Coping with Bipolar Disorder

A CBT-Informed Guide to Living with Manic Depression

Steven Jones, Peter Haywood, Dominic Lam

• Publisher: Oneworld Publications
• Year: 2009
• ISBN:
  9781780740119
• Topic: Personal Development
• Subtopic: Self Improvement

A guide to coping with bipolar disorder which offers information on all the key areas, including medication, dealing with stress, and using psychological techniques to cope with manic depression. "Coping with Bipolar Disorder" is designed specifically for sufferers of bipolar disorder, their carers, friends and families. It combines definitive coverage of the condition and information about treatment with an approach which encourages patients to manage their own psychological health using cognitive behaviour therapy, as well as the more traditional medication regimes. The result is a straightforward book that should empower sufferers, in addition to giving them necessary advice on such key areas as sleeping habits, coping with stress and anger, and relating to family and friends.

Chapter 1

What is bipolar disorder?

Introduction

This book is intended to provide information for people who are experiencing bipolar disorder, along with their relatives, friends and other interested lay people. Bipolar disorder is the term that is now used to describe what was formerly known as manic depressive illness. The focus of this book will be on providing useful information about the nature of this illness and its treatment. This information will include both traditional treatment approaches and more recently developed psychological treatments. It is not the intention of this book to imply that people with illness should treat themselves, but rather that by having access to relevant information they can take an active and influential role in the course of their own treatment. As authors we have both clinical and research experience that attests to the usefulness of psychological approaches to bipolar disorder. We are also well aware that at present these are most effective when used in combination with more traditional forms of psychiatric treatment, in particular with appropriate forms of medication.

How common is it?

Bipolar disorder is not uncommon. Around 1–1.5% of the population in both Britain and the United States are expected to be suffering from bipolar disorder at any time. This translates to around one in every hundred people having a form of bipolar disorder that would be recognised by psychiatrists. This figure alone indicates that a large number of people are living with bipolar disorder and this does not take account of milder forms of mood difficulties that would not be diagnosed as bipolar disorder but could still cause significant problems for those experiencing them. This includes cyclothymic disorder, in which the individual tends to experience relatively frequent changes of mood (both elevated and depressed) but in which no single episode is so severe as to require a clinical diagnosis of mania or depression.

Symptoms of bipolar disorder

It is important to note first that in the press and elsewhere there is at times confusion between bipolar disorder and other psychiatric disorders, such as schizophrenia or personality problems. In actual fact the symptoms that identify bipolar disorder are quite specific. Bipolar disorder is a severe form of mood disorder during the course of which a person experiences both extremes (low and high) of mood. Extreme low mood is diagnosed as depression. There are several different means by which a clinician can diagnose clinical depression, but all these means of diagnosis identify certain essential symptoms.

Depression is characterised by persistent low mood and loss of interest in previously valued activities. Sleep is often disturbed, as is weight, and both can either increase or decrease when someone is depressed. Feeling extremely tired is common as are feeling either very slowed down or very keyed up. People will commonly feel guilty for no good reason when depressed and tend to be extremely critical of themselves. Thinking can feel difficult and attending even to quite straightforward tasks can seem to be a great burden. Thoughts of ending life or of wishing no longer to be alive can also occur.

It should be emphasised that people with depression differ substantially. Just as people are individual in the absence of mood disorder, so they are when they experience psychological distress. Whilst one person may feel agitated, guilty and indecisive, someone else may feel exhausted, slowed down and constantly in need of sleep. These symptoms need also to be present for a significant period of time, at least a couple of weeks, so that someone feeling depressed for a day or two even if they felt very low would not normally be diagnosed with depression if the problem then resolved or significantly improved. Clearly, everyone experiences mood changes and experiencing a significantly low mood is a common experience. It is the severity, duration and extent of impact of symptoms that differentiates clinical depression from ‘feeling depressed’. Following is an example of depression.

case

Laverne currently suffers from depression. She is now forty-one years old. She had two episodes of mania in her early twenties, but none recently. Her main problem is that her mood is low and negative most of the time. She has raised her daughter alone, in spite of her mental health problems, and her daughter as a young adult is now attending college and doing well. Laverne is, however, very critical of herself. She sees herself as a failure and struggles to maintain employment as a cleaner. She thinks a lot about what she sees as her own shortcomings. She has described herself as ‘Jonah, cursed by fate’.

Mania is usually thought of as being the polar opposite of depression. However, this is not entirely accurate. Whilst some people with mania can indeed feel elated or very happy, it is not necessarily the case and irritability or short temperedness are common.

Common symptoms of mania include feeling oneself to be superior to others; this can be intellectually, physically, in appearance or in terms of specific talents. People during mania often need less sleep and sometimes might go for days at a time without sleeping. There is usually a tendency to be more talkative than usual and to speak more rapidly. The listener can therefore sometimes feel bombarded by the rate, volume and length of conversation of someone in a manic phase. Ideas will often seem to appear one on top of another, cascading out in speech that can then be hard to follow as the person with mania struggles to keep up with the rate of different and divergent thoughts that they want to express. Intense interest in work, hobbies or new projects may become apparent – working excessive hours without rest or sleep in following up a big idea. Because of the person’s often high self-esteem during this phase there will be a tendency to continue putting effort into plans even when others reject and try to dissuade the person from engaging in them. The smallest element of praise can at this stage be interpreted as a ringing endorsement. When in a manic phase concentration can be poor because of easy distraction by other information, and there is also an increased danger of engaging in risk-taking activities. These might involve increases in sexual promiscuity, thrill seeking, drug or alcohol use. Often this pattern will be grossly outside the person’s ‘normal’ character.

Again, this is a pattern that needs to be present at a severe level for a significant period of time (at least a week) before a clinical diagnosis of mania can be made. As with depression, there is great individual variation. Some people will seem to have some elements of the above symptoms as part of their ‘normal’ character and therefore the manic phase is merely an extreme variation on this pattern. However, for other people the manic phase will involve behaviour and actions that appear entirely foreign to them when the phase has passed. One person might therefore experience a manic phase in which mood is elated and they are carried away with a sense of their own inspiration and superiority, which feels initially very positive but becomes less so as acting in an impulsive manner starts to cause practical problems. Another person might experience mania as being associated with high, and therefore unpleasant, levels of irritability and agitation, in which talk is very rapid, many conflicting ideas are present at the same time and it is very hard to accomplish any tasks because of this combination of other symptoms. In the following example Donald exhibits psychotic symptoms.

case

Donald is thirty-two and lives with his parents. He has been in hospital four times because of episodes of mania. The first occasion was as a student. Having been quite shy at home, he became more sociable and outgoing at university. He found his first girlfriend, started drinking and began to use cannabis. His mood became more expansive as the first year continued and he began to sleep less and less. He started to tell his friends that he was ‘inspired’ as a writer and had a great future. Over time both his writing and his speech became more rambling and incoherent and friends and family found him increasingly difficult to understand. He noticed that he had brilliant ideas that came into his head so fast that he couldn’t follow them. Towards the end of his first year at university he was found wandering around the campus and talking incoherently. He was admitted to hospital at this point and treated with anti-psychotic medication and lithium.

Psychotic symptoms can occur in either depressed or manic states. Psychotic symptoms are, essentially, unusual and false perceptions. The main psychotic symptoms that a person might experience are delusions or hallucinations. A delusion is a strongly held belief in something as a fact despite the clear presence of evidence indicating that it is not true. Hallucinations are the experiences of seeing, hearing, touching or smelling something when there is nothing there. Auditory hallucinations are commonly heard as voices speaking to the person. These voices may seem like a running commentary to the person, or the voices may be threatening. This can be distressing for some, but others live peacefully with their voices. Most common are auditory and then visual hallucinations. Here is an example of a delusional belief:

case

In her early twenties Laverne was admitted to hospital twice with manic episodes: during these episodes she believed that spirits were possessing her (a delusional belief). She slept very little and would stay up late at night listening to music and finding ‘spiritual’ meanings in lyrics to pop songs.

An additional feature of bipolar disorder is hypomania.P eople who experience hypomania will, as with mania, experience elevated mood, often increased self-esteem and greater sociability. Thoughts and speech may come more rapidly and risky behaviour (sexual, drug taking, or other stimulation seeking) may increase. It is different from mania in that there are no associated psychotic symptoms and changes in hypomania will be less severe. Many people have experienced brief periods of hypomania as a positive state in which they have been creative and productive. However, as it persists there are substantial risks of the state worsening into depression or a full mania, as the following example demonstrates.

case

Melissa is twenty-eight years old and works in advertising. Her mood fluctuated in her teens and early twenties, generally between periods of low mood in winter and feeling energised, creative and sociable in summer. During one of these ‘up’ periods she ran up big debts on her credit cards. She allowed herself to be picked up by three men during this period and found herself involved in group sex. She found this degrading and upsetting and a period of low mood followed. Memories of this incident continued to trouble her for years after the event.

Causes

Bipolar disorder has a history of being seen as a clear example of a biological form of mental illness, that is, a disorder in which there is a medical brain problem that is in need of medical treatment to return the person to health. As will be described in more detail below, there is evidence that bipolar disorder can be inherited and also that there are important biological factors involved in developing this disorder. However, it is also clear that the relationship between inheritance, biology and bipolar disorder is far from being a simple one. In fact, there is additional evidence that experiences that individuals have in their lives, how they respond to such experiences and their general patterns of thoughts, feelings and relationships are also important factors in whether or not bipolar disorder might develop. The possible role for each of these factors is discussed below.

Genetic

The first genetic evidence came from studies into the extent to which bipolar disorder (then known as manic depression) ran in families. It was found that although not everyone with this disorder had relatives with a similar illness, many people seemed to. Overall, estimates seemed to indicate that if a person had bipolar disorder, there was approximately a 13% chance of that person having a relative with depression and a 7% chance of him or her having a relative with bipolar disorder. However, it is worth considering that this also means that the chances of a person with bipolar disorder not having a relative with either disorder are vastly higher (87% and 93% respectively). Even when studies have been undertaken of twins who share identical genes (monozygotic twins), the chances of the second twin having bipolar disorder if the first did were not 100%. Around 67% of twin pairs who shared the same genes had bipolar disorder in both twins. This means that 33% of such twins did not share bipolar disorder in spite of being genetically identical.

Evidence to date does indicate that genes have a role in bipolar disorder. It is, however, also the case that many people with this diagnosis have no family history of this form of illness and, furthermore, many people with bipolar disorder go on to have children who are well. Therefore, the effects of genes on illness are complex and combine with many other different factors to determine whether or not a particular individual goes on to develop the illness itself. Recent information from the mapping of the human genome provided interesting evidence that the number of different genes in the human genome was much lower than that expected. Indeed, the figure reported was not substantially higher than that of lower mammals. This has been interpreted by geneticists as indicating that experiences after birth must have a greater impact in generating the diversity in human beings than had previously been supposed by scientists who were investigating primarily the biological and genetic elements of human functioning.

Organic

As bipolar disorder can involve many areas of human functioning, and also since there is evidence that drug treatments are effective for many people with bipolar disorder, a lot of research effort has gone into the investigation of possible abnormalities in brain function of people with bipolar disorder. Although there have been a number of studies that have seemed to show differences in brain chemistry between people with bipolar disorder and other groups, findings are not consistent. Also, there is at present insufficient evidence to link any one specific abnormality to the features of the disorder itself. For instance, the finding that the depressive phase of bipolar disorder is improved by medication, which increases the brain chemical serotonin, does not necessarily mean that reduced levels of the same chemical caused the original depression.

If brain differences are finally established, they will have to be consistent with the fluctuating patterns of bipolar disorder and take account of both extremes of mood evident in this illness. It is likely that any brain abnormalities (if present at all) will be found in the interactions between structures involved in integrating and organising different brain functions.

Environmental

If genes or biology were the only factors that influenced bipolar disorder, then the experiences a person has in life should not affect whether he or she develops the disorder or becomes ill again subsequently (relapses). However, there is clear evidence that in the period leading up to first becoming ill people will often have experienced significant changes or problems in their lives. The significance of these problems will usually be greater than those experienced by people who do not become ill. Once a person has received the initial diagnosis of bipolar disorder, further periods of ill health will again often be preceded by life events or difficulties in the period leading up to ill health recurring. In the past, there had been suggestions that this apparent relationship between people’s experiences and their subsequent mood problems was misleading. It had been argued that this association just reflected the fact that people were beginning to become unwell and their behaviour was then responsible for causing difficulties in every day life. Researchers, working first in the area of depression and later looking at bipolar disorder have therefore distinguished between events that could be described as dependent (caused by the person) and those that are independent (not under the control of the individual). An example might serve to illustrate this distinction:

If a person lost his or her job in the weeks leading up to an episode of illness, then this would be a dependent event if it were th...

Table of contents

• Cover
• Title Page
• Copyright
• Contents
• Series foreword
• Acknowledgements
• Chapter 1: What is bipolar disorder?
• Chapter 2: Treatments for bipolar disorder – medication
• Chapter 3: Treatments for bipolar disorder – professional help
• Chapter 4: Recent developments in psychological approaches to bipolar disorder
• Chapter 5: Early warnings
• Chapter 6: Helping yourself – routine, diet and relaxation
• Chapter 7: Vicious cycles and how to deal with them
• Chapter 8: The risks of sleep loss
• Chapter 9: Family issues
• Chapter 10: Feeling bad about one’s illness – guilt, shame and stigma
• Chapter 11: Survival issues
• Chapter 12: Your rights and how to protect them
• Appendix A: Useful addresses and further reading
• Appendix B: Deep muscle relaxation
• Index