Owning Bipolar

How Patients and Families Can Take Control of Bipolar Disorder

Michael G. Pipich

• Publisher: Citadel Press
• Year: 2018
• ISBN:
  9780806538808
• Topic: Crescita personale
• Subtopic: Salute mentale e benessere

"Essential... Not only for the person learning to own their bipolar, but for the support system members and treatment providers walking alongside them." —Sally Spencer-Thomas, PsyD, president, United Suicide Survivor's International Knowledge is power, and grasping the basics of bipolar disorder can give you the power you need to detect it, accept it, and own the responsibility for treatment and lifelong disease management. With its three-phase approach, Owning Bipolar can help you and your loved ones become experts on an illness that has called the shots in your life for too long. Now it's time for you to take control. The Pre-stabilization phase and recognition: confronting the causes of bipolar and the effects, including depression, anxiety, loss of energy, avoidance of responsibilities, and suicidal thoughts The Stabilization phase and acting on it: starting effective medication, accepting the disease, and treating different types of bipolar The Post-stabilization phase and living with it: undertaking long-term maintenance, accepting your new identity, and coming to terms with your responsibilities and the responsibilities of your caregivers Accessible and encouraging, and accented with empathetic firsthand stories from people who share the disorder, this book is a vital companion for readers to help them understand, treat, and live successfully with bipolar. "Will provide clarity and understanding to a seemingly complex and confusing psychiatric condition."—David B. Weiss, MD, FAPA

CHAPTER 1

Origins of Bipolar Disorder

BIPOLAR DISORDER HAS BEEN KNOWN as manic depression and by other names throughout history. Descriptions of the cycling of “genius” and “madness” along with “melancholia” date back to ancient Greece. During the Middle Ages, much of what was believed about psychological disorders came from myths, legends, and falsehoods. Bipolar disorder and other mental illnesses were feared because they were misunderstood. As a result, many people were often viewed as outcasts, rather than human beings who suffered ailments requiring specific treatments, along with compassion from others. By the nineteenth century, some physicians wanted to take mania and depression out of the dark ages of mental illness and catalog bipolar-type symptoms so they could be treated like other medical diseases, but disagreement about what causes bipolar and how to treat it continued throughout the twentieth century.¹ Not until recently has bipolar disorder been widely accepted as having biological, genetic causes.

Today the term “bipolar disorder” refers to a class of psychiatric disorders involving severe episodes of contrasting mood states. “Bipolar” literally means “two poles.” Just as the North Pole and South Pole represent the farthest points on the globe, bipolar mood swings span the length of the emotional spectrum. Although many people experience mood swings throughout their lives for various reasons, bipolar disorder is distinct in that the cycles of both mania and depression can present destructive consequences to the individual’s health and well-being.

What causes bipolar disorder? Although it is called a mental disorder, the foundations of bipolar are genetic, which is the strongest and most consistent factor for the disease.² Without this genetic factor, bipolar disorder would likely not exist in any particular individual. Moreover, it is believed that bipolar is caused by underlying problems with brain development and/or brain circuitry. Some researchers who study stem cells—the basic building blocks that form specialized cells in our bodies—note that stem cells in people with bipolar develop differently than those without bipolar.³ Other researchers who observe brain functioning believe that in people with bipolar disorder the parts of their neurology that typically regulate emotions are not well designed. Two of those brain areas are likely the prefrontal cortex or PFC and the amygdala (pronounced ah-MIG-dah-lah).⁴

The PFC, located in the front of the brain, gives humans the ability to form and use logic. It’s in charge of understanding consequences and anticipating future events based on experience. The PFC learns right from wrong and helps us think in a rational, organized, and socially appropriate way. It sometimes is referred to as the “newest” part of the brain because as humans evolved, the PFC likely was refined through living in organized social groups and civilization itself. It’s often credited with giving us a sense of self-awareness or consciousness about who we are and what our purpose should be in life.

We also refer to PFC activity as “executive functioning.” Compare it to the top executive of a company making the hardest, most complicated decisions and then passing instructions down to the workers. The workers carry out the plans and send feedback to the executive who then makes further decisions. And so it goes in our brains. The PFC acts as the top executive while other brain structures carry out orders and give feedback.

The amygdala lies deep in the central region of the brain and is involved in producing emotions and processing emotional memories. During human evolution, the amygdala was likely well in place as the PFC was developing. While the PFC is more thoughtful, the amygdala is more reactive.

Emotional memories often include those deep within that have formed over many years and even memories that are repressed or unconscious. The amygdala alerts the executive that a current situation resembles things—real or imagined—from an old or repressed memory. That is why someone reacts in fear to something that is not inherently frightening: not necessarily because it’s a real threat, but because it resembles one. Or it may explain why someone falls quickly and madly in love with another person. It’s not always because this person is worthy of it, but because of a deeper emotional memory that this person elicits.

In a person with bipolar, the functions of the PFC and amygdala, and how they communicate with each other, don’t work in the kind of balanced and consistent way necessary for normal functioning—at least not all the time.

If the parts of the brain responsible for emotion and logic don’t work well together, what could happen? Without balanced and harmonious interactions between those parts, you might expect big fluctuations in mood states that are inadequately limited by logical thoughts or moral beliefs. For example, the amygdala may alert the rest of the brain to some potential consequence in a sudden burst of emotion and physical reactions, like increased heart rate and muscle tension. It puts the body in a state of readiness for action. But the PFC uses logic and reason to assess the real extent of the potential danger and the best way to handle the situation. If a person with bipolar is in a manic zone and feeling euphoric, the PFC may be blunted and not in sync with the amygdala’s signals. As a result, the person either may ignore the possible danger of the consequence, or feel so good that he or she interprets the distress signal the wrong way and believes that this experience isn’t dangerous at all! In fact, the person may view it as fun, or a sign that he or she is impervious to such a danger.

Along with shifting brain patterns lacking proper regulation between the PFC and the amygdala, measurable shifts in brain chemicals occur during mood swings, changing how nerve cells communicate with each other. These chemicals are called neurotransmitters because they allow chemical messages to transmit from nerve cell to nerve cell. One neurotransmitter is dopamine, which in the right amount produces a sense of pleasure, and helps provide a “reward” when we are learning something, or need a sense of motivation. Another neurotransmitter is serotonin, which in the proper concentration, prevents depression and aids in overall mood stability. Problems in mood regulation occur if there is too much or too little serotonin in the brain. Likewise, serious problems can occur when there is too much or too little dopamine, including possible psychotic symptoms.

This helps explain what people with bipolar experience. Perhaps you can now appreciate why bipolar patients can’t simply stop their mood swings through sheer will. People can’t just close their eyes, grit their teeth, and make their brains do something they were not designed to do. But understanding the brain should help in considering the needs of people with bipolar and can help us act more compassionately toward reworking some of these faulty brain functions.

Causes of Bipolar Disorder

There are two groups of causes:

1. Predispositional

2. Catalytic

Predispositional causes involve genetics and faulty brain development with respect to mood regulation. Catalytic causes, or catalysts, include all other factors outside or inside the body that switch on the actual mood swing from one extreme to another.

Predispositional Causes

Bipolar disorder is passed through family genetics and appears to affect how the brain is formed to handle mood regulation. When someone has a gene that likely can produce a certain medical disorder, scientists may say the person has a “predisposition” for that disorder. When I evaluate new patients, I ask about their family’s mental health histories to understand whether they may be predisposed to bipolar disorder. If anyone in the family tree, particularly the closest genetic relatives, experienced mood swings, I know they could be predisposed to bipolar. I then make precise inquiries into their backgrounds, especially where bipolar symptoms may have been hiding in their own life history.

For example, did Mom or Dad show signs of mood swings? High levels of irritability followed by deep sadness? What about Grandma or Grandpa? Were there stories of erratic behavior? Were there aunts or uncles who had serious bouts of depression or psychotic symptoms? Did anyone need serious psychiatric care? Suffer from addictions? What happened to these family members? A little detective work may be useful to figure out a genetic history of bipolar. Such information should be given to a mental health professional ahead of any bipolar-disorder evaluation.

Catalytic Causes

I refer to the many ways bipolar is triggered as manic catalysts. Why do I say “manic” catalysts and not “bipolar” catalysts? Because many people have periods of severe depression before they have mania. Depressive episodes can be triggered, too, but mania (and hypomania in Bipolar II) defines bipolar disorder separately from major depression alone.

Let’s look at some manic catalysts. As people mature, their brains have to find a way to deal with various stressors and challenges. The rigors of developing into an adult and all the added responsibilities could build into manic catalysts. Depression and anxiety may be present at any point in life, but often the specific symptoms of bipolar disorder emerge in adolescence or early adulthood.

Another catalyst for mania can be related to hormonal changes. These are certainly expected for any adolescent bipolar patient, but they also explain why some women with postpartum hormonal changes begin to develop bipolar symptoms if they are predisposed to bipolar. In fact, a presentation of mental illness in the early postpartum phase is an indicator for possible bipolar disorder.⁵ Other internal factors in a person’s changing physiology, including thyroid problems and other medical conditions, can be catalysts for mania.

A critical manic catalyst is substance abuse. You may wonder whether it would be considered an internal catalyst because the chemical inside the body affects the brain, or an external one because the individual is compelled to ingest the substance. It’s both. In addition, substance abuse often involves its own variety of external cues, such as social events or stressors. The brain of an addicted person also provides its own triggers to ingest more of the drug. It’s important to remember that not only can substances lift bipolar symptoms out of hiding, they also can be used to “self-medicate” those symptoms, especially when the user is depressed. Self-medication means the person abusing substances isn’t just trying to get high, but is really trying to improve his or her bipolar symptoms to feel better—even if he or she does not recognize this as the real reason for using those drugs. I will discuss later how this idea fits in to treating people who have both bipolar disorder and a substance abuse problem.

I’m frequently asked about the role of psychological trauma in triggering mania and bipolar in general. If a person has struggled with traumatic experiences now or in the past, symptoms can form sooner and/or more severely. Traumatic experiences are extraordinary and terrible events that either happened directly to us or we witnessed. Trauma certainly can result in many different and severe mental disorders; however, I’m convinced these catalysts would require having a predisposition for bipolar to form the disorder in the chronic, lifelong pattern we know.

To summarize, bipolar is genetic in its foundations, but life events can act as catalysts that arouse symptoms or make them worse.

Types of Bipolar Disorder

Bipolar disorder has three basic types:

1. Bipolar I Disorder

2. Bipolar II Disorder

3. Cyclothymia

Bipolar I is marked by severe manic episodes, what many call “full-blown” mania. Although Bipolar I may be easier to diagnose than the other types, it’s often harder to treat over the course of the illness. Someone with Bipolar I will suffer longer or sometimes more intense episodes of mania than other types and therefore will experience more consequences. Some instances of Bipolar I include psychotic symptoms, such as hallucinations or severely delusional thinking. More opportunities are available for treatment of Bipolar I because severe levels of the disorder tend to get more attention. However, consistent participation in care is difficult to sustain, because the consequences of Bipolar I can injure personal resources—such as financial and social supports—and thus make the ability to avoid symptom relapses more difficult. Bipolar I can emerge anytime, but the average age of onset is about 18 years old.⁶

Bipolar II is marked by manic episodes of shorter duration and sometimes with less intensity, known as hypomania (which literally means “under mania”). The same manic symptoms as in Bipolar I might exist, but the hypomanic episodes tend to last at least four days instead of seven days as in Bipolar I. Thus, it can do somewhat less damage to the individual’s life, at least in the shorter term. Bipolar I had generally been considered the worst form of bipolar, but that assessment is changing. That’s because the depressive episodes of Bipolar II can be just as severe—or even worse—than depressive episodes in Bipolar I. Moreover, those with hypomanic episodes are harder to diagnose. Hypomanic episodes may be viewed as symptomatic of active people too stressed out by life, or people who have another kind of mental health problem such as anxiety or a personality disorder. Bipolar II patients tend to be somewhat older than Bipolar I patients, with an average age of onset in the mid-20s,⁷ so hypomania could be confused with a hard-driving, young adult lifestyle. And because Bipolar II patients tend to be highly productive and more “functional” than Bipolar I patients, they may not consider mood regulation to their benefit. People around the Bipolar II person would tend to disagree. A hypomanic episode indicates a definite change in the person’s behavior compared with when hypomania or depression is not present. Daily life functioning is impaired as a result, including mismanagement of responsibilities in one’s job or school, and a decline in health, finances, and relationships. Bipolar II may be somewhat easier to treat, but it can be more difficult to identify and diagnose adequately.

Cyclothymia literally means “cycling emotions.” This form of bipolar is marked by less severe but more frequent changes in mood than other kinds of bipolar disorder. It forms a chronic, consistent pattern that lasts at least two years in adults and one year in children. The mood episodes are very compact in time. A person with cyclothymia can go from extremely excited and “happy” to sad, anxious, and tearful in a matter of a day or two, or even just a few hours. For people in the earliest stages of bipolar, it is not unusual to show a cyclothymic or “rapid cycling” pattern. This is observed as a “prodromal” form of the disease, which means the full disorder has not yet presented itself. This happens commonly with adolescent patients in particular. Whe...

Table of contents

• Title Page
• Dedication
• Copyright Page
• Table of Contents
• Foreword
• Preface
• INTRODUCTION - Nobody Is at Fault
• CHAPTER 1 - Origins of Bipolar Disorder
• CHAPTER 2 - Diagnosing Bipolar Mania, Hypomania, Depression
• CHAPTER 3 - Why Bipolar Can Be Difficult to Accept
• CHAPTER 4 - Understanding the Bipolar Experience
• CHAPTER 5 - Bipolar Therapy: A Three-Phase Approach
• CHAPTER 6 - The Medication Conversation
• CHAPTER 7 - Bipolar Medications
• CHAPTER 8 - Thriving in Life After Stabilization
• CHAPTER 9 - Postpartum Onset in Bipolar Disorder
• CHAPTER 10 - Hospital/Inpatient Treatment
• CHAPTER 11 - Need for Support from Families and Beyond
• CONCLUSION - Going to the Next Level
• Reference Guide to Bipolar Medications
• Acknowledgments