Living Bipolar (5 page)

You have to know your illness. But with that said, once you know your pattern, once you know how the medications affect you, and once you know that even with the best of medicines -- no matter what combination you are on -- you can still have some break through mood problems. You might get a phase of depression, you might get a phase of mania, but these phases don’t reach the threshold of severity where you need hospitalization, or you need ECT, or you need a whole do over of your medication. You need to be aware of the fact that medications do wear off, and that’s parcel to anything in psychiatry. People develop a tolerance to medications. These are all known things which can help us. You know understanding the illness, and what’s the next step for us. So I think
education is the most important thing
.

In terms of what’s the next step proceeding education, I had a friend who managed his mood swings by running excessively. He would run eight miles a day. It helped his sleep patterns. He usually did this when he was in a manic phase. He would have to be out there running, and he had to pound the pavements for his eight miles. But it helped him.
Running was his mood stabilizer.
Thus, EXERCISE is very important. Science is not quite sure yet what the significance is yet, but there is a brain chemical that is released when we do aerobic exercise that might have some benefit in depression, but we (the scientific community) are not quite sure where it fits in with Bipolar disorder that’s Brain-derived
neurotrophic factor
(BDNF), and that is released with aerobic activity. But I can’t speak fully on all of the ramifications of that.

It’s kind of exciting because it causes or tends to help regeneration of brain tissue. And that’s exciting. As opposed to thinking that we just have a closed system of this many brain cells, to think that regeneration of brain cells can occur, that changes the way that we think about some of these illnesses. So exercise is on top of the list. There is no question about that.

It might just be my knowledge base of foods, but I wouldn’t say one food over another is important for the Bipolar illness. Although it seems like omega-3 fatty acids have some mood stabilizing properties. I read some studies where three grams a day have some benefit both ways, for depression and when you are manic. I’m not really sure if there is anything which just supports those dietary supplements as enough to maintain mood. It certainly isn’t where it’s not going to benefit you if you do take it.

What about caffeine and sugar?

You’ve got to be careful with caffeine. You’ve got to be careful with caffeine.

Why?

You
don’t want to disrupt your sleep patterns.
That’s another thing when you talk about what else can we do aside from medications, you want to maintain good sleep hygiene. Good sleep hygiene would be something like not taking too much caffeine and certainly not drinking any caffeine too close to bed time that’s going to disrupt your pattern, because that can send you in to a manic phase as soon as that sleep pattern is disrupted. You don’t want to trigger that sort of a problem. And concerning sugar, a lot of patients complain about having low sugar, hypoglycemic, and feeling some mood swings with that. Irritability tends to happen.

I know personally if I’m not eating appropriately I get a little bit irritable. But as a trigger for mood I’m not quite sure about diet. I haven’t seen that as a classic pattern, but good nutrition is the route which needs to be followed. You want to make sure that you are giving your body subsistence. Unfortunately sometimes, especially in a manic phase people might overeat or not eat at all. Mania can almost be as if a person is speeding on cocaine. Or similar to if a person was on amphetamines. Sometimes mania can cause a person to stay away from food, but you can’t neglect your body. The same thing can happen in depression where you are not eating. You’ve got to maintain some level of subsistence for your body to function.

Other than good nutrition make sure you hydrate yourself -- especially if you are on lithium, you want to make sure you are drinking enough water. And all these medicines tend to dry you out. You’ve got to
make sure you are hydrating yourself
. You don’t want to be dehydrated, especially on lithium; you never want to get dehydrated because you can get toxic. So these are all good things to do.

You mentioned “triggers.” How can Bipolar people discover what their triggers are?

Well that takes time. What we know about Bipolar disorder it seems like some stressful event happens, like most of the disorders in psychiatry. You have, maybe, an underlining predisposition to develop the disorder. It seems like some stressful event occurs, and that precipitates the first signs of the illness, whether it’s Bipolar disorder, major depression, schizophrenia, it seems like that’s the best general way we can describe the onset of the problem. So what’s the watershed event? What’s the one event that might have precipitated it -- was it a very stressful thing. Well, it’s probably specific for the individual. It doesn’t necessarily need to be a catastrophic event.

Can you give an example?

Puberty. It happens to all of us, and that in itself might be enough to precipitate it, with all the turmoil associated with it. That developmental phase of our lives, combined with all the stresses and strains of trying to become an adult -- the evolution in our sexuality. Approaching that aspect of our lives might be enough to cause it -- you know the hormonal rages. That could be enough to precipitate it, and it’s a normal human event. We all go through it.

Or, it could be a series of events. It could be the lost of a parent, which seems like a high risk factor in developing depression. But once it’s manifested it doesn’t seems like it needs stressors. It has a life of its own. However, the better we are at copping with those stressors -- that’s something else we need to work on. The better we are able to say, “Okay, this is the stress of our life. How are we going to manage it?” And we are going to have stress in our life by definition.

Do we take time outs? Are we getting enough sleep? Are we eating well enough? Are we taking care of ourselves in terms of meditating, giving ourselves some vacation time?

Those sorts of things. That’s going to help our illness. That’s going to help us stay illness free.

You mentioned working through some of the stressors. How important is it for Bipolar people to work with a therapist?

It’s very important. From a primary level a psychiatrist might think the most important thing for a patient to do is stay on their medications, but I think in a life management way working with a good therapist is essential as well. And the therapist doesn’t have to be an expert in Bipolar disorder. It doesn’t need to be something like that. It just needs to be a therapist that can understand you and your problems, and be effective enough to recognize the disorder for what it is, the ups and downs of the illness, and the many colors of the manifestations of the illness. And to be able to work with the day to day stresses of living.

This type of therapist would be considered a good one to have. It doesn’t have to be some specialized guru in Bipolar disorder. Just someone who is sensitive to the needs of a human being, and can help another human being cope with their stressors. I think that’s very important. There is reason to support that patients in therapy and taking their medications as well, are more apt to stay stable.

Are there reasons for why Bipolar patients do well taking their medications and being in therapy?

There could be a few reasons for that. First of all, the person feels connected with someone that’s listening to them. They have a disorder. The patient feels understood. They feel like they aren’t alone in the world. Sometimes patients with Bipolar disorder have an interesting way expressing themselves that might push other people away. Unless they are around other patients with Bipolar disorder, then they feel like they have a kindred spirit. But taken in isolation sometimes that’s how the patient feels, so when they are talking to a therapist that understands them, or attempts to understand them, and feels for their problems and trials and tribulations. Just like any good relationship it’s very helpful.

Now let’s talk about communication with doctors. Thanks to HMO’s patients get 15 minutes to talk. How am I as a patient to know what I need to talk about in that 15 minutes?

Can I make a joke? Talk fast!

But if I talk fast then I’m hyper verbal to you!

Well, I’ll just make a note of it. Appears to be manic!

You know if you are doing therapy, one of the old thoughts of doing psychiatry and therapy,
you wouldn’t want patients bringing in notes
. You would want your patient to
describe their problems so you can see the process of the person’s problems unfolding.
But I think in a lot of ways when patients outline
their problems, making bullet notes: I’ve had a problem sleeping
; you want to make sure you cover this with your doctor. Another example is, “it seems like I’m having a problem falling asleep and waking up in the middle of the night, and this pattern has been going on for the past two weeks. You want to make sure you cover that. Or you might note that you’re racing thoughts worse in the morning, or whatever the pattern is.

When you do the bullet approach that’s helpful
.
That organizes the patient, and that organizes the doctor
. Having suicidal thoughts, or anything that is a detriment to your health are things to bullet. Any suicidal or homicidal thoughts. Any psychotic processes where you’re thought patterns are way off. Any hallucinations. Making bullet points of these things. Even if it was a short lived hallucinatory period. The doctor is going to want to know these things.

So whatever that is going to key you to utilize that time the best you can. That’s good.

Okay, so I am a novice. Can you elaborate further on hallucinatory periods? How would I know I am experiencing it?

Hallucinations are when you are hearing and seeing things that aren’t there. They are perceptual difficulties, as opposed to illusionary difficulties. Illusions would be like a person misinterpreting real data. Looking at this plant, and thinking the shadow of it looks like a ghost. Well, that’s a little bit bizarre, but it’s a real stimulus. There is a plant there, and it’s a misinterpretation of a real stimuli. Versus interpreting stimuli that aren’t there, like hearing a voice outside of the persons head.

The person suffering from that would be drawn to it as if someone was actually talking to them. That’s a hallucination. That’s an auditory hallucination: hearing sounds repeatedly, any dialogue of voices, people talking back and forth to each other, maybe talking about the individual or seeing things. It could be a function of drug abuse or sometimes medical problems. Perceptual difficulties with no real stimuli are hallucinations.

Can you give examples of what it’s like for a person who hears voices?

Classically it’s a voice of some sort -- male or female -- sometimes the sexual identity of the voice cannot be discerned. It’s mumbled. But it’s typically outside the head. Or often times it’s a disparaging voice, kind of putting the person down. We used to make a joke in training that you very rarely hear a patient complaining about hearing a voice that says, “Get a job!” I’ve had one or two patients say that, but it’s not a typical pattern.

That’s a little bit of a joke, but conversely you don’t hear a patient’s voice that reports, “Don’t work,” either. Those are not the typical patterns of hallucinations. It’s usually something that’s disparaging, and it usually relates to some themes the patient is suffering from, they might have a paranoid back ground; they might have a sexual background. The patient may have some fear of homosexuality.

I’m recalling one patient that felt when he walked into a room the most prominent thing he heard was “You’re a fag. You’re a fag. You’re a fag.” He wasn’t homosexual at all, but he had the fear of being a homosexual. This was the theme of the voices that he heard.

How common is suicidal thinking and suicidal ideations among Bipolar people?

Oh, that’s very common. I think Bipolar patients -- you could check the statistics on this one -- I’m not sure if it’s 10% to 15% of patients with Bipolar disorder commit suicide. The frequency of patients experiencing suicidal thoughts is -- I don’t know the actual number -- but it’s fairly high.

I bring this up because I have suicidal thoughts, and for a couple of years I wouldn’t talk about it, instead deeming myself as inadequate. It took me a couple of years to communicate these thoughts with you and other people, because I thought I just hated my life, and I didn’t want to be committed back into a psychiatric hospital.

See it becomes a condition of the illness, a symptom of the illness. As opposed to something to act on, you know this is your option; you are in the hopelessness of the disorder.
You recognize more that it is the disorder talking
. This is something you certainly discuss. I’ve noticed a lot of patients when they feel free enough to say something about it they really don’t have a suicidal plan or an intention, but
the thoughts are a reflection of the pain they are feeling
. And
sometimes just talking about it is a relief of the pain.

As a clinician we get nervous, of course, when a patient starts having suicidal thoughts, does this person need to be hospitalized? Do we need to involuntary contain the patient? And those are appropriate thoughts because we are concerned about the patients well being. But for a good deal of patients it’s just the expression of those feelings, just as you said, you have those types of thoughts. Am I nuts? Am I crazy? What’s wrong with me that I’m having these types of thoughts?

What’s wrong with you is your illness. It’s the illness talking.

Talk about Bipolar people and their tendency towards substance abuse and addiction.

Well, with some of the research they're looking at right now there might be a connection between impulsivity -- there might be a commonality between impulsivity, and Bipolar disorder, and patients afflicted with addiction. The common ground is the impulsivity nature, just the same with patients with ADHD. If you look at that continuum of impulsivity, verse compulsively, that might be a common genetic predisposition. A person with Bipolar disorder can be more apt, especially in a manic phase, to be a little bit more thrill seeking, just as any impulsive person may be, and that thrill seeking side of us needs to be satiated.