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Turning Black and White into GrayMood Disorders: Discovering New Horizons of Understanding and Enlightenment
By Sarah Kennedy Keith Conrad
iUniverse, Inc.Copyright © 2012 Sarah Kennedy, MFT, and Keith Conrad
All right reserved.
Chapter OneCycling Depression/Bipolar Disorder
The Story Begins
Sarah Kennedy started psychotherapy sessions with Keith Conrad in April 2004. At that time, he had depression, anxiety, difficulty concentrating, and trouble controlling his temper. The temper problem was becoming worse and sometimes resulted in "temper tantrums," which scared him and the people around him. He admitted drinking three to six beers every day after work. He felt the beer helped to relax him. This was usually a social event with a few friends who drank with him at his shop.
Keith sought help because his problems were getting worse and were interfering with his career and personal life. Keith's wife was becoming irritated by his late evenings at the shop and "friends" she felt were using him. His work was suffering from his unstructured, chaotic schedule.
Sarah was impressed by Keith's understanding of his weaknesses and problem behaviors. He had undergone many years of prior therapy and knew himself well. However, he had no name for his condition.
Keith was an only child who was intelligent like his father. He was close to both parents in early childhood. When he was eight, his parents separated, and his world began to crumble. He lived with his mother but enjoyed frequent visits with his father.
Approximately one year after the separation, his father committed suicide. After the suicide, Keith's mother suffered from severe mood swings and a nervous breakdown. She moved Keith to another state to be closer to her family. Keith's stability was rocked and he became a confused, traumatized, lonely boy.
Keith reported that his involvement in a martial arts program as a teenager taught him discipline and provided structure. As an adult, he was involved in a number of short-term relationships.
At age forty-five, Keith had been married for five years and felt his wife was losing patience with his mood swings. His wife's family was somewhat chaotic and outgoing, which was very unlike his. Her parents and four siblings lived close by and celebrated holidays together. She also had two adult children from a previous marriage and shared a close relationship with them. Keith felt he had a good relationship with the members of his wife's family. Before starting therapy, Keith had tried unsuccessfully to reestablish a relationship with his mother, who lived in Nevada (Keith lived in South Dakota).
Keith was pleasant and talkative. He understood how his problems were affecting his life. He was particularly concerned about his excessive anxiety, difficulty sleeping, temper outbursts, and drinking. He was also having negative (dark) thoughts, but he was not suicidal.
Dark thoughts are common in depression. Unipolar depression is usually caused by environmental factors like the death of a loved one, loss of a job, or other personal failure. In unipolar depression, negative thoughts replace positive ones. A sense that nothing is right and something terrible will happen is common. "I'll never get a job because I'm too old" (or "because the economy is failing)" are examples of negative thoughts in unipolar depression. These thoughts cause sadness and immobilization with resulting hopelessness and helplessness.
The same pattern is seen in the downward cycle of a patient with bipolar disorder. However, when mania sets in, anxiety can cause negative thoughts to have a "racing" and extremely violent quality. The gruesome thoughts often will not leave the mind. These racing, dark thoughts are terrifying during the day and prevent sleep at night. The patient is fearful that dark thoughts could become reality when he is unable to "escape" them during sleep.
A history of anxiety, racing thoughts, and/or difficulty sleeping is a red flag for considering a diagnosis of a cycling type of depression. Because of its genetic nature, family history is also important. Family members with reports of suicides, "nervous breakdowns", postpartum depression, drug abuse, and/or alcoholism could cause further suspicion of a bipolar diagnosis. This terminology and self-medication could be evidence of a family's tendency toward chemical imbalance associated with a genetic form of depression.
Keith tested highly positive for attention deficit hyperactivity disorder (ADHD) and mild depression. Sarah suspected a cycling type of depression (possibly bipolar disorder) because of Keith's mood swings, anxiety, dark thoughts, sleep problems, and temper tantrums. She was further suspicious because of his father's suicide and mother's nervous breakdown. She recommended psychiatric evaluation for formal diagnostic evaluation of Keith's condition and treatment of his condition.. Keith was unable to schedule an appointment with a psychiatrist for six weeks. He chose to see his primary medical doctor for immediate treatment of his anxiety symptoms and then transfer his care to a psychiatric care facility within two weeks.
In the first two weeks, Keith saw his medical doctor for an emergency appointment. The doctor wrote him a prescription for an antianxiety medication, (Xanax). This was to help him manage anxiety and temper outbursts until he could see the psychiatric specialist. Xanax is effective for occasional or short-term use, but is potentially highly addictive. While on Xanax, Keith's anxiety decreased and his temper outbursts were controlled. However, it was likely that the psychiatric specialist would prescribe a different long-term medication.
When Keith was seen by the psychiatric specialist, his Xanax was decreased and then discontinued. Keith was started on Prozac, which is a selective serotonin reuptake inhibitor (SSRI) commonly used to treat depression. Initially, Keith did extremely well on Prozac. He said he had "never felt so good; this was his first window of feeling normal." He was happy, relaxed, and could sleep. His dark thoughts were gone and he had an optimistic attitude. Unfortunately, he developed side effects that forced him to discontinue the medication.
He was then changed to Wellbutrin. This is a medication that is effective in treating both depression and attention deficit disorder. The psychiatric specialist hoped it would help with both problems. On Wellbutrin, Keith's concentration improved and he could perform his job duties better. He felt like raging but could talk himself out of his anger and avoid temper outbursts. Wellbutrin is not as sedating as Prozac. Therefore, Keith was given a small quantity of Xanax to help him relax and sleep. This was carefully monitored.
Bipolar disorder is usually treated most effectively with a mood stabilizer. Mood stabilizers are the "big guns" of psychotropic medications and are generally prescribed and monitored by psychiatrists. Mood stabilizers include lithium and antiseizure medications like Depakote, Lamictal, and Tegretol. Primary medical doctors and psychiatric physician assistants are comfortable prescribing antidepressants and antianxiety medications. However, when a mood stabilizer is necessary, referral to a psychiatrist is indicated.
Keith reported that medications were always very effective on him and he usually required only a minimal dose. It made sense that Wellbutrin and Xanax would be adequate to treat his symptoms and psychiatric evaluation could be postponed. Keith agreed to follow up in Sarah's office often to work on relationship problems and to continue on his current medications.
Keith was stable for four months. His dark thoughts were controlled and he was able to reason with people; he was rebuilding his relationships and business. He had less anxiety and could talk himself out of temper outbursts.
Keith continued weekly therapy sessions to work on relationship issues. Hypnotherapy helped with his anxiety and sleep difficulties.
All was well from April until mid-August, when Keith and his wife came to see Sarah for couples' therapy. In the couples' session, Sarah noticed that Keith was different. He thought he could "do anything" in his printing business. He was not sleeping while working long hours. It seemed there was nothing he could not accomplish. Day and night he worked endless hours to finish printing jobs. His wife was concerned, but Keith had a grandiose feeling of accomplishment. Sarah noted this questionable manic episode.
Keith returned a few days later, more stable and relaxed. He reported he was sleeping and no longer spending long hours at his job. The following week in a couples' session, Keith and his wife were doing well.
When seen alone the next week, Keith was depressed and suicidal. His optimism had been replaced by a negative attitude. Much of the work he had finished while manic was returned to him with complaints about mistakes and omissions. He was frustrated having to correct these jobs. He said he felt like he was "chasing his tail." He reviewed his life and verbally beat himself up for past failures. It was the first time Sarah had a hard time following Keith's logic.
Sarah felt she had seen Keith go from mania into the depths of depression in a very short time. She was very worried about Keith and instructed him to schedule an appointment with a psychiatrist for diagnosis and treatment of probable bipolar disorder. He was further advised to contact his psychiatric specialist. He promised to check in with Sarah daily and to call immediately if his condition worsened. Keith's wife was called and informed about his condition.
Keith saw the psychiatrist, who confirmed the diagnosis of bipolar disorder. The psychiatrist prescribed a mood stabilizer and Keith gradually improved.
Sarah continued to see Keith regularly and to coordinate his care with the psychiatrist when indicated. Through their work together, Keith's understanding of his condition improved and his outcome was excellent.
I have often thought that bipolar is the cruelest of all mood disorders because of the way patients experience windows of "normal" (whatever that is). These windows can last days, weeks, months, or longer. When the patient subsequently enters a manic or depressed state, there is great confusion. Where did "normal" go and how can it return? Was it a dietary or sleep change, or something environmental? This search for the window of "normal" is frustrating. It is difficult to understand and accept the chemical nature of the mood changes. There is nothing that can be done to find this elusive "normal". It is a chemical change in the brain.
People in a manic state see life with a greater intensity than most of us, and that can be both a blessing and a curse. Brilliant minds produce creativity that lends itself well to artistic genius. A combination of grandiose ideas, racing thoughts and sleepless nights often become ideal for converting brilliance into greatness. With treatment some passion is lost. The intensity with which patients experience life and express themselves through art, poetry, music and writing can be decreased. Sometimes bipolar patients exchange genius for mediocrity; sometimes they must in order to survive.
The list of famous people with characteristics of bipolar disorder is fairly long. While we can't go back in history to diagnose these creative geniuses, there's much evidence to indicate that composers Amadeus Mozart and Ludwig van Beethoven, poet Edgar Allan Poe, author Ernest Hemingway, artist Vincent van Gogh, actresses Patty Duke and Carrie Fisher, singer Judy Garland, entertainer Marilyn Monroe, and musician Kurt Cobain had characteristics of bipolar disorder.
The list above offers only some of the people whose names would be recognized. Consider the great contributions society has received from people coping with their bipolar conditions. While we benefit from their gifts, many have paid a high price-lived lives of anxiety, loneliness or sadness that sometimes led to suicide. When treated, the highs aren't as high anymore, but the lows aren't as low either. Some passion is replaced by predictability and stability. Adults who are used to the productive highs are often reluctant to lose them by taking medication. They have learned to compensate. They find the newly-medicated versions of themselves to be dull and mediocre.
When considering proper treatment, each patient must make a careful decision on the basis of this double-edged sword and the recommendations of the treating psychiatrist.
Mild bipolar disorder is called cyclothymia. Many people with cyclothymia are not aware they have a form of the disorder and may just believe they have mood swings. "Cycling depression" is a label that can be used for patients who fall somewhere within the bipolar spectrum. The term "bipolar disorder" can be frightening to patients and most do not understand what "cyclothymia" means. "Cycling depression" is a descriptive term that is nonthreatening.
Sarah's Clinical Background:
I had a lot of personal and professional experience with pathological patients. I had raised a child with many problems including Tourette syndrome, ADHD, dyslexia and bipolar disorder. I often wondered what caused the unusual behavior I observed. I had good insight from a parent's point of view.
In the early years of my clinical practice in California, I learned how ADHD, Tourette syndrome, bipolar disorder, autism, OCD, and other mood and neurological disorders adversely affected siblings, parents, and patients.
Over the years, the number of patients with bipolar disorder increased. I observed the tragic effects as families and patients tried to cope with this illness and I helped in whatever ways I could. There was limited information available but I continued to be fascinated by the challenge and the frustrating way it caused so much chaos. It seemed there was little understanding of something that was becoming so common. I wanted to educate the public and help the troubled people who suffered from this condition. At that time, I had little knowledge of a patient's subjective feelings. How did it feel to be the person with the disorder?
When I relocated my practice to South Dakota, I would learn about that from a bipolar patient who had excellent insight and a unique ability to express it.
Perhaps because of the change of seasons and a prevalence of seasonal affective disorder (SAD), I found bipolar disorder to be more common in the Midwest than in California. Many patients with the disorder began to surface in South Dakota. SAD is associated with cycling depression or bipolar disorder. As the weather becomes dark and dreary in the winter months, depression increases for the bipolar patient. A sunny climate improves bipolar symptoms and many people with SAD purchase sunlamps to help improve their moods through the long winter months. These sunlamps are an electrical substitute for Mother Nature and help alleviate the darkness of winter.
It is possible that bipolar disorder is the most underdiagnosed and undertreated psychological disorder in the United States. Untreated bipolar disorder can lead to family problems, drug addiction, alcoholism, crimes, and suicides.
New Kind of Depression
Over the past few years, a new kind of depression has emerged in the United States. It is a cycling type of depression that is both genetic and biochemical. It responds best to mood stabilizers rather than the standard antidepressants (mainly selective serotonin reuptake inhibitors, or SSRIs) that have been used for generations to treat environmentally-induced unipolar depression.
I've been a practicing counselor since 1994 and watched this new type of depression become more common. The following is a list of experiences afflicted patients have described.
1. Episodes of problems with sleep.
2. Problems with out-of-control spending.
3. Family (or personal) history of alcoholism or drug abuse.
4. Family (or personal) history of nervous breakdowns.
5. Family (or personal) history of postpartum depression.
6. Road rage, rage episodes, or family members with rage episodes.
7. Family history of suicide.
8. Personal suicide attempt(s).
9. Seasonal affective disorder.
10. Racing thoughts.
11. Self-mutilation (cutting, eraser burning, head banging, etc.).
13. Symptoms began or became severe in teen years.
It is extremely important as a clinician to take a thorough and careful patient and family history if bipolar illness is suspected. Many of the above criteria are often present.
It is also important to note that many of these patients appear to be functionally normal or above normal, making it even more important to take a careful history.
The bipolar patient frequently presents in a manic state and is therefore having severe difficulty with anxiety and lack of sleep. Many times, well-meaning clinicians prescribe SSRIs before considering a mood stabilizer when the patient clearly has signs of bipolar disorder. SSRIs are the class of drugs, including Prozac, Luvox, Paxil, Zoloft, Lexapro, and Celexa, that generally regulate levels of serotonin in the brain.
Excerpted from Turning Black and White into Gray by Sarah Kennedy Keith Conrad Copyright © 2012 by Sarah Kennedy, MFT, and Keith Conrad. Excerpted by permission of iUniverse, Inc.. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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