fact, fact, the the opposite opposite may mayb e

true. Most M o s t professionals professionals believe believe that that bipolar bipolar people people do d o better better in in their their art, art, mu­ mutrue. sic, or or writing writing when w h e n they're they're in in remission remission from f r o m their their disorder, disorder, or or perhaps perhaps sic, slightly hypomaniC h y p o m a n i c but b u t not n o t fully fully manic m a n i c or or depressed. depressed. It's It's interesting interesting that that slightly a m o n g eminent e m i n e n t writers, writers, the the bipolar bipolar II II form f o r m of of the the disorder disorder (depression (depression with with among h y p o m a n i a ) is is more m o r e common c o m m o n than than the the full full bipolar bipolar disorder, disorder, suggest suggesting that hypomania) ing that milder manic m a n i c states states may m a y be b e more m o r e clearly clearly linked linked to to creativity creativity than than full full manic manic milder

states (Andreasen, (Andreasen, 1987; 1987; Richards Richards & & Kinney, Kinney, 1989; 1989; Carreno Carreno & & Goodnick, Goodnick, states 1998). In In this this sense, sense, medication medication may m a y even even be be helpful helpful to to your your work work if if it it suc1998). suc­ cessfully controls controls your your more m o r e severely severely manic manic swings. cessfully Swings. If you you do do think think that that your your lithium or your your anticonvulsant anticonvulsant is is affecting affecting your your If lithium or creativity, talk talkto toyour yourdoctor doctorabout aboutreducing reducing the thedosage dosagebefore beforeyou you decide decide to to creativity,

go off off it. it. Perhaps Perhaps he he or or she she will will think think it's it's safe safe for for you you to to experiment experiment with with a a go lower dosage, dosage, especially especially if if you you have have been been stable stable for for a a while. lower while. "Medication Unacceptable SideSide Effects" "MedicationGives GivesMeMe Unacceptable Effects"

As in Chapter 6, all6,ofall theofmajor stabilizers, antiAs II talked talkedabout about in Chapter the mood major mood stabilizers, anti­ psychotics, and a n d antidepressants antidepressants have h a v e side side effecLS, effects, which w h i c h can c a n range range f r o m the psychotiCS, from the mild (for (for example, e x a m p l e , thirst thirst on o n lithium) lithium) to to the the severe severe (toxic (toxic reactions, reactions, kidney kidney mild functioning problems, p r o b l e m s , rapid rapid cycling, cycling, agranulocytosis). agranulocytosis). In In many m a n y cases, cases, medica­ medicafunctioning tion side side effecLS effects are are transient transient and a n d will will disappear disappear or or at at least least become b e c o m e milder milder after after tion

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easy you've medication forfor a while. OtherOther side effects are not soare to so easy t you've been beenon onthe the medication a while. side effects not ignore ignore and and can can be be continuous. continuous. Many M a n y people people go go off off their their medication medication because because they they find find the the side side effects effects too too unpleasant and disruptive. This This is is also also true true when w h e n people people are are prescribed prescribed medi­ mediunpleasant and disruptive. cations for for traditional traditional medical medical conditions. conditions. Blood Blood pressure pressure medications, medications, for for ex­ excations ample, make feel ample, can can m a k e people people fatigued. fatigued. Allergy Allergy medications medications can can make m a k e people people feel sleepy up.n Even sleepy or or "dried "dried up." Even "natural» "natural" or or "herbal" "herbal" substances substances have have side side effects. effects. For For example, example, Sl. St.John's John'swort, wort,an analternative alternativeantidepressant, antidepressant,can cangive giveyou youstom­ stomachaches, achaches, make m a k e you you sun-sensitive, sun-sensitive, and, and,ififnot nottaken takenalongSide alongsideof ofaamood m o o dstabi­ stabilizer, lizer, callse cause switches switches into into mania mania (Nierenberg (Nierenberg et et al., al, 1999). 1999). Taking a a medication medication is is a a cost-benefit cost-benefit decision. decision. There There are are clearly clearly benefits Taking benefits to mood m o o d stabilizers. stabilizers. Bm But they theyalso alsohave have costs, costs,including includingside sideeffects effectsand andactual actual to financial outlays outlays (see (see the self-rated cost-benefit cost-benefit exercise exercise at at the the end of this financial the self-rated end of this chapter). Most Most people people with with bipolar bipolar disorder, disorder, if able to to weigh weigh the the costs costs and and chapter). if able benefits benefits objectively, objectively, come c o m e down d o w n on on the the side side of of continuing continuing to to take take their their medi­ medication, especially especially if they've been been through through some some painful painful mood m o o d disorder disorder epication, if they've epi­ sodes. But But that doesn't m e a n you you should should have have to to live live with with terrible terrible medication medication sodes. that doesn't mean side effects effects as as a a trade-off trade-off for for health health and and mood m o o d stability. side stability. First, managing managing your your side side effects effects should should be be a a collaborative collaborative process process beFirst, be­ tween you you and and your your physician. physician. Don't Don't try try to to adjust adjust your your medication medication on on your your tween own. own. Instead, Instead,keep keepaarecord recordof ofwhich whichside sideeffects effectsyou youexperience experienceeach eachday, day,and and tell your your physician physician about about them. them. The The exercise exerciseon on page page 139 139 will willhelp help you you orga­ orgatell nize your your thoughts thoughts about about which which side side effects effects you you experience experience from from which which medi­ medinize cations. Copy Copy the completed record, record, bring bring i to your your next next medication medication visit, cations. the completed itt to visit, and go go over over it it with with your your doctor. doctor. and Ask your your physician physician what what can can be be done done to to control control your your side side effects. effects. Many Many Ask can be be managed managed with with a a simple simple dosage dosage adjustment adjustment (for (for example, example, dropping dropping the can the number of of lithium lithium tablets tablets so so that that you feel less less sluggish sluggish mentally) mentally) or or by by taking taking you feel number your pills pills in indifferent differentdosing dosing pauerns. patterns.For For example, example,if ifyou youtake takelithium lithiumin inone one your dosage rather rather than than several, several, you you may m a y have need to to urinate urinate frequently. frequently. If If dosage have less less need you take take the the extended-release extended-release form form of of Depakote, Depakote, you you may m a y have have less less gastroin­ gastroinyou testinal testinal distress. distress. Other Other side side effects effects can can be be controlled controlled with with additional additional side-efside-ef­ beta fect fect medications. medications. For For example, example, hand hand tremors tremors can can be be helped helped by by adding adding a a beta blocker, propranolol propranolol (lnderan, (Inderal),to toyour yourmedication medication regimen. regimen.The The hair hairthinning thinning blocker, associated with Depakote can can sometimes sometimes be managed with with zinc zinc or or selenium selenium associated with Depakote be managed supplements. supplements. Your doctor doctor may m a y also also decide decide to to switch switch you you to to another another medication medication entirely. entirely. Your For example, example, if ifyou you have have problems problems with with memory m e m o r y or ormotivation motivation on on lithium, lithium,he he For side or or she she may m a y switch switch you you to to Depakote, Depakote, which which is is less less likely likely 1O to produce produce these these side effects (Stoll (StoH et et aI., al, 1996). 1996). If If you you have have problems problems with withweight weight gain gain on on DepakOle, Depakote, effects

ComillQ Coming 10 to Terms Termswith withYOUI YourMedicO�Ofl Medication

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KEEPING KEEPING TRACK TRACK OF O F YOUR Y O U R SIDE SIDE EFFECTS EFFECTS Date/day Date/day of of week week

Side effects effects Side Medications Medications taken taken

Weight at at beginning beginning of of week week Weight

_ _ _ _

Dosage

End of of week week End

experienced* ex perienced""

i

_ _ _

*Examples: dry dry mouth, mouth, urinating urinating frequently, frequently, rash, rash,acne, acne,stomachaches, stomachaches,nsomnia, headaches, fatigue, hair *Examples: i insomnia, headaches, fatigue, hair

loss,problems problemswith withconcentration, concentration,hand handtremor. tremor.IfIfyou're you'renot notsure surewhich whichmedication medicationcauses causeswhich whichside sideef­efloss,

fect,Simply simply list listeach eachsside effectyou you experience experienceand and put put aa�?� "?" next nextto toeach eachone. one. fect, ide effect

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CAUSESAND ANDlRUTMEN1S TREATMENTS CAUSES

thethe newer anticonvulsant, then Tegretol,oror newer anticonvulsant, Topamax, be alternatives for then Tegretol, be alternatives for Topamax, maymay you. New you. N e w drugs drugs for for bipolar bipolar disorder disorder are are being being developed developed all all of of the the time, time, and and it it tolerated medications "Big m a y be be that that easily easily tolerated medications that that work w o r k just just as as well well as as the the "Big may Three" will eventually available. Three" will eventually become become available. The not be basis The decision decision to to switch switch medication medication will wiH not be decided decided solely solely on on the the basis will come out of a of your side effects, of course. Hopefully. this decision of your side effects, of course. Hopefully, this decision wiH c o m e out of adis­ discussion cussion between between you you and and your your physician physician concerning concerning the the pros pros and and cons cons of of cer­ certain medications tain medications from from the the vantage vantage point point of of effectiveness effectiveness versus versus adverse adverse effeclS. effects. You Y o u may m a y feel feel angry angry at atyour yourdoctor doctorififyou youfeel feelhe heor orshe sheshould shouldhave havealerted alerted you time to effects you're you're experiencing. you ahead ahead of of time to the the side side effects experiencing. Your anger is is under­ underYour anger standable, standable, but butkeep keep in inmind mind that thathe he or orshe shemay m a y not notbe beable ableto topredict predictyour yourpar­ particular time. If If you ticular profile profile of of adverse adverse effects effects ahead ahead of of time. you are are feeling feelingangry, angry,discuss discuss this with with him him or or her her rather rather than showing up for your your next next session. session. There There than not not showing up for this you coming on regular is little littlehe heor orshe shecan cando dototohelp helpyou youifif youaren't aren't cominginin ona a regular basis. is basis. The most most important important point point is side e effects represent a a problem problem for for ffects represent The is that that side which there there are are solutions solutions other other than than simply simply stopping stopping your your medication. medication. Inwhich In­ forming regular basis forming your your doctor doctor on on a a regular basis about about your your side side effects effects will willhelp help him him or or her consider and discuss to your plan. her consider and discuss with with you you the the alternatives alternatives to your treatmem treatment plan.

17aking Medication a Sign 01 Personal Weakness, Sickness, "Taking MedicationIsIs a Sign of Personal Weakness, Sickness, and Lack Control" and Lack of of Con',o/" "For allabout about control. I have always trouble authority "Forme, me,it's it's all comro!. I have always had had trouble with with authOrity figures, and and medication feels like like just just one one more more authority figure. Some­ Somefigures, medication feels authority figure. one one comes comes along along and and says, says, 'Here, justtake take this thissalt saltand and you'll you'llfeel feelbener better 'Here, just and and be be like like the the rest rest of of us.' us.' IIthink thinkit's it's garbage, and i t makes m e realize garbage, and it makes me realize thethe person doesn't doesn't know k n o w me m e very very well. well. II can can handle handle things things by by myself myself just person just fine, thank you." fine, thank you." — A 19-year-old 19-year-old mall m a n shortly shortly after after his his hospitalization hospitalization for for mania mania -A It ManyMany people feelfeel that taking sign personal weakness. It people that takingmedication medication is is aasign ofof personal weakness.

feels like likeadmitting admitting that thatyou're you'resick, sick,defective, defective,oror mentally . Certainly, taking feels mentally ill.illCertainly, taking medication daily daily can can remind remind you of your your troubles troubles and and make m a k e you you resent resent the the ill­ illmedication you of ness even even more more than than you you do do already. already. But But many m a n y people people take take this this perspective perspective ness further and and claim claim that that they they can can get get along along without without medication medication just just by by exerting exerting further self-control. tr Ifyou youare areininaahypomaniC hypomanicphase, phase,you're you'reparticularly particularlylikely likelytotofeel feel self-control. this this way. way. Unfortunately, bipolar disorder disorder cannot cannot be be controlled controlled by by sheer sheer willUnforlunately, bipolar will­ power. Neither Neither can can other other biologically biologically based based illnesses. power. illnesses. There are are many m a n y ways ways to to think think about about control. control In In some some people's people's minds, conThere minds, con-

Coming to toTerms Termswith withYour Your Medication Coming Medi(otion

141141

trol needinghelp helpfrom from anyone or anything. For others, comrol trol is isabout about not not needing anyone or anything. For others, control means m e a n s availing availing yourself yourself of of opportunities opportunities to to further further your y o u r life life goals. goals. It It is is true true that taking taking a a medication medication now n o w means m e a n s giving giving up up a a certain certain amoum a m o u n t of of control control in in that the the short short run. run. But B u t taking taking care care of of yourself yourself in in this this way w a y can can also also give o u more more give yyou trans­ control in in the the long long run. run. Achieving Achieving mood m o o d stability stability on o n an a n ongoing ongoing basis basis transcontrol lates not having lates into into a a greater greater likelihood likelihood of of staying staying out out of of the the hospital, hospital, not having to to schedule so so many m a n y doctor doctor visits, visits, saving saving money m o n e y on o n additional additional treatments, treatments, being being schedule able rela­ able to to plan plan ahead ahead for for things things you y o u want w a n t to to do, d o , better better family family and a n d romantic romantic relationships, and and a a more m o r e productive productive work w o r k life. life. In In other other words, w o r d s , taking taking medication medication tionships, can give give y o u the the kind kind of of control control you y o u crave, crave, rather rather than than eliminating eliminating it. it. Not N o t tak­ takcan you ing medication, medication, in in contrast, contrast, can can mean m e a n giving giving up u p control control if if it it leads leads to to becoming becoming ing ill again. again. ill

Later Later chapters chapters talk talk about about self-management self-management strategies strategies such such as as sleep-wake sleep-wake monitoring, with family monitoring, mood m o o d charting, charting, cognitive cognitive restructuring, restructuring, and a n d coping coping with family stress. stress. Implementing I m p l e m e n t i n g these these behavioral behavioral strategies strategies can can contribute contribute to to yyour o u r feeling feeling of control control over over your y o u r fate. fate. But B u t these these strategies strategies will will work w o r k much m u c h better better if if you y o u are are of being being Simultaneously simultaneously protected protected by b y medications. medications. "Medication "MeaicalionCarries Ca"i..aaStigma SligmaininOur OurSociety" Sociely"

Bipolar disorder disordercarries carries the thestigma stigmaofofmental mental illness,andand taking medication Bipolar illness, taking medication can can become become a a proxy p r o x y for for this this stigma. stigma. You Y o u may m a y worry w o r r y about about what w h a t employers, employers, friends, and a n d romantic romantic partners partners will will think think if if they they know k n o w you're you're on o n medication. medication. friends, This This is is not not an a n easy easy issue, issue, and a n d it it is is a a very very real real concern concern for for many m a n y people. people. There may m a y be b e jobs jobs you y o u can't can't take take because because of of being being on o n medication medication (for (for exam­ examThere ple, a a job job that that requires requires fine fine motor m o t o r control control over over your y o u r hands). h a n d s ) . Upon U p o n learning learning of of ple, an an employee'S employee's disorder, disorder, employers employers have have been b e e n known k n o w n to to react react with with anything anything from complete sympathy to finding ways to fire the person (although from complete s y m p a t h y to finding w a y s to fire the person (although such such discrimination is is illegal, illegal, as as discussed discussed in in Chapter Chapter 12). 12). But But the the situation situation is imdiscrimination is im­ proving. My M y impression, impression, especially especially over over the the last last 10 1 0 years, years, has has been b e e n that that our our soproving. so­ ciety is is becoming b e c o m i n g more m o r e and a n d more m o r e understanding understanding of of the the biological biological bases bases of of psy­ psyciety chiatric chiatric disorders disorders and a n d the the need n e e d for for psychiatriC psychiatric medications. medications. More M o r e and a n d more more people are are admitting admitting to to being being on o n mood m o o d stabilizers stabilizers and a n d antidepressants. antidepressants. Few Few people people people would w o u l d reflexively reflexively "dump" "dump" a a potential potential romantic romantic partner partner or or employee employee simply because that person person admits admits to to taking taking mood m o o d medication. medication. simply because that O f course, course, you y o u are are not not obliged obliged to to tell tell your y o u r employer employer or or other other Significant significant Of people about y o u r m o o d disorder or its treatments. Y o u m a y also w a n t to to be be people about your mood disorder or its treatments. You may also want selective in in what w h a t you y o u tell tell them. t h e m . As A s I1 discuss discuss in in Chapter Chapter 12, 12, there there are are construc­ construcselective tive ways w a y s to to educate educate others others about about your your need n e e d for for medications medications so so that that the stigma the stigma tive is minimized. minimized. is

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17be "The Medication MedicationDoesn't Doesn'tWork" Work" Some bipolardisorder disorder complain that their medication isnot just not Some people people with with bipolar complain that their medication is just

effective. mOTe mood stabilizers effective. They They wonder wonder why w h y they they should should take take one one or or more m o o d stabilizers w h e n they they don't don't feel feel that thatthe themedication medication is is really reallycontrolling controlling their theirsymptoms. symptoms. when

The The reality reality is is that that your your bipolar bipolar disorder disorder is is only only partially partially controllable controllable by by medicines medicines (see (see Chapter Chapter 6). 6). Bm But almost almost everyone everyone with with the the disorder disorder does does better better fluctuations on it. You on medication medication than than off off it. Y o u will will continue continue to to experience experience mood m o o d fluctuations on course of on medication, medication, but but if if you you examine examine the the course of your your illness illness carefully, carefully, you'll you'll probably find find that there has has been been some improvement. Keeping Keeping a am o o d chan chart probably that there some improvement. mood (Chapter 8) 8) will will help help you determine h o w your your medication medication is is affecting affecting YOUT your you determine how (Chapter sleep moods sleep and and m o o d s in in a a relatively relatively objective objective way. way. A question question to to ask ask yourself yourself is, is, "Is "Is my m y medication medication truly truly ineffective, ineffective, or ordoes does A it just just not not work work as as well well as as II would would like like it it to?" to?" Depending Depending on on your your answer, answer, you you it may m a y want want to to discuss discuss the the maner matter with with your your doctor. doctor. It is pOSSible-especially possible—especially if if It is you mood not improving you are are trying trying m o o d stabilizers stabilizers for for the the first first time-that time—that you you are are not improving as much m u c h as as you you could, could, and and you you should should not not hesitate hesitate to to tell your doctor doctorif if that thatisis as tell your what you you believe. she mmay with you you and what believe. He H e or or she a y agree agree with and suggest suggest a a different different mood mood stabilizer stabilizer or or various various adjunctive adjunctive medications medications to to enhance enhance your your current current regimen regimen (Chapter 6). 6). (Chapter Try Try to to be be objective objective about about whether whether there there has has been been any any improvement. improvement. Ask Ask relatives for for their their opinions opinions about about the impact of of the the medication medication on on your your funcrelatives the impact func­ tioning. They m a y have have seen seen effects effects that that you you aren't aren't aware aware of of (for (for example, example, be­ betioning. They may ing less less easily easily provoked provoked to to anger, anger, smiling smiling more more often, often, being being less less irritated irritated by by ing changes in your environment, environment, seeming seeming like likeyour your old old seiO. self).Sometimes Sometimesthe theben­ benchanges in your efits aren't aren'tas asstraightforward straightforward as asmood m o o d stability. stability.For Forexample, example,Neil, Neil,age age 18,did did 18, efits not think think his his Tegretol Tegretol had had any any effect effect on on his his moods. moods. He H e did did believe, believe, however, however, not that he he was was gelling getting along along better better with his parents and friends friends since since starting starting it. it. with his parents and that "My Are Psy,hologi,.I, Psychological, Biological" "MyProblems Problems Are NotNot Biologi,.I"

If youfeel feel problems are of only of a psychological origin (for example, If you thatthat youryour problems are only a psychological origin (for example, related to childhood childhood trauma trauma or or disturbed disturbed family family relationships, relationships, problems problemsrelat­ relatrelated to ing to to authority authority figures), figures), then then it it may m a y not not be be obvious obvious to to you you what what role role medicaing medica­ tion tion has has in inyour your treatment. treatment.You Y o u may m a y feel feelthat thatyour your underlying underlying vulnerabilities vulnerabihties have more more to to do do with with a a negative view of of yourself yourself than than to to biological biological or or genetic genetiC have negative view factors. factors. Take a a look look again again at at Chapler Chapter 5, 5, in in which which II talk talk about about the the vulnerabilityTake vulnerability­ stress model. model. Psychological Psychological stress, suchas asinterpersonal interpersonalor orfamily familyconflicts conflictsor or stress stress, such loss experiences, experiences, can caninteract interactwith withaaperson's person'sbiological biologicaland and psychological psychologicalvul­ vul loss nerabihties (for (for example, example, a a low low opinion opinion of of your your intellect intellect or or your your abihties). abilities). nerabilities

Coming o Terms Termswirfl withYour YourMedica�oo Medication Comingtto

143 143

Thisis is one oneofofthe This wewe recommend medication and psychotherapy in in thereasons reasons recommend medication and psychotherapy

combination, e m e m b e r , your rather than than as as substitutes substitutes for for each each other. other. RRemember, your probprob� combination, rather lems e biological h e y can e both. lems needn't needn't bbe biological or or psychological. psychologicaL TThey can bbe both. Medication a y actually a k e yyour o u r psychotherapy o r e successful. ost Medication mmay actually mmake psychotherapy mmore successful. M Most psychotherapists u c h wwhen h e n aa person psychotherapists say say that that they they can't can't accomplish accomplish mmuch person with withbibi­ polar a n i c , or i x e d state. medication severely depressed, depressed, mmanic, polar disorder disorder is is in in aa severely or mmixed state. If If medication mmakes a k e s yyour o u r mmood o o d stable, n o u g h that o u can a k e it stable, or or at at least least stable stable eenough that yyou can mmake it to to regreg­ ular n d carry n therapy o m e w o r k assignments, ular appointments appointments aand carry through through oon therapy hhomework assignments, you'll o r e ffrom r o m the e able [0 deal deal you'll benefit benefit aa great great deal deal mmore the psychotherapy. psychotherapy. You'll You'll bbe able to mmore o r e productively a y bbe e contributing productively with with the the underlying underlying issues issues that that mmay contributing to to unhappiness or or distress. distress. your unhappiness your

"Taking Means I'm Giving in to Parents (or My '7.ki.gMedication Medic./io. Me•• s I'm Givi.g i. My /0 My P.re./s (orSpouse)" My Spouse)" "I'm a product of what I learned from from my parents, but I've also learned "I'm a product of what I learned my parents, but I've also learned things f r o m other college, after after college, college, in various wwork o r k situathings from other people, people, in in college, in various situa­ tions, relationships, relationships, and a n d the hard knocks k n o c k s of of life. life. If g o on o n medication, tions, the hard If II go medication, it it

can't be b e their Whether I g o back b a c k on o n it, when I g o back, how their decision. decision. Whether I go it, when I go back, how can't

mmuch u c h II go g o back b a c k on o n it, it, and a n d who w h o will w i H be b e my m y doctor, doctor,are are all allthings things I've I've gOl got to to

decide by b y myself. myself. If If they they make m a k e the the decision decision for for me, m e , even even if agree with decide if 1I agree with it, it, won't be b e able able to to follow f o H o w through." through." II won't — ^ A 23-year�old 23-year-old woman w o m a n with with bipolar bipolar II disorder disorder -A As this says, and as and Kate as MHlet in says the quote atquote the beginning As woman this woman says, Katesays Millet in the at the beginning of this this chapter, chapter, taking taking medication medication can can mean m e a n feeling feehng like like you're you're giving giving in in to to of your family's family's demands. d e m a n d s . If If you y o u are are aa young y o u n g adult adult and a n d live live with with your your parents, parents, your y o u can can quickly quickly get get tired tired of of hearing hearing them t h e m nag n a g you y o u to to take take your y o u r medication, medication, in­ inyou terpret your y o u r emotional emotional responses responses to to everyday everyday things things as as signs signs that that you y o u need need terpret m o r e medicine, medicine, or or remind r e m i n d you y o u that that you're you're the the sick sick one o n e in in the the family. family. You Y o u may may more believe that that others others in in the the family family also also have have the the disorder disorder and a n d that that they they should should be be believe the the ones ones taking taking medicine, medicine, not not you. you.

M o s t people people want w a n t independence independence from f r o m their their parents. parents. Taking Taking medication medication Most can feel feel like H k e giving giving up u p your y o u r independence: independence: Swallowing S w a H o w i n g pills, pills, seeing seeing doctors, doctors, can a n d getting getting your y o u r blood blood level level tested tested may m a y feel feel like H k e you y o u are are under u n d e r your your parents' parents' and t h u m b . The T h e reality reality is isthat that taking taking medication, medication, while while perhaps perhaps initially initially reflecting reflecting thumb. your acquiescence acquiescence to to your y o u r parents' parents'plans, plans,greatly greatly increases increases your y o u r chances chances of of in­ inyour d e p e n d e n c e from f r o m them t h e m later. later. If Ifyour y o u r mood m o o d is is stable, stable,there there is is aa greater greater chance chance dependence thatyou'll you'H be b e able able to to function function away a w a y from f r o m home. h o m e . But But it's it'shard hard to to take take this this long­ longthat term view v i e w when w h e n taking taking medicine medicine makes m a k e s you y o u feel feel like like you're you're aa child c h d d again. again. term Ifyou're you'remarried marriedor orpartnered, partnered,you y o u may m a y have have the thesame s a m e feelings feeHngs about aboutyour your If

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CAUSES CAUSESAND ANDIREAIMEHIS TREATMENTS

some of my spouse. Your line with you;you; spouse. Your spouse spouse may may be be taking takinga ahard hard line with some of diems' my clients' spouses have have even even threatened threatened to to leave leave if if their their bipolar partner didn't didn't remain remain spouses bipolar partner consistent in in taking taking his his or or her her medication. medication. Your Your spouse's insistence that you spouse's insistence that you consistem take medication can m a k e the option feel all the more unappealing to you. take medication can make the option feel all the more unappealing to you. How have eventually H o w do do people people resolve resolve this this dilemma? dilemma? Many M a n y of of my m y clienlS clients have eventually come around around to to realizing realizing the the neceSSity necessity of of mood m o o d stabilizers stabilizers not not only only for for their come their own but also family members. o w n mood m o o d stability stability but also for for their their relationships relationships with with their their family members. But it it is is important important that you feel feel the the decision decision to to take take the the medicine medicine is is largely But that you largely your your own. own. Chapter Chapter 12 12 gives gives you you some some tips tips on on how h o w to to communicate communicate with with fam� family members how ily members on on problems problems related related to to your your illness, illness, including including h o w to to negotiate negotiate the sometimes sometimes volatile issue of of medication-taking. medication-taking. the volatile issue Perhaps Perhaps even even more more important, important, try try to to make make a a distinction distinction between between the the way way you feel feel about about your your medicine medicine and and the the w a y everyone everyone else else seems seems to feel about about it. it. you way to feel D o you you think think the the medication medication helps helps you, you, even even if if it's it's less less than than you'd you'd like? like? Does Does Do taking medicine medicine have have to to mean m e a n feeling feeling like like a a child? child? If If so, so, what what do do we w e make make of of taking the the many m a n y successful people who w h o have have had had this this illness illness and and took took medication? successful people medication? Many M a n y of of my m y clients clients have have reported reported feeling feeling beuer better abom about laking taking medicine medicine once once they health they began began to to view view drug drug treatment treatment as as important important for for maintaining maintaining their their health status the transition status and and furthering furthering their their personal personal life life goals. goals. Some S o m e have have made m a d e the transition from from engaging engaging in in power power struggles struggles with with their their parents parents or or spouse spouse to to take take more more responsibility responsibility for for managing managing their their own o w n medication medication (for (for example, example, keeping keeping to to the the regular dosing dosing schedule schedule so so that that reminders reminders from others become become unnecessary, unnecessary, regular from others monitoring their side effects, effects, arranging arranging their o w n doctor visits and and blood blood monitoring their side their own doctor visits tests). This This transition transition helped helped them to feel feel that that medication medication was was less of a a threat tests). them to less of threat to their their independence independence and and sense sense of of identity. to identity. "I Can't Can'tRemember Remember to toTake TakeMy MyMedication" Medication" HI

This is problem and one that phYSicians oftenoften underestimate. In This isaavery veryreal real problem and one that physicians underestimate. In fact, one one factor factor that that predisposes predisposes people people with with bipolar bipolar disorder disorder to to noncon­ nonconfact, cordance is is haVing having to to remember remember a a greater greater number of medication medication dosages dosages cordance number of (Keck et et aI., al, 1997; 1997; Sachs, Sachs, 2000). 2000). Sometimes Sometimes people people forget forget whether whether they they have have (Keck taken a a morning morning or or an an afternoon afternoon dosage, dosage, and and then then end end up up taking takingan an extra extradose dose taken in the the evening, evening, which which can canincrease increasetheir theirchances chancesof ofgetting getting too toomuch m u c h of ofaamed­ medin ication. ication. If you you are are using using alcohol alcohol or or street street drugs drugs regularly, regularly, including including marijuana, marijuana, If you're going going to have particular particular problems remembering to to take take your your medica­ medicayou're to have problems remembering tion. Thisisisprobably probablyone oneofofthe thereasons reasonsthat thatsubstance substanceabuse abuseisisso sohighly highlycor­ cortion. This related with with medication nonconcordance (e.g., (e.g.,Strakowski Strakowskiet etaI., al,1998). 1998).IfIfyou you related medication nonconcordance 8), are able able to to get get your your substance substance use use problem problem under under control control (see (see Chapter Chapter 8), are

Coming to toTerms Termswith with Your Medication Coming Your Medko�on

145145

you'll havea amuch much easier remembering take your medication. Also, you'H have easier timetime remembering to taketo your medication. Also, the medication medication will will almost almost certainly certainly be b e more m o r e effective! effective! the If If you y o u are are having having trouble trouble remembering r e m e m b e r i n g to to take take your y o u r tablets, tablets, ask ask your y o u r phy­ physician whether w h e t h e r you y o u can c a n be b e given given the the medication medication in in its its least least complex c o m p l e x dosing dosing sician pattern. Some S o m e medication, medication, including including lithium, lithium, can c a n be b e taken taken all all in in one o n e dosage. dosage. pattern. Sometimes S o m e t i m e s the the regime regime can c a n be b e simplified simplified to to morning m o r n i n g and a n d evening evening dosages dosages only. only. Don't you Don't be b e ashamed a s h a m e d of of forgetting-it's forgetting—it's a a more m o r e common c o m m o n problem p r o b l e m than than y o u think. think. There T h e r e are are also also ways w a y s to to remind r e m i n d yourself. yoursell Some S o m e people people use use pill pill boxes boxes with with morning, the day. m o r n i n g , afternoon, afternoon, and a n d evening evening doses doses laid laid out o u t at at the the beginning beginning of of the day. Some a day's S o m e people people have h a v e key k e y chains chains with with an a n attached attached container container with with room r o o m for for a day's

dosage. use watch dosage. You Y o u can c a n usually usually get get these these at at a a drug d r u g store. store. Other O t h e r people people use watch alarms or or palm p a l m pilots pilots to to alert alert them t h e m when w h e n they they need n e e d another another dosage. dosage. Others alarms Others try try to time time their their dosages dosages around a r o u n d events events that that will will "cue" "cue" them, t h e m , like like meals meals or or waking waking to uplbedtime at up/bedtime routines. routines. Some S o m e people people keep k e e p spare spare pills pills in in their their desk desk drawers drawers at work the w o r k in in case case they they forget forget to to bring bring them. t h e m . Others Others acquaint acquaint their their spouse spouse with with the medication medication routines routines and a n d ask ask for for reminders. reminders. If If you y o u are are comfonable comfortable with your with your spouse taking taking this this role, role, it it may m a y be b e helpful helpful to to you y o u in in staying staying on o n schedule. schedule. spouse In In the the next next chapter chapter on o n maintaining maintaining wellness, wellness, you'll you'll be b e introduced introduced to to the the the num­ daily self-rated self-rated mood m o o d chart. chart. On O n the the chart chart you'll you'll see see places places to to record record the numdaily ber ber of of tablets tablets of of each each medication medication you've you've taken. taken. Keeping K e e p i n g track track of of your y o u r moods moods and not your a n d medication medication on on a a daily daily basis basis will will n o t only only remind r e m i n d you y o u to to take take y o u r medi­ medicine but b u t will will also also help help you y o uto tosee seethe therelations relations between b e t w e e n your y o u r medication medication con� concine sistency and a n d the the stability stability of of your y o u r mood m o o d states. states. One O n e of of my m y clients clients related related the the sistency following: "Breakfast "Breakfast and a n d medications medications were w e r e always always connected connected for for mme. e . But B u t then then follOwing: w h e n II got got my m y new n e wjob, job,IIforgot forgot to toeat eat breakfast breakfast and a n dalso also missed missed my m y morning morning when medication dose-l d o s e — I took took it it to to work w o r k with with me m e and a n d would w o u l d completely completely forget forget medication about it. it. When W h e n my m y mood m o o d started started dropping dropping and a n dIIstarred startedkeeping keeping aamood m o o d chan, chart, about II discovered discovered II wasn't wasn't taking taking my m y morning m o r n i n g dose dose as as frequently frequently as as II thought thought II was. was. Keeping track track made made me m e more more conscious conscious of of remembering remembering my m y morning morning dose Keeping dose and and also also helped helped me m e make make breakfast breakfast more more of of aa priority." priority."

SummarizingthethePros Summarizing andand Cons of 01 Medication: A Self-Rated ChartChart Pros Cons Medication: A Se/l·Rated After you've After some of the issues just discussed, it may be useyou've thought thoughtthrough through some of the issues just discussed, it may be use­ ful to to summarize s u m m a r i z e the the costs costsand a n dbenefits benefits of ofmedication medication in inyour y o u r own o w n terms. terms.The The ful exercise on o n page p a g e 146 1 4 6 will will help help you y o u organize organize your y o u r thinking thinking about about pros pros aand nd exercise cons and a n d about about things things you y o u can c a n do d o to to make m a k e medication medication feel feel more m o r e acceptable acceptable to cons to you. This This is is another another page p a g e that that you y o u may m a y want w a n t to to copy c o p y and a n d bring bring with with y o u to you. you to your y o u r doctor's doctor's office-it office—it can c a n provide provide a a format format for for discussing discussing issues issues of of concern concern to to you. y o u . It It may m a y also also be b e helpful helpful to to review review this this list list if if you y o u have h a v e the the impulse impulse to to disdis-

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CAUSES AND ANDTREATMENTS TREATMENTS CAUSES

THE PROS PROS AND AND C O N S OF O F TAKING TAKING MEDICATION MEDICATION THE CONS

REASONS R E A S O N S TO T O TAKE T A K E MOOD M O O D MEDICATION MEDICATION

(Examples: helps control my manic helps with my depressed improves (Examples: helps control my symptoms, manic symptoms, helps with mymood, depressed mood, impro improves mymrelating withwith my focus, decreases mymanxiety, m y sleep, sleep,makes makesme m ebener betterable abletoto focus, decreases y anxiety, improves y relating level, other other people, people, decreases decreases my m y conflict conflict with with family family members, members, improves improves my m y energy energy level, at work. from makes me m e feel feel more more confident, confident, makes makes me m e concentrate concentrate better better at work, keeps keeps me m e from makes

spending too too much much money, money, helps helps me m e avoid avoid traffic traffic tickets) tickets) spending 1I. .

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2. 2.

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3. 3.

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4. 4.

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5. 5.

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DISADVANTAGES DISADVANTAGES OF O F MOOD M O O D MEDICATION MEDICATION

(Examples: sideeffects effects [give specifics], high periods, cost of medication and (Examples: side [give specifics]. missing missing my high my periods. cost of medication and psychiatry visits, visits, disliking disliking having having my m y moods moods controlled, controlled, disliking disliking my m y doctor, doctor, disliking disliking psychiatry making making medical medical appointments, appointments, makes makes me m e feel feel less less sexual sexual or or less less creative, creative, medications medications

carry a a stigma, stigma, medicat medications aren't that that effective) effective) carry ions aren't 11. .

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2. 2.

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T H I N G S II CAN C A N DO D O TO T O IMPROVE I M P R O V E THE T H E SITUATION SITUATION THINGS {Examples: discussside sideeffects effects with physician, consider medications or dosing (Examples: discuss with physician, consider otherother medications or dosing strategies, take take more more responsibility responsibiUty for for my m y own o w nregime, regime,change change my m y doctor, doctor,change change m myy strategies. insurance plan, plan, educate educate others others about about m y disorder, disorder, create create reminders reminders to to take take medication, medication, insurance my cut down d o w n my m y use use of of alcohol alcohol or or drugs) drugs) cut 1. 1.

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2. 2.

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3. 3.

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4. 4.

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5 5..

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Coming Medication Coming to toTerms lermswith withYour Your Medication

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continue yourmedication, medication, remind yourself your reasons taking continue your to to remind yourself of of your reasons for for taking themthem in the first place and the other alternatives available to you. in the first place a n d the other alternatives avaflable to you. Try Try to to individualize individuahze this this exercise exercise as as much m u c h as as possible: possible: You Y o u may m a y know k n o w of of advantages listed here. advantages and a n d disadvantages disadvantages of of the the medications medications that that II have have not not listed here. Once O n c e again, again, your y o u r family family members m e m b e r s may m a y be b e able able to to help help you y o u identify identify the the costs costs a n d benefits benefits of of your y o u r medication. medication. and •

•

•

The T h e decision decision to to commit c o m m i t to to a a long-term long-term program p r o g r a m of of medication medication is is a a very very difficult difficult one. one. As A s you y o u can can see see from f r o m this this chapter, chapter, people people with with bipolar bipolar disorder disorder struggle terms with struggle with with many m a n y practical practical and a n d emotional emotional issues issues when w h e n coming c o m i n g to to terms with their their need n e e d for for medication. medication. You Y o u are are not not alone alone in in your y o u r struggles struggles to to accept accept the the disorder and a n d its its required required treatments. treatments. disorder New N e w drugs drugs for for bipolar bipolar disorder disorder are are being being developed developed and a n d tested tested all all of of the the time. time. In In all all likelihood, likelihood, some s o m e will will prove prove successful successful and a n d others others will will come c o m e into into vogue vogue for for a a while while and a n d then then disappear. disappear. But But there there is is good g o o d reason reason to to believe believe that that you y o u will will find find a a medication medication regimen regimen that that will will work w o r k for for you y o u over over the the long long term term and and won't won't require require you y o u to to tolerate tolerate debilitating debilitating side side effects. effects. concordance: Above all, remember the meaning of the term A b o v e all, r e m e m b e r the m e a n i n g of the term concordance: aa collaborative collaborative process between b e t w e e n you y o u and a n d your y o u r physician. physician. It It is is very very important important to to communicate communicate process your your concerns concerns to to your y o u r physician physician and a n d see see if if anything anything can can be be done d o n e to to adjust adjust your regimen r e g i m e n so so that that it it is is maXimally maximally effective effective as as well well as as more m o r e easily easily tolerated. tolerated. your M o s t physicians physicians are are open o p e n to to this this kind kind of of communication c o m m u n i c a t i o n and a n d even even w e l c o m e it, Most welcome it, particularly if if you y o u talk talk to to them t h e m before before you y o u decide decide to to stop stop or or make m a k e your your own own particularly decisions about about changing changing your y o u r medicine. medicine. The T h e exercises exercises in in this this chapter chapter can can decisions help help you y o u organize organize information information about about your y o u r drug drug treatmem treatment so so that o u can can that yyou w o r k with with your y o u r physician physician more m o r e efficiently efficiently within within the the limited limited time time blocks blocks that that work m a n a g e d care care allows. allows. managed Fortunately, managing m a n a g i n g bipolar bipolar disorder disorder is is not not just about taking taking medica­ medicaFortunately, just about tion. In In addition addition to to medication medication to to help help control control your y o u r disorder, there are are selftion. disorder, there self­ m a n a g e m e n t strategies strategies you y o u can can use use during during periods periods of of wellness wellness (Chapter (Chapter 88), ), management w h e n experiencing experiencing the the beginning beginning signs signs of of mania m a n i a (Chapter (Chapter 9), 9 ) , and and w h e n de­ dewhen when pressed or or suicidal suicidal (Chapters (Chapters 110 0 and a n d 111). Try to to think think of of medication as one o n e elpressed 1 ). Try medication as el­ e m e n t in in a a collection collection of of strategies strategies for for managing m a n a g i n g your y o u r disorder. disorder. ement

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How Can Disorder? H o w C a n I I Manage M a n a g e My M y Disorder? P R A C T I C A L WAYS W A Y S PRACTICAL

TO T O MAINTAIN M A I N T A I N WELLNESS WELLNESS

Amy, age age 33, 33, had had aa six-year six-year history history of of bipolar bipolar disorder. disorder.Three Threeyears yearsafter after Amy, being diagnosed, diagnosed, she she began began aa period of rapid rapid cycling cycling that seemed to to be be being period of that seemed provoked, with her boy­ provoked, in in part, part, by by an an on-again, on-again, off-again off-again relationship relationship with her boyfriend. When W h e n she sheabruptly abruptlyrelocated relocatedOUl-Or-Slate out-of-statedue dueto tohis hisbusiness, business,her her friend. rapid cycling cycling intensified. intensified.She Sheobtained obtainedpart-time part-timework workin inher hernew newcity cityand and rapid sought psychiatric psychiatric treatment. treatment. Her Her psychiatrist gave her her aa combination combination of sought psychiatrist gave of lithium and and Depakole, Depakote,which which helped helpedeven evenout outher hercycles, cycles,but butshe shestill stilex­ l exlithium perienced unpleasant unpleasant ups ups and and downs. downs. Her Her sleep sleep was was quite quite variable variable from from perienced night to to night. night. night Her psychiatrist psychiatrist suggested suggested that that she she supplement supplement her her medication medication treat­ treatHer ment with with therapy therapy from from aa psychologist psychologist with with whom w h o m she she (the (the psychiatrist) ment psychiatrist) worked. The The psychologist psychologist encouraged encouraged her her to to start start aamood mood chart, chart,ininwhich which worked. she kept kept track track of ofher her moods moods on on aadaily dailybasis, basis,the thenumber numberofof hours sleep she hours ofof sleep she had had each each night, night,her hermedication, medication,and andany anyevents eventsthat that shefound foundstress­ stressshe she ful,whether whetherpositive positiveorornegative. negative. firs t she found this assignment to abe a ful, AtAt first she found this aSSignment to be hassle. hassle.She Shetold toldher hertherapist therapistthat thatitit took time and she didn't like being took time and she didn't like being re­reminded of of her her illness illness so so frequently. frequently. Her Her therapist therapist acknowledged acknowledged the the dis­ disminded comfort of of the the assignment assignment but but reminded reminded her her that that tracking tracking her her moods moods was was comfort a first firststep steptoward towardgaining gainingmore morecontrol controlover overthem. them.After Aftersome somediscussion discussion a she agreed agreed to to try try it itbut butmade made no no commitment commitment to tokeeping keeping the thechart charton on aa she regular basis. regular basis. 151

lSI

152 IS2

Sm-MANAGEMENT SELF-MANAGEMENT

Amy and Amy her therapist began examining her chartsher during their charts during their and her therapist began examining weekly meetings. meetings. Over Over a a period period of of several several momhs, months, they they began began to to identify weekly identify certain with Amy's ex· certain behavioral behavioral pauerns patterns associated associated with Amy's mood m o o d swings. swings. For For example, Amy A m y learned learned that that her her mixed mixed mood m o o d states states often began with a rejecample, often began with a rejec­ tion by by her her boyfriend boyfriend (such (such as as being being ignored ignored or or slighted slighted by by him him in in the the tion company of Rather than directly confronting him about ex­ company of others). others). Rather than directly confronting him about these these experiences, periences, she she would would usually usually go go out out drinking drinking with with her her female female friends friends that that night or or the the next next night. night. Her Her sleep sleep would would then then become become more more disturbed, disturbed, night and irritable, anxious and her her mood m o o d would would take take on on an an irritable, anxious quality. quaHty. Her Her mood mood would usually usually stabilize stabilize once once she she had had reestablished reestablished a a regular regular bedtime bedtime and and would wake time. wake time. She asked asked her her friends friends whether whether they they would would feel feel any any differently differently about about She her if ifshe she went went out outwith with them them but but didn't didn'tdrink. drink.None N o n e seemed seemed particularly particularly her bothered by not stop did bothered by this. this. Although Although she she did did not stop drinking drinking entirely, entirely. Amy A m y did find that find thatlimiting limitingher heralcohol alcoholintake intakehelped helped her hersleep sleepbeuer, better,which whichinintum turn m a d e her her feel feel less less irritable, irritable, anxious, anxious, and and depressed depressed the next day. day. She She made the next made m a d e clear to her her therapist therapist that that she she had had no no intention intention of of giving giving up her clear to up her "outrageous But with "outrageous side." side." But with time, time, she she has has become become more more consistent consistent with with these these lifestyle lifestyle habits, habits, pleasantly pleasantlysurprised surprisedby by the thebeneficial beneficialeffects effectsthey've they've had stability. had on on her her mood m o o d stability. WhatWhat can you do to your intervals wellness and andminimize minimizethe the can you domaximize to maximize your intervalsof of wellness time spend ill? ill? Many M a n y people people go go for for long long periods periods of of time without having having time you you spend time without significant symptoms, symptoms, but but virtually everyone with with the the disorder disorder has has recurSignificant virtually everyone recur­ rences of of illness at some some pOint. point. In In my m y experience, experience, the the people people who w h o do do the the best rences illness at best their over time are those those who w h o not only take take their medication regularly regularly and and see see their time are not only their medication over

doctors bm but also also successfully successfully implement implement self-management self-management strategies. doctors strategies. W h a t does does i m e a n to tomanage manage bipolar bipolardisorder disordersuccessfully? successfully? In In Chapter Chapter 55 What itt mean w e talked talked abom about the the risk risk factors in bipolar bipolar disorder disorder (things (things that that make m a k e your your ill­ illfactors in we ness worse). There are also also protective protective factors: factors: things things that that keep keep you you well well when when There are ness worse). of you are are vulnerable vulnerable to m o o d Swings. swings. You Y o u are are already already familiar familiar with with some some of you to mood these protective protective factors from earlier earlier chapters-for chapters—for example, example, consistency consistency with with these factors from medication and and having having social social supports. medication suppOrts. In essence, essence, maintaining maintaining wellness wellness means means minimizing minimizing the the risk risk factors factors and and In risk maximizing the the protective factors (see (see the the table table on on page page 153). 153). Sometimes Sometimes risk protective facrors maximizing and and protective protective factors factors are are simply simply opposite opposite sides sides of the same same coin. coin. For For exam­ examof the

ple, steep sleepdeprivation deprivationis isaarisk riskfactor, factor,whereas whereas staying a regular sleep-wake ple, staying onon a regular sleep-wake rhythm is is aaprotective protectivefacLOT. factor.InInother othercases, cases,protection protection involves introducing involves introducing aa rhythm n e w element element into into your your daily daily life, life,such such as askeeping keeping aamood m o o d chart. chart. new Minimizing Minimizing risk risk and and maximizing maximizing protection protection will will almost almost certainly certainly improve improve

your course course of of illness illness and and the the quality quality of of life. life. But But doing doing so socan canbe bedifficult. difficult.lrIt your can require require giving giving up up things things that that you you have have come c o m e to to depend on (for (for example, example, can depend on

How How (on Can IIManage ManageMy MyDisorder? Disorder?

153 153

drinking alcoholtotorelax, relax,staying stayingupup lateatatnight). night).It It will impossi­ drinking alcohol late will probably probably beheimpossible for you every protec­ ble for y o u to to avoid avoid every every risk risk factor factor and a n d take take full full advantage advantage of of every protective tive factor factor in in the the table. table. For F o r example, e x a m p l e , some s o m e people people are are able able to to stay stay scrupulously scrupulously close it close to to their their medication medication regimen r e g i m e n and a n d have h a v e learned learned to to avoid avoid alcohol alcohol bbut u t find find it impossible relatively con­ impossible to to prevent prevent sleep sleep disruption. disruption. Others O t h e r s are are able able to to keep k e e p relatively consistent their exposure sistent daily daily and a n d nightly nightly routines routines but b u t find find it it difficult difficult to to regulate regulate their exposure to to family family stress stress or or other other interpersonal interpersonal conflicts. conflicts. If If you y o u know k n o w yourself yourself well, well, you you m a y be b e able able to to decide decide which w h i c h risk risk factors factors you y o u can c a n and a n d cannot c a n n o t realistically realistically may avoid, avoid, and a n d which w h i c h self-management s e l f - m a n a g e m e n t strategies strategies are are possible possible to to implement i m p l e m e n t within within y o u r current current lifestyle. your lifestyle. This chapter chapter will will acquaint acquaint you y o u with w i t h practical practical self-management s e l f - m a n a g e m e n t strategies strategies This that that fall fall into into four four broad b r o a d categories: categories:

• Tracking your mooda through a daily chan • Tracking your mood through daily chart •

• Maintaining Maintaining regular regular routines routines and a n d sleep-wake s l e e p - w a k e cycles cycles

•

• Avoiding A v o i d i n g alcohol alcohol and a n d other other mood-altering mood-altering substances substances

•

• Developing D e v e l o p i n g and a n d maintaining maintaining social social supports supports

Risk Risk and and Protective Protective Factors Factors in in Bipolar Bipolar Disorder Disorder

Risk factors that increase your chances becoming Risk factors that increaseof your chances ill of becoming ill Risk factors Examples Risk factors

Examples

Stressful life life changes changes Stressful

Lossof ofaajob, job,gaining gainingororlosing losinga anew newrelationship, relationship, birth Loss birth ofof a a child child Drinking ing with Drinking binges, binges, experiment experimenting withcocaine, cocaine,LSD, LSD,oror Ecstasy, Ecstasy,excessive excessivemarijuana marijuanause use Changing Changing time time zones, zones, cramming cramming for forexams, exams,sudden sudden changes changes in in sleep-wake sleep-wake habits habits High High levels levels of of criticism criticism from from aa parem, parent, spouse, spouse,ororpartner; partner; Provocative ily members or Provocative or or hostile hostile imerchanges interchanges with with fam family members or coworkers coworkers Suddenly stopping your mood stabilizu; regularly missing Suddenly stopping your mood stabilizer; regularly missing one or more dosages

Alcohol Alcohol and and drug drug abuse abuse Skep Sleep deprivation deprivation Family iinterpersonal terpersonal Family distress distress or or OIher other n conflicts conflicts Inconsistency with medication

Inconsistency with medication

one or more dosages

Protective factors Protective that helpfactors protect becoming that you help from protect you from ill becoming

ill

Protective factors Examples Protective factors

Examples

Observing and and monitoring your your own own Observing moods moods and and triggers triggers for for fluctuations fluctuations

Keeping a daily daily mood mood chan chart or or social social rhythm rhythm chart Keepi ng a

Maintainingregular regular and nightly Going to and bedwaking and waking up same at the same time; Going to bed up at the time; having a Maintaining dailydaily and nightly predictable routines predictable social social schedule schedule routines

having a

Relyingononsocial social and family supports Clear communication with relatives; your Clear communication with relatives; asking yourasking Significant Relying and family supports others others for for help help in in emergencies emergencies Staying Engag ing in Engaging in regular regular medical medical and and Staying on on aa consistent consistent medication medication regime, regime, obtaining obtaining psychotherapy, psychOSOCial psychosocial treatment treatment psychotherapy, attending attending support support groups groups

signific

154 154

SELF-MANAGEMENT SElF-MANAGEMENT

well feeling or expe­ well or e The you'll learnlearn will bewill of most whenhelp you are feeling The strategies strategies you'll be help of most when you are riencing only only mild mild mood m o o d swings. swings. They They can can also also help help protect protect you you from from more more seriencing se­ vere bipolar bipolar episodes. episodes. Throughout Throughout the the chapter, chapter, II show s h o w you you how h o w other other people people vere with bipolar bipolar disorder disorder have have used used these these strategies strategies in intheir theirdaily dailylives livesand andhow h o wthey they with have of the have avoided avoided some some of the pitfalls pitfallsassociated associatedwith with implementing implementing them. them.Chapters Chapters 9, 10, 10, and and 11 11 give give you you 100is tools to to use use w h e n you you want to stop stop a a developing developing manic, manic, 9, when want to depressive, depressive, or orsuicidal suicidalepisode episodefrom from spiraling spirahngbeyond beyond your yourcontrol. control.

Maintaining Wellness Wellness Tip Tip Na. N o . 11: Keeping a a Maad M o o d Chart Chart Maintaining : Keeping

If you've a psychiatrist for a for longa time, familiar familiar If you'vebeen beenseeing seeing a psychiatrist long you're time, probably you're probably with some some form episode, your psychiatrist or or with form of of mood m o o d chart. chart.If Ifthis thisisisyour yourfirst first episode, your psychiatrist therapist may therapist m a y not not have have introduced introduced this this assignment assignment yet yet. A A mood m o o d chart chart is is sim­ simply ply a a daily daily diary diary of of your your mood m o o d states, states, with withdates datesindicating indicatingwhen w h e n these thesemoods moods start and and stop. stop. The The chart chart can can also also incorporate incorporate information information about about your start your sleep, sleep, medication, medication, and and life life stressors. stressors. W h y should should you you keep keep a a mood m o o d chart? chart? First, First,becoming becoming aware awareof ofeven evensubtle subtle Why changes your mood and activity help you if you are changes in in your m o o d and activity levels levels will will help you recognize recognize if you are having disorder relapse relapse and having a a mood m o o d disorder and determine determine whether whether you you should should contact contact your your doctor doctor lO to see see if if aa change change in in medication medication would would be be helpfu1. helpful.Many M a n y bipolar bipolar people have have been able to to "head "head off off at at the the pass" pass" their their episodes episodes by by observing observing the the people been able minorfluctuations on their o o d charts, which often oftenherald herald the theonset onset of ofma­ maminor fluctuations on their m mood charts, which jor manic, manic, mixed, mixed, or or depressive depressive episodes. episodes. A A picture picture is is worth worth a a thousand thousand jor words! words! Second, your your doctor doctor will will find find the the chan chart useful, useful, in in that that he he or or she she will will be be Second, able to to see see how h o w well well your your medication medication is is working working or, or, alternatively, alternatively, when w h e n it it is is able making you feel worse worse (such (such as as when w h e n antidepressants antidepressants bring bring about about rapid rapid cyyou feel cy­ making cling). H e or or she a y also also want want to to monitor monitor symptoms symptoms other other than than mania mania or or de­ decling). He she m may pression, such as as your your anxiety, anxiety, sleep sleep disturbance, disturbance, or or irritability. pression, such irritability. Third, you you can can use use your your mood m o o d chan chart information information to to identify identify environmen­ environmenThird, tal triggers triggers of of your your mood m o o d cycling, cycling, which which can can then then lead lead to to stress-management stress-management tal strategies to to lessen lessen the the impact impact of of these these triggers. triggers. With With time timeand and practice, practice,many many strategies the of my m y clients clients have have become become effective effective at at identifying identifying stress stress triggers, triggers, such as the of such as or onset of of their their menstrual menstrual cycle, cycle, arguments arguments with particular family family members, members, or onset with particular work stress. Amy, A m y ,for forexample, example,came came to torecognize recognizethrough throughmood m o o d charting chartingthat that work stress.

also conflicts with with her her boyfriend boyfriend were were a a trigger trigger for for her her mood m o o d cycling. cycling. She She also conflicts found that that her her usual usual strategy strategy for for coping coping with with distress-going distress—going out out drinking­ drinking— found was contributing contributing to to her her irritable irritable m o o d stales states for for several several days days later. later. This This realwas mood real­ ization did did not not stop her from from drinking drinking altogether, altogether, but but it did make m a k e her her weigh weigh ization stop her it did the of self-medicating the pros pros and and cons cons of of alcohol alcohol as as a a means means of self-medicating her her emotions. emotions.

How Con I ManageMyMyDisorder? Disorder? How (on I Manage

155 ISS

chart on page 156used is used in the NIMH Systematic Treatment The The chart on page 156 is in the NIMH Systematic Treatment En- En­ Program for for Bipolar Bipolar Disorder Disorder (Sachs, (Sachs, 1993, 1993, 1998). 1998). There There is is aa hancement Program hancement version of of this this chart at the the end you can can copy for your blank chart at end of of the the book book that that you copy for your blank version v.rww . manicdepressive.org. The website use, or you can download it from o w n use, or you can download it from www.manicdepressive.org. T h e website own instructions for for filling filling out out the the chart, chart, which also also contains contains instructions which are are also also detailed detailed be­ bechart allows allows you you to track your moods for up up to to one month. So, So, if low. Each chart to track your m o o d s for one month. if low. Each you have started the the chart in the the middle the month, continue to have started chart in middle of of the month, continue 1O use use the the you same sheet sheet until the middle middle of the next and then begin a e w sheet. until the of the next month, month, and then begin a nnew sheet. In In same first of the month. be the the 10th, 10th, other words, words, "day "day 1" 1" need need not not be be the the first of the month. It It could could be other and day day 110 could be be the the 20th. and 0 could 20th. People bipolar disorder disorder find find this this to to be a "user-friendly" "user-friendly" method People with with bipolar be a method of of recording the the cycling cycling of of their their moods m o o d s over over time, time, even even though though it recording it looks looks intimiintimi­ inin a few min­ dating at at first. first. Once O n c eyou youget getused used to toit, it,you youcan canusually usuallyfill filit l out it out a few mindating utes indefinite baba­ utes each each day. day. I1 usually usually suggest suggest that that people people keep keep the the chart chart on on an an indefinite sis,but butififthis thisseems seemsdaunting daunting then thentry tryititfor foraamonth m o n t h or ortwo two to tosee seeif ifititproves proves sis, useful. After After that, you may m a y decide decide to tochan chartyour your moods m o o d s in inaadifferent differentway w a y (or (or useful. that, you your your doctor doctor may m a y have have another another chart chart for for you you to to use). use). For now, n o w , let's let's consider consider Amy's Amy's mood m o o d chan, chart, which which she she completed completed during during aa For month in in which which she she experienced experienced Significant significant mood m o o d fluctuations. month fluctuations. Her Her "X" "X" marks marks indicate indicate her her mood m o o d states states on on any any given given day. day. Notice Notice that that on on some some days days she has has made m a d e two two ratings, ratings, one one for for mania mania and and one one for for depression depression (her (her mixed mixed she mood states) . m o o d states). A m y identified identified some s o m e of of the the factors factors that that contributed contributed to to her her mood m o o d swings, Amy swings, including life events such as the illness of her dog. Her m o o d had been including life events such as the illness of her dog. Her mood had been relarela­ tively stable stable (note (note the the absence absence of of "peaks" "peaks" between between the the argument argument with with her her dad dad tively and the the rejecting rejecting event event with with her her boyfriend) boyfriend), but then then she she stayed stayed out out late at a and , but late at a concert and and experienced experienced aa hypomanic hypomanic period. period. By By day day 16 16 of of the the month, month, she'd she'd concert had seven seven consecutive consecutive nights nights of of poor poor sleep sleep and and began began to to experience experience mixed mixed had m o o d symptoms. symptoms. Her Her medication medication was was not not changed changed during during this this interval, interval, bUl but mood she had had been been inconsistent inconsistent with with her her regimen regimen during during days days 10 10 and and 111. So she she she 1 . So identified four four things things that that may m a y have have correlated correlated with with her her mood m o o d shifts shifts during during identified this particular particular month: month: events events involving involving her her pet, pet, problems problems with with her her boyfriend, boyfriend, this sleep sleep deprivation, deprivation, and and medication medication inconsistencies. inconsistencies. W e don't don't know k n o w for for sure sure whether whether these these variables variables would would have have affected affected We Amy's moods m o o d s during during aa different different month. month. This This is is one one of of the the reasons reasons it it is is im­ imAmy's portant to to keep keep the the chart chart on on an an ongOing ongoing basis-to basis—to detennine determine whether whether you you portant have aa predictable predictable set set of of "mood " m o o d triggers" triggers" (for (for example, example,arguments arguments with with fam­ famhave ily members, members, final exams, changing changing time time zones, zones, aa specific specific pattern pattern of of sleep sleep ily final exams, deprivation). Identifying Identifying mood m o o d triggers triggers is is an an important important step step in in gaining gaining con­ condeprivation). trol over over your your moods, m o o d s , as as you'll you'll learn learn more more about about in in this this and and subsequent subsequent trol

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How How (an Can IIManage ManageMy My Disorder? Disorder?

157 157

Step Raling VourYour MoodMood Each Each Day Day Step 1:1: Rating

The stepstep in learning to fill out mood chart is to become familiar with a familia The first first in learning toa fiH out a mood chart is to become numerical numerical scale scale that that corresponds corresponds to to various various levels levels of of your your mood mood disturbance. disturbance. daily The The sidebar sidebar gives gives you you guidelines guideHnes for for making making judgments judgments about about your your daily mood, mood, using using aa scale scale from from -3 -3 (severe (severe depression) depression)to to+3 +3(severe (severemania). mania).ItIt gives gives examples people with what they they examples of of how h o w people with bipolar bipolar disorder disorder feel feel and and think think (and (and what Not evev­ say) when when they're they're in in these these various various states states (see (see also also Young Young et et aI., al, 1978). 1978). Not say) in order ery example example or or descriptive descriptive label label in in the the table table need need apply apply to to you you in order to to use use ery the corresponding corresponding scale scale number. number. Rather, Rather, try try to to figure figure out out which which category category of the of depression or or elevation elevation best best describes describes how how you you feel feel on on aa given given day. depression day. Mood Mood charting charting requires requires aa bit bit of of practice. practice.You Youmay maybe beaaperson personwho w h o isis nat­ naturally depressed, urally able able to to judge judge for for yourself yourself whether whether you you are are feeling feeling manic manic or or depressed, and and you you may may be be easily easily able able to to describe describe the the experience experience to to others. others. Alternatively, Alternatively, the the descriptive descriptive label label "manic'· '"manic" or or "depressed" "depressed" may may not not fully fully capture capture the the way way you feel If this is the case, take time to learn the mood chart and numerical you feel. If this is the case, take time to learn the mood chart and numerical scales with your scales and and try try to to see see if if you you can can equate equate the the terms terms used used in in the the chart chart with your depressed can mean particular particular way way of of describing describing mood mood stales. states.For Forexample, example, depressed can meanthe the "wired." same same thing thing as as "crashed"; "crashed"; elevated elevated can can mean mean the the same same thing thing as as "wired." Practice mood today today Practice by by seeing seeing if if you you can can apply apply aa mood mood descriptor descriptor La to your your mood unsure and and yesterday, yesterday, using usingthe the-3 -3--++33scale. scale.I fIfyou youare are unsureasastotowhether whetheryour your rating is is reasonable, reasonable, ask ask someone someone who w h o knows knows you you well well (perhaps (perhaps a a family family rating member or or your your partner) partner) ififhe heor orshe shewould wouldagree agreewith withyour yourrating. rating.IfIfyou youfeel feel member that that your your mood mood varies varies conSiderably considerably during during the the day, day, make make a a "best" "best" and and a a "worst" rating rating (for (for example, example, you you may maybe beat ataa-2 -2in inthe themorning morningand and aa-1 -1 or or00 "worst" by by evening). evening). If If your your mood mood has has been been both both elevated elevated and and depressed depressed on on the the same same day, day, make make two two ratings, ratings, indicating indicatingthe thehighest highestand andlowest lowestpoints. points. In In choosing choosing your your level, level,try tryto tothink thinkabout aboutthe theleast leastand andmost mostdepressed depressedor or manic you've you've ever ever been been in in your your life lifeand anddetermine determinewhere wherethese thesestates statesfitfiton onthe the manic scale. scale.For Forsome somepeople, people,their their worst period ever might have been a 1-1; for oth; for oth­ worst period ever might have been aers it it might might have have been been a a -3. -3. If If your your mood mood has has never never gone gone above above or or below below a a 2, ers 2, use use these these as as benchmarks benchmarks for for judging judging your your mood mood today today and and throughout throughout the the week. week. Compare your your depression depression level level today todayagainst againstaatypical typicalday day(your (yourbaseline, baseline, Compare or or how how you you feel feel most mostof ofthe thetime, time,which whichwould wouldrate ratea a0). 0).Then Thencompare compareyour your mood mood to to other other days days when when you you felt felt blue blueor orout outof ofsorts sortsbut butnot notimpaired impaired (-1), (-1), days when when you you have have felt feltimpaired impairedbut butcould couldstill stillfunction functionwith withsignificant significantdif­ difdays ficulty ficulty (-2), (-2), and, and, if if applicable, applicable,days dayswhen whenyou youfelt feltsosodown downthat that youcould could not you not work at at all all or orinteract interactwith withothers others(-3). (-3).These These comparisons comparisonsshould should help help you you work determine today's today's rating. rating. likewise, Likewise, try try to to think think of of the the most most manic determine manic or or hypomanic you've you've ever ever felt. felt. IfIfyou youwere wereever everseverely severelymanic manicand andin inthe thehospihospihypomanic

158 158

SELF-MANAGEMENT Sm-MANAGEMENl

Mood M o o d Descriptors Descriptors (0) "WNL" (within normallimits). limits). is baseline: your baseline: Yourismood is (within normal ThisThis is your Your mood (0) "WNL"

not elevated elevated or or depressed, depressed,your yourenergy energylevel levelis isnormal normalfor foryou, you,sleep sleepisis not normal, and you're able able to carry out out your your daily daily work w o r k and and other other tasks tasks normal, and you're to carry with of with little little or or no no difficulty. difficulty. You Y o u have have no no other other obvious obvious symptoms symptoms of your your mood m o o d disorder. disorder.

Elevated Mood Mood Elevated (+1) Mildlyelevated. elevated. feeling cheerful, or energized, or (+ 1) Mildly YouYou areare feeling giddy,giddy, cheerful, or energized, or somewhat more more irritable irritable or or anxious anxious or or nervous nervous than than usual. usual, but but you you somewhat are more energy are nol not really really impaired; impaired; you you have have more energy and and more more ideas, ideas, and and

you feel feel more more self-confident self-confident but have been able to to work w o r k effectively but have been able effectively you and relate normally and relate normally to to others. others. ''I'm "I'm more more restless/animated/talkative restless/animated/talkative

today than than usual," usual," "I'm "I'm making making more more phone phone calls," calls," ''I'm "I'm getting getting by by today with with a a little little less less sleep" sleep" (for (for example, example, one one or or two two hours hours less less than than usual). snapping at usual), "I'm "I'm more more easily easily distracted distracted today," today," "I'm "I'm snapping at people people

more," "I'm more frustrated frustrated by by little little things," things," "I'm "I'm somewhat somewhat revved revved more. "I'm more n

up or or wired," wired," "My " M y mind mind is is clicking clicking along along a a little little faster," faster," "I'm "I'm feeling up feeling sexier," ''I'm "I'm more more optimistic," optimistic," '''I'm "I'm hypomanic." hypomanic." sexier,"

(+2) Moderately (+2) Moderatelyelevated. elevated. "High" or moderately manic; mood "High" or moderately manic; youryour mood is is euphoric or or very very irritable irritable and and 'anxious, anxious, and and people people have you it euphoric have told told you it seems inappropriate; inappropriate; you you feel feel like like breaking things; you you feel feel heavily heavily seems breaking things; goal-driven and and hypersexual hypersexual and and your thoughts are are going going very very fast; goal�driven your thoughts fast; you have have Significant significant difficulty difficulty fOCUSing focusing on on your your work; work; you you are are having having you run-ins with people (they seem moving and run-ins with people (they seem to to be be moving and talking talking too too slowly); slowly);

people are are complaining complaining that that you you seem seem angry angry or or grouchy grouchy or or are are people moving moving way w a y too too fast; fast; you you yelled yelled at at others others inappropriately. inappropriately. You Y o u are are

sleeping as as little Httle as as four four hours hours per per night night and and not not feeling feeling tired. tired. "I'm "I'm sleeping feeling very very impatient impatient today," today," "1 "I think think 1I can can get get by by with with a a lot lot less feeling less sleep," "I'm "I'm very very preoccupied preoccupied with with sex," sex," "My " M y mind mind is is working working faster sleep," faster than ever," ever," "I "I have have so so much m u c h to tosay say and and IIhate hatebeing beinginterrupted." interrupted,""I'm "I'm than feeling irritated, irritated, angry angry at ateverything." everything." feeling

(+3) Severely elevated/manic. Euphoric or aggresSive; you are laughing (+3) Severely elevated/manic. Euphoric or aggressive; you are laughing constantly or or your your irritability irritability is is out outof ofcontrol; control;you youhave havehad hadloud loudver­ verconstantly bal or bal or physical fights with with people; people; you you feel feel like like you you are are exceptionally exceptionally physical fights

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talented or or have h a v e special special powers p o w e r s (for (for example, e x a m p l e , the the ability ability to to read peotalented read peo­ ple's ple's minds, m i n d s , to to change c h a n g e the the weather), weather), you y o u are are constantly constantly moving m o v i n g about about

a n d cannot cannot sit sit still; still; you y o u are are unable unable to to work w o r k or or get get along along with with others; and others; you in trouble the police y o u have h a v e gotten gotten in trouble in in public, public, have h a v e been b e e n stopped stopped by b y the police

or have h a v e been b e e n taken taken to to the the hospital; hospital; you y o u are are sleeping sleeping little little or or not not at at all. aU. or

Depressed Depressed Mood Mood

(-1) Mildly depressed. depressed. Youare are feeling slightly slowed down or sad; ( 1) Mildly You feeling slightly slowed down or sad; -

you have have trouble trouble keeping keeping certain certain negative negative thoughts thoughts out out of of your your head; head; you you feel feel more m o r e self-critical, self-critical,you youwant wanttotosleep sleepmore moreor orare arehaving havingslight slight you trouble trouble falling falling or or staying staying asleep, asleep,and andyou you feel feelsomewhat somewhatmore morefatigued fatigued than don't seem in­ than usual; usual; you you wonder wonder if iflife lifeisisworth worthliving; living;things things don't seemasas in-

teresting as as they they usually usually do; do; you you are are still still able ableto towork w o r k effectively effectivelyand and teresting are relating relating nonnally normally to to others, others, even even though though you you may m a y feel feel less less effec­ effecare tive; your your depression depression is isnot not obvious obvious to toothers. others. tive;

(-2) Moderately down (-2) Moderately depressed. depressed.You You are are feeling feelingvery verysad, sad, down in in the the dumps, d u m p s , hopeless, hopeless, moderately moderately slowed slowed down, d o w n , or or uninterested uninterested in in things things

for most most of of the the day; day; you you are are sleeping sleeping more more or or having having a a lot lot of of trouble trouble for falling asleep or staying staying asleep asleep (for (for example, example, waking waking up u p regularly regularly in falling asleep or in the middle middle of of the the night) night);; fewer fewer and and fewer fewer things things are are of of interest interest to you; the to you; you are are ruminating ruminating a a lot lot about about current current or or past past failings; failings;you you are arefeeling feeling you grouchy and and irritable; irritable; you you have have significant significant difficulty difficulty getting getting your your grouchy w o r k done done (missing (missing days days at at work w o r k or or school school or or being being less less productive); productive); work your concentration concentration is is impaired; impaired; others others comment c o m m e n t that that you you seem seem mo­ moyour rose or or slowed slowed down d o w n or or that that you're you're speaking speaking slowly; slowly;you you have have consid­ considrose ered ered suicide suicide and and have have thought thought of of various various methods. methods.

(-3) Severelydepressed. depressed. You feel deeply or numb; have (-3) Severely You feel deeply sad sad or numb; youyou have lostlost interest in in almost almost eVerything; everything; you you are are experiencing experiencing severe severe suicidal interest suicidal feelings, you you wish wish to todie dieor orhave have made m a d e an an attempt attempt on on your your life; life;you you feelings, feel extremely extremely hopeless; hopeless; you you believe believe you you have have sinned sinned terribly terribly and and feel should should be be punished; punished; you you are are unable unable to to work, work, concentrate, concentrate, interact interact

with others, others, or or complete complete self-care self-care tasks tasks (for (for example, example, bathing, bathing, wash­ washwith ing clothes); clothes); you you stay stay in in bed bed most most of of the the day day andlor and/or cannot cannot sleep sleep and and ing have have severe severe problems problems with with lack lack of of energy. energy.

Sources:Sachs Sachs(1998); (1998);Young Youngctet (1978); Williams (1988) Sources: al.al. (1978); Will iams (1988)

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been at thal lime time would have have ele­been eletal, yourrating rating at that would youever have ever tal, your you If have been been a +3. aIf+3. vated to vated to the the extent extent that that you you were were having having trouble trouble functioning functioning at at work, work,your your rat­ ratupbeat," but ing would would be be a a +2. +2. If If you you have have been been "wired" "wired" and and ""upbeat," but this thisstate state did did ing not cause 1 (hypomanic) not cause run-ins run-ins with with olhers others or or make m a k e it it difficult difficult to to sleep, sleep, a a+ +1 (hypomanic) your own probably probably applies. applies. In In other other words, words, think think in in terms terms of of your o w n personal personal benchmarks. benchmarks.

Step 2:Recording RecordingYour Your Anxiety Irritability Slep 2: Anxiety .ndand Irrit.bility You'll notice that mood chart you to your rateanxiety your anxiety You'll notice that thethe mood chart alsoalso asks asks you to rate and irri­and irritability levels levels on on a a 0-3 0-3 scale. scale. There There are are two two reasons reasons La to do do this. this. First, First, anxiety anxiety tability and irritability irritability can can be be the the first first signs signs of of a a new n e w manic manic or or mixed episode. Sec­ Secand mixed episode. ond, some medications ond, some medications may m a y produce produce these these symptoms symptoms as as side side effects effects (for (for exex­ ample, the SSRI So, it's track these ample, the SSRI antidepressants). antidepressants). So, it's a a good good idea idea to to track these symp­ symp-

toms, even even if if you're you're not not sure sure how h o w they they are are related related to to the cycling of your the cycling of your toms, bipolar disorder. bipolar disorder. Examples of of "1" "1" levels levels of of irritability irritability include include feeling feeling somewhat somewhat snappish snappish or or Examples grumpy, but but not not to to the the extent extent that that you you can't can't function function alongside alongside people. people. A "2" grumpy, A "r would at would mean m e a n moderate moderate irritability irritability that that causes causes problems problems for for you you at at work work or or at home. "3" would mean angry to home. A A "3" would m e a n that that you you were were severely severely irritable irritable and and angry to the the ex­ ex-

tent that that you you were were having having real real trouble trouble functioning. functioning. Likewise, Likewise, aa"1" "1" anxiety anxietyrat­ rattent ing would would mean m e a n feeling feeling mildly jittery, apprehensive, apprehensive, and and perhaps perhaps scared scared but but ing mildly jittery, able to to get get along along with effort. A A "2" "2"would would mean m e a n moderate moderateanxi­ anxiable with minimal minimal extra extra effon. ety chores; ety that that makes makes it it difficult difficult to to work, work, read, read, socialize, socialize, or or perform perform daily daily chores;

however, you're still able able to to function with extra extra effort. effort. A A "3" "3" would would mean mean however, you're still function with overt panic panic and and severe, severe, incapacitating incapacitating anxiety. anxiety. overt Step 3:Recording RecordingYour Your Hours of Sleep Slep 3: Hours of Sleep Along with your your mood mood rating, rating,make makea a daily rating of many how many hours of sleep Along with daily rating of how hours of sleep you had had the the previous previous night. night. If Ifyou're you're rating rating your your mood m o o d for, for,say, say,Thursday, Thursday,re­ reyou cord the hours you you slept slept Wednesday Wednesday night night to to Thursday Thursday morning. morning. If Ifyour your sleep sleep cord the hours asleep. is intermittent, intermittent, try try to to estimate estimate the the actual actual number number of of hours hours you you were were asleep. is

Your recall of of your your prior night's sleep sleep may m a y be be most most accurate accurate when w h e n you you ffirst irst Your recall prior night's wake up in the the morning. morning. wake up in

If you If you take take naps naps regularly, regularly, separately separately recording recording nighttime nighttime and and daytime daytime sleep will will allow allow you to investigate investigate whether whether napping napping in in the the afternoon afternoon makes makes sleep you to the it harder harder to to sleep sleep that that night night or or makes makes your your mood m o o d worse worse by by the the end end of of the it

day. day_ After a a week week or or more more of of doing doing this this charting, charting, you you may m a y begin begin to to see see how how After your sleep sleep and and mood m o o d are related. Many M a n y people people are are surprised surprised at at the the result. your are related. result.

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getget Amy, for example, had had always assumed that lack of of sleep sleepcaused causedher hertoto for example, always assumed that lack Amy, more more depressed, depressed, yet yet she she found found from from her her mood m o o d chaning charting that that sleep sleep loss loss was was more more consistently consistently associated associated with with her her hypomanic hypomanic periods periods (note (note the the shift shift on on day 10 10 of of her her chan). chart). day

Step 4:raking TakingDai/y Daily Notes Events and Social Stressors Not., on on LifeLife Events and Soci./ Stresso" Step 4:

that your mood hashas been influenced by one more eventsevents or inter­ If youfeel feel that your mood been influenced by or one or more or interIf you Some actions with with others, others, record record these these on on your your chart chart under under "Daily "Daily Notes." Notes." S o m e of of actions these these may m a y be be Significant significant (for (for example, example, breaking breakingup up with withyour your partner, partner,quitting quitting your job) job) and and others others may m a y seem seem minor minor (having (having a a change change in in work work hours; hours; racing your racing to the the airport airport to to catch catch a a plane; plane; getting getting stuck stuck in in a a traffic trafficjam). jam). Record Record all allevents events to that you you feel feel may m a y be be important, important, even even if ifthey theyseem seem as asif ifthey theywould wouldbe beinconse­ inconsethat quential For example, relatively rourou­ quential for for many m a n y people. people. For example. Amy A m y found found that that even even relatively tine quarrels quarrels with with her her father father were were associated associated with with a a mild mild drop drop in in her her m o o d (to tine mood (lO a -1). -1). The The purpose purpose here here is is to to observe observe the the connection connection between between specific specific events events a and specific specific mood m o o d changes. changes. When W h e n reviewing reviewing the the day day and and filling filling out your and out your chart, chart, consider consider questions questions such such as as the the following: following: • What happened right right before I last felt hypomanic? • What happened before I last feltirritable irritable ororhypomanic? •

• What W h a t happened happened right right after after my m y irritable irritable mood m o o d set set in? in?

•

• What W h a t happened happened right right before before my m y mood m o o d spiraled spiraled downward? downward?

WhenWhen you'reyou're recording stressors, recall inChapter Chapter5:5:it it recording stressors, recallthe theissue issue raised raised in

can can be be difficult difficult lO to tell tellwhether whether stress stresswas was the thecause cause or orthe theeffect effectof ofyour your mood. mood. Over time, time, mood m o o d chaning charting may m a y help help you you determine determine the the timing timing of of events in re­ reOver events in lation to to changes changes in in your your mood. m o o d . For For example, example, did did you you race race to to the the airport and lation airport and then feel feel an an increase increase in in your your energy energy level level and and mood, m o o d , or or were were you you feeling then feeling speedy before before you you raced raced to to the the airport? airport? Did Did you you get get into into an an argument argument with with speedy your your father father and and then then feel feel down d o w n about about yourself, yourself, or or were were you you feeling feeling down d o w n bebe­ fore you you got got into into the the argument? argument? Don't Don't wony worry for for now n o w if ifyou're you're not not sure sure which which fore caused which. which. Instead, Instead, just just try try to to identify identify the the factors factors that that coincide: coincide:stressful stressful caused events, patterns. events, mood m o o d states, states, and and sleep sleep patterns. The "Daily "Daily Notes" Notes" section section is is also also a a good good place place to to record record your The your alcohol alcohol or or drug use. use. If If you you drank drank on on aa specific specific day, day,record record that thatinformation information as as an an event event drug even even if if your your intake intake seemed seemed trivial trivial (for (for example, example, "drank "drank one one beer" beer" or or "had "had aa margarita"). Then T h e n you you can can observe observe for for yourself yourself whether, whether, and and to to what what degree, margarita"). degree, alcohol or or drug drug usage usage affects affects your your mood m o o d the the next next day. day. You You m a y also alcohol may also learn learn whether you you are are using using substances, substances, in in part, part, lO to alleviate alleviate a a negative negative mood m o o d state whether state from from the the previous previous days days or or week. week.

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Step 5: Treatments Step 5:Recording RecordingYour Your Treatments Record all thethe medications andand dosages you you are supposed to take the top Record allofof medications dosages are supposed to at take at the top of left columns of the the left columns of ofthe the chart, chart,including includingmedications medicationsthat thatare arenot notspecifically specifically for your your bipolar disorder (for (for example, example, blood blood pressure pills). In In the the boxes for bipolar disorder pressure pills). boxes corcor· ac­ responding responding to to the the day day of of the the month m o n t h you're you're rating, rating, record record the the number n u m b e r you you acmally took. This will will help help you, tually took. This you, your your physician, physician, and and other other members members of of your your if inconsistencies your use use of treatment team team to to know k n o w if inconsistencies in in your of medication medication is is affect­ affecttreatment ing your night she ing your day-ta-day day-to-day mood. mood. Amy A m y missed missed her her evening evening dosages dosages on on the the night she went went to to the the coneen concert and and the the next next evening evening as as well, well, which which probably probably comributed contributed to her her mood m o o d instability. instability. As As IItalk talkabout aboutin inChapler Chapter7, 7,most mostpeople peoplemiss missaamedi­ medito cation track of these seem­ cation dosage dosage once once in in a a while, while, but but it's it's important important to to keep keep track of these seemingly minor inconsistencies. place aa check ingly minor inconsistencies. likewise, Likewise, place check mark mark next next to to any any days days w h e n you attended a a psychotherapy psychotherapy session. session. As A swith with medication, medication,some some people people when you attended are altendance. are quite quite regular regular and and others others are are quite quite irregular irregular in in their their therapy therapy attendance. You Y o u may m a y be be taking taking some some of of your your medications medications "as "as needed." needed." For For example, example, some to some people people take take a a medication medication like like Klonopin Klonopin only only when w h e n they they can't can't get get to sleep. Indicate Indicate "as "as needed" needed" on on the top left left column column of your mood m o o d chart chart next next to sleep. the top of your to medications fit is medications that that f it this this description. description. Some S o m e people people find find that that their their mood m o o d is lower find lower on on the the day day after after they they have have taken taken an an as-needed as-needed medication. medication. Others Others find that the allergy that cenain certain as-needed as-needed medications medications (for (for example, example, the allergy medication medication pseudoephedrine) m a k e them feel temporarily energized, wired, or even even pseudoephedrine) make them feel temporarily energized, wired, or hypomanic. hypomanic. of Your physician will be be able able to to use use your your medication medication records records in in a a number number of Your physician will ways. Let's Let's imagine imagine that that he he or or she she has has prescribed prescribed Depakote Depakote and and an an SSRI SSRI antiways. anti­ depressant. Let's also imagine that your chart indicates improvements in your depressam. Let's also imagine that your chart indicates improvements in your m ood a a week or two two after after you you staned started the the SSRI, SSRI, but but then you began began to to report mood week or then you report "roller-coastering" or or rapid rapid cycling cycling of of your your emotions emotions and and energy energy levels. levels. If If all aU "roller-coastering" of this documented on on your your chan, chart, your your physician physician may m a y decide decide to to disconof this is is documented discon­ tinue the the antidepressant antidepressant or or adjust adjust your your dosage dosage as as a a way w a y of of stabilizing stabilizing your your tinue mood. mood.

Step Step 6: 6: Recording Recording Your Your Weight Weight and and Menses Menses Two ofinformation information will help round mood chart. Twoother other pieces pieces of will help round out out youryour mood chart. First,First, record your your weight at least least once once during during the the month. month. It's It's best best to to weigh weigh yourself yourself record weight at on the the same same day day each each month m o n t h so so that that you you can can see your medication, medication, on see whether whether your stress, or or mood m o o d cycling cycling is is connected connected with changes in in your your weight. weight. For For exam­ examstress, with changes ple, if if you are gaining gaining weight weight on on an an atypical atypical antipsychotic antipsychotic (for example, ple, you are (for example, Zyprexa), your your physician physician may m a y choose choose to to switch switch you you to to a a different different medication medication Zyprexa), within the the same same class class (for (for example, example, Risperdal) Risperdal) or or adjust adjust your dosage. If If you you within your dosage.

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are a a woman, woman, circle which youyou had had your your period. You and are circlethe thedays daysonon which period. Youyour and your doctor doctor may m a y wish wish to to examine e x a m i n e whether whether your your mood m o o d cycles cycles begin begin before, before, during, during, or after after the the onset onset of of your your menses. menses. or

E.a/uating Yaur Chart Evaluating Your Mood Mood Chart Share mood chartchart with with your your therapist or physician during during Share your yourcompleted completed mood therapist or physician each visit. visit. Together, Together, you y o u can can evaluate evaluate the the influence influence of of certain certain stressors stressors on on each your your mood, m o o d , the the influence influence of of sleep sleep disturbances, disturbances, and a n d the the effects effects of of various various medications medications and a n d your your consistency consistency with with them. them. Even E v e n if ifyou're you're not not meeting meeting regu­ regularly larly with vidth your your doctor doctor or or therapist, therapist, make make a a point point of of examining examining the the chart chart at at the the end of of each each week w e e k to to see see if if any any patterns patterns jump j u m p out out at at you. you. Keeping Keeping the the chart chart end hypotheses about over a a year year or or more m o r e will will enable enable you y o u to to develop develop longer-range longer-range hypotheses about over which mood which biological biological or or social social factors factors are are provoking provoking shifts shifts in in your your m o o d (for (for ex­ example, ample, periods periods of of greater greater alcohol alcohol or or marijuana marijuana usage, usage, the the onset onset of of winter, winter, the the onset onset of of spring, spring, the the Christmas Christmas holidays, holidays, periods periods of of increased increased work w o r k or or school school stress). stress).

Prohlemswith with Mood MoodCharting Charting Problems Moodcharting chartingcan can feelreductionistic: reductionistic: It It does Mood feel does nm not do do justice justiceto tothe themany many var­ varied ied experiences experiences you y o u have have on on a a daily daily basis. basis. It It is is also also very very present-focused. present-focused. Some Some people feel feel that that their their mood m o o d shifts shifts are are related related to to factors factors that that can't can't be be eaSily easily repeople re­ corded past or in corded on o n the the chart chart (for (for example, example, traumatic traumatic events events in in the the recent recent past or in childhood). Even E v e n with with these these limitations, limitations, however, however, mood m o o d charting charting is a very efchildhood). is a very ef­ ficient ficient way w a y of of summarizing summarizing a a great great deal deal of of information information very succinctly for for very SUCcinctly yourself and and your your doctor. doctor. If If you y o u are are using using mood m o o d charting charting as as a a supplement supplement to to yourself your your personal personal psychotherapy, psychotherapy, think think of of it it as as a a point of departure departure for for exploring exploring point of larger issues issues that that affect affect your your mood. m o o d . For For example, example, events events such such as as minor m i n o r dis­ dislarger agreements with with a a partner partner can can have have profound profound effects effects on o n your your mood m o o d if if they they agreements trigger trigger fears fears of of separation separation or or loss. loss. You Y o u may m a y wish wish to to explore explore these these larger larger issues issues with your your therapist. with therapiSt. M o o d charting charting can can also also be be difficult difficult to to remember r e m e m b e r to to do d o every every day. day. Try Try to to Mood pick pick one one time time each each day day to to complete complete your your chart, chart, and and stick stick to to this this time time on on a a day­ dayto-day basis. basis. Some S o m e people fill it it out out right right before before getting getting ready ready for others to-day people fill for bed; bed; others tie tie mood m o o d charting charting to to a a specific specific daily daily activity activity (for (for example: example: just just after after finishing finishing dinner, after after walking walking the the dog, dog, before before watching watching the the evening evening news). n e w s ) . Avoid Avoid dinner, choosing the the worst worst moment m o m e n t of of the the day day to to fill fill out out the thechart chartif ifthat thatmoment m o m e n t does does choosing not represent represent how h o w you've you've felt felt for for the the whole w h o l e day. day. So So if if you y o u usually usually feel feel quite quite not u n h a p p y when w h e n you y o u first first wake w a k e up u p but but feel feelbetter better within within half halfan an hour h o u r or or so, so, pick pick unhappy another, out a another, more m o r e representative representative time time of of day. day. Avoid Avoid trying trying to to fill fill out a month's month's

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worth worth of of mood m o o d charts charts just just before before your your doctor doctor appointments, appointments, as as people people some­ sometimes do. do. The The more: more accurate accurate the the information information you you convey convey to to your your doctor, doctor, the the times better you and your doctor can make. better the the treatment treatment decisions decisions you and your doctor can make.

Maintaining Wellness Tip Tip No. N o . 2: 2: Maintaining Maintaining Regular Regular Daily Daily Maintaining Wellness and Nightly Nightly Routines Routines and

really feel that I benefited from from psychoanalysis. I was in four a times a "I"Ireally feel that I benefited psychoanalysis. I it was in times it four week. But But II don't don't think think it it was was all all that that learning learning about about my m y childhood. childhood. week. There therapeutic about There was was something something very very therapeutic about always always having having a a place place to to go go to in morning, seeing seeing the the same same therapist therapist every every day, day, seeing seeing the the same same atin the the morning, at­ to tendant . . II tendant in in the the parking parking lot, lot, getting getting back back in in my m y car car at at [he the same same time time .... found found all all of of that that structure structure very very comforting." comforting." — A 40-year-old 40-year-old woman w o m a n with with bipolar bipolar II II disorder disorder -A

In Chapter I talkabout aboutthe the beneficial on your mood stability of In Chapter 5, I5, talk beneficialeffects effects on your mood stability of social external external "time "time keepers, keepers," and and the the potentially potentially negative negative effects effects of of events events or or social demands yOUT daily cycles (Ehlers demands that that disrupt disrupt your daily routines routines and and sleep-wake sleep-wake cycles (Ehlers et et aL, al, 1988, 1993). 1993). Actively Actively maintaining maintaining daily daily and and nightly nightly routines routines is is one one o of the most most 1988, f the important behavioral behavioral changes changes you you can can undertake---aside undertake—aside from from regularly regularly taking taking important your medication-to medication—to help keep you you in in the the driver's driver's seat seat in in managing managing your your disoryour help keep disor­ der. In In this this section, section, II discuss discuss the the Msocial "social rhythm rhythm stability" stability" approach approach to to mainder. main­ taining wellness. taining well ness. n

Keeping a a Social Social Rhythm Rhythm Char' Chart Keeping The Rhythm Metric Metric (SRM) (SRM) is more time-consuming time-consuming device devicethan thanthe the The Social Social Rhythm is aamore m o o d chan, chart, but it is is also also potentially potentially more more informative informative (Monk ( M o n k et et aL, al, 1990, mood but it 1990, 1991). In In this this chart, chart, you you keep keep track track of ofwhen w h e n you you eat, eat,sleep. sleep,exercise, exercise,and and so­ so1991). cialize, and and make m a k eratings ratingsof ofyour yourdaily dailymood. mood.With With lime, time,you youcan canwork workon onsta­ stacialize, bilizing daily routines routines as as a a means means of of stabilizing stabilizing your your mood. mood. This involves bilizing your yOUT daily This involves planning your regular activities activities for for predictable predictable times times of of the the day day or or night. planning yOUT regular night. The SRM The S R M was was developed developed as as a a central central part part of of Ellen Ellen Frank's Frank's and and David David Kupfer's work work on on interpersonal interpersonal and and social social rhythm rhythm therapy therapy (IPSRT). (IPSRT). As As I Kupfer's I talked about about in in Chapler Chapter 6, 6, Frank Frank and and her her colleagues colleagues have have shown s h o w n that that the the com­ comtalked bination of of IPSRT and medication medication is is effective effective in in improving improving the the course course ofbipo­ of bipobination IPSRT and social lar disorder disorder (Frank, (Frank, 1999; 1999; Frank Frank et al, 2000). 2000). II was was trained in Frank's Frank's social lar et aL, trained in rhythm therapy therapy approach some years years ago ago and and have have become become convinced convinced of of the the rhythm approach some

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value of value ofdaily daily rhythm tracking stabilization for persons with disor­ bipolar disor rhythm tracking andand srabilization for persons with bipolar der. der.

The purpose of of social social rhythm rhythm tracking tracking is is to to allow allow you you to to discover discover the the relarela­ T h e purpose tionship between levelsof ofinterpersonal interpersonal stimu­ stimutionship between changes changes in in your your daily daily routines, routines, levels lation, sleep-wake cycles, cycles,and and mood. m o o d . Over Over several severalweeks weeks or ormonths, months,you you will will lation, sleep-wake begin to see cerrain patterns patterns emerge emerge (as Amy did). For For example, begin to see certain (as A m y did). example, you you may m a y find find that changes in levels or or sleep development in your your activity activity levels sleep patterns patterns presage presage the the development that changes of n e w episodes. episodes. In the beginning beginning phases m a y observe observe a of new In the phases of of mania mania you you may a gradual gradual decrease an increase the time in the the time time you you spend spend sleeping sleeping and and an increase in in the time you you spend spend decrease in exercising. Likewise, you m a y find find that that as as you from a exerCising. likewise, you may you recover recover from a manic manic or or dede­ pressive pressive episode, episode, your your activity activityand and sleep sleep patterns patterns naturally naturallygo go back back to to the theway way were before became ill ill. In words, your activity patpat­ they were before you you became In other other words, your sleep sleep and and activity they terns can be a a sign better or or terns can be sign of of whether whether your your mood m o o d problems problems are are getting getting better worse. worse. As mood A s with with the the m o o d chart, chart, it's it'sbest bestto tofill fillOul outthe theSRM S R M every everyday dayand andreview review it with your your therapist Keeping the the it each each week w e e k by by yourself yourself and and wdth therapist or or psychiatrisl. psychiatrist. Keeping social spot shifts shifts social rhythm rhythm chart chart on on a a regular, regular, ongOing ongoing basis basis will will enable enable you you to to spot in in your your daily daily routines routines and and sleep-wake sleep-wake cycles cycles that that may m a y be be of of subtle subtle importance importance in in determining determining your your mood. mood. The chart chart on on page page 166 166 was was completed completed by by Leslie, Leslie, a a 40-year-old 40-year-old woman woman The with the with bipolar bipolar II disorder disorder (a (a blank blank Social Social Rhythm R h y t h m Metric Metric form form is is provided provided at at the end end of of the the book). book). First First notice notice the the upper upper left-hand left-hand corner, corner,where where she shehas has made made daily mood m o o d rating rating on on aa -5 -5 - +5 +5 scale. scale.In Inthis thisrespect respectititisislike likethe themood m o o d chan. chart. aa daily But 7 activities will But notice notice that that there there are are 117 activities listed Hsted on on the the left left side; side; most most people people will do some some ponion portion of of these these every every day. day. Indicate Indicate in in the the boxes boxes what what time you did did do time you these these activities: activities: what what time timeyou you woke w o k e up, up,had had your yourfirst firstcup cup of ofcoffee, coffee,went wenttoto work, went went to to school school or or did did some s o m e other other daily daily activity, activity, ate ate lunch, lunch, exercised, exercised, work, came home, h o m e , ate ate dinner, dinner, and and went went to to bed. bed. These These daily daily routines, routines, in inpart, part,"drive" "drive" came your your sleep-wake sleep-wake habits habits (Frank (Frank et et aI., al, 2000). 2000). For For example, example, if if you you have have a a shiftshift­ ing work work schedule schedule that that demands demands that that you you work work from from 8 8 A.M. a.m. to to 4 4 P.M. p.m. one one day day ing and and then then 4 4 P.M. p.m. to to 112 a.m. the the next, next, your your bedtime bedtime and and wake w a k e time time will wiH be be corre2 A.M. corre­ spondingly altered altered from from day day to to day, day, and and your your mood m o o d may m a y change change (up (up or or down) down) spondingly in in the the days days that that follow. foHow. In In contrast, contrast, if if you you eat, eat, exercise, exercise, work, work, and and interact interact with others others at at fairly fairly regular regular times times of of the the day day or or evening, evening,you you will wiH come c o m e to to ex­ exwith pecl pect sleep sleep at at aa cerrain certain time. time. The SRM S R M also also asks asks you you to to record record who w h o did did each each oof these activities activities with with you you f these The and how how stimulating stimulating they they were. were. The T h e degree degree to to which which your your interchanges interchanges with with and others are are provocative, provocative, conflict-ridden, conflict-ridden, or or otherwise otherwise stimulating, stimulating, versus versus low­ lowothers key or or "laid "laid back," back," can can be be important important determining determining factors factors in in the the degree degree of of sta­ stakey bility you you experience experience in in your your emotional emotional states states and and possibly possibly even even your your sleep. sleep. bility Say you you ate ate dinner dinner with with your your wife wife or or husband husband but but had had an an argument, argument, and and then then Say

166 166

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MyMyDisorder? How How (on Can IIMonoge Manage Disorder?

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on stimula­ a "3" (rated house ends opposite wenttotoopposite youwent of you the the two two of ends of of thethe house (rated a "3" on stimulation); tion); you y o u would w o u l d probably probably have have more m o r e trouble trouble falling falling asleep asleep that that night. night. Com­ Compare that that night night to to another another night night when w h e n you y o u and a n d your your spouse spouse had had a a relaxing relaxing din­ dinpare "-"others just ner together together (which (which might might be be rated rated aa "1 "1"—"others just present"). present"). ner High H i g h levels levels of of stimulation stimulation from from other other people people can can feel feel quite quite positive positive hut but still StiH affect affect your your mood m o o d or or sleep-wake sleep-wake cycle cycle negatively. negatively. Deborah, Deborah, age age 26, 26, found found that her her evening evening waitressingjob waitressing job at at aa bar, bar, which w h i c h she she enjoyed enjoyed aa great great deal, deal, con­ conthat tained tained highly highly stimulating stimulating bursts bursts of of activity activity (usually (usually three-hour three-hour blocks blocks in in which she she was w a s in in great great demand d e m a n d by b y the the patrons). patrons). She She consistently consistendy had had more more which trouble trouble falling falHng asleep asleep after after getting getting home h o m e than than she she did did on o n nights nights when w h e n she she was­ wasn't working. working. She She had h a d an a n easier easier time time when w h e n she she was w a s assigned assigned the the early early evening evening n't shift. shift. Katherine, Katherine, age age 42, 4 2 , enjoyed enjoyed the the intensive intensive contact contact with with people people she she had had

through through her her job job in in the the clothing clothing section section of of aa department department store. store. However, H o w e v e r , the the social social stimulation stimulation rose rose to to almost almost intolerable intolerable levels levels during during the the weekends w e e k e n d s prior prior to irrita­ to the the Christmas Christmas holidays, holidays, and a n d she she found found herself herself becoming b e c o m i n g increasingly increasingly irritable. ble. She She learned learned not not 10 to schedule schedule any any social social activities activities on o n the the weekend w e e k e n d evenings evenings following following these these workdays w o r k d a y s as as a a way w a y of of modulating modulating her her exposure exposure to to stress stress and and stimulation. stimulation. Leslie's Example: SocialRhythm Rhythm Ch.rl Chart ••I••,ing •aSoci.1 mple: EEvaluating Leslie's E••

166, page example Leslie'sexample shown day Although isisshown in in Leslie's on on page 166, we we can can de- de­ oneday onlyone Althoughonly velop velop some s o m e hypotheses hypotheses about about factors factors that that affected affected her her mood m o o d states. states. For For her, her, a a mixed mixed mood m o o d state state is is a a day day of of depresSion, depression, along along with with agitation, agitation, nervousness, nervousness, and irritability. irritability. Note N o t e that that even even though though the the sample sample day day occurred occurred during the during the and spring, spring, w h e n daylight daylight hours hours were w e r e longer, longer, she she still still had had a a relatively relatively short day short day when (woke up u p at at 9:30 9:30 a.m. and went w e n t to to bed bed at at 10 10 P.M.). p.m.). She She was w a s sleeping sleeping too much. (woke 100 much. A.M. and She She also also had h a d several several high-stimulation high-stimulation interactions interactions during during the the day day (including (including an an argument argument over over the the telephone telephone with her ex-husband ex-husband about about their their child, a and a child, and with her confrontation confrontation with with a a roommate r o o m m a t e whom w h o m she she felt felt was w a s being being inconsiderate). inconsiderate). She She had at at least o n e alcoholic alcoholic drink drink w h e n alone. alone. In In addition addition to to her her biological pre­ biological prewhen least one had dispositions, these factors may m a y have have partially her agitated, de­ agitated, dedetermined her partially determined these factors dispositions, pressed mood. mood. pressed It is It is possible possible that that these these events events and a n d activities activities resulted from her her m o o d state state mood resulled from (for (for example, example, she she might might have have been anxious and and irritable a n d therefore more therefore more irritable and been anxious prone to prone to confrontations). confrontations). To T o help help determine determine which w h i c h caused caused which, which, Leslie Leslie col­ collected r h y t h m and and m o o d information o n herself over a several of several period of a period herself over information on mood social rhythm lected social people, months. o w provocative certain people, with certain interactions with began to provocative interactions She began how see h months. She 10 see sleep patterns, patterns, a n d alcohol alcohol c o m b i n e d to change her her m o o d , as o w her sleep her as hhow well as as well mood, to change combined and m o o d states affected the timing a n d frequency events aand n d habits. She habits. She these events of these frequency of and the timing states affected mood

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sleeping moremore became andand became increasingly certainthat that alcohol before bedtime sleeping increasingly certain alcohol before bedtime than more prone her nervous than nine nine hours hours combined combined to to make m a k e her nervous and and irritable irritable and and more prone to ith people. people. to run-ins run-ins w with

"HowCan Can I' Regu'ate "How Regulate My My Doily DailyRoutines?" Routines?" The next next step step is is to to devise devise strategies strategies that that help you regulate regulate your daily routines. routines. The help you your daily Keeping routines sounds Keeping regular regular routines sounds straightforward, straightforward, bUl but if ifyou've you'veever ever tried triedto todo do it, you you know k n o w that that significant significant challenges challenges are are likely likely to to arise. arise. You Y o u can can do do this it, this alone, alone, but butaatherapist therapistmay m a y be beable ableto tohelp helpyou you develop develop and and keep keep "target "targettimes� times" for exercise. for various various activities activities such such as as sleep sleep and and exercise. The The first, first,most mostimportant importantingredient ingredientisistotogo golOtobed bedatatthe thesame sametime timeevery every night and and wake wake up up at at the the same same time time every every morning. morning. Try Try to to maintain maintain this this pat­ patnight tern tern on on weekends, weekends, even h e n you'd you'd rather rather sleep sleep late. late. Of O f course, course, there there will will be be even w when times times when w h e n geuing getting to to bed bed at at your your target targethour hour or or waking waking up up at ataaspecific specifictime timeisis impossible, impossible, such such as w h e n you you travel, travel, have have social social plans plans on on a a weekend, weekend, have have a as when a sick sick child, child, or or need need to to get get up up extra extra early early to to pick pick up up someone someone at at the the train train sta­ station. these events tion. Some S o m e of of these events will will be be controllable controllable by by you you (for (for example, example, whether whether to go go to to the the early early or or late late showing of a a certain certain movie) and some some will will not not (for to showing of movie) and (for example, flight). If example, the the timing timing of of an an airline airlineflight). Ifyour yourschedule scheduleisisshifted shiftedby byan anhour hour or reinstate your or two two on on a a given given night, night, try try to to reinstate your original original sleep-wake sleep-wake target target times times as soon soon as as possible. as possible. Try Try to to maintain maintain your your sleep sleep patterns patterns even even if if events events conspire conspire to to make m a k e you you change change them. them. For For example, example, if ifyou you have have lost lostyour yourjob, job,try tryto toget getup u p at atthe thesame same time you you would would have have gotten gotten up up when w h e n you were going going in in to to work. work. If If your your new new time you were job requires requires different different hours (say, getting getting to to work work by by 8 8 A.M. A.M. instead instead of of 9 9 A.M.), A.M.), job hours (say, adjust your your bedtime bedtime to to an an hour hour earlier. earlier. ll's It'sbest besttotoease easeinto intoyour yournew n e wschedule schedule adjust gradually rather rather than than suddenly. suddenly. gradually You can can also also work work with with your your therapist therapist to to anticipate anticipate events events that that will change You will change your your daily daily routines, routines,and andplan planways waysto toregulate regulateyourself yourselfonce oncethese theseevents eventsoccur. occur. For example, if you k n o w that you m a y be changing jobs soon or traveling For example, if you know that you may be changing jobs soon or traveling more in in the the near near future, future, you you can can anticipate anticipate that thatyour your sleep sleep will willbe be disrupted. disrupted. more M a k e plans, in advance, to go to bed and wake up at consistent times, evenaf­ afMake plans, in advance, to go to bed and wake up at consistem times, even ter these disruptive events events have have occurred. occurred. ter these disruptive Second, if you have been having troublesleeping sleeping (see (seethe thesection sectionon on sleep, sleep, Second, if you have been having trouble lost below), try try to to avoid avoid Msleep "sleep hingeing," bingeing," in in which which you you calch catch up up from all the the lost below), from all sleep during during the the week by sleeping sleeping more more on on weekends. weekends. You'll You'll probably probably find week by sleep find that sleep sleep bingeing bingeing has has a a negative negative impact impact on on your your mood m o o d (typically (typically depression; depression; that see, for for example, example, a a study study of of sleep sleep disturbance disturbance by by Wolfson Wolfson &. & Carskadon, Carskadon, see, 1998). 1998). It It also also makes it harder harder to to sleep the next makes it sleep the next night. night. Third, try try to to see see if if you you can can maintain maintain the the same same hours hours each each day day at atwork work or or Third,

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to take classes during the same each day.each Try day. Try school.For Forexample, example,try try to take classes during theinterval same interval school. to avoid having all of your classes on one or two days and none on the other avoid having all of your classes on one or two days and none on the other to parallel your regular job job hours, hours, try try to to exercise at the the same same time time (for (for three. o paraHel your regular exercise at three. T To example, just after work) rather than late in the evening on one night example, just after work) rather than late in the evening on one night and and early in in the the morning morning the the next next day. Try to to have have a regular period to unwind then early day. Try a regular period to unwind then going to to bed. having your your most most stimulating with before before going bed. Avoid Avoid having stimulating interactions interactions with try to to go sleep. partners, friends, friends, or or coworkers coworkers right right before before you you try go to to sleep. panners,

Prodi,a' Challenges ta Maintaining Regu'a, Routines Practical Challenges to Maintaining Regular Routines There are practical practical problems be solved, of course. The courses youtowant to There are problems to to be solved, of course. The courses you want

have aa take may m a y be be offered offered at at all all different different times times of of the the day day or or night. night. You Y o u may m a y have take job that that requires requires a a lot lot of of travel, travel, necessitates necessitateslong longshifts shiftson on weekends, weekends,requires requires job work at at home h o m e in in the the evening evening on on some s o m e nights nights but but not others, or work not others, or involves involves changing changing shifts. shifts. An A n example example is isaacontract contractnursing nursingjob, job,in inwhich which people people are areof­ often called called for for a a full full eight-hour eight-hour shift shift only only an an hour hour before before the the shift shift is is to to start. stan. ten Restaurant jobs jobs often often have have shifting shifting schedules schedules as as well. well. In In Chapter Chapter 12, 12, you'll you'll Restaurant find light find some some suggestions suggestions for for negotiating negotiating work w o r k hours hours with with your your employer employer in in light of of the the limitations limitations your your disorder disorder can can impose. impose. Here social Here are are examples examples of of how h o w some s o m e of of my m y patients patients have have kept kept regular regular social rhythms rhythms even even when w h e n faCing facing the the demands demands of of school school or or job. job. Walter Walter had had an an open open discussion with with his his employer employer about about his his mood m o o d disorder. disorder. His His employer employer agreed agreed discussion to keep keep him him on on the the 8-5 8-5 daily daily shift shift at at his his computer computer programming programming job, job, rather to rather than than the the constantly constantly variable variable shifts shifts that that were were typical. typical.Juanita, Juanita,who w h otraveled traveledfre­ frequently, always always tried tried to to get get the the same same number n u m b e r of of hours hours of of sleep sleep each each night, quently, night, even when w h e n she she was was in in a a new n e w time time zone. zone. Maintaining Maintaining her her sleep sleep habits habits required required even aa degree degree of of assertiveness, assertiveness,given giventhat thatshe shewas wasoften oftenencouraged encouragedby byher hertraveling traveling to stay out late. coworkers coworkers to stay out late. Candace (discussed (discussed more m o r e on on page page 179-180) 179-180) found found that that her her weekends weekends inCandace in­ volved volved long long periods periods with with little Htde contact contact with with others, others, and and her her depressions depressions usu­ usuallybecame became worse worse then. then.Scheduling ScheduHng low-key low-key activities activitieswith with friends friendsor oracquain­ acquainally tances during during weekend weekend days days gave gave her her aa greater greater feeling feeling of of consistency consistency in in tances routines from from the the week w e e k to to the the weekend weekend and and helped helped improve improve her her mood. m o o d . LikeLike­ routines wise, wise, Wesley, Wesley, who w h o became became depressed depressed after after breaking breaking up up with with his his girlfriend, girlfriend, found that that scheduling scheduHng activities activities with with other other people people each each morning, morning, or or at at mini­ minifound mum, m u m , taking taking trips trips to to aa coffee coffee shop shop by by himself, himself,helped helped get get him him out out of of bed bed by by a a certain time. certain time. The SRM S R M can can help help you you design design aa daily daily schedule schedule of of sleeping, sleeping,eating, eating,exercis­ exercisThe ing, ing, and and SOCializing sociaHzing that that is is comfortable comfortable and and feasible, feasible, given given the the demands demands of of your current current social, social, family, family, and and work w o r k life. life.Try Tryto toset setgoals goals[or forwhen w h e nyou youplan plan your to togo go to to bed bed and and when w h e n you you want want to to wake w a k e up, up, and and try try not not to to deviate deviate from from these these

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plans there are rewarding ac­ acplans by bymore more than than30 30minutes minutestoto hour, even when there are rewarding an an hour, even when tivities (for (for example, example, parties. parties, late-night late-nightmovies) movies)that thatyou you feel feelwould would improve improve tivities your members of your mood. mood. Other Other members of your your family, family, if if living living with with you you (for (for example, example, your your spouse spouse or or partner), partner), may m a y be be able able to to help help you you design design this this program program and and stick to it. stick to it.

Resislonees T,oeking andand Keeping Reguloted Roulines Resistances10to Tracking Keeping Regulated Routines S o m e people people complain complain that that social social rhythm rhythm tracking tracking is is tedious tedious and and reminds reminds Some them of of doing doing homework h o m e w o r k assignments assignments for for school. school. Like Like most treatment and and them most treatment self-management self-management techniques, techniques, the the SRM S R M is is not notwithout without its itscosts costsin interms termsof oftime time and find you at at the end and effort. effort. But Butas asyou you get getused used to toit, it,you youwill will findthat that youcan cando doitit the end of about five of the the day day in in about five minutes. minutes. With With time, time, you you may m a y find find that thatcertain certainitems items others. For on the the chan chart are are morc more imponam important to to record record than than others. Forexample, example,your yourbed­ bedon time, wake wake time, time,job jobhours, hours,and andexercise exercisetimes timesmay m a ybe becritical criticalin indetermining determining time, your your mood m o o d stability, stability, but butyour your mealtimes mealtimes or orTV T V habilS habitsmay m a y be be less lesscentral. central. In In my m y and and other other clinicians' clinicians' experience, experience, the the bigger bigger issue issue that that people people with with bipolar disorder disorder face face is is the trade-off involved involved in in regulating regulating their their daily daily roubipolar the trade-off rou­ tines: up aa degree tines: It It means means giving giving up degree of of spontaneity. spontaneity. People People sometimes sometimes wonder, wonder, " W h y can't can't II have have the the same same kind kind of of 'devil 'devil may m a y care' attitude that thatothers othershave? have? "Why care' altitude If everyone everyone else else is is staying staying up up until until 2 2 A.M. a.m. to to party, party, why w h y can't can't n" I?" If If you're you're haVing having these these reactions, reactions,that's that'sunderstandable. understandable. For For Amy, A m y , keeping keeping If regulated routine routine made m a d e her her feel feel that that she she was was different different from from everyone everyone else. aa regulated else. O n the the other other hand, she came came to to realize realize that that the the unpredictability unpredictability and and social On hand, she social stimulation she she craved craved was was like like a a drug. drug. She She usually had a a ""mood m o o d hangover" hangover" stimulation usually had the next day. the next day. There is is comfort comfort in in knowing knowing that that you you are are doing doing something something proactive proactive to There lO manage manage your your disorder. disorder. You Y o u will will almost almost certainly certainly see see benefilS benefits in in terms terms of of your your m o o d stability stability and and productivity productivity when w h e n you you structure structure your days and and nights. your days nights. mood With time, time, a a regulated regulated routine will give give you you a a sense sense of of security security and and control control With routine will over your your fate. over fate. Even apart apart from from the the issue issue of of mood m o o d stabilization, stabilization, some some of of my m y clients clients find Even find that social social rhythm rhythm tracking tracking helps helps them them manage manage their their disorder disorder and and lifestyle lifestyle in in that ways they they hadn't hadn't expected. expected. For For example, example. Cannen, Carmen, age age 29, 29, found found that that SRM SRM ways tracking helped helped remind remind her her to take her her medication, medication, which which until untd that thatpoint pointhad had tracking to take been haphazard haphazard and and unpredictable. unpredictable. After After filling filling out out his his chart chart for for several several been weeks, Arthur, Arthur, 35, 35, observed observed that "I have have a a habit habit of of jamming jamming in too many many weeks, that "I in too things to to avoid avoid depression, depression, but butthen then IIget getlike likeaacar carthat's that'srun runout outof ofgas. gas.I 1 want things want contact with with people, people, but but II can get to to the the poim point where where I'm I'm doing doing too much. II contaC[ can get too much. need some some more more conSistency, consistency, and and I1 need need not not to to be be constantly constantly overstimulated overstimulated need and running away from and running away from myself." myself."

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It is not only people with mood disorders who have stay regular, It is not only people with mood disorders who have to to stay onon regular, schedules. Parents Parents usually usually need need to to follow very predictable rou­ regimented schedules. follow very predictable rouregimented tines to to manage manage the the daily daily activities activities of of their their children. children. Athletes Athletes need need to to stick stick to to tines well-regulated training training schedules. schedules. People People w who become expert expert performers, performers, well-regulated h o become such as accomplished accomplished professional such as often developed professional musicians, musicians, have have often developed highly highly regimented craft (for example, Krampe Krampe regimented routines routines to to help help them them accomplish accomplish their their craft (for example, & Ericsson, Ericsson, 1996). 1996). &

Nonetheless, regimented routine too stifling, discuss Nonetheless, if if you're you're finding finding a a regimented routine too stifling, discuss this with doctors. There There may m a y be be compromises compromises that can be be made. Perhaps this with your your doctors. that can made. Perhaps your you can can identify identify the the point at which whichfluctuating point at fluctuating routines routines negatively negatively affect affect your you mood. For For example, your bedtime bedtime m may make mood. example, a a 30-minute 30-minute departure departure from from your ay m a k e no no difference, difference, but but 90 90 minutes minutes might might make m a k e aabig bigdifference. difference.Try Try to tosee seeif ifyou youcan can identify the the range range of offluctuation in routines routines within within which which you you can can function function identify fluctuation in and stable. and still still feel feel stable.

"OK, "OK, Now N o w Tha' That I'm I'm Going Going '0 to Bed Bed on on Time, Time, How H o w 00 D o II F." Fall Asleep?" Asleep?" toss and and turn, turn, look look at at the "I"I toss the clock, clock,sneer sneerand and snort snortthrough throughmy my nose, nose, walk around around the the house house .... do my m y yoga, yoga, do do my m y meditation, meditation, turn turn on on Ameri­ Ameriwalk . . do can . , but I still can't sleep. It irks end can Gladiators Gladiators ... . ., but I still can't sleep. It me irkstom no e to no that end my thatwife m y wife can can just just lie lie down d o w n and and she's she'sout. out.IIalmost almostwant wanttotowake wakeher herup uptotomake m a k eher her suffer like Hke II am, a m , but but II don't. don't. .... It goes goes like Hke this this every every night, night, and and then, suffer . . It then, of of course, I'm a wreck at work the next day." course, I'm a wreck at w o r k the next day." — A 51 51-year-old m a n with with rapid rapid cycling cycling bipolar bipolar disorder disorder -A -year-old man For For somesome bipolar people, getting totobed time isn't isn't main bipolar people, getting bedatatthe the right right time thethe main problem. The T h e problem problem is is falling falHng asleep asleep and and staying staying asleep. asleep. There There is is nothing nothing problem. more more frustrating frustrating than than lying lying awake awake and and trying trying to to fall fall asleep. asleep. Sleep Sleep disturbance disturbance is isaakey key symprom s y m p t o m of ofbipolar bipolardisorder disorderand and sometimes sometimescan canbe beaaside sideeffect effectof ofan­ antidepressant medications. can also duetoto substances like caffeine, excestidepressant medications. I tIt can also bebe due substances like caffeine, exces­ sive sugar, tobacco, or alcohol, especially if these are ingested close to your sive sugar, tobacco, or alcohol, espeCially if these are ingested close ro your bedtime. bedtime. Your docror doctor may m a y decide decide to to give give you you medications medications for for sleep, sleep, such such as as Your Klonopin or or zolpidem Zolpidem (Ambien). (Ambien). Although Although these these medications medications often often work work Klonopin weH, not not everyone everyone likes likes to to take take them them because because you you can can become become addicted addicted or or tolwell, tol­ erant (that (that is, is,you youmay m a yneed needaabigger biggerdosage dosageover overtime timero toachieve achievethe thesame sameef­ eferant fect). Butyou you and andyour yourphYSician physicianmay m a y decide decidethat thataasleeping sleepingmedication medicationis isthe the fect) . But best best alternative alternative in in order order to to keep keep sleep sleep disturbance disturbance from from contributing contributing to to your your worsening worsening mood m o o d state. state. Fortunately, is aa literature literature on on behavioral behavioral interventions interventions for for sleep sleep there Fortunately, there is

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Ways W a y s to to Combat C o m b a t Sleep Sleep Disturbance Disturbance •

Keep stress outofof the bedroom Keep stress out the bedroom

•

Give yourself yourself time time to to unwind unwind before before sleep sleep Give

•

Never "compete" "compete" to to get get to to sleep sleep Never

•

Use muscle muscle relaxation relaxation techniques techniques Use

•

Adjust your your sleep sleep cycle cycle before before travel Adjust travel

Source:Dtw OttoctetaLal.(1999 (1999) Souru: )

p r o b l e m s . Michael M i c h a e l Otto Otto and a n d his his colleagues colleagues at at the the Harvard H a r v a r d Medical M e d i c a l SchooV School/ problems. Massachusetts General General Hospital Hospital (1999) ( 1 9 9 9 ) have h a v e developed developed rrecommendations e c o m m e n d a t i o n s for for Massachusetts w a y s to to improve i m p r o v e sleep sleep if you're suffering f r o m bipolar bipolar disorder disorder (see (see the the ways if you're suffering [rom

sidebar this page), bee applicable to sidebar on o n this p a g e ) . Some S o m e of of these these sleep sleep techniques techniques would would b applicable to people without w i t h o u t bipolar bipolar disorder disorder as as well. people well.

in the EExamples x a m p l e s of of "stress "stress in the bbedroom" e d r o o m " include include having having arguments a r g u m e n t s wwith i t h your your spouse, preparing spouse, o r k assignments for the e x t dday a y while e d , examining examining preparing wwork aSSignments for the nnext while in in bbed, yyour o u r next o r k schedule, schedule, checking a r k e t pages, checking next day's day's wwork checking the the stock stock mmarket pages, checking yyour o u r e-mail e-mail o n e last last time, time, eating eating in inbed, b e d , and a n dmaking m a k i n g last-minute last-minute phone p h o n e calls. calls. one TThese h e s e activities e avoided e d t i m e . MMore o r e generally, activities should should b be avoided right right before before bbedtime. generally, try try to to kkeep e e p the o u r just of stressful o that o u can can the last last hhour just before before sleep sleep free free of stressful activities activities sso that y you uunwind nwind a n d relax. o u r bbedroom e d r o o m ssuch u c h that and relax. If If possible, possible, try try to to arrange arrange yyour that noise noise is is blocked u t (for x a m p l e , the telephone is is (Urned turned off, off,no n o radios radios are are playing) playing) blocked o out (for eexample, the telephone or e a r earplugs. or wwear earplugs. Paradoxically, Paradoxically, activities activities that that people people often often take take for for granted granted as as necessary necessary for for falling a y actually o r eexample, x a m p l e , many many falling asleep asleep mmay actually contribute contribute to to sleep sleep disturbance. disturbance. FFor people a t c h the e w s in e d before u t the u t the news people wwatch the evening evening nnews in bbed before turning turning oout the Hghts, lights, bbut the news overstimulates h e m aand n d cranks h e m uup. p . Likewise, a n y people overstimulates tthem cranks tthem likewise, mmany people feel feel they they can't can't fall i t h o u t reading o o k , yet o m e t i m e s reading, v e n if fall asleep asleep wwithout reading a a bbook, yet ssometimes reading, eeven if it's it's only only aa novel, a n get u n n i n g in H sorts you've been been novel, ccan get the thebrain brain rrunning in aall sorts of ofdifferent different directions. directions. If If you've reading it may m a y be be hard hard to to put put down d o w n and and stop stop thinking thinking reading a a good good murder murder mystery, mystery, it about! most people people believe believe that thatregular regular exercise exercise contributes contributes to to good good about! Likewise, likewise, most sleep you out out and and relaxes relaxes your your muscles. muscles.But Butititcan canalso alsokeep keepyou you sleep because because it it tires tires you awake you exercise exercise right rightbefore beforebedtime-try bedtime—tryto togive giveyourself yourself m u c hasasthree three awake if ifyou asasmuch hours between finishing your exercises and going to bed. hours between finishing your exercises and going to bed. sleep If If you you want want to to investigate investigate which which activities activities are are contributing contributing to to your your sleep problems, problems, try try nights nights with with and and without without these these activities activities and and record record the the changes changes

How Can I1 Monoge ManageMy MyDisorder? Disorder? How (on

173 173

your mood mood chart SRM example, write on Thursday on your chart oror SRM (for(for example, write "no "no TV" TV" on Thursday night,night, on and TV" on Friday night, night, a and your sleep sleep for for each). Try to to see see if and "yes "yes T V" o n Friday n d record record your each). Try if y o u can can detect doing or doing certain activities affects detect whether whether doing or not not doing certain activities affecLS your your sleep sleep you and mood. mood. and Some people feel that falling falling asleep is like athletic competition, competition, like like S o m e people feel that asleep is like an an athletic race in in a a certain certain time. time. Being Being unable unable to to sleep sleep makes makes them them feel feel inade­ running a race inaderunning a quate anxiety" begins begins to their quate or or incompetent, incompetent, and and ·'performance "performance anxiety" to accompany accompany their altempts to to sleep. Try not not to attempts sleep. Try to think think of of your your ongoing ongoing sleep sleep disturbance disturbance as as somesome­ thing you're doing doing to to yourself, yourself, but butrather ratheras asaabiological biologicalsign signof ofyour your disorder. disorder. thing you're Rather than than wrestling with yourself about being being unable sleep, instead instead expe­ expeRather wrestling with yourself about unable to to sleep, rience physical sensations sensations of bed, including including how your body body feels, feels, rience the the physical of being being in in bed, h o w your how the covers against your h o w you you experience experience the covers over over you, you, or or how h o w the the pillow pillow feels feels against your you may head. If you have access to a relaxation tape or meditation exercises, you may head. If you have access to a relaxation tape or meditation exercises, lead to to wish to to use use these these to to help help you you experience experience the the physical physical sensations sensations that that lead wish sleep sleep (Otto (Otto et et al., al., 1999). 1999). Many fly from from the the M a n y people people have have trouble trouble sleeping sleeping when w h e n they they travel. travel. If If you you fly West West Coast Coast of of the the United United States States to to the the East East Coast, Coast, you you may m a y arrive arrivewhen w h e n every­ everyone else else is is going going to to sleep, sleep, but but for for you you it it is is three three hours hours earlier. earlier. Transatlantic one Transatlantic travel travel (for (for example, example,flying from Chicago Chicago to to Paris) Paris)is isparticularly particularly difficult difficult for for flying from people circa­ people with with bipolar bipolar disorder disorder because because there there is is such such a a dramatic dramatic shift shift in in circadian dian rhythms. rhythms. But But travel travel is is often often unavoidable. unavoidable. O n e way w a y to to combat combat this this travel travel disruption disruption is is to to gradually gradually adjust adjust your One your interinter­ nal time time clock clock to to the the new n e w place place you're you're going, going, before before you you actually actually leave. leave. So, nal So, over the the course course of of the the week w e e k before before you you travel travel to to a a later later time time zone, zone, go go to to bed bed an an over hour earlier earlier than than usual, usual, then then an an hour hour and and a a half, half, and and then then two two hours hours earlier, hour earlier, and and so so forth. forth. By By the the time time you you arrive, arrive, ititmay m a y be beeasier easierto toadjust adjustto tothe thehours hours of of the new n e w time time zone. zone. This This procedure procedure usually usually works works best best if if you'll you'll be be in in the the new new the time zone for more than a few days. time zone for m o r e than a few days. There are are other other strategies strategies you you can can use use to to improve improve your your sleep, sleep, some some of of There which go go beyond beyond our our scope. scope. If If you've you've been been having having difficulties, difficulties, consider considerread­ readwhich ing ing self-help self-help books books specifically specifically oriented oriented toward toward sleep sleep issues, issues, such such as as William Wilham Dement and and Christopher Christopher Vaughan's Vaughan's (1999) (1999) The The Promise Promise of of Sleep Sleep or or Peter Peter Dement Hauri Nights. Hauri and and colleagues' colleagues' (1996) (1996) No N o More More Sleepless Sleepless Nights.

Maintaining Well Wellness Tip No. N o . 3: 3: Avoiding Avoiding Alcohol Alcohol Maintaining ness Tip and and Recreational Recreational Drugs Drugs Ruth, a 32-year-old woman who who had just beenbeen diagnosed withwith bipolar 1 I a 32-year-old woman had just diagnosed bipolar Ruth, disorder,had hadaasevere severeproblem problemwith withdrinking drinkingthat thatusually usuallybegan beganwhen w h e n she she disorder,

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relationships was was relatively bipolarsymptoms. symptoms.Typically, Typically, romantic relationships relativelyfree free of of bipolar romantic with men with m e n or or conflict-ridden conflict-ridden business business entanglements entanglements were were the the background background of to of these these episodes. episodes. Her Her drinking drinking binges binges were were so so severe severe that that she she often often had had to be be hospitalized hospitalized and and detoxified. detoxified. She She went went through through an an Antabuse Antabuse program, program, in required to week to in which which she she was was required to come c o m e in in twice twice a a week to take take a a medication medication which which made m a d e her her vomit vomit if if she she drank. drank. But But she she quit quit this this program program and and went went back back 10 to drinking. drinking. Her Her own o w n view view was was that that her her bipolar bipolar disorder disorder was was making making her her drink. drink. Many lOTS and M a n y observers, observers, including including her her doc doctors and family family members, members, felt felt that that iit t was way around: that was the the other other w a y around: that her her drinking drinking came came first first and and led led to to her her mood m o o d cycling. cycling. She She constantly constantly complained complained of of the the pain pain of of the the mood m o o d swings swings and their their associated associated anxiety, anxiety, but but her her symptoms symptoms co-occurred co-occurred so so consisand consis­ tently tently with with drinking drinking that that it it was was difficult difficult to to tell tell which which were were due due to tothe thebi­ bipolar disorder disorder and and which which to to the the alcohol. polar alcohol. During During one one interval, interval, Ruth Ruth became became convinced convinced that thatshe sheshould shouldgive giveup up alcohol alcohol and and stayed stayed abstinent abstinent for for almost almost six six months. months. Her Her bipolar bipolar swings swings were were much m u c h improved improved during during this this interval: interval: She She still still had had aa mild mild depression depression but mixed symptoms. but no no mania mania or or mixed symptoms. She She was was able able to to obtain obtain a a regular regular waitressing job and and began began functioning functioning better better than than she she had had in a long long time. waitressingjob in a time. During this this period period of ofrecovery, recovery,however, however,Ruth Ruthcame cameto tothe theconclusion conclusion During that she she had had no no real real problem problem with with drinking. drinking. She She began began to to reinterpret reinterpret her her that past almost terms of new past almost exclUSively exclusively in in terms of her her n e w bipolar bipolar diagnosis, diagnosis, denying denyingany any causal influence influence of of alcohol. alcohol. For For example, example, she she labeled labeled her alcohol causal her past past alcohol binges as as -rapid "rapid cycling" cycling" and and ··self-medicating." "self-medicating." She She reasoned reasoned that that she she binges wouldn't again again lose lose control control of of her her drinking drinking since since her her m o o d disorder disorder had had wouldn't mood become stable. become stable. About About five five months months into into her her period period of of abstinence, abstinence, she shetraveled traveledto toPalm Palm Springs for for a a weekend weekend with with her her new n e w boyfriend. boyfriend. Quite Quite deliberately, deliberately,she shedis­ disSprings continued her her Antabuse Antabuse program program five five days days before before the the trip. trip. Within Within one one continued week she she was was back back in in the the hospital hospital in in need need of of detoxification. detoxification. Her Her depresweek depres­ sion was was much m u c h more more severe severe upon her hospital and she she ension upon her hospital discharge, discharge, and en­ rolled, once once again, again, in in the the Antabuse Antabuse program. program. rolled,

Alcohol Alcohol and and Drugs: Drugs: What What Are Are the the Risks? Risks? Most psychiatrists and psychologists agree you bipolar have bipolar disorder, Most psychiatrists and psychologists agree that that if youifhave disorder, you should should avoid avoid alcohol alcohol and and recreational recreational drugs drugs altogether. A s IItalk talkabout aboutin in you ahogether. As Chapter 5, alcohol and and drugs drugs interfere interfere with with the the effects effects of of your your medication medication and and Chapter 5, alcohol worsen the the course of your your illness illness (for (for example, example, Sonne Sonne & & Brady, Brady, 1999; worsen course of 1999; Strakowski et et aI., al., 2000). 2000). If If you you use use alcohol alcohol and and drugs, drugs, you you are are likely likely to to bebe­ Strakowski come inconsistent inconsistent with with your your medicat medication regimen and and will have more come ion regimen will have more trouble trouble becoming stable stable as as a a result result (Keck (Keck et et aI., al., 1998; 1998; Strakowski Strakowski et etaI., al.,1998). 1998).Worst Worst becoming

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of alcohol and drug useuse puts youyou at aatmuch greater risk risk for committing of all, all, alcohol and drug puts a much greater for committing

suicide Oamison, (Jamison, 2000b; 2000b; see see also also Chapter Chapter 111). 1). suicide Some S o m e doctors doctors will will tell tellyou you that thatyou you can candrink drinkalcohol alcoholin invery very small smallquanti­ quanti-

ties (for (for example, example, a a single single glass glass of of wine wine with with dinner). dinner). There There may m a y be people ties be people honest, II with bipolar bipolar disorder disorder who w h o can can do do this this and and stay stay stable, stable, but, but, to to be be honest, with

drinking at at all all k n o w very very few. few. II tend tend to to take take the the more more extreme extreme view view that that not not drinking know and not not using using any any drugs drugs (including (including marijuana) marijuana) is is one one of of the the best best ways to main­ mainand ways to tain wdlness. wellness. People People with with bipolar bipolar disorder disorder are are quite quite strongly strongly affected-in affected—in tain terms certain terms of of their their mood m o o d stability stability and and behavior-by behavior—by even even small small amounts amounts of of certain substances substances (see (see ChapLer Chapter 5). 5). This This is is especially especially the the case case if if they theyindulge indulge in in alco­ alco-

hol or or drugs drugs when w h e n their their mood m o o d states states are are already already starting starting to to fluctuate. fluctuate. hol Many M a n y bipolar bipolar people, people, like like Ruth, Ruth, have have a a codiagnosis codiagnosis of of alcohol alcohol or or drug drug

abuse or or dependence dependence (the (the "dual "dual diagnosis" diagnosis" situation). situation). People People with dual diagabuse with dual diag­ noses become abstinent, noses must must learn learn to to become abstinent, because because the thetwo two disorders disorderscan can worsen worsen each each other, other, much m u c h as as they they did did for for RUlh. Ruth. If If you you have have previously previously had had problems problems

with alcohol alcohol or or drugs, drugs, consider consider joining joining a a 12-step 12-step program program such such as Alcoholics with as Alcoholics Anonymous A n o n y m o u s (as (as Ruth Ruth did) did) or or Narcotics Narcotics Anonymous. A n o n y m o u s . These These groups groups can can serve serve

as powerful powerful resources resources in in helping helping people people maintain maintain abstinence. abstinence. If If you you don't don't like like as groups, example, moti­ groups, 12-step 12-step and and other other programs programs for for addictive addictive behavior behavior (for (for example, moti-

vational vational interviewing; interviewing; Miller Miller & & Rollnick, Rollnick, 2002) 2002) can can often often be be obtained obtained on on an an individual basis. individual therapy therapy basis.

Spencer, age age 45, 45, fought fought his his desire desire to to drink drink for for many m a n y years. years. However, However, Spencer, through couples' couples' educational educational therapy therapy sessions sessions about about his his disorder disorder and through through and through m o o d charting, charting, he he learned learned to to recognize recognize his his signs signs of of mood m o o d cycling: cycling: subtle subtle inmood in­ creases in in irritability irritabihty and and anger, anger, lethargy, lethargy, and and insomnia. insomnia. During During these these cycling creases cycling intervals, he he learned learned to to drink drink nonalcoholic nonalcoholic beer beer when w h e n he he was was with intervals, with his his wife wife and friends friends who w h o were were drinking. drinking. He H e eventually eventually gave gave up u p drinking. drinking. He H e summa­ summaand rized rized his his experience experience this this way: way:

"I�lused be aa two-drink-a-night two-drink-a-nightperson, person, every night, for many years. usedto to be every night, for many years. I fi­ I finally came came to to the the conclusion conclusion that that II just just couldn't couldn't do do it. it. It It wasn't wasn't some some nally moral thing, thing, ititwas wasactually actuallyjust justaasimple simpledecision decisionthat thatdrinking drinkingcreated createdaa moral state in in me m e that that was was miserable. miserable. For For two two days days after after drinking drinking even even just state just small amounts amounts II would would feel feel irritated irritated with with everybody, everybody, emotionally emotionally exsmall ex­ hausted, and and want want to to sleep sleep all all day. day. The The price price 1I was was paying paying was was too too high. high. hausted, But before before II could could quit, quit,1 I hadtoto have hard evidence that alcohol waswors­ worsBut had have hard evidence that alcohol was ening my m y life, Hfe, that that it itwas was something something IIdidn't didn'tneed needtotodo dototomyself. myself.1 Ifinally finally ening saw alcohol alcohol as as a a big big contributor contributor to to my m y anger anger and and my m y problems problems with peosaw with peo­ ple. Without Withoutalcohol, alcohol,I I can decide I want to w o ron k on y anger; t's withple. can decide ifif I want to work mymanger; it'siwith­ in my m y power power to to do do so. so. With With alcohol, alcohol, the the anger anger just just takes takes me m e over." in over."

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Beliefs aboutOri.ki." Drinking, Drug Abuse, and Bipolar Disorder B./i.,s about Drug Abuse, a.d Bipo/ar Disorder

and bipo­ People oftenhave havemistaken mistakenbeliefs beliefs about alcohol, substances, and bipoPeople often about alcohol, drug drug substances, lar page. lar disorder. disorder. Some S o m e of of these these are are listed listed in in the the sidebar sidebar on on this this page. I've I've heard heard people people with with bipolar bipolardisorder disorder claim claim that thatmarijuana marijuana or or cocaine cocaineis is just as as effective effective as as a a mood m o o d stabilizer stabilizer such such as as Depakote Depakote in in controlling controlling their just their mood m o o d states. states. They They argue argue that thatalcohol alcoholcalms calmsthem them down, d o w n ,or orreduces reducestheir theiranxi­ anxiety, their depression; they argue that marijuana their ety, or or improves improves their depression; they argue that marijuana boosts boosts their m o o d when w h e n they they are are depressed. depressed. One O n e patient patient said, said, "For "For me, m e , alcohol alcohol is is like like the the mood ropes ropes that keep the the hot air balloon balloon from going up up .. .. .. and and on on the other side side is is that keep hot air from going the other like like a a disguise disguise covering covering over over the the depreSSion." depression." S o m e people people do do drink drink or or use use drugs drugs to to make m a k e themselves themselves feel feel better, better, but but Some whether whether these these substances substances are are really really doing doing the the trick-as trick—^as opposed opposed to to making making their m o o d s worse-is worse—is another another question. question. We W e know k n o w that that alcohol alcohol worsens worsens detheir moods de­ pression (as (as in in the the examples examples given given above) above).. People People who w h o have have both both bipolar bipolar dispression dis­ order and and alcohol alcohol problems problems also have more more rapid rapid cycling, cycling, mixed mixed symptoms, symptoms, order also have and anxiety anxiety or or panic panic than than those those who w h o do do not drink. Alcohol Alcohol can can also also interfere and not drink interfere with which can with sleep, sleep, which can worsen worsen mania. mania. People often often assume, assume, as as Ruth Ruth did, did, that that their their depression depression came came first first and and that that People they use use alcohol alcohol or or drugs drugs for for the the purpose purpose of of self-medicating self-medicating this this depression. they depression. For many m a n y people people with bipolar disorder, disorder, however, however, the the alcohol alcohol abuse abuse precedes precedes For with bipolar the depression depression rather rather than than the the reverse reverse (Strakowski (Strakowski et et aI., al., 2000). 2000). For For some, some, a a the vicious cycle cycle lakes takes over: over: They They drink drink heavily heavily and and get get depressed depressed and and anxious, vicious anxious, then stop stop drinking drinking and and experience experience a a recurrence recurrence of of depression depression or or panic panic symp­ sympthen toms that that is is attributable attributable to to the the alcohol alcohol withdrawal. withdrawal. Then T h e n they they try try to to selftoms self­ medicate these these mood m o o d symptoms symptoms with with more more alcohol. alcohol. This This pattern makes the the medicate pattern makes course of of both disorders much m u c h worse. worse. course both disorders Marijuana, although although perhaps perhaps not not as as toxic toxic for for bipolar bipolar persons persons as as alcohol, Marijuana, alcohol, can also also be be detrimenlal detrimental to to your your mood m o o d stability. stability. In InStrakowski Strakowskiand andcolleagues' colleagues' can

Mistaken Beliefs about Bipolar Disorder Disorder Mistaken Beliefs about Bipolar a n d Alcohol or Drug D r u g Abuse Abuse and Alcohol or • Alcohol Alcohol or or drugs drugscan canbebeused usedasas moodstabilizers stabilizers mood

•

• Hard Hard drugs drugs like like amphelamine, amphetamine, LSD, LSD, or or cocaine cocaine can can be be used used

•

as antidepressants antidepressants as • Substances Substances cannot cannot worsen worsen your your disorder disorder if if your your mood m o o d has has • been stable been stable

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study study (2000), (2000), marijuana marijuana use use was was associated associatedwith withmanic manicsymptoms, symptoms, whereas whereas alcohol put it alcohol use use was was associated associated with with depressive depressive symptoms. symptoms. One O n e patient patient put it this this way: "Marijuana "Marijuana makes makes me m e think think and and think think and and think, think, and and then then it it keeps keeps me me way: from from sleeping. sleeping. It's It's like likeaacatalyst catalystfor forsomething something in inme." me."Marijuana Marijuana can can also also in­ into remem­ terfere with with your your attention attention and and concentration concentration as as well well as as your your ability ability to rememterfere ber find it ber to to take take your your medication. medication. Some S o m e people people find it makes makes them them lethargic lethargic and and unmotivated. unmotivated. Rationalizing Rationalizing their their heavy heavy drug drug use, use, some s o m e people people claim claim that that L S D ("acid"), LSD ("acid"), amphetamines antide­ amphetamines (speed), (speed), cocaine cocaine (or (or "crack"), "crack"), and and "Ecstasy" "Ecstasy" are are really really antidepressants. a pressants. They They argue argue that that these these drugs drugs can can help help their their depression depression more more than than a standard standard antidepressant antidepressant such such as as Prozac. Prozac. Some S o m e even even know k n o w about about studies studies show­ showing ing that that LSD L S D stimulates stimulates the the action action of of certain certain serotonin serotonin receptors receptors or or that that am­ amantidepres­ phetamine phetamine stimulates stimulates and and prolongs prolongs dopamine dopamine activity, activity, as as some some antidepressants do. But they are misinterpreting the clinical implications of these these sants do. But they are misinterpreting the clinical implications of studies. Even Even though though many m a n y street street drugs drugs do do affect affect the the same same neurotransmitter neurotransmitter studies. systems stability. systems as as antidepressants, antidepressants, street street drugs drugs do do not not produce produce true true mood m o o d stability. Instead, neuronal activity Instead, they they tend tend to to produce produce short-term short-term bursts bursts of of neuronal activity accompa­ accompanied by by elation elation or or irritability irritability (much ( m u c h like like mania mania or or hypomania), hypomania), rather rather than than nied truly truly alleviating alleviating depression. depression. Some elated S o m e people people with with bipolar bipolar disorder disorder use use substances substances to to intenSify intensify the the elated and and grandiose grandiose aspects aspects of of their their hypomanic hypomanic or or manic manic states. states. They They feel feeldriven drivento­ toward further further stimulation stimulation and and novelty. novelty. Cocaine Cocaine and and amphetamine amphetamine are are espeespe­ ward cially likely likely to to be be used used in in this this way. way. The The result result is is often often a a severe severe increase in increase in cially manic or or mixed mixed symptoms, symptoms, or or the the initiation initiation of of rapid rapid cycling cycling states states leading leading to manic to hospitalization. hospitalization. Y o u may m a y believe believe that that taking taking alcohol alcohol or or drugs drugs is is fine fine as as long long as as you you have have You been feeling feeling well well for for a a period period of of time. time. This This was was Ruth's Ruth's logiC, logic, and and she she tested testeditit been frequently by by going going "off "off the the wagon" wagon" whenever whenever she she had had a a period period of of mood m o o d stafrequently sta­ bility. For Forher, her,ordinary ordinarylife lifeseemed seemedvery verydrab. drab.The The up u p and and down d o w n periods periodsthat that bility. alcohol brought brought were were somehow s o m e h o w preferable preferable to to feeling feeling that that life lifehad had become become ordi­ ordialcohol nary nary and and boring. boring. Many M a n y people people whose whose bipolar bipolar disorder disorder is is stable stable report that al­ alreport that cohol and and drugs drugs provide provide a a relief relief from from their theirfeelings feelingsof ofemptiness. emptiness.But But it itisisonly only cohol a a temporary temporary relief, reHef,as asthese thesesubstances substancestrigger triggernegative negativemood m o o d states statesthat thatare arefar far more more unpleasant unpleasant than than boredom. boredom. The exercise exercise on on page page 178 178 may m a y help help you you identify identify what what makes makes you you want want to The to drink drink or or use use drugs drugs (after (after McCrady, McCrady, 2001). 2001). Its Its purpose purpose is istotohelp helpyou youidentify identify • Triggers • Triggers forfor use (for with people peoplewhom whom you imuse (forexample, example, being being with you want want to to im­

press) press) • The T h e feelings feelingsyou you want want to to alleviate alleviate (for (formany m a n y people people with with bipolar bipolar disor­ disor• der, der, depression depression or or anxiety) anxiety)

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A MAINTAINING M A I N T A I N I N G WELLNESS W E L L N E S S EXERCISE: EXERCISE: A IDENTIFYING TRIGGERS T R I G G E R S FOR F O R ALCOHOL A L C O H O L AND A N D DRUG D R U G ABUSE, ABUSE, IDENTIFYING YOUR Y O U R RESPONSES R E S P O N S E S TO TO T H O S E TRIGGERS, TRIGGERS, A ND T H E CONSEQUENCES CONSEQUENCES THOSE AND THE List the thetype typeofofalcohol alcohol drug you use mostfrequently frequently (examples: List or or thethe drug you use most (examples: beer,beer, wine,wine, marijuana, marijuana, cocaine). cocaine).

List List the the situations situations in in which which you you are are most most likely likely [0 to get get drunk drunk or or high high (examples: (examples: being being alone; afternoon after work; with specific people). alone;being being out outwith withfriends; friends;parties; parties;Friday Friday afternoon after work; with specific people).

List feelings you List the the/eelings you ordinarily ordinarily have have right right before before you you drink/get drink/get high high (examples: (examples: depressed, depressed, anxious, anxious, irritable, irritable, excited). excited).

Describe Describe your your expectations expectations about about what what this this drink/drug drink/drug will will do do for for you you (examples: (examples: it it will will

make me m e relax relax and and ease ease up up with with people; people; help help me m e deal deal with with difficult difficult situations; situations; decrease decrease make m y depression; depression; help help me m e sleep; make me m e think think more more clearly), clearly). my sleep; make

Describe the the actual actual consequences consequences of of your your drinking/drug drinking/drug use use the the last last few few times. times. Try Try to to Describe

distinguish (1) (1)what whathappens happensimmediately immediatelyafter afteryou youdrink/get drink/gethigh high(examples: (examples:relaxed relaxedme, me, distingUish got me m e into into an an argument, argument, alleviated alleviated my m y depression, depression, made made me m e feel feelmore moresocial) social)versus versus (2) (2) got the delayed delayed eff effects (made me m e feel feelmore more depressed depressed the thenext nextday, day,had hadhangover, hangover,got gottoto work the ects (made work late). late). Immediate effects: effects: Immediate

Delayed effects: Delayed effects:

-------� -----

•r)fSS-WKW>5WJ«8aM

How (on Can I I Manage Disorder? How Manage MyMy Disorder?

179 179

• Your expectations • Your expectations •

• The T h e immediate immediate consequences consequences of of using using the the drug/alcohol drug/alcohol (for (for example, example,

feeling feeling relaxed, relaxed, feeling feeling more more confident, confident, forgening forgetting your your medications) medications) • • The T h e extended extended or or delayed delayed consequences consequences of of use use (for (for example, example, sleep sleep dis­ disturbance, turbance, missing missing work w o r k the the next next day, day, feeling feeling irritable, irritable, drowsy, drowsy, or or anx­ anxious several several days days later) ious later) drinking or or drug useuse as one event in a in sequence of of In other otherwords, words,think thinkofof drinking drug as one event a sequence In events rather rather than than a a singular, singular,isolated isolatedact. act.Then T h e nyou'll you'Hbe bein ina aposition positiontotothink think events about changing changing this this sequence. sequence. For For example, example. Amy A m y learned learned to toavoid avoid certain certain situ­ situabout ations and and people people who, w h o , she she believed, believed, made m a d e her herdrink drinkmore. more.Earl, Earl,who w h osmoked smoked ations marijuana heavily, heavily, learned learned to to plan plan things things for for times times of of the the day day when w h e n he he was was marijuana most finished his classes). most likely likely to to get get high high (typically (typically late late afternoons afternoons after after he hefinished his classes). Bethany depressions. Bethany learned learned to to challenge challenge her her belief behef that that alcohol alcohol alleviated alleviated her her depressions. When W h e n she she systematically systematically evaluated evaluated the the results results of of her her drinking, drinking, she she concluded concluded that that she she felt felt bener better at atfirst firstbut butmore moreirritable irritableand anddepressed depressedlater. later.She Shebegan begantoto think problems. think of of alcohol alcohol as as a a cause cause rather rather than than an an effect effect of of her her mood m o o d problems.

Maintaining Maintaining Wellness Wellness Tip Tip No. N o . 4: 4: Relying Relying on on Social Social Supports Supports Candace, a 49-year-old woman withwith bipolar II IIdisorder, sufferedfrom froman an Candace, a 49-year-old woman bipolar disorder, suffered ongoing depreSSion depression that that was was not not alleviated alleviated by by antidepressants antidepressants or or mood mood ongOing stabilizers. After After becoming becoming frustrated frustrated with with the the myriad myriad of of medications medications she she stabilizers. had tried, tried, she she consulted consulted a a psychotherapist, psychotherapist, who w h o observed observed that that she she was was had quite quite SOcially socially isolated: isolated: She She had had broken broken up u p with with her her boyfriend boyfriend two two months months earlier, she she had had few few new n e w friends friendsor oreven even acquaintances, acquaintances,and and she she had had be­ beearlier, c o m e disconnected disconnected from from her her parents parents and and her her two two sisters. sisters.Her Her therapist therapisten­ encome couraged her her to to try try some s o m e new n e w social social activities, activities,which whichshe shestrongly stronglyresisted resisted couraged doing. Her Her weekends weekends were were largely largely spent spent alone alone in in her her apartment, apartment, where where doing. "my alive." " m y thoughts thoughts eat eat me m e alive." Candace had had few few hobbies hobbies in in her her current current life life but but had had played played soccer soccer in Candace in college. With With some s o m e reluctance, reluctance, she she joined joined a a group group who w h o played played soccer soccer on on college. weekends. She She felt felt awkward awkward at at first. first."They're "They're not not my m y kind kind of of people," she weekends. people," she observed. At At the the beginning beginning she she had had to to force force herself herself to to go. go. little Little by by little, observed. little, however, she she found found that that her her weekends weekends became became more more structured structured because because however, of the of the the soccer soccer practices. practices. Although Although she she never never admitted admitted to to enjoying enjoying the m e m b e r s of of the the team, team, she she did did notice notice that that her her mood m o o d brightened brightened w h e n she she members when participated in in an an activity activity with with them. them. At At first first she she thought thought this this was was due due to participated to physical exercise, exercise, but butshe she found found that thather her mood m o o d also alsobrightened brightened when w h e n she she physical went to to pot-luck pot-luck dinners dinners or or movies movies at at the the team team members' members' houses. She went houses. She eventually disclosed disclosed her her illness illness to to a a few few of of her her teammates, teammates, who w h o "weren't "weren't eventually

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fazed fazed like I Ithought be."With Withtime, time, group became a second thoughtthey'd they'd be. thethe group became likelike a second like family to to her, her, and and she shebegan began dating dating one one of ofthe themen. m e n .After After playing playingwith with the the family learn acknowledged in that team for for six six months, months, she she acknowledged in one one of of her her therapy therapy sessions sessions that her chronic chronic depression, depression, while while still present,was was nOl not as asbad bad as asit ithad hadbeen been her still presem, before before she she had had made m a d e these these connections. connections. n

Social Social support—feeling emotional connections with people with whom support-feeling emotional connections with people with whom

one regularly regularly interacts-is interacts—is an an important important protective protective factor factor against one against depression. depression. Sheri Johnson and her her colleagues colleagues found found that that after after an an episode episode of of depreSSion, depression, Sheri Johnson and people with with bipolar bipolar disorder disorder who w h o had had good good social social support support systems systems recovered recovered people more had less pe­ more qUickly quickly and and had less severe severe depression depression symptoms symptoms over over a a six-month six-month period riod than than those those with with small small or or nonexistent nonexistent support support systems systems Qohnson al., Oohnson et et al.,

1999). depres­ 1999). Similar Similar findings findings have have come c o m e from from studies studies of of people people with with major major depres-

sion (for (for example, example. Brown Brown & 61 Harris, Harris, 1978). 1978). In In other other words, words, having a group group of of sion having a people well, whom people you you know k n o w well, w h o m you you trust trustwith with knowing knowing abom aboutyour your bipolar bipolardis­ disorder, whom some regularity bener in in order, and and w h o m you you see see with with some regularity will will help help you you do do better terms terms of of the the cycling cycling of of your your disorder. disorder.

You may m a y be be a a person person who w h o seeks seeks our out others others naturally, naturally, or or you you may m a y prefer You prefer spending time time by by yourself. yourself. Either Either way, w h e n you're you're depressed, depressed, it it is is hard hard to spending way, when to interact with with anybody. anybody. Unless Unless you you have have a a social social support support system system in in place place when when interact you're you're well, well, you you may m a y find finditithard hardto toreach reachout outfor forthe thevery veryhelp helpyou youneed needwhen when

depression strikes. strikes. Likewise, Likewise, maintaining maintaining regular regular contact contact with your social depression with your social

support group group when w h e n you're you're well well will will do do m u c h to to prevent prevent future depression. support much future depression. W h e n you you encounter encounter the the inevitable inevitable conflicts conflicts that that come c o m e up u p with with family family mem­ memWhen bers or or coworkers, coworkers, your friends and and supportive supportive relatives relatives can can be be like like a a landing landing your friends bers

pad for for comfort comfort and and steadiness. steadiness. They They provide provide a a counterpart counterpart to, to, and and minimize minimize pad the impact of, stressful stressful conflicts. the impact of, conflicts. don't want want 1O to overSimplif oversimplify things by by implying implying that that just just having having people people 1I don't y things around around you you is is all all that that counts. counts. As As II discussed discussed in in Chapter Chapter 5, 5, high high levels levels of of concon­ flict withcertain certain membersofof yourcore core circle, particularly family members, flict with members your circle, particularly family members, can be be associated associated with with a a more more difficult difficult course course of of your your illness. illness. It It is is empathiC, empathic, can give-and-take relationships relationships with with members members of of your your core core circle, circle, and and just just plain give-and-take plain low-key social social time, that will will best protect you you from from depression. depression. Needless Needless to time, that best protect to low-key say, that won't always be possible. Chapter 12, on family and work relationsay, that won't always be possible. Chapter 12, on family and work relation­ ships, will will acquaint acquaint you you with with skills skills to to help help you you maximize maximize the the positive ships, positive influinflu­ ences of of your your social social support support system. system. ences Your Core CCircle Your Core ircle

keep­ As you'll you'll see in the chapters, your supports social supports can be in kee As see in the nextnext chapters, your social can be critical in critical

ing your your illness illness from from cycling out of of control. control. But Butfirst, let's identify identify who w h o these these ing cycling out first, let's people people are. arc.

How How Can Con IIMonaga ManageMy MyDiSOfdet? Disorder?

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Complete the exercise that follows, " Identifying Your Core Circle." You Complete the exercise that foUows, "Identifying Your Core Circle." You may people, the m a y be b e surprised surprised at at your y o u r list! list! For For some s o m e people, the core core circle circle consists consists of of members m e m b e r s of of a a church church or or synagogue, synagogue, or or a a group group devoted devoted to to a a particular particular hobby hobby

(as and (as was w a s the the case case for for Candace). Candace). Other Other people people regularly regularly rely rely on on a n d socialize socialize with just a few few friends friends or or family family members. m e m b e r s . IIt isn't simply simply the the number n u m b e r of of people people just a t isn't with the quality in your your life Hfe that that protects protects you y o u from from a a drop drop in in your your mood m o o d but but the quaHty of of in

these relationships relationships and a n d the the regularity regularity of of the the contact. contact. these

IDENTIFYING IDENTIFYING YOUR Y O U R CORE C O R E CIRCLE CIRCLE

Listallall of people the people you consider/riends—those whomfeel youyou feel can in confide List of the you consider friends-those whom you canyou confide (talk in (talk to, to,get getemotional emotionalsupport supportfrom) from)and andwho w h o you yousee seeor orhave havephone phonecontact contactwith withat atleast leastonce once

a week. week. List List their their phone phone numbers numbers in in the the second second column. column. a

List which which/amily members you you see see regularly regularly and and feel feel comfortable comfortable confiding confiding in. in. List Listtheir their List family members

phone numbers numbers in in the the second second column. column. phone

If you you were were ever ever in in trouble trouble (for (for example, example, having having a a medical medical emergency) emergency) and and needed needed If somebody to to help help you, you, whom w h o m would would you you be be most mostlikely likelyto tocontact contactand and in inwhat what order order (list (list somebody them in in order order of ofpreference, preference,from fromfirst firsttotofourth)? fourth)?List List their phonenumbers numbersininthe thesecond second them their phone column. column.

Are Are there there any any groups groups of of people people who w h o could could help help you you feel feel less less lonely lonely or or assist you if you assist you if you

were having having any any kind kind of of emergency emergency (examples: (examples: church church or or synagogue synagogue groups, groups, support support were

groups like like Alcoholics Alcoholics Anonymous, Anonymous, groups groups dedicated dedicated to to certain certain activiti activities—art, cooking, groups es-art, cooking, foreign foreign languages, languages, or or sports) sports)

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Maintaining While Avoiding Alcohol or Drugs MaintainingFriendships Friendships While Avoiding Alcohol or Drugs

What if your social socialcircle circle is that one relies that relies on or alcohol drugs? DisWhat if your is one heavily heavily on alcohol drugs?orDis­ pensing with negative pensing with alcohol, alcohol, marijuana, marijuana, or or hard hard drug drug use use can can indeed indeed have have negative social out with their social implications. implications. For For example, example, some some people people find find it it hard hard to to go go out with their friends (this was friends without without drinking drinking (this was the the case case for for Amy). A m y ) . Some S o m e say say [hat that their their friends their efforts these problems con­ friends devalue devalue their efforts to to Slay stay sober. sober. If If these problems apply apply to to you, you, consider one or Do sider discussing discussing your your dilemma dilemma with with one or more more trusted trusted friends. friends. D o they they un­ understand abom about your your disorder disorder and the likely likely impact impact of of alcohol alcohol or or drug drug use? use? derstand and the If friends, If you're you're not not comfortable comfortable disclosing disclosing the the disorder disorder to to any any of of your your friends, consider consider giving giving other other justifications justifications for for why w h y you you don't don't want want to to drink. drink. Many Many people today today respect respect any any measure taken to to improve improve physical and mental mental people measure taken physical and health and and fitness, fitness, so so saying sayingyou're you're trying trying to tolose loseweight, weight,or or that thatdrinking drinking at at health (0, or out when night discourages discourages you you from from getting getting up up and and working working out w h e n you you want want to, night or that you drink you need that when w h e n you drink you you don't don't have have the the mental mental sharpness sharpness you need at at work work the next next day, day, might might keep keep them them from from pushing pushing you you further. the further. Many so­ M a n y of of my m y clients clients repoTl report lhat that giving giving up up alcohol alcohol or or drugs drugs does does make m a k e soCializing however, experience cializing with with cenain certain people people more more awkward. awkward. Very Very few, few, however, experience outright rejection rejection if if their their friends friends understand understand their their motivations: motivations: They They are are aboutright ab­ staining or staining out out of of a a desire desire to to take take care care of of their their health-rather health—rather than than to to judge judge or place themselves themselves above above others. place others. *

*

*

Think about about managing managing your your disorder disorder in in stages. stages. Some S o m e techniques techniques are are best Think best applied w h e n you're well (this (this chapter), chapter), and and olhers, others, during during various various phases phases of of when you're well applied your illness (Chapters 9-11). 9-11). In In previous chapters II emphaSize emphasize the the imporyour illness (Chapters previous chapters impor­ tance of maintaining consistency with your medication regimen and with your tance of maintaining consistency with your medication regimen and with your psychotherapy sessions. sessions. The strategies covered covered in chapter for for maintaining maintaining psychotherapy The strategies in this this chapter wellness—mood chaning, charting, keeping regular sleep-wake sleep-wake routines, routines, avoiding avoiding alwellness-mood keeping regular al­ of cohol and and drugs, drugs, and relying on social supports-can supports—can enhance enhance the the effects effects of cohol and relying on social your psychiatric treatments in keeping your m o o d stable. In the next three your psychiatric treatments in keeping your mood stable. In the next three chapters you'll see how h o w the the lifestyle lifestyle management management techniques techniques discussed discussed here here chapters you'll see down­ can be adjusted w h e n you feel your m o o d s start to spiral upward or downcan be adjusted when you feel your moods stan to spiral upward or ward. ward.

9 9

What W h a t Can C a n I I Do D o If If I I Think T h i n k I ' m Getting G e t t i n g Manic? M a n i c ? I'm

Roben, He'd had Robert, 45, 45, managed managed a a successful successful landscape landscape architecture architecture firm. firm. He'd had three three manic manic episodes episodes in in the the four four years years since since he he had had been been dating dating his his curcur­ rent girlfriend, girlfriend,Jessie, Jessie,with withwhom w h o mhe hewas wasnow n o wliving. living. T w oofofhis hisepisodes episodes Two rent involved hospitalizations. hospitalizations. He H e maintained maintained close close contact contact with with his two kids involved his two kids from from a a previous previous marriage, marriage, IS-year-old 18-year-old Angie Angle and and 22-year-old 22-year-old Brian. Jessie Brian. Jessie had no no children. had children. His most most recent recent manic manic episode, episode, which which had had led ledto toaahospitalization, hospitalization,in­ inHis volved an an identifiable identifiable set set of of warning warning Signs. signs. The The first firstsign sign he he reported was volved reported was becoming disimerested disinterested in in his his job job and and irritable irritable with with his his coworkers, coworkers, about about becoming w h o m he he had had become become mistrustful. mistrustful. This This was was a a difficuil difficult lime time to become diswhom to become dis­ interested; his his business business was was flourishing due to to a a new n e w housing housing developinterested; flourishing due develop­ ment project project he he had had been been involved involved in in planning. planning. During During the the earliest earliest stages stages ment of his his manic manic episode, episode, he he described described being being aware aware that that something something was was of wrong: His His thoughts thoughts began began to to race race and and he he was was full full of of great great ideas. ideas. He H e had had wrong: stillbeen beenable ableto tosleep sleepmost most of ofthe thenight, night,however, however,and andsaw sawno noneed needto tocall call still his psychiatrist. his psychiatrist. According to to jessie, Jessie,Robert Robert became became "overly "overly expressive" expressive" and and "took "took on on According this this physical physical dominance dominance stance" stance" during during the the one-week one-week interval interval prior prior to to his his hospitalization. For For example, example, he he attended attended Angie's Angle's basketball basketball g a m e and and hospitalization. game "was the the loudest loudest one one in in the the bleachers. bleachers. At At some some point point the the coach coach asked him Mwas asked him to leave." leave." On O n another another evening evening jessie Jessie and and Robert Robert had had gone gone to to a a fast-food to fast-food restaurant in which he had "barked" his order at the waitress. H e later in which he had "barked" his order at the waitress. He later restaurant apologized to to the the waitress. waitress. jessie Jessie and and Robert Robert discussed discussed his his escalating escalating apologized 183

183

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behavior and and Robert admitted thatthat he he was was being "hyper" but but alsoalso felt behavior Robert admiued being "hyper" felt good: before." good: "I'm "I'm seeing seeing things things more more clearly clearly than than ever ever before." Theyfinally call his his doctor, w h o m he seen face-toThey finally agreed agreed to to call doctor, whom he hadn't hadn't seen face-to­ face in in almost year. Robert's doctor talked talked with him by by phone phone but but didn't didn't face almost aa year. Robert's doctor with him really mood really ask ask questions questions about about his his m o o d state, state, fOCUSing focusinginstead insteadon onhis hisfeelings feelings about his work situation. situation. She She concluded concluded that that "you "you need need some some rest. rest. You You about his work sound exhausted." exhausted." No N o changes changes were recommended in in his medication rewere recommended his medication sound re­ gime, which which consisted consisted of of relatively relatively low low dosages dosages of of Depakote Depakote and and veragime, vera­ pamil p a m d (Isoptin, (Isoptin, a a calcium calcium channel channel blocker), blocker). Things took took a a turn turn for for the the worse worse when w h e n Roben, Robert, irritated irritated that that his his son son Things Brian had had not Brian not returned returned his his calls, calls, went went down d o w n 1O to the therecord record store storewhere where Brian worked. worked. He H e and and Brian Brian had had a a verbal verbal show-down show-down next next to to the the cash cash regBrian reg­ ister, involving involvingmuch m u c h profanity. profanity.Brian's Brian'sboss bossangrily angrilytold toldRobert Robertand andBrian Brian ister, to "take "take it it somewhere somewhere else." else."Brian Brian was was quite quiteupset upset and and told toldRobert Robert never never to to again. to come c o m e see see him him at at work work again. In the the next next few few days, days, Robert's Robert's behavior behavior escalated escalated dramatically. dramatically. His His In movements became became rapid and frenetic. frenetic. He H e became became angry, angry, paranOid, paranoid, and and movements rapid and fixated fixated on on grandiose grandiose notions notions about about a a music music career, career, even even though though he he had had been playing playing the the guitar guitar only occasionally, as as a a hobby. hobby. He H e bought bought an an exbeen only occaSionally, ex­ pensive Fender Fender Stratocaster Stratocaster guitar guitar but but then then impulSively impulsively traded traded it it at ataagui­ guipensive tar show show for for an an instrument instrument worth m u c h less less money. money. He H e and Jessie began began tar worth much and Jessie to have bitter arguments arguments in in which, which, according according to to Robert, Robert, "she "she took took on on this to have bitler this angry, resentful, resentful, removed removed tone tone but but also got controlling controlling and and know-il-all.� know-it-aH." angry, also got H e impulSively impulsively moved m o v e d oul out of of their their apartment apartment and and went to live live at at his his ofHe wenL to of­ fice. He H e called called her, her, in in tears, tears, one one night night to to say say he he had had begun begun to to paniC panic befice. be­ cause he he thought thought he he was was dying dying or or that that he kill himself. himself.Jessie Jessiecalled called cause he might might kill the police, police, who w h o found found him him in inhis hisoffice officestaring staringfixedly fixedlyat atthe theceiling. ceiling.They They the escorted him to a a local local state state hospital. hospital. He H e stayed stayed there there for for two two weeks weeks beescorted him to be­ fore being discharged on on a a new n e w regime regime of Depakote (at (at a a higher higher dosage) dosage) fore being discharged of Depakote and Zyprexa Zyprexa (an antipsychotic). and (an antipsychotic). A manic episode can wreak havochavoc with with a person's life. episode can wreak a person's life.ItItcan candrain drain fifi­ A manic nances, ruin ruin marriages marriages and long-term relationships, relationships, destroy destroy a a person's person's physiand long-term nances, physi­ cal health, health, produce produce legal problems, and and lead lead to to loss loss of employment. h It can can cal legal problems, of employment. even lead lead to to loss loss of of life. life. The The fall-out fall-outcan canbe belong-lasting: long-lasting:William William Coryell Coryelland and even his colleagues at at the the University University of of Iowa Iowa Medical Medical Center Center (1993) (1993) found found that that the the his colleagues five social and and job-related job-related effects effects of of a a manic manic episode episode are are observable observable for for up up to to five social years after after the the episode episode has resolved itself. years has resolved itself. Ifyou you think think back back to toyour your last lastmanic manic episode, episode,you youwill willprobably probablyrecall recallthat that If it was was quite quiteexhilarating exhilaratingat atthe thetime. time.There There may m a y be be aa pan partof ofyou you that thatwants wants to to it that re-create the the manic manic phases phases for for the the euphoric, euphoric, energized, energized, confident confident feelings feelings that re-create accompany them them (see (see also also Chapter Chapter 7). 7). When W h e n your your mood m o o d was was escalating, escalating,your your accompany thought processes processes probably probably seemed seemed very very purposeful purposeful and and brilliant brilliant to to you, you, even even thought

I'm Gening What What(an CanIIDoDoIf IIfThink I Think I'm GettMani(? ing Manic?

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highly of being feeling enjoyed probably Youprobably bizarre.You thembizarre. ifothers others found found them enjoyed the the feeling of being highly if energized energized and a n d goal-driven. goal-driven. Perhaps Perhaps you y o u even e v e n knew k n e w you y o u were w e r e getting getting manic manic but but didn't didn't want w a n t to to shut shut off off the the intoxicating intoxicating feelings. feeHngs. This This was w a s the the case case for for Rob­ Robert, as as it it is is for for many m a n y bipolar bipolar people people with with whom w h o m I've I'veworked. worked. ert, In or In retrospect, retrospect, you y o u probably probably feel feel that, that, if if it it had h a d been b e e n possible possible to to prevent prevent or at least least minimize m i n i m i z e the the damage d a m a g e associated associated with w i t h your y o u r manic m a n i c episodes, episodes, you y o u would would at have have done d o n e so. so. After After his his hospitalization, hospitalization, Robert Robert expressed expressed aa great great deal deal of of re­ reto morse m o r s e at at the the toll toll his his manic m a n i c episodes episodes were w e r e laking: taking: Jessie Jessie was w a s threatening threatening to his leave leave him, h i m , and a n d his his son s o n Brian Brian was w a s not n o t talking talking to to him. h i m . His His relationships relationships with with his employees were were damaged damaged as as well. well. employees If If you you have have not not had had full full manic manic or or mixed mixed episodes episodes but but only only hypomaniC hypomanic ones ones (that (that is, is,you youhave havebipolar bipolarIIIIdisorder), disorder),little Htdedamage damagemay m a y have havebeen beendone done during your your activated activated states. states. Nonetheless, Nonetheless, you you may m a y have have found found that that hypo­ hypoduring manic manic episodes-much episodes—much like like their their more more severe severe counterparts-bring counterparts—bring on on major major depressions depressions in in their their aftermath. aftermath. The The adage adage that that "what "what goes goes up up must must come come disorder. d o w n " applies applies only only too too well well to to the the processes processes involved involved in in bipolar bipolar disorder. down" Because Because of of their their biological biological bases, bases, you you can't can't fully fully prevent prevent future future manic manic or or hypomanic hypomanic episodes episodes from from occurring occurring altogether. altogether. But Butyou youmay m a y be be able ableto tocontrol control

learn to how how severe severe they they get get and and limit limit the the damage damage they they cause. cause. You You can can learn to "head "head them them off off at at the the pass" pass" by by recognizing recognizing when w h e n they they are are starting starting to to occur, occur, and and then then putting putting into into motion motion plans yourself from spiraling upward upward even even from spiraling preventing yourself for preventing plans for further. In Robert's Robert's case, case, there there was was a a brief brief window w i n d o w of of opportunity opportunity in in which which his his further. In early early warning warning signs signs were were apparent apparent and and more more could could have have been been done done to to prevent prevent his his escalation escalation into into a a full-blown full-blown episode. episode. You'll You'll learn learn more more about about h o w Robert Robert how and and Jessie Jessie learned learned to to antiCipate anticipate and and derail derail his his worst worst manic manic symptoms later in in later symptoms this chapter. chapter. this If If you you can can successfully successfully implement a plan plan to to prevent prevent or or decrease decrease the sever­ the severimplement a ity of of your your manic manic episodes, episodes, then then your your family, family,job, job, and and social socialfunctioning functioning will will ity almost almost certainly certainly improve. S o m e aspects aspects of of this this plan will involve things you do you do involve things plan will improve. Some on on your o w n . Some S o m e will will involve the actions of your m e m b e r s and sig­ and sigfamily members your family actions of involve the your own. nificant others. others. Still Still other other aspects involve your doctor and and therapist nificant (if therapist (if your doctor will involve aspects will

you have you have one). W h e n mania escalating, you you will willneed need the the help help of ofothers others be­ beis escalating, mania is one). When

cause cause i will be to rein yourself. to m a k e relapse relapse prevention prevention make best to It's best f It's in yoursel rein in hard to be hard itt will plans plans w h e n you're h e n you you will willhave have aa diffi­ diffiescalating, you are escalating, you are when because w well because you're well when behavior and your behavior with your associated with dangers associated potential dangers the potential time recognizing cult time cult recognizing the and what cycle. upward cycle. the upward do to to do what to to curtail curtail the II think think of of a a developing developing manic manic episode episode as as like like aa train train leaVing leaving a a station. station. get to get wants to someone wants and someone station and of the to move starting to is starting the train When W h e n the train is m o v e out out of the station off, off, the before i train before the train stop the to stop time to has time still has conductor still the conductor speed. full speed. reaches full itt reaches But if But w n trajectory trajectory and passengers and passengers own its o on its be on will be train will the train long, the too long, waits too he waits if he will w n . Manic episodes Manic episodes its oown. on its crashes on or crashes stops or it stops until it train until the train on the stuck on be stuck will be

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can can feel feel like Hke this this (rain. train. The The key key is is to to be be able able to to tell teH when w h e n the train has has staned started the train tracks. La move and to try to get off of it before it's barreling down the to m o v e and to try to get off of it before it's barreling d o w n the tracks.

The Relapse Relapse Prevention Prevention Drill The Drill How know when when you gettingmanic? manic? One One study study indi­ indiHowimportant importantis is it it totoknow you are are getting

cated disorder: cated that that there there were were twO two predictors predictors of of rehospitalization rehospitalization in in bipolar bipolar disorder: nOl not taking taking medications, medications, and and failing failing to to recognize recognize the the early early signs signs of of relapse relapse Qoyce, 1985). 1985). On On a a more more hopeful hopeful note, note, people people with with bipolar w h o re(Joyce, bipolar disorder disorder who re­ ceive educational educational interventions, interventions, such such as as learning learning to to identify identify early early warning warning ceive signs and then signs of of mania mania and then seeking seeking mental mental health health services, services, are areless lesslikely likelyto tohave have full recurrences recurrences of ofmania mania and and have have better bettersocial socialand and work work functioning functioning over over 18 18 full months al., months than than those those who w h o do do not not receive receive this this kind kind of of education education (Perry (Perry et et al, 1999). As As Roben Robert said, said, once oncehe heand andJessie Jessiehad hadbegun begun (0 toimplement implementaasuccessful successful 1999). relapse plan, "I relapse prevention prevention plan, "I used used to to think think II was was in in the the driver's driver's seat seat when w h e n II was was manic, but but that thatwas was just justthe theillness iHness talking. talking.Now N o w I Ithink think I'minin the driver's seat I'm the driver's seat manic, when getting manic." w h e n II can can stop stop myself myself from from getting manic." In train In this this chapter, chapter, you'll you'll learn learn a a three-step three-step strategy strategy for for getting getting off off the the train before mania you for The method, before mania takes takes you for a a harrowing harrowing ride. ride. The method, called called a a "relapse "relapse driH," was was developed developed by by Alan Alan Marlatt Marlatt and and Judith Judith Gordon Gordon (1985) (1985) for for the the treat­ treatdrill," ment of of alcoholism alcoholism relapses. The relapse relapse drill drill was was used used successfully successfully in ment relapses. The in our studies studies of family-focused treatment treatment for for people people with with bipolar bipolar disorder disorder our of family-focused (Miklowitz &. & Goldstein, Goldstein, 1997; 1997; Rea Rea et et aL, al., 2001; 2001;see seeChapter Chapter6). 6).AArelapse relapsepre­ pre(MiklowilZ vention method is also also a a central part of of the the "collaborative "collaborative care" care" program program for vention method is central part for patients in in NIMH's NIMH's Systematic Systematic Treatment Treatment Enhancement Enhancement Program Program for for Bipolar Bipolar patients Disorder (Sachs, 1998; 1998; Otto Otto et et aI., al., 1999). 1999). Disorder (Sachs, A relapse relapse drill drill is is like like the the fire fire drills drills you you took took part part in in back back in in schooL school. like Like A fire drills, drills,relapse relapsedrills drillsare areformulated formulatedwhen w h e n everything everythingis issafe safeand andgoing goingwell weH fire so that that you k n o w exactly exactly what what to to do do should should a a disaster disaster occur. occur. Like Like fire fire drills, drills, so you know the relapse relapse drill drill involves involves a a series series of of steps steps to to try try to to prevent prevent the the damage damage the to take take to done by by an an anticipated anticipated event: done event: • Identify your prodromal symptoms • Identify your prodromal symptoms •

• List List preventative preventative measures measures

•

• Create Create aa writlen written plan plan or or contract contract detailing detailing prevention prevention procedures procedures

In the first yourprodromal prodromal symptoms, symptoms, you you make make aa list list In the firststep, step, identifying identifying your (usually with with the the help help of of others) others) of of early early warning warning signs signs that signal the the begin(usually that Signal begin­ ning of of a a manic period. Identifying Identifying warning warning signs signs may m a y also also involve identifying ning manic period. involve identifying heavily, the circumstances circumstances that that elicit elicit these these symptoms symptoms (for (for example, example, drinking drinking heavily, the

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medication dosages, missing your therapy or physician appointments, missing medication dosages, missing your therapy or physician appointments, missing encountering snessful stressful work w o r k situations) situations).. encoumering In In the the second s e c o n d step, step, listing listing prevemative preventative measures, m e a s u r e s , you y o u brainstorm brainstorm with with signs ap­ your relatives relatives about a b o u t what w h a t actions actions to to take take if if one o n e or or more m o r e prodromal p r o d r o m a l signs apyour pear (for (for example, e x a m p l e , call call your y o u r psychiatrist, psychiatrist, go g o in in for for an a n emergency e m e r g e n c y medical medical ap­ appear pointment, in­ pointment, arrange arrange for for others others to to take take care care of of your y o u r children). children). These T h e s e actions actions involve you, y o u , your y o u r doctor, doctor, and a n d members m e m b e r s of of your y o u r core core circle circle (see (see also the also the volve examples in in the the sections sections that that follow) follow).. examples In In the the third third phase p h a s e you, y o u , your y o u r significant significant olhers, others, and a n d your y o u r doctors doctors put p u t the the is a first and a n d second s e c o n d steps steps together together and a n d develop develop a a written written plan, plan, which w h i c h is a kind kind of of first contract, for for what w h a t to to do d o when w h e n you y o u feel feel a a manic m a n i c episode episode coming coming o n . It's It's impor­ imporcontract, on. tant that that all all key k e y players players have h a v e ready ready access access to to the the comract contract so so that that they they can can help help tant y o u put put it it imo into action action when w h e n you y o u are are beginning beginning to to cycle-since cycle—since that that is is when when you you're least least likely likely to to seek seek help. help. you're This chapter chapter focuses focuses only only on o n the the prevention prevention of of manic m a n i c episodes. episodes. This mateThis This mate­ rial rial is is also also relevam relevant to to preventing preventing hypomanic h y p o m a n i c episodes, episodes, which w h i c h often often have have a a similar set set of of warning w a r n i n g signs signs and a n d can c a n be b e derailed derailed with with some s o m e of of the the same s a m e preven­ prevensimilar tative strategies. strategies. The T h e next next two t w o chapters chapters discuss discuss ways w a y s to to prevent prevent or or minimize minimize tative the the downward d o w n w a r d spiral spiral of of depression. depression. But B u t before before 11 get get imo into the the actual actual mechanics mechanics of developing a comract, let me say something about a sensitive issue of developing a contract, let m e say s o m e t h i n g about a sensitive issue that that may may have have already already occurred occurred to to you: y o u : the the discomfort discomfort of of relying relying on o n others others when w h e n you you are ill. are becoming b e c o m i n g ill.

A Little Little Help H e l p from f r o m Your Y o u r Friends Friends A "I"Istart I'mI'm suddenly happy again,again, my sleep disstartyelling yelling and andthen then suddenly happy my gets sleepall gets all dis­ turbed, my m y thoughts thoughts go g o so so fast fast II can't can't grasp grasp them. t h e m . II get get high-spirited high-spirited and and turbed, strong-willed. But B u t the the weirdest weirdest thing thing to to me m e is is that that II don't don't even e v e n know k n o w I'm I'm strong-willed. iH,, and a n d why w h y would w o u l d II take take my m y medications medications if if I'm I'm not not ill? ill? My My h u s b a n d alill husband al­ w a y s knows k n o w sfirst, y sister n d then y best ways first, mmy sister next, next, aand then mmy best friends. friends. I'm I'm always always the the last " last one o n e to to know k n o w when w h e n I'm I'm getting getting manic. manic." — A 33-year-old 33-year-old woman w o m a n with with bipolar bipolar II disorder disorder -A The loss of insight into into yourself is a neurological sign of mania—people The loss of insight yourself is a neurological sign of mania-people don't see see anything anything a b n o r m a l about about their their behavior behavior when w h e n in in the the height height of of an a n ep­ epdon't abnormal isode, and a n d sometimes s o m e t i m e s even e v e n when w h e n they're they're cycling cycling upward u p w a r d or or coming c o m i n g out out of of an an isode, is It's much episode episode (Ghaemi ( G h a e m i et et al., al., 1995). 1 9 9 5 ) . It's m u c h like like when w h e n someone s o m e o n e has has a a stroke stroke but b u t is u n a w a r e of of the the memory m e m o r y deficits deficits that that follow, follow, or or when w h e n someone s o m e o n e is is hypnotized hypnotized unaware or or in in a a dream d r e a m state state but b u t doesn't doesn't realize realize he h e or or she she is is acting acting differently. differently. Because of Because of this this lack lack of of insight, insight, close close relatives relatives (your (your parents, parents, Siblings, siblings, or or spouseJromamic spouse/romantic

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partner) partner) and and friends friendsare are often to recognize your developing often thethe firstfirst to recognize your developing mania, mania, from seeing things in your behavior that you cannot (see the quotations from relaseeing things in your behavior that you cannot (see the quotations rela­ tives on on page page 190). 190). For that reason, reason, it's it's essential essential to to involve involve them in the the three tives For that them in three steps steps of of the the relapse relapse drill driH process. process. Refer Refer back back to to the the exercise exercise in in Chapter Chapter 8, 8, in in which which you you were were asked asked to to lisl list lhose thosefamily familymembers m e m b e r s and and friends friendswhom w h o m you you feel feel you could you could trust trust in in an an emergency. emergency. Close relatives relatives should should be be involved involved in in the the care care of of any any person person with with a a chronic chronic Close illness, whether whether it it is is a a psychiatric psychiatric disorder or a a traditional traditional medical disorder illness, disorder or medical disorder like heart heart disease. disease. We W e know k n o w from from research research in in health health psychology psychology that that people people like who practices tend in w h o have have the the best best health-care health-care practices tend lO to engage engage family family members members in changing changing their their unwanted unwanted habits. habits. For For example, example, their their family family members members encour­ encourage healthy foods, However, inage them them to to eat eat healthy foods, avoid avoid smoking, smoking, or or get get exercise. exercise. However, in­ volving others is is aadouble-edged double-edged sword: sword:Accepting Accepting the the help help or oroversight oversightof ofan­ anvolving others other will probably distress other person person will probably generate generate a a certain certain amount amount of of psychological psychological distress in you in you (Lewis (Lewis & & Rook, Rook, 1999). 1999). W h a t is is this thisdistress distressabout? about?Most Mostpeople peopleresent resentthe theidea ideaof ofhaving havingothers­ others— What particularly particularly their their close close relatives-in relatives—in a a position position of of aUlhority authority when w h e n they they start start to to become like become ill. ill.In Inthe theextreme, extreme,ititcan canfeel feel likeagreeing agreeingtotohave havesomeone someoneelse elsetake take away your independence. independence. These These are are understandable understandable reactions reactions shared shared by people away your by people with many m a n y other other medical medical illnesses. illnesses. For Forexample, example,people peoplewith withinsulin-dependent insulin-dependent with diabetes dislike dislike the the idea idea that that someone someone else else might might have have to to inject inject them, ifthey theygo go diabetes them, if into shock. shock. People People with with high high blood blood pressure pressure or or cardiovascular cardiovascular diseases diseases dislike into dislike the idea spouse might might monitor monitor their their food food or or salt salt intake. intake. the idea that that aa spouse People with with bipolar bipolar disorder disorder seem seem espeCially especially prone prone to to feeling feeling this this way. way. 1I People have heard heard the the statement statement "I "I hate hatethe theidea ideaof ofgiving giving up up control controlto toanyone" anyone"from from have m a n y clients, clients,whether whetherthe thecontrol controlis isbeing beinggiven givenup uptotoa alover, lover, a spouse, a docmany a spouse, a doc­ tor, or or(especially) (especially)aaparent. parent.IIthink think there thereare areseveral severalreasons reasonswhy w h y the theissue issueof of tor, control is is so so salient salient to to people people with with bipolar bipolar disorder. disorder. First, First, when w h e n you you experi­ expericontrol ence the the internal internal feelings feelings of of chaos chaos that o o dfluctuations itcan canbecome become ence that m mood fluctuations cause, cause, it especially important important to to feel feel like like you're you're at at least least in in control control of of your your outside outside especially world. Second, Second, the the feelings feelings of of confidence confidence and and power associated with the early early world. power associated with the the ad­ and later later stages stages of of mania a k e you you especially especially prone prone to to rejecting rejecting the adand mania m make disor­ vice,opinions, opinions,or ordirect directhelp helpof ofothers. others.Third, Third, m a n people y people with bipolar disorvice, many with bipolar der well­ der have have had had bad bad experiences experiences in in the the past past when w h e n others-however others—however wellintentioned—tried to to exert exert control control over over them them during emergencies. intentioned-tried during emergenCies. If your your reaction reaction to to involving involving others others is isnegative, negative,think think about about why w h y you you feel feel If really this way. way. What W h a t bothers bothers you most about about leaning leaning on on others? others? Is Is the the issue issue really this you most about control control or or personal personal autonomy? autonomy? Is aboutcompetition? competition?Do D oyou youfear fearthat that about Is ititabom there will will be be "strings "strings attached" attached" to to the help? Alternatively, Alternatively, do do you you feel feelthat thatyou you there the help? to already ask ask too too much m u c h of of that person? In In addreSSing addressing the the issue issue of of whom w h o m to already that person? choose choose to help in emergencies, clients clients have said: "The "The only only person person who w h o would would to help in emergencies, have said: probably do do this for me m e is is exactly exactly the the person person II don't don't want want to to have have any any more more probably this for

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mylife—my life-my mother"; "My relationship with my such that control control over over my mother"; "My relationship with my wife iswife suchisthat there's always always a a price price to to pay. pay. If If II lean lean on o n her, her, she'll she'll slam slam me m e in s o m e other other in some there's w a y " ; and a n d "My " M y brother brother and a n d 1I have h a v e always always been b e e n competitive. competitive. If If he he w e r e to to step step way"; were when I got manic, it would be kind of like saying, 'You won.' '' It's impor­ in w h e n I got m a n i c , it w o u l d b e k i n d of like saying, 'You w o n . ' " It's i m p orin tant to to try try to to understand understand what w h a t issues issues are are at atstake stake for foryou y o uwhen w h e n you y o useek seek help help tant from others. others. from With can the W i t h these these issues issues in in mind, m i n d , there there are are various various ways w a y s that that you you c a n make m a k e the involvement of of others others feel feel more m o r e acceptable. acceptable. First, First, remember r e m e m b e r that that you're you're asking asking involvement them to to step step in in when w h e n you y o u get get sick, sick, not not when w h e n you y o u are are healthy healthy and a n d competently competently them running running your y o u r day-to-day day-to-day life. life. You Y o u may m a y fear fear that that if if you y o u let let others others control control oone ne difficult interval interval in in your y o u r life, life, giving giving up u pcontrol controlin inother other areas areaswill willsoon s o o n follow. follow. difficult You Y o u may m a y fear fear that that your y o u r wife, wife, husband, h u s b a n d , or or family family member m e m b e r will will always always be b e hover� hovering ing over over you y o u and a n d making m a k i n g sure sure you y o u eat, eat, sleep, sleep,work, w o r k , and a n dsocialize socialize according according to to his a his or or her her rules. rules. But B u t the the truth truth is is that that you y o u are are giving giving up u p control control over over only only a fragment of of your y o u r life, life, and a n d for for only only the the brief brief period period during during which w h i c h you y o u are are esca­ escafragment lating lating into into mania. m a n i a . In In fact, fact, you y o u may m a y want w a n t to to make m a k e this this point point clear clear to to them: t h e m : that that you only when not you're well. well. y o u are are asking asking for for help help only w h e n you y o u become b e c o m e ill, ill, n o t when w h e n you're Second, try try to to involve involve people people with with whom w h o m you y o u do d o not n o t have have a a long long history history Second, of of control control battles. battles. If If you y o u have h a v e aa history history of of severe severe confliclS conflicts with with your y o u r mother m o t h e r or or father over over independence, i n d e p e n d e n c e , involve involve your y o u r Siblings siblings or or close close friends friends instead. instead. There There father may m a y be be members m e m b e r s of of your your core core circle circle whom w h o m you you see see frequently, frequently, who w h o would would k n o w if if something something was was going going wrong, wrong, and and whom w h o m you you would would trust trust with with a a deknow de­ gree gree of of deCision-making decision-making capacity capacity during during a a time time of of crisis. crisis. A practical practical problem problem that that can can come c o m e up u p when w h e n relying relying on on social social supporlS supports is A is that that no no one one in in your your core core circle circle m a y see see you you often often enough enough to to know, k n o w , within within a may a brief time, time, whether whether you you are are showing showing the the early early warning warning signs. signs. If If your your relatives brief relatives live live far far away away or or speak speak to to you you only only by by phone, they may m a y not not observe observe the the subtle subtle phone, they changes that constitute your cycling, or they m a y not have the practical changes that constitute your cycling, or they may not have the practical rere­ sources sources (for (for example, example, access access to to your your physician) physician) to to be be able able to to help. help. Clients Clients have handled handled this this by by relying relying more more heavily heavily on on local local friends friends or or roommates roommates to have to perform the the same same functions functions or or by by giving giving long-distance long-distance relatives relatives the the phone phone perfonn numbers of of their their phYSicians, physicians, with with instructions instructions to to call call if if the the relative relative has has con­ connumbers cerns. cerns. If If you you do do not not have have local local connections connections with with significant significant others, others, then then i beitt be­ comes all all the the more m o r e important important to to observe observe your your own o w n mood m o o d and and behavior behavior and and comes seek help help from from your your doctor doctor when w h e n you you need need it. it. Some S o m e people people use use the the fluctuafluctua­ seek tions tionson ontheir theirmood m o o dcharlS charts(Chapter (Chapter8) 8)to todetermine determinewhen w h e nto toincrease increasecontact contact with with their their therapist therapist or or physician. physician. You Y o u may m a y observe observe very very minor minor increases increases in in your your mood m o o d as as the the episode episode is is building, building, even even over over intervals intervals as as short short as as a a few few days. days. Although Although subjective, subjective, these these observations observations can can still stiH inform inform your your treatments treatments and are are far far preferable preferable to to ignoring ignoring your your illness illness and and letting letting it it take take ilS its own own and course. course.

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Step Identifyingthe theEarly Early Warning Signs Mania Step 1: I : Identifying Warning Signs of of Mania "He gets "He getsdisconnected disconnectedand andwithdrawn, withdrawn,kind kindofofoverwhelming, overwhelming,irritable irritable ..in sounds like someone inin inyour your face, face,loud, loud,insensitive. insensitive.He H ealmost almost sounds like someoneelse else

his body. body. But But at at this this poim point LI know k n o w what what it it looks looks like." his like."

-The — T h e wife wife of of a a 50-year-old 50-year-old bipolar bipolar II patient patient "I"Istart thinkingthat thatI made I mademistakes mistakes a refrigerator start Lhinking at at mymy jobjob las[as a refrigeralOT repair­repair. IIstart I wired things incorrectly and then that the man!. m a n ] .... startwondering wonderingifif I wired things incorrectly and then that the .

.

refrigerator . . II start refrigerator in in someone's someone's house house wlll will blow blow up up and and burn burn them them.. .... start

wondering whether I've just thought thought things things or or said said them them out out loud. loud. It wondering whether I've just It makes me m e pull pull away away from from everybody. everybody. II gel get tight-lipped." makes tight-lipped."

— A 60-year-old 60-year-old man m a n with with bipolar bipolar II disorder disorder with with psychotic psychotic features features -A

"She's shy,but butwhen when she's she'sgeuing getting high in people's "She'susually usually shy, high she she gelSgets in people's faces; faces; she she gets gets imposing, emotional and and effusive, telling her whole imposing, overly overly emotional effusive, like like telling her whole

life story to to a a bank bank teller. teller. . ... cansee seeother otherpeople peoplebacking backing off offand and sort sort life story . . IIcan of looking looking at at me, of m e , but but she she doesn't doesn't know k n o w that's that'show h o w she's she'scoming comingacross. across." n

I disorder diso,.der — T h e husband husband of of a 3 7-year-old w o m a n with -The a 37-yea,.-0Id woman with bipolar bipola,. I

Defining YourProdromal ProdromalPha,e Phase Defining Your Recall thatinin Chapter described the manic syndrome as involving Recall that Chapter 2, I2,1 described the manic syndrome as involving changeschanges in o o d , energy thinking and and perception, perception,sleep, sleep,and and impulse mood, energy or or activity activity levels, levels, thinking impulse in m control. of control. Think Think about about the the beginning beginning phases phases of of mania mania as as involving involving any any or or all all of these. onset pmdmmal phase, phase. usually usually defined defined as as the the period period from from the the first first onset these. The The prodromal of symptoms to to the the point point at at which which symptoms symptoms reach reach the the height height of of their their seversever­ of symptoms ity, can last last a a day day or or two two to to even even a a week week or or several several weeks. weeks. During During this this ity, can prodromal prodromal phase, phase, your your symptoms symptoms will will probably probably be be mild mild and and not nOl necessarily necessarily troublesome—and troublesome-and therefore ver­ therefore difficult difficult to to detect. detect. They They are are usually usually muted muted versions sions of of the the symptoms symptoms of of a a full full manic manic episode. episode. It It is is during during this this prodromal prodromal

the phase phase that that the the train train has has only only just just begun begun to to leave leave the the station, statioll, and and you you have have the most y clients err on on the the side side of of caucau­ most control control over over your your fate. fate. II encourage encourage m my clients to to err toto tion: Theappearance appearanceof ofeven evenone onemild mildprodromal prodromalsymptom s y m p t o misisoften often signal Signal aa tion: The seek help. seek help. and In In a a study study of of the the prodromal prodromal phases phases of of manic manic episodes, episodes, Emily Emily Altman Altman and

our U C L A (1992), (1992), observed observed people people with with bipolar bipolar disorder disorder over over a a nine­ nineour group group at at UCLA mmonth o n t h period period following following a a hospitalization hospitalization and and rated rated their their symptoms symptoms every every month. o m e had month. S Some had manic manic episodes episodes during during the the observation observation period. period. The The patients patients wwho h o developed developed mania mania showed showed very very mild mild increases increases in in "unusual "unusual thought thought concan-

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beforetheir theirfull fullepisodes. episodes.These These unusual thoughts were re­ tent" in in the the month month before unusual thoughts were retent" flected in in statements statements the the patients patients made m a d e during during clinical clinical interviews interviews regarding regarding flected their their beliefs beliefs in in the the influences influences of of spirits, spirits, psychic psychic powers, p o w e r s , or or the the occult; occult; their their overly overly optimistic optimistic schemes s c h e m e s for for making m a k i n g money m o n e y qUickly; quickly; their their feeling feeling that that others others w e r e staring staring or or laughing laughing at at them; t h e m ; or or believing believing that that their their mind m i n d was w a s sharper sharper were everyone else's (in other words, mild psychotic symptoms). than everyone else's (in other w o r d s , m i l d psychotic s y m p t o m s ) . These These than changes in in thinking thinking were w e r e mild, mild, and a n d in in some s o m e cases, cases, even e v e n the the person person expressing expressing changes t h e m could could admit a d m i t the the ideas ideas sounded s o u n d e d odd o d d or or unrealistic. unrealistic. So, S o , observable observable them changes in in the the content content of of your y o u r thinking thinking and a n d speech speech in in the the month m o n t h before before aa mallie manic changes episode may m a y be be a a due clue that that you y o u are a r e beginning beginning to to cycle. cycle. episode A survey survey by by Grace Grace Wong W o n g and and Dominic Dominic Lam L a m (1999) (1999) asked asked people people with with biA bi­

previous manic polar disorder disorder to to describe describe their their early early warning warning Signals signals prior prior to to previous manic polar episodes. in­ episodes. The T h e most most frequent frequent Signals signals reported reported were were reduced reduced sleep sleep and and an an increase in in activity, activity, both both repofted reported by by over over 40% 4 0 % of of the the respondents. respondents. Less Less frefre­ crease quently, quently, people peoplereported reported feeling feelingeuphoric euphoric or orirritable, irritable,having havingracing racingthoughts, thoughts, or just before or being being energetic energetic and and productive productive (goal-driven) (goal-driven) in in the the interval interval just before their their episode. episode. It appears appears that that many m a n y people people with with bipolar bipolar disorder disorder are are able able to describe It to describe h o w they they behave behave when w h e n they're they're getting getting manic, manic, at at least least when w h e n they're they're asked asked afhow af­ ter ter the the fact. fact. The The harder harder question question is, is, how h o w do do you you know k n o w ahead ahead of of time time what what symptoms you you should should be be looking looking for? for? One O n e way w a y to to increase increase the the probability probability symptoms that you you or or others others will will recognize recognize a a developing developing episode episode is is to to mahe make a when that a list, list, when you're well, of early early wanting warning signs signs recalled recalled from from your your last last few In you're well, of few episodes. episodes. In other words, words, take take advantage advantage of of the the greater greater insight insight you you have have into into your your illness other illness w h e n you you are are well. well. This This kind kind of of objectivity objectivity will will be be harder harder to to summon s u m m o n when when when you you are are heading heading into into an an episode, episode, but but having having the the list list available available m a y help help you you may view view your your escalating escalating mood, m o o d , thoughts, thoughts, and and behaviors behaviors in in a a different different light. light. Soon I'll I'll talk talk about about what what you you can can actually actually do do when w h e n these these prodromal prodromal signs Soon signs appear. appear. The follOwing foUowing exercise exercise will will help help get get you you stafted started recording recording your your prodromal prodromal The symptoms. Your Your early early warning warning signs, signs,however, however,may m a y be bedifferent differentfrom from the theones ones symptoms. Hsted in in the the exercise. exercise. Nancy Nancy experienced experienced the the onset onset of of her her hypomaniC hypomanic episodes episodes listed as as an an increase increase in in anxiety anxiety and and worry. worry. Pete Pete reported reported that, that, despite despitefeeling feehngspeedy speedy and and internally internally stimulated, stimulated, he he withdrew withdrew more more when w h e n he he was was escalating escalating because because he he knew k n e w that that he he would would alienate alienate other other people people once once he he became became manic. Heather manic. Heather became obsessed obsessed with with a a certain certain movie movie star star and and began began "seeing "seeing things things out out of of the the became eye." corner corner of of my m y eye." It is is important important to to distinguish distinguish the the early early warning warning signs signs of of mania mania from It from those those of depression, depression, which which usually usually involve involve feeling feeling slowed slowed down, d o w n , fatigued, of fatigued, selfself­ critical, hopeless, hopeless, or or uninterested uninterested in in things things (see (see the the next next chapter). chapter). Holly critical, Holly rere­ ported periods of increased irritabflity and anxiety prior to manic episodes but ported periods of increased irritability and anxiety prior to manic episodes but

LISTING YOUR YOUR PRODROMAL PRODROMAL SYMPTOMS SYMPTOMS OF OF MANIA MANIA OR OR HYPOMANIA HYPOMANIA LISTING

your mood With the help friends or relatives, With the help of ofyour yourclose close friends or relatives, list aofcouple of adjectives describing what you list a couple adjectives describing what

islike likewhen w h e n your your manic manic or orhypomanic hypomanic episodes episodesfirst firstbegin begin(examples: (examples:up. up,happy, happy,more moreaware, aware, willful, is willIu l, more more reactive, reactive, cranky, cranky, irritable, irritable, euphoric, euphoric,anxious, anxious,wired, wired,cheery, cheery,like likeaayo-yo, yo-yo,pumped p u m p e dup). up).

Describe ("goal­ Describe changes changes in in your your activity activity and and mergy energy levels levels as as your your manic manic episode episode is is developing developing ("goal-

directed directed behavior"). behavior"). Include Include changes changes in in how h o w you you relate relate to to others others (examples: (examples: call call 1olS lots of of people, people, make make

lots of of new n e w friends, friends, take takeon onmore moreprojects projectsor orstart start"multitasking," "multitasking,"talk talkmore more and and faster, faster,get getininpeople's people's loIS faces, faces, tell tell people people off, off, feel feel"horny" " h o m y " or orvery very sexually sexually driven). driven).

Describe Describe changes changes in in your your thinking thinking and and perception perception (examples: (examples: thoughts thoughts race race or or at at least least go go fasler, faster,sounds sounds gel dodo anything, I think others areare looking at at memor laughing get louder, louder, colors colorsget getbrighter, brighter,I Ithink thinkI can I can anything, I think others looking e or laughing at really smart and I start thinking at me, m e , II get getmore more interested interestedin inreligion religionor or the theoccult, occult,I Ifeel feel really smart andconfident, confident, I start thinking about about many m a n y new n e w ideas ideas involving involving money, money, other other people people seem seem boring boring and and closed-minded, closed-minded, II get get extrasensory nk about extrasensory perception, perception, II have have psychic psychic abilities, abilities, IIthi think abouthurting hurtingor orkilling killingmyself, myself,IIruminate ruminate about about things, things, II get get easily easily distracted). distracted).

Describe changes changes in in y your sleep patterns patterns (examples: (examples: sleeping sleepingtwo two hours hoursless lessthan thanusual usualbut butnot notfeeli feeling Describe our sleep ng

tired the the next next day, day, waking waking up u p aalot lotduring during the thenight, night,staying stayingup u plate lateand andrelying relyingon o ncatnaps catnapsduring duringtht the tired.

day, not not needing needing sleep). sleep). day,

Describe anything anything you've you've done done in in the the last last week week that thatyou you wouldn't wouldn't ordinarily ordinarily do do (examples: (examples:spent spentaalot lot Describe

of money m o n e y or or invested invested money m o n e y on o n impulse, impulse, got got one one or or more more speeding speeding tickets tickets or or drove drove recklessly, recklessly,had had of more sexual sexual encounters encounters with with partner partner or or other other partners, partners, gambled gambled money). money). more

Describe the the context (any (any changes, changes, events, events, or or circumstances) circumstances) associated associated with with these these symptoms symptoms Describe (examples: an an increase increase in in your your work work stress, stress, stopping stoppingor orbecoming becoming inconsistent inconsistentwith withyour yourmedication, medication, (examples:

missing your your doctor's doctor's appointments, appointments, starting startingto todrink drink or oruse use drugs, drugs,starting startingaanew n e w project, project,changes changesinin missing your work work hours, hours, travel travel across across t time zones, more more family family or or re1.ationship relationship conflicts, conflicts, starting starting a a nnew ew your ime zones, relationship or or ending ending another another one, one, changes changes iin your f financial circumstances). relationship n your mancial circumstances).

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about her to learning misidentified these of of depression. Prior to learning more more about her Prior depression. signs theseasassigns misidentified disorder, disorder, she s h e used u s e d to to self-medicate self-medicate her her irritability irritabdity with w i t h over-the-counter over-the-counter reme­ remedies dies such s u c h as as St. St. John's John's wort. wort. During D u r i n g one o n e period period of of escalation escalation she s h e even e v e n con­ convinced an a n internist internist to to prescribe prescribe an a n antidepressant, antidepressant, which w h i c h made m a d e her her manic manic vinced s y m p t o m s much m u c h worse. w o r s e . With W i t h time, time, she she observed observed that that irritability irritability and a n d anxiety anxiety symptoms usually portended p o r t e n d e d mania m a n i a rather rather than than depression, depression, and a n d she s h e learned learned to to rely rely on on usually more m o r e traditional traditional prevention prevention methods, m e t h o d s , such s u c h as as increasing increasing the the dosage dosage of of her her m o o d stabilizer. stabilizer. mood If If you've you've had h a d only only one o n e or or two t w o episodes, episodes, you y o u may m a y have h a v e difficulty difficulty listing listing your prodromal prodromal symptoms. symptoms. Your Your family family or or friends friends may m a y be be able able to to help help you you your here,as asmay m a y your yourdoctor. doctor.In InChapter Chapter 2, 2,1 talkabout abouthow h o w mania mania can can look lookquire quite I talk here, different to to people people who w h o have have the the disorder disorder versus versus how h o w it it looks looks to to their their family family different members members or or doctors. doctors. You Y o u may m a y not not agree agree with with your your relatives relatives that that a a certain certain example. (for pattern thinking or aggreSSiveness) your example. (for behavior behavior (for example, your aggressiveness) or thinking pattern (for example, distractibihty) characterizes characterizes you you when w h e n you're you're getting getting manic, manic, but but it's it's better better to to distractibility) list these these behaviors behaviors or or thinking thinking patterns patterns if if they they might might in in some some way w a y help help your your list relatives relatives recognize recognize your your episodes episodes early. early. Likewise, Likewise, record record your your own o w n views views of of your early early warning warning signs signs or or eliciting eliciting circumstances circumstances even even if if these these views views don't don't your coincide with with what what your your relatives relatives think. think. coincide feel­ Robert, Robert, the the man m a n discussed discussed at at the the beginning beginning of of the the chapter, chapter, reponed reported feelhis ing ing very very sexual sexual and and having having racing racing thoughts thoughts before before he he had had changes changes in in his mood. His His girlfriend girlfriend Jessie Jessie saw saw it it differently: differently: She She thought thought he he became became irritable irritable mood. first, then then loud loud and and phYSically physicallyintrusive. intrusive.Another Another person personwith with bipolar bipolardisor­ disorfirst, der, Tom, T o m , said said that his manias manias almost almost always always involved involved religious religious preoccupa­ preoccupathat his der, tions tions and and paranoia. His parents parents described described him him as as "getting "getting a a certain certain look look in in his his paranoia. His eyes" and and "muttering "muttering stuff stuff underneath underneath his his breath." breath." The The physician physician who w h o treated treated eyes" Alan, Alan, the the 60-year-old 60-year-old refrigerator refrigerator repainnan repairman who w h o believed believed that that others others could could hear his was his Alan's "bouncy, hear what what he he was was thinking, thinking, felt felt that that Alan's "bouncy, upbeat upbeat quality" quality" was first prodromal prodromal sign. sign.Characterizations Characterizations like Hke these these are are helpful helpful in in rounding rounding out out first what what your your prodromal prodromal phases phases look look like like from from your your own o w n vantage vantage point point and and the the vantage others. vantage point point of of others. If you have have bipolar bipolar II II disorder, disorder, you you may m a y wonder wonder whether whether your If you hypo­ your hypomanias really really have definable beginning and end. end. HypomaniC Hypomanic episodes episodes can be can be beginning and a definable have a manias very very subtle, and, because because they do not not Significantly significantly interfere interfere with with your day-to­ your day-tothey do subtle, and, day day functioning, functioning, they they can can be be hard hard to to distinguish distinguish from state. baseline state. your baseline from your However, even even hypomania hypomania involves involves observable observable physical, physical, cognitive, cognitive, and emoand emo­ However, tional changes tional changes relative relative to your ordinary ordinary state. state. Typical Typicalprodromal prodromal symptoms symptoms of of to your hypomania are are sleep (sometimes a a change change of of only only an an hour hour or in­ two) , inor two), loss (sometimes sleep loss hypomania creases creases in in energy levels, increases increasesin inthe thespeed speed of ofyour your thoughts thoughts or orspeech, speech,and and energy levels, irritability or impatience. impatience. Perhaps h e n these oc­ last occhanges last these changes when recall w can recall you can Perhaps you irritability or curred and you n e w something different. was different. something was knew you k curred and

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Identifying Context in Which Warning Signs Occur Identifying thethe Context in Which Your Your Early Early Warning Signs Occur

You may mayhave have an an easier easier time your prodromal signs if you also also re­ reYou timedescribing describing your prodromal signs if you the context which they they occur. cord information information ahoUl about the context in in which occur. For For example, example, Roben Robert cord felt irritability during was closely in felt that that his his irritability during his his last last episode episode was closely tied tied to to increases increases in his work demands annoyances expressed by coworkers, who his work demands and and annoyances expressed by coworkers, w h o had had begun begun pressuring pressuring him him about about the the company's company's financial financial outlook. outlook. For For Ruth Ruth (see (see Chapter Chapter 8), were nearly always precipitated 8), manic manic cycles cycles were nearly always precipitated by by alcohol alcohol usage, usage, sometimes sometimes even space to even in in small small quantities. quantities. In In the the exercise exercise above, above, there there is is a a space to record record any you-or any of your any eliciting eliciting circumstances circumstances (usual (usual or or unusual) unusual) that that y o u — o r any of your relatives-think relatives—think may m a y be associated with early warning be associated with your your early warning signs. signs. Identifying circumstances associated associated with with your prior manic manic episodes episodes can can Ident ifying circumstances your prior help you minimize the impact of of the the next next one. one. If If you k n o w that particular help you minimize the impact you know that aa particular circumstance holi­ circumstance (for (for example, example, an an increased increased workload workload due due to to the the Christmas Christmas holidays) was associated associated with with your your last you don't don't think days) was last episode episode (even (even if if you think it it caused caused your illness), your illness), you you may m a y want wantto tobecome become more more vigilant vigilantabout about your yourfeeling feelingstates states or or behavior behavior during during the the next next interval interval in in which this or or a a similar similar source source of of stress stress which this occurs next lime you know your wwork will inin­ occurs (for (for example, example, the the next time you k n o w your o r k demands demands will crease). vigilance crease) .This Thiskind kindofof vigilancecan canhelp helpyou youdetermine determinewhen w h e nyou youshould shouldask ask for help. for medical medical or or other other kinds kinds of of help. Teresa worked as Teresa worked as an an accountant. accountant. She She carne came to to realize realize that that tax tax season, season, with with irs longer work its much m u c h longer work hours, hours, was was aa trigger triggerfor forher her manic manic episodes. episodes.Prior Priorto totax tax season, she she obtained obtained a a prescription prescription from from her doctor for for a a tranquilizing tranquilizing medi­ mediseason, her doctor cation (in (in her her case, case, Seroquel) Seroquel) to to be be started started if if she she was unable to to sleep, sleep, experi­ experication was unable enced enced racing racing thoughts, thoughts, or or felt felt overly overly goal-driven. goal-driven. She She was able to to arrange arrange was also also able few days days off off in in the the middle middle of of tax tax season season when w h e n she she felt felt her her mood m o o d escalating. escalating. aa few As a a result, result, she she was was able ableto toget getthrough through tax taxseason seasonwithout without aafull fullepisode, episode,al­ alAs though she she remained remained aware aware of of an an underlying underlying energized energized state state that that was was only only though partially masked masked by by the medication. partially the medication.

Step 2, 2, Part Part A: A: Preventative Preventative Steps Steps You You Can Can Take Take Yourself Yourself Step or with with Others' Others' Help Help or The focus ofthis this section is preventative on preventative maneuvers you your and your signifiThe focus of section is on maneuvers you and signifi­ cant others others can take at the appearance appearance of one or or more more early early warning warning Signs. signs. I've I've cant can take at the of one separated this section from from the the next next (Part (Part B), B), which concerns negotiating negotiating help help which concerns separated this section from your doctor and the mental health system. Later, we'H put Steps 1 and your doctor and the mental health system. Later, we'll put Steps 1 and 22 from together into into a contract (Step (Step 3). 3). together a written written contract Not all all of of the the following following preventative preventative steps steps will apply to to you. For example, example. Not will apply you. For

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may a person has trouble with sexual indis­ you may behe a person whowho has trouble with with money money but not but withnot sexual indisyou but cretions. You Y o u may m a y have have a a history history of of making m a k i n g impulsive impulsive life life decisions decisions b u t have have cretions. may never driven driven recklessly. recklessly. Your Y o u r individual individual pattern pattern of of prodromal p r o d r o m a l symptoms symptoms m ay never

dictate which w h i c h of of the the following following preventative preventative measures m e a s u r e s are are most m o s t urgent urgent aand nd dictate which wail. So, w h i c h can c a n wait. S o , for for example, e x a m p l e , if if your y o u r prodromal p r o d r o m a l symptoms s y m p t o m s are are irritability irritability

and a a decreased decreased need n e e d for for sleep, sleep, your y o u r may m a y want w a n t to to see see your y o u r physician physician immedi­ immediand ately, but b u t asking asking someone s o m e o n e else else lO to hold hold on o n to to your y o u r credit credit cards cards m ayn o t be b e as may not as ately, essential (unless irritability past, heralded essential (unless irritability and a n d sleep sleep disturbances disturbances have, have, in in the the past, heralded

a drive drive toward t o w a r d haphazard h a p h a z a r d investments). investments). a

Managing Money Monog;ng Money "One took aacab cab way downtown, tipped the driver 50%, and then "Onetime time II took way downtown, tipped the driver 50%, and then bought bought two two very very expensive expensive dresses dresses at at aa department department store store that that II thought thought was dresses was having having aa big big sale. sale. It It turned turned out out they they weren't. weren't. II bought bought the the dresses without knowing knowing anything anything about about the the materials materials II was was buying buying or or whether without whether the the prices prices were were good, good, without without taking taking anyone anyone with with me, me, which which II would would have have done done normally. normally. II spent spent over over aa thousand thousand dollars, dollars, which which we we didn't didn't have. have. I1 eventually eventually took took one one of of them them back, back, but but (when [when IIwas was manic] manic]IIde­ destroyed stroyed the the other other one one by by leaving leaving an an iron iron on on top top of of it." it." — A 55-year-old 55-year-old woman w o m a n with with bipolar bipolar II disorder disorder -A describing a a manic m a n i c episode episode describing Bipolar disorder managing money moneymuch much harder harder than it would Bipolar disorder makes makes managing than it would ordi­ ordinarily be. W h e n people are becoming manic, and especially when they narily be. When people are becoming manic, and especially when they are are fully fully manic, manic,they theyoften oftengo goon onspending spendingsprees spreesand andinvest investwildly. wildly. many ways InIn many ways this is is one one of of the the more humorous symptoms symptoms of of bipolar bipolar disorder. disorder. Jamison's Jamison's this more humorous 1995 1995 autobiography, autobiography. An An Unquiet UnquietMind, Mind,has hasgood goodexamples examplesofofthe thethinking thinkingbe­ behind spending spending sprees. sprees. But But as as Jamison Jamison recounts, recounts, spending spending sprees sprees and and foolish hind foolish business investments investments can can damage damage your your life life and andcontribute contributeto toyour yourfeelings feelingsof of business hopelessness hopelessness after after the the manic manic episode episode has has cleared. cleared. Mania tends tends to to generate generate "hyperpositive "hyperpositive thinking," thinking," in in which which you you overestiMania overesti­ mate your your abilities abilities to toachieve achieve(for (forexample, example,make makea alot lotofofmoney) money)and andunder­ undermate estimate the the risks risks (for (for example, example, going going into into debt) debt) of of your your behavior behavior (Leahy, estimate (Leahy, 1999; When 1999; Quo Otto et et al., al., 1999; 1999; Newman N e w m a n etetal., al.,2001). 2001). W h e nyou youhave havehyperpositive hyperpositive thoughts, it it can canbe behard hard to tostep stepback back and and evaluate evaluate them them objectively. objectively.In In fact, fact, thoughts, some some people people equate equate imagining imagining being being able able to to do do something something with with actually actually being being able to to do do il. it. If If you you can can imagine imagine making making aa lot lot of of money money very very qUickly, quickly, how how able much it? much harder harder could could it it be be to to actually actually do do it?

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You You and your significant others can become attuned to to noticing when and yOUT signific3m others can become attuned noticing when your your thinking thinking takes takes on on an an overly overly optimistic optimistic or or hyperpositive hyperpositive turn. turn. Do D o you you suddenly suddenly believe believe you you have have found found qUick quick answers answers to to financial financial problems problems that that have been been plagUing plaguing you you for for some some time? time? Are Are you you becoming becoming more more and and more more en­ enhave thralled thralled with with "get "get rich rich quick" quick" schemes? schemes? Do D o you you find find yourself yourself unusually unusually preoc­ preoccupied with money or merchandise, driven to purchase expensive things cupied with m o n e y or merchandise, driven to purchase expensive things (see (see the the example example of of Robert Robert and and his his electric electric guitars)? guitars) ?Do D o you you think thinkthat thatyou youmust must have have those those things, things,sooner sooner rather rather than than later, later, or or else else you you will will be be "ripped "ripped off"? off? Have Have you you come c o m e to to believe believe that that your your finances finances aTe are virtually virtually unlimited? unlimited? Do D o you you feel feel impatiem impatient with with your your spouse spouse when w h e n he he or or she she tells tellsyou you that thatyou you can't can'tafford afford something? something? You You may m a y not not be be able able to to prevent prevent these these thoughts thoughts from from occurring, occurring, but but here here are some some concrete concrete things things you you can can do do when w h e n they they first first appear: appear: are • Have someone else else holdhold on to credit • Have someone on your to your creditcards cards •

• Avoid Avoid trips trips to to the the bank bank unless unless you you are are going going to to take take aa trusted trusted person person with you you with

•

• Stay Stay away away from from your your favorite favorite stores stores

•

• Avoid Avoid watching watching television televisionstations stationswhose whose primary primary purpose purpose is isto tosell sellyou you goods goods

•

• Don't Don't give give your your credit credit card card numbers numbers or or bank bank account account information information to to

"telemarketers'' or or investment w h o call call you you with with their their spe­ spe"telemarketers" investmem counselors counselors who cial (an advisable even when feeling well, well, of of cial deals deals (an advisable practice, practice, even w h e n you're you're feeling course!) course!) • • Avoid Avoid investing investing in in the the stock stock market market altogether altogether or or making making sudden sudden changes in, or withdrawals withdrawals from, from, your accounts changes in, or your retirement retirement accounts • Stay Stay away away from from on-line on-line trading trading • In other words, words, decreasing decreasingyour youraccess access means implementing your to to thethe meaflS of of In other implementing your plans them out. plans makes makes iitt less less likely likely you you will will actually actually carry carry them out.

Some S o m e people people recommend rule: Wait 24 hours hours after good recommend aa 48-hour 48-hour rule: Wait 24 after two two good ex­ nights making a that exceeds exceeds a certain Hmit (for exnights of of sleep sleep before before making a purchase purchase that a certain limit (for ample, N e w m a n et 2001).During During these these48 48 hours, hours,discuss discussthe the ample, Leahy, Leahy, 1999; 1999; Newman et al., aI., 2001). intended a n y as as three imended purchase purchase with with as as m many three trusted trusted people people (a (a family family member, member, aa friend, ask yourself: the waiting waiting period, period, ask friend, and and a a doctor doctor or or therapist). therapist). During During the yourself: • If• someone elseelse wanted to to do do what I am intending totodo, If someone wanted what I am intending do, what whatadvice advice would would II give give that that person? person? • W h a t is is the the worst worst thing thing that that could could happen happen if if II wasn't wasn't able able to to follow foHow • What through y plans? through with with mmy plans? • What • W h a t is is the the worst worst thing thing that that could could happen happen if if II did did carry carry them them out? out?

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The passage own critique of the situation, andand the the input of othpassageofoftime, time,your your own critique of the situation, inpU[ of oth­ The ers may m a y help help you y o u evaluate evaluate the the likely likely success success of of your y o u r financial financial decisions. decisions. ers Another it A n o t h e r practical practical maneuver m a n e u v e r is is to to arrange, arrange, when w h e n you're you're well, well, to to make m a k e it logistically difficult difficult for for you y o u to to get get a a hold hold of of large large sums s u m s of of money m o n e y in in a a short short logistically period of of time. time. There T h e r e are are several several ways w a y s to to do d o this, this, including including keeping keeping your your period m o n e y in in small small amounts a m o u n t s spread spread across across several several accounts accounts in in different different banks, banks, money or keeping keeping the the majority majority of of your y o u r money m o n e y in in a a joint joint account account that that requires requires a a co­ coor signer for for a a withdrawal. withdrawal. Karla, Karla, a a 35-year-old 35-year-old woman w o m a n with with bipolar bipolar II disorder, disorder, signer m a d e the the following following agreement a g r e e m e n t with with her her boyfriend, boyfriend, Taki: Taki: Karla Karla obtained obtained made three three bank b a n k debit debit cards cards from f r o m their their three three shared shared accounts. accounts. Each E a c h of of her her cards cards was clothing") and had a w a s labeled labeled with w i t h an a n expense expense category category (for (for example, e x a m p l e , ""clothing") and h ad a posted she posted spending spending limit. limit. The T h e two t w o agreed agreed to to determine determine which w h i c h purchases purchases she h a d already already made m a d e and a n d how h o w close close she she was w a s to to the the spending spending limit limit in in each each catecate­ had gory on on a a weekly w e e k l y basis. gory basis. If you y o u work w o r k closely closely with w i t h an a n investment investment counselor, counselor, it it may m a y be b e possible possible to If to entrust entrust him h i m or or her her with w i t h information information about about your y o u r illness illness so so that that he h e or or she she can can stop him stop you y o u from f r o m investing investing too too wildly wildly or or irrationally. irrationally. Consider Consider asking asking h i m or or her her to set set an an upper upper limit limit on on how h o w much m u c h money m o n e y you you can can exchange exchange within within a a single to single transaction. transaction. Of course, course, maintaining maintaining these these kinds kinds of of controls controls over over your your finances finances implies implies Of that that your your thinking thinking is isstill stillfairly fairlyrational rationaland andthat thatyou youcan canmake m a k egood gooddecisions. decisions. Rational thought thought is is often often possible possible during during the the prodromal prodromal phases phases of of mania Rational mania (an(an­ other reason reason to to catch catch your your episodes episodes early). early). But But as as you you may m a y know, k n o w , once once your your other symptoms symptoms have have accelerated, accelerated, it it becomes becomes difficult difficult to to make m a k e logical logical decisions decisions of of any type type and and you you may m a y become b e c o m e highly highly resentful resentful of of anyone anyone else's else's intervention. intervention.IfIf any you get get your your Significant significant others others involved involved early early in in the the escalation escalation process, and you process, and trust them them enough enough to to take take your your credit credit cards, cards, provide provide final final signamres signatures on on intrust in­ vestments, or or offer offer input input into into your your spending spending decisions, decisions, you you may m a y be be able vestments, able to to avoid a a major major financial financial collapse. collapse. Remember R e m e m b e r that that most most major major financial financial deciavoid deci­ sions require require a a second second opinion opinion even even in in the the best best of of circumstances! circumstances! sions

Giving Up the theCar CarKeys Keys Giving Up

Are Art your your manic manic episodes episodes usually usually characterized characterized by by reckless reckless driving? driving? This This is is the the case for for some s o m e people people and and not not for for others. others. One O n e male male client cHent put it SUCCinctly: succinctly: "My "My case put it highs almost almost always always go go along along with with some some problem problem involving involving my m y car." car." If If you you do do highs have have a a poor poor driving driving record, record, your your early early warning warning signs signs may m a y Signal signal the the need need to to stop driving driving for for now. n o w . Mania-much M a n i a — m u c h like like drinking drinking alcohol-makes alcohol—makes your stop your drivdriv­ ing ing unsafe unsafe for for yourself yourself and and others. others. You Y o u are are at at espeCially especially high high risk risk for auto for an an auto accident if if you you are are in in a a manic manic state state and and are are also also drinking drinking and and driving, driving, as assome some accident people people do. do.

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is yet anotherarena Your sig­ ThisThis is yet another which it ithelps helpstoto have others' input. Your sigarena in in which have others' input. nificant good judgments nificant others others can can collaborate collaborate in in helping helping you you make m a k e good judgments about about

whether you you can can drive drive safely. safely. While While you you will will resent resent that your spouse spouse or or sibwhether that your sib­ lings have have access access to to the the car car and you don't, don't, remember remember that thatit itisisonly onlyfor forthe thelim­ limlings and you ited until your manic or doc­ ited time time until your manic or hypomanic hypomanic symptoms symptoms have have cleared. cleared. Your Your doctor's tor's input input will will also also be be valuable if he he or or she she knows k n o w s your your driving driving history. history. valuable if

Avoitling Decisions Avoiding Maior MajorLife Life Decisions When youhave haveone oneor or more early warning avoid making decisions when you more early warningsigns, signs, avoid making decisions that that

could affect affect your your or or olhers' others' futures, futures, particularly particularly if if these these decisions decisions involve could involve meetings with people meetings with people who w h o have have a a degree degree of of "fate "fate controL" control." Now N o w is is not not the the time time

to ask ask your your boss boss for for a a raise raise or or a a change change in in job job duties-you duties—you are are likely likely to to come come to him or strate­ across to to him or her her as as demanding demanding and and entitled entitled (see (see also also Chapter Chapter 12 12 on on strateacross

gies for for coping coping in in the the work work setting) setting).. If If you you are are an an employer, employer, delay delay your your decigies deci­ sion employees to structural changes sion to to assemble assemble your your employees to inform inform them them of of major major structural changes in about your your family family life in the the company. company. Likewise, Likewise, avoid avoid making making decisions decisions about life that that could could lead lead to to long-term long-term consequences, consequences, such such as as getting getting married, married, divorced, divorced, de­ deciding ciding to to have have children, children, deciding deciding to tobuy buy aanew n e w house, house,moving moving to toanother anothercity, city,

or Switching switching your your children children to to a a new n e w school. or school. It's It's hard hard to tomake m a k e these theseagreements agreements with withyourself, yourself,and and even even harder harder to toim­ im-

plement them them when w h e n you you feel feel so so good, good, so so optimistic, optimistic, and and so so elated. elated. The The deciplement deci­ sions you you feel feel pressed pressed to to make m a k e when w h e n you you are are getting getting manic manic seem seem like like great sions great ideas at at the the time, time, even even though though to others—or even even to to yourself yourself when w h e n you're you're ideas to others--or well—the ideas seem seem unrealistic unrealistic and and extremely extremely risky. risky. Try Try to to think of the the preswell-the ideas think of pres­ sure to to m a k e these decisions, along alongwith withyour your feeling feelingof ofgreater greatermental mentalclarity, clarity, sure make these decisions, as a a pan part of of your your illness illness (especially (especially if if you you also also notice notice other othersymptoms, symptoms,such such as as as distractibility, racing racingthoughts, thoughts,or oran an increase increase in inyour your sex sexdrive). drive).People Peoplewith with distractibility, bipolar disorder disorder almost almost invariably invariably make m a k e their their best best life life decisions decisions when w h e n they're bipolar they're in the remitted, euthymic euthymicstate, state,and andthey theyusually usuallyend endup upregretting regrettingthose thosedeci­ decithe remitted, in sions they they made m a d e while while manic. manic. sions

Avoiding Risley RiskySexua' Sexual Situations Avoitling Situations "I" Iwas manic and and got got tired tiredofofbeing beingaround aroundCarol Caroland andthe the wasgetting getting real real manic kids, so so II went out to to a a bar. bar. II ran ran into into this this old old girlfriend and got got drunk drunk kids, went out girlfriend and with her. W e wound w o u n d up up in in bed bed that that night. can't believe believe II did did that-I'm that—I'm with her. We night. II can't not that that kind kind of of person person!! IItt seemed like such such a a great great thing thing at at the the time. Of not seemed like time. Of course, II felt felt terrible terrible about about it later and and it it really really hun hurt my m y relationship relationship with with course, it later

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Carol. though she about knows about and its and all that, Carol. EvenEven though she knows mania andmania its biology andbiology all that,

she still still blames b l a m e s me m e for for geuing getting myself myself in in that that situation situation in in the the first place. she first place. S h e thought thought it it was w a s what w h a t II really really wanted w a n t e d to to do, d o , and a n d the the mania m a n i a just just gave gave She m e the the excuse excuse to to do d o it." me it."

-A — A 46·year·old 46-year-old man m a n with with bipolar bipolar II disorder disorder rewarding endeavors, has a particular when you're get· Like Like many many rewarding endeavors, sex has asex particular pull whenpull you're get-

ting manic. m a n i c . This This can c a n be b e lrue true even e v e n if ifyou're you're aaperson person who w h o is issexually sexually conserva­ conservaling tive in in your y o u r stable stable times. times. People People get get themselves themselves into into very very risky risky sexual sexual situa­ situative tions tions when w h e n they they are are escalating, escalating, and a n d sometimes s o m e t i m e s the the emotional emotional results-which results—which

can include include feelings feelings of of shame, s h a m e , humiliation, h u m d i a t i o n , and a n d anger-worsen a n g e r — ^ w o r s e n their their cycling cycHng can m o o d state. state. And, A n d , as as you y o u know, k n o w , impulsive impulsive encounters encounters carry carry a a high high risk conmood risk of of con­ tracting sexually sexually transmitted transmitted diseases. diseases. tracting A s 1I discuss discuss in in Chapter C h a p t e r 2, 2, mania m a n i a is is more more a a goal-driven goal-driven state state than than a happy As a happy one. W h e n you y o u feel feel strongly strongly pulled pulled toward toward rewards, rewards, it's it's hard hard to to step step back b a c k and and one. When ask whether w h e t h e r you're you're making m a k i n g healthy healthy decisions decisions for for yourself. yourself. Some S o m e people benefit ask people benefit from k n o w i n g that that they're they're prone p r o n e to to sexual sexual �acting "acting out" out" when w h e n they're they're in the from knowing in the prodromal yourself is is the the first first p r o d r o m a l and a n d active active phases phases of of mania. m a n i a . Knowing K n o w i n g this this about about yourself

step toward controlling it. step toward controlling it. The sexual situations T h e best best way w a y to to avoid avoid dangerous d a n g e r o u s sexual situations is is to to sspend p e n d as as much much time as possible possible with with people people yyou trust, wwho can talk talk yyou out of of time as o u kknow n o w aand n d trust, h o can o u out

impulsive sexual sexual encounters. encounters. That T h a t is, is, when w h e n you y o u go g o out o with impulsive out at at night, night, ggo with a a friend who w h o knows k n o w s about about your y o u r illness and w h o can can "run "run interference'' when friend illness and who interference" when y o u start to show s h o w ppoor o o r jjudgment. u d g m e n t . MMake a k e special efforts to stay away a w a y from f r o m alcoyou start to special efforts to stay alco­ hol and hol a n d street drugs: There T h e r e is w o r s e than than "self-medicating" n escalatstreet drugs: is nothing nothing worse "self-medicating" a an escalat·

ing mmood o o d wwith i t h caffeine, alcohol, which w h i c h will will almost almost certainly certainly contrib­ contribing caffeine, drugs, drugs, or or alcohol, ute o u r mmood o o d escalation n d lower o u r threshold threshold for n aa sexual sexual ute to to y your escalation aand lower yyour for acting acting oon impulse. EEncourage ncourage y o u r friends ou h o m e if they think think you're you're making making impulse. your friends to to take take y you home if they foolish omefoolish decisions. decisions. Ultimately Ultimately the the decision decision to to have, have, or or not not have, have, sex sex with with s some­ o n e is u t limit-setting f r o m others quite irritating irritating to to you you one is yours yours alone, alone, b but limit-setting from others (even (even if if quite

at a n help e e p yyou o u ffrom r o m getting at the the time) lime) ccan help k keep getting into into encounters encounters that that you'll you'll regret regret later. later. SSome o m e people improve people report report that that their their primary primary romantic romantic relationships relationships improve wwhen h e n they a n i c or y p o m a n i c because e c o m e mmore o r e sexually they get get mmanic or hhypomanic because they they bbecome sexually enen­ gaged n increase gaged with with their their partners. partners. Others Others report report that that aan increase in in their their sexual sexual enen­ counters i t h their p w a r d escalation ania. counters wwith their partner partner contributes contributes to to their their uupward escalation into into mmania. But, o s t people, a n i c doesn't e a n having But, for for mmost people, being being mmanic doesn't mmean having to to avoid avoid sex sex with with their their regular a n bbe e aa ggood o o d outlet o u r energy regular partner. partner. In In fact, fact, sex sex ccan outlet for for yyour energy if if it it is is with with the e r s o n at h e kkey e y is o u r mmania a n i a to the right right pperson at the the right right time. time. TThe is not not to to allow allow yyour to drive drive yyou o u ttoward o w a r d irresponsible irresponsible or or risky risky sex. sex.

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A Reminder Reminder to to Use Use YOUI YourIIMaintaining "Maintaining Wellness" Strategies A WeI/ness" Straleg;es When stagesofofmania, mania, is essential to implement Whenyou youare arein inthe the early early stages it it is essential to implement the the strategies for for maintaining maintaining wellness wellness outlined outlined in Chapter 8. 8. [I won't won't reiterate strategies in Chapter reiterate them them all all here; here; suffice suffice it it lO to say say that that now n o w is is an an especially especially important important time time to to Try as night's maintain maintain a a regular regular daily daily routine. routine. Try as well well as as you you can can to to get get a a full full night's sleep sleep (your (your doctor doctor may m a y be be able able to to recommend recommend sleeping sleeping medications) medications) and and to to keep week to Avoid stressful keep your your hours hours consistent consistent from from the the week to the the weekend. weekend. Avoid stressful in­ interactions with other other people, people, particularly family members, members, lO to the the extent extent possi­ possiteractions with particularly family ble. Stick Stick closely closely to to your your medication medication regimen. regimen. Continue Continue lO to chart chart your your mood mood ble. on possible. on a a daily daily basis basis to to identify identify changes changes in in your your status status as as early early as as possible.

Step Maneuvers Your Doctor Step 2, 2, Pari PartB:B:Preventative Preventative ManeuversInvolving Involving Your Doctor Collaborating with your psychiatrist to prevent or diminish the impact your of your Collaborating with your psychiatrist to prevent or diminish theofimpact manic will tell manic episodes episodes is is more more complicated complicated than than it it sounds. sounds. Most Most psychiatrists psychiatrists will tell you that you you that you should should call call them them for for an an emergency emergency medical medical appoimment appointment when when you you think think your your illness illness is is getting getting worse. worse. This This sounds sounds like like a a "no "no brainer." brainer." But But the reality reality is is that that you you may m a y not believe you you are are really really ill ill or or that that your your illness illness is is the not believe bad bad enough enough to to warrant warrant a a phone phone call. call. Alternatively, Alternatively,you you may m a y not notfeel feelcomfort� comfortable calling calling your your doctor, doctor, especially especially if if he he or or she she is is n e w to to you you or or if you have have new if you able had bad experiences experiences with with calling calling him him or or her the past. had bad her in in the past. Even if if you you see see the the need need for for emergency emergency care, care, you you rr.. m_ay have doub[S doubtsaboUl about Even ay have how h o w much m u c h your your dOClor doctor will wiH really really help help you. you. You Y o u may m a y fear fear that he or or she she will wiU that he introduce medication medication changes changes that that have have worse worse side side effects effects than than the the ones ones you you introduce already experience. experience. You You m a y fear that he he or or she she will will immediately immediately hospitalize already may fear that hospitalize you, which which would would cause cause you you social social embarrassment embarrassment at at work work or or at at home. home. Of Of you, course, you you are aremore more likely likelyto toavoid avoid hospitalization hospitalization if ifyou you call callyour your physician physician course, early than than if if you you wait wait until the point point of of "no "no return. return." But But calling calling during during an an until the early emergency requires requires a a certain certain amount amount of of trust trust thal that the the physician physician will wiH approach approach emergency you compaSSionately compassionately and and take take steps steps that that will wiH alleviate, aHeviate, not notworsen, worsen,your yoursymp­ sympyou physician toms. This This section section deals deals with strategies for for collaborating collaborating with toms. with strategies with your your physician during times of emergency. emergency. during times of �

"When Should Call, and What Should I Say?" "When Should II Cott, ond Wha' Should I Say?" A good ofthumb thumb isistoto caH soon as you like mood your mood or energy good rule rule of call as as soon as you feel feel like your or energy A level has changed upward or downward, or if you believe (or if a significant level has changed upward or downward, or if you believe (or if a significanl In other believes) believes) that that you've you've developed developed one one or or more more prodromal prodromal symptoms. symptoms. In other

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other words, err err on the getting when you or others thinkor you might think y other words, onside theofside ofhelp getting help when you others need it, rather rather than than assuming assuming you you don't don't and and being being wrong. wrong. need it, Make sure your doctor's phone numbers numbers (or the numbers of the the clinic clinic Make sure your doctor's phone (or the numbers of he or or she she works) works) are are easily accessible, including where easily accessible, includinghis hisor orher heremergency emergency where he contact information. information. There There are are places your mania contact places on on your mania prevention prevention contract contract (at (at the end end of of this this chapter) this information. information. Most Most physicians physicianshave have an­ anchapter) to to record record this the doctor available on weekends. weekends. other doctor available for for emergencies emergencies during during vacations vacations or or on other Usually the the phone numbers of of this this backup backup physician physicianare areincluded included in inthe themes­ mesUsually phone numbers sage on on your your doctor's doctor's or or the the clinic's clinic's emergency emergency phone phone line. line. When W h e n you you do do sage reach reach your your phYSician physician or or his his or or her her backup, backup, be beready readyto torecount recountany anyprodromal prodromal symptoms you you think you have have developed. developed. think you symptoms Below interchange between bipolar I I disor­ Below is is a a telephone telephone interchange between a a person person with with bipolar disorder, Chad, and der, Chad, and his his psychiatrist, psychiatrist, Dr. Dr.Eastwood. Eastwood. CHAD: Yeah, think I'm I'm going off again. Chad: Yeah,1 I think going off again. DR. Dr. EASTWOOD: Eastwood: What's What's going going on? on? Chad: I'm I'mtaking takingmy m y medication, medication,but butI'm I'mhaving havingall allsorts sortsofofthoughts thoughts andstuff. stuff. CHAD: and

DR. Dr. EAsTWOOD: Eastwood: ThoughlS Thoughts about about what? what? CHAD: Chad: Like Like about about the the past. past. About Aboutmy m y dad dad and and his hisdeath deathand and stuff. stuff. DR. Dr. EASTWOOD: Eastwood: How's How's your your mood, mood, Chad? Chad? Any Any changes? changes? Chad: Yeah, Yeah, just justmore more pissed pissedoff, off, getting gettinggrouchy, grouchy,yelling yellingat atthe thekids. kids.IIjust just CHAD: don't know know if if I1 wanna wanna do do the the whole whole family family thing thing anymore. anymore. don't Dr. EASTWOOD: Eastwood: How's How's your your sleep sleep been been the the last last few few nighlS? nights? DR. Chad: OK, O K , but but not not great; great; can't can'tstay stayasleep asleepvery verylong. long.I've I've beenpacing pacingatatnight night CHAD: been and stuff. stuff.ThoughlS Thoughtsgoing goingaamile mfleaaminute. minute.Bed's Bed'snot notcomfortable. comfortable. and Dr. EASTWOOD: Eastwood: Sounds Sounds like Hke aa lot's lot'sgoing goingon onright rightnow. now. Anything Anythingelse elseI need I needtoto DR. know? Are Are you you thinking thinking about about hurting hurting yourself? yourself? Do D o you you feel feel like Hke you you know? need need to to be be in in the the hospital? hospital?

CHAD: Chad: No, No, not not there there yet. yet. Just Just upset upset and and stuff. stuff.Mad, Mad,can't can'tsleep. sleep. DR. Dr. EAsTWOOD: Eastwood: How H o w have have things things gone gone with with your your medications? medications? Chad: II missed missed my m y lithium Hthium this this morning, morning, took took it it this this evening. evening. CHAD: In this interchange. Dr.Eastwood Eastwood has done a quick assessment and conIn this interchange, Dr. has done a quick assessment and con­ cluded cluded that that Chad Chad may may be be in in the the prodromal prodromal phases phases of ofaa manic manic or or aa mixed mixed epi­ episode. sode. At At this this stage, stage, Chad's Chad's escalation escalation can can be be treated treated on on an an outpatient outpatient basis, basis, which Dr. Dr. Eastwood Eastwood did did by by setting setting up up an an emergency emergency medical medical appointment, appointment,in­ inwhich creasing the the dosage dosage of of Chad's Chad's lithium, lithium,and andadding addingaasmall smalldose doseof ofan anantipsyan tipsycreasing

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chotic medication. medication.AAblood bloodtest test revealed Chad's lithium was low, chotic revealed thatthat Chad's lithium levellevel was low, even though though Chad Chad said said that that he he had had been been taking taking the the medication medication relatively regueven relatively regu� larly. These Thesechanges changesto tohis hismedication medicationregimen regimendid didthe thetrick trickwithout withoutaahost hostof of larly. n e w side side effects. effects. Within Within aaweek, week,Chad's Chad'smania mania had had stopped stopped escalating escalatingand and he he new state. began began 1O to return return to to his his baseline baseline state. Chad Chad did did a a good good job job of of describing describing his his prodromal prodromal symptoms. symptoms. Dr. Dr. Eastwood Eastwood guided him him toward toward describing describing these these symptoms symptoms and and his his medication medication usage. usage. She She guided was off the the track. was fairly fairly task-oriented task-oriented and and kept kept Chad Chad from from going going off track. Notice Notice that that Dr. Eastwood Eastwood did not pursue pursue any psychotherapeutic issues issues over over the the phone, Dr. did not any psychotherapeutic phone, such that such as as Chad's Chad's feelings feelings about about his his father father or or his his current current family. family. Expect Expect that w h e n you you call call your physician under under emergency emergency circumstances, circumstances, in in most most cases when your physician cases he he or or she will not not conduct conduct a a psychotherapy psychotherapy session session with with you. you. This This may m a y be be she will frustrating because because you a y feel feel that that certain certain personal personal issues issues are are important important in frustrating you m may in explaining explaining your your symptoms. symptoms. Many M a n y people people believe believe that that their their manic manic symptoms symptoms are triggered by feelings of loss. as are triggered by feelings of loss, as was was Chad's Chad's belief. belief. But But the the emergency emergency phone call call to to your physician is is mainly mainly for for the the purpose purpose of of evaluating evaluating whether whether phone your physician a change change in in medication medication is is necessary necessary or, or, in in more more extreme extreme circumstances. circumstances, a whether you you need need to to be be hospitalized. hospitalized. In a session session with with your therapist, once once whether In a your therapist, your have settled or she may you make your symptoms symptoms have settled down, d o w n , he he or she m a y be be able able to to help help you make sense of of how h o w current current or or past stressors are are contributing contributing to to your your escalating escalating sense past stressors mood. mood. "What I'm Uncomfortable Uncomfortablewith with Physician?" If I'm MyMy Physician?" "WhatIf Robert, described described at at the the beginning beginning of of this this chapter, chapter, did did not notparticularly particularlylike likehis his Robert, physician and saw saw her her infrequently. infrequently. Perhaps Perhaps as as a a result, result, this thisdoctor doctorwas was not notas as physician and helpful as as she she could have been been in in preventing preventing his his manic manic episode. episode. Had H a d he he been been could have helpful in contact contact with with a a doctor doctor with with whom w h o m he he had had a a good good relationship, face-to-face in relationship, aaface-to-face session might have been been arranged arranged qUickly, quickly, with with more positive results. session might have more positive results. Not everyone everyone feels feels comfortable comfortable calling calling his his or or her her doctor doctor during during an an emerNot emer­ gency, and and during during a a manic escalation your your discomfort discomfort may m a y be be exaggerated exaggerated gency, manic escalation (most emotions emotions become become more more dramatic dramatic during during mania). mania). One O n e of of my m y psychotherpsychother­ (most called apy clients, clients. Holly, Holly, had had longstanding frustrations with with her her doctor. doctor. She She called apy longstanding frustrations Dr. Nelson on on a a number number of of occasions occasions when w h e n she she felt she was was rapidly rapidly cycling. felt she cycling. Dr. Nelson Typically, Dr. Dr. Nelson Nelson did did not call her her back. back. She She considered considered Switching switching physiTypically, not call physi­ cians but convinced she she had had given given Dr. Nelson a a fair fair try. but wasn't wasn't convinced Dr. Nelson try. cians encouraged Holly Holly to to talk talk over over this this dilemma dilemma with with Dr. Dr. Nelson, Nelson, aa man man II encouraged w h o m II had had experienced experienced as as very very approachable. approachable. But But Holly Holly felt felt uncomfortable uncomfortable whom broaching the the topic, topic, fearing fearing that that he he was was going going to to "fire m e as as a a patienl." patient." II fi­ fibroaching "fire me nally interceded interceded and called Dr. Dr. Nelson Nelson when w h e n Holly Holly developed developed mixed mixed affective nally and called affective talk symptoms and and suicidal suicidal thoughts. thoughts. Dr. Dr. Nelson Nelson laid told me m e that that he he had had tried tried to to talk symptoms

Whol I'm IGelling What (on Can IIDoDaIfIIfThink I Think 'm GettiMani{? ng Manic?

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to Holly Holly on ona anumber number of occasions bUl that she hadn't returned his calls. He to of occasions but that she hadn't returned his calls. He also her symptoms, also found f o u n d that that when w h e n giving giving Holly Holly advice advice on o n how h o w to to control control her symptoms, frustrations on she would w o u l d become b e c o m e angry angry and a n d uncooperative. uncooperative. So S o there there were w e r e frustrations on she both sides. sides. both Eventually, Eventually, we w e scheduled scheduled a a meeting m e e t i n g involving involving Holly, Holly, Dr. Dr. Nelson, Nelson, and a n d my­ myself self and a n d hammered h a m m e r e d out out a a series series of of agreements agreements regarding regarding what w h a t steps steps would w o u l d be be Dr. Nelson raken taken if if she she developed developed mixed m i x e d or or manic m a n i c symptoms s y m p t o m s in in the the future. future. Dr. Nelson gave an a n additional additional phone p h o n e number n u m b e r to to Holly, Holly, and a n d explained, explained, again, again, his his emer­ emergave gency gency and a n d backup/vacation backup/vacation policies. policies. There T h e r e is is still still tension tension in in their their relationship relationship about handling handling emergencies emergencies b u t to to a a lesser lesser degree. degree. Ultimately, Ultimately, Holly's Holly's treatabout but treat­ ment m e n t was w a s made m a d e more m o r e successful successful by b y the the direct direct contact contact between b e t w e e n her her psychiatrist psychiatrist a n d psychotherapist psychotherapist (see (see also also Chapter Chapter 66). ). and Your Y o u r best best option option is is to to talk talkover over your y o u r concerns concerns with with your y o u r physician physician until until you you feel reasonably reasonably comfortable comfortable aboUl about contacting contacting him h i m or or her her in in an a n emergency. emergency. feel Explain Explain your y o u r fears fears about a b o u t new n e w medications, medications, side side effects, effects, or or the theneed n e e d for forhospital­ hospitalization "bottom ization (discussed (discussed more m o r e on o n pages pages 206-208). 2 0 6 - 2 0 8 ) . If If your your " b o t t o m line" line" is is that that you you would w o u l d never never call call this this person person when w h e n you're you're feeling feeling bad, bad, find find another another physician. physician.

"ShouldSomebody Somebody Me?" "Should ElseElse CallC.II for'0' Me?" When youyou feel exhilarated, excited, and goal-driven, youyou may may see no to When feel exhilarated, excited, and goal-driven, seereason no reason to destroy it it by b y taking taking what w h a t the the physician physician has has to to offer-which o f f e r — w h i c h is is usually usually more more destroy medication. For F o r this this reason, reason, it it may m a y make m a k e sense sense for for someone s o m e o n e dose close to to you y o u to medication. to m a k e the the call call to to your y o u r physician. physician. Give G i v e members m e m b e r s of of your y o u r core core circle circle s o m e leemake some lee­ way w a y in in deciding deciding when w h e n 10 to make m a k e this this call, call, recognizing recognizing that that you you m a y not agree may not agree that your y o u r physician's physician's help is needed. needed. It It is is my m y strong strong impression-both i m p r e s s i o n — b o t h in in my my that help is clinical clinical practice practice and a n d in in our o u r research research studies-that studies—that people people who w h o have h a v e allowed allowed m e m b e r s of of their their core core circle circle to to call call their their doctors doctors in in emergencies emergencies have h a v e had had members better better outcomes o u t c o m e s (for (for example, e x a m p l e , Miklowitz Miklowitz et et aI., al., 2000). 2 0 0 0 ) . For F o r example, e x a m p l e , Paul, the Paul, the h u s b a n d of of Lorraine, Lorraine, a a 64-year-old 64-year-old woman w o m a n with with bipolar bipolar II disorder, disorder, routinely routinely husband called called his his wife's wife's doctor doctor whenever w h e n e v e r she she became b e c a m e giddy, giddy, delusional, delusional, or or agirated. agitated. Lorraine's doctor doctor was w a s usually usually able able to to deal deal with w i t h the the escalation, escalation, over over the the Lorraine's phone, p h o n e , by b y making m a k i n g adjustments adjustments to to her her prescriptions, prescriptions, instead instead of of hospitalizing hospitalizing her. her. Contact between b e t w e e n your y o u r relatives relatives and a n d your y o u r doctor doctor may m a y require require mmutual u t u a l un­ unContact derstanding derstanding about a b o u t treatment treatment policies. policies. Your Y o u r doctor doctor should should make m a k e clear clear to to you you a n d your y o u r relatives relatives the the circumstances circumstances under u n d e r which w h i c h they they should should call call (for (for exam­ examand ple, when w h e n you y o u are are clearly clearly escalating, escalating, when w h e n you y o u are are refusing refusing all o u r treatple, all yyour treat­ m e n t s ) . Your Y o u r relatives relatives may m a y have have a a set set of of expectations expectations that that may m a y bbe e unrealistic, ments). unrealistic, such as: as: Your Y o u r doctor doctor will will call call them t h e m as as soon s o o n as as you've you've missed missed an a n appointment appointment such or as as soon s o o n as as you've you've reported reported any any symptoms; s y m p t o m s ; your y o u r doctor doctor will will discuss discuss any any or

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SSElF�MANAGEMENI ELF-MANAGEMENT

they can call planned plannedmedication medication adjustments withbefore them making before them; making them; they can c adjustments with them whenever whenever there there has has been been aa family family argument argument or or whenever whenever they they want want to to know know something something about about bipolar bipolar disorder. disorder. These Theseare areassumptions assumptionsyour yourphysician physicianmay may not your doctor, not share. share. Remember Remember to tosign signaarelease-of-information release-of-informationform formfor for your doctor, al­ allowing lowing your your chosen chosen relative relative to to exchange exchange infonnation information with with him him or or her. her. Consult can accom­ Consult your your physician physician as as to towhether whetheraafriend friendor orclose closerelative relative can accom-

pany you you to to your your emergency emergency medical medical visits. visits. IfIfyou youhave havebecome becomeconfused confusedoror pany distractible other may bebe better able to to distractibledue dueto toyour yoursymptoms, symptoms,your yourSignificant significant other may better able recall recall the the physician's physician's recommendations recommendations when when you you need need to to implement implement them them later also Chapter 12). later (see (see also Chapter 12).

"Who' "What Will WillMy M y Doc'or Doctor001" Do?"

During session, your physician will probably the stepstake out­ the step Duringan anemergency emergency session, your physician willtake probably

lined in in the the sidebar. sidebar. He He or orshe shewill vidllstart start assessing your symptoms and lined byby assessing your symptoms and re­reevaluating your your medication medication regimen. regimen.Your Yourdoctor doctormay maydecide decideto tomake makechanges changes evaluating to AA major to your your regimen regimen over over the thephone phone if ifan anappointment appointmentcan't can'tbebearranged. arranged. major

intent of of catching catching and and treating treatingyour your symptoms symptoms early earlyis isto tohelp helpyou youavoid avoidhos­ hosintent pitalization, is is notnot possible, your doctor can can helphelp youyou arrange one.one. pitalization,but butififthis this possible, your doctor arrange He questions Dr. East­ He or or she shewill willusually usuallybegin beginby byasking askingyou youthe thekinds kindsofof questions Dr. East-

wood asked asked Chad. Chad. Physicians vary on on which which symptoms symptoms they they emphaSize emphasize (some (some wood PhYSicians vary focus on on mood mood and and others others on on activity activity levels levels or orsleep), sleep),but butgenerally, generally, the more focus the more you can can speak speak to to him or her her in in the the language language of of prodromal prodromal symptoms symptoms (for (forex­ exyou him or ample, racing racing thoughts, thoughts, goal-driven goal-drivenbehavior, behavior,decreased decreased need need for forsleep), sleep),the the ample, more he he or or she she will will know know what what to torecommend. recommend.Your Your physician physician will willprobably probably more want to know know if if you you have havemissed missed any any dosages dosages of ofyour your medication, medication,and and you you want to should be be as as honest honestas aspossible possibleabout aboutthis! this! Itnot 's not at uncommon all uncommon for people should It's at all for people

Steps Your Physician Will Will Take Take Steps Your Physician to Prevent Prevent the the Escalation Escalation of of Mania Mania to •

• Perfonn Performananassessment assessment of severity the severity of your symptoms of the of your symptoms • Evaluate Evaluate blood blood levels levelsof ofyour your mood mood stabilizing stabiHzing medications medications • • Make Make changes changes to toyour your medication medication regimen, regimen,including includingadding addingor or • subtracting certain certain medications medications or or increasing increasing the the dosage dosage of subtracting of current medications medications current • Arrange Arrange aahospitalization, hospitalization,ifif necessary • necessary

What I'm Getting Mani
205205

(especiallyif if they to take take aa lot lot of they to miss miss dosages dosages (especially they are are expected expected to of pills) piHs) when when they to

are becoming becoming manic or hypomanic. hypomanic. are manic or

If your doctor If you you are are on on lithium, lithium, Depakote, Depakote,or or(less (lessfrequently) frequently)Tegretol, Tegretol, your doctor may be interinter­ m a y ask ask you you to to get get your your blood blood level level tested. tested. He H e or or she she will will most most likely likely be

1 4 hours ested in in your your "trough" "trough" level, level,which whichis isusually usuallycollected collected10-10-14 hoursafter afteryour your ested last dose dose (people (people who w h o get get their their blood blood level level checked checked just just a a few few hours hours after after taklast tak­ when, fact, ing their their last last dose dose may m a y appear appear to to be be getting getting enough enough medication medication w h e n , in in fact, ing

they are are not). For example, example, if if you you have have been been taking taking lithium lithium and and your trough they not). For your trough level level is is 0.6 0.6 mEqll m E q / L or or less less (see (see Chapter Chapter 6), 6), he he or or she she may m a y conclude conclude that that you've you've

missed dosages dosages or or that that your your dosage dosage is is too too low low to to be be therapeutic therapeutic and and recom­ recommissed

mend m e n d that that you you increase increase your your lithium Hthium dosage dosage as as a a way w a y of of preventing preventing further further es­ es-

calation. Because Because it it may m a y take take a a few few days days before before your your blood blood level processed, level is is processed, calation. your your doctor doctor may m a y decide decide not not to to wait wait for for that that information information before before changing changing your your dosage, all dosage, especially especially if if he he or or she she has has been been collecting collecting blood blood level level information information all

along. along. If If possible, possible, he he or orshe shewill willincrease increasethe thefrequency frequency of ofYOUT your treatment treatment ses­ ses-

sions during during the the interval interval in in which which your your symptoms symptoms are are worsening. worsening. sions

If stabilizer, If your your physician physician increases increases the the dosage dosage of of your your primary primary mood m o o d stabilizer, you of you and and your your significant significant others others will will want want to to become become familiar familiar with with the the signs signs of as­ "neurotoxicity" "neurotoxicity" (see (see also also Chapter Chapter 6), 6), which which are are the the medical medical complications complications as-

sociated with with getting getting too too much m u c h of of a a medication. medication. For For lithium, lithium, these these symptoms symptoms sociated include diarrhea, include drowsiness, drowsiness, severe severe nausea, nausea, abdominal abdominal discomfort, discomfort, severe severe diarrhea,

blurry vision, vision, slurred slurredspeech, speech,muscle muscletwitching, twitching,or orbeing beingconfused confusedas astotowhere where blurry or who w h o you you are. are. For For Depakote, Depakote, they they include include severe severe dizziness, dizziness, drowsiness, drowsiness, ir­ iror regular breathing, breathing, severe severe trembling, trembling, or or coma. coma. For For Tegretol, Tegretol, they they include include dou­ douregular ble ble vision, vision, unsteadiness unsteadiness when w h e n walking, walking, or or feeling feeling dizzy. dizzy. If If you you show s h o w any any of of

these symptoms, symptoms, your your doctor doctor should should be be notified notified immediately-by immediately—by you you or or a these a m e m b e r of of your your core core circle--so circle—so that that he he or or she she can can adjust, adjust,or oreven even take takeyou you off, off, member these medications. these medications.

Your doctor doctor may m a y add add some s o m e of of the the medications medications discussed discussed in in Chapter Chapter 6, in6, in­ Your cluding atypical atypical anti antipsychotics with mood m o o d stabilizing stabiHzing properties properties such such as as cluding psychotiCS with Zyprexa, Zyprexa, or or benzodiazepines benzodiazepines such such as as Klonopin Klonopin or or Ativan. Ativan. These These medications medications

m a y help help bring bring you you down d o w n from from an an activated, activated, agitated agitated state, state, improve improve your your may sleep,and and treat treatdelusional delusionalthinking thinking(for (forexample, example,paranoia). paranoia).If Ifyou you are areon on only only sleep, one one mood m o o d stabilizer, stabilizer, your yourdoctor doctormay m a y add addaasecond second one one (for (forexample, example,adding adding

Depakote to to lithium). lithium). These These decisions decisions are are often often based based on on physician physician choice choice Depakote rather rather than than research research data. data. For For example, example, we w e do do not not know k n o w whether whether simply simply inin­

creasing the the dosage dosage of of lithium lithium or or valproate valproate is is more more or or less less effective effective in in preventcreasing prevent­ ing ing relapses relapses of of mania mania than than taking taking the the two two mood m o o d stabilizers stabilizers together together (Sachs, (Sachs,

1998). 1998). Don't be be surprised surprised if if your your physician physician believes believes that that the the best best treatment Don't treatment for for your escalating escalating mania mania is is to to stop stop taking taking one one of of your your current current medications medications rather rather your

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SELF-MANAGEMENT SElF�MANAGEMENT

than to start start you a newone. one. If you getting andbelieved are believed to than to you onon a new If you are are getting manicmanic and are to have rapid inter­ have rapid cycling cycling (four (four or or morE': more episodes episodes per per year) year),, the the most most effective effective inter-

vention m a y be be to to discontinue discontinue your your antidepressant, antidepressant, if if you you are are on on onE': one vention may (Kukopulos (Kukopulos et et al., al., 1980; 1980; Wehr W e h r et et al., al, 1988; 1988; Sachs, Sachs, 1996). 1996). Your Your physician physician is is

unlikely to to start start you you on on an an antidepressant antidepressant when w h e n you you are are escalating escalating (see (see Chap­ Chapunlikely ter 6). 6). Your Your physician physician m a y also also recommend recommend that that you you discontinue discontinue your your antimay anti­ ter psychotic medications periodic use psychotic medications or or your your periodic use of of caffeine caffeine or or bronchodilators bronchodilators such (Sachs, 1996). such as as Proventil Proventil (Sachs, 1996).

�'WhenIs Is Hospitalization Required?" "When Hospitalization Required?" M a n y people people with with bipolar bipolar disorder disorder never never need need to to be be hospitalized. hospitalized. In In addition, addition, Many alternatives to to inpatient inpatient hospitalization-such hospitalization—such as as partial partial hospital or day day hospialternatives hospital or hospi­ tal tal programs-have programs—have emerged emerged in in recent recent years years as as shan-term short-term strategies strategies for for emer­ emer-

gencies. These These programs provide close close monitoring monitoring of of your your symptoms symptoms and and gencies. programs prOvide treatment response without the need need to treatment response without the to enter enter an an inpatient inpatient facility. facility. But Butififyour your manic manic symptoms symptoms escalate escalate to to a a cenain certain point point of of disruptiveness, disruptiveness, or or if ifyou you are areac­ ac-

tively suicidal suicidal or or dangerous dangerous to to others, others, there there is is a a good good chance chance that that your your doctor tively doctor

will recommend will recommend thal that you you be be hospitalized hospitalized for for a a period period of of time. time. You Y o u are are more more

likely to to be be hospitalized hospitalized if if you you are are manic manic (or mixed) than than if if you you are likely (or mixed) are hypomanic or or depressed. depressed. hypomanic

It is very very common c o m m o n for for people people in in manic manic episodes episodes to to believe believe that that being being in h is in

the hospital hospital is is not not necessary. necessary. Often Often they they insist insist on on leaving leaving very very soon soon after after they the they are admitted, admitted, thinking thinking they are closer closer to to recovery recovery than doctors or or others others are they are than their their doctors m a y think. you have have had had some some of these experiences. experiences. But if your your docmay think. Perhaps Perhaps you of these But if doc­ tor believes tor believes that that you you are are at imminent risk risk of of hurting hurting yourself yourself or or someone someone else, at imminent else,

or are are otherwise otherwise not not able able to to take take care care of of yourself, yourself, it is his his or or her her professional, or it is profeSSional, ethical, and and legal legal responsibility responsibility to to seek seek permission from a a judge judge to to continue continue ethical, permission from inpatient treatment, treatment, under a court order if if necessary. necessary. You Y o u won't won't feel feel good good inpatient under a coun order about this course of of action, action, but butititmay m a ybe benecessary necessarytotopreserve preservesafety safetyfor foryour­ yourabout this course self and and others. self others. If your doctor doctor does does recommend recommend hospitalization, hospitalization, it is usually usually easiest easiest if if he he If your it is or she she calls calls the the hospital hospital to arrange for inpatient bed. bed. In some cases, cases, you you or or or to arrange for an an inpatient In some your family family members a y have to make m a k e the the arrangements arrangements (for (for example, example, ifif your members m may have to your doctor hasn't hasn't seen seen you you in in some some time time or or doesn't doesn't have have hospital hospital admitting admitting your doctor privileges). As As a a relapse relapse prevention prevention maneuver, keep the the phone phone number of the the privileges). maneuver, keep number of recommended hospital's easily recommended hospital's emergency emergency room room and and your your insurance insurance cards cards in in easily

accessible places places (see (see the Contract for for Preventing Preventing Mania Mania exercise exercise on on pages pages accessible the Contract 209-210). 109-110). Nowadays, many m a n y people people have have "managed "managed care'· care" health health insurance insurance plans plans that Nowadays, that Before stipulate which which hospitals hospitals can can or or cannot cannot admit admit them, them, and and for for how h o w long. long. Before stipulate

Whol I'm Getting What (on CanIIDoDoIf IIfThink I Think I'm GettMonic? ing Manic?

207207

signing up upfor for aa new newinsurance insurance policy, signing policy, ititisis important tolOfind important findout outififthe thepsychipsychi­

atrist whom w h o m you y o u see see is is "in "in network" n e t w o r k " and a n d if if the the hospitals hospitals at at which w h i c h he h e or or she she hhas as atrist admission privileges privileges are are providers providers within within the the plan. plan. Otherv.rise, Otherwise, y o u r health health inadmission your in­ surance hospilal from surance policy policy could could require require you y o u to to be b e admitted admitted 1O to a a different different hospital from

the one one your your doclOr doctor might might recommend. recommend. the

"WhatWill WillHappen Happen in the Hospit.I?" "What to to Me Me in the Hospital?" do have haveananinpatient inpatient hospitalization,you you will probably meet a daily If you If you do hospitalization, will probably meet on aon daily

basis with with an a n inpatient psychiatrist (who ( w h o may m a y or or may m a y not not be b e your y o u r regular regular doc­ docbasis inpatient psychiatrist tor).. You Y o u should should expect expect some s o m e individual individual or or group g r o u p counseling counseling sessions sessions con­ conlOr) cerning justment. In the cerning life life issues, issues, relapse relapse prevention, prevention, and a n d posthospital posthospital ad adjustment. In the

best case case scenario, scenario, family family or or spousal spousal visits visits are are encouraged encouraged and a n d become b e c o m e an a n inte­ intebest gral part part of of the the treatment treatment plan. plan. gral Hospitalization can c a n be be a a scary scary proposition. proposition. Many M a n y people people fear fear that that psychiHospitalization psychi­ atric people are are atric hospitals hospitals are are like like snake s n a k e pits-a p i t s — a place place where w h e r e things things are are dirty, dirty, people violent, this is is violent, the the nurses nurses are are cruel, cruel, and a n d little little help help is is delivered. delivered. Although A l t h o u g h this

largely a a distortion distortion based based on o n the the past, past,hospitals hospitals do d ovary vary considerably considerably in inqual­ quallargely ity, ity,just just as asdo d o the thedoclOrs doctors and a n dnurses nurses who w h owork w o r k within within them. t h e m . Many M a n y hospitals hospitals are are are excellent excellent and a n d proVide provide slate-of-the-an state-of-the-art mental m e n t a l health health care. care. Others Others are under-funded, under-funded, employ e m p l o y out-of-date out-of-date models m o d e l s of of intervention, intervention, and a n d are are not not ori­ ori-

ented toward toward treatment treatment as as much m u c h as as the the protection protection of of others. others. If If y o u have h a v e been been emed you in a a hospital hospital more m o r e than than once, o n c e , you y o u probably probably have h a v e had h a d diverse diverse experiences, experiences, de­ dein pending on o n which w h i c h hospilal hospital you y o u went w e n t 1O to and a n d the the condition condition in in which w h i c h you y o u were were pending admitted. admitted. Consider the the following following if if you y o u need n e e d 1O to be b e hospitalized. hospitalized. First, First, many m a n y people people Consider confuse being being hospitalized hospitalized with w i t h being being institutionalized. institutionalized. The T h e latter latter usually usually confuse means m e a n s that that a a person person is is kept kept in in a a hospital hospital for for months m o n t h s or or years years at at a a time. Nowatime. Nowa­ days, days, psychiatric psychiatric hospitalizations hospitalizations are are very very short, short, averaging averaging about about a a week w e e k long. long.

Second, the the treatment treatment you y o u receive receive in in the the hospital hospital is is usually usually geared geared toward toward Second, controlling your y o u r acute acute symptoms s y m p t o m s (including (including suicidal suicidal thoughts thoughts or or intentions) intentions) controlling and a n d keeping keeping them t h e m from f r o m worsening w o r s e n i n g in in order order to to reduce reduce the the immediate i m m e d i a t e risk risk to to you y o u and a n d those those around a r o u n d you. y o u . Hospitalization Hospitalization also also allows allows you y o u to to "dry "dry out" if you you out" if

have been b e e n drinking drinking or or using using drugs drugs during during your y o u r manic m a n i c escalation. escalation. Your Y o u r inpa­ inpahave tient stay stay will will enable enable you y o u to to start start a a new n e w regimen r e g i m e n of of medications medications or or newly n e w l y adtient ad­ justed dosages, dosages, or or try try other other treatments treatments (for (for example, e x a m p l e , electroconvulsive electroconvulsive ther­ therjusted apy apy if ifyou y o u are are acutely acutely manic, m a n i c , mixed, m i x e d , or ordepressed depressed and a n dnot not responding responding to to mood mood

stabilizers, antipsychotics, antipsychotics, or or other other agents). agents). However. H o w e v e r , your y o u r stay stay will will probably probably stabilizers, not be b e long long enough e n o u g h 1O to know k n o w if ifyour y o u rnew n e wregimen r e g i m e nisiseffective effectivein inthe thelong long term. term. not Third, hospitalization hospitalization is is not not a a personal personal failure. failure. You Y o u have have a a biological biological iim­ mThird, balance that that is is not not fully fully under u n d e r your y o u r control, control, and a n d it it is is not not your y o u r fault fault if y o u need need balance if you

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to run your hospitalization. Being hospitalized does not that meanothers that have others have to run your hospitalization. Being hospitalized does not mean life life from from now n o w on. on. Instead, it signifies signifiesthe thetemporary temporary giving giving up u p of ofcontrol controlfor foraa Instead, it short period period of of lime. time. You Y o u will will have have your your life life back back soon soon enough, enough, especially especially iif f short you effective you are are successful successful in in collaborating collaborating with with your your daclOT doctor in in developing developing an an effective posthospital plan. posthospital plan. Finally, hospitalization hospitalizationcan canprovide provideyou youwith withaamuch-needed much-needed rest restor orbreak break Finally, from from the the stressors of your your day-ta-day day-to-day life. life.Ahhollgh Althoughyou'd you'dno nodoubt doubtrather ratherspend spend stresSOTS of week in in the the Bahamas, Bahamas,aashort shortor oreven evenaalonger longerhospital hospitalstay staycan cangive giveyou youtime timetoto aa week think is and think through through what what is and isn't isn'tworking workingahoUl aboutyour yourtreatment treatmentplan. plan.ItItcan canalso also give give you you distance distancefrom from your your relatives, relatives,which whichyou you(and (andthey) they)may m a yneed needfrom fromtime time to time. time.Robert's Robert'shospitalization hospitalizationhelped helpedhim himrethink rethinkhis hisfeelings feelings about Jessie and to aboutJessie and his his children, children, and and upon u p o n being beingdischarged, discharged,he he felt feltmore moreresolved resolvedtotomake m a k ethings things admitted toto a hospital, work. work. It It will willbe behard hardto totake takethis thisview viewwhen w h e nyou youare arefirst first admitted a hospital, but experience. but later later you you may m a y have have quite quite a a different different view view of of the the experience.

Step 3: 3: Developing Developing a a Mania Mania Prevention Prevention Contrad Contract Step

Now Iel's put everything discussed so farsoinfar thisin chapter into a writ­ Now let's puttogether together everything discussed this chapter into a written contract for ten contract for relapse relapse prevention. prevention. The The following following exercise exercise asks asks you you to to sum­ summarize steps you marize what what you you have have concluded concluded about about your your prodromal prodromal phase, phase, the the steps you and your your Significant significant others others can can take take to to prevent prevent relapse, relapse, and and emergency emergency proce­ proceand dures involving involving your your doctors. doctors. Consult Consult with with your your family family members, members, spouse, dures spouse, doctor, and and other other trusted persons 1O to make m a k e sure sure that that everyone everyone understands understands doclOr, trusted persons what he he or or she she is is being being asked asked to to do. what do. W h e n fill filling out this this contract, contract, try try to to include include as as many m a n y options options as as possible. possible. ing out When others, S o m e of of the the options options will will probably probably seem seem more more comfortable comfortable to to you you than than others, Some but it's it's better betterto towrite write them them down d o w n even even ififyou youdon't don'tend endup upusing usingthem. them.En­ Enbut courage your your Significant significant others others to to be be open open about about what what they they do do and and don't don't feel courage feel comfortable doing doing w h e n you're you're cycling cycling into into mania. mania. Write into the the COnlract contract comfortable when Write into only those those responsibilities responsibilities you you and and they they are are willing willing to to accept. accept. Alternatively, Alternatively, only list all all of of your your possible possible options options and and rank rank each each one one from from top top to to bottom bottom as as to list to h o w preferable preferable it it is. is. Ask Ask everyone everyone to to sign sign the the contract. how contract. Troubleshooting YOUI Your Con'lo,' Contract Tlouhleshooling Things improved for for Robert after discharge. founda new a new Things improved Robert afterhis his hospital hospital discharge. HeHefound dis­ psychiatrist. Dr. Dr. Barnard, Barnard, who w h o met met with with him several times times after after his his dispsychiatrist, him several charge to to help him optimize optimize his his medication medication regime. regime. Roben Robert and and Jessie Jessie also also charge help him met with a a psychologist, psychologist, who w h o helped helped them them develop develop a a relapse relapse prevention prevention mel with

CONTRACT C O N T R A C T FOR F O R PREVENTING P R E V E N T I N G MANIA MANIA _ _ _ _ _ _ _ _

Your Your physician's physician'sname: name: Phone number, office: Phone number, office: Phone Phone number, number, emergency: emergency:

_ _ _ _ _ _ _

Your therapist's name: Your therapist's name: Phone number, office: phone number, office: _ _ _ _ _ _ _ _

phone Phone number, number, emergency: emergency:

_ _ _ _ _ _ _

_ _ _ _ _ _ _

_ _ _ _ _ _ _

Name N a m e of of local local hospital: hospital:

_ _ _ _ _ _ _ _

Emergency room room number: number: Emergency

Your Your insurance insurance carrier: carrier:

_ _ _ _ _ _ _ _

Policy Policy number: number:

Group Group number number (if (if applicable): applicable):

_ _ _ _ _

_ _ _ _ _ _ _ _ _

_ _ _ _ _

1 . List List your early warning (prodromal) signssigns of a manic episode (from the 1. yourtypical typical early warning (prodromal) of a manic episode (from the exercise exercise on on page page 192 192 above). above).

2. to 2. List List the the circumstances circumstances in in which which these these prodromal prodromal symptoms symptoms are are most most likely likely to occur. occur.

3. Ask Ask one one or or more more members members of of your your core core circle circle to to add add any any other other early early warning warning signs 3. signs they've observed, observed, and, and, if if relevant, relevant,the the circumstances circumstances in in which which these these signs signs first first they've

appeared. appeared.

4. List List what what behaviors behaviors you you can can perfonn perform when w h e n these these symptoms symptoms start start to to appear appear 4. (examples: calling calling your your doctor, doctor, getting getting your your blood blood level level tested, tested, sticking sticking closely closely to (examples: to your medication medication regimen, regimen, trying trying to to get get regular regular sleep, sleep, getting getting back back on on a a structured structured your daily and and nightly nightly romine, routine, avoiding avoiding alcohol, alcohol, drugs, drugs, or orcaffeine, caffeine,giving givingup upyour yourcredit credit daily cards and and car car keys, keys, avoiding avoiding major major financial financial or or other other life life decisions, decisions, aVOiding avoiding risky cards risky sexual sexual situations). situations).

(cant.) (conI.) 209 209

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sm-MANAGEMENI SELF-MANAGEMENT CONTIIACT CONTRACT FOR FOR PRMNTlNG PREVENTING MANIA MANIA (ron,nuea) (contlnuedj

5. List what behaviors your relatives, significant significant others, or friends can perform 5. List what behaviors your relatives, others, or friends can perfo (t'Xtlmples: what you (examples: call call your yourphysician, physician,talk talktotoyou youinina asupportive supportiveway, way,tell telyou l you what you are are doing doing that that worries worries them, them, tell tell you you how how much much they theycare careabout aboutyOll, you,keep keepyou you from from overscheduling overscheduling yourself, yourself, call callthe thehospital hospitalemergency emergencyroom, room,remind remindyou youto totake take your medication, accompany you to doctor's appointments, take care of your your medication, accompany you to doctor's appointments, take care of your children, accompany accompanyyou youwhen whenyou yougo goout outat atnight, night,help helpmanage manageyour yourmoney, money, help children, help you stay stay on on aa regular regular sleep-wake sleep-wake cycle, cycle,help helpyou youstay stayaway away from fromalcohol alcoholor ordrugs). drugs). you

6. List List what whatyou you would would like likeyour yourpsychiatrist psychiatristto todo do (examples: (examples:meet meetwith withyou youon onan an

emergency your emergency basis, basis, take takeyour yourblood bloodlevel, level,revise revise yourmedication medicationregimen regimenasas appropriate. appropriate, call callthe thehospital hospitaland andarrange arrangefor foradmittance, admittance,ifinecessary). f necessary).

Signatures Signatures

Date Date

contract. Together Together they they developed developed a a list list of of his his prodromal prodromal symptoms, symptoms, contract. which included included mild mild irritabihty, mistrustfulness, standing standing too too close close to which irritability, mistrustfulness, to people people and talking too too loud, loud, aasudden sudden disinterest disinterestin inhis hisjob, job,an anincrease increasein in and talking his sex drive, drive, and and a a subjective subjective feeling feeling of of mental mental clarity. clarity. They They made m a d e aadis­ dishis sex tinction between between these these early early warning signs and and signs signs of of his full-blown ma­ matinction warning signs his full-blown nias, such as feeling or expansive, expansive, SOCially socially inappropriate inappropriate outbursts outbursts nias, such as feeling elated elated or of anger, spending excessively and impulsively, grandiose beliefs about anger, spending excessively and impulSively, grandiose beliefs about of his musical musical talents, severeloss lossof ofsleep, sleep,and and aafirm firm denial denialthat thatanything anything talents, severe his was wrong. They also also agreed agreed on on the the environmental environmental circumstances circumstances associwas wrong. They associ­ ated with with his his escalations: escalations: an anexcessive excessiveworkload, workload,family familyarguments, arguments,and andfi­ fiated nancial problems. nancial problems. Robert and]essie and Jessie negotiated negotiated a a series series of of prevention prevention steps. steps. One O n e of of these these Robert

Whot What (on Can IIDoDoIfIIfThink I Ihink I'm Getting Manic? I'm Genin g Monic?

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involved giving jessiethe the freedom to call his psychiatrist if Robert ap­ involved giving Jessie freedom to call his psychiatrist if Robert appeared peared to to be b e escalating. escalating. They T h e y also also agreed agreed that that when w h e n his his symptoms s y m p t o m s were were

still mild, mild, Jessie Jessie would w o u l d help help get get him h i m away a w a y from f r o m his his immediate i m m e d i a t e stressors stressors still (for her). They (for example. example, encourage encourage him h i m to to take take a a few few days days off off work w o r k with with her). They agreed, agreed, as as a a couple, couple, to to try try to to maintain maintain regular regular sleep-wake sleep-wake routines, routines, espe­ especially Finally, cially when w h e n one one or or more more of of his his prodromal prodromal signs signs were were observable. observable. Finally,

Robert consented consented to to have have jessie Jessie accompany accompany him h i m to to the the hospital hospital emer­ emerRobert gency room, room, if if it it became became necessary. necessary. gency Robert Robert did did not not stay stay episode-free, episode-free,however. however.His Hisnext nextmanic manic episode episodebe­ began gan about about two two months months later, later, but butthis thistime timehe he and andjessie Jessiecaught caught ititearlier. earlier. Once ad­ Once again, again, he he refused refused to to make m a k e an an appOintment appointment with with his his doctor: doctor: He H e admitted mitted that that he he was was probably probably escalating escalating but but didn't didn't want want to to take take any any more more

medication. He H e and and jessie Jessie began began to to argue. argue. As A s Robert Robert later later described described it, medication. it, finger-pointing, serious, notnot lOving. " jessie gotgot in­ injessie Jessie became became "rigid "rigid ... .. . finger-pointing, serious, loving." Jessie

creasingly more more desperate desperate when w h e n she she found found that that Dr. Dr. Barnard Barnard was was out out of creaSingly of town. She She called called Dr. Dr. Barnard's Barnard's backup, backup, who w h o preSCribed prescribed an an increase increase in in the town. the dosage of of Robert's Robert's antipsychotic antipsychotic medicine. medicine. Robert Robert agreed agreed to to the the medicadosage medica­ tion tion adjustment, adjustment, which which kept kepthim him from from going goingback back into intothe thehospital. hospital.None­ Nonetheless, theless, more more damage damage was was done done to to their their relationship, relationship, and and jessie Jessie consid­ considand other ered leaving. leaving. Robert Robert also also had had more more conflicts conflicts with with his his coworkers coworkers and other ered family interval. family members m e m b e r s during during this this interval.

A meeting meeting with with his his psychologist, psychologist, arranged arranged about about a a week w e e k after after Roben Robert A changed changed his his medication, medication, focused focused on on troubleshooting troubleshooting the the relapse relapse preven­ preven-

tion plan. plan. Roben, Robert, who w h o was was still still slightly slightly hypomaniC, hypomanic, complained complained that that the tion the plan hadn't hadn't worked worked because because of ofjessie's Jessie's emotional emotional stance. stance. He H e said said that he plan that he needed her her to to be be "kinder "kinder and and gentler" gentler" in in her her approach. approach. The The psychologist psychologist needed asked him h i m to to be be more m o r e specific, specific,and andhe hesaid, said,"I"Iwant wanther hertototell tell m eshe she loves asked me loves m e , and and in in a a more more tender tender way w a y tell tellme m e that thatshe shethinks thinksIIneed need help helpand and why, why, me, even if if I'm I'm not not receptive. receptive." H e added added that that he he wished wished she she wouldn't wouldn't take take his even " He his irritability so so personally personally and and instead instead see see it it as as part part of of his his disorder. disorder.jessie, Jessie,in in irritability turn, expressed expressed frustration frustration that that he he hadn't hadn't gone gone to to his his medication medication appointtum, appOint­

ments when w h e n Dr. Dr. Barnard Barnard had had been been in in towo. town. "1 "I want want him him to to go go for for me m e or or ments for our our relationship, relationship, if ifhe hewon't won'tdo do ititfor forhimself, himself,knOwing knowingthat thatI'm I'mspeak­ speakfor ing out out of of caring caring for for him. him." She She wasn't wasn't sure sure if if she she could could take take a a gentler gentler emo­ emoing n

tional stance stance when w h e n dealing dealing with with his his escalating escalating mood. mood. tional T h e psychologist psychologist encouraged encouraged Robert Robert and and jessie Jessie to to practice practice communi­ communiThe cating in in the the way w a y the the other other wished: wished: jessie, Jessie, to to be be more more tender tender in in her her apcating ap­ proach and and Robert, Robert, to to cede cede a a degree degree of of control control to to her. her. They They also also discussed discussed proach the potential potential involvement involvement of of other other family family members, such as as Robert's the members, such Robert's son, son, at times times of of emergenCies. emergencies. Robert Robert decided, decided, however, however, that that he he wanted wanted to at to shield Brian Brian as as much m u c h as as possible possible from from his his illness illness and and didn't didn't want want his his son son shield interacting interacting with with his his doctors. doctors. jessie Jessieagreed. agreed. W h e n she she returned returned from from her her trip, trip. Dr. Dr. Barnard Barnard met met with with Roben Robert and and When

Jessie and and told told them them of of a a medication medication plan plan to to undenake undertake if if Roben Robert had one had one jessie

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or more: prodromal signs could immediately getin in to to see or more prodromal signs andand could notnot immediately get see her: her:in­increase his dosage and add add a benzodiazepine (K!onopin) for crease his dosage of of Zyprexa Zyprexa and a benzodiazepine (Klonopin) for sleep. She wrote wrote aaprescription prescription with with aaplan planfor forincreasing increasing the thedosage, dosage,with with sleep. She the understanding understanding that that Robert Robert would c o m e in to see her as as soon soon as as possi­ possithe would come in to see her ble after initiating ble after initiating the the new n e w dosing dosing schedule. schedule. These These modifications modifications were were all aU written written into their modified modified COnlract contract (for (for example, example, "Robert "Robert to to increase into their increase Zyprexa dosage; his doctor and be let jessie Zyprexa dosage; Robert Robert to to call call his doctor and be willing willing to to let Jessiemake make the call if he he will willnot; not;Jessie Jessieto totry trytotorecognize recognizeRobert's Robert'sirritability irritabilityas aspart part the call if of the the manic manic syndrome"). syndrome"). Roben Robert and and Jessie to reexamine reexamine the the conof Jessie agreed agreed to con­ tract and revise necessary. tract every every three three months months and revise it it as as necessary. Robert has has continued to have have m o o d cycles, but his episodes increasRobert continued to mood cycles, but his episodes increas­ ingly resemble rather than manias. H He re­ ingly resemble hypomanias hypomanias rather than manias. e feels feels he he has has a a good good relationship with with Dr. Barnard and and his his psychologist, he and lationship Dr. Barnard psychologist, and and he and Jessie Jessie are are still still together togetherand and working working on on their theirproblems. problems.He H e has hasexplained explained his hisbipolar bipolar disorder his son, son, w who, with time, disorder to to his h o , with time, is is becoming becoming more more understanding. understanding. Think of your mania prevention comractasasaa work-in-progress. work-in-progress. The Think of your mania prevention contract Thepre­ prevention can be be defined, defined, agreed-upon, agreed-upon,and andpracticed practicedwhen w h e nyou're you'rehealthy, healthy, vention steps steps can

bUl no one how will work you put but no one can can be be certain certain h o w well well they they will work until until you put them them into into ac­ action. Knowing your prodromal signs, being tion. Knowing your prodromal signs, being responsive responsive to tothe thefeedback feedback of ofoth­ others, and knowing w h e n to to ask for help are all all cemral central to to making making the ers, and knowing when ask for help are the contract contract effective in in real real life. life. effective If you you do do have have aa manic manic episode episode despite despite your your prevention prevention contract, contract,sit sitdown down If with your doctor, family, or or therapist therapist after after the the dust try to to dede­ with your doctor, family, dust has has settled settled and and try cide what did not not work. work. W e r e you to reach reach your physician or or a what did did and and did Were you unable unable to your physician a cide backup physician? physician? If If so, so, ask ask your doctor to to recommend recommend medication medication adjustbackup your doctor adjust­ ments that that you can make m a k e on on your o w n the the next next time time you to escalate. escalate. Ask Ask ments you can your own you start stan to him or her her to to write write d o w n your emergency medicine medicine plan plan in prescription form, form, him or down your emergency in prescription

early with the understanding understanding that that you will fill fill the the prescription prescription w h e n your with the you will when your early warning arrange an an in-person in-person meeting meeting as as soon as possible warning signs signs appear appear and and arrange soon as possible thereafter. thereafter. Were W e r e there there other other problems problems that that prevented prevented the the contract contract from from working? working? For For their example, were to significant others, w h o then then threw threw up up their example, were you you hostile hostile to Significant others, who hands refused to to help help any any further? further? Were W e r e your unnecessarily conand refused your relatives relatives unnecessarily hands and con­ trolling? Alternatively, Alternatively, did did you ask for for help avaUable? If If so, so, trolling? you ask help but but no no one one was was available? perhaps can think think of of other other relatives relatives or or friends friends to to w h o m you are less likely perhaps you you can whom you are less likely no­ to react react negatively in emergencies, or who w h o might available with negatively in emergencies, or might be be available with Htde little noto tice. tice. W a s the the contract contract ineffective ineffective because found the the recommendations recommendations Was because you you found m a d e by by Significant significant others others unacceptable? unacceptable? If If so, so, h o w could could the the contract contract be be how made modified to to make m a k e these these recommendations recommendations more more palatable? palatable? For For example, example, Ga­ Gamodified

briel briel refused refused to to see a certain certain doctor doctor whom w h o m his parents insisted insisted he see. H e was, was. see a his parents he see. He

What I'm IGetting What (an Con IIDoDoIfIfI Think I Think 'm GettiManic? ng Manic?

213213

willingtolOsee seeaa doctor doctorhehehad had found himself. Being to see however, willing found by by himself. Being ableable to see his his however, preferred doctor doctor was w a s entered entered as as a a modification to their their mania m a n i a prevention prevention con­ conpreferred modification to tract. You Y o u will will find find that the contract contract has has a a much m u c h greater greater chance chance of of succeeding succeeding tracl. that the if you y o u have h a v e had h a d input input into into each each step, step, have h a v e listed listed choices choices of of strategies strategies rather rather if than only only one o n e singular singular strategy, strategy, and a n d can c a n troubleshoot troubleshoot and a n d revise revise the the contract contract than as you y o u go g o along. along. as *

*

*

Because Because of of the the influences influences of of your y o u r individual individual neurophysiology, neurophysiology, you y o u should should not not expect expect lO to be b e able able lO to fully fully prevent prevent manic m a n i c episodes. episodes. But B u t you y o u have have a a window window of opportunity opportunity in in the the early early stages stages of of manic m a n i c escalation escalation in in which w h i c h you y o u may m a y be be of able to identify able to to decrease decrease the the severity severity of of your y o u r oncoming o n c o m i n g episode. episode. Being Being able able to identify your you your episodes episodes early early and a n d receive receive emergency e m e r g e n c y treatment treatment will will give give y ou a a greater greater feeling of of autonomy a u t o n o m y in in the the long long run, run, even e v e n if if it itmeans m e a n s having having to togive giveup u p control control feeling to to others others in in the the short short run. run. A A written written contract, contract, especially especially if if it it is is developed developed and and fi lled out likelihood that filled out when w h e n you y o u are are feeling feeling well, well, will will enhance e n h a n c e the the likelihood that your y o u r and and others' prevention prevention efforts efforts will will be b e successful. successful. others' Depressive they ddo Depressive episodes episodes have have a a differem different quality. quality. For F o r most m o s t people, people, they o not not for c o m e on o n suddenly suddenly and a n d often often last last longer longer than than manic m a n i c episodes. episodes. But B u t as as is is true true for come mania, m a n i a , identifying identifying and a n d combating c o m b a t i n g the the early early warning w a r n i n g signs signs of of depression depression will will help you y o u feel feel more m o r e in in control control of of your y o u r disorder. disorder. In In Chapter Chapter 10, 10, you'll you'll see how help see how y o u can can use use the the support support of of your y o u r core core circle, circle, along along with with certain certain personal you personal stratestrate­ gies such s u c h as as behavioral behavioral activation activation and a n d cognitive cognitive restructuring, restructuring, to to keep keep gies to try try lO your your depressions depressions from f r o m becoming b e c o m i n g more m o r e serious serious or or debilitating. debilitating.

1 0

1

0

What I Do Iff II Think W h a t Can C a n I D o I Think I ' m Getting G e t t i n g Depressed? Depressed? I'm

"One "One day day you you realize realize that that your your ent entire ire life life is isjust justawful, awful,not notworth worthliving, living, aa horror and and a a black black blot blot on on the white terrain terrain of of human h u m a n existence. existence. One One horror the white I I morning you wake wake up up afraid afraid you you are are going going to to live live. . That's thing morning you . ... .. That's thethe thing want to to make m a k e clear clear ahoUl about depression: depression: It's It's got got nothing nothing at at all all to to do do with with want life. In In the the course course of of life, life, there there is is sadness sadness and and pain pain and and sorrow, sorrow, all all of life. of which, in in their their right right lime time and and season, season, are are normal-unpleasant, normal—unpleasant, bUl but norwhich, nor­ mal. Depression Depression is is in in an an altogether altogether differem different zonE': zone because because it it involves involves a mal. a complete absence: absence: absence absence of of affect, affect, absence absence of of feeling, feeling, absence absence of of rere­ complete sponse, absence absence of of interest. interest. The The pain you feel feel in in the the course course of of a a major major pain you sponse, clinical depresSion depression is is an an attempt attempton on nature's nature'spart part(nature, (nature,after afterall, all, abhors clinical abhors a vacuum) vacuum) to to fill fillup up the theempty empty space." space." a — W u r t z e l (1994, (1994, p. p. 22) 22) -Wurtzel In bipolar disorder, depressioncan canoccur occur in "pure" form—in which disorder, depression in "pure" In bipolar feel feel form-in which you you extremely sad, sad,slowed sloweddown, d o w n ,lethargic, lethargic,fatigued, fatigued, n u m b — o as r as part ofmixed a mixed extremely oror numb-or part of a episode—which means means you feel both both the thesympLOms symptoms of ofdepression depression and and those thoseof of episode-which you feel mania. Many M a n y writers writers have described the the despair despair of depression,both bothbipolar bipolarand and mania. have described of depreSSion, 2000a; unipolar (major (major depressive) depressive) forms forms (for (for example. example, Jamison, Jamison, 1995. 1995, 2000a; unipolar Manning, 1996; 1996; Solomon, Solomon, 2001; 2001; Styron, Styron, 1992; 1992; Thompson, T h o m p s o n , 1996). 1996). W h a t is is im­ imManning, What portant for for you, you, however, however,isisthat that youlearn learnLOtorecognize recognizethe theearly early warningsigns signs portant you warning you that your depresSion depression is isrecurring. recurring.The Thecentral centralgoal goalof ofthis thischapter chapterisis give you that your toto give 214 214

What (on Can 1I110DoIfIfI Think I Think 'm Getting Depressed? Whol I'm I6eHing Depresse d?

215 215

psychological self-managemem techniques that you to greatest psychological self-management techniques that you can usecan to use greatest benefitbenefit

during the the early early phases p h a s e s of of depression, depression, before it becomes b e c o m e s incapacitating. incapacitating. When When during before it s e l f - m a n a g e m e n t techniques techniques effectively effectively improve i m p r o v e your y o u r mood m o o d during during these these early early self-management stages, you able to avoid the are usually re­ stages, y o u may m a y be b e able to avoid the medical m e d i c a l imerventions interventions that that are usually re-

quired wwhen h e n depression depression reaches reaches its its most m o s t severe severe poim. point. quired Medical M e d i c a l imervemions interventions usually usually include include amidepressam antidepressant agents, agents, higher higher dos­ dos-

ages of of mood m o o d stabilizers, stabilizers, ECT, E C T , and a n d hospitalization. hospitalization. For F o r reasons reasons that that are are dis­ disages cussed in in Chapter C h a p t e r 6, 6, it's it's best best to to avoid avoid some s o m e of ofthese these alternatives alternatives if ifyou y o u possibly possibly cussed can (for (for example, e x a m p l e , antidepressants, antidepressants, wwhich h i c h can c a n inadvertently inadvertently lead lead to to rapid rapid cycan cy­ cling). these medi­ cling). Nonetheless, Nonetheless, it's it's essential essential to to consult consult your y o u r physician physician about a b o u t these mediis not cal alternatives alternatives if if self-management s e l f - m a n a g e m e n t or or your y o u r personal personal psychotherapy psychotherapy is not cal

keeping your y o u r depression depression from f r o m getting worse. keeping getting worse. In In the the next next chapter, chapter, II talk talk about a b o u t suicidal suicidal episodes episodes and a n d how h o w to to combat combat very common them. Suicidal Suicidal thoughts thoughts and and impulses impulses are are a a very c o m m o n component component of of the the them. bipolar nothing to bipolar syndrome. syndrome. They They are are nothing to be be ashamed ashamed of-virtually of—^virtually everyone everyone with there with this this disorder disorder has has thought thought about about suicide suicide at at some s o m e point. point. Fortunately, Fortunately, there are ways to yourself from you begin begin to sui­ are ways to protect protect yourself from sinking sinking further further when w h e n you to feel feel suicidal. cidal. Mostly, about hope. Mostly, this this chapter chapter is is about hope. Depression Depression is is a a painful painful aspect aspect of of the the human and people bipolar disorder it more more inin­ h u m a n condition, condition, and people with with bipolar disorder experience experience it tensely virtually anyone pain may tensely than than virtually anyone else. else. To T o make m a k e matters matters worse, worse, the the pain m a y not not

be obvious to to those those around around you, you, and and they they may m a y want you to to just just snap snap out out of of it. be obvious want you it. You can't can't do do that, that, but but there thereare aresome s o m e things thingsyou you can can do-often do—often with with the thesup­ supYou port it. port of of others-to others—to help help combat combat it.

Bipolar Depression: Depression: An A n Illness, Illness, Nol Not aa Character Character Flaw Flaw Bipolar Alexis, a 37-year-old with bipolar II IIdisorder, Alexis, a 37-year-oldwoman woman with bipolar disorder, had had been been dealing dealing with an an ongoing ongoing depressive depressive state state for for years—a state that that occasionally occasionally bewith years-a state be­ came worse and incapacitated incapacitated her. her. She She had had tried tried to to alleviate alleviate her her deprescame worse and depres­ sion through through various antidepressants, medicinal medicinalherbs, herbs,cognitive cognitive therapy, therapy, sion various antidepressants, group .. driving group treatment, treatment, and, and, at at times, times, "exercising "exercising to to a a fault fault driving myself myself constantly until until my m y body gave out" out." Her Her depressions depressions were were usually usually accom­ accomconstandy body gave panied by self-accusations about about being weak, not not haVing having the the courage courage to panied by self-accusations being weak, to face up u p to to her her problems, problems, and and not not being being able able to to accomplish her goals. goals. She She accomplish her face had heard heard that that depression depression had had a a strong strong biological biological basis, basis, especially especiallyin inbipo­ bipohad lar disorder, disorder, but had never never really really connected connected this this fact fact to to her her situation. lar but had situation. A breakthrough occurred in in her her therapy therapy when w h e n her her clinician clinician said said to A breakthrough occurred to her, "If "If you you had had diabetes, diabetes, would you be be blaming blaming yourself yourself for for not her, would you not being being able began to idea able to to control control your your blood blood sugar sugar levels?" levels?" She She began to entertain entertain the the idea that she she needed needed to to "make "make an an end end run run around around my m y depression" depression" rather rather than than that

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to do gelrid ridof of it so. to do so. trying trying to to get itand andfeeling feeling a failure notable being able likelike a failure for notfor being When W h e n she she started started thinking thinking of of her her depression depression as as a a physical physical illness illness that that was was caused her control-and caused by by factors factors not not entirely entirely within within her control—and something something she she needed to to learn learn to live with-her with—her mood m o o d began began to to improve, improve, albeit albeit graduneeded to live gradu­ ally. She ally. She learned learned that that accepting accepting the the reality reality of of her her depression depression was was not not the the same same as as giving giving into into it it or or becoming becoming immersed immersed in in it. it. She eventually eventually recognized recognized that, that, when w h e n depressed, depressed, she she needed needed to to slow slow She down, balance her d o w n , lake take care care of of herself herself (sleep (sleep regularly regularly and and balance her pleasurable pleasurable versus work work activities), activities), "give "give myself myself a a break," break," and and not not try try too too hard hard to versus to drive with frenetic She has en­ drive her her depression depression away away with frenetic activity. activity. She has never never been been entirely free free of of depression, depression, bm but n o w she she has has a a different different perspective: perspective: "I can tirely now "I can now ignore those old tapes in my mind telling me I'm a bad person. I n o w ignore those old tapes in m y mind telling m e I'm a bad person. I now now see talking." see that that this this is is the the depression depression talking."

If you you had had a a bad bad case case of of the theflu, what would would you you do? do? Most Most of of us us would would If flu, what take time time to to convalesce convalesce and and not not expect expect too too m u c h of of ourselves ourselves while while recovertake much recover+ ing. you were ing. Likewise, Likewise, if if you were suffering suffering from from chronic chronic pain, pain, such such as as severe severe back back problems, you would terms of your physical problems, you would probably probably give give yourself yourself a a break break in in terms of your physical expectations of of yourself yourself by by declining declining to to lift lift heavy objects, not not siuing sitting in in the expectations heavy objects, the same position position for for hours, hours, and and carefully carefully selecting selecting a a "back-friendly" "back-friendly" form form of of ex­ exsame ercise. all likelihood to those that ercise. In In all likelihood you you would would pay pay close close anemion attention to those things things that helped alleviate alleviate your pain and and avoid avoid those those that m a d e it it worse. worse. helped your pain that made Try to to think think of of bipolar bipolar depression depression in the same same way w a y you you would would think think of of aa Try in the flu, flu,chronic chronicpain, pain,or orperhaps perhapsa along-term long-termmedical medicalillness illnesssuch suchasasdiabetes. diabetes.No No one would would think think of of blaming blaming aa diabetic diabetic for for not not being being able able to to control control the the way way his his one or her her body body processed processed sugar. sugar. No N o one one would would blame blame a a person person with epilepsy for or with epilepsy for having seizures. seizures. likewise, Likewise, you you should should nOl not blame blame yourself yourself for for haVing having depreshaving depres­ sion. As As IItalk talkabout aboutin inChapter Chapter 5, 5,bipolar bipolardepression depressionisisstrongly strongly influenced sion. influenced byby biochemical, genetic, genetic, and and neurological neurologicalfactors. factors.It Itisisnot notthe theproduct productof ofaachar­ charbiochemical, acter flaw, personality defect, or lack lack of of moral moral fiber. acter flaw, personality defect, or fiber. Even the the well-known well-known explanatory concept for for depression depression of of low low selfEven explanatory concept self­ esteem is is suspect suspectwith with regard regard to tobipolar bipolar depression. depression.Many M a n y people people think think that thatifif esteem you're depressed, depressed, you you must must not not think think much m u c h of of yourself. yourself. This This low low estimation estimation you're feel might characterize characterize the the way w a y you you feel feel when w h e n you're you're depressed, depressed, but but you you may m a y feel might self­ quite differently differently about about yourself yourself when w h e n you're you're well. well. In other words, words, low low selfquite In other esteem is is not not a a traiL trait. Rather, Rather,ititmay m a yjust justbe bea asymptom s y m p t o mofofyour yourdepression. depression.InIn esteem fact, one one of of the leaders in in our our field, field, Martin Martin Seligman, Seligman, of of the University of of fact, the leaders the University Pennsylvania, has hascompared compared self-esteem self-esteem to toaafuel fuelgauge: gauge:It Itisisa a measureofof how measure how Pennsylvania, we're doing doing at at anyone any one time-how t i m e — h o w much m u c h fuel fuel is is in inthe thetank-but tank—but it itcan canchange change we're depending on on what what we w e are are able able to to accomplish accomplish (Seligman (Seligman el et al., al., 1996). 1996). depending

What What (on Con tI Do Do IfIf tIThink ThinkI'm I'mGetting Getting Depressed? Depressed?

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Depression is not due anunwillingness unwillingness to fearsfears of of Depression is not due totoan to accept acceptresponsibility, responsibility, coping with with reality, reality, laziness, laziness, cowardice, cowardice, or or weakness. weakness. It It is is atl an illness. T o be be illness. To coping

sure, or at sure, there there are are things things you you can can do do to to make m a k e yourself yourself feel feel better better or at least least SlOp stop the your depreSSion depression from from worsening. worsening. But But the the fact fact that that you you have have depreSSion depression in in the your first place, place, or or that that you're you're having having a a di££icult difficult time time making it go go away, probably first making it away, probably says more more about about your your biology biology than than it it does does about about your your effort, effort, willpower, says willpower, or or self-esteem. Knowing Knowing this this basic basic fact fact about about depression depression will will not not make make i disapself-esteem. itt disap­ pear, but but may m a y make m a k e it it easier easier to to cope cope with. with. pear,

DiHerent Coping with Different Styles Styles 01 of Coping with Depression Depression As and thethe next, you'll see that recommend a diverse As you you read read this thischapter chapter and next, you'll see Ithat I recommend a diverse set of of techniques for coping coping with with depression. depression. These These involve involve changes changes in your set techniques for in your behavior and and thinking thinking as as well well as as in in your your relationships with others. others. You'll see relationships with You'll see behavior that that some some of of the the techniques techniques involve involve distraction. distraction. Distracting Distracting yourself yourself in in a a posiposi­ tive tive manner manner means means seeking seeking OUl, out, and and engaging engaging in in activities activities that that keep keep you you busy, busy, give give you you pleasure, pleasure, and and help help keep keep your your mind m i n d off off your your pain pain and and angUish. anguish. Exam­ Examples ples include include spending spending time time with with others others with with whom w h o m you you feel feel close, close, exercising, exercising, listening 1O to music, reading, and and relaxing. relaxing. listening music, reading, Some S o m e of of the the coping coping strategies strategies involve involve emotion-focusing. emotion-focusing. That That is, is, you you learn learn to recognize recognize that that you're you're depressed depressed and and experiencing experiencing pain pain and and you you teach teach your­ yourto self to to look look at at it, it, label label it, it, and and accept accept it it without without becoming becoming overwhelmed overwhelmed by by it, self it, as Alexis Alexis learned learned 1O to do. do. Emotion-focused Emotion-focused coping coping usually usually involves involves talking talking as about about your your feelings feelings with with people people who w h o are are supportive supportive and and empathic. empathic. A third third strategy, strategy, cognitive cognitive coping, coping, involves involves learning learning to to combat combat and and chalA chal­ lenge lenge negative negative thinking thinking patterns patterns about about specific specific situations situations or or events events (for (for exam­ example, ple, self-blaming self-blaming thoughts) thoughts) and and considering considering alternative alternative ways ways to to view view these these sit­ situations or or events. events. As A s you'll you'll see, see, these these strategies strategies are are not not mutually mutually exclusive. exclusive. In In uations fact, the the people people who w h o do do best best with with bipolar bipolar depressions depressions seem seem able able to to sample sample fact, from from all all three, three, using using different different strategies strategies at at different different times. times.

Are Are You You Depressed Depressed Right Right Now? Now? Depression isnOl notjust just sadness. know you've a serious depresDepreSSion is sadness. As As youyou know if if you've hadhad a serious depres­ sion, it it can can be be a a blunted, blunted, empty, empty, inhibited inhibited state state marked marked by by loss loss of of interest sion, interest in in most things, things, an an inability inability to to experience experience pleasure, pleasure, and and withdrawal withdrawal from from everymost every­ body and everything (see the quote by Elizabeth Wurtzel that opened body and everything (see the quote by Elizabeth Wurtzel that opened this this chapter). Some S o m e people don't even even feel feel sad sad when w h e n they're they're depressed. depressed. Instead, Instead, people don't chapter).

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they just numb. you've hadhad mixed episodes, you're probably familiar they justfeel feel numb.IfIf you've mixed episodes, you're probably familiar up, irritable, with the feeling with the feeling of of being being fatigued fatigued and and drained drained but but also also charged charged up, irritable, and In the that mania and anxious anxious ("tired ("tired but but wired"), wired"). In the same same way w a y that mania is is not not always always a a mania, depression happy state, depression is not always a sad state. But unlike mania, depression happy state, depression is not always a sad state. But unlike is almost almost never never enjoyable enjoyable or or intoxicating. intoxicating. is Try taking taking the the lung Zung (1965) (1965) Self-Rating Self-Rating Depression Depression Scale Scale that that follows. Try follows. This scale scale is is intended intended to to measure measure the the severity severity of of your your depression depression as as you've you've exThis ex­ perienced perienced it itin inthe thepast pastseveral severaldays. days.Fill Fillout outthe thescale scaleaccording according to tohow h o w you've you've felt most most of of the the time tally your total score, score, which which can can range from 20 20 (not (not felt time and and tally your total range from at at all all depressed) depressed) to to 80 80 (very (very depressed), depressed). In In adding adding up up your your score, score, you'll you'llnotice notice that some some of of the the items items are are positive and some some are are negative. negative. The The negative negative scale that pOSitive and scale items (for (for example, example, "I "I have have trouble trouble sleeping sleeping at at night") night") are arescored scoredaa11ififyou youan� anitems of the swered swered "a "a little little of of the the time" time" and and 4 4 if if you you answered answered "most "most of the time." time." The The positive positive items items are are reverse·scored. reverse-scored. That That is, is, "I "Ifeel feelhopeful hopefulabout aboutthe thefuture" future"and and "I still still enjoy enjoy the thethings things]Iused used to" to"are arescored scored aa 11 if ifyou youanswered answered"most "mostof ofthe the "1 if you time" and 4 time" and 4 if you answered answered "a "alittle littleof ofthe thetime." time."The Thereverse-scored reverse-scoreditems itemsare are starred. starred. Generally, Generally, people people who w h o have have scores scores of of less less than than 50 50 are are considered considered not not dede· pressed pressed and and those those in in the the 50-59 50-59 range, range, mildly mildly depressed. depressed. People People with vnth scores scores in in the the 60-69 60-69 range range have have a a moderate moderate to to marked marked level level of of depression depression that that warrants warrants serious and the attention the attention of of a a doctor doctor or or therapist; therapist; and and over over 70 70 indicates indicates a a serious and probably incapacitating incapacitating depression depression that urgently requires requires treatment treatment (Nezu probably that urgently (Nezu et et al., 2000; 2000; Zung, Zung, 1965). 1965). Your Your score score may m a y change change from from one one week w e e k to to the the next. next. aI., This is is the the nature nature of of depression, depression, particularly of the the bipolar bipolar type. This particularly of type. If you you scored scored between between 50 50 and and 70, 70, the the self-management self-management techniques techniques deIf de· scribed in in this this chapter chapter and and the the next next are are particularly particularly relevant relevant to to you you right right now. now. scribed But they they may m a y also also be be helpful helpful if if you you are are not not feeling depressed (below (below 50) but 50) but feeling depressed But in want to develop develop skills skills for for preventing preventing or or alleViating alleviating episodes episodes of of depression want to depression in the future. the future.

H o w Does Does Your Your Depression Depression Wax W a x and Wane? How and Wane?

talk I talk Depression comes comes and and goes goes in indifferent different ways different people. Depression ways for for different people. Here I Here about two two types types of of depressive depressive onset onset as as experienced experienced by by people people with with bipolar bipolar disabout dis­ order. It It is is helpful helpful to to know k n o w that for some some people, people, depressive depressive onsets onsets are are draorder. that for dra· matic, whereas whereas for for others, others, the the onsets onsets are are subtle. subde. If If your onsets are are subtle, subtle, itit matic, your onsets m a y not not always always be be clear clear to to you you (or (or your your Significant significant others) others) whether whether your your demay de­ pression is is a a new n e w episode episode or or the the continuation continuation of of an an existing existing one. one. With pression With experiexperi. sever· ence, you you may m a y be be able to distinguish distinguish minor differences over over time the severence, able to minor differences time in in the ity of of your your depressed depressed m o o d or or your your energy energy and activity levels. ity mood and activity levels.

What Con Can II 00 Do IfIfI Think I ThinkI'mI'mGetti Getting Depressed? Whol ng Depl"essed?

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ZUNG Z U N G SElF·RATING S E L F - R A T I N G DEPRESSION D E P R E S S I O N SCALE SCALE Date Date

_ _ _ _

Read each each statement statement and and decide decide how h o w much m u c h of of the the time time the the statement statement describes describes h o w you you Read how have been been feeling feeling during during the the past past several several days. days. have A A Good Good little little of of Some S o m e of of part part of of Most of Most of Make iate column. M a k e check check mark mark (..J) (V) in in appropr appropriate column. the the time time the the time time the the time time the the time time I. 1. II feel feel down-hearted down-hearted and and blue blue

2. 2. Morning Morning is is when w h e n II feel feel the the best"" best* 3. pells or 3. II have have crying crying sspells or feel feel like like it it 4. ping at 4. II have have trouble trouble slee sleeping at night night 5. 5. II eat eat as as much m u c h as as II used used to"" to* 6. joy sex"" 6. II still still en enjoy sex*

7. ght 7. II notice notice that that II am a m losing losing wei weight 8. pation 8. II have have trouble trouble with with consti constipation 9. 9. Mv M y heart heart beats beats faster faster than than usual usual

10. et tired 10. IIg get tired for for no no reason reason

11. Mv M y mind mind is is as as dear clear as as it it used used to tobe"" be* 11.

12. 12. II find find it it easy easy to to do do the the things things II used used to* to"" 13. II am a m restless restless and and can't can't keep keep still still 13.

14. 14. II feel feel h hopeful about the the future* opeful about future" 15. 15. II am a m more more irritable irritable man than usual usual 16. 16. II find find it it easy easy to to make m a k e decisions'" decisions*

17. 17. II feel feel that that II am a m useful useful and and needed" needed* 18. 18. M My y life life is isp pretty retty full* full·

19. 19. 1I feel feel that that others others would would be be better better off off if if I I were dead dead were 20. II still still eenjoy the things things II used used to to do"" do* 20. njoy the N o w , total total up u p your your score, score, which which should should range rangefrom from 20 20 to to80. 80. The The starred starreditems items (2, (2, 5, 5,6, 6, Now,

11, 12, 12, 14, 14,16, 16,17, 17,18, 18, and and 20) 20)are arereverse-scored reverse-scored (a (alittle littleof ofthe thetime time::=44and and most most of ofthe the II, time time ", = 1 )1). . The The remaining remaining items items are are scored scored from from 11 (a (a little little of of the the time) time) to 4 (most of the the to .. (most of ime). t time).

Adapted by by permiss permission from Zung Zung (1965). (1965).Copyright Copyrightby bythe the American AmericanPsychiaaic PsychiatricAssociation. Association. I also wish Adapted ion from I also wish to acknowledge GlaxoSmithKline GlaxoSmithKline for for reprinting reprinting this thisscale scaleon ontheiT theirwebsite, website, www.wellbutrin-sr.com/hcp/ www .wdlbulrin-sr.comlhcpl to

depression/zung.html, July,2001. 2001. depress ionlzung.html, July,

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first type,which whichI Icall call the the classic type, a full-bore In the first type, classicrecurrent recurrent type, a full-bore In the de­ depression or or mixed mixed disorder disorder develops develops either either following following a a period period of of lime time in pression in which you've been functioning functioning at at your your baseline baseline (or (or what, what, for you, is is your your which you've been for you, typical mood m o o d state) or just just after after a a manic manic episode, episode, with with little little or or no no break break in in typical slale) or between. between. The The onset onset of of this this depressive depressive episode episode is is usually usually not not as as sudden sudden as as the onset onset of of a a new n e w episode episode of of mania mania or or hypomania. hypomania. Instead, Instead, it usually init usually in­ the volves volves a a gradual gradual winding winding down d o w n of of your your mood m o o d state state over over a a period period of of days, days, weeks, reach aa stale weeks, or or even even months, months, until until you you reach state of of full full clinical clinical depression depression or or mixed disorder. For For some some people people the the onset onset can can be be tied to specific specific life life events events mixed disorder. tied to (see 5). (see ChapLer Chapter 5). In the the other other type, type, called called double double depression, depression, you you have have an an ongOing ongoing Slate state of of In sadness sadness (dysthymia) (dysthymia) that that m a y have have been been present present for for years years and and is is quite quite unmay un­ but still allows you to function. Then, a major depressive episode pleasant but still allows you to function. Then, a major depressive episodede­ depleasaOl velops This new depres­ velops on on top top of of this this slate state of of dysthymia. dysthymia. This n e w episode episode of of bipolar bipolar depression is is kind kind of of a a "slow "slow burn" burn":: It It develops develops gradually gradually and and perniciously, perniciously, almost almost sion imperceptibly imperceptibly from from day day to to day. day. When W h e n this this severe severe depression depression remits, remits, you you m a y return to a milder state of depression or dysthymia rather than to a may return to a milder state of depression or dysthymia rather than to a depression-free slate. state. This This cycle cycle can can be be quite quite frustrating frustrating and and demoralizing. demoralizing. depression-free Norice depres­ Notice that that in in describing describing these these course course patterns, patterns, II don't don't refer refer to to depression sion as as a a change change from from normal normal m o o d . In In my m y experience, experience, people with bipolar bipolar mood. people with disorder disorder do do not not ever ever feel feel like like they they get get to to a a stale state of of nonnal normal mood. mood. In In fact, fact, they feel feel that that their their moods m o o d s are are always alwaysfluctuating. M a n y say say that that they they are are al­ althey fluctuating. Many ways somewhat somewhat depressed. depressed. Of Of course, course, it's it's not not entirely entirely clear clear what what normal normal ways m o o d means means for for the the typical typical person-some person—some people people seem seem to to feel feel fine fine most most of of mood the time, time, whereas whereas others others are are always always somewhat somewhat anxious, anxious, angry, angry, bored, bored, disapthe disap­ pointed, or or sad. sad. pOinted, Whether you you have have classic classic recurrent recurrent or or double double depression, depression, it it is isimportant important Whether to learn learn to to recognize recognize your your prodromal prodromal signs signs of of a a new n e w episode. episode. As A s IItalk talkabout aboutin in to Chapter 9, prodromal signs are those early indicators that your m o o d state is Chapter 9, prodromal signs are those early indicators that your mood state is changing. If Ifyou you live livein in an an ongOing ongoing state stateof ofdysthymia, dysthymia,the theprodromal prodromal signs signsof of changing. aa new n e w depressive depressive episode episode will will probably probably be be more more subtle subtle than than those those experienced experienced by people with classic classic recurrent recurrent depressions, depressions, and and will will mainly mainly reflect reflect changes changes by people with in the the degree degree to to which which you experience depressive depressive symptoms symptoms (for (for example, example, the the in you experience seriousness of of your your suicidal suicidal thoughts). thoughts). Nonetheless, Nonetheless, knowing knowing how h o w to to interseriousness inter­ well­ vene when w h e n these these signs signs appear appear can can be be central central to to your your mood m o o d stability stabiHty and and wellvene being. You You may m a y be be able able to to implement implement the the self-care self-care strategies strategies in in this this chapter chapter to being. to keep the the depression depression from from becoming becoming as as bad bad as as it itotherwise otherwisemight mightbecome, become,or orto to keep m a k e your your "rebound" "rebound" dysthymia dysthymia more tolerable. It isimportant important to to keep keep these these make more tolerable. It is targets in in mind m i n d — tthe h e fact fact that that your your depression depression doesn't doesn't disappear disappear entirely entirely is isnot not targets a sign sign dial that you you have have failed failed in in your your attempts attempts to to cope cope with with it it (see (see the the earlier earlier ex­ exa ample of of Alexis). Alexis). ample -

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How H o w Do D o You You Know Know " If You're You're GeHing Getting More M o r e Depressed?: Depressed?: The Mood M o o d Spiral Spiral The One O n e symptom s y m p t o m of of depression depression seems seems to to feed feed on on others: others: negative negative moods m o o d s like like sad­ sadleth­ ness ness and and anxiety, anxiety, along along with with the the physical physical symptoms symptoms of of depression depression like Hke leth"self­ argy or or insomnia, insomnia, produce produce negative negative thinking thinking (for (for example, example, negative negative "selfargy statements," statements," the the harshly harshly critical critical voice voice in in your your head), head), and and vice vice versa. versa. The T h e com­ combination bination of of negative negative mood, m o o d , negative negative thought thought patterns, patterns, and and physical physical changes changes can can make m a k e you you feel feel less less motivated motivated to to try try hard, hard, which which can can make m a k e you you withdraw withdraw and, and, in in turn, turn, worsen worsen your your negative negative thinking thinking and and mood. m o o d . This This undesirable undesirable pat­ pattern tern is is called called the the mood m o o d spira1. spiral. Consider Consider the the follOwing following experiences experiences of of two two peo­ people with with bipolar bipolar depressions. depressions. ple de­ Denise, Denise, a a 27-year-old 27-year-old with with bipolar bipolar II II disorder, disorder, was was typically typically mildly mildly dere­ pressed pressed and and pessimistic pessimistic in in her her day-to-day day-to-day life, life, despite despite being being loyal loyal to to her her regime gime of of Tegretol Tegretol and and Paxil. Paxil. Her Her more more serious serious depresSiOns depressions had had a a gradual gradual but but predictable predictable course. course. Her Her first first sign sign of of a a depresSive depressive recurrence recurrence was was ruminating ruminating about about things things that that were were realistic realistic but but blown blown out out of of proportion. proportion. For For example, example, work at colleague a by slighted felt she episode, recent most her to prior prior to her most recent episode, she felt slighted by a colleague at work and and ex­ angry angry at at herself herself for for not not having having responded responded adequately adequately to to the the slight. slight. She She exno one panded panded the the Significance significance of of this this minor minor event event into into thinking thinking that that no one at at work work liked her. her. She She then then became became very very self-critical, self-critical, claiming claimingitit was washer her lack lackof ofinter­ interliked personal skills skills that that led led others others to to dislike dislike her. her. Her Her depressed depressed mood m o o d worsened, worsened, personal and she she had had more more and and more more difficulty difficulty going going to to work. work. Her Her performance performance started and started to deteriorate, deteriorate, and and she she developed developed insomnia. insomnia. "Sick "Sick days" days" followed. followed. Eventually Eventually to she took took a a leave leave from from her her job and became inactive and and withdrawn withdrawn in her she in her became inactive job and home. home. At At this this point point she she became became tearful tearful and and suicidal. suicidal. Denise eventually eventually came came out out of of her her depressions depressions through through a a combination combination of Denise of medication changes changes (for (for example, example, an an increased increased dosage dosage of of her her mood m o o d stabilizer), stabilizer), medication regular psychotherapy, psychotherapy, and and behavioral behavioral activation activation exercises exercises assigned assigned to by regular her by to her her her therapist. therapist. These These exercises exercisesusually usuallyincluded includedspending spendingtime timewith with friends friendsand and neighbors, various variousforms forms of oflight lightphysical physicalexercise, exercise,and andactivities activitiesthat thatinvolved involved neighbors, her young niece. young niece. her Carlos, age age 35, 35, had had bipolar bipolar II disorder disorder with with classic classic recurrent recurrent depressions. depressions. Carlos, He'd numerous episodes episodes and and learned learned to to recognize recognize the the symptoms sigthat sig­ symptoms that had numerous He'd had naled naled the the onset onset of of a a depressive depressive episode episode with mixed features. features. His prodromal His prodromal with mixed fatigue, sleepiness, mild fatigue, of mild the form took the signs took signs form of sleepiness,and andpoor poorconcentration. concentration.These These signs were dread, and signs restless a restless and a anxiety, dread, of anxiety, feelings of with feelings intermixed with usually intermixed were usually "jumping y skin" feeling. skin" feeling. my of m out of "jumping out Fortunately, w h e n he he had had been been well, well, Carlos Carlos and and his his therapist therapist had had put put into into Fortunately, when place a prevention plan for staving off his worst symptoms. His plan included place a prevention plan for staving off his worst symptoms. His plan included

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and fewer getting bedtime/wake-up routine, eating moremore protein gettingon ona aregular regular bedtime/wake-up routine, eating protein and fewer carbohydrates, carbohydrates,avoiding avoidingalcohol alcoholand andstreet streetdrugs, drugs,scheduling schedulingat atleast leastone onecon­ contact tact each each day day with with a a person person who w h o could could give give him him pOSitive positive input, input, and and taking taking breaks breaks from from work work when w h e n he he needed needed to. to. He H e also also kept kept a a "thought "thought record" record" (see (see page page 232) 232) in in which which he he recorded recorded examples examples of of self-blaming self-blaming statements statements or or

overgeneralizations about about his his situation situation (for (for example, example, "My " M y life life has has never never had had overgeneralizations any any joy joy or or fulfillmentn). fulfillment"). He H e also also learned learned to to counter counter these these thoughts thoughts with with more more

adaptive ones ones ("I'm ("I'm going going through through a a tough tough time time.. ... .. I've . I've dealt with this before adaptive dealt with this before and and come c o m e out out of of it. it. . .

Depression Depression isisgoing going to tocolor color the the way w a y I Ifeel feelabout about

things"). things"). The following following exercise exercise will will help help you you list list the the prodromal prodromal signs signs of of your your deThe de­ pression pression (your (your mood m o o d spiral). spiral). The The list list is isnot notexhaustive, exhaustive,and andspaces spacesare areleft leftfor for

symptoms that that are are not not included included here. here. In In completing completing the the exercise, exercise, try try to think symptoms to think back on on the the last last time time you you became became depressed. depressed. If If you you are are currently currently depressed, depressed, back you may m a y be be able able to to recall recall ilS its earliest earliest phases. phases. What W h a t were were ilS its first signs? If If you you you first signs? were already already depressed depressed when w h e n the the new n e w episode episode developed, developed, h o w did did you you know know were how it it was was getting gettingworse? worse? As As you you did didwhen w h e n listing listingyour your prodromal prodromal signs signsof ofmania, mania,

include the the input input of of your your spouse spouse or or another another family family member m e m b e r or or friend friend who w h o has has include observed you you during during the the early early phases phases of of depression. depression. observed Notice Notice how h o w the the prodromal prodromal signs signs of of depression depression differ differ from from the the signs signs of of ma­ ma-

nia (Chapter (Chapter 9). 9). The depressive warning warning Signals signals usually usually involve involve feeling feeling slowed slowed The depressive nia down, and hopeless. hopeless. down, negative, negative, unmotivated, unmotivated, uninterested, uninterested, mentally mentally sluggish, sluggish, and

The mania signals involve feeling sped sped up, up, goal-driven, goal-driven, energi energized, mentally The mania Signals involve feeling zed, mentally swift, and, often, overly overly optimistic optimistic or or even even grandiose. swift, and, often, grandiose. Keep your your list list of ofdepression depressionwarning warning signs signsin inaaplace placewhere where you you can can find finditit Keep later. If Ifyou youfeel feelyour your m o o doror energy level start shift, refer back to the later. mood energy level start to to shift, refer back to the listHst to to see if you are areexperiencing experiencing aanew n e w onset onset of ofdepression. depression.You Y o ucan canthen thenmove m o v eon onto to see if you introducing self-care self-care strategies strategieswhen w h e none oneor ormore moreof ofthese thesesigns signsappears. appears. As you introdUcing As you did with your your mania mania list, list,share sharethis thislist listwith withyour yourclose closerelatives relatives(your (yourspouse, spouse, did with trusted friends, friends,parents) parents)so sothat thatthey theycan canlearn learntotorecognize recognizewhen w h e nyou're you'regetting getting trusted depressed and and are are in a position offer help help (for (for example, example, listen Hsten supportively, depressed in a position to to offer supportive1y, look after after your provide aa distraction, distraction,help helpyou youcontact contactyour yourdoctor). doctor). look your kids, kids, provide

Self-Care The Behavioral Behavioral Activation Method Self·Care Strategy Strategy No. No. 1: I : The Activation Method "When I get hardfor for even in pubHc. I with"When I getdepressed, depressed, it's it's hard memetoto even be be outout in public. I with­ draw, gettired, think in in very very black black and and white white terms, terms, II disqualify disqualify any­ anydraw, I I get tired, II think thing n o w that 12 thing good good that that happens. happens. But But I've I've learned learned not not to to give give up. up. I I k know that 12 in the is my m y worst worst time, time,so so IIforce forcemyself myselfto togo goto tothe thegym g y m then. then. in the afternoon afternoon is just pray pray no no one one will wiH talk talk to to me. m e . On O n other other days days I'll I'Hjust justhave havecoffee coffeewith with I1 just

What Coil Can IIDo Do IfIfI Thillk I ThinkI'mI'm6ening GettingDepressed Depressed? Whol ?

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LISTING LISTING YOUR Y O U R PRODROMAL P R O D R O M A L SIGNS S I G N S OF O F DEPRESSION DEPRESSION Listaa couple couple of ofadjectives adjectives describing what your moodisislike like whenyour yourdepressive depressive describing what your mood when list episodes episodes first first begin begin (examples: (examples: sad, sad, anxious, anxious, fearful, fearful, irritable, irritable, grouchy, grouchy, down d o w n hearted, hearted, blue, "blah," "blah," flat, flat, numb, n u m b ,bored). bored). blue,

Describe changes changes in in your your activity activity and and energy energy levels levels as as your your depressive depressive episodes episodes develop develop Describe (examples: (examples: feeling feeling slowed slowed down, d o w n , withdrawing withdrawing from from people, people, moving moving more more slowly, slowly,talking talking more fatigued, feeling feeling more slowly, slowly, doing doing fewer fewer things, things, having having little little or or no no sex sex drive, drive, feeling feeling fatigued, "tired "tired but but wired"). wired").

Describe Describe changes changes in in your your thinking thinking and and perception perception (examples: (examples: thoughts thoughts go go more more slowly, slowly, can't get get interested interested in in things, things, colors colors seem seem drab, drab, people people look look like like they're they're moving moving too can't too fast, fast, feel oror self-blaming, feel guilty, regret pastpast deeds, feel feel hopeless, feelself-doubting, self-doubting,self-critical, self-critical, self-blaming, feel guilty, regret deeds, hopeless, concentrate poorly, poorly, feel feel dumb, d u m b , can't can't make m a k e decisions, decisions, think think about about hurting hurting or or killing concentrate killing myself, myself, ruminate ruminate and and worry worry about about things). things).

Describe changes changes in in your your sleep patterns patterns (examples: (examples: want wanting to sleep sleep more, more, waking waking up up in ing to in Describe the the middle middle of of the the night night or or not not being being able able to to fall fall asleep asleep easily, easily,waking wakingup up an an hour hour or ortwo two earlier earlier than than usual). usual).

Describe anything anything else else that that seems seems different different when w h e n you're you're getting getting depressed. depressed. Describe

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doIthis, I do this, a friend. tough, I dread feel I'm and so down and can't a friend. It's It's lough, I dread it, Iit, feel Ilike I'mlike so down I can't just can't. can't. But, But, without without aa doubt, doubt, it it helps helps me." me." just -A 41-year-old — A 41-year-old woman w o m a n with with bipolar bipolar II II disorder disorder Behavioral activation is is oneone of the mostmost important components of activation of the important components Behavioral of cognitive-behavioral therapy therapy (Beck (Beck el et aI., al., 1979; 1979; Jacobson Jacobson el etaI., al.,1996). 1996). There There cognitive-behavioral are behind behavioral are two two assumptions assumptions behind behavioral activation. activation. First. First, depression depressionresults resultsinin aa loss ities or loss of of pleasurable pleasurable activ activities or "positive "positive reinforcements." reinforcements." That That is, is,being beingde­ depressed makes makes you you less less likely likely to to do do the the sons sorts of of things things that that will will help help you you get get pressed something positive positive from from your your env environment. Second, the the lack lack of of these these reinsomething ironment. Second, rein­ want to withdraw even forcements your depression forcements worsens worsens your depression and and makes makes you you want to withdraw even more. It is cerlainly certainly true true that that being being depressed depressed makes makes it it very very difficult difficult to to get more. It is get yourself combination wilh your bi­ yourself to to do do anything. anything. But But it's it'sequally equallytrue truethat, that,inin combination with your biological predispositions, not engaging engaging with with your environment keeps keeps you you deological predispositions, not your environmem de­ pressed and eventually makes makes you you feel worse. pressed and evenlUaUy feel worse. Depression has aa way Depression has w a y of of spoiling spoiling your your experience experience of ofthings thingsyou youused usedto tolove love to do. do. They They just just don't don't seem seem fun anymore. Sometimes Sometimes the the events events that that make m a k e you you to fun anymore. depressed (for (for example. example,the theending endingof ofaarelationship) relationship) result limiting your condepressed result inin limiting yourcen­ tact with people people whose whose company company you you used used to toenjoy enjoy and and decreasing decreasing your your access access laCt with to that used to give give you you pleasure. pleasure. All of this this will will mmake you feel feel like to activities activities that used to All of a k e you like withdrawing. h e n you're depressed, the stayin in withdrawing. But But wwhen you're depressed, the worst worst thing thing you you can can do do is is stay bed, sitat athome, h o m e ,and andavoid avoidpeople. people. It'certainly s certainly understandable that you'll want bed, sit It's understandable that you'll want to and you you may m a y have have to tofrom from time time to totime. time.But Butififlhis this state to do do these these things, things, and Slate ofof in­inactivity your depression depression will willonly only get getmore more severe. severe."The "The activity dominates dominates your your life, life, your more e do, depressed we w e feel; feel;and andthe theless lessdepressed depressedwe w efeel, feel, the more more wwe do, the the less less depressed the more w e wiH 74). we will feel feel encouraged encouraged to to do do things" things" (Lewinsohn (Lewinsohn et el al, aI., 1992, 1992, p. p. 74). The your contact goal behind behind behavioral behavioral activation activation is is to to try try to to increase increase your COnlact The goal with feelyour physical physical and and social social environment, environmem, to to the the point point where where you you start Slart feel­ with your ing ing better better about about yourself. yourself. Of Of course, course, you you need need aa regular regular slate slate of of routines routines and and pleasurable h e n you're e H (Chapter t's especially especiallyim­ impleasurable activities activities even even wwhen you're wwell (Chapter 8), 8), but but iit's portant h e n you to introduce introduce activating activating exercises exercises wwhen you recognize recognize aa worsening worsening poTtam to state giveyou youaabrief briefset setof ofinstructions instructionsfor forim­ imstate of of depression. depression. In In this this section, section, IIgive plementing p1ememing the the behavioral behavioral activation activation method. method. For For more more thorough thorough directions, directions, consult consult the the self-help self-help book book Control Control Your Your Depression Depression by by Peter Peter Lewinsohn Lewinsohn and andhis his associates associates (1992). (1992). Make Pleasurable Activities M.kea• List Li,t ./ofPle.,ur.ble Activitie, Start byexamining examiningthe theprevious previous week if prefer, you prefer, takeon notes on yourself yourself Start by week or,or, if you take notes for o o d chart for the the forthcoming forthcoming week. week. Your Your mmood chart should should help help you you track track informainfonna­ tion about your your daily daily habits. habits. Ask Ask yourself yourself the the follOWing: foHowing: tion about

What I'm IGetting Depressed? What (on Con IIDoDoIfIfI Think I Think 'm Getting Depressed?

225 225

Are days yourcharacterized days characterized byofa structure? lack of structure? • Are• your by a lack •

• Are A r e there there long long periods periods of of time time when w h e n you y o u have h a v e nothing nothing to to do? do?

•

• Are A r e there there particular particular points points during during the theday d a ywhen w h e n you y o u feel feel down? down?

•

to? • Are A r e the themornings m o r n i n g s long long expanses, expanses, with with nothing nothing to tolook look forward forward to?

•

• Do D o you y o u dread dread [he theweekend w e e k e n d because because there there is isnothing nothing to to do? do? • Is Isthe the beginning beginning of ofthe the workday w o r k d a y inviting inviting just just because because it it gets gets you y o u out o u tof of the house? house? the

•

Alternatively: Alternatively: • Have yourbeen daysdominated been dominated by too many activities, most are of which are • Have your days by too many activities, most of which

required by b y your y o u r work w o r k or or family family life life but b u t which w h i c h you y o u don't don't find find rewarding? rewarding? required •

• If Ifyou're you're not n o tworking, w o r k i n g , has h a sthere there been b e e n aa good g o o d balance balance between b e t w e e n pleasant pleasant activities a n d "must " m u s t do" d o " activities? activities? activities and

•

• Are A r eyou y o uengaged e n g a g e d in in enough e n o u g h positive, positive, rewarding rewarding activities activities to to keep k e e p your your m o o d from from spiraling spiraling downward? downward? mood

Next, listas as many manypleasurable pleasurable or or engaging as you can.can. II It Next, try try to to list engaging activities activities as you can depressed, but can be be hard hard to to think think of of pleasurable pleasurable things things to to do do when w h e n you're you're depressed, but boltom you'll filling filling out out the the exercise exercise on on page page 226 226 will will get get you you started. started. At At the the bottom you'H find a list of examples of activities many people find pleasurable when they're find a list of examples of activities m a n y people find pleasurable w h e n they're feeling down. down. List List all all of of the the activities activities that that could could be be pleasurable pleasurable for for you, even if feeling you, even if they they don't don't seem seem feasible feasible (for (for example, example, you you may m a y really really enjoy enjoy fishing, fishing, but but there there is is nowhere nowhere to to fish fish nearby). nearby). Just Just because because you you list listaanumber n u m b e r of ofactivities activitiesdoesn't doesn'tmean m e a n you you should should try tryto to do do all all of of them. them. In In fact, fact, the the objective objective here here is is first first to to make make a a list list of of pleasurable pleasurable events events and and then then to to introduce introduce one one each each day, day, or or perhaps perhaps more more than one if if you you than one feel up up to toit. it.Make M a k e aa panicular particular effort effortto tolist listactivities activitiesthat thathave havethe thepotential potentialto to feel (1) (1) keep keep you you engaged engaged with with other other people people and and make m a k e you you feel feel valued valued or or rere· spected spected (for (for example, example, hiking hiking with with a a friend), friend), (2) (2) give give you you a a sense sense of compeof compe· tence tence and and purpose purpose (for (for example, example, taking taking a a piano piano lesson lesson or or a a foreign foreign language language class), class), and and 0) (3) make m a k e you you likely likely to to experience experience emotions emotions other other than than depression depression (for example. example, watching watching a a humorous humorous movie, movie, being being out out in in nature). nature). Keep (for Keep in in mind mind that what is is pleasurable pleasurable to to other other people people may m a y not not be be pleasurable pleasurable to to you, that what you, and vice vice versa versa (see (see the the extended extended list list prOVided provided by by Lewinsohn Lewinsohn et etaI., al., 1992). 1992). Try Try and to to list list only only activities activities that that you you want want to to do do and and know k n o w you you would would enjoy. enjoy.

Scheduling PI.asurableActivities Activities Scheduling Pleasurable Next, choose c h o o s e one o n e or or two t w o activities activities from f r o m this this list list to to do d o each each day d a y of the next next Next, of the w e e k (see (see the the first first exercise, exercise, "Scheduling "Scheduling Pleasurable Pleasurable Activities," Activities," on o n page p a g e 2227). 27). week

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LISTING PLEASURABLE P L E A S U R A B L E ACTIVITIES ACTIVITIES LISTING

Ust many as youas can think that you findwould rewarding pleasurable. Listasas manyactivities activities you canofthink of would that you findand rewarding and pleasurab

Include activities activities that keep you you engaged engaged with other people, people, activities activities that increase your your Include that keep with other that increase that might you to sense of of competence, competence, and and activities activities that might allow allow you to experience experience emotions emotions other sense other

than depression. than depression.

(Examples: taking a walk, walk, going going to to a a church church or or synagogue synagogue group, group, playing playing a a musical musical (Examples: taking a onon the instrument, instrument, walking walkingthe thedog, dog,watching watchingaaTV T Vprogram, program,going goingtotothe thelibrary, library,talking talking the phone watching a comedy movie, having phone to to a a friend, friend,talking talkingto toaatherapist, therapist,playing playinga aspan, sport, watching a comedy movie, having sex, riding listening toto music, practicing a hobby. sex, ridingaabicycle, bicycle,visiting visitingthe theHumane H u m a n eSociety, Society, listening music, practicing a hobby, siuing in sewing, dancing, working at aathomeless shelter, writing sitting in aa cafe, cafe, cooking, cooking,driving, driving, sewing, dancing, working a homeless shelter, writing in a a journal, journal, taking taking phomgraphs. photographs, taking taking aa class class, painting or or d drawing, soaking in the the in , painting rawing, so aking in bathtub, eating eatingat ataarestaurant, restaurant,listening listening a relaxationtape, tape, shopping, hiking, gardening, bathtub, toto a relaxation shopping, hiking, gardening, praying, meditating, meditating,going goingfor foraaswim, swim,eating eatinglunch lunchoutside, outside,attending attending a lecture, washing a lecture, washing praying, your face face or or hair, hair, lying lyingout outin in the thesun, sun,playing playingwith with aapet) pet) your

Source: Lewinsohn al. Sourct: Lewinsohn et al.et (1992)

(1992)

Pick the the day day you y o u will will do d o each each activity activity and a n d set set a a target target time time in in the the "Day "Day of of the the Pick Week" W e e k " column. c o l u m n . If Ifyou y o u feel feel that that one o n e activity activity per per day day is istoo too much, m u c h , choose choose one one to to d o every every other other day day or or even even one o n e every every three three days, days, and a n d build build up u p from from there. there. If If do you're feeling feeling very very depressed depressed or or low l o w in in energy, energy, pick pick easy easy activities activities such such as as you're putting on on a a favorite favorite piece piece of of clothing, clothing, taking taking a a bath, bath, or or spending spending five five minutes minutes putting outside in in the the sun. sun. It It will will feel feel therapeutic therapeutic to to be b e able able to to do d o something something small s m a H for for outside yourself each each day, day, or or every every few few days, days, when w h e n it feels impossible impossible to to do d o more. more. yourself it feels S o m e activities activities and a n d events events require coordination of of other other people's people's sched­ schedSome require coordination ules, extensive extensive travel, travel, m o n e y , and a n d reservations reservations m a d e well w e U in in advance advance (for (for ex­ exules, money, made ample, concert concerttickets, ski lessons). lessons). You Y o u may m a y find it easier easier to to choose choose activities activities ample, tickets, ski find it that do d o not not reqUire require such planning. Perhaps Perhaps activities activities that require planning planning can can that such planning. that require be introduced introduced later. be later.

What Do IfIfI IThink ThinkI'm I'mGell Getting Depressed? Whol Can Con II Do ing Depressed?

227 277

SCHEDUUNG PLEASURABLE ACTIVITIES ACTIVITIES S C H E D U L I N G PLEASURABLE

Day of of the Day the week week time target time and target and Monday Mondav

Tuesday Tuesday

--

--

Wednesday Wednesday

Thursday Thursdav

Friday Fridav

Saturday Saturday

--

--

--

Pleasurable Pleasurable activities activities

I. 1.

I. 1.

2. 2

2. 2

2. 2

2. 2

I. 1

I. 1

2. 2

2 2.

I. 1

I. 1

I. 1

2. 2

2. 2

2 2.

I1.

I. 1

Mood Mood before before and and after each activity activity (-3/+3) ( 3/+3)

I. 1

2. 2

2. 2 Sunday Sundav

Actual day Actual time time of of day each each activity activity was was done done

I1.

I1.

2 2.

I. 1

I. 1

2. 2

2. 2

Try to to pick pick activities activities that that win will not not disrupt disrupt your your work w o r k routine routine or or your your Try sleep-wake sleep-wake cycle. cycle. For For example, example, if if you you like like to to exercise, exercise, avoid avoid doing doing it it in in the the

evening,especially especiallyright rightbefore beforeyou yougo go to tobed. bed.If If you you enjoy enjoyconversations conversationswith with evening, a a specific specific person person but but feel feelwired wired or or energized energized by by these these talks, talks,avoid avoidthem themafter afteraa certain certain time time of ofnight. night. Try Try not not to to be be too too ambitious ambitious (at (atleast, least,atatfirst) first) schedulinin schedul­ ing ing activities activities early early in in the the morning. morning.

Next, record record the the actual actual time time of of day day that that you you completed completed each each activity. activity. Re­ ReNext, cord cord your your mood m o o d on o n the the -3 -3 (severely (severely depressed) depressed) to to +3 +3 (severely (severely manic) manic) scale scale

that you you used used for for your your mood m o o d chart chart in in Chapter Chapter 8. 8. Rate Rate your your mood m o o d before before you you that

begin begin the the activity activity and and again again as as soon soon as as you you are are finished. finished. For For example, example, if if your your

activity was was gardening, gardening,record record how h o w you you felt feltjust justprior priorto togoing goingout outto tothe thegar­ garactivity den and and then then give give yourseU yourself another another rating rating for for the the hour hour or or so so after after finishing. finishing. den M a k e copies copies of of this this form form before beforefilling itout out so so that thatyou you can can use use it it in in subse­ subseMake filling it quent quent weeks. weeks.

Notice that that I've I've asked asked you you to to keep keep track track of of your your high high as as well w e H as as your your low low Notice

moods. As A s you you know k n o w from from previous previous chapters, chapters,certain certain activities activities can can contribute contribute moods. to manic manic symptoms. symptoms. For For example, example, exercise exercise generally generally improves improves aa person's person's to

Im·MANAGEMENT SELF-MANAGEMENT

228 228

hypomanic. It's It's immoods, moods, but but some some people people exercise exercise to to excess excess and im� and become become hypomanic. s portant aco that that you you can can determine determine whether whether certain certain ac­ to keep keep data data on on yourself yourself so portant to tivities improve improve your your m mood or "overcorrect." "overcorrect. " tivities o o d or

rroubleshooti.g Your PI•• Troubleshooting Your Plan After scheduHng pleasurable pleasurableevents events a week or more, evaluate whether After scheduling forfor a week or more, evaluate whether the the plan is is working. working. Are Are your your m mood ratings more more positive positive on on the the days days in in which plan o o d ratings which you did did one or more more pleasurable activities? T To determine this, this, complete complete the the you one or pleasurable activities? o determine

"Impact of Your Behavior Plan" exercise (on this page), in which "Impact of Your Behavior Activation Activation Plan" exercise (on this page), in which you day in in the the last last week on the the -3 to +3 +3 scale and make a check you rate rate each each day week on -3 to scale and make a check

mark days you completed at at least one of activities. If If mark next next to to the the days you completed least one of your your planned planned activities. your varied considerably conSiderably during your mood m o o d varied during any any given given day, the rating you day, use use the rating that that you think the whole how at a particu­ think best best characterizes characterizes the whole day, day, rather rather than than h o w you you felt felt at a particularly larly tough tough moment. m o m e n t . Then, Then, calculate calculate an an average average mood m o o d rating rating for for the the days days that that you you did, did, and and did didnot, not,complete complete your your activities. activities.You Y o ushould shouldbe beable abletototell tell from from this has had had a on your this overview overview whether whether your your activity activity plan plan has a beneficial beneficial impact impact on your mood m o o d in in the the last last week. week. If are If your your plan plan is is not not working working yet, yet, consider consider the the possibility possibility that that you you are choosing are too choosing events events that that are too hard, hard, that that require require too too much m u c h planning, planning, or orthat thatyou you

don't really really en enjoy. Forexample, example,if ifyou youhave haveincluded includedtaking takingaaforeign foreignlanguage language don't joy. For classbut butdon't don'treally reallylike likethe theprocess process of oflearning learningaalanguage, language,you youmay m a ynot notwant want class to include include this this activity. activity.Also, Also,consider considerthe thebalance balancebetween betweenactivities activitiesyou youmust must to

IMPACT OF O F YOUR Y O U R BEHAVIOR BEHAVIOR ACTIVATION ACTIVATION PLAN PUN IMPACT Check ((V) youfollowed followed Check ..;) ififyou Day Day of of the the week week

Mood that that dav day (-3 (-3 to to +3) +3) Mood

your activityplan plan our activity

Monda y Monday Tu",", y Tuesday Wednesda y Wednesday Thursdav Thursday Friday Friday Saturday Saturday Sunday Sunday

Average Average mood mood rating rating for for the the days days you you followed followed your your plan plan Average Average mood mood rating rating for for the the days days you you did did not not follow follow your your plan plan

What I'm Getting Depressed? What Can Can II00DoIfIfI Think I Think I'm Getting Depressed?

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and those thoseyou youreally reallywant want do. your depression related the absence do and toto do. IfIfyour depression is is related toto the absence do activities that of pleasurable pleasurable events events as as well well as as the the avoidance avoidance of of unpleasant unpleasant activities that of taxes), in­ have to to be b e done d o n e (for (for example, e x a m p l e , sweeping s w e e p i n g the the garage, garage, preparing preparing yyour o u r taxes), inhave troduce troduce a a combination c o m b i n a t i o n of of pleasurable pleasurable and a n d required required activities activities into into yyour o u r sched­ sched-

ule. Start Start slowly: slowly: Don't Don't ny try to to schedule schedule a a "must " m u s t do" d o " activity activity every every day. day. Work Work ule. your way w a y up u p to to a a reasonable reasonable balance, balance, such s u c h as as two t w o pleasurable pleasurable activities activities aand nd your o n e required required activity activity per per day. day. one If things have h a v e gone g o n e well well for for you y o u so sofar, far,and a n d you've you've noticed noticed that that your y o u r mood mood If things has improved improved (or, (or, at at minimum, m i n i m u m , your your prodromal prodromal depressive depressive symptoms symptoms haven't haven't has worsened), start start introducing introducing more more pleasurable pleasurable activities activities into into various various parts parts of of worsened), your day. day. You Y o u may m a y find, find, for for example, example, that that you you feel feel beller better if if you you have have some­ someyour thing at an out­ thing pleasurable pleasurable to to do do during during the the lunch lunch hour hour (for (for example, example, silling sitting at an outdoor door picnic picnic table) table) as aswell wellas assomething somethingto tolook lookforward forwardto towhen w h e n you you get gethome home from or going to from work, work, school, school, or or other other activities. activities. If If you you are are not not working working or going to school, school, it's it's espeCially especially important important to to have have rewarding rewarding activities activities at at the beginning the beginning

and end end of of the the day day so so that that some s o m e structure structure is is introduced introduced into into your and your routines. routines. The too The behavioral behavioral activation activation method method may m a y seem seem somewhat somewhat superficial superficial or or too obvious. prob­ obvious. You Y o u may m a y feel, feel, "Of "Of course course II should should be be doing doing those those things-the things—the probit becomes lem lem is is that that II can't!" can'tV When W h e n your your depression depression is is gradually gradually worsening, worsening, it becomes

especially important important to to reengage reengage with with your your environment environment and and do do the the things things especially that give give you you a a different different experience experience of of your your emotions. emotions. The T h e key key is is not push that not to to push yourself too too hard hard with with these these activities. activities. Don't Don'ttry tryto todo do too toomany m a n y all allat atonce. once.At At yourself first,pick pickaafew fewyou you can cando doeasily easily(for (forexample, example,taking takingaashort shortwalk, walk,listening listening first, to to music, music, taking taking a a bath, bath, birdwatching, birdwatching, playing playing cards) cards).. Then Then work work on on building building up up to to a a reasonable reasonable number n u m b e r each each day, day, until until you you find find yourself yourself looking looking forward forward

to the the next next day day because because of of the the pleasant pleasant activities activities you've you've scheduled. scheduled. Troubleto Trouble­ shoot shoot the the plan plan at at the the end end of of each each week w e e k to to determine determine why w h y it it didn't didn't work. work. On On your your first first few few tries, tries, you you probably probablywon't won'tbe beable ableto tocomplete completecertain certainaspects aspectsof of the the plan. plan. Try Try not not to to get get discouraged; discouraged; it it may m a y take take a a few few weeks weeks to to formulate formulate a a plan plan that that really really works works for for you. you.

Even if if it it sounds sounds simple, simple, you you may m a y be be surprised surprised at at how h o w well your plan plan Even well your helps helps to to prevent prevent your your depression depression from from spiraling. spiraling. In In all all likelihood, likelihood, you'll you'llget getaa feeling feeling of of mastery mastery from from making making your your plan plan work, work, which which will will make m a k e you you want want to to extend extend it it further. further.

Self-Care Strategy Strategy No. N o . 2: 2: The The Cognitive Cognitive Restruduring Restructuring Method Method Self·Care You You are probably aware aware that thatmood mood states areaffected affected things are probably states are by by thethe things you you tell tell

yourself—^by what what we w e call call "cognitionsn "cognitions" or or "self-statements." "self-statements." Many M a n y studies yourself-by studies have shown s h o w n that that negative negative thinking thinking is is associated associated with with depressed depressed and and anxious anxious have m o o d s (for (for example, example, Clark Clark et et al, 1999; DeRubeis DeRubeis et et al., al., 1998). 1998). People People with with moods aI., 1999;

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(for example, depression often "core beliefs" themselves depression oftenhave havenegative negative "core beliefs" themselves (for example, aboutabout are "I'm not not a a likable likable person"), person"), about about people people in in general general (for (for example, example, "people "people are "I'm generally motivated motivated by by selfish selfish concerns") concerns"),, and and ahoUl about their their future future ("I'm ("I'm never never generally going to to accomplish accomplish my m y goalslbe goals/be lovedlbe loved/be healthy"). healthy"). The The assumption assumption of of cogni­ cognigoing tive-behavioral events provoke tive-behavioral therapy therapy (Beck (Beck et et a1., al., 1979) 1979) is is that that certain certain events provoke disdis­ lOrted un­ torted "automatic "automatic negative negative thoughts" thoughts" that that reflect reflect core core beliefs beliefs about about one's one's unworthiness or or unlovability. unlovability. These These automatic automatic thoughts thoughts and core beliefs beliefs are worthiness and core are important in in causing causing and and maintaining maintaining depressed depressed mood m o o d and and behaviors behaviors (for (for ex­ eximportant ample, from others) ample, withdrawing withdrawing from others).. In In cognitive cognitive restructuring, restructuring, you you hold hold your your up to assumptions assumptions up to the the light light to to see see if if they they are are logical logical and and accurate accurate or or if if there there are other ways ways to to make m a k e sense sense of of your your experiences. experiences. You Y o u may m a y recall recall my m y discusare other discus­ 6; it one of treat­ sion therapy in sion of of cognitive cognitive therapy in Chapter Chapter 6; it is is one of [he the most most effective effective treatments for depressive depressive and and anxiety anxiety disorders disorders (Clark (Clark el et al., al., 1999). 1999). ments for The The relationship relationship between between thoughts thoughts and and mood m o o d states states is is probably probably not not one­ oneway: moods and increase per­ way: Depressed Depressed m o o d s also also generate generate distorted distorted thoughts thoughts and increase a a pernegative memories memories or son's access son's access La to negative or images images (Gollib (Gotlib & & Krasnoperova, Krasnoperova, 1998). 1998). But learning learning La to modify modify negative negative thoughts thoughts and and replace replace them them with with more more adapBut adap­ tive or or balanced balanced cognitions cognitions can can go go a a long long way w a y toward toward alleviating alleviating your your deprestive depres­ sion. sion. Cognitive Cognitive restructuring restructuring involves involves a a sequence sequence of of techniques. techniques. First, First, you you identify dis­ identify the the automatic automatic thoughts thoughts or or self-statements self-statements associated associated with with certain certain disturbing situations situations or or life life events events and and link link these these thoughts thoughts with with your your mood mood turbing states. You You will willprobably probablyfind findthat thatcertain certainthoughts thoughtsor orimages imagesare aremore morepower­ powerstates. ful than than others others in in provoking provoking your your emotional emotional reactions reactions ("hot ("hot cognitions"). cognitions"). Sec­ Secful ond, thoughts. ond, you you evaluate evaluate the the evidence evidence for for and and against against these these automatic automatic thoughts. Next, based on this this for/against for/against evaluation, evaluation, you you learn learn to to replace replace your your original Next, based on original thoughts with with self-statemems self-statements that provide a a more balanced interpretation interpretation of thoughts that prOvide more balanced of your experiences. Last, Last,you youobserve observethe theeffects effectsof ofthese thesenew n e wself-statements self-statementson on your experiences. your mood. your mood. This method method is is nor not a a matter matter of of blithely blithely replacing replacing bad bad thoughts thoughts with with good good This ones, which which many m a n y people people find find superficial superficial and and unrealistic. unrealistic. Instead, Instead, it it involves involves ones, thinking up alternative or more balanced balanced ways ways of understanding the the things things that that thinking up alternative or more of understanding have happened happened to to you you and and looking looking at atyour your situation situationfrom fromaanumber numberof ofdifferent different have vantage points. A simple simple example: example: Some S o m e people people automatically automatically blame blame them­ themvantage points. A selves when w h e n someone someone else else treats treats them them badly, badly, without without conSidering considering the thepossibil­ possibilselves ity this other other person person is is having having a a bad bad day day or or often behaves in in a a similar ity that that this often behaves similar manner with other people. manner with other people. In this this section, section, II describe describe the the method method of of cognitive cognitive restructuring restructuring and and outIn out­ line exercises exercises to to help you learn it. Like Like the the pleasurable pleasurable activity activity scheduling, scheduling, line help you learn it. cognitive restructuring restructuring will will probably probably have have its its greatest greatest power power once once you you have have cognitive noticed noticed the the ·appearance appearance of of one one or or more depressive prodromal prodromal symptoms, symptoms, bebemore depressive

What (on Can IIDoDoIfIfI Think I Think 'm Getting Depressed? Who) I'm IGening Depressed?

231231

getsreally reallysevere. severe. If If you wanttotoexplore explorethis thismethod method fore your your depression depression gets you want fur-fur� fore ther, ther, II suggest suggest consulting consulting the the book b o o k Mind M i n d Over O v e r Mood M o o d by b y Dennis D e n n i s Greenberger Greenberger a n d Christine Christine Padesky P a d e s k y (1995) ( 1 9 9 5 ) or or books b o o k s on o n the the use u s e of of cognitive�behavioral cognitive-behavioral and therapy therapy with w i t h people people who w h o have h a v e bipolar bipolar disorder disorder (Basco (Basco & & Rush, R u s h , 11996; 996; N e w m a n et et al., al., 2001). 2001). Newman Step I: 1: Ide.lilyi.g Identifying Neg.five Negative Thoughls Thoughts Sfep

Jacob, struggled withsevere severebipolar bipolar depressions depressions that Jacob, ageage 49,49, struggled with that alternated alternated with popular with mixed mixed episodes. episodes. When W h e n he hewas was feeling feelingwell, well,he fiewas wasa a popularcoach coachofof aa children's children's soccer soccer team. team. Bm But when w h e n he he felt felt he'd he'd had had aa bad bad day day of of coaching coaching (for re� (for example, example, his his concentration concentration had had been been poor poor or or the the kids kids had had not not responded mood a sponded to to his his suggestions), suggestions), his his m o o d would would sink. sink. He H e became became aware aware of of a self�statement I have have ma� self-statement that that went went like like this: this: "I'm "I'm just just no no good good with with kids. kids. I maJOT flaws that jor character character flaws that they they can can see see in in me." me." Sometimes, Sometimes, just just the the word word character mood drop. character would would pop pop into into his his mind, mind, and and he he would would feel feel his his m o o d drop. Character became became a a hot hot cognition cognition closely closely tied tied to to his his mood m o o d state depresCharacter state of of depres­ sion. sion. Jacob Jacob was was actually actually quite quite good good with with children, children, and and the thekids kidsand and parents parents on Nonetheless, on his his team team frequently frequently expressed expressed their their appreciation appreciation of of him. him. Nonetheless, his to his thinking thinking and and resulting resulting mood m o o d contributed contributed to to his his increasing increasing desire desire to quit coaching coaching altogether. altogether. When W h e n asked asked to torecount recountwhy w h y he he thought thoughthe he had had aa quit bad character, character, he he tended tended to to focus focus on on one one or or more more mistakes mistakes he he had had made made bad and and magnify magnify or or overgeneralize overgeneralize these these mistakes mistakes ("1 ("I was was impatient impatient with one with one of my m y kids. kids. II was was too too hard hard on on him. him. 1I can't can't work w o r k well well with with people people because because I1 of can't be be patient patient with Mdth myself'). myself). can't The The firstfirst stepstep in cognitive restructuring aware of the in cognitive restructuringisistotobecome become aware of the

though15, images, or that thoughts, images, or memories memories that that crop crop up up when w h e n you you have have experiences experiences that negatively affect affect your your mood. m o o d . Be Be particularly particularly attuned attuned to to experiences experiences involVing involving negatively your your work, work, family, family, or or close close relationships. relationships. Take Take a a look look at at the the thought record thought record exercise exercise on on page page 232, 232, which which we'll we'll be be completing completing throughout throughout this this section. section. Pick Pick out three three negative negative experiences experiences you've you've had had in in the the past past week w e e k and and record them in record them in out the the table table (column (column 1). 1). Rate Rate the the intensity intensity of of your your mood m o o d (column (column 2) 2) in in reaction reaction to to these these events events on on a a scale scale of of 0% 0 % (not (not depressed) depressed) to to 100% 1 0 0 % (very (very depressed). depressed). (Alternatively, (Alternatively, use use the the -3 -3 - +3 +3 scale scale we w e talked talked about about in in Chapter Chapter 8 8 if if you're you're more more comfortable comfortable with with that that rating rating format). format). List List other other moods m o o d s you you may m a y also also be be feeling distinguish feeling (for (for example, example, anxiety) anxiety) and and also also rate rate their their intensity. intensity. Try Try to to distinguish h o w you you felt felt during during or or immediately immediately after after the the event, event, not not how h o w you you felt felt that that enhow en­ tire tire day. day. Now N o w see see if if you you can can recall recall any any negative negative self-statemen15 self-statements that that came came into into your your

THOUGHT THOUGHT RECORD RECORD 5. 5. Evidence Evidence that dCM"S does

1. 1. Situation Situation

2. 2. Moods Moods

3. 3. AUiomatic Automatic thOUi-hlS thoughts(ima.2es) (images)

�;

4. Evidence Evidence thai that supports

not s upport the hot not support hot

6. Altemativdbalanccd 6. Altemative^alanced

the the hot hot thouSlht thought

thou thought

thoughts

7. Rate Rate moods now moods now

Ask yourself: yourself: Ask Ask yourself: Ask yourself:

What What was was going going through through my my mind mind just just before before II slana! started to to feci feel

Ask yourself: Ask yourself:

this way? way? this

does this this mean about about me? me? What docs

When nOI ffecling W h e n I1 am a m not feeling

m y Iifd life? my m y future? my fUlurd What is is the the worst worst thing thing that What

W h o m were were Whom you with? with? you were What were you doing? doing? you

Describe ach each Describe

could could happen happen if if Ihis this isislnle? true?

m o o d in in ont: one mood

What What does does this this mean mean aboUi about how how

word. word. Rate Rate

When W h e n was was it? intensity intensity of of Wlu:re Where were were you? you?_

mood m o o d (()... (0-

100%). 100%).

th� the othu other person(s) person(s) fecl(s)! feel(s)/ think(s) think(s) about aboutme? me?

What What images images or or memories memories do do I1 have have of of !:his this situation? situation?

this this way, way, do do IIthink think

Circle hot hot thought thought in previous previous Circk column for for which which you you are looking for for evidence. evidence. looking Write factual factual evidence to support this this conclusion. conclusion. (Try (Try to to avoid avoid mind-reading mind-reading and and re interpretation of reinterpretation of facts.) facts.)

Adapted by by permission permission from from Greenberger Greenberger and and Padesky Padesky (l99S). (1993). Copyright Copyright by by The The GUilford Guilford Press. Adapted Press.

about this type of

situation any any Situation Have I1 had had differently? Have any any experiences experiences that

show that show !:hat this !:his thought is is not not completely completely true

all the t time? all ime?

is there an alternative or Is mon: more balanced way way of thinking about this situation? If someone else Copy Copy the was in this situation, was situation, how how mo"'" moods would I I suggest thai would that he he or or from from she understand understand it? Write Column Column 2. down alternative or bl.lanc�d balanced Rerate me down the thoughts. o w much much thoughts. Rate h how intensity intensity or of you believe in each one each each mood mood (()...100%). (0-100%). (0-100%). (0-100%).

Whaf Con Can 1I110DoIfIfI Think I Think 'm Getting Depressed? Whot I'm IGetting Depressed?

233 233

rightbefore beforeyou you started feeling bad, notice record any come that come head started feeling bad, or or notice and and record any that headright into the "Auto­ into your y o u r mind m i n d now n o w as as you y o u review review the the events. events. Write W r i t e these these in in the "Automatic matic Thoughts" T h o u g h t s " column. c o l u m n . To T o help help you y o u "snag" "snag" these these statements statements or or automatic automatic

thoughts, thoughts, try try to to be b e attuned attuned to to questions questions like like these these (Greenberger (Greenberger &: & Padesky, Padesky,

1995): 1995): • Why this eventhappen? happen? • Why did did this event • What What was wasgoing goingthrough throughmy m y mind mindjust justbefore before] Istarted started feel this way? totofeel this way? • • What What does does this thisevent event say say about about me m e or or what what others others think think of of me? me? • • • What What does does this thismean mean will willhappen happen in in my m y future? future? • • What What is is the the worst worst possible possiblereason reason this this could could have have happened? happened?

Don't surprised if not not immediately aware of any thoughts im­ Don't be be surprised ifyou're you're immediately aware of any or thoughts or i ages. ages. You You may may find findthat thatyou you can't can'tquite quiteremember remember how how you you felt feltororwhat whatyou you thought thought after after aaparticular particularevent. event.IfIfyou youare arehaving havingtrouble troubleremembering, remembering,prac­ practice ticeby byfocusing focusingon onrecent recentevents eventsthat thatcaused causedyou youtotohave havestrong strongemotional emotionalre­ reactions actions (for (for example, example, rejections rejectionsfrom from aaromantic romanticpartner, partner,run-ins run-inswith withpeople, people, problems with your boss at work) . These events are probably most closely problems with your boss at work). These events are probably most closely as­ associated with with certain certain identifiable identifiable hot hot thoughts. thoughts. Try Try talking talking or or writing writing about sociated about this this experience experience to to see see if if you you can can identify identify thoughts thoughts as as opposed opposed to to feelings. feelings. You tape recorder to You may may find find it it helpful helpful to to carry carry aa note note pad pad or or hand-held hand-held tape recorder to record your your thoughts thoughts when when you you experience experience emotion-provoking emotion-provoking events. events. This This record kind kind of of on-line on-line recording recording will will increase increase the the probability probability of of tracking tracking your your thoughts accurately, accurately,rather ratherthan thantrying tryingto toreconstruct reconstructthem themafter afterthe thefact. fact. With thoughts With time, time, as as you you become become more more familiar familiar with with this this thought thought tracking tracking method, you method, you may may no no longer longer need need recording recording devices. devices. Some people people are are more more visual, visual,and andtheir theirhot hotthoughts thoughtscome comein inthe theform form of of Some disturbing images images (for (for example, example, aa picture picture of of themselves themselves as as a a child child being disturbing being picked on on by by other other kids kids on on the the playground). playground). For For others, others,specific specificwords wordsare arehot hot picked thoughts. For For Jacob, Jacob, ititwas wasthe theword word character. character.For ForSuzanna, Suzanna, wasthe theword word itit was thoughts. crazy. mood changes, crazy. If If single single words words or or images images are are associated associated with with your your mood changes, re­ record cord them them in in the Automatic Thoughts Thoughts column, column, and and see see if if you you can can expand expand the Automatic them them into into a a full full sentence sentence(for (forexample, example,-as "aslong longas asIIact actthis thisway, way,people peoplewill will always always think think of of me m e as as being being crazy"). crazy"). Let's imagine imagine you you had had an an unpleasant unpleasant conversation conversation with with your your father father last last Let's week, week, and and that thatyou youhave havebeen beenruminating ruminatingabout aboutit, it,onon and off, since then. Reand off, since then. Re­ cord cord the the event event as as "Conversation "Conversation with with Dad Dad that that didn't didn't go go well" well" in in the the "Situa"Situa­ tion" column. column. Let's Let's also also assume assume your your resulting resulting depressed depressed mood mood was 0% 70% tion" was 7 (quite For the col­ (quite depressed) depressed) out out of of aa possible possible 100% 100% (extremely (extremely depressed) depressed).. For the colu m n labeled labeled "Automatic "Automatic Thoughts," Thoughts," you you would would record record the the self-statements self-statements or umn or images that that came came up up during during the the conversation conversation or or immediately immediately after after it. Examimages it. Exam-

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SELF-MANAGEMENT SElF·MANAGEMENT

pies piesmight mightinclude include never be to able to his expectations" or "I "I "I never will will be able live to up live to hisup expectations" or "I let him him down d o w n again," again," both both of of which which might might fuel fuel your your low low mood. mood. Step 2: 2:Challenging Challenging Negative Thoughts Step Negative Thoughts N o w let's let's work work on on modifying modifying your your automatic automatic thoughts. thoughts.Your Your thoughts thoughts can canbe be Now considered considered hypotheses, hypotheses, rather rather than than hard hard facts, facts, ahom aboutcenaill certainevents. events.Complete Complete the the next next two two columns, columns, "Evidence "Evidence That That Supports" Supports" and and "Evidence "Evidence That That Does Does Not Support" Support" your your hot hot thoughts. thoughts. Be Be a a scientist scientist observing observing your your own o w n thought thought Not process: Is there there any any evidence evidence for for or or against against your your conclusion conclusion that you let let your your process: Is that you dad down d o w n or or can't can't live up to to his his expectations? expectations? Did Did your your father father say say anything anything dad live up that Have you you had re­ that indicated indicated differently? differently? Have had any any experiences experiences with with your your dad dad recently that these cently that that would would show show that these conclusions conclusions are are not not always always true? true? Are Are you you discounting have made discounting anything anything positive positive that that he he said? said? Could Could your your sad sad mood m o o d have made you view view the itt really you the conversation conversation differently differently from from what what i really was? was? Would W o u l d you you have viewed itt differently in a the outcome of the the have viewed i differently in a different different mood m o o d state? state? Was W a s the outcome of conversation really really within within your your control? control? (Greenberger (Greenberger &. & Padesky, Padesky, 1995). 1995). conversation The next next step step is is to to complete complete the the column column titled titled "AltemativelBalanced "Alternative/Balanced The Thoughts." the chance Thoughts." This This is is the chance to to consider consider alternative alternative viewpoints viewpoints that that are are more more balanced you don't balanced (as (as opposed opposed to to distorted) distorted),, even even if if you don't believe believe them them fully. fully. Try Try writing writing down d o w n all all of of the the other other causes, causes, explanations, explanations, or or conclusions conclusions you you could could have drawn drawn from from this this event, event, and and rate rate each each of of them on a a 0-100% 0 - 1 0 0 % scale scale as as to have them on to h o w credible credible you you find find them them (100% ( 1 0 0 % means means you you believe believe this this alternative alternative explanahow explana­ tion 0 % means all). Examples Examples might might include: include: "I "I think think Dad Dad was was tion fully, fully, 0% means not not at at all). just in in a a bad bad mood m o o d that that day day and and II got got defensive" defensive" (40%); (40%); �We " W e got got on the touchy touchy just on the subject of of money, money, which which always always makes us both both uncomfortable" (70%); and and subject makes us uncomfortable" (70%); to "Dad expressed expressed disappointment disappointment in in me, m e , but but some some important important things came to "Dad things came re­ light that that we w e needed needed to to talk talk about" about" (50%). (50%). Once Once you have generated generated and and reyou have light flectedon onthese thesealternative alternativethoughts, thoughts,make m a k enew n e wratings ratingsofofyour yourmoods m o o d s(de­ (denected pression, anxiety, anxiety, or or any any other other emotions emotions you you listed in column column 2) 2) using using the the pression, listed in same 0 1 0 0 % (or -3 +3) scale. same 0-100% (or -3 - +3) scale. In developing developing alternative alternative thoughts, thoughts, consider consider the the follOWing following strategies In strategies the (Greenberger &. & Padesky, Padesky, 1995). 1995). Write a sentence sentence that summarizes all aH of of the (Greenberger Write a that summarizes "for" and and ""against" evidence for for your your cognition cognition about about this this event event (perhaps (perhaps link against" evidence "for" link the evidence evidence with with the the word word and and or or but, hut, as as in in the the examples examples in in the the preceding preceding the paragraph). Consider Consider what what advice advice you you would would give give another another person person who w h o was was in paragraph). in the same same situation, situation, had had the thesame same thoughts thoughtsand and moods, moods,and and had had given givenyou you the the the same for/against for/against evidence. evidence. Consider Consider the the best, best, worst, worst,and and most mostlikely likely(realistic) (realistic) same outcomes if if your your hot turns out out to to be be true. true. For For example, example, if if the the hot hot outcomes hot cognition cognition turns cognition ""I let Dad Dad down d o w n again" again" turns turns out out to to be be true, a worst-case outcome I ler true, a worst-case outcome cognition might be be that that he he reminds reminds you you of of your your failings faihngs the the next next lime time you you talk talk to to him him might

What (an Can IIDoDoIfIfI Think I Ihink 'm Getting Depressed? What I'm IGetting Depressed?

235 235

and you upup feeling even worse; a best-case outcome mightmight be that apoland youend end feeling even worse; a best�case outcome behe that he apol� ogizes admits he ogizes and a n d admits h e was w a s wrong, w r o n g , and a n dyou y o u feel feel great; great;aa realistic realistic outcome o u t c o m e might might that you the next next time bUl that y you bbe e that y o u feel feel tension tension the time you y o u talk talk to to him himb u t that o u effectively effectively

steer the the conversation conversation ttoward o w a r d more m o r e comfortable steer comfortable topics. topics. Jacob, the soccer coach, to evaluate for a and Jacob, the soccer coach, learned learned to evaluate the the evidence evidence for n d against against

his automatic, self-blaming thought t h o u g h t that "I'm no n o good g o o d with with kids." h e r e wwas as his automatic, self�blaming that '''I'm kids." T There plenty of of evidence evidence to the contrary, contrary, given given the m a n y positive positive comments comments h e reto the the many he re� plenty ceived, and par� ceived, on o n an a n ongoing o n g o i n g basis, basis, from f r o m his his wife, wife, the the soccer soccer players, players, a n d their their parents. ents. He H e was w a s able able to to generate generate more m o r e balanced balanced thoughts: thoughts: "Sometimes " S o m e t i m e s the the kids kids

get uncooperative uncooperative when w h e n I'm I'm nnot o t feeling feeling my m y best"; best"; "Coaching " C o a c h i n g can can b ea difficult be a difficult get task no n o matter matter how h o w good g o o d you y o u are"; are"; "Today " T o d a y the the kids kids were w e r e getting getting overstimu� overstimutask upon in� lated and and weren't weren't in in the the mood m o o d to to learn." learn." His His mood m o o d tended tended to to improve improve u p o n inlated

troducing and and repeatedly to himself these countelVaihng countervailing thoughts. troducing repeatedly restating restating to himself these thoughts. Another person person with with bipolar bipolar disorder, disorder, Katrina, Katrina, age age 41, 41, had had emigrated emigrated to Another to the job at at an the United United States States from from Hungary. Hungary. A A year year after after arriving arriving she she obtained obtained a a job an

inner city city school school teaching teenagers who w h o were were developmentally developmentally disabled. inner teaching teenagers disabled. DurDur� ing a a particularly particularly difficult difficult day, day, three three of of the the boys boys in in the the class class cursed cursed at at her her and and ing told her her she she was was the the worst worst teacher teacher they'd they'd ever ever had. had. By By day's day's end, end, she she felt felt quite quite told depressed depressed and and anxious, anxious, and and didn't didn't want want to to go go back back to to work. work. She She took took two two days days off, this off, Citing citing "mental "mental exhaustion." exhaustion." She She recounted recounted thoughts thoughts in in reaction reaction to to this event, event, such such as, as, "Maybe "Maybe II shouldn't shouldn't be be a a teacher teacher

don't know k n o w if have the if I1 have the .. II don't

strength and and willpower willpower ... . . I'm effective; I can't with it myself by myself. strength . I'm notnot effective; I can't dealdeal with it by . . I. 1 don't belong; belong; II can't can't make m a k e it." it." She She identified identified "I'm "I'm not not effective" effective" as as the most don't the most powerful, emotion-provoking emotion-provoking hot hot thought. thought. powerful, In examining examining the the evidence evidence for for and and against against this this thought, thought, Katrina Katrina cited cited the the In fact fact that that she'd she'd had had to to call call in in the the school school counselor counselor to to help help mediate mediate the the conflict, conflict,

that the the kids kids liked liked her her only only when w h e n she she was was being being friendly friendly and and casual casual but but not not that w h e n she she was was actually actually teaching, teaching,and and that thatshe sheseemed seemedmore more powerfully powerfullyaffected affected when by by this this incideOl incident than than the the other other teachers teachers thought thought she she should should be. be. She She was was also also

able to to generate generate evidence evidence against against her her hot hot cognition, cognition, including includingthe thefact factthat thatshe she able had received received positive positive evaluations evaluations of of her her teaching teaching from from the the school school administra� administrahad tion tion and and that that her her earlier earlier teaching teaching experiences experiences in in Hungary Hungary had had been been quite quite posiposi�

tive. She She admitted admitted that that "the "the kids kids are are troubled troubled and and angry angry at at everybody" everybody" and and tive. "I've seen seen them them curse curse out out other other teachers." teachers." She She also also recalled recalled that that the the incident incident "I've began after after one one of of the the boys boys had had verbally verbally taunted taunted another another boy boy in in the the class. began class. She eventually eventually settled setded on on more more balanced balanced views views that that did did not not rule rule out out her her She o w n role role in in causing causing the the incident incident but but that that included included the the contrary contrary evidence: evidence: "I'm own "I'm good teacher, teacher,but butI Ihave haveaadifficult difficultset setof ofstudents studentsthat thatanyone anyonewould would have haveaa aa good problem with with. sometimes struggle struggle with with my m y own o w n boundaries boundaries and and how h o w to to . .... . . II sometimes problem set limits limits with with people. people. ... . I'm new this, and hard y buttons I'm new at at this, and it'sit's hard notnot set getget mym buttons to to pushed I'm still making a difference in in their lives, andand they're teaching me m e pushed.. ... .. . I'm still making a difference their lives, they're teaching

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SELF-MANAGEMENT SElF-MANAG£MENT

sometimes." Her mood a lot lotabout aboutmyself myself even though they hurt feelings sometimes." Her mood a even though they hurt my my feelings in reaction reaction to to the the confrontation confrontation improved improved significantly significantly upon u p o n reviewing reviewing these in these balanced thoughts. thoughts. Over Over time, time, as as her her depression depression lifted, lifted, she she focused focused on on the the balanced larger which had larger question question of of whether whether she she wallled wanted to to teach, teach, which had become become confused confused in in her her mind mind with with whether whether she she was was good good at at it. it.

What'sDifferent Differe.t about Patter.s i. Bipolar Depressio.? Whafs aboutThinking Thinking Patterns in Bipolar Depression?

So far, the cognitive restructuring methodmethod I've described could apply to almost So far, the cognitive restructuring I've described could apply to almost disor­ any form form of of depression or anxiety. anxiety. The The method method applies applies well well to to bipolar bipolar disordepression or any der, der, but but bipolar bipolar depressions depressions tend tend to to be be much m u c h more more severe than those severe than those experiexperi­ enced by people going through through life life transitions. transitions. So, So, in in constructing constructing your your alterenced by people going alter­ native or or balanced balanced thoughts, thoughts, consider consider the the role role of of your your disorder—particularly, native disorder-particularly, its biological and genetic genetic underpinnings-in underpinnings—in modulating modulating your your view view of of the the its biological and causes imbalances of ex­ causes of of negative negative events. events. Do D o chemical chemical imbalances of [he the nervous nervous system system explain your flaws? Could plain your behavior behavior in in certain certain situations situations better better than than character character flaws? Could your heat of been due due to dis­ your emotional emotional reactions reactions in in the the heat of the the moment m o m e n t have have been to your your disorder rather than order rather than your your inability inability to to deal deal with with people? people? Jacob, Jacob, for for example, example, recognized recognized that that soccer soccer coaching coaching did did not not go go as as well well when w h e n he he experienced the physical physical signs signs of of depression depression or or anxiety anxiety (for (for example, example, experienced the poor concentration, headaches, low poor concentration, headaches, low energy) energy).. On O n days days in in which which his his coaching coaching and athletic athletic performance impaired, he he introduced introduced balanced balanced thoughts, and performance were were impaired, thoughts, such as, as, "1 "I can can tell thatmy m y mood m o o d and and energy energy are areoff offkilter kiltertoday; today;this thisisisone oneofof such tell that those days days II can't can'texpect expectas asmuch m u c h from from myself myself. . This is not about m y flawed those . . .. ..This is not about my flawed character; i t's about about my m y biology. biology. .. . . My M y depression depression isiscausing causing me m e to toview view character; it's a things more more peSSimistically pessimistically than than II have have to—it doesn't follow follow that not a to-it doesn't that I'm I'm not things good person person because because II can't can't control control my m y moods." moods." These These thoughts thoughts gave gave him him a good a sense of of self-acceptance self-acceptance when w h e n his his moods m o o d s interfered interfered with with his his high high standards standards of of sense performance. performance. Katrina worried worried that that "I'm "I'm too too emotionally emotionally unstable unstable to to be be a a consistent consistent fig­ figKatrina ure in in their their (her (her studems') students') eyes." eyes." Indeed, Indeed, negative negative interactions interactions with with her her stuure stu­ dents probably probably had had a a more more powerful powerful effect effect on on her her mood m o o d states than might might be be dents states than the case case for for a a person person without without bipolar disorder, bUl but not notOUl outof ofher herown o w n choice choice. . the bipolar disorder, She learned learned to to internally internally rehearse rehearse the the self-statements self-statements "I'm "I'm going going to to have have more more She severe ups and and downs downs than the ordinary ordinary teacher," teacher," "Not "Not all aH of of my m y emotional emotional re­ resevere ups than the actions wHl be under m y control, but that doesn't m e a n I can't teach," and actions will be under my comrol, but that doesn't mean I can't teach," and "I'm good good at at what what IIdo, do,and andthere thereisisa agreat great dealofof meaningininit." it." Shealso alsorec­ recUl'm deal meaning She ognized the the need need to to give give herself more time time to to relax and decompress decompress after after work work ognized herself more relax and than might be be required required by by some some of of her than might her coworkers. coworkers. interac­ Consider Consider another another example. example. Say Say you've you've had had a a string string of of negative negative interactions with with your your employer employer over over the the last last week week but but generally generally have have had had good good relarelations

What (on Can IIDoDoIIIIfThink I Think 'm Getting Depressed? What I'm IGelling Depressed?

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tions with with him possible that that your your irritability irritabilitywith withyour your boss boss derives derives tions himor orher. her. Is Is it it possible from mixed f r o m depressive depressive or or m i x e d symptoms s y m p t o m s rather rather than than your y o u r "short "short fuse," fuse," "angry "angry nature," "problems " p r o b l e m s getting getting along along with with people," people," or or "problems " p r o b l e m s with authority nature," with authority figures"? II am a m not n o t saying, saying, "Blame " B l a m e everything everything on o n your y o u r bipolar bipolar disorder." disorder." I'm I'm figures"? influ­ recommending r e c o m m e n d i n g that that you y o u take take a a more m o r e balanced balanced perspective perspective on o n the the factors factors influencing events events in in your y o u r life, life, including including your y o u r disorder. disorder. encing T o sum s u m up, u p , cognitive cognitive restructuring restructuring has has the the potential potential to to help help you y o u alleviate alleviate To y o u r depressed depressed mood m o o d by b y identifying identifying and a n d revising revising the the automatic automatic thoughts thoughts that that your trigger low l o w mood m o o d states. states. The T h e role role your y o u r bipolar bipolar disorder disorder may m a y play play in in stimulat­ stimulattrigger ing your y o u r emotional emotional reactions reactions to to persons, persons, situations, situations, and a n d challenging challenging events events ing should should not n o t be b e underestimated. underestimated. In In combination c o m b i n a t i o n with with behavioral behavioral activation activation m e t h o d s , cognitive cognitive restructuring restructuring has h a s the the potential potential to to help help alleviate alleviate your y o u r de­ demethods, pression or, or, at at minimum, m i n i m u m , keep k e e p it it in in check. check. pression *

*

*

This chapter chapter has h a s introduced introduced you y o u to to important important self-management self-management tools tools for This for coping coping with with your y o u r depresSion. depression. Implementing I m p l e m e n t i n g these these toolS-identifying tools—identifying your your early warning w a r n i n g signs, signs, scheduling scheduling pleasurable pleasurable and/or and/or activating activating events, a n d reearly events, and re­ considering considering the the way w a y you y o u think think about, about, and a n d respond r e s p o n d to, to, the the events events in in yyour o u r life­ life— can can go go a a long long way w a y toward t o w a r d comrolling controlling the the negative negative spiral spiral of of depression. depression. Don't be b e too too concerned c o n c e r n e d if if you y o u don't don't take take to to these these m e t h o d s right right away. away. Don't methods T h e y require require guided guided practice practice and a n d skill skill before before they they feel feel natural. natural. If If you y o u hhave a v e ac­ acThey cess cess to to a a cognitive-behavioral cognitive-behavioral therapist, therapist, consider consider doing doing these these exercises exercises with with his first. his or or her her guidance guidance at at first. T h e next next chapter chapter deals deals with w i t h an a n issue issue that that many-in m a n y — i n fact, fact, most-people most—people The with bipolar bipolar disorder disorder deal deal with w i t h at at one o n e time time or or another: another: suicidal suicidal thoughts thoughts or or acwith ac­ tions. tions. This This topic topic is, is, for for many, m a n y , an a n uncomfortable uncomfortable one. one. But B u t like like many m a n y other other atat­ tributes of of bipolar bipolar disorder, disorder, you y o u will will put p u t yourself yourself in in the the driver's driver's seat seat once o n c e you you tributes are are able able to to understand understand suicidal suicidal impulses impulses as as symptoms s y m p t o m s of of your y o u r illness Hlness that that rere­ quire management. m a n a g e m e n t . You Y o u will will see see the the special special role role of of psychotherapy, psychotherapy, medication, medication, quire social supports, supports, and a n d self-management s e l f - m a n a g e m e n t tools tools in in alleviating alleviating suicidal suicidal despair. despair. social

1 1 1

1

D e a l i n g with w i t h Suicidal S u i c i d a l Thoughts Thoughts Dealing and a n d Feelings Feelings

"I had had been been getting getting mort': more and and more more depressed depressed and and had had thought thought about about kUl"{ kill­

ing ing myself, myself, but but somewhere somewhere in inthere thereIIdecided decided lO tofinally finallydo do it. it.One O n enight nightI I came home h o m e from from work work to to my m y apartmem apartment and and went through a a whole whole ritual. came went through rituaL had decided decided II was was going going to to do do it it by by overdosing overdosing on on my m y lithium, lithium, since since II had that's the the drug drug II had had the themost most of. of.IItook tookit, it,little littleby bylillie, little, throughout the that's throughout the evening, pill pill, and and then then II got got in in the the shower, shower, but but by by then then I1 was was evening, pill after after pill, starting to to puke and got the runs really badly badly.. .... think1I1051 lostconscious­ consciousstarting puke and gOl the runs really . . II think ness at at some some point, point, and and somewhere somewhere in in there there II had had the the presence presence of of mind mind ness to call call Dylan Dylan {boyfriend] [boyfriend], w h o called called the the paramedics, paramedics, and and they they took me , who took me to to the the hospital. hospital. II ended ended up up there there with with a a catheter catheter and and the the whole whole thing. thing. II to looked awful awful and and felt felt awful. awful. Everybody Everybody was was telling telling me m e how h o w fortunate fortunate I looked 1 was to to be be alive, alive,but butthat thatmade m a d e me m e feel feelworse. worse.1 Isure sure didn't feel fortunate." was didn't feel fortunate." — A 28¥year-old 28-year-old woman w o m a n with with bipolar bipolar II disorder, disorder, -A recounting her her first first suicide suicide attempt attempt recounting If you are are cycling into a period ofof depression, common totohave If you cycling into a period depression, it it is is common have

all thoughts of of ending ending your Hfe. You Y o u may m a y have have been been having having these thoughts all thoughts your life. these thoughts along, but but they they can can become become more severe if your depression depression is isgetting getting worse. worse. along, more severe if your Y o u may m a y also also find find that that your your suicidal suicidal thoughts thoughts go go along along with with an an increase increase in You in your anxiety anxiety and and worry. worry. Some S o m e people people feel feel suicidal suicidal chronically, chronically, not not just just when when your they are are depressed. depressed. One O n e patient patient said, said, "I "I know k n o w I'll I'll kill kill myself myself someday. someday. IIt's t's they gonna happen. happen. The The only only question question is is when." when." gonna 238

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Suicide be accomplished in impulsive a suddenactimpulsive act or a carefully Suicide can becan accomplished in a sudden or a carefully planned episode, but planned event. event. It It usually usually occurs occurs during during a a depressive depressive or or a a mixed m i x e d episode, but some s o m e people people with with bipolar bipolar disorder disorder kill kill themselves themselves accidentally accidentally or or on o n impulse impulse w h e n they they are are psychotic psychotic and a n d in in the the manic m a n i c phase. phase. when By the B y some s o m e estimates, estimates, people people with w i t h bipolar bipolar disorder disorder are are at at 15 1 5 times times the risk for for committing c o m m i t t i n g suicide suicide of of people people in in the the general general population population (Harris (Harris & & risk Barraclough, Barraclough, 1997). 1 9 9 7 ) . Up U p to to 15% 1 5 % of of people people with w i t h bipolar bipolar disorder disorder die die by b y suicide; suicide; as many m a n y as as 50% 5 0 % attempt attempt suicide suicide at at least least once o n c e in in their their lives lives Oamison, Q a m i s o n , 2000b; 2000b; as a Simpson Simpson & & Jamison, J a m i s o n , 1999). 1 9 9 9 ) . Tragically, Tragically, suicidal suicidal thoughrs thoughts and a n d feelings feelings are are a part of of bipolar bipolar illness, illness, connected connected with with irs its biological biological and a n d genetic genetic mechanisms. mechanisms. part We who W e know k n o w that that levels levels of of serotonin serotonin aTe are lower lower in in the the brains brains of of people people w ho attempt et attempt or or complete c o m p l e t e suicide suicide (Mann ( M a n n et et al., al., 1999; 1 9 9 9 ; Asberg A s b e r g et et al., al., 1986; 1 9 8 6 ; Arango A r a n g o et a1., to the the neuro­ al., 1995). 1 9 9 5 ) . In In other other words, w o r d s , suicidal suicidal impulses impulses are are related related to neurophysiology physiology of of your y o u r disorder; disorder; they they are are not n o t caused caused by by a a mmoral o r a l failing failing or or weak­ weakness on o n your y o u r part. part. ness Therefore, f, suiddal Therefore, you y o u should should not notfeel feel alone alone with, with, or o rashamed a s h a m e d oof, suicidal thoughts. thoughts. Virtually f suicide Virtually every every person person with with bipolar bipolar disorder disorder has has entertained entertained the the idea idea o of suicide at at one o n e point point or o r another. another. In In fact, fact, many m a n y people people without without the the disorder disorder have have thought thought about about it, it, even e v e n if ifjust just in inpassing. passing. But B u t among a m o n g people people with with bipolar bipolar disor­ disorder, likely to der, the the thoughts thoughts often often become b e c o m e frequent frequent and a n d intense intense and a n d are are more m o r e likely to be be aniculated yourself with with pills at a a articulated into into a a plan plan of of action action (for (for example, e x a m p l e , to to kill kill yourself pills at specific specific time). time). For F o r first-person first-person accounrs accounts of of suicidal suicidal feelings feelings and a n d actions actions a m o n g people people with with bipolar bipolar disorder, disorder, read read Kay K a y Jamison's Jamison's 1995 1 9 9 5 autobiography, autobiography. among An A n Unquiet Unquiet Mind, M i n d , or or her her recent recent book b o o k on o n suicide, suicide, Night Night Falls Falls Fast Qamison, Fast Oamison, 2000a). 2000.).

The The Desire Desire 10 to Escape Escape People with bipolar bipolarand andother otherdepressive depressive disorders often hopeless, People with disorders often feel feel hopeless, as if as if

nothing nothing will will ever ever change change for for the the better. better. They They feel feel a a strong strong need need for relief from from for relief "psychic pain colored by the fear and anticipation of increasing, uncontrolla'-psychiC pain colored by the fear and anticipation of increasing, uncontrolla­ ble, ble, interminable interminable pain" pain" (Fawcett (Fawcett et et al., al., 2000, 2000, p. p. 147). 147). Some S o m e people people honestly honestly want want to to die. die. But But in in my m y experience, experience, most most people people with with bipolar bipolar disorder disorder want want rere­ lief from from the the intolerable intolerable life life circumstances circumstances and and the the emotional, emotional, mental, and lief mental, and physical physical pain pain that that goes goes along along with with depression depression and and anxiety. anxiety. When W h e n your your depres­ depression is is spiraling spiraling downward d o w n w a r d and and you you feel feel a a sense sense of of dread dread and and apprehension, apprehension, sion you may m a y desperately desperately want want to to live, live, but but suicide suicide can can feel feel like Hke the the only only escape escape you from your your intolerable intolerable feelings. from feelings. Even when w h e n severe, severe, however, however, suicidal suicidal thoughrs thoughts can can be be managed managed and and concon­ Even trolled medically. medically. There There is is strong strong evidence evidence that that long-term long-term treatment treatment with with lithtrolled lith-

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ium suicide attempts completions by people bipolar decreases suicide auempts andand completions by people withwith bipolar disor­disorium decreases Simpson der (Baldessarini (Baldessarini et et a1., al., 1999; 1999; Tondo T o n d o &: & Baldessarini, Baldessarini, 2000; 2000; Simpson &: & der Jamison, 1999). The Jamison, 1999). The antidepressant, antidepressant, anticonvulsant, anticonvulsant, and and antipsychotic antipsychotic drugs drugs decrease actions decrease the the agitation agitation and and aggressiveness aggressiveness that that can can bring bring about about suicidal suicidal actions

Qamison, 2000b). 2000b). Oamison, The The challenge challenge in in dealing dealing with with suicidal suicidal despair despair is is to to find find other other ways ways of of es­ es-

caping from from your your intolerable intolerable feelings. feelings. As As IItalk talkabout aboutin inthis thischapter, chapter,your yourop­ opcaping tions treatment, psychotherapy, tions can can include include drug drug treatment, psychotherapy, the the help help of of supportive supportive friends techniques. Your hopeless­ friends or or family family members, members, and and self-management self-management techniques. Your hopeless-

ness, pain, and emptiness emptiness are are temporary, temporary, not not permanent permanent states, states, even even though though ness, pain, and they that way time. they may m a y nOl not seem seem that w a y at at the the time.

Risk Risl( Factors Factors for for Suicide Suicide You You should know about factorsthat that increase your probability of actually should know about the the factors increase your probability of actually

hurting or or killing yourself, so so that that you you and and your your doctor doctor can can determine determine how how hurting killing yourself, imminent imminent the the danger danger to to you you has has become. become. If Ifyou you plan planon on switching switching doctors, doctors,tell tell your the your new n e w doctor doctor about about your your risk risk factors factors so so that that he he or or she she can can determine determine the

seriousness of of your your iOlent intent and and hopefully hopefully be be of ofgreater greater help help to to you you in in aa crisis. crisis. seriousness You are are at at particularly particularly high high risk risk for for committing suicide if if you you . .. . You committing suicide • have a bipolar disorder alsodrinking drinking alcohol or using • have a bipolar disorder and and are are also alcohol or using drugsdrugs reg­ regularly (in (in addition addition to to making making your your illness illness worse, worse, using using these these substances substances ularly makes it it unlikely unlikely that that you you will will take take your your mood m o o d stabilizers stabilizers regularly regularly or or makes seek help help from from others others when wheri suicidal) suicidal) seek • are are male male

•

• have have been been ill illfor foraashort shortlime timeand andhave havehad hadonly onlyaafew fewbipolar bipolarepisodes episodes

• •

• have have panic panic attacks, attacks,agitation, agitation,restlessness, restiessness,or or other other indicators indicators of of severe severe anxiety anxiety

•

• are are prone prone to to impulsive impulsive acts, acts, such such as as driving driving recklessly recklessly or or violent violent outoutbursts bursts

•

• have have recently recently been been hospitalized hospitalized

•

• have have preViously previously tried tried to to kill killyourself yourself

•

• have have one one or or more more relatives relatives in in your your family family tree tree who w h o committed committed suicide suicide or commiued committed a a violent act or violent act

•

• have have experienced experienced aa receOl recent stressful stressful life lifeevent event involving involving loss loss (for (for exam­ example, a a divorce divorce or or the the death death of of a a family family member) member) ple,

•

• are are isolated isolated from from friends friends and and family family members members

•

• do do not not have have ready ready access access to to aa psychiatrist psychiatrist or or psychotherapist psychotherapist

Dealing with withSuicidal SuicidalThoughts Thoughts Feelings Dooling andand Feelings

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• have feelings of hopelessness about your future and/or do andlor not feeldo younot feel you feelings of hopelessness about your future • have

rais­ have h a v e strong strong reasons reasons to to keep k e e p living living (for (for example, example, a a commitmeOl c o m m i t m e n t to to raising children) children) ing • • have h a v e thought t h o u g h t about a b o u t aa specific specific plan plan (for (forexample, e x a m p l e ,tototake takepills, pills,shoot shoot yourself, jump j u m p from f r o m aa high h i g h place) place)and a n d have h a v e the themeans m e a n s to todo d o it it(access (access to to yourself, pills or or a a gun) gun) (Fawcett (Fawcett et et aL, al., 2000; 2000; Jamison, Jamison, 2000b) 2000b) pills

feelsuicidal, suiddal, you therapist, If you feel you should should always alwaysinfonn informyour yourpsychiatrist, psychiatrist, therapist, If you family ficant people family members, members, and and other other Signi significant people in in your your core core circle. circle. This This is is espe­ especially true true if if you you have have one one or or more more of of the the preceding preceding risk risk factors. factors. Don't Don't stop stop cially yourself yourself from from disclosing disclosing your your suicidal suicidal thoughts thoughts because because you you are are afraid afraid of of wor­ worway rying people people or or hurting hurting their their feelings. feelings. Many M a n y people people feel feel this this w a y and and then then rying don't get get the the help help they they need. Err on on the the side side of of informing informing your your doctors doctors and and don't need. Err significaOl suicide. significant others, others, even even if if you're you're not not sure sure how h o w serious serious you you are are about about suicide. Later in in this this chapter chapter II talk talk about about what what your your doctor, doctor, therapist, therapist, friends friends and/or and/or Later family times. family members m e m b e r s can can do do to to help help you you at at these these times.

H o w Can Can You You Prated Protect Yourself Yourself from from Suicidal Suicidal Adions? Actions? How

"Anyone suggests coming suicidal despair "Anyone whowho suggests thatthat coming back back from from suicidal despair is a is a straightforward journey journey has has never never taken taken it." straightforward it."

— JJamison a m i s o n (2000b, (2000b, p. 49) p. 49)

If you have been spiraling or mixed mixed episode episodefrom fromyour your If you have been spiralinginto iOlOaa depressive depreSSive or

baseline baseline state, state, or orififyour yourongoing ongoingdepression depressionhas hasbeen beengetting gettingworse, worse,you you may may have noticed noticed an an increase increase in in your your suicidal suicidal thoughts. thoughts. These These can can be be vague vague at at first first have (for example, example, "I "I wonder wonder what what it it would would be be like like to to be be dead?"), dead?"), then then more more seri(for seri­ ous ("I ("I know k n o w that that II want want to to kill kiH myself, myself, II just just don't don't know k n o w how"), h o w " ) , then even ous then even more more serious serious ("I've ("I've thought thought of of various various suicide suicide plans plans and and have have settled settled on on one, one, as as well well as as a a time time and and a a place"). place"). The feelings, feeHngs, thoughts, thoughts, and and behaviors behaviors that that make m a k e up up suicidal suicidal despair despair are The are quite complex complex and and not not well well understOod understood by by behavioral behavioral scientists. scientists. Nonetheless, Nonetheless, quite w e know k n o w that that there there are are some s o m e things things you you can can do do to to protect protect yourself yourself from from acting acting we on on these these impulses. impulses. In In this this chapter, chapter, you'll you'll leam learn how h o w to to put put tOgether together a a suicide suicide prevention prevention plan. plan.

Suicide prevention involves decreasing your access access to to the the means means to to commit commit Suicide prevention involves decreasing your suicide and increasing your your access access to to support support systems systems (doctors, (doctors, therapists,fam­ therapists, famsuicide and increasing ily ily members, members, and and friends). friends). You Y o u might might wonder, wonder, at at what what point point do do these these plans plans work, and and at at what what point point is is it it already already too too late? late? Keep Keep a a general general caveat caveat in in mind mind work,

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when you your plan: plan:You Youhave havemore moreleverage leverage suicide prevention if when in in suicide prevention if you develop develop your ittat you you have have a a plan plan in in place place when w h e n you're you're feeling feeling well well and and begin begin implementing implementing i at the first first emergence emergence of of suicidal suicidal thoughts thoughts or or other other prodromal prodromal signs signs of of depresthe clepres· sian. sion. Don't Don'twait waitumil untilyou you are arereally reallyfeeling feelingdesperate-don't desperate—don'tlet letyourself yourselfget gettoto that point. point. When W h e n suicidal suicidal thoughts thoughts and and plans plans accompany accompany the the lowest lowest point point of of that the depressive depressive or or mixed mixed episode, episode, suicide suicide attemplS attempts can can occur occur by by impulse. the impulse. Strategy No.,:1: Get of the Means to Hurt Yourself Stlotegy No. Get RidRid of the Means to HUlt YouISelf O n e practical practical step step you take right right away away is is to toput put those those items itemsyou you might might use use One you can can take to kill kiH yourself yourself out out of of your your reach. reach. These These include include guns, guns, sleeping sleeping pills, pills, poisons, poisons, to ropes, and and sharp sharp knives knives or or other other weapons. weapons. Give Give them to a a trusted trusted friend friend who who ropes, them [Q lives apart apart from from yOll, you, or or even even your your psychiatrist psychiatrist or or therapist therapist. To T o avoid avoid overdoslives overdos­ ing ing on on your your psychiatric psychiatric medications, medications, keep keep only only a a couple couple of of days' days' dosages dosages in in your your house house and and have have your your friend friend or or relative relative (or (or perhaps perhaps your your doctor) doctor) hold hold on on to the the rest rest of of the the pills, pills,dispensing dispensingthem them as asyou youneed need them. them.Though Though this thispracti­ practito cal maneuver maneuver may m a y seem seem like like i only scratches scratches the the surface surface (you (you are, are, after after aH, cal itt only all, only getting getting rid rid of of the the means, notyour your intentions), intentions),ititwill will greatly decrease the only means, not greatly decrease the chances that chances that you you will will actually actually kill kill yourself. yourself.In In the the same same manner, manner,limiting limitingyour your access to to such such items items as as a a gun gun decreases decreases the the chances chances that that you you will will use use it it on on access yourself else. yourself or or someone someone else. Strategy No.2:2: See Your Psychiatrist and Therapist Immediately Stlategy No. See YOUI Psychiatlist and Thelapist Immediately If your your next next appointments appointments with with your your psychiatrist psychiatrist and and therapist therapistare are not not sched­ schedIf uled for several several weeks, weeks, call call them them and and let let them them know k n o w you you are are at at risk, risk, or or ask ask a uled for a m e m b e r of of your your core core circle circle to to make m a k e lhe the contact. contact. If If at at all all possible, possible, see see your your member doctor and and therapist therapist together together (assuming (assuming they are not not the the same same person) person) so so that they are that doctor they can can help help you you develop develop an an integrated integrated plan for managing managing your your suicidal suicidal im­ implan for they pulses, depression depression or or anxiety, stress, and and medication. medication. anxiety, stress, pulses, sui­ W h a t will will your your doctors doctors do do to to help help you you when w h e n you you first first start start feeling feeling suiWhat cidal? In all likelihood, likelihood,they theywill willstart startby byasking askingyou youquestions questionsabout aboutyour yoursui­ suicidal? In all cidal intentions, intentions, such such as as any any plans you've been been thinking thinking about and your cidal plans you've about and your hishis­ tory of of suicide suicide attempts attempts (if (if they they don't don't already already know k n o w about those). Expect Expect to tory about those). to spend some some time time on on these issues before before they they get get to to the the reasons you want to kill kill spend these issues reasons you want to yourself, which which may m a y be be foremost foremost in inyour your mind. mind.Be Be honest honest about aboutyour yoursuicidal suicidal yourself, intentions, even even if if these feelings are are new n e w to to you, you, foreign, foreign, or, or, in in your intentions, these feelings your view, view, shameful. Tell h o w serious serious you you are, are, that that you you may m a y not not feel safe at home, shameful. Tell them them how feel safe at home, and and that you have have access access to to weapons weapons or or other other means means of of hUrling hurting yourself. that you yourself. S o m e people don't feel feel comfortable comfortable disclOSing disclosing information to their their doc­ docSome people don't information to tors about about their suicidal impulses. impulses. In In my m y experience experience they they fear fear that their doctor doctor their suicidal that their tors

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hospitalizethem, them, deeply disappointed in and them and will (1) (1) immediately immediately hospitalize (2)(2) be be deeply disappointed in them will feel that that the the treatmeD[ treatment plan plan has h a s failed, failed, or or (3) (3) be b e uncomfortable u n c o m f o r t a b l e wwith i t h the the topic topic feel of In of suicide. suicide. None N o n e of of these these predictions predictions is is entirely entirely a a distortion distortion on o n your y o u r part. part. In fact, your y o u r doctor doctor may m a yindeed indeed hospitalize hospitalize you y o uif ifhe h eor orshe she feels feels the the risk risk to toyour your fact, Hfe is is imminent. i m m i n e n t . Keep K e e p in in mind m i n d that that this this may m a y be b e the the best best thing thing for for you. y o u . Hospi­ Hospilife to talization talization gives gives you you a a chance c h a n c e to to get get emergency e m e r g e n c y treatment, treatment, "regroup, "regroup," talk talk to others others who w h o feel feel the the same s a m e as as you, y o u , and a n d get get your y o u r medication medication reevaluated reevaluated and a n d ad­ adjusted (see (see also also Chapter C h a p t e r 9). 9 ) . It It will will also also get get you y o u away a w a y from f r o m the the stimuli stimuli that that m ay justed may b e provoking p r o v o k i n g your y o u r suicidal suicidal thoughts thoughts (for (for example, e x a m p l e , certain certain family family members, members, be noises, pictures in tele­ noises, pictures in your y o u r hhome, o m e , your y o u r bbedroom, e d r o o m , certain certain kinds kinds of of mmusic, u s i c , the the telep h o n e ringing). ringing). If If you y o u do d o go g o into into the the hospital, hospital, at at least least some s o m e of of yyour o u r inpatient inpatient phone treatment should s h o u l d involve involve suicide suicide prevention prevention planning planning for for the the interval interval follow­ followtreatment ing your y o u r discharge. discharge. ing S o m e doctors doctors are are indeed indeed more m o r e comfortable comfortable and a n d effective effective in in dealing dealing with with Some suicide risk risk than t h a n others. others. If y o u fear fear that that your y o u r doctors doctors (that (that is, is,your y o u r psychiatrist psychiatrist suicide If you and/or psychotherapist) psychotherapist) will will be b e uncomfortable u n c o m f o r t a b l e with w i t h your y o u r disclosure disclosure of of sui­ suiandlor cidal cidal thoughts, thoughts, tell tell them t h e m so. so. You Y o u may m a y be b e surprised surprised at at how h o w forthcoming forthcoming they they are in in expressing expressing their their concern c o n c e r n for for you. y o u . Your Y o u r therapist therapist or or medical medical doctor doctor hhas as are probably probably had h a d experience experience with w i t h many m a n y other other suicidal suicidal people people and a n d wworks o r k s best best when and w h e n he h e or or she she knows k n o w s the the truth, truth, even e v e n if if it it does d o e s mean m e a n reviewing reviewing a n d revising revising his haven't done his or or her her treatment treatment plan. plan. Your Y o u r doctors doctors may m a y indeed indeed feel feel like like they they haven't done their job job right, right, but b u t it it isn't isn't your y o u r responsibility responsibility to to take take care care of of their their feelings. their feelings. Rather, it's it's essential essential that that you y o u can c a n be b e open o p e n with w i t h them t h e m about a b o u t your y o u r feelings feelings of of de­ deRather, spair. spair. Y o u r psychiatrist psychiatrist is is likely likely to to reevaluate reevaluate your y o u r medication medication regime. Among Your regime. Among the options h e or s h e will probably consider is a d d i n g a n antidepressant to options he or she will probably consider is adding an antidepressant to the y o u r regimen, r e g i m e n , switching svdtching to to a a different different antidepressant antidepressant if if you y o u are are already n your already o on one, one, increasing increasing the the dosage d o s a g e of of your y o u r mood m o o d stabilizer, stabilizer, or or adding adding a a second s e c o n d mood mood stabilizer. In In extreme e x t r e m e cases cases he h e or or she she may m a y recommend r e c o m m e n d electroconvulsive electroconvulsive therstabilizer. ther­ apy. apy. If If you y o u have h a v e prominent p r o m i n e n t anxiety anxiety symptoms, s y m p t o m s , agitation, agitation, or or psychOSiS, psychosis, your your (see doctor doctor may m a y introduce introduce an a n antipsychotic antipsychotic medication medication or or a a benzodiazepine benzodiazepine (see Chapter 6). 6 ) . When W h e n anxiety anxiety or or agitation agitation are are controlled controlled with w i t h drug d r u g treatment, treatment, sui­ suiChapter cidal cidal thoughts thoughts sometimes s o m e t i m e s diminish diminish (Fawcett (Fawcett et et aI., al., 2000). 2000). T r y to to be b e realistic realistic about a b o u t the the speed s p e e d with w i t h which w h i c h your y o u r medical medical treatments are Try treatments are likely to to take take effect. effect. It It can c a n be b e quite quite frustrating frustrating to to have h a v e to to go g o through through a a lrial trial and and likely error period period of of adjusting adjusting medications medications and a n d substituting substituting others others wwhen h e n you're you're alerror al­ ready feeling feeling hopeless hopeless and a n d pessimistic. pessimistic. You Y o u may m a y have h a v e the the impulse i m p u l s e to give up up ready to give w h e n the the first first modification modification to to your y o u r medication medication regime r e g i m e does d o e s not n o t immediately immediately when achieve the the intended intended result. result. Your Y o u r state state of of suicidal suicidal despair despair will will almost almost certainly certainly achieve i m p r o v e with w i t h the the proper proper medication medication adjustments, adjustments, but b u t it it may m a y take take several several improve before the the worst worst symptoms symptoms go go away away (Fawceu (Fawcett et et al., al., 2000). 2000). NonetheNonetheweeks before n

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less, I have been continually amazed at the to which less, I have been continually amazed atdegree the degree to even whichminor even medi­ minor medication most suicidal cation adjustments adjustments can can positively positively affect affect even even the the most suicidal person. person. One One client client with with bipolar bipolar (mixed) (mixed) disorder, disorder,Gerard Gerard(age (age48), 48),tried triedLO toasphyxiate asphyxiatehim­ himself self by by locking locking himself himself in in the the garage garage and and turning turning on on his his car. car.After Afteraabrief briefhos­ hospitalization, his hisdoctor doctor added added Paxil Paxil(an (anantidepressant) antidepressant)to tohis hismood m o o d stabilizer stabilizer pitalization, regime. de­ regime. His His suicidal suicidal thoughts thoughts and and intentions intentions rapidly rapidly diminished, diminished, and and his his depression pression lifted, lifted, though though somewhat somewhat less lessrapidly. rapidly. W h a t will will your your psychotherapist psychotherapist do? do? The The answer answer depends depends on on his his or or her her What theoretical theoretical orientation orientation and and how h o w long long he he or or she she has has been been working working with with you. you. Most Most will will try try lO to provide provide emotional emotional support support and and teach teach you you ways ways to to handle handle your your suicidal impulses example, using using distraction, distraction, relaxation relaxation techniques, techniques, or or suicidal impulses (for (for example, cognitive cognitive restructuring) restructuring) to to help help alleviate alleviate your your immediate immediate pain. pain. Your Your therapist therapist and and you you may m a y examine examine the the antecedents, antecedents, behaviors, behaviors, and and consequences consequences of of your your suicidal suicidal thoughts thoughts and and actions actions (perhaps (perhaps using using different different tenns). terms). Many M a n y therathera­ pists, particularly particularly those those with with a a cognitive-behavioral cognitive-behavioral or or interpersonal interpersonal orientapists, orienta­ tion (see Chapter Chapter 6), 6), view view suicidal suicidal thoughts thoughts or or actions actions as as occurring occurring in in a tion (see a context—as one one response response in in a a series series of of responses. context-as responses. Certain Certain events, events, situations, situations, images, images, or or memories memories may m a y stimulate stimulate suicidal suicidal thoughts or or actions. actions. In In turn, these thoughts thoughts or or actions actions are are sometimes sometimes inadverthoughts turn, these inadver­ tently rewarded by other people. For Maria, age 39, suicidal thoughts tently rewarded by other people. For Maria, age 39, suicidal thoughts often often came food. When came up up in in response response to to food. W h e n depressed, depressed, she she would would eat eat voraciously voraciously and and then look in the mirror, thinking she had grown fat and ugly. It was usually then look in the mirror, thinking she had grown fat and ugly. It was usually then that that she she felt feltsuicidal. suicidal.She Shesought soughtreassurances reassurancesabout abouther herappearance appearancefrom from then others at these times, but these reassurances did little to alleviate her suicidal others at these times, but these reassurances did little to alleviate her suicidal thoughts. Instead, Instead, she shewould would become become more more suicidal suicidaland and then thencall callmore morepeople people thoughts. for reassurance. reassurance. Maria's Maria's therapist therapist assisted assisted her her in in disrupting disrupting this this chain chain of for of events by working working directly directly with with her her on on binge binge eating eating as as a a means means of of selfevents by self­ medicating her her depression, depression, developing developing alternative alternative thinking thinking patterns patterns when w h e n she she medicating felt unallractive, unattractive, and and aVOiding avoiding the the pull to seek seek reassurance reassurance regarding regarding her her apfelt pull to ap­ pearance. Successfully Successfully obtaining obtaining reassurance from others, others, he hebelieved, believed,was wasin­ inpearance. reassurance from advertently reinforcing reinforcing her her suicidal suicidal thoughts thoughts rather rather than than alleviating alleviating her her disadvertently dis­ tress. tress. Your therapist therapist may m a y also also be be able able to to help help you you frame frame your your suicidal suicidal feelings feelings in in Your terms of of broader broader life life issues, issues,such suchasasregrets regretsabout aboutevents eventsininthe thepast pastor orfeelings feelings terms of discouragement discouragement about about your your future. future. He H e or or she she may m a y help help you you understand understand of your suicidal suicidal impulses impulses in in terms terms of of how h o w they they relate relate to to the the cycling cycHng of of the the bipolar your bipolar syndrome. Finally, Finally, your yourtherapist therapistcan can help helpyou you develop developaa"safety "safetyplan," plan,"which which syndrome. can include include calling calling him or her her and/or and/or going going to to the hospital when w h e n you you experihim or the hospital experi­ can ence your your next next suicidal suicidal impulse. impulse. Possibly, Possibly, he he or or she she will wiH invite invite your your family ence family members or or close close friends friends to to come c o m e to session with with you you to to make m a k e sure sure they're members to aa session they're aware of of your your suicidal suicidal thoughts, thoughts, and and so so that that they they can can help help you you design design and and PUl put aware

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into place aamore more detailed suicide prevention plan (discussed into place detailed suicide prevention plan (discussed later in later this in this chapter, pages pages 252-253). 252-253). chapter, Many M a n y of of these these interventions interventions will w H l be b emost m o s t powerful p o w e r f u l in inthe the time time period period pre­ preceding to use ceding when w h e n you y o u become b e c o m e actively actively and a n d dangerously dangerously suicidal. suicidal. Be B e sure sure to use y o u rfirst a signal y o u nneed e e d to y o u r physician nd first suicidal suicidal thoughts thoughts as as a signal that that you to see see your physicianaand your therapist o n a n e m e r g e n c y basis. basis. therapist on an emergency

S".'egy Strategy No. N o . 3: 3 : Use U s e Your Your Core Core Circle Circle "When I stan thinking the future, into and a panic, "When I start thinking about abom the future, I go intoI agopanic, that's and that's w h e n II think think about about suicide. suicide. But Butsomehow s o m e h o w when w h e n IIget getwith withother otherpeople, people,I I when can fantasize fantasize about about how h o w things things could could be, be, and and that that injects injects some some energy energy can into . . It effective­ into me m e .. .... It gives gives me m e the the feeling feeling of of purpose, purpose, like like II have have some some effectiveness ness or or competence, competence, like like II can can channel channel my m y energy energy in in a a good good way. way. It's It's not not just just about about geuing getting rid rid of of loneliness, loneliness, or or being being needy. needy. It's It's a a feeling feeling of of being being able to to make m a k e other other people people laugh, laugh, or or affecting affecting other other people people in in some some way, way, able that makes makes me m e feel feel alive alive again." that again." I disorder -A — A 43-year-old 43-year-old man m a n with with bipolar bipolar I disorder As you one theme of theme this book valueisof your coreof circle Asknow, you know, one of is thisthe book the value your of core circle of family members m e m b e r s and a n d friends friends in in helping helping keep k e e p you y o u well. well. In In Chapter Chapter 9 9 II talk talk family about how h o w members m e m b e r s of of your y o u r core core circle circle can c a n help help keep k e e p you y o u from f r o m escalating escalating into into about aa full-blown full-blown manic m a n i c episode. episode. They T h e y can c a n also also be b ehelpful helpful when w h e n you y o u are are feeling feeling sui­ suicidal. For F o r the the man m a n quoted q u o t e d above, a b o v e , contact contact with w i t h other other people people was w a s like like a n antidecidal. an antide­ pressant, giving giving him h i m temporary t e m p o r a r y feelings feelings of of relief relief from f r o m painful painful emotions. emotions. When When pressant, y o u are are becoming b e c o m i n g suicidal, suicidal, contact contact and a n d support support from f r o m others others is is absolutely absolutely critiyou criti­ cal to to keep k e e p you y o u from f r o m sinking sinking further. further. cal Be B e aware a w a r e that that you're you're more m o r e likely likely to to reject reject help help when w h e n you're you're mmost o s t dde­ epressed and suicidal (Fawcett et aI., 2000). You will feel vulnerable at those pressed a n d suicidal (Fawcett et al., 2 0 0 0 ) . Y o u will feel vulnerable at those times times and a n d expect expect others others to to reject reject you. y o u . The T h e tthought h o u g h t that that "I "I can't can't be b e helped, helped, I'll I'll be b e disappointed, disappointed, II might m i g h t even e v e n get get worse" w o r s e " will will go g o through t h r o u g h your y o u r mmind, i n d , contrib­ contributing uting to to your y o u r sense sense of of hopelessness. hopelessness. You Y o u may m a y start start to to believe believe that that "I'm "I'm all all alone with w i t h this-no t h i s — n o one o n e can c a n really really help help me." m e . " It's It's important important to to challenge challenge these these alone cognitions by b y making m a k i n g yourself yourself seek seek support support from f r o m others, others, even e v e n if if doing d o i n g so so feels feels cognitions useless useless at at first. first. Evaluate Evaluate the the evidence evidence that that being being with w i t h others others mmakes akes y o u feel feel you worse. In In all all likelihood, likelihood, your y o u r attempts attempts to to seek seek assistance assistance will will generate generate compas­ compasworse.

sion sion ffrom r o m others, others, which w h i c h in in turn turn will will help help ease ease your y o u r pain. pain. Start by by reviewing reviewing the the exercise exercise for for "Identifying "Identifying Your Your Core Core Circle" Circle" in Start in Chapter 8 8 (page (page 181). 181). Who W h o on on your your list listcan canhelp helpyou you when w h e n you you first firststart startfeel­ feelChapter ing suicidal? suicidal? If If you you have have been been depressed depressed or or anxious anxious for for some some time, time, whom w h o m have have ing

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you relied relied on you onwhen when you you needed needed to to "vent"? "vent"?Has Hasthis this person these people) people) these (or(or person been been able able to to help help you you clarify clarify important important issues issues and and potential potential solutions solutions without without bringing you you down d o w n further? further? Have Have you you been been able able to to feel feelcloser closer to to this thisperson personas as bringing result of of confiding confiding in in him him or or her? her? One O n e of of the the few few pOSitive positive things things about about de­ deaa result pression pression is is that that it it can can resulL result in in your your making making connections connections with with others others in in ways ways you would would not not typically typically initiate. initiate. you In In evaluating evaluating your your list, list,try try to to think think of of who w h o is is likely likely to to be be supportive supportive in in ways ways that thatyou you would would find find genuinely genuinely helpful. helpful. Is Is there there someone someone on on the the list listwho who can listen listen to to you you talk talk about about wanting wanting to to die die without without "freaking "freaking out"? out"? Some S o m e peo­ peocan par­ ple ple with with bipolar bipolar disorder disorder find find they they can't can't discuss discuss these these matters matters with with their their parents ents bUl but can can do do so so with with a a sibling, sibling,aafriend, friend,aaspouse, spouse,or oraarabbi rabbior orpriest. priest.The The exact relationship relationship you you have have to to the the person person (be (be it it family family member m e m b e r or or friend) friend) isis exact probably probably less less important important than than whether whether you you trust trust that that person person 10 to listen listen 10 to you you calmly calmly and and attentively attentively and and acknowledge acknowledge your your despair, despair, without withoutjudgment. judgment.ItItisis also also helpful helpful to to choose choose someone someone whose whose style style is is optimistic optimistic and and hopeful hopeful but but also also realistic (that (that is, is, aware aware of ofthe thelimitations limitationsimposed imposed by by your yourdisorder disorderand and your your realistic environment). environment). Don't Don't choose choose a a "Pollyanna." "Pollyanna." Finally, Finally,if ifyou youare areclose closetotoa aperson person w h o has has some some understanding understanding of disorder (see (see the the sidebar sidebar in in Chapter Chapter bipolar disorder of bipolar who Disorder for 12, 12, "A "A Quick Quick Fact Fact Sheet Sheet on on Bipolar Bipolar Disorder for Family Family Members, Members," on on pages pages 260-261), or or someone someone who w h o has has gone gone through through periods periods of of depression depression himhim- or or 260-261), herself, that thatperson personmay m a y be beable ableto tooffer offeraaunique uniqueperspective perspectiveon on ways ways 10 tocope cope herself, with your despair. despair. with your If no no one one on on your your list listreally reallyfits fitsthese these descriptors, choose person person thethe choose [0 to trytry descriptors, If or persons persons who w h o comes comes the the closest. closest. It's It's best best to to include include on on your your list list as as many many or people as as possible possible and and not not rely too heavily heavily on on any any one one person. their Record their person. Record rely too people names on the the Suicide Suicide Prevention Prevention Plan Plan on on pages pages 252-253. 252-253. names on N o w think think about about how h o w you you can can get members of of your core circle circle to assist to assist your core get members Now you. the three mentioned at atthe the beginning beginning of ofChapter Chapter 10 10 styles II mentioned coping styles three coping Recall the you. Recall (emotion-focused, cognitive, your encourage your First, encourage coping). First, distraction coping). and distraction cognitive, and (emotion-focused, significant talk about feelings. Tell TeH and feelings. thoughts and your thoughts about your you talk to you listen to 10 listen others to significam others them you don't for them them to to solve o m e up with up with come or c problems or your problems of your all of solve all need for don't need them you the "bromide" that m a k e all the pain pain go go away, away,but butyou youdo doneed needhelp helpto tofo­ foall the will make that will the "bromide" cus doing at doing best at probably best are probably TherapiSts are why. Therapists and why. pain and you pain causing you what's causing on what's cus on this, but if ifyou youhave haveaafriend friendor orfamily familymember m e m b e rwho's who'saagood goodlistener, listener,give give him him this, but or her a chance. or her a chance. Second, e m b e r to you find find a a way way to to prevent prevent help you to help family mmember or family friend or your friend ask your Second, ask the yourself The The objective objective is isto to keep keep you you safe. safe.IfIfyou youhave­ have£0 yourself. danger to immediate danger the immediate n't ask your your friend friend 10 to therapist, ask or therapist, doctor or your doctor call your to caH yourself to get yourself to get able to been able n't been do your hands. hands. If Ifyou you need need off your pills off or pHls weapons or the weapons take the to take her to or her him or Ask him so. Ask do so. to you won't won't or or can't can't If you you. If accompany you. to accompany her to or her him or ask him hospital, ask the hospital, to the go to to go go to go ishe heor orshe shewilling willingto tostay staywith withyou, you,even evenovernight overnightififnecneehospital, is the hospital, to the n

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you feel unable to take essary, until you you feel If If you feel unable to take carecare of of essary, until feel you're you're out outof ofdanger? danger? your your kids, kids, can c a n that that person p e r s o n do d o it it temporarily temporarily or or help help you y o u make m a k e other other arrange­ arrange-

ments with with someone someone who w h o can? can? ments Third, Third, use use distraction distraction. M a n y people people with with bipolar bipolar disorder disorder are are concerned concerned . Many

that talking talking about about their their painful painful emotions emotions will will be be a a burden burden lO to others. others. If If you you are are that concerned concerned about about this, this, consider consider increasing increasing the the amount amount of of low-stress, low-stress, low­ low-

demand social social time time you you spend spend with with your your Significant significant others others or or friends. friends. These These demand them to see activities don't don't have have to to involve involve talking talking about about your your struggles. struggles. Invite Invite them to see activities

a movie movie with with you, you, go go for for aa walk, walk, take take aa drive, drive, have have dinner, dinner, or or read read together. together. a Physical Physical or or social social activities activities that that have have a a degree degree of of structure structure lO to them them and and involve involve

other people, such as asthose thoseon on your yourpleasurable pleasurableactivities activitieslist list(Chapter (Chapter 10), 10),are are other people, such especially important important to to do do right right now n o w to to take take your your mind mind away away from your suiespecially from your sui­ cidal thoughts. thoughts. cidal

Be Awa,e Be Aware of of Otbers' Others'Limitations Limitations You may may feel feel skeptical about thethe ability of members of your help to help You skeptical about ability of members of core yourcircle core to circle you. you. You Y o u are are probably probably correct correct that that if if the the people people you're you're confiding confiding in in do do not not have the have bipolar bipolar disorder disorder themselves, themselves, they they will will not not be be able able to to fully fully understand understand the

depth fre­ depth of of your your depression depression or or why w h y your your suicidal suicidal thoughts thoughts are are increasing increasing in in frequency. friends or seem irritated irritated quency. You Y o u may m a y become become distressed distressed by by friends or relatives relatives who w h o seem

with you you and and insist insist that that you you pull pull yourself yourself out out of of it. it.Be Bepatient patientwith withthem. them.Their Their with irritation irritation probably probably derives derives from from anxieties anxieties about about your your fate fate or or their their frustration frustration at they at not not being being able able to to help help more. more. Likewise, Likewise, try try not not to to be be frustrated frustrated when w h e n they give give you you platitudes, platitudes, which which people people often oftenissue issuewhen w h e n they theycan't can't think think of ofwhat what

else to to say say (for (for example, example, "We've "We've got got only only one one life life to to live live and and we w e have have to live it it else to live fully"). [ully"). Karen, age age 35, 35, complained complained that that no no one one wanted wanted to to hear hear about about her Karen, her depresdepres­ sive sive or or suicidal suicidal feelings. feelings. Her Her typical typical pattern pattern was was to to spend spend hours hours with with others others

talking about about her her sadness sadness and and then then to to tell tell them, them, "Now " N o w II feel feel a whole lot talking a whole lot worse." worse." It It is is not not surprising surprising that that her her friends friends became became burned burned out and didn't OUl and didn't

want to to help help her her anymore. anymore. It's It's important important to to reward reward or or reinforce reinforce members m e m b e r s of of want your your core core circle circle for for their their efforts efforts from from time time to to time. time. Remember, Remember, they are trying they are trying

to help, help, even even if if what they do do is is not not always always helpfuL helpful. They They need need to to hear from you you to what they hear from that that talking talking to to them them or or simply simply spending spending time time with with them them is is helping helping you. you. It It

probably is, is, even even if if only only minimally, minimally, and and it's it's important important to to tell tell them them so. probably so.

Strategy Reviewing You, Reasons fa, for Living StrategyNo. No.4:4: Reviewing Your Reasons Living There will will be be times times when, w h e n , alone alone with with your your suicidal suicidal thoughts thoughts and and feelings, feelings, they they There begin to to ovetwhelm overwhelm you. This is is because because suicide suicide is, is, in in part, part, a a cognitive cognitive proprobegin you. This

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cess. When people feelmost most desperate, desperate, they begin evaluate the pros cess. When people feel they begin to to evaluate the pros and and

cons cons of of suicide suicide as as a a means means of of solving solving their their problems. problems. Suicide Suicide begins begins to to feel feel like like a a more more viable viable alternative alternative when w h e n you you believe believe that that nothing nothing you you do do will will yield yield a a positive positive outcome, outcome, or or that that your your depression depression or or other other life life problems problems will will always always haunt The flip flip side if haunt you. you. The side is is that that you you will will be be most most protected protected against against suicide suicide if you you believe believe that that you you will will be be able able to to cope cope effectively effectively with with life's life's problems, problems,view view life value, or that Olhers exis­ life as as having having intrinsic intrinsic value, or feel feel that others are are dependent dependent on on your your existence people are tence (Linehan, (Linehan, 1985; 1985; Strosahl Strosahl et et a1., al., 1992). 1992). In In short, short, people are protected protected from suicide suicide when w h e n they they can can access access good good reasons reasons to to live. from live. Marsha Linehan Linehan and and her her associates associates have have developed developed an an inventory inventory of of Marsha The inventory gen­ "Reasons sidebar on "Reasons for for Living" Living" (see (see the the sidebar on page page 249). 249). The inventory was was generated erated by by nonsuicidal nonsuicidal people people who w h o were were asked asked to to write write down d o w n the the reasons reasons they previously considered they did did nOl not kill kill themselves themselves at at a a point point when w h e n they they had had previously considered it, the now, the reasons believed it, the reasons reasons they they would would not not do do so so n o w , and and the reasons they they believed other (Linehan et other people people did did not not (Linehan et al., al., 1983). 1983). Linehan Linehan and and colleagues colleagues have have found the Reasons for found that that nonsuicidal nonsuicidal individuals individuals endorse endorse mOTe more items items on on the Reasons for Living Living Invemory Inventory than than those those who w h o have have attempted attempted or or thought thought seriously seriously about about people believe suicide (Linehan (Linehan et et aI., al., 1983; 1983; Osman O s m a n el et al., al, 1996). 1996). When W h e n people believe suicide they they can can overcome overcome life's life's problems, problems, and and when w h e n they they feel feel a a strong strong sense sense of of re­ responsibility to to family family and and children, children, they they are are less less likely likely to to make make a a serious serious sponsibility suicide attempt. suicide attempt. While this logic may m a y seem seem obvious, obvious, it it has has an an implication for the the things things While this logic implication for you can do on your o w n w h e n you start to have suicidal thoughts. W h e n peoyou can do on your own when you start to have suicidal thoughts. When peo­ ple are are suicidal, suicidal, they theyusually usuallyhave haveaagreat greatdeal dealof oftrouble troubleaccessing accessingany anypositive positive ple reasons for being alive (Linehan, 1985). So, w h e n you're feeling well, generate reasons for being alive (Linehan, 1985). So, when you're feeling well, generate a llist ofyOUT yourreasons reasonsfor forliving livingor orreasons reasonswhy w h y you you would would not notcommit commit suicide suicide s i t of a if you were starting to think about it. Y o u can then review these reasons when if you were staning to think about it. You can then review these reasons when suicide begins begins to to feel feel like like a a viable viable option. option. suicide Start by by checking checking the the items items in in the the inventory inventory (on (on page page 249) 249) that that you you beStan be­ are heve to to be be true. true. Then, Then, in in the the blank blank spaces, spaces, add add your your own o w n reasons reasons if if they they are lieve not covered in the other items. Try to do this while you're feeling reasonably not covered in the other items. Try to do this while you're feeling reasonably for stable and and not seriously depressed. W h e n you're you're depressed, depressed, your your reasons reasons for stable not seriously depressed. When living m a y be be harder harder to endorse, even even though you might might ordinarily ordinarily believe believe in living may to endorse, though you in them. them. You'll see see that the items items cover cover a a broad broad spectrum spectrum of of reasons, reasons, including including the the You'll that the behef that that you can cope cope with, with, and and overcome, overcome, your troubles, the value you you put put belief you can your troubles, the value on life life itself, itself,the thedegree degreetotowhich whichyou youfeel feel optimistic, concernsrelated relatedtotoyour your on optimistic, concerns family and children, children, fears fearsof ofdisapproval disapprovalby by society, society,moral moralbeliefs, beliefs, and fears family and and fears ofof the suicidal suicidal act act itself itself (Linehan (Linehan et et al., al, 1983). 1983). Some S o m e of of these these reasons reasons may m a y be be the mOTe relevant to to more relevant to you you than than others. others. Reviewing Reviewing the the reasons reasons you you do do not not want want to kiH yourself yourself when w h e n the the thought thought crosses crosses your your mind mind may m a y help help protect protect you you from from kill acting on on a a self-destructive self-destructive impulse. impulse. acting

THE T H E REASONS R E A S O N S FOR F O R UVING LIVING INVENTORY INVENTORY Check the the statements statements below nor commit commitsuicide suicide if if the check below that that indicate indicatewhy why you you would would not the

thought were were to to occur occur to to you you or or if if someone someone were were to to suggest suggest it itto toyou. you. thought ___

have aa responsibility responsibihty and and commiunent commitment to to my m y family. family. II have

___

just to, believe II can can learn learn to to ad adjust to,or or cope cope with, with, my m y problems. problems. II believe

___ ___

believe IIhave have control control over over my m y life life and and destiny. destiny. II believe

II believe believe only only God G o d has has the the right right to to end end aa life. life. II am a m afraid afraid of of death. death.

___

II want want to to watch watch my m y children children as as they they grow. grow.

___

Life Life is is all all we w e have have and and is isbener betterthan than nothing. nothing.

___

I1 have have future future plans plans IIam a m looking looking forward forward to to carrying carrying out. out.

___

No N o matter matter how h o w bad bad II feel, feel, IIknow k n o w that thatititwill willnot notlast. last.

___

II love love and and enjoy enjoy my m y family family too too much m u c h and and could could not not leave leave them. them.

___

II am fail. a m afraid afraid that that my m y method method of of killing killing myself myself would would fail.

___

II want want to to experience experience all all that that life lifehas has to to offer, offer,and andthere thereare aremany m a n y experiences experiencesII

have not not had had yet yet that that II want want to to have. have. have ___

___

It It would would not not be be fair fairto toleave leave the the children children for forothers others to to take take care care of. of

have aa love love of of life. life. II have

II am a m too too stable stable to to kill kill myself. myself

___

My M y religious religious beliefs beliefs forbid forbid il. it.

___

The effect effect on on my m y children children could could be be harmful. harmful. The

___

It would would hurt hurt my m y family family too too much m u c h and and II would would not notwant want them them (0 tosuffer. suffer. It

___

a m concerned concerned about about what what others others would would think think of of me. me. II am

___

consider it itmorally morallywrong. wrong. II consider

___

stillhave have many m a n y th things left to to do. do. II still ings left

___

have the the courage courage to to face face life. life. II have

___

II am a m afraid afraid of of the the actual actual "act" "act" of of killing killing myself myself (the (the pain, pain,blood, blood, violence). violence).

___

believe killing killing myself myself would would not not really really accomplish accomplish or or solve solve anything. anything. II believe

___

Other people people would would think think II am a m weak weak and and selfish. Other selfish.

___ �

would not not want want people people to to think think II did did not not have have control control over over my m y life. life. II would would not not want want my m y family family to to feel feelguilty guilty afterward. afterward. II would

List List other other reasons reasons for for living. living.

Adapted by by penniss permission from Lint-han Linehan et etal. al.(1983). (1983).Copyright Copyright 1983 the American Psychological AssoAdapted ion rrom 1983 byby the American Psychological Asso­ ciation. ci ation.

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StrategyNo. No.S:5: "Improving Moment" Tools Tools Mom.nr' ing Ihethe "Improv SIralegy

even in the background is always despair suicidal their feel that people feel Some people Some that their suicidal despair is always in the background even learn­ w h e n they they distract distract themselves themselves from from it. it. Suicide Suicide prevention prevention can can include include learnwhen ing to to tolerate tolerate feelings feelings of of despair despair when w h e n you you can't can't make m a k e them them go go away. away. What What ing follows are are some some "improving "improving the the moment" m o m e n t " strategies strategies for for tolerating tolerating your your dis­ disfollows tress tress (after (after Linehan, Linehan, 1993). 1993). M a n y people people turn turn to to religion religion when w h e n they they are are alone alone and and feel feel depressed depressed and and Many suicidal. For For some, some, religion religion is is best best practiced practiced in in group group settings settings like like aa church, church, suicidal. synagogue, synagogue, or or temple, temple, but but others others prefer prefer solitary solitary prayer. prayer. For For some, some, praying praying for for strength gives gives them them a a sense sense of of purpose purpose and and belonging. belonging. Likewise, Likewise, some some people people strength find find spiritual spiritual readings readings helpful helpful because because they they put put suffering suffering into into a a larger larger perspec­ perspective. tive. For Forexample, example,readings readingsby bythe theDalai DalaiLama L a m a seem seem quite quiteinspirational inspirationalto topeo­ people j Happiness ple in in pain pain (The (The Art Art o of Happiness by by Lama Lama & & Cutler, Cutler, 1998, 1998, or or Ethics Ethics for for the the N e w Millenium Millenium by by Lama, Lama, 1999). 1999). New If Significant If your your depressed depressed and and suicidal suicidal feelings feelings are are accompanied accompanied by by significant anxiety, you you may m a y benefit benefitfrom fromself-relaxation self-relaxationexercises. exercises.Usually, Usually, relaxation in­inrelaxation anxiety, volves sitting sitting in in a a comfortable comfortable chair; chair; tensing tensingand and relaxing relaxingeach each of of yOUT yourmuscle muscle volves your face; moving up your feet groups, groups, starting starting with with your feet and and moving up to to your face; and and imagining imagining re­ relaxing, laxing, pleasant pleasant scenes scenes (for (for example, example, lying lying on on a a beach). beach). Relaxation Relaxation exercises exercises thoughts. often often decrease decrease the the anxiety anxiety and and agitation agitation that that accompany accompany suicidal suicidal thoughts. Consult books give you you step-by-step step-by-step instructions instructions on on how h o w to to relax and relax and that give books that Consult breathe more more eaSily easily as as well well as as h o w to to create create your your own o w n relaxation relaxation tapes tapes (for (for ex­ exhow breathe ample, Craske, Craske, 2001; 2001; Davis et aI., al., 2000; 2000; Wilson & Wilson, Wilson, 1996). 1996). Wilson & Davis et ample, For others, others, exercise exercise is is helpful. helpful. Many M a n y people people report report that that their their mood m o o d im­ imFor proves Significantly significantly and and suicidal suicidal thoughts diminish after after they have exercised. exercised. they have thoughts diminish proves Of course, course, it's it's hard hard to togo go and and work work out outwhen w h e n you you feel feellow low in inenergy, energy,apathetic, apathetic, Of or hopeless. Try some some light light exercise exercise if you feel feel especially especially lethargic, such as as lethargic, such if you hopeless. Try or walking, stretching, stretching, or orriding ridingaastationary stationarybicycle bicyclefor foraafew fewminutes. minutes.When W h e n ex­ exwalking, that ercising, attention on on your and the sensations that physical sensations the physical body and your body your attention focus your ercising, focus accompany the the movement. movement. accompany experience of of any any of of these "improving the m o m e n t " tasks tasks is is posi­ posithe moment" these "improving your experience IIff your tive, consideradding adding them them to toyour yourbehavioral behavioralactivation activationlist list(Chapter (Chapter 10). 10). It's It's tive, consider regular important to and make m a k e them them a part of once and than once more than these more try these to try important your regular of your a part routine maximize their impact. their impact. routine to maximize

Developing a Suicide Prevention Plan Prevention Plan a Sui,ide Developing

Now to pul putall all of this information together into a prevention suicide prevention plan. plan. imo a suicide together information of this try to Nowtry The pages 252-253 beginning of the beginning At the template. At a template. as a used as be used can be 252-253 can on pages sidebar on The sidebar of

in exercises in the exercises (see the depresSion (see of depression prodromal signs your prodromal list your exercise, list the exercise, the signs of

Feelings andand Thoughts Dealing Dealingwith withSuicidal Suicidal Thoughts Feelings

2S1 251

list any suretotolist Besure 10).Be Chapter those including impulses, thoughts suicidal thoughts Chapter 10). any suicidal oror impulses, including those

that seem s e e m fleeting fleeting or or insignificant insignificant (for (for example, e x a m p l e , "1 "1 start start thinking thinking about a b o u t dying, dying, that but but [I would w o u l d never never do d o anything anything about a b o u t it"). it"). Then, T h e n , examine e x a m i n e the the list list of of self­ selfmanagement m a n a g e m e n t strategies, strategies, all all of of which w h i c h have h a v e been b e e n described described in in this this and a n d the the prior prior

chapter. Circle Circle those those items items that that seem s e e m like like reasonable reasonable things things for for you y o u and a n d others others chapter. to do d o when w h e n you y o u experience experience suicidal suicidal thoughlS thoughts or or other other signs signs of of depression. depression. to of Next, N e x t , share share this this exercise exercise with w i t h your y o u r doctor/therapist doctor/therapist and a n d the the members m e m b e r s of

your core core circle, circle, and a n d see see if ifthey'd they'd be b e willing willing to to perform p e r f o r m these these tasks, tasks, should s h o u l d you you your g o into into aa cr crisis. If aa friend friend or or family family member m e m b e r is is not n o t willing w i H i n g to to accept accept responSi­ responsiisis. If go bihty for for a a given given item item (for (for example, e x a m p l e , taking taking care care of of your y o u r kids, kids, calling calling your y o u r ther­ therbility apist) consider consider assigning assigning that that task task to to another another person. person. List List each each member m e m b e r of of apist) your your core core circle circle at at the the end e n d of of the the exercise exercise and a n d indicate indicate which w h i c h items items on o n the the list list

can be b e assigned assigned to to him h i m or or her. her. can to Keep K e e p your y o u r suicide suicide prevention prevention plan plan in in aa place place that that is is readily readily accessible accessible to members m e m b e r s of of your y o u r core core circle. circle. It It may m a y make m a k e sense sense to to attach attach ititto toyour y o u r mania m a n i a pre­ pre-

vention contract contract (Chapter (Chapter 99). ). vention *

*

*

Suicide Suicide is is "a "a permanent p e r m a n e n t solution solution to to a a temporary t e m p o r a r y problem" p r o b l e m " (Fawcett (Fawcett et et aI., al.,

:WOO, 2 0 0 0 , p. p. 147). 1 4 7 ) . But B u t the the intolerable intolerable feelings feelings that that go g o along along with w i t h suicidal suicidal preoccu­ preoccupations pations can c a n be b e so so painful painful that that they they feel feel permanent. p e r m a n e n t . It's It's important important to to combat combat

these states states with with a a variety variety of of self-management s e l f - m a n a g e m e n t tools tools to to help help activate activate yourself, yourself, these view view your y o u r circumstances circumstances from f r o m alternate perspectives, and a n d reengage reengage with w i t h iim­ malternate perspectives,

portant sources sources of of emotional e m o t i o n a l and a n d practical practical support. support. Try T r y to to b eu p front with front with up be portant your doctor doctor and a n d therapist a b o u t yyour o u r suicidal impulses and a n d take considyour into consid­ take into suicidal impulses therapist about eration eration their their recommendations r e c o m m e n d a t i o n s for for emergency e m e r g e n c y mmedical e d i c a l treatment. treatment. MMost o s t of all, of all,

remain r e m a i n hopeful hopeful that that your y o u r most m o s t severe severe depreSSive depressive symptoms s y m p t o m s will eventually will eventually disappear disappear and a n d that that you y o u will will return return to to a a more m o r e tolerable tolerable emotional emotional state. It's state. It's

hardest see yyour o u r way w a y out w h e n you y o u have h a v e hit o t t o m , so so try try to to iimplement m p l e m e n t as hit bbottom, out when to see hardest to as m a n y of of these these strategies strategies as as possible possible wwhen h e n you y o u experience experience the the first first signs de­ of designs of many pression or or suicidal suicidal despair. despair. pression T h e final final chapter chapter offers a different different wwindow i n d o w on o n the the question question of The self-man­ of self-manoffers a aagement: g e m e n t : how h o w to to ccope o p e effectively effectively in o u r family n d wwork o r k eenvironments n v i r o n m e n t s after after and family a your in y aa bipolar bipolar illness illness episode. episode. People People with w i t h bipolar bipolar disorder disorder often often experience experience trou­ trouin bboth ble ble in o t h settings-trouble settings—trouble nnot o t entirely entirely ddue u e to their o w n behavior. a n y of of behavior. MMany own to their

their r o b l e m s derive r o m others' having an a n inadequate the of the understanding of inadequate understanding others' having derive ffrom problems their p

disorder the eexample x a m p l e of a r t h a in h a p t e r 1). 1). I1 discuss several strategies strategies discuss several Chapter in C Martha of M (see the disorder (see

that will that o u feel m p o w e r e d in o u r family, n d work work social, aand family, social, negotiating yyour in negotiating feel eempowered help yyou will help

relationships. A s you've h r o u g h o u t this o o k , mmanaging a n a g i n g yyour o u r disorder disorder this bbook, seen tthroughout you've seen As relationships. involves acquainting involves i t h the facts aabout b o u t it n d being n yourself oon clear yourself being clear and it a the faclS others wwith acquainting others what will, what and will willnot, not, be be helpful helpful1O toyour your recovery. recovery. will, and

SUICIDE SUICIDE PREVENTION P R E V E N T I O N PLAN PLAN list early warning signs of a depressive episode. Listyour yourtypical typical early warning signs of a depressive episode.

Circle Circle the the things thingsyou you can can do do if ifone oneor ormort': moreof ofthese theseearly earlywarning warningsymptoms symptomsappear, appear,or orifif

you have have suicidal suicidal thoughts thoughts or or impulses. impulses. you

L Get Get rid dangerous weapons 1. rid of ofallall dangerous weapons 2. 2. Call Call your your psychiatrist psychiatrist and and psychotherapist psychotherapist to to ask ask for for an an emergency emergency appointment appointment 3. ng 3. Implement Implement your your behavioral behavioral activation activation plan plan by by scheduling scheduling rewarding rewarding or or distracti distracting activities activities 4. 4. Challenge Challenge negative negative thoughts thoughts through through cognitive cognitive restructuring restructuring 5. 5. Ask Ask your your core core circle circle of of friends friends and and family family members members for for support support 6. 6. Practice Practice relaxation relaxation techniques techniques 7. 7. Exercise Exercise 8. 8. Rely Rely on on input input from from religious religious and and spiritual spiritual sources sources 9. 9. Review Review your your reasons reasons for for living living inventory inventory

Circle thethings things your doctor therapist can do. Circle the your doctor and and t,herapist can do. 1. L 2. 2. 3. 3. 4. 4.

See you you on on an an emergency emergency basis basis See

Modify your your medication medication regimen regimen Modify

Arrange aa hospitalization hospitalization (if (if necessary) necessary) Arrange Help you you understand understand where where your your suicidal suicidal thoughts thoughts are are coming coming from from and and what what Help effects they they are are having having on on you you or or others others effects

5. Work W o r k with with you you on on behavioral behavioral strategies strategies for for handling handling your your painful painful thoughts thoughts and and 5. emotions emotions Circle thosethings things that members your can do. your corecore circlecircle can do. Circle those that members of of 1. 1. 2. 2. 3. 3. 4. 4. 5. 5. 6. 6. 7. 7. 8. 8.

Listen to toyou, you,validate validate your feelings, and suggestions offer suggestions Listen your feelings, and offer

Avoid being being critical critical or or judgmental judgmental Avoid

Distract you you through through mutually mutually enjoyable enjoyable activities activities Distract Help you you take take care care of of responsibilities responsibilities that that have have become become burdensome burdensome or or difficult difficult to Help to perform (for (for example, example, child child care) care) perfonn Stay with with you you until until you you feel feel safe safe Stay Call your your doctor doctor to to help help you you arrange arrange an an appointment appointment Call

Take you you to to the the hospital hospital (if (ifnecessary) necessary) Take

Agree to to store store your your weapons weapons or or pills pills away away from from you you Agree

252 252

list List members members of ofyour yourcore corecircle circleand andput putnumbers numbersafter aftereach eachindicating indicatingwhich which of ofitems itemsI­ 1ate). 8 they they are are willing willing to to perfonn perform (list (listmore more than thanone oneitem, item,ififappropri appropriate). S

List List your your doctors' doctors'names names and and phone phone numbers. numbers.

253 2S3

1 2

1

2

C o p i n g Ef E f fectively f e c t i v e l y in i n the t h e Family F a m i l y Coping and a n d Work W o r k Settings Settings

B

disorder poses poses significant significant challenges challenges for for daily daily life, life,both bothat at iPolar disorder B .'ipolar h o m e and and at at work. work. When W h e n your your family family members members first first learned learned about aboutyour your disor­ disorhome der, they they may m a y have have been been supportive, supportive, intrusive, intrusive, anxious, anxious, or or angry. angry. Some S o m e may may der, have been been eager eager to to help, help, while while others others subjected subjected you you to to overt overt rejection. rejection. But But have even after after everyone everyone has has seemed seemed to to adjust adjust to to life life with with bipolar bipolar disorder disorder in in the the even family, difficulties difficulties often often reappear reappear with with the the next bipolar episode. family, next bipolar episode. Likewise,you you may m a y experience experiencefrustration frustrationin inthe thework work setting. setting.Perhaps Perhapsyou you Likewise, want La to work work and and be be productive, productive, but but you you don't don't k n o w how h o w to to deal deal with with the the know want stigma of of the the disorder, disorder, the the lack lack of of understanding understanding by by employers employers or or coworkers, coworkers, stigma or workplace workplace demands demands that that are are incompatible incompatible with with your your attempts attempts to to manage manage or your illness. illness. From F r o m many m a n y research researchstudies studieswe w e know k n o w that thatthe thesymptoms symptoms of ofbipo­ bipoyour lar disorder disorder affect affect a a person's person's ability ability to to function function in in the the family family or or work work setting lar setting (CoryeH el et aI., al., 1993; 1993; Dion Dion et et aI., al., 1988; 1988; Goldberg Goldberg et et aI., al., 1995; 1995; Miklowitz & Miklowitz &: (Coryell Goldstein, 1997). 1997). The The good good news news is is that that you you can can learn learn to to negotiate negotiate the the con­ conGoldstein, flicts and demands your family and work through a variety of communiand demands of of your family and work lifelife through a variety of communi­ flicts cation skills skills and and self-care self-care strategies. cation strategies. R e m e m b e r Martha Martha (Chapter (Chapter 1)? 1)? After After her her manic manic episode episode and and hospitalizaRemember hospitaliza­ tion, her children became suspicious, withdrawn, and fearful. Her husband tion, her children became suspicious, withdrawn, and fearful. Her husband to acted rejecting rejecting at at some some points points and and overprotective overprotective at at others, others, before he came came to before he acted better understanding understanding of of the the disorder disorder through through their their couples' couples' counseling. counseling.Back Back aa better at her her computer computer programming programming job, job, Martha Martha had had problems problems concentrating. concentrating. She She at found the the computer computer screen screen newly newly confUSing confusing and and forgot forgot h o w to to use use the the proprofound how 254

254

Coping ondand W()rk Settings Coping Effectively Effectivelyininthe theFomily Family Work Settings

255 2SS

grams shehad had been expert at using before. Her quickly boss qUickly impa� grams she been so so expert at using before. Her boss became became impatient her tient with w i t h her h e r lower l o w e r performance. p e r f o r m a n c e . Her H e r coworkers c o w o r k e r s avoided avoided h e r and a n d even even seemed s e e m e d nervous n e r v o u s in in her h e r presence presence after after learning learning of of her her difficulties. difficulties. If If you've you've recently recently recovered recovered from from a a manic, m a n i c , mixed, m i x e d , or or depressive depressive episode, episode, y o u may m a y feel feel ready ready to to reintegrate reintegrate yourself yourself into into the the family family and a n dthe the workplace, workplace, you only way only to to find find that that those those you y o u live live and a n d work w o r k with w i t h don't don't treat treat you y o u the the w a y they they used to. to. Your Y o u r loved loved ones o n e s may m a y become b e c o m e angry a n g r y and a n d critical critical or or overprotective. overprotective. used Y o u r partner m a y s e e m hesitant to reestablish intimacy w i t h y o u .A o r k yyou ou partner may seem hesitant to reestablish intimacy with you. Att wwork Your m a y feel feel like like "It's "It's the the same s a m e old old men m e " but b u t get get the the impression impression that that your y o u r col­ colmay leagues don't don't see see it it that that way. w a y . And A n d if if you y o u really really do d o need n e e d to to adjust adjust your y o u r work work leagues setting and a n d work w o r k routines routines to to help help you y o u maintain maintain mood m o o d stability, stability, h o w much m u c h ccan an setting how y o u tell tell them t h e m about a b o u t your y o u r disorder disorder and a n d still still get get them t h e m to to treat treat you y o u as as the confiyou the confi­ dent, competent c o m p e t e n t person p e r s o n you y o u were w e r e before? before? dent, These T h e s e issues issues pose p o s e undeniable undeniable challenges, challenges, but b u t II have h a v e been b e e n continually continually iim­ mpressed with with how h o w effectively effectively people people with w i t h bipolar bipolar disorder disorder can c a n learn learn to deal pressed to deal with them. t h e m . Establishing Establishing close close family family or or couple couple relationships relationships is is pOSSible possible even even with after the the mmost o s t severe severe of of mood m o o d disorder disorder episodes. episodes. So S o is is reclaiming reclaiming successful successful after w o r k lives lives and a n d reaching reaching career career aspirations. aspirations. As A s you'll you'll soon s o o n see, see, maintaining maintaining work successful successful family family and a n d work w o r k relationships relationships has has a a 101 lot to to do d o with w i t h how h o w you y o u educate, educate, c o m m u n i c a t e , and a n d solve solve problems p r o b l e m s with w i t h others others as as they they go g o through t h r o u g h their their inevicommunicate, inevi­ table table ups u p s and a n d downs d o w n s in in reacting reacting to to your y o u r disorder. disorder.

"What Family Family Problems Problems Might Might II Encounter Encounter "What after an an Illness Illness Episode?" Episode?" alter During your your period periodof ofrecovery, recovery, your close relatives are to going have confusDuring your close relatives are going have to confus­ ing ing feelings feelings about about your your illness illness and and confuSing confusing thoughts thoughts about h o w to to help help you. about how you. In In the the following following sections sections II explore explore the the most most common c o m m o n problems problems that m a y arise. that may arise. Negative Emotional Reactions from YourYour Relatives Negalive Emolional Rea,'ions 'rom Re/alives Randy, a 45-year-old plumber, had two had episodes depression and several and several Randy, a 45-year-old plumber, two of episodes of depression h y p o m a n i c episodes. episodes. His H i s most m o s t recent recent episode, episode, a a depreSSion, depression, led led to to the the loss loss hypomanic of his his job. job. His H i s wife, wife, Cindy, C i n d y , had hada a rrudimentary u d i m e n t a r y understanding understanding of of bipolar bipolar of disorder but b u t was w a s fairly fairly intolerant intolerant of of his his apparent apparent inability inability to to function. function. She She disorder frequently spoke s p o k e to to him h i m in in derogatory derogatory psychiatric psychiatric lingo: "That's your y o u r mma­ afrequently lingo: "That's nia nia talkingn; talking"; "Last "Last night night when w h e n we w e got got into into that that argument, a r g u m e n t , you y o u were w e r e totally totally rapid cycling" cycling";; "You're "You're doing d o i n g your y o u r ADD A D D [attention [attention de£icit deficit disorder! disorder] thing thing rapid again." In In marital marital sessions, sessions, however, h o w e v e r , Cindy C i n d y revealed revealed that that she she really really didn't didn't again.n believe his his mood m o o d problems p r o b l e m s were w e r e of of a a biological biological origin. origin. She S h e bblamed l a m e d them them believe

256 256

SELF-MANAGEMENT SElf·MANAGfMfNT

on his "crazy, dysfunctional family," on his "crazy, dysfunctional family,"his his "temperamental "temperamentalnature," nature," and and "unconscious, "unconscious, unresolved unresolved stuff stuff with with mc." me." She She also also wasn't wasn't convinced convinced by by the the genetic genetic evidence evidence that that Randy's Randy's father father had had had had bipolar bipolar disorder. disorder. Their debates debates about about the the causes causes of of his his behavior behavior tended tended to to degenerate degenerate Their into into escalating escalating interchanges interchanges in in which which Cindy Cindy would would berate berate Randy Randy and and he he would would try try to to defend defend himself. himself. He H e typically typically ended ended up up agreeing agreeing with with hcr, her,just just to to stop stop the the argument, argument, but but then then would would feel feel resentful resentful and and withdraw withdraw to to pun­ punish ish her. her. Annoyed Annoyed at at his his withdrawal, withdrawal, she she would would continue continue her her atr.ack attack later later with the the accusation accusation that that "You've "You've never never been been able able to to deal deal with with things things diwith di­ rectly." rectly." He H e began began to to consider consider going going off off his his medications medications just just to to prove prove "that "that II can can deal deal with with all all of of this this without without anyone anyone or or anything'S anything's help." help." is Cindy so angry? Most of the familymembers members I haveworked worked Why Why is Cindy so angry? Most of the family I have with with are honestly want for are well-intentioned, well-intentioned, caring caring peopJe people who w h o honestly want to to do do what's what's best best for their their bipolar bipolar relative. relative.But Butthey theydon't don'talways alwaysknow k n o w what what to todo dowhen w h e n their theirbipo­ bipolar feeling lar relative relative reacts reacts negatively negatively to to their their attempts attempts to to help. help. They They end end up up feeling disor­ frustrated and and burdened burdened by by the the effort effort reqUired required of of them them to to adapt adapt to to the the disorfrustrated der, der, and and then then often often say say and and do do things things that that are are critical critical or or unhelpful. unhelpful.

Your relatives' relatives' reactions reactions to to your your disorder, disorder, particularly particularly during during the the period period Your when w h e n you you are are recovering, recovering, often often reflect reflect the the same same styles styles of of coping coping or or "causal "causal at­ at-

tribution" that that you you used used at at various various stages stages of of adjusting adjusting to to your illness (see tribution" your illness (see Chapter 4): 4): Underidentif Underidentifying with the the disorder disorder (attributing (attributing your your behavior behavior ying with Chapter changes to to your your personality personality or or habits) habits) or oroveridentifying overidentifyingwith withitit(attributing (attributingall all changes or most most of of your your behaviors, behaviors, even even normal ones, to to your your illness). illness). Highly Highly critical or normal ones, critical relatives are are often often underidentifying underidentifying you you with with the the disorder, disorder, as as Cindy Cindy was was dorelatives do­ ing. They They may m a y believe believe that that your your biologically biologically based, based, illness-related illness-related changes changes in ing. in behavior—including any any residual residual mood m o o d swings swings from from your your last last episode episode that that behavior-including haven't cleared cleared up up yet-are yet—are really really caused by your your character character or or morals, morals, your your caused by haven't unconscious motivations, motivations, or or your your lack lack of of effort. effort. If If a a family family member m e m b e r believes believes unconscious that these these factors factors play play a a causal causal role, role, he he or or she she will will also also believe believe that that you you have have that more control control over over your your mood m o o d swings swings than than you you really really do. do. Your Your relative relative may may more then become become angry angry and and critical critical (Hooley, (Hooley, 1987). 1987). then

Overprotectiveness Overprolectiveness Alternatively, you mayfind find that your relatives to watch you care­ very careAlternatively, you may that your relatives want want to watch you very fuHy and and manage manage your your disorder disorder to to the the point point where where you you feel feel you're you're being being fully treated like like aa child child (overprotectiveness (overprotectiveness or or overinvolvement). overinvolvement). Relatives Relatives who who treated label are overprotective overprotective often often tend tend to to overidentify overidentify you you with with the the disorder, disorder, or or label are your your everyday everyday reactions reactions as as signs signs of of your your illness. Hlness. For example, they they say say that that For example,

your illness illness is is reflected reflectedin ingetting gettingangry angryabout aboutthings thingsyou you might mightvery verywell wellhave have your

Coping Effectively Effectively in in the the Family Family and and Work Work Settings Settings (oping

2 257 57

gotten Sometimes you and they areare both gotten angry angryabout aboutbefore beforeyou youbecame became ilL ill. Sometimes you and they both right-your right—^your anger anger may m a y be be stimulated stimulated by by real real things, things, but but your your disorder disorder makes makes you you react react with with a a level level of of emotional emotional intensity intensity that that is is out out of of proportion proportion to to the the of circumstances. Nonetheless, Nonetheless, you you may m a y begin begin to to register register that that their their labeling labeling of circumstances. your worse. Relatives to your behavior behavior makes makes you you feel feel worse. Relatives may m a y remind remind you you repeatedly repeatedly to take therapist take your your medication, medication, tell tell you you to to communicate communicate with with your your doctor doctor or or therapist about about minor minor problems problems you you have have at at home h o m e or or at at work, work, or or even even go go behind behind your your

back to to talk talk with with your your physician. physician. back find, as con­ You may m a y even evenfind, as some s o m e of of my m y clients clients have have found, found, that that when w h e n you you conYou

frontyour your relatives relativesabout about their theiroverprotectiveness, overprotectiveness,they theyuse useyour yourbipolar bipolardiag­ diagfront nosis as as a a weapon w e a p o n against against you. you. For For example, example, you you might might express expressannoyance annoyance at ataa nosis relative for for asking asking too too many m a n y questions questions about about your your medication, medication, only only to to have have relative him or or her her tell tell you you that thatyour yourreaction reactionis is aasign signof of your your illness. illness.You Y o ucan cangel getinto into him a vicious vicious cycle cycle in in which which you you complain complain about about their their intrusiveness, intrusiveness,your yourrelatives relatives a react react as as if if you you are are cycling cycling into into an an episode, episode, you you get getmore more annoyed annoyed with with their theirla­ la-

beling of of you you as as mentally mentally ill, ill, their their beliefs beliefs about about your your cycling cycling become become more more beling confirmed, and and then then they they become become more more protective. confirmed, protective.

Prohlems with Problems withIntimacy Intimacy

Nowlet's let's consider a different kindkind of emotional reaction that often arises be­arises beNow consider a different of emotional reaction that often

tween spouses spouses or or romantic romantic partners partners during during the the recovery recovery period: period: a a discomfort discomfort tween with physical physical intimacy intimacy in in your your partner's partner's relationship relationship with with you. spouse's with you. Your Your spouse's discomfort discomfort may m a y not not be be associated associated with with criticism criticism or or overprotectiveness; overprotectiveness; inin­

stead,you you may m a y experience experiencehim h i m or orher heras asemotionally emotionallywithdrawn. withdrawn.Physical Physicalinti­ intis.tead,

macy may m a y have have stopped stopped altogether altogether during. during, or or shortly shortly after, after, your your last lastepisode episode macy (as Martha Martha experienced experienced with with her her husband husband after after her her hospitalization), hospitalization), or or it it may may (as have time after have gradually gradually diminished diminished over over time after multiple multiple episodes. episodes. It It is is quite quite common c o m m o n for for relationships relationships to to be be at at a a vulnerable vulnerable point point during during the the recovery recovery period, period, even even if if the the episode episode was was only only a a minor minor one. one. Many M a n y spouses spouses feel feel angry angry about about events events that that occurred occurred during during the the episode episode and and don't don't feel feel comfort­ comfortable close. able being being close.

If you you are are currently currently hypomaniC, hypomanic, you you may m a y have have an an increased increased sex sex drive. drive, but but If your your spouse spouse may m a y have have pulled pulled away away because because of of mistrust mistrust related related to to your your disordisor­ der der (for (for example, example, an an increase increase in in your your irritability). irritability). The TheoppOSite oppositecan canalso alsooccur: occur:

You may m a y be be depressed, depressed, and and your your spouse spouse may m a y want want to to reestablish reestablish physical physical con­ conYou tact,but butyou you may m a y feel feelunder underpressure, pressure,uncomfortable uncomfortablewith withyour your body, body,or orbad bad tact, about about yourself yourself as as a a sexual sexual parmer. partner.

If you've you've been been weU well for for some some time, time,you you may m a y have havean aneasier easiertime time negotiating negotiating If intimacy with with your your parmer. partner. But But even even clients clients who w h o have have remained remained well well com­ comintimacy plain that that basic basic issues issues of of trust trust between between them them and and their their parmers partners were were violated violated plain

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intimacy by illness states and that and physical has by their their earlier earlier illness states and emotional that emotional and physical intimacy has been been hard hard to to reestablish. reestablish. If If you you are are experiencing experiencing one one or or more more of of these these prob­ problems, lems, you you are are certainly certainly not not alone. alone. Fortunately, Fortunately, these these couple couple problems problems can can be be addressed addressed using using a a number number of of relationship-building relationship-building skills, skills, outlined outlinedin inthe thenext next few sections. few sections.

Tools Tools for for Improving Improving Family Family Relationships Relationships alter after on an Episode Episode Educating EducatingYour YourFamily Family The ffectively with family members fter an is to The first first step step in in dealing dealing e effectively with family members a after an episode episode is to educate educate them them about about your your disorder disorder.. This This is is generally generally a a good good idea idea even even if if your your family family is is functioning functioning well, well, but but it it is isespeCially especiallyimportant important during during your your recovery recovery period, negative emotions period, when w h e n negative emotions aTC are often often at at their their peak. peak. Your Your relatives relatives may m a y harbor harbor many m a n y misconceptions misconceptions about about the the illness, illness, its its treatments, treatments, or or what what the the future future holds holds for for all all of of you. you. This This can can happen happen even even if if they they have have interacted interacted with with your your doctors, doctors, read read any any of of the the excellent excellent popular popular

books books on on the the subject subject Oamison, Qamison, 1995; 1995; Copeland, Copeland,1998; 1998;Court Court& & Nelson, Nelson,1996; 1996; Fawcett Fawcett et et aI., al., 2000; 2000; Mondimore, Mondimore, 1999; 1999; Papolos Papolos & & Papolos, Papolos, 1999), 1999), and and have have

listened explanations. listened to to your your explanations. Flawed Flawed or or incomplete incomplete information information about about bipolar bipolar disorder disorder can can cause cause your your

loved ones ones to to be be critical critical or or overprotective overprotective of of you. you. Make M a k e copies copies of of the the sidebar sidebar loved on pages pages 260-261, 260-261, which which summarizes summarizes the the basic basic facts facts about about bipolar bipolar disorder, on disorder, so that that you you have have it itavailable availablefor forall allfamily familymembers members(whether (whetheror ornot notthey theyhave have so directly shared shared in in your your experience), experience), including including your your adult adult or or teenage teenage children, directly children, parents, siblings, and and other otherextended extended relatives. relatives. parents, Siblings, It is is imponant important to to have have a a common c o m m o n language language when w h e n communicating communicating with with It close relatives relatives about about your your symptoms symptoms or or changes changes in in functioning. functioning. Hidden Hidden within within close the different different terms terms your your family family members members use use in in discussing discussing your your behavior behavior are are the often subrle subtle differences differences in in beliefs beliefs about about what what causes causes you you to to behave behave in in these these often ways. Acquainring Acquainting your your relatives relatives with with the the facts facts about about the the disorder disorder may m a y make make ways. them think think twice twice about about what what causes causes your your mood m o o d Swings. swings. For For example, example, your your them

family members members will will be be more more supportive supportive of of you you if if they they understand understand that that infamily in­ creases in in your your irritability irritability are are a a sign sign of of the the disorder's disorder's cycling rather than creases cycling rather than evievi­ dence that that "you've "you've gonen gotten mean" mean" or or "you're "you're more more hostile hostile than than you you used to be" be" used to dence or "you've "you've got got a a temper temper problem." problem." Likewise, Likewise, they they should should come c o m e to to understand understand or that you you are are suffering suffering from from "depressed "depressed mood" m o o d " or or "fatigue" "fatigue" or or "concenrration "concentration that problems" rather rather than than "mental "mental laziness" laziness" or or "a "a pessimistic pessimistic outlook outlook on on life." problems" life." Family members members who w h o know k n o w the the basic basic facts facts about about bipolar bipolar disorder disorder w will also Family i ll also be more more supportive supportive of of your your efforts efforts to to maintain maintain consistency consistency in in your your treatment. be treatment.

(oping Coping Effectively Effectivelyininthe theFomily Family ondand Work Work Settings Settings

2S9 259

Well-meaning relatives dounderstand not understand the disorder may view drug Well-meaning relatives whowho do not the disorder may view drug that you're being too too treatment treatment or or psychotherapy p s y c h o t h e r a p y as as crutches, crutches, or or believe believe that you're being watchful over over your y o u r health health and a n d moods. m o o d s . They T h e y may m a y give give you y o u direct direct or or indirect indirect watchful messages or messages about a b o u t how h o w they they liked liked you y o u better better before before you y o u began b e g a n your y o u r medicine m e d i c i n e or therapy. therapy. These These messages messages may may make make you you feel feel even even more more ambivalent ambivalent than than you you why you are already feel feel about about your your treatments. treatments. Your Your family family needs needs to to know know why you are already taking medication, medication, attending attending psychotherapy, psychotherapy, and and engaging engaging in in self-managetaking self-manage­ ment tasks tasks like like sleep-wake sleep-wake regulation. ment regulation. Spend some some time time answering answering their their questions questions after after they they have have read read the the fact fact Spend sheet. sheet. They Theymay may have havetrouble troubleunderstanding understandinghow how you youhave haveexperienced experienced cer­ certain symptoms, symptoms, where where in in the the family family tree tree the the illness illness may may have have originated, originated, or or tain why you you are are taking taking aa certain certain combination combination of of medications medications (for (for example, example, a why a mood stabilizer stabilizer and and an an antidepressant). antidepressant). If If you you are are sharing sharing information information about about mood your disorder disorder with with your your school-age school-age children, children, try tryto tosee seeififyou you can cansimplify simplifyitit your to fit fit their their developmental developmental level. level. One One man m a n explained explained to to his his six-year-old six-year-old son, to son, "You know know how h o w happy happy you you get get during during your your birthday birthday parties? parties? II get get that that way way "You sometimes work." sometimes for for a a whole whole week, week, and and then then it it gets gets hard hard for for me m e to to do do my m y work." One woman w o m a n explained explained to to her her seven-year-old, seven-year-old, "You "You know know how how when when you you get One get excited,you youcan canusually usuallycalm calmyourself yourselfdown? down?When W h e n Daddy Daddygets getsexcited, excited,hehe excited, gets gets going going really really fast fast and and he he can't can't calm calm down down right right away." away." Another Another woman woman tum it explained explained to to her her daughters daughters that that when when she she became became sad, sad, she she couldn't couldn't turn it off off like like they they could. could. "You "You know know how how when when you're you're upset upset and and someone someone ttells ells you aa joke, joke, you you feel feel better? better? Mommy M o m m y gets gets upset, upset, but but things thingslike likejokes jokeswon't won't you get her her over over it it right rightaway-she away—she needs needsmore more time." time."She She also alsomade made ititclear clearto to get them that that they they should should not not blame blame themselves when she she became became depressed depressed or them themselves when or withdrawn. withdrawn. Use age-appropriate age-appropriate terms terms when when describing describing your your disorder. disorder. Kids Kids relate Use relate better to to tenns terms such such as, as, "happy," "happy," "excited," "excited," "amped," "amped," "wired," "wired," "sad," better "sad," or or "bummed" than than to to "manic" "manic" or or "depressed." "depressed." You You may may have have to to explain explain the dis"bummed" the dis­ order order to to them them in in several several different different ways ways and and at at different different times, times, however. however.Fol­ Following aa lengthy lengthy discussion discussion of of the the disorder, disorder, one oneparent parentreported reportedhearing hearingher her lOwing nine-year-old son son say say to to one one of of his his friends, friends, "My "My mother mother has has aa bipolar bipolar in nine-year-old in her her head!" head!" Helping Your the the Medical BasesBases of Your Disorder Helping YourRelatives RelativesUnderstand Understand Medical of Your Disorder It's important that close relatives understand that that at least a portion of It's important thatyour your close relatives understand at least a portion of your behavior behavior is is biologically biologically and a n d chemically chemically determined. determined. When W h e n they they finally finally your come c o m e to to accept accept this, this, they they will will probably probably bbecome e c o m e less less angry angry or or hostile, hostHe, as as Rebecca did: Rebecca did:

ly Members A A Quick Quick Fact Fact Sheet Sheet on on Bipolar Bipolar Disorder Disorder for for Fami Family Members

W h a t Is Is Bipolar Bipolar Disorder? Disorder? What swings, severe may have that I that means disorder Having Havingbipolar bipolar disorder means I may havemood severe mood swings,

inwhich which IIgo gofrom fromvery veryhigh highand andenergized energized(manic) (manic)to tovery verylow, low,un­ unin from motivated, motivated,and andlethargic lethargic(depressed). (depressed).My M yhigh highperiods periodsmay maylast last from aa few longer, much last may periods fewdays daysto toaamonth monthor ormore. more.My M ylow low periods may last much longer,

p

from eople in from several several weeks weeks to to several severalmonths. months. About About 11 in in every every 70 70 people in

the United United States States has has bipolar bipolar disorder. disorder.It Itmost mostoften oftenaffects affectsaaperson person the for for the the first firsttime timein inadolescence adolescenceor oryoung youngadulthood. adulthood.

W h a t Are Are the the Symptoms? Symptoms? What overly feelingfeeling may include period main symptoms My My main symptoms during duringa high a high period may include overly

happy and and excited excited or or overly overly irritable irritable and and angry. angry. II may may also alsofeel feellike likeI I happy can can do do things things that that no no one one else else can can do do (grandiosity). (grandiosity). 1Imay maysleep sleepless less than than usual usual or or not not at at all, all,do domany manythings thingsatatonce, once,have havemore moreenergy, energy, talk talk faster faster and and express expressmany many ideas ideas(some (some realistic realisticand and some some unrealis­ unrealis1 may tic),and andbe beeasily easilydistracted. distracted. I may things that impulsive when when impulsive areare that things dodo tic), manic,like likespend spendaagreat greatdeal deal money unwisely drive recklessly. recklessly. drive oror unwiSely money ofof manic, may experience experience the the symptoms symptoms of of depression depression at at other other times, times, II may which can can include include feeling feeling very verysad, sad,down, down,irritable, irritable, anxious, losing lOSing anxious, or or which interest in in people people or or things, things, sleeping sleeping too too much or being being unable to unable to much or interest sleep, having having little Htde or or no no appetite, appetite, having having trouble trouble concentrating concentrating or or sleep, making deCisiOns, decisions,feeling feelingfatigued fatiguedor orlow lowininenergy, energy, moving talking talking oror moving making slowly,feeling feelingvery verybad bador orguilty guHtyabout aboutmyself, myself,ororcontemplating contemplatingsui­ suislowly, cide or or actually actually carrying carrying out attempts. suicide attempts. out suicide cide

H o w Does Family? the Family? Affect the Disorder Affect Bipolar Disorder Does Bipolar How My disorder affect my abihty toour others in our others in to relatetotorelate my ability affect maymay bipolar disorder My bipolar family in the the work work setting, setting,especially especially whenI become I become Our family family Our ill.iU. when or in family or or after just after or just during or apparent during most apparent be most may be problems may relationship problems or relationship m y episode mania or or depresSion, depression,but butthen thenwill wUlprobably probablyimprove improveas as of mania episode of my I get better. better. We W e can canresolve resolveour ourfamily familyconflicts conflictsthrough throughgood good com­ comI get munication other, each other. for each support for emotional support solving, emotional problem solving, and problem munication and

260

and and encouragement. encouragement. We W e may maywant wantto toget getthe theadditional additionalhelp helpof ofa afam­ fam-

ily or or couples couples counselor counselor or or a a family family support support group. group. ily

What W h a t Causes Causes Bipolar Bipolar Disorder? Disorder? Having disorder means that 1that haveIimbalances in the brain's Having bipolar bipolar disorder means have imbalances in the brain's neurochemistry neurochemistry involving involving the the ways ways that that cells cells communicate communicate with witheach each other. other. Nobody Nobody chooses chooses to to become become bipolar. bipolar. It's It'spossible possiblethat thatIIinher­ inher-

ited these these imbalances imbalances from from my m y blood blood relatives, relatives,although althoughnot notnecessar­ necessarited ily ily from from my m y parents. parents. My M y mood mood swings swings may may also also be be affected affected by by llife ife

stress or or sudden sudden changes changes in in my m y sleep-wake sleep-wake habits. stress habits.

How H o w Is Is Bipolar Bipolar Disorder Disorder Treated? Treated?

am probably probably being treated with stabilizing mood stabilizing medications such II am being treated with mood medications such as lithium, lithium, Depakote, Depakote,Tegretol, Tegretol,or orLamictal. Lamictal.IImay may also alsotake takeantide­ antideas pressantmedications medicationsor ordrugs drugsto tocontrol controlmy m yanxiety anxietyor orproblems problemswith with pressant thinking. aa psychiatrist regularly thinking. These Thesemedications medicationsrequire requirethat thatI 1see see psychiatrist regularly to get out ofof hand and to get mymblood tomake makesure suremy m y side sideeffects effectsdon't don't get out hand and to get y blood levels family levels checked. checked. II may may also also benefit benefit from from individual individual Lherapy, therapy, family

counseling sessions, sessions,or orsupport supportgroups. groups.Therapy Therapymay mayhelp helpme m etotolearn learn counseling more about about my m y disorder, disorder, learn learn to to prevent prevent relapses, relapses, monitor monitor moods moods more and and sleep-wake sleep-wake cycles, cycles, and and function functionbetter betterin inthe thefamily familyand andwork­ work-

place. IfIfI I a mone one the many people with bipolar disorder w h ohave have place. am ofof the many people with bipolar disorder who problems with with drugs drugs or or alcohol, alcohol, mutual mutualsupport supportprograms programslike likeAlco­ Alcoproblems holics Anonymous Anonymous may may also also help help me m e and and our our family. holics family.

What W h a t Does Does the the Future Future Hold? Hold?

in the It isis likely that Ithat will have highhave and low mood future. in the futu It likely I will high andepisodes low mood episodes

But there thereis isevery everyreason reasontotobebehopeful. hopeful. With the help a regular proBut With the help of of a regular pro­ gram of of medication, medication,therapy, therapy,and andsupport support fromothers, others, m mood y mood disgram from my dis­ order episodes episodes can can become become less less frequent frequentand andless lessextreme. extreme.With Withhelp help order and and support, support, II can can accomplish accomplish many many of of my m y goals goals for for my m y family family and and work work llife. ife.

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hadbought boughtconcert concert tickets tickelS and forfor "I"I had and was was looking looking fOlWard forward to tothe theevent event weeks. weeks. The The night night we w e were were supposed supposed to to go, go, my m y husband husband said said he he wasn't wasn't go� going ing to to go, go, that that he he was was too too tired tired and and depressed. depressed. II was was enraged-it enraged—it just just

seemed t felt seemed like like something something he he should've should've known k n o w n before. before. IIt felt like like he he was was do­ doing ing it it to to hun hurt me m e and and disappoint disappoint me. m e . I1 had had really really wanted wanted us us to to do do this this to­ together. gether. 1I called called to to cancel cancel the the babysitter babysitter and and the the next next day day went went to to the the

ticket office office for for aa refund, refund, feeling feeling like like II was was arguing arguing from from a a position position of of ticket ill­ weakness. weakness. To T o my m y surprise, surprise, II told told them, them, 'My 'My husband husband has has a a medical medical ill-

ness.' ness.' Somehow, S o m e h o w , that that cut cut through through my m y anger. anger. It It helped helped me m e do do away away with with what what II felt felt he he was was doing doing to tohun hurtme. m e .That Thatwas was how h o w IIdecided decidedtotoexplain explainitit to to

myself myself and and to to the the outside outside world." world."

Rebecca's realizationthat that her concert notnot necessarily Rebecca's realization herhusband husband skipped skippedthe the concert necessarily because because he he didn't didn't want want to to go go but but because because he he could could not not go, go, made m a d e her her feel feel less less resentful resentful of of the the limitations limitations his his illness illness placed placed on on their their lives. lives. Understand, Understand,how­ however, that the will ever, that the frustration frustration and and dissatisfaction dissatisfaction that that such such limitations limitations cause cause will not time and to not evaporate evaporate overnight. overnight. Family Family members members need need time and practice practice to to come come to grips grips with with the the changes changes in in their their lives. lives. Consider Considerthe theway w a ythat thatEvan's Evan'srelationship relationship with with his his father father evolved: evolved: "Foryears, years, he and wewecould barely talktalk to each Olher.other. "For he didn't didn'tunderstand, understand, and could barely to each

I'd shout shout and and scream scream and and spread spread my m y self-loathing self-loathing all all over over him, him, and and of of I'd course he'd he'd get get pissed pissed off. off. Then Then I'd I'd get get depressed depressed and and even even less less able able to course to deal with with him. him. But But after after my m y second second wife wife and and II split splitand and then then IIlost lostmy m yjob, job, deal finally told told him him II had had bipolar bipolar disorder, disorder,and and we w e were were really really open open about about II finally it.I Ijust just toldhim, him, 'Dad, this one main reasons we've had many it. told 'Dad, this is is one of of thethe main reasons we've had so so many problems between between us.' us.' II explained explained how how i t's a a chemical chemical thing and that that it it problems it's thing and wasn't about about how h o w he he raised raised me, m e , and and he he didn't didn't believe believe me m e at at first. first.But Butin inan­ anwasn't other way w a y it it made m a d e sense sense to tohim�he's him—he's got gotaascientific scientificmind mind and and ititput putso so other m a n y different different things things ioro into place place .. many

m y temper, temper, my m y job stuff, my m y prob­ probmy job stuff,

lems when w h e n II was was aateenager. teenager.When W h e nhe hecame cametotoaccept acceptitit andwe w ecould couldtalk talk lems and about it, it, he hewas was able ableto topull pullback backand and think thinkabout abouthis hisown o w n responses responsesto to about m e . And A n d I've I've gotten gotten a a lot lot calmer calmer and and less less reactive reactiveto tohim. him. ... we . wget e get along along me. m u c h better better now." now." much It'sIt's unhkely that will immediately adopt a medical view unlikely thatyour yourrelatives relatives will immediately adopt a medical view of of your disorder�it disorder—it took took Evan's Evan's father father quite quite some some lime. time. But But with with repeated repeated expo­ expoyour sure to to educational educational information, information, your your relatives relatives may m a y begin begin to to reevaluate reevaluate their their sure belief that that you you are are behaving behaving out out of of ill iH will will or or negative negative intentions. intentions. This This was was the the belief case for for Gray, Gray, who, w h o , with with his his wife, wife, Arlene, Arlene, was was geuing gettingmarital maritaltherapy therapy to tohelp help case adapt to to Arlene's Arlene's bipolar bipolar disorder. disorder. adapt

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263 263

ARLENE: When 1 get depressed, like a veil just comes at all Arlene: When I get depressed, it'sit's Hke a veil just comes overover me. me. It's It's not not at all

like when w h e n you y o u get get tired tired after after work. w o r k . It's It's like like being being numb, n u m b , like like a at o n of ceton of ce· like m e n t siuing sitting on o n my m y heart. heart. ment Gray: II know, k n o w , honey, honey, but but IIjust justdon't don'tthink thinkthe theanswer answeris isto tomope. m o p e .You've You'vegona gotta GRAY: get out out there there and and deal deal with with things. get things. THERAPIST: like, and Therapist: Arlene, Arlene, can can you you say say more more about about what what that that depression depression is is like, and

what you you think think causes causes it? what it? Arlene: It's It's probably probably something something chemicaL chemical. It It feels feels physical; physical; it it doesn't doesn't feel feel like like ARLENE: you realize lack of of effort. effort. 1Iknow k n o w how h o w frustrated frustratedyou youget, get.Gray, Gray,but but youhave havetoto realize lack it's it's not not something something II want want either. either. If If 1Icould could pull pull myself myselfout, out, 1Iwould-in w o u l d — i n aa minute. minute.

CommunicDtion Skillsfor forReducing Reducing Criticism Dnd Conflict Communication Skills Criticism and Conflict In the between Arlene Arlene made an to effort to validate In the interchange interchange between Arlene and and Gray,Gray, Arlene made an effort validate her her husband's husband's point point of of view. view. Effective Effective communication c o m m u n i c a t i o n is is a a very very important important com· component of of managing m a n a g i n g your y o u r family or marital marital relationships relationships and a n d can c a n even even help help faponent family or fa· cilitate your y o u r recovery recovery ffrom r o m yyour o u r illness illness episode episode (Falloon (Falloon et et aL, al., 1984; 1 9 8 4 ; Jacobson Jacobson dlitate

&: & Margolin, Margolin, 1979; 1979; Liberman Liberman et etal., al., 1981). 1981). In In our our study study of offamily-focused family-focused ther­ ther-

apy, apy, one one of of the the most most consistent consistent changes, changes, over over time, time, among a m o n g patienlS patients whose whose bibi­

polar disorder disorder improved improved was was an an enhanced enhanced ability ability to to communicate communicate with with their polar their spouse or or parents parents (Simoneau (Simoneau et et al., al., 1999). 1999). Following Following is is a a selection selection of commuof commu­ spouse nication skills skillsyou you can can try tryout outwhen w h e n dealing dealingwith with criticism, criticism,tension, tension,oror conflict nication conflict in relationships. in your your close close relationships.

Although the the skills skills look look easy easy on on the the surface, surface, they they can can be be difficult difficult to to apply apply Although and require require regular regular practice. practice. Certainly, Certainly, couples couples and and families families without without bipolar and bipolar disorder have have to to practice practice regularly regularly to to make m a k e these these communication communication skills skills work work disorder for for them them (Stanley (Stanley et et al., al., 1996). 1996). Yet Yet the the stress stress of of family family life Hfe after after an an episode episode rere­

quires you you to to be be even even more m o r e skillful skillful in in your your communication communication than than you would you would quires ordinarily have have to to be. be. And A n d when w h e n your your mood m o o d is is swinging swinging up u p and and down d o w n and and you you ordinarily feel feel that that your your relatives relatives are are unfairly unfairly jumping jumping on on you, you, using using new n e w communica­ communication tion skills skHlscan can be be doubly doubly hard. hard.These These skills skHlsrequire requirethat thatyou you step step back back when when you you feel feel the the heat heat rising rising and and put put yourself yourself in in another another person's person's place. place. A s with with As

m a n y self-management self-management strategies, strategies, familiarizing famiharizing yourself yourself with with these these skills many skills when w h e n you you are are well well makes makes them them easier easier to to use use when w h e n you you are are il1. ill.

No. L 1: Active ActiveLiltening Listening Skill No. After dealing dealing with with an an episode episode of of bipolar bipolar disorder disorder or or any any other other kind kind of signifiAfter of signifi­ cant stressor, stressor, you you will wHl have have trouble trouble listening listening to to the the feelings, feelings, ob objections, cant jections, or or

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troubles But troubles of of other other family family members. members. This difficulty quite understandable. understandable. But This difficultyis is qUite ifyour your family family members m e m b e r s don't don't feel feelthat thatyou y o u or or others others in in the the family family care care enough enough if to to listen, listen, they they will will probably probably be b e unwilling unwilling to to perform perform some s o m e of of the the other other tasks tasks that are essential to your recovery (for example, keeping the home environ­ that are essential to your recovery (for example, keeping the h o m e environm e n t low-key). low-key). So, So, if ifyour y o u r parents, parents,spouse, spouse,or or kids kids are are responding responding to to you y o u neg­ negment atively atively or or with with criticism, criticism, consider consider helping helping them t h e m modulate modulate their their anger anger by b y lis­ listening tening and a n d expressing expressing an a n understanding understanding of of their their pOSition, position, even even if if you y o u do d o not not agree agree with with it. it. This Thisis isaatechnique technique called calledactive activelistening, listening,and a n d attempts attempts to touse useit it will will almost almost cenainly certainly change change the the outcome o u t c o m e of of what w h a t would w o u l d otherwise otherwise be b e unpro­ unproductive ductive interchanges. interchanges. The T h e sidebar sidebar on o n this this page page lists lists the the steps. steps. In In active active listening, listening, you y o u become b e c o m e less less active active in in the the speaking speaking pan part of of commu­ communication nication than than you y o u might m i g h t be b e used used to, to, and a n d you y o u become b e c o m e more m o r e active active on o n the the listen­ listening ing end. end. You Y o u don't don't just just sit sit there there and a n d hear. hear. You Y o u maintain maintain eye eye contact contact with with the the person person speaking speaking to to you, y o u , offer offer nonverbal nonverbal acknowledgments, a c k n o w l e d g m e n t s , paraphrase paraphrase or or oth­ otherwise listen­ erwise check check out out what w h a t you've you've heard heard (otherwise (otherwise known k n o w n as as "reflective "reflective listening"), and a n d ask ask questions questions designed designed to to get get the the speaker speaker to to clarify clarify his his or or her her point point ing"), of of view. view. This This is is a a good g o o d skill skill to to use use whenever w h e n e v e r you y o u talk talk with with your y o u r family family mem­ members, bers, but but it itwill willbe b eespecially especiallyhelpful helpfulwhen w h e n arguments argumentsstart startto toescalate. escalate.There Thereis is nothing nothing like like validating validating someone s o m e o n e else's else's point point of of view v i e w in in the the middle middle of of an a n argu­ argumment e n t to to reduce reduce his his or or her her anger-it's anger—it's hard hard to to be be m a d at s o m e o n e who w h o is is mak­ makmad at someone ing a a genuine genuine attempt attempt to to understand understand you. you. ing Active listening listening requires requires that that you y o u avoid avoid any any implication the implication of of blaming blaming the Active other person. person. That That is, is, stay stay away a w a y from from any any reflective reflective statements statements or or quest questions other ions that imply imply the the other other person person is is at at fault fault for for his his or or her her reactions or that that involve involve that reactions or name-calling. For example, the statement "So "So yyou o u feel feel that if you're you're m e a n to name-calling. For example, the statement that if mean to mme, e , I'll I'H change for the not really a reflective reflective statement statement but but more m o r e of an change for the better" better" is is not really a of an accusation. TThe h e question question " W h y would w o u l d you you w a n t to e aa nnag a g if y o u are are trying trying accusation. "Why want to bbe if you to gel get mme e to to d o something n my m y own?" o w n ? " mmay a y feel feel like a reasonable to do something oon like a reasonable question. question,

S tep p ss of Listening Ste of Active Active Listenin g •• Look Lookatatthe thespeaker speaker •• Attend Attend to to what w h a t is is said said •• Nod N o d your your head head or or say say ·uh-huh" "uh-huh" •• Ask A s k clarifying clarifying questions questions •• Check C h e c k out out what w h a t you y o u heard heard (paraphrase) (paraphrase) Adapted Copyrightby by The The Guilford Guilford Press. Press. Adapted by permission from from Miklowitz Miklowitz. and and Goldstein Goldstein (1997). Copyright

(Coping Oiling Effectively andand Wor� SeNings EffectivelyininthetheFamily Family Work Settings

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it will nothelp helpresolve resolve disagreement. It's hard to avoid but it wiH not thethe disagreement. It's hard to avoid saying saying things things but like like that that when w h e n you're you're angry a n g r y or or irritable. irritable. But B u t if if you y o u stay stay at at the the level level of of asking asking simple, simple, straightforward straightforward questions questions and a n d paraphrasing paraphrasing exactly exactly what w h a t you y o u have have heard heard from f r o m your y o u r relative relative (even (even word w o r d for for word, w o r d , if if necessary), necessary), you y o u will will be b e less less hkely to to say say something s o m e t h i n g to to cause cause him h i m or or her h e r to to take take offense. offense. likely Consider is Consider the the following foHowing interchange interchange between between Randy Randy and and Cindy. Cindy. Randy Randy is practicing the the skill skill of of active active listening. listening. practicing Randy: You were mad at me this morning. What What was RANDY: You were pretty pretty mad at me this morning. was up? up? [clarifying [clarifying question] question) Cindy: II tried tried to to get get you you to to talk talk about about that that tax-related tax-related thing, thing, and and you youjust justblew blew CINDY: m e off. off. Why W h y do do II keep keep trying? trying? me Randy: (pausing) (pausing) So So you you were were frustrated frustrated with with me. m e . You Y o u wanted wanted me m e to to get get iit t RANDY: done, (paraphrasing] [paraphrasing] done.

CINDY: Cindy: (still (still irritated) irritated) Yes, Yes, of of course course II didl did! And A n d II had had asked asked you you a a million milHon times. times. RANDY: Randy: (nods) (nods) Yes, Yes, II understand understand how h o w that that would would be be frustrating. frustrating. But But partly partly it's it's because wouldn't get get because I'm I'm having having a a tough tough time. time. Were W e r e you you concerned concerned that that II wouldn't it done? done? (clarifying [clarifying question] question] it CINDY: Cindy: (so (softens) M a y b e 1I came came down d o w n too too hard hard on on you, you, but but the the question question is, ftens) Maybe is, w h e n are are we w e gonna gonna do do it? it? The The 15th 15th is is coming coming up up pretty pretty quick. when quick. Randy'S reflectivelistening listening and of of Cindy's point of view helped Randy's reflective and validation validation Cindy's point of view helped reduce reduce her her irritation irritation and and the the antagonism antagonism that that had had built built up up between between them. them. Ideally, this thisdiscussion discussionwould would then thenmerge mergewith withproblem problemsolving, solving,another anotherskill skill Ideally, that that will will help help you you negotiate negotiate a a more more productive productive relationship relationship with with your spouse your spouse or or parent parent (explained (explained later later in in this this section). section). But active listening listening doesn't always But active doesn't always have have its its intended intended effect, effect, as asis isdiscussed discussedin inthe thetroubleshooting troubleshootingtips tipslater laterin inthis this section. section. ill No. No. 2: 2: Positive Positive Requests Requests for for Chonge Change Skill

Another way Another way to reduce tension tensionand andavoid avoid the verbal attacks thattum caninto turn into to reduce the verbal auacks that can full-scale war to phrase phrase your your comments to family members as full-scale positive rere­ war is is to comments to family members as positive quests for for change change (Falloon (FaHoon et et al., al., 1984). 1984). This This involves involves stating, stating, specifically specifically and and quests diplomatically, what you'd like like to see happen happen differently in your your interactions diplomatically, what you'd to see differently in interactions with your your relative. Criticisms lell tell people what they have done done w r o n g — " I rewith relative. Criticisms people what they have wrong-"l re­ sent sent that that you you always always bring bring up u p my m y illness illness when w h e n my m y friends are a r o u n d " — and and friends are around"naturally generate defensiveness. Stating Stating the the same same thought way— naturally generate defensiveness. thought in in a a positive positive way-

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"It's very important that whenwe're we're with our friends, we talk about important to to meme that when with our friends, we talk about "It's very things things of of importance importance to to us us other other than than my m y illness" illness"— is is almost almost certain certain to to reduce reduce -

any any defenSiveness, defensiveness, even even though though it's it's not not guaranteed guaranteed to to prevent prevent it it altogether. altogether. If If

you're you're not not entirely entirely sure sure of of the the difference difference between between the the two, two, note note that that positive positive

requests requests usually usually ask ask someone someone to to do do something something new n e w and and poSitive, positive, whereas whereascrit­ criticisms icisms usually usually involve involve telling telling someone someone to to stop stop doing doing something. something.

After After being being hospitalized hospitalized for for a a mixed mixed episode episode of of her her bipolar bipolar disorder, disorder, Carol Carol

returned returned to to her her apartment, apartment, only only to to discover discover that that her her father, father, Roy. Roy, was was con­ con-

stantly stantly coming coming over, over, unannounced, unannounced,and and then thencriticizing criticizingher herfor forhow h o w messy messyshe she

kept sensitive issue for kept her her living living room. room. This This surveillance surveillance was was a a particularly particularly sensitive issue for

Carol, Carol, who w h o felt feltstrongly stronglythat thather herautonomy autonomyand andindependence independencewere wereimportant important

to to her her recovery. recovery. Roy, Roy,however, however,had hadbecome become hypervigilant hypervigilantand and worried worried that thatshe she

would would deteriorate deteriorate into into another another bipolar bipolar episode. episode. He H e felt felt that that his his concerns concerns were were

justified episodes. justified by by the the fact fact that that she'd she'd had had several several recent recent mood m o o d episodes.

Carol Carol began began saying saying things things like like "Just "Just don't don't come c o m e over over here here anymoren anymore" or or

be­ "Why " to " W h y don't don't you you leave leave me m e alone? alone?" to which which her her father father responded, responded, "1 "I do do it it be-

cause cause 1I don't don't think think you you can can take take care care of of yourself." yourself." During During family family counseling counseling

sessions, into sessions, her her therapist therapist encouraged encouraged her her to to try try transforming transforming her her criticisms criticisms into

positive first she positive requests requests for for change. change. At Atfirst she had had trouble trouble with with this this communication communication

tool, tool,saying sayingthings thingslike like"Dad, "Dad,could couldyou you leave leaveme m e alone alonemore? more? That'd That'dmake m a k e my my

life much m u c h better." better."With With coaching, coaching,she shewas was able able to toword word her her request requestmore more dip­ diplife lomatically, and and her her father father responded responded more more pOSitively positively as as a a result: lomatically, result:

Carol: Dad, will willyou youplease please call me before you're to over? come over? CAROL: Dad, call me before you're goinggoing to come That'd That'd give me m e the the chance chance to to clean clean up up first. give first Therapist: Good, Good, CaroL Carol. And A n d how h o w would would that that make m a k e you you feel? THERAPIST: feel?

Making a a Positive Positive Request Request Making • Look Look at your family familymember member at your

•

• Say Say exactly exactly what what you you would would like like him him or or her her to to do do • Tell Tell him him or or her her how h o w it itwould would make m a k e you you feel feel • •

• Use Use phrases phrases such such as: as:

•

"I would would like like you you to to "1

" "

"I would would really really appreciate appreciate it it if if you you would would "I

"

_____

"It's very very important important to to me m e that that you you help help me m e with with the the "!t's

"

____

by permission permission n-om from MikIowitz Miklowitz and Goldstein Goldstein (1997). (1997). Copyright Copyright by The Guilford Press. Adapted by Press.

Coping Effective� Effectivelyininthe thefamily Family Work Settings Coping andand WOlk Senings

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I'dlike like it, it, and I'd probably probablyfeel feelgrateful gratefulthat thatyou you cared about me and CAROL:I'd Carol: and I'd cared about me and

w h a t II need. n e e d . It'd It'd also also be b e nice nice to to see see you. you. what

THERAPIST: just Therapist: That That was was excellent. exceflent. Roy, Roy, what what did did you you think think about about what what Carol Carol just

said? said? hear. And ROY: Roy: Much M u c h better, better, easier easier to to hear. A n d I1 might might even even do do it it (laughs) (laughs)\l (From [From

Miklowitz & 6a: Goldstein, Goldstein, 1997, 1997, pp. pp. 21�2111 210-211] Miklowitz

family members are often doing their besttototry try to to help YourYour family members are often doing their best help you. you. They They may differ­ may benefit benefit from from knowing, knowing, in in a a constructive constructive way, way, what what they they can can do do differa tat first, but it will ently. Making Makingpositive positiverequests requestsin inthis thisway w a ymay m a yfeel feelartificial artificial first, but it will ently. help relatives. help you you make m a k e your your needs needs known k n o w n without without alienating ahenating your your relatives.

Skill 3: Problem Solving toFamily Defuse Family Conflicts Skill No.No. 3: Problem Solving to Defuse (onflicts Someof of the members reduced to to Some the arguments arguments you you have have with withyour yourfamily family memberscan canbebe reduced

a specific specific problem problem that that can can be be solved. solved. As A s you you know, k n o w , bipolar bipolar disorder disorder some­ somea times times generates generates practical practical problems problems that that need need to to be be addressed addressed as as aa family family or or

couple, particularly particularly in in the the aftermath aftermath of of an an illness illness episode. episode. These These can can include include couple, financial family roles roles financial problems, problems, difficulties difficulties related related to to resuming resuming your your work w o r k or or family (for (for example, example, child child rearing), rearing), problems problems related related to to your your treatments treatments or or medica­ medica-

tion,or orrelationship relationshipand andliving livingsituation situationconflicts conflicts(Miklowitz (Miklowitz& & Goldstein, Goldstein, tion,

1997). 1997). Often, Often, these these unresolved unresolved but but relatively relatively specific specific problems problems fuel fuel your your relarela­ tives' expressions expressions of of criticism criticism or or resentment. resentment. The The more more you you can can help help direct tives' direct conversations with with your your family family members m e m b e r s toward toward identifying identifying and and solving solving speconversations spe­ cific cific problems, problems, the the less less tension tension there there will will be be during during your your recovery recovery period. period. The The steps steps in in the the Problem-Solving Problem-Solving Worksheet Worksheet on on pages pages 268-269 268-269 prOvide provide a a

structure for for resolving resolving your your disagreements disagreements (Falloon (Falloon et et al., al., 1984; 1984; Liberman structure Libennan et et aL, al., 1981) 1981) .. Let's Let's imagine, imagine, for for example, example, that that you you gOl got into into an an argument argument with with your your spouse spouse about about the the lack lack of of intimacy intimacy in in your your relationship relationship since since your your last eplast ep­ isode isode of of bipolar bipolar disorder. disorder. You Y o u might might find find yourself yourself getting getting increaSingly increasingly irriirri­ tated, tated, especially especially if if you you were were unclear unclear about about what what your your spouse spouse wanted. wanted. First, First,

discuss the the definition definition of of this this problem problem (Step (Step 1) 1) with with your your spouse: spouse: Can C a n the the discuss broad broad issue issue of of intimacy intimacy be be redefined redefined as as a a more more specific specific problem problem (for (for example, example,

lack of of time time spent spent together together away away from from the the kids)? kids)? Try Try to to get get him him or or her her to to slow slow lack d o w n and and help help you you define define what the disagreement disagreement is is about about. Use Use your your listening down what the listening

skills skills to to help help your your spouse define what is really really bothering bothering him him or or her. spouse define what is her.

Next, encourage encourage your your spouse spouse or or other other family family members m e m b e r s to to suggest suggest as as many many Next, solutions as as possible possible to to the the problem problem you've you've defined defined (Step (Step 2). 2). Let's imagine Let's imagine solutions you've defined defined it it as as lack lack of of time time spent spent together. together. Potential Potential solutions solutions could you've could inin­ clude cordoning cordoning off off an an hour hour or or more more of of your your time time during during the the evening evening when when clude

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SElF-MANAGEMENT SELF-MANAGEMENT

PROBLEM·SOLVING P R O B L E M - S O L V I N G WORKSHEET WORKSHEET Step 1: Define"What "Whatisisthe theproblem?� problem?"Talk Talkand andlisten, listen, ask questions, and everybody's Step 1: Define ask questions, and gelget everybody's opinion. opinion.

Step Step 2: List all allpossible possiblesolutions, solutions,even evenones onesthat thatdon't don'tseem seemfeasible. feasible.Do D onot not evaluate the 2: List evaluate the pros yet. pros or or cons cons of of any any solution solution yet.

1. 1.

__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

2.. 2

__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

3. 3.

__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

4. 4.

__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

5. 5. Step 3: 3: Discuss Discussand andlist list advantages and disadvantages each possible Step the the advantages and disadvantages of eachofpossible solution. solution. Advanta ges Advantages

Disadvanta ges Disadvantages

. I1.

2. 2. 3. 3. 4. 4. 5. 5. Step 4: 4: Choose Choose the the best best possible possible solution solution or or solutions, solutions, and and list. list.Include Includecombinations combinationsofof Step possible possible solutions. solutions.

Step 5: 5: Plan Plan how h o w to to carry carry out out the the chosen chosen solutions, solutions, and and set set aa date date to to implement implement them. them. Step Date Oate

_ _ _ _ _ _

Listwho who will willdodowhat. what. List

Coping ffectively in inthe theFamily Familyand andWork WorkSettings Settings (oping EEffedive/y

269 269

List what what resources resources you'll you'll need need (for (for example, example, mmoney, a babysitter, babysitter, access access to to a a car, car, List oney, a reservations). reselVations).

Step 6: Implement Implement the the chosen chosen solution solution and and praise praise each each other's other's efforts. efforts. Step 6:

7: After the solution, solution, go the Step Afteryou've you'veimplemented implemented the go back back to to Step Step 11 and and decide decide whether whether the Step 7: problem a s solved. ome u p with problem wwas solved. If If not, not, try try to to redefine redefine the the problem problem and and c come up with solutions solutions that that will wwork o r k better. will better.

Adapted by bypennission permission from Miklowitz Goldstein (1997). Copyright by The Guilford Press. from Miklowiu and and Goldstein (1997). Copyright by The Guilford Press.

the kids kids are are not n o t allowed a l l o w e d to to disturb disturb you, y o u , arranging arranging a a weekly w e e k l y night night oout u t together, together, the exercising together together once once or or twice twice a a week, or having having one one meal meal at at h o m e each each exercising week, or home week without without the the kids kids present. W h e n generating generating solutions, solutions, be be careful careful not week present. When not to to evaluate evaluate whether whether they they are are good good or or bad bad ideas ideas just justyet. yet. It's It's importam important to to get get all all of of the first. the ideas ideas out out on on the the table table first. In solu­ In Step Step 3, 3, weigh weigh the the advantages advantages and and disadvantages disadvantages of of each each proposed proposed solu-

tion.For Forexample, example, weeklynight nightout outtogether togetherhas hasthe theadvantage advantageofof beingfun fun tion. aa weekly being and and pleasurable; pleasurable; its its disadvantages disadvantages might might include include its its costs. costs. Then Then try try to to choose choose

one solution solution or or a a combination combination of of solutions solutions based based on on your your mutual mutual discussion discussion one of of the the pros pros and and cons cons of of each each possibility possibihty (Step (Step 4). 4). For For example. example, you you may m a y agree agree that that going going out out once once aa week w e e k is is too too costly costly but but that that aa meal meal at at home h o m e together, together,

w h H e the the kids kids are are at at aa babysitter's babysitter's house. house, achieves achieves the the same same objective objective (bring­ (bringwhile ing ing the the two two of of you you closer) closer) without without the the cost. cost.

In Step Step S, 5,think think about about the the tasks tasks involved involved in in making making the the solution solution work. work. In In In this example, example,you'll you'H need need to to choose choose aa night night to to have have dinner dinner together, together,buy buy food food this to to cook, cook, and and arrange arrange aa babysitter. babysitter. You Y o u will vnH find find it it easier easier to to implement implement the the

solution—and the the result result will wiH probably probably be be more more satisfying-if satisfying—if you you divide divide up up solution-and the the tasks tasks such such that thatyou you do do some s o m e of ofthem them and and your your spouse spouse does does some s o m e of of them. them.

In Step Step 6, 6, try tryimplementing implementing your your solutions solutions and and see see if if the the original original problem problem In has has been been addressed. addressed. Problem Problem solving solving does does not not guarantee guarantee that that you'll you'H come c o m e up up

with aa solution solution that that will v^dH work. work. Nonetheless, Nonetheless, give give some s o m e encouragement encouragement or or with praise to to your your spouse spouse for for his his or or her her willingness wiHingness to to work w o r k with with you, you, even even if if you you praise don't feel feel the the problem problem is issolved solved yet. yet. For For example, example,say, say,"I'm "I'm really really glad glad you're you're don't working with with me m e to to solve solve this. this.ItItmakes makesme m efeel feelgood goodthat that youcare." care." Yourrela­ relaworking you Your tivesneed need to to know k n o w when w h e n they they are are doing doing things thingsright, right,and andit's it'simportant importantto toteU teH tives them them so so as as often often as as possible. possible.

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SElf-MANAGEMENT SELF-MANAGEMENT

that the You You may go through a problem-solving exercise only totodiscover the may go through a problem-solving exercise only discover that original problem was was not not defined defined adequately adequately in in the the first first place. place. For For example, example, original problem the between the problem problem might might be be the the lack lack of of personal, personal, intimate intimate conversations conversations between you and and your your spouse rather than than simply simply not not having having enough enough time time away you spouse rather away from from the kids. kids. If If so, the so,try tryredefining redefining the the problem problem and and going going through through the the solution solution steps steps again (Step 7). You may be more more successful successful the second time time around. again (Step 7). Y ou m a y be the second around. S o m e famihes or couples couples find find i useful to toselect selectaa weekly weekly time time lO tosit sitdo'NIl down Some families or itt useful and and solve solve problems have cropped during the problems that that have cropped up up during the week. week. Often, Often, they they deal deal with problems problems such such as as household household chores, chores, managing managing finances, finances, or or planning planning soso­ with cial events. events. The The structure structure that that a regular meeting meeting provides proVides helps helps assure assure that that cial a regular certain nagging disagreements, however trivial, get certain nagging disagreements, however trivial, getresolved. resolved.

Communicating and Relatives WhoWho AreAre Overprotective Communicating and Problem Problem Solving Solvingwith with Relatives Overprotective "BipolarHlness illness is emotionally to to the the family, and most families "Bipolar is so sotaxing taxing emotionally family, and most famihes don't have have the skills for for knOwing knowing how h o w to deal with it. W e feel don't the skills to deal with it. We feel overover­ whelmed and the whelmed and our our skills skiHs are are exceeded, exceeded, and and we w e can't can't get get answers answers from from the mental health health system. system. All All the the while while we w e see see our our loved loved one one in in pain. Who mental pain. Who wouldn't circumstances?" wouldn't get get overprotective overprotective under under these these circumstances?" — A 34-year-old 34-year-old son son who w h o rakes takes care care o of his bipolar bipolar mother mother -A j his during her her manic manic and and depressive depressive episodes episodes during Communication and problem solving can also help youyou negotiate Communication and problem solving can also help negotiatethe thedifdif­ ficulties that that arise arise when w h e n your your relatives relatives start start to to overmonitor overmonitor your your behavior. behavior. ficulties Your first first task task is is to to try try to to understand understand the the source source of of their their responses. responses. If If you've you've Your been i l l recently, your relative is probably very concerned that you'll become been ill recently, your relative is probably very concerned that you'll become illagain. again.He H e or orshe shemay m a y fear fearthat thatyou you will willkill killyourself, yourself,hurt hurtsomeone, someone,impul­ impulill sively leave leave the the family, family, spend spend aalot lotof ofmoney, money,or orotherwise otherwisedamage damageyourself yourselfor or Sively others. This This anxiety anxiety can can result result in in a a desire desire to to control control things, things, which which often oftenleads leads others. to overprotective behavior. to overprotective behavior. Use active active listening listening as as you you gemly gently encourage encourage your your relatives relatives to to recognize recognize Use and verbalize verbalize their their fears fears about about your your future, future, ififthey theyhaven't haven'tmade m a d ethese theseclear clearto to and you already. already. Reassure Reassure them them that that you'll you'll work work hard hard to to manage manage your your disorder disorder on on you be­ your own. For example, you might say, "I k n o w you're afraid I'm going to beown. For example, you might say, " } know you're afraid I'm going to your come ill illagain againand andthat thatthings thingswill willbe behard hardfor forour ourfamily family\validating [validatingtheir theirfeel­ feelcome mem is ings]. .I am I am taking care myself, though, and best w ayou y you can help e is ings) taking care of of myself, though, and thethe best way can help to let let me m e do do as as much m u c h as as I1 can can on on my m y own." own." They They may m a y be be relieved relieved to to hear hear you you to say this. Y o u m a y also be able to use your positive request skills to set approsay this. You may also be able to use your positive request skills to set appro­ priate boundaries boundaries with with them, them, as as Carol Carol did did with with her her father. father. priate In addition, consider the role of problem solving w h e n dealing dealing with with relaIn addition, consider the role of problem solving when rela­ tiveswho w h o overmonitor overmonitor your your behavior. behavior.Can C a n you you develop develop agreemenlS agreementswith with them them tives

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you something to allay anxiety, and they, in agree turn, not agree not in which which you dodo something to allay theirtheir anxiety, and they, in turn, in you Bart, 118, by his to wwatch atch y o u so so closely? closely? Bart, 8 , was w a s being being constantly constantly rreminded eminded b y his to

Greta, to to take take his his medication medication and get his his bblood level checked. He got mmother, o t h e r , Greta, a n d get l o o d level checked. H e got his in a a rather tablets aaround the his revenge revenge in rather uunproductive n p r o d u c t i v e wway: a y : leaving leaving lithium lithium tablets r o u n d the for h her to find find (for the kitchen floor, b behind the toilet). toilet). hhouse o u s e for e r to (for example, e x a m p l e , on o n the kitchen floor, e h i n d the

became more and anxious and increased increased her her monitoring Greta then then became more annoyed annoyed and anxious and monitoring Greta his behavior. that he he was take his and even of his behavior. Bart Bart said said that was willing willing to to take his medication medication and even of

have his level checked, checked, but but not it meant meant that his mother mother "follows me have his blood blood level not if if it that his "follows me

feel like like taking taking hand." Understandably, he wanted wanted to around with with pills pills in in her her hand." Understandably, he to feel around

medication was his Greta expressed that he he would would take take medication was his own o w n decision. decision. Greta expressed doubt doubt that

medication without her vigilance. She She complained, complained, " H o w can can 1 n o w if he's medication without her vigilance. "How I k know if he's taking it if taking it if II don't don't ask?" ask?"

Through problem problem solving, solving,Bart Bartand and his hismother mother generated generated aalist listof ofpossible possible Through

scenarios: Greta taking taking all all scenarios: Bart Bart taking taking full full responsibility responsibility for for his his medication; medication; Greta

the responsibility; responsibility; Greta Gretareminding reminding him h i m only onlyonce onceper perday; day; Greta Greta having having more more the

phone physician. Eventually Eventually they that Greta Greta would phone contact contact with with his his physician. they agreed agreed that would

place tablets on morning. He place Bart's Bart's four four daily daily lithium lithium tablets on a a plate plate for for him him in in the the morning. He

was not to to mention was to to agree agree to to take take them them during during the the day, day, and and she she was was to to agree agree not mention

his pills on the house his medication medication unless unless she she found found pills on the the plate plate or or lying lying around around the house

by at by the the day's day's end. end. They They also also agreed agreed that that she she could could see see his his lithium lithium level level repon report at the the end end of of each each month. month. This This agreement agreement worked worked well well for for both both of of them. them.

W h a t if if it it is is your your spouse spouse who w h o is is behaving behaving in in an an overprotective overprotective way? way? Some Some What

of my m y clients clients say say that that their their spouses spouses feel feel less less anxious anxious if if they they are are allowed allowed to to at­ atof

tend tend the the drug drug monitoring monitoring visits visits with with the the psychiatrist. psychiatrist. There There are are some some advan­ advan-

tages tages to to doing doing this: this: Your Your spouse spouse will will feel feel more more secure secure if if he he or or she she has has input input

into your your care care and and has has a a connection connection with with your your physician physician (which (which can can be be helpinto help­

ful in in emergencies). emergencies). Your Your spouse spouse may m a y also also remember remember certain certain of of the the physician's physician's ful

recommendations that that have have slipped slipped your your mind mind (and (and likewise, likewise, you you may m a y recall recaH recommendations

things that that your your spouse spouse has has forgotten). forgotten).If Ifyou you decide decide to togo go this thisroute, route,you youmay may things

want to to establish establish some s o m e agreemenls agreements ahead ahead of of time time about about what what role role you you wanl want want

your your spouse spouse to to play play in in these these medication medication visits. visits.For Forexample, example,you youmight mightsay, say,"}"1

want want to to invite invite you you to to my m y next next medication medication session, session,but but1Ineed needto todo do most mostof ofthe the

talking about about my m y stale state and and what what the the medication medication is is doing. doing. You Y o u can can chime chime in, talking in,

but but it's it's really really me m e who w h o has has to to describe describe my m y own o w n experiences.n experiences." Your Your spouse spouse may may

feel feel less less of of aa need need to to closely closely monitor monitor your your behavior behavior if if his his or or her her opinions opinions are are

regularly regularly incorporated incorporated into into your your treatmenl treatment plan. plan.

Use of of Communication and Problem-Solving Skills Skills TTroubleshooting rouhleshoot;ngYour Your Use Commun;c.t;on .nd Prohlem-Solving Putting c o m m u n i c a t i o n and a n dproblem-solving problem-solving skills skHls into into practice practice during during your your Putt ing communication

recovery period period presents presents some s o m e challenges. c h a H e n g e s . As A s II mentioned m e n t i o n e d preViously, previously, even even recovery

the healthiest healthiest of of families families can c a n have h a v e trouble trouble communicating c o m m u n i c a t i n g clearly clearly and a n d effieffithe

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ciently. But whenyou youare are also dealing dysregulations inmood your and mood and ciendy. BUl when also dealing withwith dysregulations in your

thought stale­ thought processes, processes, it can be be even harder to to step step back back and and phrase phrase your your stateit can even harder ments to to relatives relatives in in the the ways ways that that I've I've outlined, outlined, or or to to take take a a step-by-step step-by-step apments ap­ proach proach to to problem problem solving. solving. You Y o u will will probably probably feel feel easily easily provoked provoked and and impa­ impatient. in conflict tient. As As a a result result you you may m a y quickly quickly abandon abandon the the skills skills when w h e n in conflict with with relatives, which relatives, which will willthen then keep keep the thenegative negative cycles cyclesgoing. going. There There are are several several things things you you can can do do to to address address problems problems in in implementing implementing these skills. skills. First, First,try trytotoflag flag those instances w h e nyou youare are getting too upset these those instances when getting too upset toto listen situation. listen effectively effectively or or solve solve problems, problems, and and then then diplomatically diplomatically exit exit the the situation. For example, consider the scenario in which your relative is being critical For example, consider the scenario in which your relative is being criticaland and accusatory, and and the the thought thought "this "this is is so so unfair" unfair" keeps keeps going going through through your your accusatory, mind. fyou mind. IIf you feel feel tlu: the heal heat rising rising and and can can tell tellthat that the the conversation conversation is isgoing goingin inaa negative negative direction, direction, ask ask for for a a "time-out." "time-out." For For example, example, you you might might say, say, "} "I don't don't think now. Let's both calmed think II can can discuss discuss this this right right now. Let's talk talk later later when w h e n we're we're both calmed down." down." A A time-out time-out gives gives you you breathing breathing room r o o m so so that that you you can can think think abom about what what you also enables you do do and and don't don't want want to to say say to to your your parent, parent, spouse, spouse,or orSibling. sibling.ItIt also enables you to to examine examine what what is is happening happening that thatis ismaking makingyou youso soupset. upset.You Y o umay m a ywant want you to to resolve resolve the the disagreement disagreement with with your your relative relative later later or or perhaps perhaps just just drop drop it, it,ififitit doesn't cost of after doesn't seem seem worth worth the the cost of another another argument. argument. There There may m a y be be a a period period after the when but this this the time-out time-out w h e n things things are are awkward awkward and and icy icy in in your your household, household, but probably probably would would have have occurred occurred anyway anyway if if you you had had let let the the argument argument continue continue along its its destructive destructive path. along path. Here's another another difficulty difficulty you you might might experience: experience: You Y o u know k n o w the the steps steps of of a a Here's skill (for (for example, example, making making a a positive positive request) request) but but then then forget forget them them as as soon soon as skill as an argument argument starts. starts. It is hard to remember remember to to draw draw on on communication communication skills an It is hard to skills w h e n you you are are angry angry and and in in the the midst midst of of a a conflict conflict with with someone someone w h o is is angry angry when who at you. you. When W h e n you you recall recallthe the conversation conversation later later on, on,you you may m a y think think of ofaa number number at of things things you you could could have have said said to to help help defuse defuse the the argument. argument. of If thisdifficulty difficultysounds sounds familiar, familiar,practice practiceusing usingthe theskills skillsfirst firstwith withpeople people If this outside the the family family who w h o don't don't provoke provoke you you and and with with whom w h o m you're generally outside you're generally comfortable. For For example. example, make make a a positive positive request request of of a a coworker coworker ("I'd ("I'd really comfortable. really appreciate it it if ifyou you could could cover cover for forme m e next next weekend weekend so so that that I1can can take take some some appreciate time ofr). off), or or try try paraphrasing paraphrasing the the statements statements of of a a friend friend who w h o has has described described to time to you a a problem problem he he or or she she is is haVing having (for (for example, example, "Sounds "Sounds like like you're you're going going you through a a rough rough time"). Y o u may m a y find find that that by by applying applying a a skiH in non­ nonthrough time"). You skill in threatening circumstances, circumstances, it it becomes becomes easier easier to to remember remember to to apply apply it it when when threatening the stakes stakes are are higher. the higher. N o w consider consider the the scenario scenario in in which which you you are are doing doing your best with with the Now your best the communication tools tools but but there seems to to be be little Htde impact on your your relationship. communication there seems impact on relationship. You may m a y feel feel annoyed annoyed that thatyou you are arethe theonly only one one who w h o is istrying trying to tocommunicate communicate You or solve solve problems problems effectively, effectively, whereas whereas others others seem seem to to keep keep doing doing whatever whatever or

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they've been beendoing. doing. example, youbemay bediplomatic quite diplomatic asking your they've ForFor example, you may quite in askinginyour close to close relatives relatives to to change c h a n g e their their behavior, behavior, yet yet the the way w a y they they ask ask you y o u continues continues to sound s o u n d challenging challenging and a n d demeaning. d e m e a n i n g . Of O f course, course, if if you y o u were w e r e to to ask ask your y o u r family family members m e m b e r s for for their their view v i e w of of this this problem, p r o b l e m , they they might m i g h t say say that that they they try try to to be b e dip­ dip-

lomatic but b u t that that you y o u get get very very defensive defensive in in return. return. lomatic ilS of of If you y o u find find yourself yourself in in this this stalemate, stalemate, consider consider the the long-term long-term benef benefits If "unilateral in rela­ "unHateral change." change." In In other other words, w o r d s , try try to to change c h a n g e your y o u r own o w n behavior behavior in relato yyour relatives first, first, wwith the expectation expectation that, that, wwith time, they they will will tion to o u r relatives i t h the i t h time, tion

change their their behavior behavior toward t o w a r d you. y o u . In In other other words, w o r d s , keep k e e p trying! trying! Your Y o u r repeated repeated change attempts attempts at at problem p r o b l e m solving solving or or diplomacy d i p l o m a c y (for (for example, e x a m p l e , continuing continuing to to validate validate

other people's people's emotions e m o t i o n s even e v e n when w h e n they they refuse refuse to to do d o so so for for you) y o u ) will w H l eventu­ eventuother ally have h a v e an a n iimpact m p a c t on o n their their responses, responses, especially especially if if you y o u are are able able to to stick stick with with ally the formalS formats outlined for engaging engaging in in active active listening listening and a n d making m a k i n g positive positive rethe outlined for re­ quests quests for for change. c h a n g e . Of O f course, course, this this requires requires a a high high tolerance tolerance for for frustration, frustration, but but

there is is potentially potentially a a high h i g h payoff payoff over over time. time. there T o increase increase the the chances c h a n c e s that that your y o u r relatives relatives improve i m p r o v e their their way w a y of of commu­ commuTo nicating nicating with w i t h you, y o u , be b e sure sure to to praise praise them t h e m for for even e v e n minor m i n o r attemplS attempts on o n their their part part (for (for example, e x a m p l e , "Thanks " T h a n k s for for asking asking me m e if if II was w a s upset upset after after our o u r conversation. conversation. I'm I'm glad glad you y o u noticed noticed that that it it bothered bothered me"). m e " ) . The T h echances c h a n c e sare arehigh high that, that,over over re­ repeated peated discussions discussions with w i t h your y o u r relatives, relatives, they they will will do d o or or say say something s o m e t h i n g helpful helpful or or that that shows s h o w s an a n awareness a w a r e n e s s of of yOUT y o u r viewpoint. viewpoint. Be B e ready ready to to acknowledge a c k n o w l e d g e their their

attempts to to make m a k e things things better, better, even e v e n if if these these attemplS attempts seem s e e m overshadowed overshadowed b y auemplS by everything else else they they have h a v e said. said. The T h e cardinal cardinal rule rule of of behavior behavior modification everything modification is is that that people people increase increase the the frequency frequency of of those those behaviors behaviors that that get get rewarded rewarded by by others. others.

Y o u may m a y feel feel that that the the communication communication or or problem-solving problem-solving strategies strategies outYou out­ lined lined here here are are artificial artificial or or superficial. superficial. If If you you are are still still hypomaniC hypomanic or or energized, energized, it it may m a y feel feel stifling stifling to to talk talk in in this this very very measured, measured, careful careful way. way. What W h a t happened happened to to the the eXCiting, exciting, spontaneous spontaneous interchanges interchangesyou you used used to tohave havewith with your your partner partner or or yOUT your Siblings? siblings? Remember R e m e m b e r that that you you are are trying trying to to improve improve life life during during a a spespe­

cific interval-your interval—your recovery recovery period. period.This This period period requires requiresthat thatyou you be be extra extra ef­ efcific ficient in in your your communication communication and and problem-solVing problem-solving styles, styles, above above and and beyond beyond ficient what is is required required of of others others who w h o do do not not have have to to cope cope with with bipolar bipolar disorder. what disorder. Think of of incorporating incorporating these these skills skills as as trying trying on on a a new n e w pair pair of of shoes. shoes. At Think At first, first, they they won't won't fit or feel feel comfortable. comfortable. If If they're they're still still uncomfortable uncomfortable after after you've you've fit or worn worn them them for for a a while, while, you you may m a y decide decideyou you don't don'tlike likethem them and and take take them them off. off.

But they they have have the the potential potential to to work for you you if if you you break break them them in. Bm work well well for in. PracPrac­ ticingthe theskills skillsrepeatedly repeatedlywill wiHeventually eventuallymake m a k ethem themfeel feellike likesecond secondnature nature ticing and and will will probably probably lead lead to to changes changes in in the the way w a y that that your your famLly family members m e m b e r s rere­

spond to to you. you. As A s you you recover recover and and your your family family relationships relationships improve, improve, you you may may spond be able able to to return return to to more spontaneous ways ways of of communicating communicating or or making making be more spontaneous your your needs needs known. known.

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Reestablishing Physical Intimacy with Partner Your Partner an Episode Episode after anafter with Your Intimacy Physical Reestablishing to In In the theprevious previoussection, section, an example of problem solving as related to as related solving of problem an example sawsaw youyou

emotional intimacy intimacy in in aa couple's couple's relationship. relationship. As As for for physical physical intimacy, intimacy, you you emotional and and your your partner partner will will probably probably need need some some time time to to get get reacquainted reacquainted with with each each other. other. If If you you both both would would like like to to reinitiate reinitiate a a physical physical relationship, relationship, consider consider getting getting the the help help of of a a couple couple counselor counselor who w h o specializes specializes in in sex sex therapy. therapy. Tradi­ Traditional tional sex sex therapists therapists encourage encourage couples couples to to take take pan part in in "sensate "sensate focus" focus" exer­ exer-

cises that that they they do do together together at at home h o m e (for (for example, example, LoPiccolo LoPiccolo &. & LoPiccolo, LoPiccolo, cises

1978). 1978). After After Mara's Mara's bipolar bipolar mixed mixed episode, episode, she she and and her her husband husband Kevin Kevin aban­ aban-

doned their their sex sex life, life, deciding decidingthat that··our "ourprimary primarygoal goalas asaacouple coupleisisMara's Mara'sre­ redoned covery." covery." In In their their couple couple sessions, sessions, they they both both recognized recognized that that sex sex had had become become

frightening to to them them and and that that the the illness illness had had become become an an excuse excuse for for not not dealing dealing frightening directly with with each each other. other. Once Once they they agreed agreed that that they they wanted wanted to to reestablish reestablish a a directly between romantic romantic life, life,their theircounselor counselorencouraged encouragedthem themto totake takesmall smallsteps, steps,inin between sessions, sessions, toward toward greater greater intimacy. intimacy. They They started started by by going going our out together together on on an an

evening date date one one week, week, giving giving each each other other back back rubs rubs the the follOwing following week, week, hug­ hugevening ging and and kissing kissing the next, taking taking a a bath together the the next, next, and and gradually graduallywork­ workbath together the next, ging ing ing back back up up to to a a sexual sexual relationship. relationship. This This relaxed, relaxed, step-by-step step-by-step approach approach was was very very important important for for Mara Mara and and Kevin Kevin in in regaining regaining the the trust trust and and intimacy intimacy they they

had shared shared prior to her episode. her episode. prior to had Y o u may m a y feel feel that that the the gUidance guidance of of a a couple couple therapist therapist is is not not necessary. But necessary. But You m a n y couples couples do do have have significant significant anxiety anxiety concerning concerning sex. so, a a therapist therapist can can If so, sex. If many teach you you relaxation and desensitization techniques (like (like those those above) above) to to desensitization techniques relaxation and teach practice with with your your spouse spouse between between sessions. sessions. practice The most most important important point point to to remember remember is is that that anxiety anxiety or or discomf discomfort about ort about The being dose close is part o off coping coping as as a couple with bipolar disorder, particdisorder, partic­ with bipolar a couple natural part a natural is a being ularly during during the the recovery recovery period. M a n y couples couples are able to to overcome overcome this this dis­ disare able period. Many ularly comfort by by moving moving slowly, slowly, not expecting too u c h from from each other at at first, first, each other much too m not expecting comfort and being being willing to try try again if their attempts at at sexual sexual intimacy intimacy are are not not first attemplS their first again if willing to and as as they they had hoped. had hoped. satisfying as as satisfying

Bipolar and the tlie Work Woric SeHing Setting Disorder and Bipolar Disorder Louise, a 35-year-old with bipolar disorder,had hada manic a manic episode episode bipolarII disorder, with woman a 35-year-oldwoman Louise, of the development to the hospitalization. Prior to a led to that a short short (five-day) (five-day) hospitalization. Prior to development of that led her episode, as a a paralegal law firm. for trigger for The trigger firm. The a law in a paralegal in worked as had worked she had episode, she her her a legal case, for firm the firm which the for which legal case, been a have been to have appeared to hospitalization appeared her hospitalization had she work for several several weeks prepare help prepare to help weeks to night for at night late at work late that she insisted that had insisted the arguments. auorneys' arguments. the attorneys' Her episode kept her out out of of work month. W h e n she had she had When a month. almost a for almost work for kept her Her episode

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mostly recovered, she returned to her Shenot decided not tell her em­ mostly recovered, she returned to her job. Shejob. decided to tell hertoemthat s she had in the the hospital hospital a and instead explained explained that thatsshe ployers he h a d bbeen e e n in n d instead he ployers that hhad ad h ad a n uunnamed n n a m e d physical n d did o t elaborate ut had an physical illness, illness, a and did n not elaborate further. further. BBut she b e c a m e physically n c o m f o r t a b l e , easily n d irritable she became phYSically uuncomfortable, easily fatigued, fatigued, a and irritable after after her e c o n d wweek eek o n the o b wwhen hen h e r eemployers m p l o y e r s started er on the jjob her started to to increase increase hher her ssecond wwork o r k load h e y expected o r k late n e night n d early load again. again. TThey expected her her to to wwork late shifts shifrs oone night aand early mmorning o r n i n g shifts h e ffound o u n d that a s uunable n a b l e to menshifts the the next. next. S She that she she w was to function function men­ at wwork the m morning after a a night night shift. shift. EEven they aSSigned tally o r k the o r n i n g after v e n wworse, o r s e , they assigned tally at her e w task p o n arriving w o r k in o r n i n g : calling calling clients ho an new task uupon arriving at at work in the the mmorning: clients wwho her a were delinquent on their bills bills or who hadn't rresponded to letters. letters. SShe w e r e delinquent o n their or w h o hadn't e s p o n d e d to he her this way: ssummarized ummarized h e r experience experience this way: "It as a ab a d idea for m e to d o ssomething o m e t h i n g like like that the "It w was bad idea for me to do that first first thing thing in in the morning. It made it hard for for m e to even get get up go to job. My M y body body It made it hard me to even up to to go to this this job. morning. was slow, m y mind mind was was slow. slow.ItIt took took me m e aalong long time timeto tocome come out out of ofmy my was slow, my haze. 1 had toto bebe haze. IfIf1Igot gottotowork workatat9,9,1 had 6 just m mind y mind rolling. upup byby 6 just to to getget my rolling. I I felt then depressed. MyMboss gotgot controlling and started felt rushed, rushed,irritable, irritable, then depressed. y boss controlling and started criticizing my m y work. work. .... gotstressed stressedout outand andanxious, anxious,and andthen thenI Iwould would criticizing . . I1got try to to calm calm down down and and couldn't. triedto tomake makemyself myselfbusy, busy,but butthen thenI I felt try couldn't. 1Itried felt even job done." done." even more more lethargic lethargic and and couldn't couldn't get get the the job Louise was was on on the the verge verge of of quitting quitting her her job job when when she she decided decided to to have have louise an an open open conversation conversation about about her her bipolar bipolar disorder disorder with with one one of of the the partners partners in been onon her side. Louise apol­ in the the law law firm, firm,aawoman w o m a n who, who, she shefelt, felt,had had been her side. Louise apologized for for her her irritability irritability and and explained explained that that she she needed needed more more consistent ogized consisteD[ work hours, hours,adding addingthat thatthe theunpleasant unpleasanttasks tasks she had been assigned the work she had been aSSigned inin the morning were were better better off off assigned assigned to to the the afternoon. afternoon. The The law law partner partner was was morning unwilling to to compromise compromise on on the the amount amount of of work work aSSigned assigned to to Louise Louise or or the the unwilling quaHty she expected. But given that Louise was a valued employee, the quality she expected. But given that Louise was a valued employee, the partner did did compromise compromise on on some some other other issues: issues:limiting Hmitingthe thenumber numberof oflate late partner nights she she would would have have to to work, work, allowing allowing her her to to do do some some of of her her work work at nights at home, and and deferring deferring the the unpleasant unpleasant tasks tasksuntil untH later later in inthe theday. day. These Thesead­ adhome, justments made made aa great great deal deal of of difference difference to to Louise. Louise. She She eventually eventually dejustments de­ cided to to cut cut to to aa half-time half-time work work week, week, which which was was much much better better for for her her cided from from the the standpOint standpoint of of mood mood stability. stabHity.

If youhave If you disorder, can be still be successful in your cho haveaa bipolar bipolar disorder, you you can still successful in your chosen career. A A survey survey done done by by at at the the Center Center for for Psychiatric Psychiatric Rehabilitation Rehabihtation at career. at Boston University discovered that 7 3 % of 500 professionals and managers discovered that 73% of 500 profesSionals and managers Boston University (including nurses, nurses, newspaper newspaper reporters, reporters, corporate corporate executives, executives, lawyers, lawyers, and and (including professors), previously diagnosed with a serious psychiatric Hlness, were professors), previously diagnosed with a serious psychiatric illness, were able to to maintain maintain full-time fuH-time employment employment in in their their chosen chosen occupatiOns occupations (Ellison (EHison able & Russinova, Russinova,2001). 2001). Of Of the the respondents respondents to to the the survey, survey,62% 6 2 % had had worked worked in in &. their position position for for more more than than two two years, years,and and 69% 6 9 % had had increased increased their their levels levels their ofresponsibility responsibility in in their theirjobs. jobs.Most Most (84%) (84%)were weretaking takingsome some kind kind of ofpsychi­ psychiof atricmedication, medication,and and two-thirds two-thirds had had been been hospitalized hospitalized three three or or more more times. times. atric

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Above all, many getting back to their jobs was Above all, many respondents respondents said saidthat that getting back to their jobsirnpor� was important to to their their recovery. recovery. tant Nonetheless, Nonetheless, as as the the story story of of Louise Louise illustrates, illustrates,people peoplewith withbipolar bipolardisor­ disorder der face face significant significant challenges challenges in in the the workplace. workplace. Some S o m e of of these these challenges challenges arise arise from from the the stigma stigma of ofbipolar bipolar disorder disorder and and the the reactions reactions of ofothers. others.But Butfor formost mostof of m y clients, clients,the thebigger biggerchallenge challengeisisfinding findinga ajob jobthat thatisis satisfying but also helps my satisfying but also helps keep fluctuating keep them them from from mood m o o d cycling. cycling. It It is is difficult difficult to to balance balance severely severely fluctuating moods m o o d s with with a a stable stable work work life, life,as asLouise Louisefound. found.Jobs Jobsthat thatpermit permitthis thisbalance balance are hard to find, but they do exist or can be created. are hard to find, but they do exist or can be created. Maintaining job. Maintaining aa stable stable mood m o o d is is essential essential to to functioning functioning well well at at your your job. This This is, is,of ofcourse, course,another anotherreason reasontotostay stayconsistent consistentwith withyour yourmedication medicationregi­ regim e n . But But it it is is equally equally true true that that working working within within a a supportive supportive environment environment is men. is importam bal­ important to to maintaining maintaining your your mood m o o d stability. stability. The Thekey keyisisfinding findingthe theright right balance ance of of stability stability in in work work hours, hours, levels levels of of stress, stress,levels levelsof ofstimulation, stimulation,and andsatis­ satisfaction faction with with the the directions directions your your job job is is taking takingyou. you.IIam a moptimistic optimisticthat thatyou youcan can find some strategies toto help you find this this balance. balance.In Inthis thissection, section,I Idiscuss discuss someself-care self-care strategies help you get get back back into into the the working working world world after after an an episode. episode.

"HowWill Will Bipo'ar AHec, My Job Perlormance?" "How BipolarDisorder Disorder Affect My Job Performance?" "I"Iwas weekend, really really pushing envelope. washypomanic hypomaniCall all last last weekend, pushing thethe envelope. Me Me andand

the guys guys were were up up partying partying until 3 in in the the morning morning both both Friday Friday and and SaturSatur­ the until 3 day nights, nights, and and then then IIslept sleptuntil until111 thenext nextday, day,even even though though IIknew k n e w it it 1 the day was a a bad bad idea idea because had to toget getup up at at66 for forwork w o r k on on Monday. Monday. IIforgot forgot was because II had to take take my m y medications medications on on Sunday Sunday morning, morning, and and 1I didn't didn't sleep sleep that well to that well Sunday night. night. By By Monday M o n d a y II was was tired, tired, cranky, cranky, withdrawn, withdrawn, snappy snappy with with Sunday m y boss, boss, and and just just really really wasn't wasn't all all that that efficient. efficient. My M y boss boss reacted, reacted, men­ menmy tioned that that I1 seemed seemed like likeI1was wasin inaabad badmood, m o o d ,hinted hintedthat thatmaybe maybein inthose those tioned circumstances II should shouldjust justtake take the theday day off. ofL He H e didn't didn'tknow k n o w about about my m y bi­ bicircumstances polar disorder. disorder. II could could just feel the the old old 'authOrity 'authorityfigure' stuff coming coming up up polar just feel figure' stuff again, but butIIalso alsorecognized recognizedI I was having depression hangoverofof sorts. again, was having aa depression hangover sorts. I 1 took it it easy easy after afterwork work Monday M o n d a y aflernoon, afternoon,did did some some low low stress stressstuff stufflike like took talking on on the the phone phone and and going going for for a a run, run, had had dinner dinner and and went went to tobed bed at at talking the usual usual time. slept fine and was was back back in in the the swing swing of of things things by by Tues­ Tuesthe time. II slept fine and day. II apologized apologized to tomy m y boss boss and and everything everything was was OK O K after afterthat, that,but butI Ireal­ realday. ized at some some point, might have have to to tell tell him about my m y problems." ized that, that, at point, 1I might him about problems." — A 27-year-old 27-year-old man m a n with with bipolar bipolar II II disorder disorder -A

As is for your mood mood state wiHinfluence influence your day-to-day Astrue is true formost mostpeople, people, your state will your day-to-day job performance. cycle of sleep deprivation deprivation and and overstimulation overstimulation job performance. This This man's man's cycle of sleep

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irritability, lethargy, lethargy,and anddepression depression could described foUowed byby irritability, could havehave described almostalmost followed

anyone. The T h e difference difference is is that that this this cycle cycle is is magnified magnified in in bipolar bipolar disorder, disorder, and and anyone. the intensi[)7 intensity of of your y o u r resulting resulting mood m o o d can c a n affect affect your y o u r work w o r k performanc,e p e r f o r m a n c e more more the than than would w o u l d be b e the the case case for for the the average average person. person. How or H o w are are bipolar bipolar symptoms s y m p t o m s expressed expressed in in the the work w o r k setting? setting? Manic M a n i c or at things h y p o m a n i c reactions reactions can c a n take take the the form f o r m of of flying flying off off the the handle h a n d l e at things that that hypomanic normally that normally wouldn't wouldn't annoy a n n o y you y o u or or being being preoccupied preoccupied by b y so so many m a n y ideas ideas that concentrating concentrating on o n your y o u r job j o b becomes b e c o m e s difficult. difficult. You Y o u may m a y start start more m o r e projects projects than than

y o u can c a n possibly possibly complete, c o m p l e t e , darting darting from f r o m task task to to task task without w i t h o u t accomplishing accomplishing you inter­ w h a t you y o u originally originally set set out o u t to to do d o ("multitasking"). ("multitasking"). During D u r i n g hypomanic h y p o m a n i c interwhat or vals, you y o u may m a y be b e particularly particularly prone p r o n e to to arguments a r g u m e n t s with w i t h irritating irritating coworkers c o w o r k e r s or vals, confrontations my confrontations with w i t h your y o u r boss boss (a (a client client said, said, "[ "I usually usually just just think think m y cowork­ cowork-

ers are are idiots. idiots. When W h e n I'm I'm manic, m a n i c , II also also tell tell them t h e m sso"). o"). ers W h e n you're you're in in a a depressed depressed phase, p h a s e , your y o u r physical physical state state is is much m u c h like like a a severe severe When flu. AtAthese times you will not to to expeclas much flu. t these times y o (and u ( a nothers) d others) will n obe t bable e able expect as m u c from h f r oyour­ m your-

self. Your Y o u r thinking thinking and a n d physical physical responsiveness responsiveness (for (for example, e x a m p l e , your y o u r typing typing self. speed) speed) may m a y be b e slower. slower. You Y o u may m a y also also suffer suffer from f r o m considerable considerable anxiety, anxiety, which w h i c h can can interfere chart to to interfere with w i t h your y o u r concentration. concentration. As A s always, always, you y o u can c a n use use your y o u r mood m o o d chart anticipate anticipate when w h e n you y o u are are entering entering one o n e of of these these phases phases of of mood m o o d disorder. disorder. On O n the the other other side, side, some s o m e people people report report that that their their bipolar bipolar disorder disorder enhances enhances their their job job performance. p e r f o r m a n c e . Many M a n y persons persons with w i t h bipolar bipolar disorder disorder work w o r k in high-level in high-level

business or or government g o v e r n m e n t positions positions and a n d are are known k n o w n for for their their high h i g h work w o r k output. output. business T h e y report report that that when w h e n they they have have a a major m a j o r writing writing project project to to do, d o , an a n oral oral presen­ presenThey tation, tation, or or an a n impotlam important sales sales meeting, meeting, they they use u s e the the "adrenaline "adrenaline rush" rush" of of link between hypomania h y p o m a n i a to to their their advantage. advantage. You'll You'll recall recall from f r o m Chapter Chapter 7 7 the the link between

mania m a n i a and a n d creativity creativity or or productivity productivity Oamison, (Jamison, 1993). 1993).

In In my m y experience, experience, people people with vvdth bipolar bipolar disorder disorder are are able able to to benefit benefit from from hypomania h y p o m a n i a in in the the work w o r k setting setting only only if if they they are are able able to to harness harness it. it. Harnessing Harnessing

h y p o m a n i a includes includes learning learning to to recognize recognize when w h e n you y o u are are moving m o v i n g or orspeaking speaking hypomania too fast, fast, setting setting limits limits on o n yourself w h e n work w o r k starts to make m a k e you y o u overly overly goal­ goaltoo yourself when starts to driven, trying trying to to accomplish a c c o m p l i s h only only one o n e task task at at aa time, time,accepting accepting feedback feedback from from driven,

others about about how how you you are are coming coming across, across, and andbacking backingoff offwhen when people peopleseem seem others to to be be reacting reacting [0 to your your intensity. intensity.ItItmay mayindeed indeedbe bepossible possibleto totranslate translateyour yourin­ in-

creased energy energy into into work work productivity, productivity,but butalso alsobe beaware awareofofwhen whenyou youneed needto to creased slow break. slow down down and and take take aa break.

Self-Disclosure Self-Disclosure io in 'he the Workplace: I Tell People about My Illness?" Workplace:"Should "Should I Tell People .bou' My lIIoess?" Can bipolar be be kept a secret? In my and that of that manyof ofmany of Can bipolardisorder disorder kept a secret? In experience my experience and m y colleagues, c o H e a g u e s , people people with w i t h bipolar bipolar disorder disorder usually usually adopt a d o p t one o n e of of four four solu­ solumy tions tions regarding regarding disclosure: disclosure:

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1. They tellteU everybody about it, theirboss bossand andcoworkers coworkers 1. They everybody about it, including including theiT

2. They tell tell OTIe one or ormore more trusted trusted coworkers coworkers who w h o do do not notcarry carrypositions positionsof of 2. They

authority authority over over them them their 3. 3. They They do do not not tell teH anybody, anybody, but but do do admit admit to to bipolar bipolar disorder disorder on on their work-sponsored possibility work-sponsored health health insurance insurance claims claims (leaving (leaving open open the the possibility that find out) that their their employer employer could could find out) 4. not tell not use 4. They They do do not tell anyone anyone at at work, work, and and they they do do not use their their work­ worksponsored sponsored insurance insurance to to cover cover their their psychiatric psychiatric costs costs There is solution thatthat is right everybody. Let me go the There isno noSingle single solution is for right for everybody. Letthrough me go through the pros and cons pros and cons of of telling telling employers employers or or coworkers coworkers about about your your disorder, disorder, to to help help you best to in your your current en­ you decide decide which which option option seems seems best to you you in current or or future future work work environment. vironment. What Are AreIhe the Disadvantages of Disclosing?: Risk of Job Discrimination Whal Disadvanlages of Disclosing?, The Risk of The Job Discriminalion If you are arecurrently currently employed, the most obvious disadvantage of disclosing If you employed, the most obvious disadvantage of disclosing

your your disorder disorder is is that thatyou you may m a y get getfired firedor ordemoted demoted or ordenied denied aa promotion promotion or oraa raise. raise. Likewise, Likewise,telling tellinga aprospective prospectiveemployer employerabout aboutyour yourdisorder disorderintroduces introduces the telling the possibility possibility that that he he or or she she will will decide decide against against hiring hiring you, you, without without telling you why. why. you S o m e people people with with bipolar bipolar disorder, disorder, including includingsome some of ofmy m y clients, clients,have havere­ reSome job discrimination. It is ported job discrimination. It is unclear unclear how h o w often often this this occurs. occurs. In In a a study study by by poned Nicholas Glazier Glozier (1998) (1998) of of the the Institute Institute of of Psychiatry Psychiatry in in London, London, 80 80 British British Nicholas personnel personnel directors directors were were asked asked to to evaluate evaluate one one of of two two hypothetical hypothetical job job candicandi­ dates dates who, w h o , based based on on a a written written profile. profile, were were described described in inan an identical identicalmanner manner (for example, example, as as having having a a good good prior prior work work record). record). One O n e was was described described as as hav­ hav(for ing had had a a diagnosis diagnosis of of depression depression and the other other as as having having diabetes. diabetes. Personnel Personnel ing and the directors were were less less likely likely to to hire hire the the applicant applicant with with depression depression and and more more likely likely directors to believe that he or she would have an impaired performance in an executive to believe thaI he or she would have an impaired performance in an executive job. In In other other words, words, we w e have have a a long long way w a y to to go go in in educating educating employers employers about about job. depression and and bipolar bipolar disorders, disorders, their their Similarity similarity to to other other medical medical disorders, depression disorders, and how not clear whether and h o w they they will, will, and andwill wiflnot, not,affect affectjob jobperformance. performance.ItItisis not clear whether an unwillingness to hire a hypothetical candidate translates into discriminaunwillingness to hire a hypothetical candidate translates into discrimina­ an tion once a a real real person person with with depreSSion depression or or bipolar bipolar disorder disorder is is hired. Lion once hired. If you If you are are fired fired or or are are not not hired hired because because of ofyour your bipolar bipolar disorder, disorder,the the law law is on on your yourside. side.Under Under the theAmericans Americanswith withDisabilities DisabilitiesAct Act(U.S. (U.S.Equal EqualEmploy­ Employis ment Opportunities Commission, 1990), i t is unlawful to discriminate against ment Opportunities Commission, 1990), it is u"'awful to discriminate against aa "qualified individual individual with with a a disability," disability," meaning meaning a a person person who, who, "with "with or or with­ with"qualified out reasonable accommodation, can perform the essential functions of the emout reasonable accommodation, can perfonn the essential functions of the em­ ployment position position that that such such individual individual holds holds or or desires" desires" (p. (p. 4). 4). Bipolar Bipolar disorder disorder ployment

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does quahfy qualify disability,which which defined as physical "a physical or mental impair­ does asasa adisability, is is defined as "a or mental impairthat substantially substantially limits limits o one or mmore of the the mmajor activities of of such mment e n t that n e or o r e of a j o r life life activities such refers to to prejudicial prejudicial behavior behavior o on the em­ individual" (p. (p. 33). ) . Discrimination Discrimination refers n the emindividual" part in in j job ployer's o b application application procedures, procedures, hiring hiring practices, practices, promotion p r o m o t i o n or or dis­ disployer's part charge, pay, o or You legally b be an equal jjob for equal charge, pay, r training. training. Y o u ccannot a n n o t legally e denied denied a n equal o b for equal pay, others, or or classified that y your for pay, be b e segregated segregated ffrom r o m others, classified such s u c h that o u r opportunities opportunities for limited (for (for example, demoted to to working working in in the the mail mail room) advancement are limited example, demoted room) advancement are

because your disorder. because of of your disorder. for a job, "reasonable If you are are qualified qualified for a job, "reasonable accommodations" accommodations" can can be be rere­ If you

quired of of the the employer. employer. For For a a person person with bipolar disorder disorder these these m a y include with bipolar may include quired modified modified work w o r k schedules schedules (for (for example, example, consistent consistent work work shifts), shifts), job job reaSSign­ reassignments to your tolerance level, or restructurrestructur­ ments to to positions positions more more suitable suitable to your stress stress tolerance level, or

ing your your work w o r k environment environment to to avoid avoid overstimulation overstimulation (see (see examples examples in the folin the fol­ ing lowing case case and and in in the the sidebar sidebar on on pages pages 284-285). 284-285). Of O f course, course, the employer lowing the employer has to to know k n o w about your disorder disorder to to make m a k e reasonable reasonable accommodations. accommodations. Your Your has about your employer legally fire because you you need need a a employer cannot cannot legally fire you you or or refuse refuse to to hire hire you you because

reasonable accommodation, accommodation, unless unless he he or or she she can can prove prove that that such such an accomreasonable an accom­ modation would would prove prove an an undue undue hardship hardship for for the the business business (for (for example, example, place place modation the the firm firm deeply deeply in in debt) debt).. Consider worked at Consider the the experience experience of of Janine, Janine, a a 37-year-old 37-year-old woman w o m a n who w h o worked at an an advertising advertising firm. firm.

Janine waswas a valued employee of of her firm high productiv­ productivJanine a valued employee her firmbecause becauseof of her her high ity. ity. She She said said that that she she had had always always been been somewhat somewhat hypomanic hypomanic by by nature, nature, and that that this this hypomania hypomania had had served served her her well well in in her her high-demand high-demand work­ workand place. Her Her first first major major bipolar bipolar episode episode was was aa depression depression with with symptoms symptoms of of place. paranoia that that developed developed gradually gradually and and significantly significantly interfered interfered with with her her paranoia work productivity. productivity. She She took took a a leave leave of of absence absence but but didn't didn't know k n o w at at the the time time work that she she had had bipolar bipolar disorder. disorder. Following Following successful successful medical medical treatment treatment that with mood m o o d stabilizers stabHizers and and an an antipsychotic antipsychotic agent, agent,she shewrote wrote aaletter letterto toher her with firm explaining explaining what what had had happened. happened. Upon U p o n learning learning of of her her disorder, disorder, her her firm employer dismissed dismissed her. her. She She consulted consulted an an attorney attorney and and challenged chaHenged this employer this m o v e on on legal legal grounds. grounds. After After several several legal legal back-and-forth back-and-forth communica­ communicamove tions,she shewas wasinvited invitedback backtoto w o r katat thefirm, firm, but was told she could work the but was told she could dodo tions, so only only if if she she found found aa job job in in aa different different department. department. She She did did find find a a job job so within the the same same firm firm but but was was unhappy unhappy there there and and eventually eventually decided decided to to within leave.She She is is now n o w working working in in another another firm firm that that is is more more sympathetiC sympathetic to to her her leave. needs. needs. Proving thatthat jobjob discrimination can be be difficult. difficult. If think you think Proving discriminationoccurred occurred can If you you you are are being being discriminated discriminated against against because because of of the the disclosure disclosure of of your your disorder disorder

(whether it itwas was you you or or someone someone else else who w h o made m a d e the the disclosure), disclosure), 1I would would adad(whether

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Opportunities vise vise you you to to consult consultan an attorney attorneyand andthe theEqual EqualEmployment Employment Opportunities Commission. Commission. They They can can help help you you determine determine if legal action action should should be be laken taken if aa legal against your current or or former former employer. employer. against your current Janine but decided Janine could could have have continued continued LO to pursue pursue her her legal legal case case but decided that that she she did did not not want want to to work work in in a a firm firm that that held held these these attitudes attitudes toward toward her. her. Deciding Deciding whether or or not to pursue pursue a a legal legal case case is is very verymuch m u c h aapersonal personaland and often oftenaafam­ famwhether not to ily decision. Consider Consider its its potential potential impact impact on on your your mood m o o d stability stability as as well well as as ily decision. the likely outcome posi­ the likely outcome of of the the case case (for (for example, example, being being reinstated reinstated in in your your old old position, which you you may m a y no no longer longerwant want or orfeel feelcomfortable comfortablein). in).Be Be prepared preparedfor foraa tion, which long long period period of of frustrations frustrations (and (and high high economic economic costs) costs) before before your your case case is is re­ resolved. solved. Nonetheless, Nonetheless, after afterweighing weighing all allof ofthe therelevant relevantfactors factorsyou youmay m a ywell wellde­ decide that your case case is is worth cide that pursuing pursuing your worth it. it. "Can My Employer Employer Whether I Bipolar Have Bipolar "Can My AskAsk Whether I Have DisorderrDisorder?"

The Americans Americans with v.ri.th Disabilities Disabilities ActAct makes it clear that employers are not to not to The makes it clear that employers are ask require their psychiatric exex­ ask direct direct questions questions about about your your disability disability or or require their own o w n psychiatric amination amination on on a a job job application application or or during during the the course course of ofyour your employment, employment,"un­ "unless such such examination examination or or inquiry inquiry is is shown shown to to be be job-related job-related and and consistent consistent less with business business neceSSity" necessity" (p. (p. 7). 7). They They can can require require a a medical medical examination examination after with after a job job offer offer has has been been made, made, if ifone oneis isrequired requiredof ofall allnew n e wemployees, employees, part a oror asas pan ofof an employee employee health health program. program. An A n example example would would be be a a physical physical exam e x a m reqUired required an for all new n e w personnel personnel at at a a nursing nursing home. home. for all Your employer employer would would have have to to prove prove that that inquiring inquiring about about your your mental mental Your health status status is is essential essentialto toknowing knowing whether whetheryou you can can perform perform your yourjob job duties duties health or whether you would would endanger endanger the the safety safety of of others. others. In In most most cases, cases, having having bi­ biwhether you or polar disorder disorder does does not not mean m e a n that that others others are are at at risk, risk, unless unlessyou you have have aadocu­ docupolar mented history history of of violence violence or or also also have have an an alcohol alcohol or or drug drug abuse abuse problem. problem. mented These associated associated problems problems could could jeopardize jeopardize the the safety safety of of others others (for (for example, example, These if you you work work at ataa child-care child-care faCility, facility,operate operateheavy heavymachinery, machinery,or ordrive drivea avehi­ vehiif cle). cle). If the the business business to to which which you're you're applying applying does does require require a a medical medical exam, exam, it it If has to to collect collect this this information information in in a a form form that that can can be be treated treated as as a a confidential confidential has medical record, record, meaning meaning that thatyou you would would have have to togive giveaaSigned signedrelease releaseof ofinfor­ informedical mation before before your your records records were sent to to anyone. anyone. However, However, the the doctor doctor or or nurse nurse mation were sent w h o examines examines you you can can inform inform a a supervisor supervisor or or manager manager of of work work accommoda­ accommodawho tions required by your disorder, as revealed in the medical exam. Likewise,ifif required by your disorder, as revealed in the medical exam. Likewise, tions your firm firm has has safety safety or orfirst aid personnel, personnel, they they may m a y be be informed informed that that your your biyour first aid bi­ polar disorder disorder could could require require emergency emergency treatment. treatment. These These disclosures disclosures may m a y or or polar m a y not not occur occur in in your your work work sening setting and, and, in in any any case, case, cannot cannotlegally legallybe beused used to to may discriminate against you. discriminate against you.

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should doyour if your current potential employer WhatWhat should you you do if current ororpotential employer asks asksabout aboutyour your psychiatric psychiatric history, history, either either directly directly or or on on a a job job application? application? You Y o u can can say say that that point you don't don't wish wish to to answer answer the the question question (or (or leave leave the the question question blank) blank) or or point you

out that that the the question question is is inappropriate inappropriate (Court (Court &. & Nelson, Nelson, 1996). 1996). If If your your em­ emout

you, you ployer presses presses you, you don't don't have have to to lie lie about about haVing having the the disorder. disorder. Just Just say say ployer you'd not discuss that you be­ you'd rather rather not discuss this this matter matter or or that you want want to to get get a a consultation consultation be-

fore you you discuss discuss it. fore it. A potential potential employer employer can can refuse refuse to to hire hire you you upon u p o n learning learning of of your your disorA disor­ der, der, but but only only if if he he or or she she can can prove prove that that the the disorder disorder will wiH interfere interfere with with your your made. In job functions functions and and that that no no reasonable reasonable accommodations accommodations can can be be made. In most most job

cases, he he or orshe she will willhave have aa tough tough time timeproving proving these thesepoints pointsjust justbecause because you you cases, have have bipolar bipolar disorder. disorder. Of O f course, course, you you would would need need to to initiate initiate legal legal action action

against your your prospective prospective employer employer to to make m a k e your your case. against case. Disadvantages of Disclosure: with Stigma at Work Disodvontoges of Disdos.re, DeolingDealing with Stigmo ot Work If your that youyou have a mood disorder, you may experience a If yourcoworkers coworkerslearn learn that have a mood disorder, you may experience a feeling in feeling of of stigma-the stigma—the sense sense that that your your behavior behavior is is being being viewed viewed negatively negatively in light Hght of of your your illness. illness. Usually Usually this thisstigma stigmawill willbe bemost mostsalient salientto toyou you right rightafter after a de­ a major major bout bout of of mania mania or or depreSSion, depression, in in part part because because you you will will still still be be depressed others. pressed or or hypomanic hypomanic and and possibly possibly more more attuned attuned to to the the reactions reactions of of others.

But even even people people whose whose bipolar bipolar disorder disorder has has been been stable stable can can feel feel stigmatized stigmatized at But at work. For For example, example, imagine imagine that that your your illness illness is is "leaked" "leaked" by by a a fellow fellow coworker coworker work. who w h o tells tells others others in in the the office. Julie, aged aged 55, 55, became became quite quite angry angry with with a a office. Julie,

coworker one one day, day, and and the the coworker coworker left left the the office office crying. crying. Julie Julie had had earlier coworker earlier disclosed disclosed her her illness illness to to a a woman w o m a n in in the the office office whom w h o m she she considered considered to to be be a a

close friend. friend.After Afterthe theincident incidentthis thisfriend friendtold toldothers othersin inthe theoffice officeabout aboutJulie's Julie's close illness, illness, as asaaway w a y of ofexplaining explainingwhy w h yJulie Juliehad had responded responded so soseemingly seemingly irratio­ irrationally. that, Julie nally. After After that, Juliefell feltthat thatothers othersviewed viewed her her with with apprehension. apprehension. The The stigma stigma you you experience experience at at work w o r k may m a y feel feel similar similar to to the the stigma stigma you you exex­ perience in perience in in your your family. family. For For example, example, coworkers coworkers may m a y interpret interpret problems problems in your your work w o r k as as stemming stemming from from your your illness, illness, even evenwhen w h e n you you can can point pointto toother other

employees who w h o have have the the same same problems problems (for (for example, example, being being late late with with assignemployees assign­ ments, ments, reacting reacting irritably irritably to to a a disorganized disorganized or or harsh harsh boss) boss).. You Y o u may m a y also also find find that that your your coworkers coworkers become become distant distant or or overly overly cautious cautious in in their their interactions interactions with with you. you. Coworkers Coworkers may m a y even even react react by by doting doting on on you you or or becoming becoming overly overly soso­ liciwus licitous (for (for example, example, frequently frequently asking asking if if you you want want to to talk talk about about your your prob­ problems, lems, repeatedly repeatedly reminding reminding you you that that ''I'm "I'm there there for for you"). you"). All All of of these these rere­

sponses can can feel feel unhelpful. unhelpful. To T o be be fair, fair, coworkers, coworkers, like like family family members, members, are sponses are often struggling struggling to to figure figure out out how h o w best best to to respond to your your disorder. often respond to disorder. On a a more m o r e hopeful hopeful note, note, mood m o o d disorders disorders carry carry less less of of a a stigma stigma than than they On they

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used ofof thethe bravery of many used to. to.Because Because bravery of many public figures whotalked have openly talked openly public figures who have (for about depression about their their experiences experiences of of bipolar bipolar disorder disorder or or unipolar unipolar depression (for exam­ example, ple, Kay Kay Jamison, Jamison, Elizabeth Elizabeth Wurtzel, Wurtzel, Carrie Carrie Fisher, Fisher, Patty Patty Duke, Duke, Robert Robert Boorstin, Boorstin, Margot Margot Kidder, Kidder, Mike Mike Wallace, Wallace, William William Styron), Styron), and and because because of of events in­ events such such as as the the National National Depression Depression Screening Screening Day, Day, the the public public has has an an increased result, creased awareness awareness and and a a greater greater acceptance acceptance of of mood m o o d disorders. disorders. As As a a result, you you may m a y get get more more understanding understanding from from olhers others than than you you expected. expected. What Are Arethe the Advantages of Disclosing? What Advantages of Disclosing? There are are arguments arguments in in favor favor of of being being open open about about your your disorder disorder as as well. well. First, First, There disclOSing disclosing can can be be destigmatizing destigmatizing and and increase increase your your own o w n acceptance acceptance of of the the ill­ illness. ness. You Y o u may m a y feel feel that that bipolar bipolar disorder disorder is is not not so so shameful shameful if if you you tell tell a a coworker coworker and and he he or or she she does does not not have have a a strong strong negative negative reaction. reaction. Upon U p o n learn­ learning ing of of your your disorder, disorder, aacoworker coworker may m a y admit admitto tohaving havingexperienced experienced depression depression or having having a a family family member m e m b e r or or friend friend who w h o has has bipolar bipolar disorder. disorder. But But to to whom whom or reac­ you you disclose disclose requires requires careful careful thought thought. Kay Kay Jamison Jamison (1995) (1995) describes describes the the reactions tions of of others others upon upon learning learning of of her her disorder, disorder, which which varied variedfrom from empathic empathic ac­ acceptance ceptance to to outright outright rejection rejection and and insensitivity, insensitivity, in in An A n UnqUiet Unquiet Mind. Mind. When W h e n considering considering whether whether or or not not to to disclose disclose your your disorder disorder to to a a coworker coworker or employer, employer, first first ask ask yourself yourself several several questions questions (Court (Court & & Nelson, Nelson, 1996). 1996). or

Why Why do you him or herorto know? dowant you want him her to know? H o w will will it it make m a k e your your life lifeat atwork work easier-will easier—willititlead leadtotoaaspecific specificwork work How accommodation? accommodation? Will it it be behelpful helpfulfor forsomeone someone to toknow k n o w about aboutyour your disorder disorderif ifthere thereis isan an Will emergency at at work? work? emergency Will you you feel feel closer closer to to this this coworker-is coworker—is he he or or she she a a potential friend? Will potential friend? Will his his or or her her knowledge knowledge of of your your disorder disorder help help you you explain explain absences absences or or Will lapses in in your your work work productivity productivity to to your your boss? boss? lapses If there thereis isno no reason reason to toexpect expect that thatthe the illness illnesswill willimpair impair your your work, work,why why If does he he or or she she need need to to know? know? does SomeSome of myofclients have chosen oneone trusted about my clients have chosen trustedperson personatatwork workto to tell teU about the disorder. disorder. Sharing Sharing this this kind kind of of personal personal information information helps helps to to increase increase mu­ muthe tual trust trust and and can can create create an an atmosphere atmosphere of of support support within within the the work w o r k seuing. setting. If If lOal i t seems appropriate, use the Quick Fact Sheet (on pages 260-261) intended it seems appropriate, use the Quick Fact Sheet (on pages 260--2 61) intended for family family members members to to help help you you explain explain the the illness illness to to this this coworker. coworker. for There are ways to tell people of your disorder without actually using using the the are ways to tell people of your disorder without actually There label "bipolar." "bipolar." For For example, example, your disorder can can be be described described as as "a "a chemical chemical your disorder label imbalance that affects m y m o o d " or "a medical problem related to m y energy imbalance that affects my mood" or "a medical problem related to my energy

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my affect my level like explanations concentration." work level that that can can affect work and and concentration." Simple Simple explanations like these these may m a ybe b e all all that that employers e m p l o y e r s or or coworkers c o w o r k e r s require require to to understand u n d e r s t a n d why w h y your your work or w o r k performance p e r f o r m a n c e has h a s shifted, shifted, or or why w h y you y o u have h a v e been b e e n irritable, irritable, withdrawn, w i t h d r a w n , or absent lately. lately. absent DisclOSing Disclosing to to your y o u r boss b o s s early early on o n may m a y set set the the stage stage for for later later changes c h a n g e s in in the the

structure or or demands d e m a n d s of of your y o u r job j o b (see (seethe thesidebar sidebar on o npages pages 284-2 8 4 -2285). 8 5 ) . You You structure m a y have h a v e more m o r e legal legal protection protection if if you y o u disclose disclose your y o u r bipolar bipolar disorder disorder when when may time, you you you are are well. weH. 1f If your your employer employer knows k n o w s ahead ahead of of time, you can can problem problem solve solve pe­ with him him or or her her about about what what accommodations accommodations seem seem reasonable reasonable during during your your pewith

riod of of illness Hlness and and once once you you have have begun begun to to recover recover (as (as Louise Louise did). did). riod There There may m a y be be instances instances when w h e n you you feel feel you you must must disclose disclose the the disorder disorder to to your your boss, boss, such such as as when w h e n you've you've had had multiple multiple absences absences or or aa clear clear deterioration deterioration

in your your work work productivity. productivity. Some S o m e people people decide decide to to wait wait to to see see if if their their perfor­ perforin mance mance actually actually does does slip, slip,and andthen thendisclose disclosethe thedisorder disorderto tothe theboss bosswhen w h e n ask­ ask-

ing for for time time off off or or other other work w o r k ad adjustments. This can can be be a a sensible sensible plan, plan, but but justments. This ing timing timingisisimportant: important:Your Yourboss bossmay m a yfeel feelannoyed annoyedby bythis thisdisclosure disclosureififititoccurs occurs in in the the midst midst of of trying trying to to meet meet an an important important deadline. deadline. Also, Also,when w h e nyou youare arein inan an active active period period of of illness, illness, you you may m a y not notbe beable ableto totell teHififyour yourwork work performance performance

has changed changed or or that that you you need need accommodations. accommodations. has

Self-Care Strategies Strategies for for (oping Coping Effectively Effectively in in the the Work W o r k Selling Setting Self-Care Adjusting Ihe the Work Work Selling Setting 10 to Your Your Disorder Disorder Adiusling

There is There isvirtually virtually no research literature onkinds what of kinds of best jobs for arepeo­ best for pe jobs are on what literature no research

ple with with bipolar bipolar disorder. disorder. We W e suspect suspect that that people people with with the the disorder disorder should should ple avoid jobs that involve involve sudden sudden bursts of social stimulation with with little down little down social stimulation bursts of jobs that avoid time in in between between (for (for example, example, being being a a waitress waitress at at a a bar with a a "happy hour"), "happy hour"), bar with time frequent travel across time time zones, zones, or or conSistently consistently stressful with interactions with stressful interactions travel across frequent others others (for (for example, working in in aa hospital hospital emergency emergency room) room).. We W e also also suspect suspect example, working

that people with the the disorder disorder do do better better with with constant constant w o r k hours predict­ and predicthours and work people with that able able workdays workdays than in jobs requiring shifting schedules (for (for example, example, working working shifting schedules jobs requiring than in

on weekdays e e k and weekends the the next, next, or shifts evening shifts working evening or working then weekends and then week one w weekdays one on followed in restaurants, manufacturing, restaurants, manufacturing, Jobs in ones). Jobs morning ones). by morning immediately by followed immediately nursing, and and retail retailsales salesoften often require require variable variable shifts, shifts,whereas whereasjobs jobsin inaccount­ accountnurSing, ing, schools are are usually consis­ more consisusually more and schools banking, and programming, banking, computer programming, ing, computer tent. But tent. But if ifthe thejobs jobs in in the theformer former category category appeal appeal to to you, you, you you may m a y not not have have to to rule them rule some obtain some can obtain you can whether you determine whether to determine try to but try them but Pursue them out. Pursue them out.

284-285. of pages 284-285. on pages sidebar on the sidebar in the listed in accommodations listed the accommodations of the

W h a t constitutes or innovations or are innovations These are accommodations? These reasonable accommodations! constitutes reasonable What modifications o r k schedule that give give you more a more you a schedule that work or w requirements or job requirements your job in your modifications in

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Reasonable Workplace W o r k p l a c e Accommodations Accommodations Reasonable

for for Persons Persons with with Bipolar Bipolar Disorder Disorder

Work W o r k Hours Hours •

regular daily hours rather thanthan variable night/day • Working Working regular dailyorornightly nightly hours rather variable night/day work w o r k shifts shifts • Being Being assigned assigned work w o r k shifts shifts that that fit fitbest bestwith withyour yourcircadian circadianrhythms rhythms

•

0 A.M.-7 (for (for example, example, 110 a.m.-7 P.M. p.m.instead insteadof of88 A.M.-S a.m.-5P.M.; p.m.;working workingthree�hour three-hour

shifts five days shifts for forfive days rather rather than than five�hour five-hour shifts shifts for for three three days) days)

voiding work •A Avoiding work early early in in the the morning morning if ifyou you suffer sufferfrom from "medication "medication

•

hangovers" hangovers" •

• RedUcing Reducing work work hours hours or or changing changing from from full�time full-time to to part-time part-time

•

• Being Being excused excused from, from, or or getting getting reductions reductions in, in,overtime overtime work work

•

• Completing Completing some some of ofyour your tasks tasks at at home h o m e versus versus at atwork work

Stress Management Management Stress •

• Being Being allowed allowed to toshare share responsibilities for projects with others responsibilities for projects with others

•

• Being Being placed placed in in an an office office or or cubicle cubicle that that has has aa degree degree of of distance distance from from noise and and stimulation stimulation noise

•

• Working Working in in well-lit, well-lit,uncrowded uncrowdedrooms rooms

•

• Being Being excused excused from from certain certain work work assignments assignments that that histOrically historically have have been triggers triggers for for your your mood m o o d swings swings been • Obtaining Obtaining support support or or counseling counseling from from an an employee employee assistance assistance program program

• •

• Leaving Leaving work w o r k for for breaks breaks or or lunch lunch to to decompress, decompress,exercise, exercise,walk, walk,or or use self-relaxation self-relaxation techniques techniques use

•

• Taking Taking aa greater greater number number of of short short breaks breaks rather rather than than two two long long breaks breaks during an an eight-hour eight-hour work w o r k shift during shift

Absences from from Work Work Absences •

• Being Being granted grantedbrief brief absences medical appointments, chances absences forfor medical appointments, withwith chances to make m a k e up up the the hours hours to

•

• Being Being granted granted extended extended leaves leaves of of absence absence with with aa doctor's doctor's note note

•

• Being Being allowed allowed to to leave leave work work early early when w h e n having having difficult difficult mood m o o d swings swings or anxiety/stress anxiety/stress reactions reactions or

Coping Effecti Effectively the FamilV Family and and Wask Work Settings Settings Coping vely inin the

2 28S 85

Communication Communication with with Your Your Employer Employer about about P�rformance Performance Evaluations Evaluations •

andand open communication withwith your your employer • Having Havingregular regular open communication employer about your your job job performance performance about • Hearing Hearing what what you're you're doing doing right rightas aswell weH as aswhat what you're you're doing doing • wrong wrong

• Being Being judged judged by by overall overaH productivity productivity and and task task completion completion as as well weH as number number of of hours hours worked worked as • Revisiting Revisiting these these accommodations accommodations from from time time to to time time to to determine determine • if they they are are enabling enabling you you to to be be productive and remain remain stable productive and stable if

•

equal equalshot shotat at successful successfulemployment. employment.Reasonable Reasonableaccommodations accommodations are are usually usually requested byby requested by by you you as as the the employee, employee, and andare aregenerally generallynot notoffered, offered,up upfront, front,

the employer. employer. Remember Remember that that your your employer employer cannot cannot be be expected expected to to provide the provide accommodations accommodations without without knowing knowing about about your your disorder disorder and and why why these these accom­ accom-

modations are are required. modations required. The that The sidebar sidebar on on pages pages 284-285 284-285 lists lists examples examples of of accommodations accommodations that might not meant to might be be reasonable reasonable to to request request of of an an employer. employer. These These items items are are not meant to

reflect the the ad adjustments that aU all people people with with bipolar bipolar disorder disorder should should expect. reflect justments that expect. Rather,they theyare are meant meantas as examples examplesof of things thingsyou youcan canask askfor. for. Try Trytoto detennine determine Rather, which which of of these these are are negotiable negotiable for for you you and and which which are are not. not. It It is is highly highly unlikely unlikely that thatany anyemployer employer would would grant grantall all or oreven evenaamajority majorityof ofthem them (and (andsome somemay may be be against against the the nature nature or or policies policies of of the the finn). firm). Nonetheless, Nonetheless, your employer your employer might might approve approve enough enough of of these these ad adjustments to help help you you function function better better at at justments (0 work. work. Note Notethat thatsome some accommodations accommodations would would also alsobenefit benefitemployees employeeswho w h o do do not not have have bipolar bipolar disorder disorder but but who w h o are are seeking seeking ways ways to to manage manage stress. stress.

It is is not not always always possible possible (0 to know know in in advance advance which which accommodations accommodations will It will work for for you, you, but but your your employer employer will will probably probablybe bemost mostopen open to tothese theserequests requests work once you you have have been been offered offered the the job job and and are are in in the the negotiation negotiation phase. Some of phase. Some of · onCe the items items (for (for example, example, changing changing from from full-time full-time to to part-time part-time work, work, negotiat­ negotiatthe ing ing leaves leaves of of absence, absence, the the style style of of employer/employee employer/employee perfonnance performance evaluaevalua­ tions, tions,asking askingthat thatyour youroffice office moved) mayneed needtotobebe negotiated later, once bebe moved) may negotiated later, once

you have have worked worked at at the the job job for for aa period period of of time time and and have have identified identified problems problems you with the the existing existing structure. structure. with Ralph, 52, 52, worked workedas asthe theprimary primaryshort-order short-ordercook cookin inaarestaurant, restaurant,where where Ralph, he he supervised supervised two two other other cooks. cooks. He He detennined determined that that he he was was prone prone to to hyperac­ hyperac-

tivity, irritability, irritability, and and inefficiency inefficiency on on nights nights when when the the restaurant restaurant activity tivity, activity reached aa certain certain volume. volume. With With the thesupport supportof of his his employer, employer,he helearned learnedtotodeldelreached

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egate the supervising food preparation to onc of the cookscooks at egate the task taskofof supervising food preparation to one of other the other at those those times. times. He H e would would then then continue continue his his shift shift as as the the secondary secondary cook cook and and would would take take over over again again as as primary primary cook cook the the next next day. day. Tina, Tina, age age 59, 59, worked worked for for a a research research firm firm that that aSSigned assigned employees employees to to closely to closely interconnected interconnected cubicles. cubicles. One O n e of of her her coworkers coworkers insisted insisted on on listening listening to his his radio radio while while working, working, which which was was not not against against company company policy policy but but was was very very disturbing disturbing to to Tina. Tina. She She became became unable unable to to concentrate. concentrate. She She tried tried to to reason reason with with the the coworker, coworker, who w h o expressed expressed mock m o c k sympathy sympathy and and then then went went back back to to playing playing his his radio. radio. She She became became mOTe more and and more more irritated irritated and and noticed noticed that that her her thoughts thoughts began began to to race. race. She She eventually eventually consulted consulted her her boss boss about about the the problem problem without without Her boss explaining explaining that that she she had had bipolar bipolar II II disorder. disorder. Her boss felt felt that that Tina Tina was was a a good good employee employee and and decided decided to to let let her her move m o v e to to a a smaller smaller room r o o m where where she she would would have justment helped previ­ have less less contact contact with with others. others. This This ad adjustment helped Tina Tina restore restore her her previous ous level level of of productivity. productivity. Beth, Beth, a a 44-year-old 44-year-old woman w o m a n with with bipolar bipolar II disorder, disorder, discovered discovered that that her her mood m o o d swings swings were were at at their their worst worst at at the the onset onset of of her her menstrual menstrual period. period. She She worked had unable, for a variety of of worked at at aanews newsoffice officewith withvariable variableshifts; shifts;she she hadbeen been unable, for a variety financial financial and and personal personal reasons, reasons, to toobtain obtainregular regularhours. hours.Despite Despitethe theloss lossof ofpay, pay, she just she decided decided to to ask askto tobe beexcused excusedfrom fromeight-hour eight-hourwork workshifts shiftsin inthe thetwo twodays days just to the onset of her menstrual period. She resumed work at her normal pace prior to the onset of her menstrual period. She resumed w o r k at her normal pace prior ycle were once the the worst worst mood m o o d sswings associated with with her her menstrual menstrual c cycle were over. over. once wings associated Balancing Work Work Time Timeagain" against DownTime Time Balan,ing Down One work-related difficulty heard expressed by a number of people One work-related difficulty I'veI've heard expressed by a number of people with with bipolar disorder is the feeling of being wired and driven at work and then feelbipolar disorder is the feeling of being wired and driven at work and then feel­ ing spent, spent, exhausted, exhausted, or or depressed depressed once once home h o m e for for the the night. night. Their problems ing Their problems are compounded on the weekend if there is little to do and they feel liketheir their are compounded on the weekend if there is little to do and they feel like body and and brain brain have have shut shut down. down. As As a a result, result, some some people people feel feel hypomanic hypomanic body w h e n they're working and depressed w h e n they're not. when they're working and depressed when they're not. This form form of of cycling cycling is is most most likely likely to to happen happen when w h e n you you start start a a new n e w job. This job. Like most other n e w employees, you probably want to perform at your peak Like most other new employees, you probably want to perform at your peak and begin begin pushing pushing yourself yourself hard. hard. But But a a cycle cycle can can occur occur in in which which you you try try to and to produce at your m a x i m u m and are quickly rewarded with praise, compensaproduce at your maximum and are quickly rewarded with praise, compensa­ tion, or or advancement advancement by by an an appreciative appreciative boss. boss. This This reward reward may m a y make m a k e you you tion, drive yourself yourself even even harder, harder, leading leading to to more more reward reward but but also also more more hypomania hypomania drive or even even mania. mania. As As I1 mention mention in inChapter Chapter 5, 5,johnson Johnsonand andher hercolleagues coHeagues(2000) (2000) or found that that "goal "goal attainment attainment life life events" events" (events (events that that involve involve reward reward or or ad­ adfound vancement and and that that increase increase your your drive drive toward toward other other goals) goals) are are particularly particularly vancement potent in in preCipitating precipitating manic manic episodes. episodes. Unfortunately, Unfortunately, these these manic manic states states of­ ofpotent ten lead lead into into a a depreSSive depressive or or mixed mixed episode, episode, along along with with negative negative thoughts thoughts and and ten

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yourcapabiHties capabilities used to able be able to accomplish so much"). feelings about your ("1("I used to be to accomplish so much"). feelings about In turn, turn, your your boss, boss, who w h o may m a y not not know k n o w about about your your disorder, disorder, may m a y compare compare In first your performance performance when w h e n depressed depressed to to the the way w a y you you performed performed when w h e n you you first your started in his started the the job job (rather (rather than than to to the the performance performance of of other other workers workers in his or or her her

firm). firm). He H e or or she she may m a y wonder wonder what what happened happened to to you. you. job, try measured apap­ When W h e n you you first first start start a a job, try to to take take a a more more cautious, cautious, measured the proach. Turn Turn in in a a consistent consistent work w o r k performance performance and and get get your your footing footing in in the proach. new job, job, but but don't don't try try to to be be a a superstar superstar at at the the outset. outset. Know K n o w when w h e n you you are are overover­ new "start-stop" stressing yourself. yourself. It's It's better better to to be be a a consistem consistent employee employee than than a a "start-stop" stressing employee, on on whom w h o m others others are are unsure unsure they they can can depend. depend. employee, W h e n you you get get home h o m e from from work, work, allow allow yourself yourself to to relax relax but but also also introduce introduce When some structure structure (see (see Chapter Chapter 8) 8) and and a a degree degree of of low-key low-key stimulation. stimulation. Avoid Avoid some scheduling lots lots of of demanding demanding social social activities activities for for the the weekday weekday evenings. Durscheduling evenings. Dur­ ing weekends, avoid "sleep bingeing" (for example, sleeping 12 or more hours ing weekends, avoid "sleep bingeing" (for example, sleeping 12 or more hours and getting getting up u p late) late) to tocounteract counteractyour yourfatigue fatiguefrom fromgetting gettingup up at at66A.M. A.M.every every and morning during during the the week. week. Instead, Instead, keep keep your yourbedtimes bedtimesand andwake wake times timesduring during morning the weekend weekend to to within one hour hour of of your your times times during during the the week. week. Plan the within one Plan a a social social you'll activity or or exercise exercise for for the the mornings mornings during during the the weekend weekend to to assure assure that that you'll activity be regu­ be out out of of bed bed by by a a certain certain time. time. That That way, way, your your internal internal clock clock will will stay stay regulated as as you you transition transition from from the the work w o r k week week to to the the weekend. weekend. lated These These recommendations recommendations may m a y sound sound rigid, rigid,but butthey theywill willhelp helpyou you function function in the the early early stages stages of of your your new n e w job. O n c e you you have have worked worked at at a a job for a a while while in job. Once job for and and have have settled settled into into a a routine, routine, you you may m a y be be able ableto tointroduce introduce more more flexibility flexibility into into your your daily daily habits habits without without sacrificing sacrificing your your mood m o o d stability. stability. This This balance balance varies varies considerably considerably from from person person to to person, person, so so take take your your time time to to find find the the solusolu­ tion tion that that works works best best for for you. you.

Using Vocational Vocationa'Rehabilitation RehabilitationSupport Support Using If you you have have been been having having trouble trouble finding finding a a job job that that is is suitable suitable for for you, you, or or troutrou­ If ble keeping keeping jobs, jobs, you you may m a y want want to toconsider considervocational vocationalcounseling. counseling.Most Most states states ble

have have a a Division Division of of Vocational Vocational Rehabilitation Rehabilitation devoted devoted to to helping helping people people with with disabilities. Generally, Generally, you you will wiH not not have have to to pay pay for for these these services. services. To T o locate locate disabilities. these services services in in your your area, area, call call the the local local mental mental health health center center or or your your city city or or these town's town's Chamber C h a m b e r of of Commerce, C o m m e r c e , or or look look in in the the phone phone book book under under "State" the " State" in in the

government listings. government listings. Vocational rehabilitation rehabHitation specialists speciaHsts can can help help you you develop develop a a plan plan for for findVocational fmd­ ing and performing successfully in a job. These plans are focused on what you successfully in a job. These plans are focused on what you ing and performing want to to achieve achieve (for (for example, example, part-time part-time versus versus full-time full-time employment; employment; peoplewant people­ oriented versus versus more more solitary solitary work w o r k settings). settings). Rehabilitation RehabHitation can can involve involve vocaoriemed voca­ tional testing testing (for (for example, example, questionnaires questionnaires regarding regarding your your interests, interests, environtional environ-

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ments you you enjoy, enjoy, or or job training in job-seeking shills skills (for example, ments job skills); skills); training in job-seeking (for example, writing writing a a resume, resume, making making initial initial telephone telephone calls calls to to an an employer, employer, and and effective effective interviewing strategies); and job development (locating jobs in the community interviewing strategies); and job development (locating jobs in the community or skills). or sometimes sometimes even even designing designing them them to to fit fit your your aptitudes aptitudes and and skills). Job ]ob co coaching is often often the the most most active active component component of of vocational vocational rehabilitaaching is rehabilita­ tion. tion. A A job jobcoach coachgoes goeswith withyou you to toaanew n e wjob jobsite, site,helps helpsyou youlearn learnthe therequired required tasks, tasks, and and encourages encouragesyou you to tostay staymotivated. motivated.He H e or orshe shecan can facilitate facilitatecommu­ communication nication between between you you and and your your boss. boss. A A job job coach coach may m a y help help explain explain your your disordisor­ der der to to yOUT your supervisor supervisor and and clarify clarify any any special special considerations considerations you you may m a y require require (for (for example, example, a a work work environment environment with with as as few few distractions distractions as as possible). possible). Employers Employers may m a y listen listen and and respond respond more more readily readily to to a a job job coach coach than than to to an an employee. stressed employee. jamal, Jamal, a a 25-year-old 25-year-old man m a n with with bipolar bipolar II disorder, disorder, became became stressed by by his his job job at atan an auto auto parts parts store store after afterbeing being switched switched from from one one sales salesarea area to toan­ another. other. He H e didn't didn'tlike likehis hisnew n e w supervisor, supervisor,whom w h o mhe hefound foundsarcastic sarcasticand andunsym­ unsympathetic the disorder. pathetic to to the the limitations limitations imposed imposed by by the disorder.just Justbefore beforehe he qUit,jamal's quit, Jamal's job the disorder job coach coach interceded interceded and and explained explained the disorder to to this this supervisor. supervisor. They They agreed agreed on on rules rules for for their their working working relationship relationship and and strategies strategies by by which which Jamal Jamal could could temporarily temporarily leave leave the the setting setting when w h e n he he felt felt ovelWhelmed overwhelmed by by il. it. He H e even­ evenLUally fact that tually left left this thisjob joband andfound foundaanew n e wone, one,but buthe hefell feltempowered empoweredby bythe the fact that when w h e n he he left, left, his hissupervisor supervisorhad had changed changed his hisstyle styleof ofdealing dealingwith withhim. him. Job coaches coaches can can also also be be helpful helpful if ifyou you need need aaleave leaveof ofabsence absence from from work. work. job you need need to tobe be hospitalized hospitalized for foraa manic manic or or depressive depressive episode, episode,you youmay m a ynot not IIf f you be in in a a condition condition to to ask ask your your employer employer for for a a leave. leave. A A job job coach coach can canwrite writeaalet­ letbe ter or or call call your your employer employer to to advocate advocate on on your your behalf. behalf. ter Applying for forDisability Disability Applying If youhave havehad hada series a series of illness episodes or unremitting symptoms If you of illness episodes or unremitting symptoms and haveand have been unable unable to to function function at at work, work, you you may m a y wanl want to to apply apply for for disability disability pay­ paybeen ments. If Ifyou you have have preViously previously paid paid for forshort-term short-term or or long-term long-term private privatedisabil­ disabilments. ity insurance insurance through through your your employer, employer, you you may m a y be be eligible eligible for for payments payments with with ity an accompanying accompanying doctor's doctor's order. order. You Y o u may m a y also also apply apply for for disability disabflity payments payments an through (he the Social Social Security Security Administration. Administration. Social Social Security Security payments payments are are not not through large (for (for example, example, about about $500 $500 per per month), month), but but they they can can help help support support you you large during a a period period of of work work disability. during disability. Usually, you you apply apply for for disability disabflity through through a a liaison Haison at at your your local local Social Social Se­ SeUsually, curity Office. Office. The The application application process process can can be be long long (about (about six six months) months) and and ofcurity of­ ten frustrating. frustrating. The The procedure procedure usually usually requires requires that that your your doctor doctor and and psycho­ psycholen to therapist prOVide provide medical medical records records and and answer answer questions questions about about your your ability abihty to therapist work. IIf you are arein in touch touch with with aavocational vocational rehabilitation rehabihtation counselor, counselor,he he or or she she work. f you m a y be be able able to to acquaint acquaint you you with with the the application application procedures procedures or or recommend recommend may

Coping Effedively Effectively in in the the Fomilv Family and and Work Work Senings Settings (oping

2 289 89

someone whocan. can. Because of of thethe process, you may be more sta­ stasomeone who Because of of the thelength length process, you may be more ble first applied! applied! ble by by the the time time your your payments payments arrive arrive than than you you were were when w h e n you youfirst Receiving Receiving disability disabflity does does not not mean m e a n you you have have to to abandon abandon the the idea idea of of work­ working (for example, example, ing in in the the future. future. You Y o u can can be be on on disability disabihty for for a a period period of of time time (for during during a a long-term long-term depression depression that that is is not not responding responding well w e H to to medication) medication) and and

on disabildisabil­ then then reconsider reconsider the the working working world world once once you you have have recovered. recovered. Being Being on ity should should not not have have to to be be stigmatizing stigmatizing or or shameful. shameful. In In fact, fact, many m a n y people peoplewith with ity they need this bipolar disorder disorder and and other other medical medical disorders disorders conclude conclude that that they need this bipolar

kind of of support. support. In In the the Boston Boston University University survey survey of of professionals professionals and and manag­ managkind ers, one-third one-third had had received received disability disability payments payments at at some some point point in in their their past past ers, (Ellison & & Russinova, Russinova, 2001). 2001). (Ellison

*

*

*

Despite Despite the the toll toll that that bipolar bipolar disorder disorder can can take take on on your your family family and and work work

life,I Istrongly stronglybelieve believethat thatyou youcan canlearn learnto tocope copeeffectively effectivelyin inboth bothsettings. settings.As As life, you've under­ you've just just seen, seen, coping coping involves involves being being comfortable comfortable with with your your own o w n understanding limitations, standing of of the the disorder, disorder, educating educating others others about about it, it, knowing knowing your your limitations, setting envi­ setting appropriate appropriate expectations expectations for for yourself, yourself, and and trying trying to to adjust adjust your your environment to ronment to maximize maximize the the chances chances that that you'll you'll function function at at your your best. best.Remember Remember

to for support when torely relyon on the the help help of ofothers others (friends, (friends,family, family,and andcoworkers) coworkers) for support when it it seems seems appropriate. appropriate. Connie Connie Hammen H a m m e n and and her her colleagues colleagues (2000) (2000) found found that that the people people who w h o did did best best within within the the work w o r k setting setting were were those those who w h o had had strong strong the social and and relationship relationship support support outside outside of of work. work. social N o w that that you you have have arrived arrived at at the the end end of of this this book, book, II hope hope you have beNow you have be­ come convinced convinced that that the the strategies strategies recommended recommended here-learning here—learning as as much m u c h as as come you you can can about about the the disorder, disorder, getting getting consistent consistent medical medical treatment, treatment, taking taking

advantage of of psychotherapy, psychotherapy, relying relying on on social social supports, supports, and and using using selfself­ advantage management tools—can help you you cope cope with with the the disorder disorder on on a a day-to-day day-to-day management tools-can help basis. Bipolar Bipolardisorder disorderposes posesmany m a n y challenges challengesthat thatare arehard hardfor foranyone, anyone,except except basis. those those suffering suffering from from it, it, to to understand. understand. As A s one one client client who w h o has has been been stable stable for for some some time time articulately articulately expressed, expressed, "I "I have have learned learned to to manage manage my m y disorder disorder rather it." rather than than being being managed managed by by it."

R e s o u r c e s Jor f o r People People Resources w i t h Bipolar B i p o l a r Disorder Disorder with

National Organizations Organizations National Depression deDepression and andBipolar Bipolar Support SupportAlliance Alliance (800-826-3632; (800-826-3632; www.dbsalliance.org) www.dbsalliance.org) is is de­ voted to to educating educating consumers consumers and and their their family family members members about about mood m o o d disorders, disorders,decreas­ decreasvoted ing the the public public stigma stigma of of these these illnesses, illnesses, foster fostering self-help,advocating advocatingfor forresearch researchfund­ funding ing self-help, ing, and improving access access to to care. care. Y o u can can fill out aa confidential confidential on-line on-line mood m o o d disorder disorder ing, and improving You fill out screening questionnaire questionnaire to to help you identify identify whether whether you you have the signs signs of of bipolar bipolar disorscreening help you have the disor­ der. Positive Positive results results from from this this questionnaire questionnaire suggest suggest that that aa more comprehensive mental mental der. more comprehensive health evaluation evaluation may m a y be be necessary. necessary. health National Alliance Alliancefor forthe theMentally MentallyIII111 (800-950-NAMI;www.namLorg) www.nami.org) isisa agrass grass roots, National (80D-950-NAMI; roots, self-help, support support and and advocacy advocacy organization organization for forpeople peoplew with severemental mental illnesses illnesses(in­ (inself-help, ith severe cluding bipolar disorder, recurrent recurrentdepression, depression,and andschizophrenia), schizophrenia),their theirfamily familymembers, members, cluding bipolar disorder, and friends. and friends. Child and Adolescent Adolescent Bipolar Bipolar Foundation Foundation(847-256-8525; (847-256-8525;www.bpkids.org), www.bpkids.org)a, aparentparent­ Child and led organization, organization, provides provides information information and and support support to to family family members, members, health-care pro­ proled fessionals, and and the thepublic public concerning concerning bipolar bipolardisorders disordersin inthe theyoung. young.CABF C A B F advocates advocatesfor for fessionals, health serviCes services and and research research on o n the nature, causes, causes, and and treatmenl treatment of of early-onset early-onset bipolar bipolar health the nature, disorder. Particularlyuseful usefulis isinformation informationon onhow h o wtotolocate locatea amental mentalhealth healthprovider providerwho who di sorder. Particularly sees bipolar children in your area. area. Bipolar SignificantOther OtherMailing Mailinglist List(www (www.bpso.org) e-mail exchange groupinin Bipolar Significant .bpso.org) s i is anane-mail exchange group which members—relatives or or friends of persons persons with with bipolar bipolar disorder-share disorder—share information information which members-relatives friends of 290

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about provide support one another, and problem related about the the illness, illness, provide supporttoto one another, and problemsolve solveabout aboutissues issues related

to the the impact impact of of the the illness illness on o n families families and and intimate intimate relationships. relationships. to (617-726-6188; MassachusettsGeneral General Hospital Bipolar Clinic and Research Program Massachusetts Hospital Bipolar Clinic and Research Program (617-726-6188; 617-724-6058; for evaluation, 617-724-6058; www w w w .. manicdepressive.org) manicdepressive.org) provides provides information, information, referrals referrals for evaluation, research, and self-care LOols (for example, a downloadable mood chan) to treatment, research, and self-care tools (for example, a downloadable m o o d chart) to per­ pertreatment, sons with bipolar disorder and their families. sons and families. andDepression Depression (800-829-8289; www. National Alliance for for Research Research on on Schizophrenia Schizophrenia and (800-829-8289; www. National Alliance narsad.org) to narsad.org) is is the the largest largest donor-supported, donor-supported, nongovernment nongovernment organization organization dedicated dedicated to into the raising and and distributing distributing funds funds for for research research into the nature, nature, causes, causes, treatments, treatments, and and pre­ preraising vention of of severe severe mental mental illnesses, illnesses, including including bipolar bipolar disorder, disorder, schizophrenia, schizophrenia, depression, depression, vention and di­ and severe severe anxiety anxiety disorders. disorders. Their Their website website includes includes up-to-date up-to-date information information about about the the diagnosis and and treatment treatment of of severe severe psychiatric psychiatric disorders. disorders. agnosis

National Mental HealthHealth Publications (www.nimh.nih.gov/publicat/ National Institute Instituteof of Mental Publications (www.nimh.nih.gov/publicall bipolar.cfm) provides provides excellent excellent up-to-date up-to-date information information on o n the the symptoms, symptoms, course, course, causes, bipolar.cfm) causes, and and treatment treatment of of bipolar bipolar disorder. disorder. Separate Separate sections sections are are devoted devoted to to child child and and adolescent adolescent bipolar illnesses, bipolar illness, illness, suicide, suicide, medical medical treatments treatments and and their their side side effects, effects, co-occurring co-occurring illnesses, psychosocial treatmems, treatments, sources sources of of help help for for individuals individuals and and families, families, and and clinical clinicalresearch research psychosocial studies. studies. National Mental BOO-SUICIDE; www.nmha.org) is the MentalHealth Health Association (crisisline: line: 800-SUICIDE; National Association (crisis www.nmha.org) is the oldest largest nonprofit aspects of oldest and and largest nonprofit organization organization in in the the United United States States that that addresses addresses all all aspects of mental health health and and illness. illness. Research Research information, information,legislaive legislaiveupdates, updates,and and practitioner practitioner refer­ refermental rals rals are are available available on o n its its web w e b site. site.

Pendulum Resources (www.pendulum.org) offersoffers information about about the DSM-IV diag- diag­ Pendulum Resources (www.pendulum.org) information the DSM-IV nostic criteria, criteria, current current medical medical treatments, treatments, books books favored favored by by mental mental health health consumers consumers nostic and family family members, m e m b e r s , articles articles on o n how h o w to to cope cope w with depression or or bipolar bipolar disorder in your­ yourand ith depreSSion disorder in selfor or aa loved loved one, one,writings writings and and poetry poetry by by people people with with bipolar bipolar disorder, disorder,links linksto toother otherrel­ relself evant studies. evant sites, sites, and and updates updates on o n research research studies. Depression SiteSite (www.psycom.net/depression.central.bipolar.html) is anis an DepressionCentral CentralWeb Web (www.psycom.nelldepression.cemral.bipolar.html) informational web w e b sit that offers offers links links to to the the MMayo a y o Clinic's Clinic's bipolar bipolar homepage; homepage; answers answers fresit that fre­ informational quently asked asked questions questions about about bipolar bipolar disorder; disorder; discusses discusses treatment treatment guidelines; guidelines; gives gives up­ upquently to-date information information on o n topics topics such such as as novel novel treatment treatment approaches, approaches, use use of of lithium lithium during during to-date pregnancy, sleep sleep deprivation, deprivation, differential differential diagnosis, diagnosis, adjunctive adjunctive therapy, therapy, suicide, suicide, and and seapregnancy, sea­ sonal sonal mood m o o d disorders; disorders; and and provides provides aa self-screening self-screening tool. tool. Bipolar World World (www.bipolarworld.net) provides information onon bipolar diagnosis, provides information bipolar diagnOSiS,treattreat­ Bipolar (www.bipolarworld.net) ments, and and suicide, suicide, an an �ask "ask the the doctor·' doctor" link, link, personal personal stories, stories, information information on o n disabilities disabihties ments, and stigma, stigma, community c o m m u n i t y and and family family suppon, support, relevam relevant books, books, aa bipolar bipolar message message board, and and board, and chat chat rooms. rooms.

The Bipolar Child (www.bipolarchild.com) offers findings pertaining pertaining The Bipolar Child {www.bipolarchild.com) offersup-to-date up-to-dale research findings to bipolar bipolar children, children, aa newsletter newsletter on o n new n e w treatment treatment approaches, approaches, samples samples of of individualized individualized to

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to start educational programs, programs, information informationon onupcoming upcoming conferences, tips educational conferences, andand tips on on howhow to start a a support support group. group. For For contact contact information, information, go go to to http://bipolarchild.comlcontact.html. http://bipolarchild.com/contact.html. Bipolar Disorder Bipolar includes educational arti-arti� includes educational DisorderSanctuary Sanctuary(www.mhsanctuary.com/bipolar) (www.mhsanctuary.comJbipolar) cles cles on on bipolar bipolar disorder, disorder, an an �ask "ask the the therapist" therapist" discussion discussion forum, forum, first-person first-person accounts, accounts, chat chat rooms rooms for for patients patients and and family family members, m e m b e r s , aa clinician's clinician's forum, forum, links links to to new n e w research research studies, studies, and and an an on-line on-line bookstore. bookstore.

Harbor Inc. provides peer-to-peer HarborofofRefuge RefugeOrganization, Organization, Inc.(www.harbor-of-refuge.org) (www.harbor-of-refuge.org) provides peer-to-peer support sorder who support for for individuals individuals diagnosed diagnosed with with bipolar bipolar di disorder w h o are are undergoing undergoing treatment. treatment. There room. Information illness There is is aa discussion discussion forumlchat forum/chat room. Information is is provided provided on o n self-care self-care and and illness management strategies. m a n a g e m e n t strategies. International Society www.isbd.org) aims pro­ International Society for for Bipolar Bipolar Disorders Disorders (412-802-6940; (412-802-6940; www.isbd.org) aims totopromOte profes­ mote awareness awareness of of bipolar bipolar conditions conditions in in society society at at large, large, educate educate mental mental health health professionals, Its sionals, foster foster research research on on bipolar bipolar disorder, disorder, and and promOte promote international international collaborations. collaborations. Its journal, f Psychiatry journal. Bipolar Bipolar Disorders-An Disorders—An InternationalJoumal International JouiTial o of Psychiatry and and Neurosciences, Neurosciences, is is be­ becoming coming a a primary primary outlet outlet for for new n e w research research on on the the diagnosis, diagnosis, etiology, etiology, and and treatment treatment of of bi­ bipolar on-line chat polar conditions. conditions. ISBD ISBD publishes publishes aa newsletter newsletter and and has has several several on-line chat rooms, rooms, includ­ including ing an an �ask "ask the the experts" experts" exchange. exchange.

Internet Mental Health is another informaInternet Mental Health (www.mentalhealth.com/dis/p20-md02.html) (www.mentalheahh.comldislp20-md02.html) is another infonna­ tional website. website. A A strength strength of of this site site is is the the direct direct linkages linkages between between speCific specific topicS topics and and published research research abstracts abstracts pertaining pertaining to to the the topics. topics. It is aa particularly particularly good good site site for for new new published It is research on research on medications. medications. Downloadable Downloadable self-rated self-rated mood m o o d questionnaires questionnaires and and mmood o o d charts charts are are available. available. Juvenile Juvenile Bipolar Research Foundation (www.bpchildresearch.org) is the first Bipolar Research Foundation (www.bpchildresearch.org) is the firstcharitable charitable organization organization solely solely dedicated dedicated to to the the support support of of research on on the the etiology, etiology, treatment, treatment, and and juvenile-onset bipolar bipolar disorder. disorder. JBRF J B R F has has organized organized aa consortium consortium of ofcollab­ collabprevention of juvenile-onset orating orating research research groups groups and and individual individual investigators investigators from from aa number n u m b e r of of medical medical schools schools and treatment centers around around the country. country. Through Through its its website, website, parents can learn about about and and volunteer volunteer for for research research studies studies that that are are sponsored sponsored by by the the foundation. foundation. lnfonnation Information is and provided concerning concerning educational educational forums forums for for parents parents and and teachers, teachers, how h o w to to subscribe subscribe to provided professional e-mail e-mail list-serves list-serves for for physicians physicians and and therapists, therapists, and and nnew e w research research fmdings findings profeSSional childhood-onset bipolar disorder. disorder. A A case conference conference series is is planned planned for the pertinent to childhood-onset fall of 2003. 2003. For For more m o r e informalion, information, e-mail info®jbrf.org. [email protected].

Medline (www.nlm.nih.gov/medlineplus/bipolardisorder.html) MedlinePlus PlusHealth HealthInformation Information (www.nlm.nih.gov/medlinepluslbipolardisorder.html) links to National Institute of Mental Health publications and and clinical trials. trials. It inoffers links It in­ cludes overviews overviews of of current current bipolar bipolar research and and information information regarding regarding children, children, leenag· teenagcludes ers, and and seniors with the disorder. disorder. A A link to the Medline search engine for the most most recent ers, research articles on on bipolar disorder is is provided. provided. http://bipolar.about.com isan aninformational informationalsite site that contains articles, discussion forums, that contains articles, discussion forums, http://bipolar.abouLcom is book reviews, reviews, and and chat rooms. rooms. book is a comprehensive McMan's andand Bipolar WebWeb (www.mcmanweb.com) is a comprehensive web McMan'sDepression Depression Bipolar (www.mcmanweb.com) web

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links to current research, essays on first-person experiences, and an and sitewith withsubstantial substantial links to current research, essays on first-person experiences, site

opinion page. page. opinion

Books Books on on Ihe the Subjecl Subject Info/motional Informational Guides Guides Amador, Amador, X., X., && Johanson, Johanson, A. A. L. L.

(2000). (2000). II am a m not not sicll sick II don't don't need need help! help! Peconic, Peconic, NNY: Y : Vida Vida

Press. Press. Birmaher, Birmaher, B. B.

(2004). ipolar disorder. (2004). New N e w hope hope for for children children and and teens teens with with b bipolar disorder. NNew e w York: York:

Three Three Rivers Rivers Press. Press.

(1999). Thef The feeling good handbook. handbook. New N e w York: York: Plume. Plume. (1999). eeling good (2000). fa essional needs to (2000). The The life life oof a bipolar bipolar child: child: What W h a t every every parent parent and and prof professional needs to know. Duluth, Duluth, MN: M N ; Benline Benline Press. know. Press. Copeland, M M .. E. E. (199B). (1998). Living Living without without depression depression and and manic manic depression: depression: A A workbook workbook for for Copeland, maintaining mood mood stability. stability. Oakland, Oakland, CA: C A : New N e w Harbinger. Harbinger. maintaining Coun, Court, B. B. L., L., && Nelson, Nelson, G G.. E. E, (l996). (1996). Bipolar Bipolar puzzle puzzle solution: solution: AA mental mental health health clienl's client'sper­ perspective. Philadelphia: Philadelphia: Taylor Taylor & & Francis. Francis. spective. Fast, j.J. A., A.,&& Preston, Preston,j.J.D.D.(2004). (2004).Loving Lovingsomeone someonewith withbip/oar biploardisorder: disorder:Understanding Understanding Fast, and helping helping your your parlner. partner. Oakland, Oakland, CA: C A : New N e w Harbinger. Harbinger. and Fawcett, J.,Golden, Golden,B., B.,&-& Rosenfeld, Rosenfeld,N.N .(2000). (2000).New N e whope hope forpeople peoplewith withbipolar bipolardisorder. disorder. for Fawcett,)., Roseville, Health. Roseville, CA: C A : Prima Prima Health. Findling, Kowatch, R. Boston: Findling, R. R. L., L., Kowatch, R. A., A., && POSt, Post, R. R. M. M . (2002) (2002) Pediatric Pediatric bipolar bipolar disorder. disorder. Boston: Boston Medical Medical Publishers. Publishers. Boston Frank, Frank, E. E. (2005). (2005). Treating Treating bipolar bipolar disorder: disorder: A A clillician's clinician's guide guide to to interpersonal interpersonal and and social social rhythm therapy. therapy. New N e w York: York: Guilford Guilford Press. Press. rhythm Fristad, M. M . A., A., && Goldberg Goldberg Arnold Arnold,, jJ.. S. S. (2004). (2004). Raising Raising aa moody moody child: child:How H o w LO to cope cope with with Fristad, depression and and bipolar bipolar disorder. disorder. New N e w York: York: Guilford Guilford Press. Press. depression Geller, B., B.,&& DeiBello, DelBello,M. M .P.P.(Eds.). (Eds.).(2003). (2003).Bipolar Bipolardisorder disorderininchildhood childhoodand andearly earlyadoles­ adolesGeller, cence. New N e w York: York; Guilford Guilford Press. Press. cence. Goodwin, Goodwin, F. F. K., K., && jamison, Jamison, K. K. R. R. (1990). (1990). Manic-depressive Manic-depressive illness. illness. New N e w York: Oxford York: Oxford University Press. University Press. Granet, R., R., && Ferber, Ferber, E. E. (l999). (1999). Why W h y am a m II up, up, why w h y am a m rI down}: down?: Understanding Understanding bipoJar bipolar disGranel, dis­ order. Des Des Plaines, Plaines, Il: IL: Dell. Dell. order. Greenberger, D., D., && Padesky, Padesky, C. C. A. A. (1995). (1995). Mind Mind over over mood. mood. New N e w York: York: Guilford Guilford Press. Greenberger, Press. Greene, R. R. W. W . (1998). (1998). The The explOSive explosive child: child:AA new new approach approachfor for understanding understanding and and parenting parenting Greene, easilyfrustrated, frustrated, chronically chronically in inflexible children. New N e w York: York: HarperCollins. HarperCollins. easily flexible children. Jamison, K. K. R. R. (2000). (2000). Night Night falls falls ffast: Understanding suicide. suicide.New N e w York: York: Vintage Vintage Books. Books. jamison, ast: Understanding Jamison, K. K. R. R. (2004). (2004). Exuberance: Exuberance: The The passion passion for for life. life. New N e w York: York: Knopf. Knopf Jamison, Lynn, G. G. T. T. (2000). Survival Survival strategies strategiesfor for parenting parenting children children with with bipolar bipolar disorder. disorder.london: London: lynn, Jessica Kingsley. Kingsley. Jessica Miklowitz, D. D. ]J., & Goldstein, Goldstein, M. M . J. J. (1997). (1997). Bipolar Bipolar disorder: disorder: A A family-f family-focused treatment Miklowil1:, ., & ocused treatment approach. New N e w York: York: Guilford Guilford Press. approqch. Press. Mondimore, F. F. M. M . (1999). (1999). Bipolar Bipolar disorder: disorder: A A guide guide for for patients patients and and f families. Mondimore, amilies. Baltimore: Baltimore: Johns Hopkins Hopkins University University Press. Press. Johns Olson, B., B., && Olson, Olson, M. M . (1999). (1999). Win W i n the the battle: battle: The The 3-step 3-step lifesavingfonnu/a lifesaving formula to to conquer conquer de­ deOlson, pression and and bipolar bipolar disorder. disorder. Worcester, Worcester, MA: M A : Chandler Chandler House House Press. Press. preSSion Papolos, D. F., F., && Papolos, Papolos, j. J.(1997). (1997). Overcoming Overcoming depression: depression:The The definitive definitive resource resourcefor forpapaPapolos, Burns, D. D. D. D. Bums,

Carlson, Carlson, T. T.

an

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ResoUf{es Resources fOf for People People with with 8ipolor Bipolor Disorder Disorder

tients andand families withdepression depression manic-depression ed.).York: New York: tients familieswho wholive live with andand manic-depression (3rd (3rd ed.). New HarperColiins. HarperCollins. Papolos, Papolos, D. D. F., F., & & Papoios,]. Papolos, J. (2DD2). (2002). The The bipolar bipolar child: child:The The ddefinitive and reassuring reassuringgUide guide efinitive and to to childhood's childhood's most most misunderstood misunderstood disorder disorder (rev. (rev. and and expo exp. ed.). ed.). New N e w York: York: Broadway Broadway Books. Books. Stahl, f depression Stahl,S.S.M., M.,&: & Muntner, Muntner,N. N.(200D). (2000).Essential Essentialpsychophannacology psychopharmacology oof depressionand andbipolar bipolar disorder. Press. disorder. Cambridge, Cambridge, England: England: Cambridge Cambridge University University Press. Torrey, Torrey, E. E.F., F.,& & Knable, Knable,M. M . B. B.(2002). (2002).Surviving Survivingmanic manicdepression: depression:AAmanual manualon onbipolar bipolardis­ disorder order for for patients, patients,families, families,and andproviders. providers.New N e w York: York:Basic BasicBooks. Books. Waltz, Waltz, M. M . (2000). (2000). Bipolar Bipolar disorders: disorders:AA guide guideto tohelping helpingchildren childrenand and adolescents. adolescents.Sebastopol, Sebastopol, CA: CA: O'Reilly O'Reilly & & Associates. Associates. Whybrow, W h y b r o w , P. P. C. C. (1998). (1998). A A mood mood apart: apart: The Thethinher's thinker'sguide guide10 toemotion emotionand andils its disorders. disorders.New New York: York: HarperColiins. HarperCollins. medications for Wilens, Wilens, T. T. E. E. (l999). (1999). Straight Straight talk talk about about psychiatric psychiatric medications for kids. kids. New N e w York: York: Guilford Press. Guilford Press. Wider, P. P. A. A. (2001). (2001). Overcoming Overcoming depression depression and and manic manic depression depression (bipolar (bipolar disorder): disorder): A A Wider, whole-person whole-person approach. approach. Rutherford, Rutherford, NJ: NJ: Wellness Wellness Communications. Communications. Woolis, Woolis, R., R., & & Hatfield, Hatfield, A. A. (1992). (1992),When W h e n someone someoneyou you love lovehas has mental mental illness: illness:AAhandbook handbook for amily, friends, for f family, friends,and and caregivers. caregivers.Los Los Angeles: Angeles:Tarcher. Tarcher.

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Index

Index

A

Antidepressant medication m o o d stabilizers stabilizers and, and, 1114-115 mood 1+-115

Acceptance Acceptance of of diagnosis, diagnosis, 54-55 54-55

overview of, of, 103 103 overview

Accuracy of of diagnosis, diagnosis, 42--14 42-44 Accuracy

substance-induced mood m o o d disorder and, 52substance-induced 52-

Achievement-oriented Achievement-oriented events, events, 91, 91, �287 286-287

Active listening, Ustening, 263-265, 263-265, 270 270 Active Active Active phase phase of of episode, episode, 35 35

Activity level level changes. changes, 20-23 20-23 Activity See also also Social Social Rhythm Rhythm Metric Metric Su Acute phase, phase, 100-102 100-102 Acutc Addictive behavior, behavior, 27-28 27-28 Addictive ADHO A D H D (allcnlion-deficillhyperaclivity (attention-deficit/hyperactivity

disorder), 45-46 45-46 disorder), Aftennath Aftermath of of episode, episode, �7 6-7 Agranulocytosis. Agranulocytosis, III 111 Alcohol Alcohol

53 Antipsychotic medication medication and and mood mood Antipsychotic stabilizers, 1t5--1l7 115-117 stabilizers,

Anxiety, 16, 16, 160, 160, 250. 250. See See Anxiety,

Associational processing. processing, 137 137 Assodational Atretol (carhamazepine), (carbamazepine), 1110-111, 112 AUelO1 10-111, 112 Attention-deficit/hyperactivity disorder disorder Attention-deficill'hype:ractivity ( A D H D ) , 45-46 45-46 (ADHD), Automatic thoughts. thoughts. Su See Cognitive Cognitive Automatic restructuring restructuring

use:.

use. Su See Drug Drug and and alcohol alcohol use use Alliance between between doctor doctor and and person person with with Alliance disorder disorder calling doctor doctor about about symptoms, symptoms, 200-202 200-202 calling handling concerns, concerns, 202-203 202-203 handling importance of, of, 131, 131, 147 147 importance managing managing side side effects, effects, 138 138 significant other, other, involving involving in, in, 203-204, 203-204, 271 271 Significant Americans with with Disabilities Disabilities Act, Act, 278-279, 278-279, 280 280 Americans Amphetamines, 177 177 Amphetamines, Anticonvulsant medication medication Anticonvulsant carbamazepine, 110-111 110-111 carbamazepine, divalproex sodium, sodium, 108-109 108-109 divalprotx gabapentin, gabapentin, 113 113 Iamotrigine, l l-H3 lamotrigine, I112-113 predictors of ofresponse response to, to, 10� 105 predictors topiramate, 113 113 topiramate,

also Cognitive Cognitive also

restructuring restructuring

BB

Bedtime activity, activity, 172-173 172-173 Bedtime Behavior, description description of, of, 13-15 13-15 Behavior, Behavioral activation strategy strategy Behav ioral activation implementing, 229 im plementing, 229 listing pleasurable activities, activities, 214--2 224-225, 226 list ing pleasurable 5 2 , 226 overview of, of, 222, 222,224 224 overview scheduling pkasurable pleasurable activities, activities, 225-228 225-228 scheduling troubleshooting, 228-229 228-229 troubleshooting. Behavioral activation activation system, system, 91 91 Behavioral Behavioral inhibition inhibition system, system, 91 91 Behavioral Beliefs about about drug drug and and alcohol alcohol use, use, 176-179 176-179 Beliefs Benzodiazepines, 1117 Benzodiazepines. 17 Bingeing on on sleep, sleep, 168, 168,287 287 Bingeing

311 311

312 3'2

Index Index

Biochemical imbalance, imbalance, 86-89 86-89 Biochemical

psychotherapy, 121, 122-123, 133-134 133-134 psychotherapy, 121, 122-123,

Biological causes causes of of disorder disorder Biological

151-152, 155-156 155-156 self-management, 151-152.

biological biological vulnerability, vulnerabihty, 87-89 87-89

Rhythm Metric, Metric, 165-168 165-168 Social Rhythm

of, 77 overview of,

social social support, support, 119-180 179-180

vulnerability—stress model, 7'5-76 75-76 vulnerability-stress Bipolar Bipolar disorder

work setting, setting, 274-275, 274-275, 279 279 work Causal Causal factors factors

age age of of onset, onset, 82 82

biochemical imbalance, 86-89 86-89 biochemical

attention attention deficitlhyperactivity deficit/hyperactivity disorder disorder

76-84 genetic vulnerability, 76-84

compared to, 45-46 compared to, 45-46 borderline personality disorder compared to, to, 46-48 46-48 course 7, 99 course of, of, 6-6-7, 99 criteria criteria for for diagnosis diagnosis of, of, 31-35 31-35

no family history history and, and, 84-85 84-85 no overview overview of, of, 7, 7, 74 74 stress, stress, 90--97 90-97 vulnerability-stress vulnerability—stress model, model, 75-76 75-76 Change, 267 Change, positive positive requests requests for. for, 265--265-267

cyclothymic cyclothymic disorder disorder compared compared to, to, 48-49 48—49

Checklists. Checklists. See See Forms Forms and and worksheets worksheets

description description of, of, 4, 4, 15-17 15-17

Children Children

recurrent sorder recurrent major major depressive depressive di disorder compared compared to, to, 51 51 schizophrenia schizophrenia compared compared 10, to, 49-51 49-51

describing describing disorder disorder to, to, 259 259 family hiStory and family history and decision decision to to have, have, 85 85 symptoms symptoms in, in, 86 86

seasonal, seasonal, 120 120

Circadi an rhythms, Circadian rhythms, 94, 94, 95 95

substance-induced sorder compared substance-induced mood m o o d di disorder compared

Circumstances Circumstances associated associated with with manic manic episodes, episodes,

to, to, 51-53 51-53 subtypes subtypes of, of, 32-35 32-35

194 194 Classic Classic recurrent recurrent depression, depression, 220 220

Bipolar Bipolar 1I disorder, disorder, 16, 16, 32-33 32-33

Clinical Clinical interview, interview, 41-42 41-42

Bipolar

Clozapine CClozari!), (Clozaril), 116 116 Clozapine

II di disorder, 16, 32, 33-34 33-34 II sorder, 16, "Bipolar "Bipolar Symptoms: Symptoms: A A Self-Administered Checklist," 37, 3&--39 Checklist," 36-36-37, 38-39 Blaming Blaming others, others, 96--97, 96-97, 264-265 264-265 Blood Blood tests tests to monitor medication level, level, 107108, 109, 109, I111, 108, l l , 205 Books, Books, recommended, recommended, 293-294 293-294 disorder, 46-48 46-48 Borderline personality disorder, techniques, 88 88 Brain imaging techniques, n a m e of medication, medication, 103 103 Brand name episode, 104 104 Breakthrough episode,

(C

Cocaine, Cocaine, 177 177

Cognitive-behavioral therapy therapy (CBT), 124-125, 124-125, Cognitive-behavioral 224, 230, 230, 237 237 224, Cognitive coping, 217 217 Cognitive Cognitive restructuring restructuring Cognitive identifying negative thoughts, thoughts, 231-234 231-234 identifying modifying modifying negative negative thoughts, thoughts, 234-236 234-236

overview of, of, 229-231 229-231,, 237 237 overview Collaboration with doctor. doctor. See Alliance Alliance Collaboration between between doctor doctor and and person person with wdth disorder disorder

"Collecting Infonnation Information to Draw Draw Your Your �Collecting Pedigree," 80--82 80-82 Pedigree," Communication skills Communication

blockers, 118 Calcium channel blockers,

listening, 263--263-265 active listening, 265

doctor about symptoms symptoms Calling dOctor

talking with, 285 employer, talking with, 285

person with disorder, disorder, 200-202 significant other, other, 203-204 significam Carbamazepine (Tegretol, Carbitrol, Carbitrol, Atreto\), Carbamazepine (Tegretol, Atretol), 110-111, 112, 205 205 1 10---1 1 1 , 112, Car keys, giving giving up, up, 197-198 197-198 Car Case studies Case use, 173-174, 173-174, 175 alcohol use, depressive episode, episode, 215-216 215-216 depressive disorder, experience experience of. of, 3-5, 3-5, 6, 6, S-9, 8-9, 10-11, disorder. 10---1 1 , 254-255 254-255 reaction, 255-256, 255-256, 262-263 262-263 family reaction, genetics, biology. biology, and and stress, stress, 73-74, 73-74, 78, 78, 86 86 genetics, manic episode. episode, 183-184, 183-184, 208, 208, 211-212 211-212 manic modifying negative thoughts, thoughts, 235, 235, 236 236 modifying

overview of, of, 263 263 overview positive requests requests for for change, change, 265--267 265-267 positive practicing, 271-273 271-273 pranicing, problem solving, solving, 267-271, 267-271, 2N 274 problem Comorbid disorders disorders Comorbid A DH H DD (attention-deficit/hyperactivity AD Cattention-deficitlhyperactivity disorder), 45-+6 45-46 disorder), borderline personality personality di disorder, 46-48 borderline sorder, 46-48 cyclothymic disorder, disorder, 48--4 48-49 cyclothymic 9 overview of, of, 44-45 44-45 overview Concordance with with medication, medication, 130--131, 130-131, 147 147 Concordance Conflict with Significant significant others others COnnicl communication skills skills for for redUCing, reducing, 263-270 263-270 communicalion enlisting help and, 187�189 187-189 enlisting

Index Index as stress stress agent, agent, 95-97 95-97 as

thought 237 thought pattems, patterns, 25, 25, 236-236-237

time-out, time-out, asking asking for, for, 272 272

treatment of, of, 215 215 treatment

unilateral unilateral change change and, and, 272-273 lll-TTi

"Contract for for Preventing Preventing Mania," Mania," �Conuact

types types of of onsets, onsets, 218, 218, 220 220

208-213 20S-213

Control Control issues issues

views of, of, 216-217 216-217 views Diagnosis Diagnosis

medication and, and, 140-141, 140-141, 143--144 143-144 188-189 188-189 Convalescent Convalescent and and recovery recovery period period after after episode, 9, 9, 10, 10, 35, 35,68 68 episode, Coping with with diagnosis diagnosis Coping awareness of of moodiness moodiness of of others, others, 60-61 60-61 awareness emotional emotional fall-out, fall-out, 56-57 56-57 emotional vs. vs, medical illness, illness, 55-56 55-56 mantras for, for, 67-68 67-68 mantras overidentifying, overidentifying, 65-67, 65-67, 256-257 256-257 overview overview of, of, 54-55 54-55 personality vs. vs, diagnosis diagnosis problem, problem, 61-64 61-64 personality rejecting ifying With, rejecting or or underident underidentifying with, 57-60, 57-60, 256 256 work and and family family settings, settings, 254-254-255 work 255 See See also also Nonconcordance Nonconcordance with with medication: medication; Self-management strategies strategies Self-management Core cirde. circle. See See Social Social supports supports Core Couple Couple therapy, therapy, 126, 126, 274 274 Course Course of of disorder disorder over over time, time, 6-7, 6-7, 99 99 Coworker Coworker issues. issues. See See Workplace Workplace Creativity, 67-68, 67-68, 136-137 136-137 Creativity, Cyclothymic di disorder, 48-49, 62--63 62-63 Cydothymic sorder, 48-49, relapse pn:vemion prevention and, and, relapse

o

chart. See See Mood M o o d Chan Chart Daily chart. Day hospital program, program, 206 206 Day Decision-making, 198 Deci sion-making, 198 Delus ions, 16, 25, 49-50 Delusions, 16, 24-24-25, 49-50

Denial of d diagnosis, 55-56, 59--6 59-60 Den ial of iagnosis, 55-56, 0 Depakote and and Depakene Depakene (divalproex (divalproex sodium), sodium), Depakote 10S-109, 108-109, 112, 112, 205 205

Depressed mood, m o o d , desCriptors descriptors for, for, 159 159 Depressed Depressive disorder, disorder, major, major,recurrent, recurrent,51 51 Depressive Depressive Depressive episode episode

strategy, 222, 222, 224-229 224-229 behavioral activation strategy, behavioral inhibition system system and, and, behavioral

91

coping with, with, 217 217 coping warning signs signs of, of, 191, 191, 193, 193, 214--215, 214-215, early warning 220-222, 223 223 220-222, electroconvulsive therapy and, and, lls-nO 118-120 electroconvulsive experience 2 15 experience of, of, 18, 18, 19, 19, 214-214-215 mood m o o d spiral, spiral, 16, 16, 221-222 221-222

overidentifying illness in, in, 66-67 66-67 overidentif ying with illness prodromal phase, phase, prodromal

313 313

220-222, 223 223 220-222,

thoughts, 25-26, 25-26, 246-247 246-247 suicidal thoughts, symptoms symptoms of, of, 217-218 217-218

accuracy of, of, 42---4 42-44 4 accuracy criteria criteria for, for, 31-35 31-35

distinguishing bipolar bipolar mood m o o d swings swings from from distinguishing nonnal normal mood m o o d variability, variability, 20 20 purpose purpose and and benefits benefits of. of, 30-31 30-31

rejection of, of, 28 28 rejection second second opinion, opinion, seeking, seeking, 43-44 43-44

self-evaluation, 36-37, 36-37, self-evaluation,

38-39 3S-39

steps steps in in process process of, of, 37, 37, 39-42 39-42

time lag lag between between Hrst first episode episode and, and, time

13-14 13-14

traditional traditional approach approach to, to, 14-15 14-15 See See also also Comorbid Comorbid disorders disorders

Diagnostic f Mental Diagnostic and and Statistical Statistical Ml.ml/al Manual o of Mental Disordm, Disorders, 4th 4th edWall edition (OSM-IV), (DSM-IV), 31-33 31-33

Diagnostic referral, 39-40 39-40 Diagnost iC referral, 48 48 288-289 28S-289 Disclosure of of disorder disorder in in workplace workplace Disclosure advantages advantages or, of, 282-283 282-283 disadvantages of, of, 27S-280, 278-280, 281-282 281-282 disadvantages Discrimination in in employment, employment, 27S-280 278-280 Discrimination Distraction 7 247, 247. See Distraction techniques, techniques, 21 217, See also also Behavioral activation activation strategy strategy Behavioral Divalproex sodium sodium (Depakote, (Depakote, Depakene), Divalproex Depakene), 10S-109, 108-109, 112, 112, 205 205 Doctor Doctor alliance between between person person with with disorder disorder and, and, alliance 131, 138, 138, 147 147 131, calling about about symptoms, symptoms, 200-202 200-202 calling clinical interview, 41---4 41-42 clinical 2 contact with with Significant significant others, 203-204, 203-204, contact 211 271 decision tree tree for for recommending recommending decision antidepressants, 115 115 antidepressants, discomfort with, with, 202-203 202-203 discomfort distinguishing bipolar mood m o o d swings swings from from distinguishing normal mood m o o d variability, 20 nonnal emergency session with, with, 204-206, 242-245 242-245 emergency hospitalization and, and, 206--207 206-207 hospitalization medical records review, review, 40 40 medical referral to, to, 39--40 39-40 referral relapse prevention prevention and, and, 200-208 200-208 relapse second opinion, opinion, seeking, 43--44 43-44 second suicidal thoughts thoughts and and feelings, feeUngs, infonning informing of, of, suicidal 242-245 242-245 working with, vidth, 44 44 working Double depression, depression, 220 220 Double up, 197-198 197-198 Driving, giving up, behavior therapy, Dialectical behavior

Disability insurance, insurance, Disability

,

314 314

Index Index shame, shame, feelings feelings of of after, after, 21 21

Drug and and alcohol alcohol use Drug 173-179 173--179 nonconcordance with medication medication and, and, 144non concordance with 144145 145 recoTding recording on on Mood M o o d Chart, Chart, 161 161 risky 199 risky sexual sexual situations situations and, and, 198-198-199 substance-induced mood m o o d disorder, disorder, 51-53 51-53 subStance-induced wellness, avoiding to maintain wdlness,

suicide suicide risk risk and, and, 240 240

as symptom, symptom, as

27-28 27-28

as trigger trigger for for biological vulnerability, vulnerability, 89 89 as 132 132 175 175 Dysthymia, Dysthymia, 16, 16, 62--63, 62-63,220 220 MDrug "Drug holiday:' holiday,"

�Dual "Dual diagnosis," diagnosis,"

time time lag lag between between first first and and diagnosis, diagnosis, IJ-...14 13-14 See also also Depressive episode; episode; Manic episode See Euthymic Euthymic mood, mood, 33 33 Evaluation Evaluation of of behavior behavior activation activation plan, plan, 228-229 228-229 of of COTe core circle circle list, list, 245-246 245-246 of of diagnosis, diagnosis, 36-42 36-42 of mani mania prevention contract, contract, 212-213 212-213 of a prevention Exercise Exercise mood m o o d and, and, 250 250 sleep sleep and, and, 172, 172, 227 227

FF

EE

Falling Falling asleep, asleep, 171-173 171-173 Family Family history history

Early Early warning warning signs signs depressive depressive episode, episode, 214-215, 214-215, 220-222, 220-222, 223 223

chiidTen, children, having, having, and, and, 85 85

identifying, identifying, 7-8, 7-8,

1111 mania mania vs. vs, depression, depression, 191, 191, 193, 193, 222 222 manic manic episode, episode, 186-187, 186-187, 190-194 190-194 E C T (electroconvulsive therapy), therapy), 1118-120 fCT 18--120

destiny vs., 85-86 destiny vs,, 85-86

Education

pedigree, examining examining your, your, 80--8 80-82 pedigree, 2

environmental condition condition hypothesis hypothesis and, and, environmcmaJ 79-80 ' ....0 ovenriew overview of. of, 76-77 76-77

about about diagnosis, diagnosis, 31 31

practical implicatiOns implications of, of, 83-84 83-84 practical

for 263 for family, family, 258-258-263

studies studies of, of, 77-79 77-79

59, 99 need need for, for, 5,5,58-58-59, 99

Family Family stress

1118-120 18--120 Elevated Elevated mood, mood, desCriptors descriptors for, for, 158-158-159 159 Electroconvulsive Electroconvulsive therapy therapy (ECT), (ECT),

Emergency phone call call to to doctor Emergency impulses, 242 242 about suicidal impulS(s, about about symptoms, symptoms, 200-202, 200-202,

203-204 203-204

Emergency session with doctoT, doctor, 204-206, 204-206, Emergency 242-245 242-245

Emotional impact of diagnosis, diagnosis, 54-55, 54-55,

56-57 56-57

See also also Coping Coping with diagnosis See Emotion-focused coping, coping, 217 217 Emotion-focused

Employment issues. issues. See See Workplace Workplace Employment

Energy level level changes, changes, 20-23 20-23 Energy

case case example, example, 8--9 8-9

communication skills skills for dealing with, with, 263263communication 270 270 conflicts, 95-97, 95-97,189 189 conflicts, education about disordeT disorder and, and, 258-263 258-263 education independence issues, issues, 143-144, 143-144, 188-188-189 independence 1B9 moodiness, 60 60 moodiness, negative sode. negative emotional emotional reactions reactions to to epi episode,

255-256 255-256 overprotect iveness, 256-257, overprotectiveness, 256-257,

Family support groups, groups, Family Family therapy, therapy, Family

126 126

stress. See See Stress agents Environmental stress.

Finances, managing, Finances,

Episodes

oil, 117-IIB 117-118 Fish oil.

vulnerability and, 89 89 vulnerability and, 104 104 factors, 74 74 causal factors, and recovery recovery period after, after, 9,9, convalescent and 10, 35, 35, 68 68 10, of, 16, 16, 36 36 duration of, mixed, 16, 16, 22. 22, 218 218 mixed, to by by family, family, negative emotional reactions to 255-256 255-256 period between, 16 between. 16 of, 35-36 35-36 progression of, everyday world follOwing, following, 8-8-10 reentering everyday 10 m o o d states, states, 17-20 17-20 roller coaster mood

270-271 270-271

127 127

195-197 195-197

of ideas, ideas, 23 23 of

biological

Flight

breakthrough,

Forms and and worksheets worksheets Forms "Bipolar Symptoms: Symptoms: A A Self-Administered Self-Administered �Bipolar Checklist,P Checklist,"

36-37, 38-39 38-39 36-37,

"Collecting Information Information to to Draw Draw Your Your «Collecting Pedigree," Pedigree:'

80-82 B0-82

"Contract for Preventing Mania," Mania," �Contract

209-210 209-210

"Identifying Triggers Triggers for for Alcohol Alcohol and and Drug Drug �Idenlifying Abuse," Abuse,"

178 178

"Identifying Your Your Core Core Cirde,� Circle," «Identifying

181 181

"Impact of Your Your Behavior Behavior Activation Activation Plan: Plan," 228 228 «Impact "Keeping Track Track of Your Your Side Effects," Effects," «Keeping "Listing Pleasurable Activities," Activities," "listing

226 226

139 139

Index Index "Listing Prodromal Symptoms S y m p t o m s of �li sting Your Prodromal Depression,� Depression," 223 223 �listing "Lisdng Your Prodromal Prodromal Symptoms S y m p t o m s of or Hypomani Hypomania," Mania or a,� 192 �Mood "Mood Chan," Chart," 295 �Problem-Solving "Problem-Solving Worksheet," Worksheet," 268--269 268-269 uThe "The Pros Pros and and Cons Cons of of Taking Taking Medications," 145-147 for Living Living Inventory:· Inventory,'' 148-249 248-249 "Reasons for of information, information, 40, 40, 204 204 release of PleasurableEvents:· Events," 227 227 "Scheduling Pleasurable "Social Rhythm Rhythm Metric Metric (SRM)," 296 296 uSocial "Suicide Prevention Prevention Plan," Plan," 252-153 252-253 uSuicide UThought "Thought Record,� Record," 125, 125, 232 232 Role Has Stress Stress Played Played in Your "What Role Illness," Illness," 92 92 "What's "What's Me M e and and What's What's My M y Illness,'· Illness," 63--64 63-64 Zung Zung Self-Rating Depression Depression Scale. Scale, 218. 218, m 219 See See also also Mood M o o d Chart 4a-hour 48-hour rule, rule, 196-197 196-197 Friends Friends getting feedback from, from, 63-64 gett ing feedback maintaining maintaining while while aVOiding avoiding alcohol alcohol or or drugs, drugs, 182 on behavior behavior and and mood, m o o d , 22 22 perspective on See See also also Significant Significant others; others; Social Social supports supports

G

(Neurontin), 113 Gabapentin (Neurontin), (tiagabine), 117 117 Gabitril (tiagabine), n a m e of of medication, medication, 103 Generic name Genetic Genetic vulnerability vulnerability children, having, having, and, and, 85 85 children, destiny destiny vs., vs,, 85-86 environmental condition condition hypothesis hypothesis and, and, environmental 79-80 79-80 family, twin, twin, and adoption adoption studies, studies, 77-79 family, ovelView overview of, of, 76-77 pedigree, examining examining your, your, 80-82 pedigree, practical implications of, of, 83-84 praClical Goal-oriented events, events, 91, 286-287 G-proteins, 88 88 G-proteins, behavior, 21 Grandiose behavior, Grandiose delusions, delusions, 24-15 24-25 Grandiose H H Hallucinations, 16, 16, 14, 24, 49-50 Hallucinations, Heritability, See See Family Family history history Heritability. Hippocampus, 87 87 Hippocampus, Hope, II 11 Hope,

31S 315

Hopelessness, feelings feehngs of, of, 239-140, 239-240, 141 241 Hopelessness, Hospitahzation, 4-5, 4-5, 8, 8, 206-208, 206-208, 143 243 Hospitalization, Hyperpositive Hyperpositive thinking, thinking, 195-196 195-196 Hypersomnia, Hypersomnia, 26 26 Hyperthymia, Hyperthymia, 62-63 62-63 Hypomania Hypomania Bipolar Bipolar II II disorder, disorder, 33--34 33-34 of, 185 185 consequences of, early early warning warning signs signs of of episode episode of, of, 193 193 symptoms symptoms of, of, 16, 16, 51 51 as as warning warning sign sign of of manic manic episode, episode, 132 132 in in work work setting, setting, 277 277 See also also Relapse Relapse prevention drill See HypothyrOidism, 106 Hypothyroidism, 106 I Identifying Identifying core circle of of social social suppOrt, support, 180-181 warning signs signs of depressive depressive episode, early warning episode, 191, 191, 193, 193, 214-215, 214-215, 220-222, 220-222, 223 223 warning signs signs of manic manic epi episode, early warning sode, 186187, 190-194 190-194 187, triggers, triggers, 154, 154, 177-179 177-179 Alcohol and and Drug "Identifying Triggers for Alcohol Abuse� Abuse" fonn, form, 178 178 �Identifying "Identifying Your Core Circle" Circle" form. form, 181 "Impact of Your Behavior Activation Plan" form, 228 228 fonn, "Improving the Moment� Moment" strategies, strategies, 250 �Improving behavior, 26-27 26-27 Impulsive behavior, Independence issues Independence and, 143--144 143-144 medication and, prevention and, and, 188-189 188-189 relapse prevention Individual therapy, therapy, 124-126 124-126 Individual Information Information diagnosis and, and, 31 31 diagnosiS for family, family, 258-263 258-263 for for, 5,5,58--59, 58-59,99 99 need for, Inpatient hospitalization. hospitahzation. See See Hospitalization Inpatient InSight, Insight, lack lackof. of,187-188 187-188 Insomnia, 26 26 insomnia, Institutionahzation vs. vs, hospitalization, hospitahzation, 207 207 Institutionalization Interpersonal and social social rhythm rhythm therapy, therapy, 125125Interpersonal 126, 164-165 164-165 126, therapy, 125 Interpersonal therapy, Intervention, See See Medication; Medication; Psychotherapy; Intervention. Treatment Intimacy discomfort with, 257-158 257-258 di scomfort with, reestabhshing, 274 274 reestablishing, counselor, 197 197 Investment counselor, Irritabihty, 160 160 Irritability,

Index Indel

316 316 JJ

Job coach, coach, 288 288 Job Job discrimination, discrimination, 278-280 278-280 Job Job performance performanceissucs, issues, 276-277 276-277 Job KK

"Keeping Track Track Of Of Vour Your Side Side Erfects' Effects'' form, form, "Keeping 139 \39 lL

Lamotrigine (lamictaJ), (Lamictal), 112-113 lamotrigine action againSt against employer, employer, 279-280 Legal action Life changes, changes, major life h e n manic, manic, 198 avoiding w when history of, 91-93 91-93 hi story of, stress agentS, agents,90-91 90-91 as strcss "Life sentence," receiving, receiving, 66, 66, 67 67 "life Light treatment, treatment, 120 light actively, 26J-265 263-265,, 270 Listening actively, "Listing Pleasurable Activitics" Activities" form, "lisdng form, 226 "Listing Your Your Prodromal "listing Prodromal Symptoms of Depression" 223 Depression- form, form. 223 "Listing "listing Your Prodromal Symptoms of Mania or Hypomania" Hypomania" form, form. 192 Lithium lithium carbonate carbonate blood tests and toxicity, toxicity, 107-1OS 107-108 blood tests and overview of, of, 104-106, 112 112 predictors of response to, 105 side eUects, effects, 106-107, 106-107. 205 suicide attempts and, and, 239-240 239-140 LSD, 177 MM Maintaining Maintaining wellness wellncss alcohol and 173-179 and drugs, avoiding, 17J-179 mmood o o d chart, keeping, 154-164 154-164 chart. keeping, overview overview of, of, 151-154 regular routines, 164-173 164-173 social supports, relying relying on, 179-182 Maintenance Maintenance phase, 100-102 Major recurrent,551 Major depressive depressive disorder, recurrent. 1 Managed Managed care care system, 39-40, 39--40, 206-207 Managing Managing disorder. disorder. See Su Self-management Self·management strategies strategies Mania 208-213 Mania prevention prevention contract, contract. 208-213 Manic Manic episode episode acceleration acceleration into, inlO, 16, 16, 185-186 185-186 behavioral behavioral activation activation system system and, and, 91

consequencts consequences of, of, lSJ-1Si 183-184 early early warning warning signs. signs, l86-lS7. 186-187, 190-194 190-194 energy energy level level in, in, 21, 21, 22 22 experience experience of. of, 18, 18, 19 19 loss loss of of insight insight and, and, 187-188 187-188 missing missing when when on on medication, medication, 134-135 134-135 phases phases of, of, 35 35 preventing preventing or or decreasing decreasing severity severity of, of, IS5185186, 186, 208-213 208-213

prodromal prodromal phase phase of, of, 190-193 190-193 symptoms of. of, 15-16, 15-16, IS+-1S5 184-185 symptoms thoughts thoughts and, and, 2J-14, 23-24, 190-191 190-191 train metaphor. metaphor, 185-186 185-186 train Su drill See also also Relapse Relapse prevention prevention drill Marijuana, Marijuana, 175, 175, 176-177 176-177 Marital stress Marital communication with, 263communication skills skills for for dealing dealing with, 270 270

education education about about disorder disorder and, and, 258-263 258-263 independence ...H4. 188-189 independence issues, issues, 143 143-144, 188-189 negative reactions to negative emotional emotional reactions to episode, episode, 255-256 255-256

ove'll rotectiventss, 256-257. overprotectiveness, 256-257, 270-271 270-271 problems intimacy. 257-258, problems with with intimacy, 257-258, 274 274 as trigger, 95-97 as trigger, 95-97 Marital therapy, 126, 274 Marital therapy, 126, 274 review, 40 Medical records records review, 40 Medication 102 acute vs, vs. preventative preventative treatment, treatment, 100-acute 100-102 ADHD, A D H D , 45--4 45-466

anticonvulsant, anticonvulsant. 105, 105, 108-113 antideprtssant. 52-53, 103, 103. 114-U5 antidepressant, 114-115 antipsychotic, 115-117 1 15-117 benefits of, 99 of. 99 changing. 103, 138, 140, 1"0, 205-206 changing, 205-206 concordance with, 130-131, 147 concordance l30-131, H7 cost-benefit decision decision of, of, 138, 138. H5-147 cost-benefit 145-147 duration duration of treatment lreatment with, with. 102-103, 147 family ramily history history and, and. 85 family reaction reaction to, 259 259 inconsistency with, with, 59-60, 59-60. 130-131 inconsistency 130-131 interaction inleraction of, of. 109 for manic manic episode episode onset, onset, 205-206 for 205-206 neurotoxicity, neurotoxicity. 205 20' overdose, overdose. avoiding, avoiding. 242 overview overview of, 16-17, 98-99 98-99 pregnancy and, and, 102 pregnancy �The Pros Pros and and Cons Cons of of Taking Taking Medications" Medications" "The fonn, 145-147 form, for for sleep, 171 171 Stevens-Johnson syndrome, syndrolnl', 111, Ill, 113 113 Stevens-Johnson stopping, stopping. 129-130, 129-130, 132-133 132-133

Index Index suicidal suicidal thoughts thoughts and, and, 243-244 243-244

317 317

Nonconcordance with with medication medication Nonconcordance

suicide suicide attempts attempts and, and, 99, 99, 239-240 239-240

consequences consequences of, of, 132-133 132-133

therapeutic therapeutic range range of, of, 104, 104, 205 205

control issues, issues, 143-144 143-144 control

therapy and, and, 98, 98, 142-143 142-143 therapy

feeling feeling fine, fine, 135-136 135-136

tolerance to, to, 1117 tolerance 17

forgetting forgetting to to take, take, 144-1-+5 144-145

"treatment "treatment refractory" refractory" persons, persons, 48 48

frequency of, of, 130-132 130-132 frequency

level of, of, 205 205 "trough" level

ineffectiveness of medication, 142

See See also also Mood M o o d stabilizers; stabilizers; Nonconcordance Nonconcordance

lOSing losing creativity, creativity, 136-137 136-137

with with medication medication

missing high high periods, periods, 134-135 134-135 missing

Melatonin, 94 94 Melatonin,

psychological origin of problems, 142-143 142-143 psychological

Memory M e m o r y loss loss and and e.!e:ctroconvulsive electroconvulsive therapy, therapy, 119 119

side side effects, effects, 137-140 137-140

Misdiagnosis, Misdiagnosis, 42-44 42-44

stigma, stigma, 141 141

Mixed Mixed episode, episode, 16, 16, 33, 33, 218 218

weakness, weakness, sickness, sickness, or or lack lack of control, control, 140140141 141

Monamine 15 Monamine oxidase oxidase inhibitors, inhibitors, 114, 114, 1115 Money, Money, managing, managing, 195-197 195-197 Monitoring Monitoring blood blood leve.! level of of medication, medication, 107107lOS, 1 1 . 205 108, 109, 109, 1111, 205

M o o d Chan Chart Mood

Norepinephrine, Norepinephrine, 88 88

o

anxiety anxiety and and irritability, irritability, recording, recording, 160 160

Olanzapine Olanzapine (Zyprexa), (Zyprexa), 116 116

daily rating, rating, 157, 160 160

Omega-3 Omega-3 fatty fatty acid, acid, 117-118 117-118

evaluating, 163 163 evaluating,

Overidentification agnosis, 65-67, Overidentification with with di diagnosis, 65-67, 256256m 257

example of, of, 155-156 155-156 example form, 295 295 form,

Overprotectiveness by by family, 256-257, 270Overprotectiveness 271 m

hours hours of of sleep, sleep, recording, recording, 160-161 160-161 keeping, keeping, 145, 145, 154-155 154-155

life events events and and social stressors, stressors, noting, noting, 161 161 life

Oxcarbazepine (Trilepta\), (Trileptal), I111 Oxcarbazepine II

problems with, with, 163-164 163-164 problems

p

treatment, recording, recording, 162 162 treatment,

Partial hOSpitalization, hospitalization, 206 206 Panial

weight and and menses, menses, recording, recording, 162-163 162-163 weight

Pedigree, drawing drawing your, your, S0-82 80-82 Pedigree,

mood m o o d descriptors, descriptors, 158-159 158-159

M o o d disorder disorder episodes. episodes. See See Episodes Episodes Mood

changes in, in, 23-25 23-25 Perception, changes

M o o d spiral, spiral, 221-222 221-222 Mood

Personality disorder, disorder, description description of, of, 47 47 Personality

M o o d stabilizers stabilizers Mood

Personality traits Personality

and, 114-115 114-115 antidepressants and,

result of of di disorder, 64-65 changes in as result sorder, 64-65

antipsychotics antipsychotics and, and, lI5-Il7 115-117

disorder symptoms symptoms compared compared to, 61-64 disorder to, 55, 55, 61-64

benzodiazepines and, and, 1117 benwdiazepines 17 carbamazepine, 1110-111 carbamazepine, 10-111 sodium, ]08-109 108-109 divalproex sodium, gabapentin, 113 lamotrigine, 112-113 lamotrig ine, 112-113 hthium carbonate, carbonate, 104-108 104-108 lithium overview of, of, 103 103 overview thyroid supplements supplements and, and, 117 117 thyrOid topiramate, topiramate, 113 113 Motivational drive, drive, changes changes in, in, 20-23 20-23 Motivational N N National organizations, organizations, 290-293 290-293 National Neurontin (gabapentin), (gabapentin), 113 113 Neurontin Neurotoxicity, 205 205 Neurotoxicity, Neurotransmitters, 87, 87, 177, 177, 239 239

as strengths, strengths, 68 68 as behavior and and mood mood Perspectives on behavior differences in, in, 13-J5, 13-15, 17, 17, 28-29, 193 differences doctor view, view, 22-23 22-23 doctor and activity level level changes, changes, 20-23 20-23 energy and friends and and family family view, view, 22 22 friends impulsive, self-destructive, or addictive impulsive, behavior, 26-28 behav ior, 26-28 roller coaster mood m o o d States. states, 17-20 17-20 roller and perception, perception, changes changes in, 23-25 thoughts and in, 23-25 Plans, inability to carry out, 22 Plans, activities Pleasurable activities listing, 224-225, 226 listing, 224-225, 226 scheduling, 225-228 225-228 scheduling, for change, 265-267 265-267 Positive requests for Prayer, 250 250 Prayer, Pregnancy and and medication, medication, 102 Pregnancy

318 318

Index Index

Preventative Preventative treatment, treatment, 100. 100, See See also also Relapse Relapse prevention prevention drill; drill; Suicide Suicide prevention prevention

Recurrences and and medication, medication, 132 132 Recurrent Recurrent major major depressive depressive disorder, disorder, 5511

Problem Problem solving, solving, 267-271, 267-271, 274 274

Referral Referral to to doctor, doctor, 39-40 39^0

"Problem-Solving Worksheet," 26S-269 268-269 "Problem-Solving

listening, 264 Reflective li stening. 264

Prodromal phase phase Prodromal

Rejecting Rejecting

depressive depressive episode, episode, 220-222, 220-222, 223 223

diagnosis, 55-56, 57-59 57-59 di agnosis. 55-56, help, 188-189, 245 help, 188--189, 245

description description of, of, 35 35 manic manic episode, episode, 190-193 190-193

See See also also Early Early warning warning signs signs Prophylaxis, 135 Prophylaxis, 135 �Pros "Pros and and Cons Cons of of Taking Taking Medications" Medications" form, form, 1-+5-147 145-147 Protective Protective factors, factors, 152-153, 152-153, 180 180 Psychiatric Psychiatric hospitalization. hospitalization. See See Hospitalization Hospitalization Psychiatrist. Psychiatrist, See See Doctor Doctor Psychological agentS, agents, 75 75 Psychological Psychomotor Psychomotor retardation, retardation, 23 23 Psychotherapy Psychotherapy benefits of. of, 121-123 121-123 benefits cognitive-behavioral, 124-125, 124-125, 224, 224, 230, 230, cognitive-behavioral, 231 237 dialectical dialectical behavior behavior therapy. therapy, 48 48 family family and and couple, couple, 126 126 indiv idual. 124-126 individual, 124-126 interpersonal interpersonal and and social social rhythm rhythm therapy, therapy, 125-126, 125-126, 164-165 164-165 medication and. and, 98, 98, 142-143 142-143 medication objectives of, of, 122 122 objectives overview of, of, 120-121 120-121 overview intimacy, dealing with with in. in, 274 274 physical intimacy, self-help groups, groups, 126-127 126-127 self-help suicidal thoughts and and feelings feelings and, 242-245 242-245 suicidal therapist, chOOSing. choosing, 123-124 123-124 therapist,

Relapse prevention prevention drill Relapse dTi!! keys, giving up, up, 197-198 197-198 car keys, contract, contract, making, making, 208-213 208-213 doctor doctor and, and, 200-208 200-208 early early warning warning signs, signs, identifying, identifying, 190-194 190-194 major major life life decisions, decisions, avoiding, avoiding, 198 198 money, money, managing. managing, 195-197 195-197 overview overview of, of, 186-187. 186-187, 194-195 194-195 sexual sexual situations. situations, avoiding avoiding risky, risky, 19S-199 198-199 social social supports, supports, relying relying on. on, 187-189 187-189 weUness wellness strategies. strategies, using, using,200 200 Relapse-rEmission Relapse-remission course course of of disorder. disorder, 6-7, 6-7, 99 99 Relaxation Relaxation strategies, strategies, 250 250

Release of of information information form, form, 40. 40, 204 204 Release Religion, Religion, 250 250 "Repressed "Repressed memory" m e m o r y " therapy, therapy, 124 124

Resentment of help from from others, others, 188-189, 188-189, Resentment "5 245 Resources Resources books, books, 293-294 293-294

national organizations, 290-293 organizations, 290-293 �A "A Quick Quick Fact Sheet Sheet on on Bipolar Bipolar Disorder Disorder for

Family Members," 260-261 260-261 Family A n Unquiet Unquiet Mind Mind Oamison), 195. 195, 239, 239, 282 282 An Risk factors factors Risk disorder, 152-153, 152-153, 174-175. 174-175, for bipolar disorder, See

a

..Iso

also Causal Causal factors

239, 240-241 240-241 for suicide, suicide, 239. Roller coaster mood m o o d states, 17-20 states. 17-20

"Quick Fact Sheet Sheet on on Bipolar Bipolar Disorder Disorder for �Quick Family Members, A," 260-261, 282 282 A,� 260-261. R

thoughts, 23 23 Racing thoughts, Rapid cycling bipolar disorder, disorder, 32, 32, 34-35 34-35 Rapid Rapid transcranial transcranial magnetic magnetic stimulation. stimulation, 120 120 Rapid

Rumination, 25

s

plan for suic suicidal 244-245 Safety plan idal impulses, 2-H-245 Schedule

balancing work work time against down d o w n time. time, balanCing 286-287 286-287

Reactions to to diagnosis, diagnosis, 58. 58, SeE See also also Coping Coping Reactions

for pleasurable pleasurable activities, activities, 225-228 225-228 for

with with diagnosis diagnosis "Reasonable accommodations:' accommodations," 279, 279, 283-286 283-286 for Living Inventory," 248-249 248-249 "Reasons for driving, 197-198 197-198 Reckless driving, Records Records review, review, 40 40 Recovery or convalescent phase phase of episode, episode, 9, 9, Recovery 10, 35, 35, 68 68 10.

regulating, 164-173 regulating. and, 283 283 workplace and, "Scheduhng Pleasurable Events" Events" form, form, 227 227 "Scheduling Schizoaffective disorder, disorder, 50 50 Schizoaffective Schizophrenia, 49-5 49-51, 76-77, 84-85 84-85 Schizophrenia, 1, 76-77, 120 Seasonal bipolar disorder, 120 Second Second messenger messenger syslems, systems, 88, 88, 105-106 105-106

Index Index Second Second opinion, opinion, seeking, seeking, 43-44 43-44

Selective serotonin serotonin reuptake reuptake inhibitors, inhibitors, 114, 114, Selective 115 m Self-blame, Self-blame, 7, 7, 216. 216, Su See also also Cognitive Cognitive

restructuring restTUClUring Self-destruct ive behavior, Self-destructive behavior, 27-28 27-28

Self-disclosure, See See Disclosure of disorder disorder in Self-disclosure. workplace workplace

Self-esteem and and depreSSion, depression, 216 216 Self-esteem Self-evaluadon, 36--37, 36-37, 38--39 38-39 Self-evaluation, Self-help Self-help groups, groups, 126--127 126-127 SeU-management Self-management strategies strategies alcohol alcohol and and dTUgs, drugs, avoiding, avoiding, 173-179 173-179 behavioral behavioral activation, activation, 222, 222, 224-229 224-229 cognitive cognitive restTUcturing, restructuring, 229-236 229-236

early warning warning signs, signs, identifying, identifying, 7--8, 7-8, I11I early m o o d chart, chart, keeping, keeping, 154--164 154-164 mood ovelView overview of, of, 7--8, 7-8, 8, 8, 151-154 151-154 4recognizing depressive episode onset, onset, 21 214-

215, 220--222, 220-222, 223 223 215, recognizing recognizing manic manic episode episode onset, onset, 186--187, 186-187, 189, 194 189, 190-190-194 regular 173 regular routines, routines, 164-164-173 social social supports, supports, relying relying on, on, 179-182 179-182 stages stages of of managing managing disorder, disorder, 182 182 in in work work setting, setting, 283-283-289 289

See See also also Early Early warning warning signs; signs; Relapse Relapse drill; Suicide Suicideprevention prevention prevention drill; Self-statements, Su See Cognitive restructuring restructuring Self-statements. Serotonin, 239 239 Serotonin, Sexual is issues Sexual sues problems problems with wdth intimacy, intimacy, 257-258, 257-258, 274 274 risky s situations, avoiding, 198-198-199 risky ituations, aVOiding, 199 effects of medication, medication, 115 115 side effects 21, 83 83 Shame, 21, Side Side effects effects of of medication medication antidepressants, 114-115 114-115 antidepressants, carbamazepine. I111 carbamaupine, II divalproex sodium, sodium, 109 109 divalproex electroconvulsive therapy, therapy, 119 119 electroconvulsive lamotrigine (lamictal), (Lamictal), 113 113 lamotrigine carbonate, 106--107 106-107 lithium carbonate, neurotoxicity, 205 205 neurotoxicity, nonconcordance with with medication medication and, and, 137137nonconcordance 140 Significant others others Significant 96-97, 264--265 264-265 blaming, 96--97, conflict with, with, 189 189 vsath dOClOr, doctor, 203--204, 203-204, 271 271 contact with perspective on on behavior behavior and and mood, 22 22 perspective resenting or rejecting help help from, from, 188-188-189, resenting 189, 245 245

319 319

See also also Family Family Stress; stress; Fr Friends; Marital See iends; Marital stress; stress; Social Social supports supports disturbance Sleep disturbance bingeing on on sleep, sleep, 168, 168, 287 287 bingeing asleep, 171-173 171-173 falling asleep, as symptom symptom and and cause, cause, 26 26 as Sleep pallell15, patterns, regulating, regulating, 168 168 Sleep Sleep-wake 95 Sleep-wake cycle, cycle, 93-93-95 Social Social Rhythm Rhythm Metric Metric challenges to to regular regular routines, 169--170 169-170 challenges 167-168 evaluating, 167-168 example example of, of, 165--168 165-168 fonn, form, 296 296 overview of, of, 164-167 164-167 overview regulation ies, devising, 169 regulation strateg strategies, devising, 168-168-169 resistance resistance 10 to regular regular routines, routines, 170--171 170-171 Social Social rhythm rhythm stability stability hypothesis, hypothesis, 94-95 94-95 Social Social Security Security Administration Administration disability disability payments, payments, 288--289 288-289 Social Social stigma, stigma, 10, 10, 141. 141, 281-282 281-282 Social supports supports Social limitations limitations of, of, 247 247 relapse prevention prevention plan plan and, and, 187-189 187-189 relapse relying on, on, 179-182, 179-182, 185 185 relying suicidal suicidal thoughts thoughts and and feelings feelings and, and, 245-247 245-247 work perfonnance performance and, and, 289 289 work See also also Friends; Friends; Significant Significant others others See St,John's John's wort, wort,138, 138,193 193 SI. Stevens-Johnson syndrome, syndrome. I111, Stevens-Johnson l l , 113 Stigma of mental mental illness, illness, 10, 10, 141, 141, 281-282 281-282 Stigma Stopping medication, medication, 129-130, 129-130, 132-133, 132-133, Su See Stopping also Nonconcordance Nonconcordance with with medication medication also drugs. See See Drug Drug and and alcohol alcohol use use Street drugs. Stress agents agents Stress in bedroom, bedroom, 172 172 in with Significant significant others, others, 95--97 95-97 conflict with of, examining, examining, 91-93 91-93 history of, major life life changes, changes, 90-91 90-91 major neurotransmitters and, 87 87 neurotransmitters overview of, of, 90 90 overview recording on on Mood M o o d Chart, Chart, 161 161 recording sleep disturbance, disturbance, 9).-.95 93-95 sleep vulnerability—stress model, 75-76 75-76 vulnerability-stress Su See also also Triggers Triggers Substance-induced mood m o o d disorder, 51-53 51-53 Substance-induced Suicidal thoughts thoughts and and feelings feelings Suicidal to escape and, and, 239-240 239-240 desire to informing others of, of, 241 241 informing risk (actors factors for for suicide, suicide, 240--241 240-241 risk symptom, 25-26, 25-26, 238--239, 238-239, 251 251 as SymplOm, treatment and, and, 99, 99, 242-245 242-245 treatment See also also Suicide prevention prevention Ste

320 320

Index Index

Suicide Suicide prevention prevention

Tolerance ion. Il7 Tolerance to to medicat medication, 117

core core circle circle and, and, 245-247 245-247

Topamax Topamax (topiramate), (topiramate), 113 113

"improving "improving the the moment" m o m e n t " strategies, strategies, 250 250

Topiramate Topiramate (Topamax). (Topamax), 113 113

overview overview of, of, 241-242 241-242

Travel, Travel, 173 173

plan plan for, for, 250-251, 250-251, 252-253 252-253

Treatment Treatment

put means means out out of of reach, reach, 242 242 put

acute acute vs. vs, preventative. preventative, 100-102 100-102

reasons reasons for for living, living, review review 0(, of, 247-249 247-249

electroconvulsive electroconvulsive therapy, therapy, 118-120 118-120

hospitalization, 206-208 206-208 hospitalization,

visit doctor and therapist, therapist, 242-245 242-245 visit dOCtor and "Suicide "Suicide Prevention Prevention Plan," Plan,'' 252-253 252-253

light light therapy, therapy, 120 120

Support groups, groups, 126-127 126-127 Support

medical, for for depression, depression, 215 215 medical,

Symptom clusters, clusters, 35-36 35-36 Symptom

recording recording on on Mood M o o d Chari, Chart, 162 162

Symptom labels, labels, reaction reaction to, to,33 33 Symptom

suicidal suicidal thoughts thoughts and and feelings, feelings, 242-245 242-245

See a/so also Medication; Medication; Psychotherapy Psychotherapy SCI:

Symptoms Symptoms in children, children, 86 86 in

"Treatment "Treatment refractory," refractory," 48 48

delusions. delusions, 16, 16, 24-25, 24-25, 49-50 49-50

Tricyclic antidepressants, antidepressants, 1114, 115 Tricyclic 14, liS

depressive episode, episode, 16, 16, 217-218, 217-218, 221-222 221-222 depressive

Triggers Triggers

describing describing to to doctor, doctor, 41-42, 41-42, 201-202, 201-202, 204 204

biological vulnerability and, biological vulnerability and, 87, 87, 89 89

grandiose grandiose behavior. behavior, 21 21

identifying, 154, 154, 177-179 177-179 identifying,

hallucinations, hallucinations, 16, 16, 24, 24, 49-50 49-50

recognizing, recognizing, 7-8 7-8

hypomania, 16, 16, 51 51 impulsive behavior, behavior, 26-27 26-27 impulSive irritability, irritability, 160 160 manic manic episode, episode, 15-16, 15-16, 184-185 184-185 motivational motivational drive, drive, changes changes in, in, 20-23 20-23 personality s t compared personality trai traits compared to, to, 55, 55, 61-64 61-64 sleep disturbance, disturbance, 26, 26, 93-95, 93-95, 168, 168, 287 287 sleep suicidal suicidal thoughts thoughts and and feelings, feelings, 25-26, 25-26, 238238239, 251 251 239, thoughts, changes changes in, in, 23-25, 23-25, 190-191 190-191 thoughts, in work work setting, setting, 277 277 in

See also Stress agents agents SCI: also Stress Trileptal II Trileptal (oxcarbazepine), (oxcarbazepine). I111 "Trough" "Trough" level level ooff medication. medication, 205 205

u U

Ultra-radian cycling, cycling, 34 34 Ultra-radian Uncomplicated Uncomplicated bereavement, bereavement, 53 53

Underidentification with vidth diagnosis, diagnosis, 58, 58, 5959Underidentification 60, 256 0, 2 56 6 Unquiet Mind, A n (Jamison), Qamison), 195, 195, 239. 239, 282 282 Unquiet Mind, An

T

v

Tardive dyskineSia, dyskinesia, 116 116 Tardive

Vocational Rehabilitation Rehabilitation Division, Division, 287287Vocational

Tegretol (carbamazepi (carbamazepine), 110-111, 112, 205 205 Tegretol ne), 11 0-11 1 , 112, 61-63 Temperament, 61--63 Test for for disorder, disorder, 88-89 88-89 Test

288 2 88 Vulnerability-stress model, model, 75-76 75-76 Vulnerability-stress

Therapeutic range range of of medication, medication, 104, 205 Therapeutic 104, 205

Ww

Therapist, choosing, choosing, 123-124 123-124 Therapist,

Warning signs. See Early Early warning warning signs signs Warning Signs. See

Testing diagnosis, diagnosis, 59 59 Testing

"Thought Record,� Record," 1125, 232 "Thought 25 , 232 Thoughts Thoughts

Weakness, seeing signs of in Weakness. being being hospitalized. hospitahzed, 207-208 207-208

changes in, in, 2 23-25, 190-191 3-25, 190-191 changes

being on on disability, 289 being disability, 289

cognitive restructuring restructuring strategy, strategy, 229-236 229-236 cognitive

depreSSive depressive episode. episode, 2l5-217 215-217

depressive episode episode and, and, 229-230, 236-237 236-237 depressive hyperpositive, 195-196 195-196 See also also Suicidal thoughts thoughts Su Thyroid supplements, 117 117 Thyroid Tiagabine (Gabitri\), (Gabitril), 117 117 Tiagabine Time lag lag between between first first episode episode and and diagnosis, diagnosis, Time 13-14 Time-out, asking asking for, for, 272 272 Time-out,

suicidal lhoughts, thoughts, 239 239 sUicidal taking medication, medication, 140-141 140-141 taking Wellness. Wellness, maintaining. maintaining. See See Maintaining Maintaining

wellness wellness "What Role Role Has Has Stress Stress Played Played In In Your Your KWhat Illness?", 92 92 Il!ncss?", KWhat's "What's Me M e and and What's What's My M y Illness" Illness" checklist, checklist,

63-64 63-64

Index Index Workplace Workplace adjustments in after after episode, episode, 9-10 9-10 ad justments in balancing balancing work work time time against against down d o w n lime, time,

286-287 286-287 communication ith employer, communication w with employer, 280-281, 280-281, 2B5 285

disability disability insurance, insurance, 288-289 288-289 job performance performance issues, issues, 276-277, 276-277, 289 289 job ovennew overview of, of, 274-276 274-276 "reasonable "reasonable accommodations" accommodations" in, in, 279, 279, 2832832B6 286

321 321

self-disclosure of of disorder disorder in, in, 277-283 277-283 self-disclosure social support support and and performance performance in, 289 social in, 289 stigma, stigma, dealing dealing with with in, in, 281-282 281-282 Vocational Vocational Rehabilitation Rehabilitation and, and, 287-288 287-288 Worksheets, Sa See Forms Forms and and worksheets worksheets Worksheets. z Zeilgebers Zeitgebers and and Zeitstorers, Zeitstorers, 94--95 94-95 Zung Self-Rating Self-Rating Depression Depression Scale, Scale, 218, 218, 219 219 Zung Zyprexa Zyprexa (olanzapine), (olanzapine), 116 116

A b o u t the t h e Author A u t h o r About

David David J. J. Miklowitz, Miklowitz,PhD, P h D ,did didhis hisundergraduate undergraduatework work at atBrandeis BrandeisUniversity University and l979�1985) and postdoctoral work and his his doctoral doctoral ((1979-1985) and postdoctoral work (1985-1988) (1985-1988) at at UCLA. UCLA. He H e has has been been on on the the psychology psychology faculty faculty at at the the University University of of Colorado, Colorado, Boulder, Boulder, since faclOrs since 1989. 1989. Dr. Dr. Miklowitz's Miklowitz's research research focuses focuses on on family family environmental environmental factors associated the major associated with with the major psychiatric psychiatric disorders, disorders, and and family familypsychoeducational psychoeducational treatments for for bipolar bipolar disorder. disorder. He H e received receivedthe theJoseph JosephGengerelli GengerelliDissenation Dissertation treatments Award from from UCLA U C L A (1986), (1986), Young Young Investigator Investigator Awards Awards from from the the lmernationai International Award Congress on on Schizophrenia Schizophrenia Research Research (1987) (1987) and and the the National National Alliance Congress Alliance for for Research on on Schizophrenia Schizophrenia and and Depression Depression (NARSAD) ( N A R S A D ) (1987), (1987), a a Research Research Research Faculty Award Award from from the the University University of of Colorado Colorado (1998), (1998), and and a a Distinguished Distinguished Faculty Investigator Award Award from from N A R S A D (2001). (2001). His His research research has has been been funded funded by by Investigator NARSAD the National National Institute Institute of of Mental Mental Health and the the John D. and and Catherine Catherine T. T. the Health and John D. MacArthur Foundation. Foundation. Dr. Dr. Miklowitz Miklowitz has has published published over over 80 80 research research papers papers MacArthur and book book chapters chapters on on bipolar bipolar disorder disorder and and schizophrenia. schizophrenia. His His articles articles have have and appeared in in the the Archives Archives of of General General Psychiatry, Psychiatry, the the British British Journal journal of of Psychia­ Psychiaappeared try, the the Journal Journal of of Nervous Nervous and and Mental Mental Disease, Disease, Biological Biological Psychiatry, the try, Psychiatry, the Journal of Consulting and Clinical Psychology, and the Journal of Abnormal Journal of Consulting and Clinical Psychology, and the Journal of Abllonnal Psychology. His His book book with with the the late late Michael Michael Goldstein, Goldstein, Bipolar Bipolar Disorder: Disorder: A A Psychology. Family-Focused Treatment Treatment Approach Approach (Guilford (Guilford Press), Press), won w o n the the 1998 1998 Outstand­ OutstandFamily-Focused ing Research Pubhcation Award Award from from the the American American Association Association of of MariLal Marital and and Research Publication ing Family Therapy. Therapy. Family

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