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Bipolar Disorder Survival Guide What You and Your Family Need to Know
By David J. Miklowitz
The Guilford Press Copyright © 2002 The Guilford Press
All right reserved.
Chapter One What Bipolar Disorder Looks Like-to You, to the Doctors, and to Everyone Else
Though bipolar disorder is very difficult to diagnose, the "textbook" descriptions of it make it sound like it shouldn't be so hard. After all, what could be more dramatic than shifting between extraordinarily manic behavior, feeling on top of the world and supercharged with energy, to feeling depressed, withdrawn, and suicidal?
Consider a surprising fact: On average, there is an eight-year lag between a first episode of depression or manic symptoms and the first time the disorder is diagnosed and treated (Goodwin & Jamison, 1990; Lewis, 2000). Why should it take so long for a person with the disorder to come to the attention of the mental health profession? In part, the answer is because the behaviors that we summarize with the term bipolar disorder can look quite different, depending on your perspective. But even when people agree on how a person's behavior deviates from normal, they can have very different beliefs about what causes the person to be this way. Consider Lauren, who has bipolar disorder:
Lauren, a 28-year-old mother of three, describes herself as an "exercise junkie."In the past three weeks, a typical day went like this: Once she got the kids off to school, she rushed to the gym, where she worked out on an exercise bicycle for up to two hours. Then, she grabbed a quick yogurt and went hiking for most of the afternoon. She would pick up her kids from school, make dinner for them, and spend the majority of the evening on the stairmaster. But she did not consult her psychiatrist until, by the end of the second week, she had become exhausted and unable to function. At this point she left the children with their grandparents and spent several days sleeping. She admitted to having had several cycles like these.
Now consider how Lauren, her mother, and her doctor describe her behavior. Lauren summarizes her problems as the result of being overcommitted. "It's incredibly difficult to take care of three kids, maintain a household, and try to stay healthy," she argues. "My ex-husband is of very little help, and I don't have many friends who can help out. Sometimes I push myself too hard, but I always bounce back." Her mother feels that she is "irresponsible and self-centered," would "rather be exercising than taking care of her kids," and questions whether her children are getting enough guidance and structure. Lauren's doctor has diagnosed her as having bipolar II disorder.
Who is right? Lauren thinks her behavior is a function of her environment. Her mother describes the same behaviors as driven by her personality attributes. Her psychiatrist thinks she has a biologically based mood disorder. These different perspectives pose a problem for Lauren, because they lead to very different remedies for the situation. Lauren feels that others need to be more supportive. Her mother thinks Lauren needs to become more responsible. Her doctor thinks Lauren needs to take a mood stabilizing medication.
Almost every patient I have worked with describes his or her behavior differently from the way a doctor or family member would. Consider Brent, who has been having trouble holding jobs. He says he is depressed but feels most of it is due to being unable to deal with his hypercritical boss. As a result, he thinks he needs to switch jobs and find a more permissive work environment. His wife, Alice, thinks he is manic and irritable, not depressed, and that he needs long-term psychotherapy to deal with his problems with male authority figures. She also thinks he drinks too much and needs to attend Alcoholics Anonymous meetings. Brent's doctor thinks he is in a postmanic depressive phase and would benefit from a combination of medication and couples therapy.
Psychiatrists and psychologists usually think of bipolar disorder as a set of symptoms, which must be present in clusters (that is, more than one at a time) and last for a certain length of time, usually in "episodes" that have a beginning phase, a phase in which symptoms are at their worst, and a recovery phase. The traditional approach to psychiatric diagnosis described in Chapter 3 follows this line of reasoning. In contrast, people with the illness often prefer to think of bipolar disorder as a series of life experiences, with the actual symptoms being of secondary importance to the factors that provoked them. Family members or significant others may have a different perspective altogether, perhaps one that emphasizes the patient's personality or that views the deviant behavior in historical perspective (for example, "She's always been moody"). Although often quite different, there is a degree of validity to all three points of view.
In this chapter you'll gain a sense of the different perspectives people take in understanding bipolar mood swings and how these different perspectives can lead to very different feelings about which treatments should be undertaken. These perspectives include the personal standpoint, as described by patients who have the disorder; the observers' viewpoint, which usually means parents, spouses, or close friends; and the doctor's viewpoint. Questions to pose to yourself when reading this chapter are:
How do I experience swings in my mood?
Are they similar to the ways others with bipolar disorder experience them?
How do I understand my own behavior?
How is my understanding different from the way others perceive me?
How do I see myself differently from the way my doctor sees me?
What kinds of problems arise from these differences in perceptions?
Understanding these varying perspectives will be of use to you, whether you are on your first episode or have had many episodes, in that you will gain some clarity on how your own experiences may differ from those of people without bipolar disorder. You may also come to see why others in your family or work/social environment think you need treatment, even if you don't agree with them.
Nuts and Bolts: What Is Bipolar Disorder?
Let's begin by defining the syndrome of bipolar disorder. Its key characteristic is extreme mood swings, from manic highs to severe depressions. It is called a mood disorder because it profoundly affects a person's experiences of emotion and "affect" (the way he or she conveys emotions to others). It is called bipolar because the mood swings occur between two poles-high and low-as opposed to unipolar disorder, where mood swings occur along only one pole-the lows.
In the manic "high" state, people experience different combinations of the following: elated or euphoric mood (excessive happiness or expansiveness), irritable mood (excessive anger and touchiness), a decreased need for sleep, grandiosity or an inflated sense of themselves and their abilities, increased talkativeness, racing thoughts or jumping from one idea to another, an increase in activity and energy levels, changes in thinking, attention, and perception, and impulsive, reckless behavior. These episodes alternate with intervals in which a person becomes depressed, sad, blue, or "down in the dumps," loses interest in things he or she ordinarily enjoys, loses weight and appetite, feels fatigued, has difficulty sleeping, feels guilty and bad about him- or herself, has trouble concentrating or making decisions, and often feels like committing suicide.
Episodes of either mania or depression can last anywhere from days to months. Some people (about 40% by some estimates; Calabrese et al., 1996) don't experience depressions and manias in alternating fashion. Instead, they experience them simultaneously, in what we call "mixed episodes," which I'll talk about in the next chapter.
Episodes of bipolar disorder do not develop overnight, and how severe the manias or depressions get varies greatly from person to person. Many people accelerate into mania in stages. Drs. Gabrielle Carlson and Frederick Goodwin (1973) observed that in the early stages of mania, people feel "wired" or charged up and their thoughts race with numerous ideas. They start needing less and less sleep and feel giddy or mildly irritable ("hypomania"). Later they accelerate into a full-blown mania, marked by euphoria, impulsive behaviors such as spending sprees, and intense, frenetic periods of activity. In the most advanced stages, the person can develop mental confusion, delusions (beliefs that are irrational), hallucinations (hearing voices or seeing things), and severe anxiety. Not everyone experiences these stages, and many people receive treatment before they get to the most advanced stage.
People also spiral into depression gradually, although its stages are less clear-cut. For some, severe depressions arise when they were otherwise feeling well. In others, major depression develops on top of ongoing, milder depressions called "dysthymias" (see Chapter 10).
The periods in between manic and depressive episodes are symptom-free in some people. For others, there are symptoms left over from the episodes, such as sleep disturbance, ongoing irritability, or dysthymic or hypomanic disorders. Most people experience problems in their social and work life because of the illness (Coryell et al., 1993; Goldberg et al., 1995).
Between 0.8% and 1.6% of the general population has "bipolar I" disorder, marked by swings from extreme depression to extreme mania. About 0.5% (1 in 200) has "bipolar II" disorder, in which people vary from severely depressed to hypomanic, a milder form of mania (Kessler et al., 1994; Regier et al., 1990). New cases of bipolar disorder have been recognized in young children and in the elderly, but the typical age at first onset is between 15 and 19 (Goodwin & Jamison, 1990). It is generally treated with a range of drugs in combination with psychotherapy:
Mood stabilizers (for example, lithium carbonate, Depakote, or Tegretol)
Antidepressants (for example, Paxil or Wellbutrin)
Antipsychotics (for example, Zyprexa or Seroquel), and/or
Antianxiety agents (for example, Klonopin or Ativan).
Different Perspectives on Mania and Depression
As noted, the symptoms associated with bipolar mood disorder can be experienced quite differently by the person with the disorder, by an observer, and by a physician. The disorder primarily affects mood and behavior. Your moods cannot always be observed by others, although you will usually be aware of them. Likewise, you may not always be aware of your behavior or its impact on others, while others (family, friends, or doctors) are acutely aware of it. When people look at and evaluate the same set of behaviors or experiences through different lenses, you can imagine how much room there is for interpretation and misinterpretation.
You may be quite articulate in describing what you are feeling and thinking. When in a manic phase, your thoughts flow rapidly and life feels exotic and wonderful. You may speak more than usual and more freely reveal your inner thoughts. An observer, such as a family member, usually focuses on your behavior, which he or she may describe as too outspoken, boisterous, verbally hostile, dangerous to yourself or others, or impulsive in ways that negatively affect others (for example, spending or investing your money suddenly). Your doctor is usually attuned to whether your mood and behavior are significant departures from your normal states, taking into account such things as whether the symptoms have lasted for a period of time, how intense they are, and whether they cause impairment in your functioning.
In the following sections, I will describe mania and depression from these three perspectives. I will focus on the personal experiences that really define episodes of bipolar disorder, which are summarized in the sidebar on page 18.
Roller Coaster Mood States
"How can I ever make plans or count on anything or anybody? I never know how I'm going to feel. I can be up and happy and full of ideas, but then the littlest things set me off. I'll drink a cup of tea and it doesn't match my expectation of how hot it should be, and I'll just react-I'll cuss, scream-I'm bitterly volatile ... I'm afraid of my own moods." -A 30-year-old woman with bipolar I disorder
Most people with bipolar disorder describe their moods as volatile, unpredictable, "all over the map," or "like a seesaw." Mood states accompanying bipolar disorder can be irritable (during either depression or mania), euphoric, elevated or excessively giddy (during mania), or extremely sad (during depression).
You may agree that you have variable mood states, but your explanation for these mood states may be quite different than those of your doctor, family members, or friends. People with bipolar disorder often get angry when their doctors bring out a list of symptoms and ask them how many they have had and for how long. They find themselves reluctantly agreeing that they suffer from irritable moods but also know the triggers for these moods that other people may not see.
"When I'm mad, nobody better get in my face. I feel like crushing everything and everybody. Every little thing will provoke me. I hate everybody, I hate my life and want to kill myself in some really dramatic way. It's like a sharp-edged, pointed anger, like a burning feeling." -A 23-year-old woman with bipolar II disorder
Family members, when describing the emotional volatility of their bipolar sibling, child, or parent, tend to emphasize the intimidation they feel in the face of sudden outbursts that they don't feel they've provoked. Consider this interchange between Kirsten, age 21, and her mother, after Kirsten had railed at her mother just minutes earlier.
Kirsten: I wanna come back and live with you. I can handle it.
Mother: But you're not in a good place right now. Look how angry you just got.
Kirsten: But you told me I wasn't ready to take care of myself! Of course I exploded!
Mother: And you're not. I can tell because you're overreacting to me, and that tells me you're probably not better yet.
It's hard to think of your mood swings as evidence of an illness, especially when every emotional reaction you have seems perfectly justifiable, given what's just happened to you. To Kirsten, her angry outburst seemed perfectly justified, because her mother had questioned her competency. Her mother knows what her daughter is like when she's well and sees her irritability as a departure from this norm.
In contrast, the elated, euphoric periods of the manic experience feel exceptionally good to the person with the disorder.
Excerpted from Bipolar Disorder Survival Guide by David J. Miklowitz Copyright © 2002 by The Guilford Press. Excerpted by permission.
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