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

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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.

38 38

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

40 40

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.

42 42

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

46 46

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?

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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

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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

IIss ItItonanIllness Illnesor s or It Me? Is IIIsMe?

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

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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;

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IIss lIon It onIllness Illnesor s or It Me? Is IIIsMe?

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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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