Living Bipolar (6 page)

Some patients are probably treating themselves , self-medicating, and some patients’ will self-medicate in a depressed phase, and in a manic phase. The Bipolar patient might be looking for a little bit more of a kick during a depressed phase, and therefore, they will be drawn toward stimulants, and in turn, some patients when they're depressed may feel somewhat euphoric with alcohol -- even though we know alcohol is a central nervous system depressants, and vice versa. A lot of people when they're manic smoke marijuana, because they feel like it calms them down, and the marijuana lessens their racing thoughts they feel. Some patients when they are manic want to continue doing cocaine, and they really want to amplify the manic phase. Then, a lot of people after using cocaine, shortly thereafter, are calming themselves down on benzodiazepines, or anxiety medicines, or opiates, it’s a vicious circle of behaviors.

If you look at that impulsivity strain, that might be the common thread, whether it's the same genetics, or whether it's the same region in the brain that gets stimulated. But I think research will help us understand more about this. There seems to be a group of patients that use drugs as a self-medicating form, but I don't think that's the ponderance of patients though, I think it relates much more to some sense of impulsivity, or thrill seeking side in the patients. Also, there doesn't seem to be a clear pattern of what drug a Bipolar patient might have addiction problems with.

Alcohol is high on the list. You definitely see a lot of alcoholism with patients who have Bipolar disorder. Often when you look at a person's history, and you're suspicious of that patient having Bipolar disorder, you look back in the family history, and discover maybe the father, or mother, had problems with alcohol. For instance, there might be descriptions that the person in the family history was a raging drunk, and very irritable, and people wouldn’t know what kind of mood daddy was going to come home with -- but he was always so drunk. Chances are this person in the family lineage was an undiagnosed Bipolar person, and they were trying to medicate themselves through alcohol.

Can drugs cause a person to become manic and stay manic? Can drugs lead to a person being Bipolar?

I think that's a great question. There's a whole category of diagnoses in DSM-IV, where you have substance abuse induced mood disturbances, substance induced mania, substance induced depression, substance induced mixed states. Usually, you would hold back making a diagnosis of major depression, or Bipolar disorder, within a given timeframe in these instances. That's kind of spelled out in the text. So there's that problem where a mood disturbance can occur by substances, and the substances can be more than just drugs of abuse or recreational drugs. There can be regular medications too that can precipitate these problems. Sometimes, and I'm thinking of a friend of mine, if we think of the diathesis stress model of mental illness, meaning there's a predisposition for a mental illness, whatever that may be -- genetic or environmental -- versus a stressor, then the substance abuse can be the stressor that precipitates the onset of the illness.

That has certainly been a possibility, whereas, a stressor in someone's life might be the loss of a parent which precipitates a mood change in a given individual, before you know it they have full blown Bipolar disorder, or major depression, or some other disorder. Substance abuse can also cause the onset of Bipolar disorder. Specifically, what's happening in the brain is there are neurotransmitter changes when you abuse a substance, so that in itself can be enough to probably pull out some underlying pathology. Although there doesn’t have to be chances are there's probably some predisposition for a mood disturbance underlying it.

So if someone's doing a lot of cocaine, and there displaying a lot of manic like symptoms, once they get off the cocaine do the symptoms go away?

Right. That would be a substance abuse induced mania by nature of the cocaine usage or the cocaine intoxication. Exactly. Versus someone who takes a couple hits of cocaine and then three, or four, months down the road they can't sleep, they have racing thoughts, they're buying impulsively, and they have all the signs and symptoms of a manic episode. This individual would have a predisposition for Bipolar disorder or another type of mood disturbance.

Is there anything parents, or spouses, can do if they’ve got someone who's Bipolar in their family struggling with an addiction problem? What's the best way for a family to cope if they've got someone who's sick, and the Bipolar patient needs to take their medication for Bipolar disorder, but they are struggling with a substance abuse problem?

For instance a family might be wondering if their loved one has a drug problem, or a substance abuse problem -- what do they do?

As long as we've ruled out it's not a substance induced mood disorder, and we clearly have an existing Bipolar disorder, that the person also has problems with addiction, yes the information for the families would be: be informed as much as possible to know that both of these illnesses occur together, and for the family to understand there's a high rate of co-morbidity with the illness. Education with the family, and the patient, that abstinence and sobriety is vital for the mood. Additionally, it’s important for the family members not to personalize how they handle their loved ones problem. They have to recognize the coexistence of both problems. But families can sometimes have a problem if there's not the coexistence of both those problems.

For example, parents can have a problem when they find out that their loved one is Bipolar in the first place, and the family does not know exactly how to handle that problem. They might have a hard time understanding the notion of mood swings, ups and downs, suicidal thoughts and behaviors, hospitalization, and the chronicity of the illness, and how important it is to be on the medication. Even when the patient is compliant, it's still difficult to get the patient to stay on their medications, and remain taking the medications, and sometimes there's a breakthrough in the mood, and how do families handle that? Geez, you're taking your medication, you're seeing your doctor, what's going on? You're still not where you should be, or where we think you need to be. Versus what kind of progress that individual is making themselves, that's an educational process, and support groups can be very helpful for this, because it’s educational for all involved.

Once families see there are other families in the same predicament, and try to understand the nature of their loved one's illness, the end result is a better understanding of the situation as a whole. And the same thing is said for substance abuse. With substance abuse we are willing to point a finger and say this is a weak willed individual. We know drugs can kill. We know drugs can worsen the pre-existing psychiatric condition, let alone Bipolar disorder. From a family's perspective, why does someone want to work against themselves? You know you're ruining yourself by doing this, whether it's a standalone illness of addiction, or the co-morbidity of addiction and Bipolar disorder. These are difficult things for families to accept.

I think what we need to do, though, is think of the analogy of diabetes, or any chronic illness. Why does the diabetic continue to not exercise? Or why do they not continue checking their blood sugar regularly? Why does the diabetic patient persist with an unhealthy diet? Why do they continue without having a full investment to help themselves in regards to their health with diabetes and their well-being? So other families in other settings can get very, very frustrated to, when the individual has a setback with their diabetes. Just the same as any other problem with medicine, it's a matter of trying to understand the nature of the illness, how much can be done, what kind of research is available, what kind of resources are available for the individual with the affliction?

If you try to manage it from this point, from the family's perspective, it can be very challenging, but it's vital that the family is not punitive, as that has no place with recovery.

Does daily stress exacerbate the Bipolar illness for the individual who is taking their medication? And if yes, what techniques can Bipolar people use to help keep their daily stress down?

The usual buzz on stress is we get back to the diathesis stress model. Some stress probably precipitated the illness, and there is the underlying predisposition for the illness itself and something happened to cause it. Whatever the signal event was who knows. It depends on who's doing the looking. People on the outside looking in, might say well that stress didn't do anything to me when I went through my life event, such as adolescence, which can cause someone else to become Bipolar. Therefore, someone else might say, “Adolescence wasn't a big deal for me, why would it be a big deal for another person?” But it's driven by the individual, and their genetic makeup.

Whatever stress may have precipitated the Bipolar illness, though, it seems like once it starts the illness has a life of its own. It doesn't seem like, at least some of the information that you gather, the Bipolar illness needs stress to make it any worse, or better, rather it just has a life of its own
. The Bipolar illness travels its own course, and you can still have breakthrough mood disturbances, whether you’re on medicine or not, although the longer you're not being treated the worse the Bipolar illness is going to get. Yet, I think over the course of time people can be susceptible to chronic or catastrophic stress, and it can affect their mood. Even when you're taking medication, and I think it's intuitive to think that way, but over the course of time seeing patients, it just doesn't follow the usual textbook story, at least in my practice anyway, that you don't need to have stressors to worsen the illness.

Having said that,
stressors do exacerbate the Bipolar illness
. Just like anyone, a healthy person, or a person with a mental health problem,
maintaining good health is a matter of how do we handle stress in our lives
? I think this is across the board, with any human being, how do we handle stress, and how do we define the stressors in our lives, and how do we define stress period? What do we consider stress? Is it a negative thing, or is it a positive thing. For instance, getting married is kind of stressful. But you approach it the same way,
what's good hygiene for you
? What's good mental health hygiene? You can apply that to someone without a mental health disorder, and someone with a mental health disorder. You can apply this to someone with an acute exacerbation versus someone who has an chronic illness.

Exercise is always good for stress, any type of aerobic exercise
, and things that you like to do.
Anything which gives you a timeout from the day,
anything, of course, other than illicit drugs.
Good hygiene is anything that's healthy for you. It might be a simple thing like reading a book or watching a movie.
Activities that are refreshers for the individual, maybe it's just being with someone. It can be as simple as having a spouse, or a good companion, good friendships, and anything a human being does with loving people. Essentially, it is anything which aides in our longevity and adds to the pleasure in our lives.

What can a Bipolar person do to help themselves not get into a full-blown rage, for instance, maybe after leaving a day of work which was very stressful?

No matter what your prominent symptom is, part of understanding your illness, is understanding yourself, and your illness.
What symptoms seem to flare up when you're in a manic state, or an irritable state, or a depressive state? What are your triggers? Whether it's in social settings, or work settings, circumstantial things, whatever they may be.
Just the same as the family needs to be educated on the illness, the patient needs to be educated on their illness as well
. You've got to know yourself and this will minimize the escalation of big flare ups.
Therefore, knowing yourself is the first key step of minimizing rage or any other emotional flare up.

While knowing yourself is all fine and dandy, sometimes people will still get triggered and fall into a rage. At this point, you will really have to work on giving yourself a mental count to 10, even when your medicine is working.
You have to be able to step back from the situation, and say, what am I doing here, what's the trigger causing this, where's my mind going with this trigger? Do I need to change the situation, do I need to change the scenery, or change my focus to stop this escalation
? Sometimes when you’re in the middle of this it can be very, very difficult to stop these feelings.
But it starts with needing to change your focus; you need to change the scenery
. For instance, if you're driving and you get in such a rage that you want to throw a hand grenade, maybe you need to pull off the road, or change the radio station to calm down.
Whatever it is for you, you will need to simply change the circumstances, and back off. Slow down.

These are kind of typical things to do, otherwise your mood will escalate, and before you know it you'll be in big trouble. And you certainly don't want to de-escalate by getting into trouble -- you hit someone, you ran into someone, or you did something to hurt someone, and then the police need to intervene in one of these costly situations.

How does a Bipolar person get to know oneself? If someone is a new patient, or if they been Bipolar for five, or ten years, how does a person go about the self-discovery process?

Biblio-therapy is really helpful, reading about the illness. In drug and alcohol treatment settings therapists give the patient a Bipolar packet. You can read things about Bipolar disorder, see what things match up with your personality, and see what things don't match up. Maybe doing a mood questionnaire to inquire into what kind of things happens from a mood standpoint, and to discover how frequently the symptoms occur. Knowing yourself is an educational process, and sometimes this takes a while, and it takes a while for the people around the patient that are supportive to learn, and understand the patient’s symptoms as well, and give feedback from a reasonable standpoint.