• Recognizing Early Warning

Signs of Mania or Depression

• Understanding Your Everyday

Ups and Downs - and When
It's Your Symptoms Talking

• Working with Your Doctor

to Find the Right Medication
and Therapy

• Preventing Mood Swings from

Ruling Your Life, and Staying
on Track at Home and Work

DAVID J. MIKLOWITZ, PhD

THE
T H E BIPOLAR
B I P O L A R DISORDER
D I S O R D E R SURVIVAL
S GUIDE
GUIDE
This page intentionally left blank
THE
T H E

BIPOLAR DISORDER
BIPOLAR DISORDER

SURVIVAL GUIDE SURVIVAL GUIDE

What You
W h a t Y o u and
a n d Your
Y o u r

Family
F a m i l y Need
N e e d tot o Know
K n o w

DAVID
D A V I D J.
J. MIKLOWITZ,
M I K L O W I T Z , PHD
PhD

�
THE
T H E GUILFORD
G U I L F O R D PRESS
PRESS
New York I/ London
New York London
©
© 2002
2002 The
The Guilford Press
Guilford Press
A
A Division
Division of
of Guilford
Guilford Publications,
Publications, Inc,
Inc.
72
72 Spring
Spring Street,
Street, New York, NY
N e w York, N Y 10012
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www.guiLford.com
www.guilford.com

All righlS
All rightsreserved
reserved

The information
The information in
in this
thisvoLume
volumeisis
not intended
not intendedas aassubstitute
a substitute
for
for consultation
consultation with heaLthcare
healthcare profesSionals.
professionals. Each
Each individual's
individual's
health
health concerns
concerns should
should bebe evaluated
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qualified professional.

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Library of
Library of Congress
Congress Cataloging-in-Publication
Cataloging-in-Publication Data
Data
Miklowitz:,
Miklowitz, Oavid
David Jay, J957-
Jay, 1957-
The bipolar disorder survival guide:
guide: what you and your family k n o w /I
famiLy need to know
David J.
J. Miklowitz.
Miklowitz.
p. cm.
cm.
Includes bibliographical
bibLiographical references and index.
index.
ISBN-lO:
ISBN-10: \-57230-525-8
1-57230-525-8 ISBN-13:
ISBN-13: 978-1-57230-525-0 (pbk.)
(pbk.)
15BN-1O: 1-57230-712-9 I$BN-13:
ISBN-10: 1-57230-712-9 ISBN-13: 978-1-57230-712-4 (doth)
(cloth)
1.
1. Manic-depressive illness-Popular
illness—Popular works. I. Title.
I. Title.

RCS16
RC516 .M554
.M554 20012001
616.89'5-dc21
616.89'5—dc21
2001040937
2001040937
Contents
Contents

Preface
Preface vii
vii

PART
PART I The
I The Diagnosis and
Diagnosis and (ourse
Courseofof
Bipolar Disorder
Bipolar Disorder

11 Why
W h y Do
D o II Need
Need This
This Book?
Book? 33

2
2 What
What Bipolar
Bipolar Disorder
Disorder Looks
Looks Lihe-to
Like—to You,
You, 13
13
to
to the
the Doctors,
Doctors, and
and to
to Everyone Else
Everyone Else

3
3 Into
Into the
the Doctor's
Doctor's Court:
Court: 30
30
What
What to
to Expect
Expect from
from the
the Diagnostic
Diagnostic Process
Process

4 Is
4 Is It
It an
an Illness
Illness or
or Is
IsIt
ItMe?:
Me?: 54
54
Tips on Coping with the Diagnosis
Tips on Coping with the Diagnosis

PARTIIIICauses
PART (ausesand
and Treatments
Treatments

5
5 Where
Where Does
Does Bipolar
Bipolar Disorder
Disorder Come
Come From?:
From?: 73
73
Genetics,
Genetics, Biology,
Biology, and Stress
and Stress

6
6 What
What Can
Can Medication
Medication and
and Psychotherapy
Psychotherapy Do
D o Jar
for Me?
Me? 98
98

77 Coming
Coming to
to Tenns
Terms with
with Your
Your Medication
Medication 129
129

,
vi
vi CContents
ontents

PAR
P A R TT IIII
I I Self-Management
Self-Management

8
8 How
H o w Can
C a n II Manage
M a n a g e My
M y Disorder?:
Disorder?: 151
151
Practical
Practical Ways
W a y s toto Maintain
Maintain WeI/ness
Wellness

9 What
9 W h a t Can
C a n II Do
D o If
IfIITlI/nk
Think I'm
I'm Getting
Getting Manic?
Manic? 183
183

10
10 What
W h a t Can
C a n II Do
D o If
If II Think
Think I'm
I'm Getting
Getting Depressed?
Depressed? 214
214

11
11 Dealing
Dealing with
with Suicidal
Suicidal Thoughts
Thoughts and
and Feelings
Feelings 238
238

12
12 Coping
Coping Effectively
Effectively in
in the
the Family
Family and
and Work
W o r k Settings
Settings 254
254

Resources
Resources for
for People
People with
with Bipolar
Bipolar Disorder
Disorder 290
290

References
References 297
297
Index
Index 311
311

About
About the
the Author
Author 322
322
Preface
Preface

predoctoral
II first
first became
predoctoral psychology
became interested
psychology intern
interested in
intern at at the
in bipolar
bipolar disorder
the University
disorder in
University of
in 1982
1982 when,
of California,
California, los
w h e n , as
Los Angeles
as a
Angeles
a

(UCLA)
( U C L A ) Medical
Medical Center,
Center, II supervised
supervised a a bipolar support group
bipolar support with a
group with fellow
a fellow
intern.
intern. The T h e assignment
assignment was was a a challenge,
challenge, but but IIwaswasimmediately
immediatelystruck
struckby byhowhow
the
the members
m e m b e r s ofof the
the group-men
g r o u p — m e n andand women
w o m e n ranging
ranging in in age
age from
from 19 to 50-
19 to 50—
had
had discovered,
discovered, quile quite independently,
independently, how h o w to
to deal
deal with
with their
their illness. They had
illness. They had
learned
learned to to ask
ask forfor medical
medical and and social
social support
support whenw h e n the
the early
early signs
signs of recur­
of recur-
rences first appeared, to rely on their Significant others for emotional support,
rences first appeared, to rely on their significant others for emotional support,
and
and lO to separate
separate themselves
themselves from from the the disorder
disorder and and fight
fight its
its stigma.
stigma.AllAllof ofthem
them
understood
understood that that leading
leading fulfilling
fulfilling lives
lives required
required moremore than
than just
just taking medica­
taking medica-
tion.
tion.
The
T h e experience
experience inspired
inspired me m e toto choose
choose a a PhD
P h D dissertation
dissertation on on this
this disorder,
disorder,
specifically
specifically about about family
family relationships
relationships among a m o n g late
late adolescents
adolescents and and young
young
adults
adults who w h o were
were recently
recently out out of of the
the hospital.
hospital. In In the
the 1515 years since, I1 have
years since, have
cared
cared for,
for, or orsupervised
supervisedthe thecare
careof,of,several
severalhundred
hundredpeople peoplewith
withbipolar f isor­
bipolar disor-
der
der and
and their
their families
families in in the
the context
context of of my
m y research
research studies
studies and
and clinical prac­
clinical prac-
tice.
tice. People
People havehave come
c o m e to
to mym y office
office inin aa variety
variety of of clinical
clinical slates,
states, each
each person
person
with his
with his oror her
her own
o w n unique
unique expression
expression of of the
the disorder
disorder and unique beliefs
and unique beliefs
about how
about h o w itit should
should be be treated,
treated,the thefactors
factorsin inhis
hisororher
hergenetic,
genetic,biological,
biological,oror
family background that
family background that caused
caused it, it,andandwhat
whatititmeant
meantfor forthe
thefuture.
future.Many
M a n yhave
have
had
had a a love-hate
love-hate relationship
relationship with with the the illness:
illness: they
theyhave
havecherished
cherished the theintensity
intensity
of
of the emotional experiences
the emotional experiences that that mania
mania provides
provides but but have
have detested
detested the the low
low
periods,
periods, the the disorder's unpredictability, and
disorder's unpredictability, and the
the emotional,
emotional, practical,
practical, and and fi-
fi­
nancial damage
nancial damage done done lO to their lives.
their lives.

vii
VII
viii
viii PPrelme
reface

My long-term
My long-term collaboration
collaboration (1979-1997)
(1979-1997) with
with thelate
the late Michael
Michael Goldstein,
Goldstein,
PhD,
P h D , of
of UCLA
U C L A resulted
resulted in
in the
the development
development of
of family-focused
family-focused therapy,
therapy, an
an edu­
edu-
cational
cational intervention
intervention that
that assists
assists people
people with
with the
the disorder
disorder and
and their
their family
family
members
m e m b e r s in
in coping
coping during
during the
the periods
periods after
after an illness episode.
an illness episode. My
M y experimen­
experimen-
tal
tal studies
studies at at the
the University
University ofof Colorado,
Colorado, and
and those
those of
of my
my UUCLA colleagues,
C L A colleagues,
showed
showed that people who
that people receive family-focused
w h o receive family-focused therapy
therapy and
and medication
medication have
have
lower rates of
lower rates of relapse
relapse and and less
less severe
severe symptoms
symptoms than than people
people who w h o receive indi­
receive indi-
vidual
vidual supportive
supportive care care andand medication.
medication. Their Their improvements
improvements can can be
be observed
observed
for
for up
u p toto two
two years
years after
after they
they begin
begin family
family treatment.
treatment. These studies, funded
These studies, funded by by
the
the National
National Institute
Institute of of Mental
Mental Health
Health andand thethe National Alliance for
National Alliance for Research
Research
on
on Schizophrenia
Schizophrenia and and Depression,
Depression, have have included
included more more thanthan 150 people. The
150 people. The
participants
participants have have ranged
ranged in in age
age from
from teenagers
teenagers to retirees; from
to retirees; from people
peopleexperi­
experi-
enCing
encing their first manic
their first manic or or depressive
depressive episode
episode to to those
those who been ill
have been
w h o have ill for
for
most
most of of their
their lives;
lives; from
from people
people forfor whom
w h o m thethe disorder
disorder poses only occasional
poses only occasional
life
life problems
problems to to those
those who w h o are
are chronically
chronically in in and
and outout of hospitals; and
of hospitals; and people
people
in
in aa wide
wide variety
variety of of living
living situations
situations and and family contexts.
family contexts.
II wrote
wrote this
this book
book to to respond
respond to to aa need
need voiced
voiced by by Virtually
virtually everyone
everyone with with
whom
w h o m II have
have worked,
worked,along alongwithwith their
theirfamily
family members.
members. PeoplePeoplewithwith thethedisor­
disor-
der
der wish
wish for for more
more understanding
understanding from from relatives,
relatives, friends,
friends,and andcoworkers.
coworkers.Their Their
family members, in
family members, in turn,
turn, want
want to toknow
k n o w how
h o w best
bestto tohelp
help their
theirbipolar
bipolar relative
relative
without
without becoming
becoming angry, angry, controlling,
controlling, or or overprotective.
overprotective. Both Both askask thethe core
core
question
question this this book
book attempts
attempts to to answer:
answer: How H o w can
can people
people withwith thethe disorder
disorder
achieve
achieve beuerbetter m mood
o o d stability
stability andand lead
lead more
more fulfil ling lives,
fulfilling lives, while
whiletaking
takingmedi­
medi-
cation
cation and and dealing
dealing withwith the realities the
the realities the illness
illness imposes?
imposes?
It
It is
is my
m y strong
strong belief that people
belief that people w who
h o do
do best
best with the disorder
with the disorder areare those
those
who have learned
w h o have learned to to recognize
recognize triggers
triggers forfor their
their mood
m o o d cycles
cycles and
and h how
o w toto mini­
mini-
mize the
mize the impact
impact of these triggers.
of these triggers. They
They are arepeople
peoplewho w h o stay
stayclose
closeto totheir
theirrec­rec-
ommended
o m m e n d e d medication
medication regimensregimens and and have
have good
good relationships
relationships with with their
their phy­
phy-
sicians.
sicians. TheyThey have regular therapiSts
have regular therapists or or go
go toto support
support groups.
groups. TheyThey have have
learned
learned as as much
m u c h as
as they
they cancan about
about thethe illness,
illness,go goto toconferences
conferenceswhere where the thelat­lat-
est
est findings
findings aboutabout the the disorder
disorder are are presented,
presented, talk talk with
with orhers
others whow h o have
have the the
illness,
illness, and and read
read books
books and and anicles
articles concerning
concerning the the latest
latest treatments.
treatments. They They
learned to
have learned
have to accept
accept the the disorder
disorder butbut do do not
not unnecessarily
unnecessarily limit limit their per­
their per-
sonal
sonal goals
goals because
because of of it.
it.
At that
At that bipolar
bipolar support
support group group years
years ago,
ago, II was
was impressed
impressed by by the
themembers'
members'
ability
ability and and willingness
willingness to to take
take care
care ofof each other as
each other as well
well as themselves. One
as themselves. One
group
group member
m e m b e r regularly
regularly made m a d e trips
trips toto the
the local hospital inpatient
local hospital inpatient unit
unit to tell
to tell
patients with
patients with the the disorder
disorder about about thethe advantages
advantages of of obtaining
obtaining medical
medical and and
psychOSOcial
psychosocial treatment
treatment at at the
the U UCLA
C L A Affective
Affective Disorders
Disorders Clinic.
Clinic. When
W h e n aamem­
mem-
ber
ber ofof the
the group
group started
started to to cycle
cycle into
into anan episode,
episode, others
others were
were quickly
quickly ableable to to
 Pre/oce
Preface ix
IX

recognize
recognize the
the early
early warning
warning signs
signs and
and offer
offer assistance.
assistance. Members
Members were
were some­
some-
times blunt with
times blunt with each
each other
other but
but would
would say
say things
things that
that needed
needed toto be said.
be said.
I'd
I'd like
like to
to think
think ofof this
this book
book as
as performing
performing thethe same
same function as that
function as that
support
support group.
group. It
It is
is my
m y sincere
sincere hope
hope that
that after
after reading
reading it,
it,you
you will
willfeel
feelless
less
alone
alone in
in your
your struggles,
struggles, realize
realize that
that there
there are
are effective
effective treatments available,
treatments available,
and
and have at your fingertips strategies to prevent mood swings from ruling
have at your fingertips strategies to prevent mood swings from ruhng
your
your life.
life. I Ihope
hopethis
thisbook
bookwill
willtell
tellyou
youthe
thethings
thingsthat
thatneed
need to
tobe
besaid
saidand
and
that
that you'll
you'll use
use them
them to your benefit,
to your benefit, even
even if
if you
you don't
don't always
always want
want to
to hear
hear
them.
them. Most
Most of of all,
all, II hope
hope you
you and
and your
your family
family members
members will
will become con­
become con-
vinced
vinced that
that you
you can
can lead
lead aa full
full life
life and
and achieve
achievemany
many ofofyour
yourpersonal
personalgoals
goals
despite
despite having
having the disorder.
the disorder.

A
A Word
Word of
of Thanks
Thanks

Many people
Many people deserve
deserve mymy heartfelt
heartfelt appreciation for supporting
appreciation me in writing
for supporting me in writ
this book.IIfeel
thisbook. feelespecially
especially grateful
grateful totomym ycollaborators,
collaborators, Ellen
EllenFrank,
Frank,PhD,
PhD,andand
David
David Kupfer,
Kupfer, MD, M D , of
of the
the University
University of of Pittsburgh
Pittsburgh School
School of Medicine, for
of Medicine, for
their
their clinical
clinical wisdom
wisdom and their encouragement
and their encouragement of of my
m y research.
research. TheThe illness
illness
management
management tools tools outlined
outlined in in this
this book-education,
book—education, relapse prevention, ef­
relapse prevention, ef-
fective
fective communication
communication and and problem
problem solVing,
solving, relying
relyingon onsocial
socialsupports,
supports,and and
social rhythm
social rhythm stabilization-in
stabilization—in many many waysways reflect
reflect aa synthesiS
synthesis of family­
of family-
focused
focused therapy
therapy principles
principles andand their
their interpersonal
interpersonal therapy
therapy approach
approach to to help­
help-
ing
ing people
people copecope more
more effectively
effectively withwith bipolar disorder.
bipolar disorder.
Many
Many teachers
teachers andand close
close colleagues
colleagues have have been
been inspirational
inspirational throughout
throughout
my career and have strongly influenced how I think about clinical problems:
m y career and have strongly influenced how I think about clinical problems:
Michael
Michael Goldstein,
Goldstein, PhD, PhD,Ian IanFalloon,
Falloon, MD,
M D Keith
, KeithNuechterlein,
Nuechterlein, PhD,
PhD,Raymond
Raymond
Knight,
Knight,PhD, PhD,Connie
ConnieHammen,
H a m m e n ,PhD,
PhD,W. W .Edward
EdwardCraighead,
Craighead,PhD, PhD,Gary
GarySachs,
Sachs,
MD,
M D , Michael
Michael Thase,
Thase, MD,M D , Steve
Steve Carter,
Carter, PhD,
PhD, Lyman
Lyman Wynne,
Wynne, M MD, Robert
D , Robert
Liberman,
Liberman, MD, M D ,Michael
MichaelGitlin,
Gitlin,MD, M D ,and
andKayKayjamison,
Jamison, PhD.
PhD. My M ygraduate
graduate stu­
stu-
dents
dents and
and postdoctoral
postdoctoral fellows
fellows at at the
theUniverSity
Universityof ofColorado
Colorado are areoften
oftenthe
thefirst
first
to
to suggest
suggestclinical
clinicalstrategies
strategiesfor forworking
working with
withindividuals
individuals ororfamilies,
families,and their
and their
research
research hashas often
often influenced
influenced the the direction
direction of of my
m y own.
own. They
They havehave included
included
Elizabeth
Elizabeth George,
George, PhD,PhD, TeriTeri Simoneau,
Simoneau, PhD, PhD, Dawn
D a w n Taylor,
Taylor, PhD, Jeff
PhD, Jeff
Richards,
Richards, MA,
M A , Tina
Tina Goldstein,
Goldstein, MA,
M A , Natalie
Natalie Sachs-Ericsson.
Sachs-Ericsson, PhD,
PhD, jennifer
Jennifer
Wendel, MA,
Wendel, M A , Kristin
Kristin Powell,
Powell, PhD,PhD,and andApama Kalbag,PhD.
AparnaKalbag, PhD.Colleagues
Colleagueswith with
whom
w h o m II collaborated
collaborated at at UCLA
U C L A hold
hold aa special
special place
place inin my
m y hean, including
heart, including
Margaret
Margaret Rea, PhD,Angus
Rea, PhD, Angus Strachan,
Strachan,PhD, PhD,Martha
MarthaTompson,
Tompson,PhD, PhD, jimJimMinlZ,
Mintz,
PhD, Amy
PhD, A m y Weisman,
Weisman, PhD, PhD, andand SunSun Hwang.
Hwang.
1I would
would likelike toto extend
extend special
special appreciation
appreciation to to several
several friends
friends and col-
and col-
x
X PPrefoce
reface

leagues who
leagues whocommented
commentedonon early drafts
early of the manuscript
drafts and, in many
of the manuscript and,cases,
in many ca
suggested additional
suggested additional material: Lori Altshuler,
material: Lori Altshuler, MD M D andand Richard
RichardSuddath,
Suddath,MD MD
(notably
(notably forfor their
their help
help with
with the
the medication
medication chapters),
chapters), Sheri
Sheri johnson,
Johnson, PhD, PhD,
joseph
Joseph Goldberg,
Goldberg, MD, M D , Greg
Greg Carey,
Carey, PhD,
PhD, Daniel
Daniel Barth,
Barth, PhD,
PhD, andand Robert
Robert
Spencer,
Spencer, PhD.
PhD.
Many
Many thanks
thanks gogo toto members
members of of my
m y family-Mary Yaeger, my
family—Mary Yaeger, m y daughter
daughter
Ariana, and
Ariana, and mym y brother,
brother, Paul
Paul Miklowitz,
Miklowitz, and and his
his family-all
family—all of of wwhom have
h o m have
brought
brought me m e great joy and
great joy and reminded
reminded me m e that
that life
life is
is not just about
not just work. My
about work. My
mother,
mother, Gloria
Gloria MiklowilZ,
Miklowitz, who who hashas published
published overover 50 books, has
50 books, has been
been a a
source
source ofof inspiration
inspiration during
during the
the often
often difficult
difficult process
process ofof writing
writing thisthis book.
book.
The
The memory
memory of of my
m y father,
father,julius
JuliusMiklowitz,
Miklowitz,aaprofessor
professorwhow h o taught
taughtme m e the
the
value of
value of research,
research,hard hardwork,
work,and anda a
life
lifof
e oflearning,
learning,hashas
guided
guidedme mthroughout
e throughout
my
m y academic
academic life.life.
Finally, tIwould
Finally, would likeliketo
toexpress
expressmy m y sincere
sinceregratitude
gratitudetototwo
twoof ofthe
themost
most
talented, patient,
talented, and knowledgeable
patient, and knowledgeable editors
editors inin the universe-Kitty Moore
the universe—Kitty Moore
and Chris
and Chris Benton
Benton of of The
The Guilford
Guilford Press.
Press.Their
Theirimprint
imprintappears
appearsthroughout
throughoutthe the
book.
book. Without
Without their
theirencouragement,
encouragement,tenacity,
tenacity,and andsupport, this
support, project
this would
project would
never
never have
have come
come to to fruition.
fruition.
II have
have enjoyed
enjoyed writing
writing this
this book
book andand wish
wish you
you success
success in
in your
your personal
personal
journey
journey through
through the the ups
ups and
and downs
downs of bipolar disorder.
of bipolar disorder.

DAVID J. Miklowitz, PhD DAVID J. MIKLOWITZ, PhD

P A RT I
P A R T

The
T h e Dia g nosis
D i ag n o s i s

and
a n d Course
C o u r s e

of
o f Bipolar
B i p o l a r Disorder
D i s o r d e r
This page intentionally left blank
 1
1

Why DDo
W h y o I
I Need This
N e e d T h i s Book?
B o o k ?

•T
• Too understand
understand the
the symptoms,
symptoms,diagnosis,
diagnosis,and
andcauses
causesoof
f yOUT
your
bipolar disorder
bipolar disorder
• To
• To learn
learn about
about effective
effectivemedical
medical andand psychological
psychological treatments
treatments
• To
• To learn
learn self-management
self-management techniques
techniques toto help
help you
you deal
deal with
with mood
mood
cycles
cycles
• To
• To improve
improve your
your functioning
functioning in
in family
family and
and work
work settings
settings

Martha, 34, ended

Martha, 34, ended up
up in
in the
the hospital
hospital after
after storming
storming out
out of
of the
the house,
house, in
in
which
which she
she lived
lived with
with her
her husband
husband and
and tWo
two school-age
school-age children,
children, and
and
spending
spending aa disastrous
disastrous night
nightin
inaatown
townover
overtwo
twohours
hoursaway.
away.Her
Herproblems,
problems,
however,
however, had
had started
started about
about two
two weeks
weeks earlier,
earlier,when
whenshe
shebecame
becameunusu­
unusu-
ally
ally irritable
irritable with her husband,
with her husband, Eric,
Eric, "slamming
"slamming about
about the
the house,n
house," as
as he
he
described
described it,
it, and
andbecoming
becomingeasily
easilyprovoked
provokedby
bythe
theminor
minor infractions
infractionsof
of
their children.She
their children. Shethen
thenbegan
beganto tosleep
sleepless
lessand
andless and
less andwas
wasincreasingly
increasingly
preoccupied
preoccupied with
with many
many ideas
ideas for
for aa new
new "dot-com"
"dot-com" business
business she
she planned
planned
to start.
to start.Despite
Despitethis
thisintense
intensefocus,
focus,Martha
Marthaseemed
seemedvery
veryeasily distracted.
easily distracted.
She
She also
also began
began speaking
speaking very
very rapidly.
rapidly.
Her
Her problems
problems came
came to
to aa head
head when
when she
she left
leftthe
thehouse
houseininaafury
furyshortly
shortly
after dinner
after dinner one
one night
night and
and impulSively
impulsively took
took aa bus
bus to
to aa gambling
gambling casino
casino
about 100 miles
about 100 miles away.
away. By
By her
her account,
account, she
shemet
metaamanm a n atataabar thesame
barthe same
night
night and
and went
went to
to bed
bed with
with him.
him. The
The next
next morning
morning she
she called
called her
her hus­
hus-
band, crying, and explained what had happened. Needless
band, crying, and explained what had happened. Needlessto
tosay,
say,he
he was
was

3
4
4 THE
THEDIAGNOSIS
DIAGNOSISAND
ANDCOURSE Of OF
COURSE BII'()�R DISORDER
BIPOIAR DISORDER

quite
quite angry
angry and and
drovedrove to the
to the casino
casino to to pick
pick herher up.
up. HeHe arrivedatalthe
arrived the
agreed-upon place and time, only to find that Martha was not
agreed-upon place and time, only to find that Martha w a s not there,
there, so
so he
he
returned home-where
returned h o m e — w h e r e he
he found
founci his wife, disheveled,
his wife, disheveled,sleep
sleepdeprived,
deprived,and and
angry.
angry. After
Aftersobbing
sobbing for forseveral
severalhours,
hours,she
she finally
finallyagreed
agreed to
togo
gowith
with him
h i mto
to
be evaluated
be evaluated at
at a
a local
local hospitaL
hospital. She
Shewas
was admitted
admitted totothe
theinpatient
inpatientunit
unitand
and
given
given aa diagnosis
diagnosis of of bipolar
bipolar disorder,
disorder,manic
manic phase.
phase.

Bipolar
Bipolar disorder
disorder is is
a amood
mood disorderthat
disorder thataffects
affects at
atleast one
least every
in in
one 70 70
every
people
people and and puts
puts them
them at at high
high risk
risk for
for the
the kinds
kinds ofof problems
problems in in their
their family,
family,
social, and
social, and work
w o r k lives
lives that
that Martha
Martha suffered.
suffered. People with bipolar
People with bipolar disorder
disorder are aTe
also
also atat high
high risk
risk for
for physical
physical problems,
problems,alcohol
alcohol and substance use
andsubstance usedisorders,
disorders,
and even suicide.
and even suicide. Fortunately,
Fortunately, there there isis much
m u c h hope.
hope. With
With medications,
medications, psy- psy­
chotherapy,
chotherapy, and and self-management
self-management techniques,
techniques, it'sit's pOSSible
possible toto control
control thethe
rapid shifts
rapid shifts in
in mood from manic
m o o d from manic highs
highs toto severe
severe depreSSive
depressive lows (called
lows (called
"mood
" m o o d disorder
disorder episodes"),
episodes"), prevent
prevent future
future episodes from occurring,
episodes from occurring, de- de­
crease the
crease impact of
the impact ""environmental [riggers,"
of "environmental triggers," and
and cope
cope effectively
effectively so that
so that
you
you can enjoy a
can enjoy full life.
a full life.
Whether
Whether you you have
have already
already been
been diagnosed
diagnosed with
with bipolar
bipolar disorder,
disorder, think
think
you might
you might have
have this illness, or
this illness, orare
areconcerned
concerned about
about someone
someone whow h ohas
hasit,
it,this
this
book
book will
will help you understand
help you understand the the disorder
disorder and
and learn
learn toto manage
manage it it effectively.
effectively.
In the
In the follOwing chapters you'll
following chapters you'll find up-to-date information
find up-to-date information on the nature
on the nature of of
the
the disorder,
disorder, its causes, medical
its causes, medical andand psychological
psychological treatments,
treatments, andand the
the life­
life-
style
style changes
changes you can make
you can m a k e to
to help
help manage
manage the the disorder.
disorder. T The
h e information
information
should
should be be relevant
relevant to to you
you whether
whether youyou have
have been
been treated
treated on
on an
an inpatient
inpatient basis,
basis,
like
like Martha,
Martha, or or on
on an an outpatient
outpatient basis,
basis, which
which isis becoming more and
becoming more and more
more
common.
common.

Understanding
Understanding the
the Fads
Facts about
about Bipolar
Bipolar Disorder:
Disorder: Its
Its Symptoms,
Symptoms, Causes,
Causes,
Treatment, and Self.Management
Treatment, and Self-Management

The The inpatientphysician

inpatient physician who saw Martha
who saw Martha diagnosed
diagnosedher heras bipolar
as bipolarvery very
quickly and recommended a regime
quickly and recommended a regime of
of mood
mood stabiliZing
stabilizing medication (lith­
medication (lith-
ium)
ium) and
and an
an antipsychotic
antipsychotic medication
medication (Haldot).
(Haldol). After
After only
only aa few days it
few days it
was
was clear
clear that
that she
she was
was responding
responding well. Butwhen
well. But when her
herdoctor
doctormade
made plans
plans
to
to discharge
discharge her,
her, Martha
Martha confronted him with
confronted him with a a litany
litany ofof questions
questions andand
worries
worries she
she had
had about
about everything
everything that
that was
washappening
happening to to her.
her.Why
W h y was
wassheshe
being
being given
given "this
"this death
death sentence"
sentence" (her
(her diagnosis)
diagnosis) andand "drugged
"druggedand anddis­
dis-
posed of
posed of so
so quickly"?
quickly"? Why
W h y was
was she being labeled
she being labeled manic,
manic, when
when most
most ofof
what she
what she had
had done,
done, she
she felt,
felt,could
couldbe
beattribUled
attributedtotoher
herpersonality
personalityor orin­
in-
terpersonal
terpersonal style?
style? "I've
"I've always
always been
been assertive,"
assertive," she
shecomplained
complainedto toher
herdoc-
doc-
 Why
Why Do
Do I INeed
NeeThis
d ThBook?
is Book? S 5

tor,tor,
herher husband,
husband, and
and almost
almost everyoneelse
everyone else she
she saw.
saw. "Since
"Sincewhen
when isisevery­
every-
thing
thing II do
do aa mental
mental illness?"
illness?" Her
Her doctor
doctor responded with sympathy
responded with sympathy but but
offered
offered insufficiem
insufficient information
information to to satisfy
satisfy Martha.
Martha. Under
Under considerable
considerable
pressure
pressure to
to get
get people
people in
in and
and out
out of
of the
the hospital
hospital quickly,
quickly, he
he left
lefther
herwith
withaa
regimen
regimen ofof medications
medications toto take
take but
but little
litde understanding
understanding of what had
of what had hap-
hap­
pened
pened to her or
to her what to
or what to expect
expect once
once she
she got
got home.
home.

If you
If you were
were in in Martha's
Martha's position, in
position, in all
alllikelihood youyou
likelihood would findfind
would the hos­
the hos-
pital
pital experience
experience as
as confusing
confusing and
and frustrating
frustrating as
as she
she did.
did. In my
In m experience,
y experience,
people
people with bipolar disorder
with bipolar disorder and
and their
their family
family members
m e m b e r s usually
usually are
are hungry for
hungry for
information
information about
about the
the disorder,
disorder, particularly
particularlyduring
duringor
orafter
afteraamanic
manic or
ordepres­
depres-
sive
sive episode.
episode. Of
O f course,
course, people
peoplewith
withthe
thedisorder
disorderhave
have an
an easier
easiertime
timeassimilat­
assimilat-
ing
ing information
information about
about it
it once
once they
they are
are over
over the
the worst
worst of
of their
their symptoms.
symptoms. But
But
even
even during
during the
the hospitalization,
hospitalization, Martha
Martha and
and her
her husband
husband would have bene-
would have bene­
fited
fited a
a great
great deal
deal from
from some
s o m e basic
basic facts:
facts: how
h o w her
herdoctors
doctorsknew
k n e w she
shehad
had the
theill­
ill-
ness,
ness, how
h o w the
the symptoms
symptoms are
are experienced
experienced by
by the
the person with the
person with disorder ver-
the disorder ver­
sus
sus everyone
everyone else,
else, and
and the
the course
course of
of the
the illness
illness over
over time.
time. They would have
They would have
benefited
benefited from
from knowing
knowing what
what to
to expect
expect after
after she
she was
was discharged
discharged from
from the
the hos­
hos-
pital,
pital, including
includingher
her risks
risksof
ofcycling
cyclingimo
intonew
n e w episodes.
episodes.Without
Without this
thisinforma­
informa-
tion, it
tion, it was
was difficult
difficultfor
forMartha
Martha to
toput
put her
her experiences
experiences in
in context.
context.As
A s aa result,
result,
she began to
she began to doubt
doubt the
the accuracy
accuracy of
of the
the diagnosis
diagnosis and,
and, by
by extension,
extension, the wis­
the wis-
dom
d o m of
of complying
complying with
with her
her prescribed
prescribed treatments.
treatments.
A major
A major assumption
assumption of
of this
this book
book is
is that
that understanding
understanding the
thefacts
facts about
about your
your
disorder will
disorder will help
help you
you accept
accept it
it and
and live
livewith
withit.
it.Important
Importantquestions
questionsthat
thatofoften
len
go unanswered because
go unanswered because mental
mental health
health providers
providers simply
simply don't have time
don't have in­
time in-
clude:
clude:

• What
• What are symptoms
are the the symptoms of bipolar
of bipolar disorder?
disorder?
•
• Who
W h o am
a m II apart
apart from
from my
m y disorder?
disorder?
•
• Where
W h e r e did
did the
the illness
illness come
c o m e from?
from?
•
• How
H o w do
do II know
k n o w when
w h e n I'm
I'm becoming
becoming ill?
ill?
•
• What
W h a t triggers
triggers my
m y mood
m o o d cycles?
cycles?
•
• What can II do
W h a t can do to
to minimize
minimize my m y chances
chances of
of becoming
becoming ill
illagain?
again?
•
• How
H o w do
do II explain the illness
explain the illness to
to other
other people?
people?
•
• What can II expect
W h a t can expect from
from my
m y future?
future?

Being
Being able
able to
toput
putyour
yourillness in in
illness an informational context
an informational helpshelps
context you to pre­
you to pre-
vent
vent or
or at
at least
least minimize
minimize the
the damage
damage associated with future
associated with recurrences of
future recurrences of
the
the disorder
disorder and
and set
set appropriate
appropriate goals
goals for
for your
your immediate
immediate and long-term fu-
and long-term fu­
ture.
ture.
66 THE
THE DIAGNOSIS
DIAGNOSIS AND
AND COURSE
COURSE OF
OF BIPOlAR
BIPOIAR DISORDER
DISORDER

Adjusting
Adjustingtotothe Aft.rmoth
the of on
Aftermath of Episode
an Episode

Manha
Martha leftleftthethe hospitalwith
hospital withprescriptions
prescriptions for for lithium
hthiumand andHaldol
Haldol andand anan
appointment
appointment to to see
see aa new
n e w doctor
doctor two two weeks
weeks later.
later. Upon
U p o n discharge
dischargeshe shehadhad
agreed
agreed to to follow
follow the the recommendations
recommendations of of the
the inpatient
inpatient staffstaff toto continue
continue
taking
taking herher medications,
medications, but but sheshe knew little about
k n e w little about what
what the the medications
medications
were
were doing
doing or or exactly
exactly whatwhat was was being
being medicated.
medicated. She She felt
felt shaky,
shaky, agitated,
agitated,
and irritable.
and irritable, and andbecame
became mentally
mentallyconfused.
confused.These Theseuncomfortable
uncomfortablesensa­ sensa-
tions
tions were
were largely
largely thethe result
result of of continuing
continuing symptoms
symptoms of of her
her disorder,
disorder, but but
in
in the
the absence
absence of of any
any information
information to to the
the contrary, Martha assumed
contrary, Martha assumed her her
confusion
confusion was was duedue entirely
entirely to to the
the lithium.
lithium.
She then
She then noticed
noticed her her mood
m o o d start
start toto drop.
drop, gradually
gradually at at first.
first. She felt
She felt
numb,
n u m b , disinterested
disinterested in in things,
things, tired,
tired, and
and unable
unable to tosleep
sleepeven
even though
thoughshe she
desperately
desperately wanted wanted to. to. She
She began
began to to spend
spend moremore time time during
during the the day
day
"sleep
"sleep bingeing"
bingeing" to to try
try toto catch
catch up u p from
from thethe night
night before.
before. She She awoke
awoke in inthe
the
afternoon
afternoon feeling
feeling worse
worse and and having
having difficulty
difficulty with
with herher usual responsibili­
usual responsibili-
ties, such
ties, such as as making
making dinnerdinner or helping the
or helping the children
children do do their
their homework.
homework.
The idea
The idea of of committing
committing suicide suicide crossed
crossed her her mind
mind for for the
the first
first time.
time. She She
felt guilty about the impact of her disorder on her
felt guilty about the impact of her disorder on her children and wondered children and wondered
whether
whether they they would
would be be better
better offoff without
without her.her.
Martha
Martha developed
developed an an upper
upper respiratory
respiratory infection,
infection, whichwhich keptkept her herup up
late at
late at night
night coughing.
coughing. Compounding
C o m p o u n d i n g this
this stress,
stress, thetheneighbors
neighborswere werehav­ hav-
ing
ing work
w o r k done
done on on their
their house,
house, and and sheshe was
was awakened
awakened from her fitful
from her fitful sleep
sleep
by
by noise
noise early
early in in the
the morning.
morning. Her Her sleep
sleep became
became more more and and more inconsis­
more inconsis-
tent,
tent, and
and herherdaily
dailyandand nightly
nightlyroutines-when
routines—^whenshe shewent
went to tobed
bed andand when
when
she woke up--began to change from day to day.
she w o k e u p — b e g a n to change from day to day.
About
About a week after
a week after being
being discharged
discharged from from the the hospital,
hospital, Martha's
Martha's
mood
m o o d escalated
escalated upward
upward again.again. HerHer thoughts
thoughts began
began to race, and
to race, and sheshestarted
started
to think
lO think again
again about
about the the dot-com
dot-com business.
business. Then,Then, in in what
what she she later de·
later de-
scribed
scribed as as a a "nash,"
"flash," she she decided
decided that that all
all of
of her
her problems-not
problems—not just just thethe
mental confusion
mental confusion but but also her cycling
also her cycling m mood,
o o d , her
her sleep
sleep disturbance,
disturbance, and and
her lethargy-were
her lethargy—were caused caused by by the
the lithium. Without checking
lithium. Without checking with with a a phy­
phy-
sician or
sician or telling
telling anyone,
anyone, she she lowered
lowered her her lithium
lithium dosage.
dosage. WhenW h e n sheshe sawsaw
no
no apparent
apparent negative
negative results,
results, she she discontinued
discontinued it it altogether.
altogether. Martha
Martha be- be­
came
came severely
severely irritable
irritable again, began to
again, began to sleep
sleep less
less and
and less,
less, and finally
and finally
ended
ended up back in
up back in the hospital only
the hospital three weeks
only three weeks afterafter her discharge.
her discharge.

Martha'S
Martha's SlOry
story is is all too
all too common. Becausethe
common. Because the nature
nature of
of the
thedisorder
disorderwas
was
not explained
not explained fully to her,
fully to her, she
she thought
thought of
of the
the episode
episode as
as a
a son
sort of
of "nervous
"nervous
breakdown"
breakdown" requiring
requiring only
only temporary
temporary medication.
medication. She
She did
did not
not understand
understand
that the
that illness could
the illness could be
be recurrent.
recurrent. In Chapters 2,
In Chapters 2, 3, and 4,
3, and 4, you will become
you will become
familiar
familiar with
with the
the expected
expected course
course of
of bipolar
bipolar disorder
disorder over
over lime
time and
and the vari-
the vari-
 Why
Why Do
Do I INeed
NeeThis
d ThBook?
is Book? 7 7

ous
ous forms
forms thatthatmoodmood recurrences
recurrencescan cantake.
take. This knowledge
This knowledge cancanhelp youyou
help stickstick
to
to aa treatment
treatment and and self-management
self-management plan plan that
that may
m a y help
help stave
stave off
off recurrences.
recurrences.
Martha
Martha also would have
also would benefited from
have benefited from knowledge
knowledge of of the
the factors
factors that
that we we
believe
believe cause
cause the the cycling
cycling of bipolar disorder:
of bipolar disorder: a a complex
complex interplay
interplay of of genetic
genetic
background, individual
background, individual biochemisLTY,
biochemistry, and and life
life stress,
stress, asas discussed
discussed in in Chapter
Chapter
5.
5. Many
M a n y people
people w who
h o have
have bipolar
bipolar disorder
disorder burden
burden themselves
themselves with with guilt
guilt and
and
self-blame because they
self-blame because believe their
they believe their mood
m o o d disorder
disorder is is caused solely by
caused solely by psy-
psy�
chological
chological factors
factors or or even
even sheer
sheer weakness
weakness of of character.
character. Martha
Martha could
could have have
avoided
avoided suchsuch self-blame
self-blame if if she
she had
had known
k n o w n that bipolar disorder
that bipolar disorder is is associated
associated
with biochemical imbalances
with biochemical imbalances of brain neurotransmitters
of brain neurotransmitters that that accelerate
accelerate dra- dra­
matic
matic mood
m o o d shifts.
shifts. Her
Her experiences
experienceswouldwould havehavemade
m a d e more
more sense
senseto toher
her ininthe
the
context
context of of her
her family
family tree:
tree: her
her mother
mother hadhad depression
depression and and her
her paternal grand­
paternal grand-
father
father waswas hospitalized
hospitalized once once forfor "mental
"mental anguish"
anguish" and and "exhaustion."
"exhaustion."
Knowing
K n o w i n g about
about the biological causes
the biological causes of of your
your disorder
disorder will
will also
also clarify
clarify whywhy
consistency
consistency with with your
your medications
medications is is essential
essential to to maintaining
maintaining good good mood sta­
m o o d sta-
bility. Martha
bility. Martha knew k n e w that
that she
she needed
needed to to take
take medication,
medication, but but not why. Chap­
not why. Chap-
ters
ters 6 6 and
and 7 7 deal
deal with
with medication
medication treatments
treatments for bipolar disorder.
for bipolar disorder. There
There are are
many
m a n y drugs
drugs available
available nowadays,
nowadays, in in various
various combinations
combinations and and dosages.
dosages. Doc­ Doc-
tors have
tors have to to bebe constantly
constantly updated
updated on which treatments
on which treatments to to recommend to
r e c o m m e n d to
which patients,
which patients, sincesince thethe accepted
accepted treatment
treatment guidelines
guidelines for for this
this disorder
disorder
change
change so so rapidly.
rapidly. You Y o u will
will feel
feel more
more effective
effective inin managing
managing your your disorder
disorder if if
you
you cancan openly
openly communicate
communicate with with your
your physician
physician about
about which
which medications
medications
are most
are most effective
effective forfor you,
you, their
their side
side effects,
effects, and
andthethemixed
mixed emotions
emotions you you maymay
feel
feel about
about taking
taking them.
them.

Self-ManagementStrategies
Self-Management Strategies
Beyond
Beyond taking
taking medications
medications and and meeting
meeting withwith a a psychiatrist,
psychiatrist, there
there are
are good
good
and bad ways
and bad ways toto manage
manage youryour disorder.
disorder. Self-management
Self-management involves learning to
involves learning to
recognize your own
recognize your o w n individual
individual triggers
triggers for
for episodes
episodes andand adjusting
adjusting youryour hfe
life ac-
ac­
cordingly. This
cordingly. This book
book will
will teach
teach you
you a a number
n u m b e r of
of self-management
self-management tools that
tools that
will probably
will probably increase
increase thethe amount
amount of of time
time that
that your
your moods
m o o d s remain stable. For
remain stable. For
example,
example, Martha would have
Martha would have benefited
benefited from
from sleep-wake
sleep-wake monitoring
monitoring or stay­
or stay-
ing
ing onon aa regular
regular daily
daily and
and nightly
nightly routine,
routine, including
including going
going to to bed and waking
bed and waking
at
at the
the same
same time,
time, sLT ategies described
strategies described in Chapter 88 (Frank
inChapter (Frank et al.,1994).
etal., 1994).Like­
Like-
v.rise,
wise, keeping
keeping a a mood
m o o d chart
chart (discussed
(discussed in Chapter 8)
in Chapter 8) would
would havehave provided
provided a a
structure for
structure for tracking
tracking her her day-to-day
day-to-day changes
changes in in emotions
emotions and and hhow these
o w these
changes
changes varyvary with
with fl uctuations in
fluctuations in sleep,
sleep, consistency
consistency with with her
her medication
medication re- re­
gime,
gime, andand stressful
stressful events (Leverich &
events (Leverich Post, 1998;
& Post, Sachs, 1993,
1998; Sachs, 1993, 1996).
1996). Recall
Recall
that
that Martha'S
Martha's worsening
worsening moodm o o d was
was precipitated
precipitated by by a a respiratory infection and
respiratory infection and
8
8 THE
THEDlAGHOSIS
DIAGNOSISAND (QURSE
AND OF Of
COURSE BIP!m
BIPOIDISORDER
AR DISORDER

the
the appearance
appearance ofofneighborhood
neighborhoodnoise,
noise,which were
which stressful
were and disrupted
stressful her
and disrupted her
sleep-wake
sleep-wake patterns.
patterns. In
In addition
addition to
to recognizing
recognizing these
these events
events as
as triggers,
triggers,Mar­
Mar-
tha
tha and
and her
her husband
husband could have developed
could have developed a a list
list of
of early warning signs
early warning signs that
that
would
would alert
alert them
them to
to the
the possibility
possibility of a n
of a new
e w episode
episode of mania. In
of mania. In Martha's
Martha's
case, these signs
case, these signs included
included irritability
irritability and
and a sudden interest
a sudden in developing
interest in a
developing a
business. Chapter 9
business. Chapter 9 provides
provides a
a comprehensive
comprehensive overview
overview of
of possible early
possible early
warning
warning signs
signs of
of mania.
mania.
W h e n Manha
When Martha first
first slarted becoming depressed,
started becoming depressed, certain behavioral strate-
certain behavioral strate­
gies
gies might
might have
have kept
kept her
her from
from sinking
sinking further,
further, including behavior activation
including behavior activation
exercises
exercises and
and cognitive
cognitive restructuring
restructuring techniques,
techniques, introduced in Chapter
introduced in 10.
Chapter 10.
She would have
She would have felt
felt supported by knOWing
supported by knowing that
that suicidal
suicidal thoughts
thoughts and
and
feelings-a
feelings—a common
c o m m o n component
component of
of the bipolar syndrome-can
the bipolar be combated
s y n d r o m e — c a n be combated
through prevention strategies
through prevention strategies involving
involving the
the support
support of
of close
close friends
friends and rela�
and rela-
tives,
tives, counseling,
counseling, and
and medications,
medications, as
as described
described in
in Chapter 11.
Chapter 11.

Coping
Coping Eff ectively in the
Effectively in Family and Work
the Family Sellings
and Work Settings

Martha
Martha spent spent
fivefive
moremoredaysdaysin in
thethehospital
hospital butbUl this
thislimetimewaswasdischarged
discharged
with a
with clearer follow-up
a clearer follow-up plan.
plan. She met the
She met the phYSician
physician who would see
w h o would see her as
her as
an
an outpatient
outpatient to monitor her
to monitor her medications
medications and blood serum
and blood serum levels.
levels. TheThe in­
in-
patient
patient social
social w work
o r k team
team also
also helped
helped arrange
arrange an an outpatient
outpatient appointment
appointment
with a
with a psychologist
psychologist who w h o speCialized
specialized in in the
the treatment
treatment of of mood disorders.
m o o d disorders.
This
This time,
time, she she felt
felt better
better about
about thethe hospitalization
hospitalization experience
experience but but was
was
quite wary of what would happen once she was back at home.
quite wary of what would happen once she was back at home.
After
After herher discharge,
discharge, Martha
Martha spoke
spoke with
with close
close friends
friends about what had
about what had
happened. They
happened. were sympathetic
They were sympathetic but but said
said things
things like
like ""II guess every­
guess every-
body's a
body's little bit
a little bit manic-depressive"
manic-depressive" and and "Maybe
"Maybe you you were
were just
just working
working
too hard." When
too hard." W h e n she disclosed to
she disclosed to one friend that
one friend that she was taking
she was lithium,
taking lithium,
the
the friend said, "Don't
friend said, "Don't getget addicted."
addicted." Although
Although she she knew
k n e w her
her friends
friends were
were
trying
trying to be supportive,
to be supportive, these messages confused
these messages confused her.her. Was
W a s she
she really
really iill
ll or
or
just going through
just going through a a tough
tough time?
time? Were
W e r e her problems really
her problems really anan illness
illness oror
just an
just an extreme
extreme of of her personality? Hadn't
her personality? Hadn't the physicians told
the physicians told her
her that
that
medications
medications were were meant
meant to be taken
to be taken over
over the
the long
long term?
term?
Martha's husband,
Martha's husband, Eric,Eric, seemed
seemed unsure
unsure of of how
h o w to
to relate
relate to to her.
her. HeHe
genuinely
genuinely cared
cared about
about her
her and
and wanted
wanted to
to help
help but
but frequently
frequently became in­
became in-
trusive
trusive about
about issues
issues such
such as whether she
as whether she had taken her
had taken medications. He
her medications. He
pointed
pointed out out minor
minor shifts
shifts in
in her emotional reactions
her emotional reactions to to things,
things, which for­
which for-
merly
merly would
would have have escaped
escaped hishis notice which he
but which
notice but he nnow relabeled as
o w relabeled as "your
"your
rapid
rapid cycling."
cycling." Martha,
Martha, in in turn, felt she
turn, felt she was
was being
being told
told she
she was
was "no"no longer
longer
allowed to
allowed to have
have normal
normal emotional reactions." She
emotional reactions." She told
told him,
him, "You can't
"You can't
just
just hand
hand me me a a tray
tray of
of lithium
lithium every time 1I laugh
every time laugh tootooloud
loud ororcrycryduring
during aa
movie."
movie."
 Why Doo I INeed
Why D NeeThis
d ThBook?
is Book? I} 9

At other
At other timestimes
Eric Eric became
became angry
angry and and criticized her
criticized her for
forthe thedeteriora­
deteriora-
tion in
tion in her
her care
care ofof the
the children. Indeed, she
children. Indeed, she didn't
didn't have
have enough
enough energy
energy to to
take them
take them to to their various activities
their various activiti.es or get them
or get them to school on
to school on time.
time. She
She
didn't feel
didn't feel up
up to
to the social demands
the social demands of of being
being a a parent.
parent. "You
uYou aren't
aren't trying
trying
hard enough,"
hard enough," Eric said. "'You've
Eric said. "You've got got to buck up
to buck up and
and beat
beal this
this thing."
thing." At At
other times
other times hehe would
would telltell her
her she
she shouldn't
shouldn't taketake onon too
too much
m u c h responsibil­
responsibil-
ity because
ity because of her illness.
of her illness. Martha became confused
Martha became confused about what her
about what her hus-
hus­
band expected
band expected of her. What
of her. W h a t neither understood was
neither understood was that most people
that most people
need a
need low-key, low-demand
a low-key, low-demand period period ofof convalescence
convalescence after after aa hospitaliza-
hospitaliza­
tion so that
tion so that they
they can
can fully
fully recover
recover from
from their
their episode
episode of of bipolar disorder.
bipolar disorder.
Her children eyed
Her children Martha with
eyed Martha with suspicion,
suspicion, expecting
expecting her her to to burst
burst into
into
irritable tirades, as
irritable tirades, asshe
shehad
had done
done prior
priorto tothe
thehospitalization.
hospitalization.She Shebegan
began to to
feel
feel that
that her
her family
family waswas ganging
ganging up u p on
on her.
her. The
T h e family
family stress
stress during
during thethe
aftermath
aftermath of her episode
of her contributed to
episode contributed to her
her depression
depression and desire to
and desire to with-
with­
draw.
draw.
Martha
Martha tried
tried to return to
to return to her
her part-time
part-time computer
computer programming
programming job job
but
but felt unable to
felt unable to handle
handle thethe long
long commute.
commute. When W h e n she
she arrived
arrived at at work,
work,
she stared
she stared atat the
the computer
computer screen.
screen. "The
"The programs
programs II used used to to kknow well
n o w well
now seem like
n o w seem like gobbledygook,"
gobbledygook," she she complained.
complained. She She finally
finally told her boss
told her boss
about
about herher psychiatric
psychiatric hospitalizations.
hospitalizations. He H e seemed
seemed sympathetic
sympathetic at at first
first but
but
soon
soon began pressuring her
began pressuring her toto return
return to
to her
her prior
prior level
level of
of functioning.
functioning. She She
felt
felt uncomfortable
uncomfortable around around her her coworkers,
coworkers,who w h o seemed
seemed edgyedgy andand avoidant
avoidant
as
as they
they "handled
"handled me m e with
with kidkid gloves."
gloves." The The shiflS
shifts inin work schedules,
w o r k schedules,
which had
which been a
had been a regular
regular part
part ofof her
her job
job before,
before, started
started to to feel like they
feel like they
were
were contributing
contributing to to her
her mood swings.
m o o d swings.

Martha had
Martha had significant
significant problems
problems reestablishing
reestablishing herself
herself in
in her
her home,
h o m e , work,
work,
and community
and community following
following her
her hospitalization.
hospitahzation. People
People who
w h o develop
develop other
other
chronic medical
chronic medical illnesses,
illnesses, such
suchas
asdiabetes,
diabetes,cardiac
cardiacdisorders,
disorders,multiple
multiplesclero­
sclero-
sis,
sis,or
orhypertension,
hypertension,also
alsohave
havetrouble
troublerelating
relatingto
totheir
theirpartner,
partner,children,
children,other
other
family
family members,
members, friends,
friends, and
and coworkers.
coworkers. When
W h e n you
you reenter your everyday
reenter your everyday
world
world following
following aa bipolar
bipolar episode,
episode, even
even well-intentioned
well-intentioned family
family members
members
don't
don't know
k n o w how
h o w to
to interpret
interpret the
the changes
changes in
in your
your behavior
behavior (for
(for example,
example, your
your
irritabihty or
irritability or lack
lack of
of motivation).
motivation). They
They often
often mistakenly
mistakenly think
think that
that you
you are
are
acting
acting this
this wayan
w a y on purpose
purpose and
and could control these
could control these behaviors
behaviors if
ifyou
you only
only tried
tried
harder.
harder. As
A s aa result,
result, they
they become
become critical,
critical, evaluative,
evaluative, and
and judgmental.
judgmental. They
They
m a y also
may also mistakenly
mistakenly think
think you
you can't
can't take
take care
care of
of yourself
yourself and
and try
try to
to do
do things
things
for you
for you that
that you
you are
are more
m o r e than
than capable
capable of
of doing
doing yourself. For example,
yourself. For example, they
they
may
m a y try
try to
to actively
actively manage
manage your
your time,
time, direct
direct your
your career
career moves,
moves, telephone
telephone
your
your doctors
doctors with
with information
information about
about you,
you, or
or become
become vigilant
vigilant about
about even
even the
the
most
most minor
minor changes
changes in your emotional
in your state.
emotional state.
In
In the
the workplace you may
workplace you m a y find
find your
your employer
employer initially
initially sympathetiC
sympathetic but
but
10
10 TNE
THE DIAGNOSIS
DIAGNOSISAND
ANDCOURSE Of OF
COURSE BIPO�R
BIPOLDISORDER
AR DISORDER

impatient.
impatient.Your
Yourcoworkers
coworkersmay
maybe
beguarded,
guarded,suspicious, or even
suspicious, scared.
or even In ad­In ad-
scared.
dition, you may
dition, you m a y feel
feel that you can't
that you can't concentrate
concentrate as well on
as well on the job as
the job you did
as you did
before you became
before you became ill.
ill. These
Thesedifficulties
difficultiesare
areall
allaapart
partof
ofthe
theconvalescent
convalescentpe­
pe-
riod
riod that
that follows
follows an
an episode.
episode. In
In all
all likelihood, your concentration
likelihood, your concentration problems
problems
will diminish
will diminish once your mood
once your becomes stable.
m o o d becomes stable. But
Butititcan bequite
canbe quiteupsetting
upsettingto
to
feel
feel like
likeyou're
you're not
not functioning
functioning at
atthe
the level
levelat
atwhich
whichyou
youknow
k n o w you're
you'recapable.
capable.
As you are
As you are probably
probably aware, bipolar disorder
aware, bipolar disorder carries
carries a social stigma
a social stigma not
not as­
as-
sociated with
sociated with medical illnesses. Even
medical illnesses. Even though
though bipolar disorder is
bipolar disorder is clearly
clearly a dis­
a dis-
order
order of
of the brain, and
the brain, its genetic
and its genetic and
and biological
biologicalunderpinnings
underpinnings are
are well
welldocu­
docu-
mented,
mented, it
it is
is still treated as
still treated as a
a "mental
"mental illness."
illness." Many
M a n y people still erroneously
people still erroneously
believe
believe it
it is
is related
related to
to your personal choices
your personal choices or
or morals.
morals. As
As a
a result, you may
result, you may
feel
feel alienated
alienated from
from others when
others w h e n they
they find
find out about your
out about your disorder.
disorder.
On
O n the
the hopeful
hopeful side,
side, there
there is
is much
m u c h you can do
you can do to
to educate
educate your
your family,
family, (0-
co-
wor/lers,
workers, and friends about
and friends about the nature of
the nature ofyour
your illness.
illness. Cenainly,
Certainly,people
peoplewill
willre­
re-
spond to
spond your disorder
to your disorder in ways that
in ways you will
that you will find
find uncomfortable, but their
uncomfortable, but their re­
re-
actions will
actions will vary,
vary, at
at least
least in
in part, with how
part, with you present
h o w you present it
it to
to them.
them. One
One
objective of
objective of this
this book
book is
isto
tofamiliarize
familiarizeyou
youwith
withthe
therole
roleof
offamily
familyand
andother
otherso­
so-
cial factors
cial factors in
in contributing
contributing to,
to, or
orameliorating,
ameliorating,the
the cycling
cyclingof
ofyour
yourbipolar
bipolardis­
dis-
order. Chapter 12
order. Chapter is devoted
12 is devoted to
to explOring ways of
exploring ways of coping
coping effectively
effectively in the
in the
family
family and
and workplace.
workplace. You'll learn how
You'll learn h o w to
to talk
talk to your family,
to your family, friends,
friends,and
andco­
co-
workers about
workers your disorder
about your disorder so
so that
that they know
they k n o w how
h o w best
best to
to help you and
help you don't
and don't
perpetuate their
perpetuate their misconceptions with you
misconceptions with you (as was the
(as was the case
case for
for Martha).
Martha). You'll
You'll
learn
learn specific
specific strategies
strategies for
for communicating
communicating effectively with your
effectively with your family
family so that
so that
disagreemems
disagreements about
about the
the disorder
disorder don't
don't escalate into unproductive
escalate into unproductive and stress­
and stress-
ful
ful arguments.
arguments.

Martha:
Martha: Epilogue
Epilogue

Martha's
Martha's firstfirstyear
yearafter
after her
her two hospitalizations was
two hospitalizations wasquite
quitedifficult, but but
difficult,
now,
n o w , several years later,
several years later, she
sheisisdoing
doingmuch
m u c hbetter.
better.She
Shefound
found a psychiatrist
a psychiatrist
with w
with whom
h o m she
she feels
feels comfonable.
comfortable. She She is is taking
taking a a regimen
regimen of of lithium,
lithium,
divalproex sodium
divalproex sodium (DepakOle),
(Depakote), and and aa thyrOid supplemem. Her
thyroid supplement. Her mood
m o o d and
and
behavior still
behavior still shift
shiftup
up and
and down,
d o w n ,but
buther
hersymptoms
symptoms are areno
no longer
longerincapac­
incapac-
itating. For
itating. For example,
example, she reacts strongly
she reacts strongly to to disagreements
disagreements v^dthwith her
her hus­
hus-
band
band andand still
still has
has periods
periods ofof feeling
feeling ddown
o w n or unmOlivated. In
or unmotivated. In part
part due to
due to
her willingness La
her willingness to commit
commit to to aa program
program of of mmood stabiliZing medications,
o o d stabilizing medications,
she
she has
has not
not needed
needed thethe intensive
intensive inpatient
inpatient treatment
treatment she received initially.
she received initially.
Martha
Martha and and Eric
Eric have
have improved
improved their
their relationship.
relationship. They
They regularly see
regularly see
a
a marital
marital therapist,
therapist, whow h o has
hashelped
helpedthem
them distinguish
distinguishhowh o w the
thedisorder
disorderaf­af-
fects
fects their relationship, how
their relationship, h o w conflicts
conflictsinintheir
theirrelationship
relationshipaffect
affectthe
thedisor-
disor-
 Why 00
Why DoI INeed
NeeThis
d ThBook?
is Book? II 11

der,der,
andand what
what problems
problems in in theirfamily
their family life
life areareunrelated
unrelated to her
to illness. To�
her illness. To-
gether
gether they
they have
have developed
developed a a list
list of
of the
the signs
signs of of her
her oncoming
oncoming episodes
episodes
and
and what
what steps
steps toto take
take when
w h e n these
these signs
signs appear
appear (for(for example,
example, calling
calling herher
physician
physician for for an
an emergency
emergency appointment
appointment to to prevent hospitalization). Her
prevent hospitalization). Her
children
children havehave become
b e c o m e more
more accepting
accepting of of her
her moodiness,
moodiness, and and sheshe has be­
has be-
come
c o m e more
m o r e enthusiastic
enthusiastic aboutabout parenting.
parenting. She She hashas had
had frustrations
frustrations in in the
the
workplace, and
workplace, and finally
finally came
came to to the
the conclusion
conclusion that that ''I'm just not
"I'm just not aa nine-to-
nine-lO­
fiver."
fiver." She
She decided
decided to to try
try freelance
freelance work,work, which
which has has reduced
reduced her her stress
stress
and
and given
given herher predictable hours.
predictable hours.
Martha
Martha now n o w has
has a bener understanding
a better understanding of of the
the disorder
disorder and and howh o w toto
manage
manage it. it. For
For example,
example, by by keeping
keeping a a mood
m o o d chart
chart she has learned
she has learned to to
distinguish-for
distinguish—for herself herself as as well
well as as for
for other
other people-between
people—between her her every-
every­
day,
day, normal
normal moodm o o d swings
swings and and thethe more
more dramatic
dramatic mood m o o d swings
swings of of her
her bi-
bi­
polar
polar illness.
illness. She
She has
has learned
learned to to maintain
maintain a a regular
regular sleep-wake
sleep-wake cycle. cycle. SheShe
recognizes
recognizes that that keeping
keeping her her disorder
disorder wellwell controlled
controlled is is the key to
the key to meeting
meeting
her
her own
o w n expectations
expectations of of herself.
herself. SheShe isis now
n o w more
more comfortable trusting
comfortable trusting
and
and enlisting
enlisting the the support
support of of her
her husband
husband and and friends
friends w when she feels
h e n she de¥
feels de-
pressed
pressed or suicidal.
or suicidal.
Martha
Martha recognizes
recognizes that that her
her disorder
disorder is is recurrent,
recurrent, but bm alsoalso feels that
feels that
she
she isis more
m o r e in
incontrol
controlof ofher
her fate.
fate.In Insumming
s u m m i n gupupher
herdeveloping
developingabilityabilityto to
cope
cope with
with the disorder, she
the disorder, shesaid,
said,"I've
"I'velearned
learnedtotoaccept
acceptthat thatI've
I'vegot
gotsome­
some-
thing biochemical that
thing biochemical that goes
goes haywire,
haywire, but but it's
it's not
not the
the sum
s u m total
total ofof wwho
h o II
am.
am. If If1Icould
could change
change oneone thing
thing about
about myself,
myself,it'd it'dbe
beother
otherpeople's
people'smoodsmoods
and
and h how
o w they
they affect
affect me,
m e , even
even when
w h e n it's
it's their
their problem
problem and and notnot mine."
mine."

all, all,
Above
Above thisthis book
book isisabout
abouthope.
hope. If
If you've
you'vejust
justbeen diagnosed
been with
diagnosed bi­ bi-
with
polar
polar disorder,
disorder, or
or even
even if
if you
you have
have had
had many
m a n y episodes, you probably
episodes, you probably have
have
fears
fears about
about what
what the
the future
future holds.
holds. Martha's
Martha's story-while
story—while perhaps representa­
perhaps representa-
tive
tive of
of only
only one
one fonn
form of
of the
the disorder
disorder and
and one
one type
type of
of life
life situation-captures
situation—captures
some
s o m e of
of the
the ways
ways that
that people
people learn
learn to
to live
live with
with bipolar
bipolar illness.
illness. A
A diagnosis
diagnosisof
of
bipolar
bipolar disorder
disorder doesn't
doesn't have
have to
to mean
m e a n giving
giving up
up your
your hopes
hopes and aspirations.
and aspirations.
As
A s you
you will soon see,
will soon see, you
you can
can come
c o m e to
to terms with the
terms with the disorder
disorder and
and develop
develop
skills
skills for
for coping
coping with
with it
it and
and still
still experience
experience life
hfe to
to its
its fullest.
fullest.

How
H o w This
This Book
B o o k Is
Is Organized
Organized

This
This book is divided
book is dividedinto
intothree sections.
three In the
sections. In remaining chapters
the remaining (2-4)(2-4)
chapters of of
this
this section,
section, "The
"The Diagnosis
Diagnosis and
and Course
Course of Bipolar Disorder,"
of Bipolar you'll learn
Disorder," you'll learn
about the
about the symptoms
symptoms and and recurrent
recurrent nature
nature of
of the
the disorder
disorder from your o
from your own van­
w n van-
tage
tage point
point as
as well
well as
as that
that of your relatives
of your relatives and
and the
the physician who
physician w makes the
h o makes the di­
di-
agnosiS.
agnosis. You'll
You'llbecome
become familiar
familiarwith
with what
what behaviors
behaviorsare considered to
areconsidered tobe
be with-
with-
12
12 THE
THE DIAGNOSIS
DIAGNOSISAND
ANDCOURSE OF OF
COURSE BIPOlAR
BIPOIDISORDER
AR DISORDER

in
in the
the bipolar
bipolar spectrum
spectrum and what to
and what lO expect
expect from
from the
the diagnostic
diagnostic process.
process.
Chapter 4
Chapter 4 offers
offers you
you tips
tips on
on how
h o w to cope with
to cope with the
the diagnosis
diagnosis and
and addresses
addresses the
the
question
question many
m a n y people
people ask
ask themselves:
themselves: "Is il an
"Is it an illness
illness or
or is
is it me?"
it m e?"
In
In Part
Part II,
II, "Causes
"Causes and
and Treatments,"
Treatments," Chapter 5 provides
Chapter 5 provides an
an overview of
overview of
the
the genetic,
genetic, biological,
biological,and
andenvironmental
environmentaldeterminants
determinantsofofthe
thedisorder.
disorder.You'll
You'll
come
c o m e to
to see
see how
h o w the
the disorder
disorder is not just
is not just about
about biology
biology or just about
or just environ­
about environ-
ment but an
ment but an interaction
interaction of
of the
the two.
two. Chapler
Chapter 6 is devoted
6 is devoted to
to medications for
medications for
treating
treating the biological aspects
the biological aspects of
of the
the disorder
disorder (mood stabilizers, antidepres­
(mood stabilizers, antidepres-
sants,
sants, amipsychorics,
antipsychotics,and
andnewer,
newer,nontraditional
nontraditionalagenlS), includingtheir
agents),including theireffec­
effec-
tiveness,
tiveness, how we
how w e think
think they work, and
they work, and their
their side
side effects;
effects; and
and the
the role
role of psy­
of psy-
chotherapy in
chotherapy in helping
helping you
you cope
cope more effectively with
more effectively with mood swings and
m o o d swings and their
their
triggers.
triggers. Chapter 7 deals
Chapter 7 with the
deals with the issue
issue of
of accepting
accepting and
and coming
coming to
to terms with
terms with
a long-term
a long-term program
program of
of medication.
medication. For
For people
people with
with bipolar
bipolar disorder-and
disorder—and
many
m a n y other recurrent illnesses-taking
other recurrent medications regularly
illnesses—taking medications regularly and
and for
for the long
the long
term
term poses
poses many
m a n y emotional and practical
emotional and practical challenges.
challenges. In
In this
this chapter you'll
chapter you'll
learn why
learn w h y taking medications consistently
taking medications consistently is
is so
so important
important and why
and w some of
h y some of
the
the common
c o m m o n arguments
arguments for
for discontinuing medications (for
discontinuing medications example, "}
(for example, don't
"I don't
need to
need to take medications w
take medications when
h e n II feel
feel well")
well") are
are erroneous.
erroneous.
Part
Part Ill,
III, "Self�Managemem,"
"Self-Management," SLarts with ways
starts with ways to manage the
to manage the disorder
disorder by
by
"Maimaining
"Maintaining Wellness" (Chapter 8),
Wellness" (Chapter strategies for
8), strategies for derailing
derailing the
the upward cycle
upward cycle
into mania (Chapter
into mania 9), and
(Chapter 9), how
and h o w to
to recognize
recognize and
and handle
handle depression
depression (Chap­
(Chap-
ter 10).
ter 10). II devote a special
devote a special chapter
chapter to
to dealing with suicidal
dealing with suicidal thoughts
thoughts and feel­
and feel-
ings (Chapter 11),
ings (Chapter which, for
11), which, many
for m a n y people with bipolar
people with bipolar disorder,
disorder, is
isaaconstant
constant
source of
source of pain
pain (see,
(see, for
for example,
example, KayKay Jamison's
Jamison's excellent book Night
excellent book Falls
Night Falls
Fast:
Fast: Understanding Suicide). You'll
Understanding Suicide). You'll learn ways to
learn ways to get
get help
help from others when
from others when
you're suicidal
you're and some
suicidal and some things you can
things you can do
do to manage these
to manage these feelings
feelings on
on your
your
own.
o w n . The
The last
last chapter,
chapter, "Coping
"Coping Effectively
Effectively in
in the
the Family
Family and
and Work Senings,n
W o r k Settings,"
talks
talks about
about handling
handling the family, social,
the family, social,and
andwork
workstress
stressthat
thatusually
usuallyaccompa­
accompa-
nies
nies the
the postillness
postillness phases
phases of
of the disorder as
the disorder well as
as well as how
h o w to
to educate
educate others
others
about the
about the challenges you face.
challenges you face.
 2
2

What
W h a t Bipolar
B i p o l a r Disorder
D i s o r d e r Looks
L o o k s Like­
Like-

to
t o You,
Y o u , to
t o the
t h e Doctors,
Doctors,

and
a n d tot o Everyone
E v e r y o n e Else
Else

T
I hough bipolar disorder
hough bipolar
descriptions
descriptions of
of it
it make
disorder is
make ititsound
isvery
verydifficult
soundlike
difficulttotodiagnose,
likeitit
shouldn't
diagnose,the
bebe
shouldn't soso
hard.
"textbook"
the
After
hard.
"textbook"
all,
After what
all, what
could
could be
be more
more dramatic
dramatic than
than shifting
shifting between
between extraordinarily
extraordinarily manic behavior,
manic behavior,
feeling
feeling on
on top
top of
of the
the world and supercharged
world and energy, LO
with energy,
supercharged with to feeling de­
feeling de-
pressed,
pressed, withdrawn,
withdrawn,and
and suicidal?
suicidal?
Consider
Consider aa surprising
surprising fact:
fact:On
O n average,
average,there
thereisis
anan
eight-year lag
eight-year between
lag between
a
a first
firstepisode
episodeof
ofdepression
depressionor
ormanic
manicsymptoms
symptomsand
andthe
thefirst time
first the
time disorder
the disorder
is diagnosed
is diagnosed and
and treated (Goodwin &
treated (Goodwin & Jamison,
Jamison, 1990;
1990; Lewis, 2000). Why
Lewis, 2000). Why
should
should it
it take
takeso
solong
longfor
foraaperson
personwith
withthe
thedisorder tocome
disorderto come to
tothe
theattention
attention
of
of the
the mental
mental health
health profession?
profession? In
In pan,
part, the
theanswer
answerisisbecause
becausethe
thebehaviors
behaviors
that
that we
w e summarize
summarize with
with the term bipolar
theterm bipolardisorder
disordercan
can look
look qUite
quitedifferenr,
different,de­
de-
pending
pending on
on your
your perspective.
perspective. But
Buteven
evenwhen
when people
peopleagree
agreeon
on how
how aaperson's
person's
behavior deviates
behavior deviates from
from normal,
normal, they
theycan
canhave
havevery
verydifferent
differentbeliefs
beliefsabout
aboutwhat
what
causes
causes the
the person
personto
tobe
bethis
thisway.
way.Consider
ConsiderLauren,
Lauren,who
w h ohas bipolar
has disorder:
bipolar disorder:

Lauren,
Lauren, a 28-year-old mother
a 28-year-old mother of of three,
three, describes herself
describes as an "exercise
herself as an "exercise
junkie." In
junkie." In the
the past
past three
three weeks,
weeks,aatypical
typicalday
daywenrlike
went likethis: Once
this: Onceshe got
she got
the kids
the kids off
offtotoschool,
school,she
sherushed thegym,
rushedtotothe gym,where
whereshe
sheworked
workedout outon
onanan
exercise bicycle for
exercise bicycle for up
up to
to two
two hours.
hours. Then,
Then, she
she grabbed
grabbed a a quick yogurt
quick yogurt
and went hiking
and went hiking for
for most
most of
of the
the afternoon.
afternoon. She
She would
would pick
pick up her kids
up her kids
from school, make dinner for them,
from school, make dinner for them,and andspend
spendthe majority
the majorityofof
the evening
the evening

13 13
14
14 IHE
THE DIAGNOSIS
DIAGNOSISAND
AND[QURSE
COURSEOFOF
BIPOlAR DISORDER
BIPOIAR DISORDER

on stairmaster.
on the the stainnaster.
ButButsheshedid
didnot
notconsult
consult her
her psychiatrist
psychiatrist until, by the
until, by the
end
end of
of the
the second
second week,
week, she had become
she had exhausted and
become exhausted and unable
unable to func­
to func-
tion.
tion. At
At this
thispoint
point she
she left
leftthe
thechildren
children with
with their grandparents and
theirgrandparents and spent
spent
several
several days
days sleeping.
sleeping. She
She admitted
admitted to
to having
having had several cycles
had several cycles like
like these.
these.

Now Now consider

consider how Lauren,
how Lauren, her mother,
her mother, and herand her doctor
doctor describe
describe her her
behavior.
behavior. Lauren
Lauren summarizes
summarizes her
her problems
problems as
as the
the result
result of being overcommit­
of being overcommit-
ted.
ted. "It's
"It's incredibly
incredibly difficult
difficult to
to take
take care
care of
of three
three kids,
kids, maintain
maintain a a household,
household,
and
and try
try to
to stay
stay healthy,"
healthy," she
she argues.
argues. "My
" M y ex-husband
ex-husband isis of little help,
very little
of very help,and
and
II don't
don't have
have many
m a n y friends
friends who
w h o can
can help
help out.
out. Sometimes
Sometimes II push
push myself
myself too
too
hard, but
hard, but II always bounce back."
always bounce Her mother
back." Her mother feels
feels that
that she
she is
is "irresponsible
"irresponsible
and self-centered," would
and self-centered," would "rather
"rather be
be exercising
exercising than
than taking
taking care
care of
of her kids,"
her kids,"
and questions whether
and questions whether her
her children
children are geuing enough
are getting enough guidance
guidance and struc­
and struc-
ture.
ture. Lauren's
Lauren's doctor
doctor has
has diagnosed
diagnosed her
her as
as having bipolar II
having bipolar disorder.
II disorder.
Who is right?
W h o is right? Lauren
Lauren thinks
thinks her
her behavior
behavior is
is a
a function
function of her environ­
of her environ-
ment.
ment. Her
Her mother
mother describes
describes the
the same behaviors as
same behaviors driven by
as driven her personality
by her personality
attributes. Her
attributes. psychiatrist thinks
Her psychiatrist she has
thinks she has a biologically based
a biologically based mood disorder.
m o o d disorder.
These
These different
different perspectives
perspectives pose
pose a
a problem
problem for Lauren, because
for Lauren, because they
they lead to
lead to
very dirrerent
very different remedies
remedies for
for the
the situation.
situation. Lauren feels that
Lauren feels that others
others need
need to
to be
be
more supportive.
more supportive. Her
Her mother
mother thinks
thinks Lauren needs to
Lauren needs become more
to become responsi­
more responsi-
ble. Her
ble. doctor thinks
Her doctor thinks Lauren
Lauren needs
needs to
to take
take a
ammood stabiliZing medication.
o o d stabilizing medication.
Almost every
Almost patient II have
every patient have worked
worked with
with describes
describeshis
hisor
orher
herbehavior
behavior dif­
dif-
ferently
ferently from
from the
the way a doctor
way a doctor or
or family
family member would. Consider
m e m b e r would. Consider Brent,
Brent, who
who
has been
has been having
having trouble holding jobs.
trouble holding He
jobs. H e says he is
says he is depressed
depressed but
butfeels
feelsmost
mostof
of
itt is
i is due
due to being unable
to being unable to
to deal
deal with
with his
his hypercritical
hypercritical boss.
boss. As
As a
a result,
result, he
he
thinks he needs
thinks he needs to
to switch
switch jobs
jobs and
and nnd
find a
a more
more permissive work environment.
permissive work environment.
His wife, Alice,
His wife, Alice, thinks
thinks he
he is
is manic
manic and
and irritable,
irritable, not depressed, and
not depressed, and that
that he
he
needs
needs long-term
long-term psychotherapy
psychotherapy to deal with
to deal with his
his problems with male
problems with male authority
aUlhority
figures.
figures. She also thinks
She also he drinks
thinks he drinks too
too much
m u c h and
and needs
needs to
to attend
attend Alcoholics
Alcoholics
Anonymous
A n o n y m o u s meetings.
meetings. Brent's
Brent's doctor
doctor thinks he is
thinks he is in
in a postmanic depressive
a postmanic depressive
phase and would
phase and would benefit
benefit from
from a
a combination
combination of
of medication and couples
medication and ther­
couples ther-
apy.
apy.
Psychiatrists and
Psychiatrists and psychologislS
psychologists usually
usually think
think of bipolar disorder
of bipolar disorder as
as a
a set
set of
of
symptoms, which must
symptoms, which must be
be present
present in
in clusters
clusters (that
(that is,
is, more
more than
than one
one at a
at a
time)
time) and last for
and last for a
a certain length of
certain length of time,
time, usually
usually in
in"episodes"
"episodes"that
thathave
have aabe­
be-
ginning
ginning phase,
phase, aa phase in which
phase in which symptoms
symptoms are
are at
at their
their worst, and a
worst, and a recovery
recovery
phase. The
phase. The traditional
traditional approach
approach to
to psychiatric
psychiatric diagnOSis described in
diagnosis described in Chapter
Chapter
3
3 follows
follows this
this line
line of
of reasoning.
reasoning. In
In contrast,
contrast,people
people with
with the
the illness
illness often
often pre­
pre-
fer
fer to
to think
think of bipolar disorder
of bipolar disorder as
as a
a series
series of
of life
life experiences,
experiences, with
with the
theactual
actual
symptoms
symptoms being
being of secondary importance
of secondary importance toto the
the factors
factors that
that provoked
provoked them.
them.
Family
Family members
members or significant others
or significant others may
m a y have
have a different perspective
a different alto-
perspective alto-
 Whot
What Bipolar Disorderlooks
Bipolar Disorder LoobUke
Like lS
15

gether, perhaps
gether, onethat
perhaps one thatemphasizes
emphasizes the
the patient'spersonality
patient's personalityor
orthat
that views
viewsthe
the
deviant behavior
deviant behavior in historical perspective
in historical perspective (for
(for example,
example, "She's always b
"She's always been
een
moody").
m o o d y " ) . Although
A l t h o u g h often
often quite different, there
quite different, there is
is a
a degree
degree of validity to
of validity to all
all
three
three points of view.
points of view.
In this
In this chapter you'll gain
chapter you'll gain a
a sense
sense of the different
of the different perspectives people take
perspectives people take
in understanding bipolar
in understanding bipolar mmood swings and
o o d swings a n d how
h o w these different perspectives
these different perspectives
can lead to
can lead very different
to very different feelings about w
feelings about which
h i c h treatments should bbe
treatments should under­
e under-
taken.
taken. These perspectives include
T h e s e perspectives include the
the personal standpoint, as
personal standpoint, as described
described b
by pa­
y pa-
tients who
tients w h o have
have the disorder; the
the disorder; the observers' viewpOint, which
observers' viewpoint, usually means
w h i c h usually means
parents, spouses, or
parents, spouses, or close
close friends;
friends; and
a n d the
the doctor's viewpoint. Questions
doctor's viewpoint. to
Questions to
pose to
pose yourself when
to yourself reading this
w h e n reading this chapter are:
chapter are:

• How• do
How do I experience
I experience svvangs swings in my mood?
in my mood?
•
• Are
A r e they
they similar
similar to
to the
the ways
w a y s others
others with
with bipolar
bipolar disorder
disorder experience
experience
them?
them?
•
• How
H o w do
do IIundersland
understand my
m y own
own behavior?
behavior?
•
• How
H o w is
is my
m y understanding
understanding different
differentfrom
from the
the way
way others
others perceive
perceive me?
me?
•
• How
H o w do
do IIsee
see myself
myself differently
differently from
from the
the way
way my
m y doctor
doctor sees
sees me?
me?
•
• What
What kinds
kinds of
ofproblems
problems arise
arise from
from these
these differences
differences in
in perceptions?
perceptions?

Understanding
Understanding these
these varying perspectives
varying perspectives willwill
be ofbe
useofto use
you,to
whether
you, whether
you
you are
are on your first
on your first episode
episodeor
orhave
havehad
hadmany
many episodes,
episodes,ininthat
thatyou
youwill gain
will gain
some
some clarity
clarity on
on how
h o w your
your own
own experiences
experiences may
may differ
differ from
from those
those of people
of people
without
without bipolar
bipolar disorder.
disorder.YouYoumay
mayalso
alsocome
cometotosee
seewhy
why others
othersininyour
yourfamily
family
or
or work/social
work/social environment
environment think
think you
you need
need treatment,
treatment,even
evenififyou
youdon't
don'tagree
agree
with
with them.
them.

Nuls
Nuts and
and Boils:
Bolts: Whal
What Is
Is Bipolar
Bipolar Disorder?
Disorder?

Let's
Let's begin by defining
begin the syndrome
by defining of bipolar
the syndrome ofdisorder.
bipolarItsdisorder.
key characteristic
Its key chara
is
is extreme
extreme mood
mood swings,
swings,from
frommanic
manichighs
highsto
tosevere
severedepressions.
depressions.ItItisiscalled
calleda a
mood
mood disorder
disorder because
because it
itprofoundly
profoundlyaffects
affectsa aperson's
person'sexperiences
experiencesofofemotion
emotion
and
and "affect"
"affect" (the
(the way
way he
he or
or she
she conveys
conveys emotions
emotions to
to others).
others).I I
ttisis
called bipolar
called bipolar
because the
because the mood
mood swings
swings occur
occur between
between two
two poles-high
poles—high and
and low-as op­
low—as op-
posed
posed to
to unipolar
unipolar disorder,
disorder,where
wheremood
mood swings
swingsoccur
occuralong
alongonly
onlyone
onepole­
pole—
the
the lows.
lows.
In
In the
the manic
manic "high"
"high" state,
state,people
peopleexperience
experiencedifferent
differentcombinations
combinationsof
ofthe
the
following:
following: elated
elated or
or euphoric
euphoric mood
mood (excessive
(excessive happiness
happiness or
or expansiveness),
expansiveness),
irritable
irritable mood
mood (excessive
(excessive anger
anger and
and touchiness),
touchiness), aa decreased
decreased need
need for
for sleep,
sleep,
grandiosity
grandiosity or
or an
an inflated
inflated sense
sense of
of themselves
themselves and
and their abilities, increased
their abilities, increased
16
16 TNE DIAGNOSIS
THE DIAGNOSISANO
ANDCOURSE
COURSEOfOF
BIPOlAR DISOROER
BIPOUR DISORDER

talkativeness, racing
talkativeness, thoughts
racing or jumping
thoughts from
or jumping one
from idea
one to to
idea another, an in­
another, an in-
crease
crease in
in activity and
activity and energy
energy levels,
levels, changes
changes in
in thinking,
thinking, auention,
attention, and per­
and per-
ception,
ception, and
and impulsive,
impulsive,reckless
recklessbehavior.
behavior.These
Theseepisodes
episodesalternate
alternatewith
withinter­
inter-
vals in
vals in which
which a
a person
person becomes
becomes depressed,
depressed, sad,
sad, blue,
blue,or
or"down
"downin
inthe
thedumps,"
dumps,"
loses
loses interest
interest in
in things
things he
he or
or she
she ordinarily
ordinarily enjoys, loses
enjoys, weight and
loses weight appetite,
and appetite,
feels
feels fatigued,
fatigued, has
has difficulty
difficulty sleeping, feels guilty
sleeping, feels guilty and
and bad about him-
bad about him- or her­
or her-
self,
self, has
hastrouble
troubleconcentrating
concentrating or
ormaking
making decisions,
decisions,and
and often
oftenfeels
feelslike
likecom­
com-
mitting suicide.
mitting suicide.
Episodes of
Episodes of either
either mania
mania or
or depression
depression can
can last
last anywhere from days
anywhere from to
days to
months.
months. Some
S o m e people (about 40%
people (about 4 0 % by
by some
some estimates; Calabrese et
estimates; Calabrese al., 1996)
et a1., 1996)
don't
don't experience
experience depressions
depressions and
and manias
manias in
in alternating fashion. Instead,
alternating fashion. Instead, they
they
experience
experience them
them simuhaneously,
simultaneously, in what we
in what w e call
call "mixed
"mixed episodes,n which I
episodes," which I'll
'll
talk
talk about
about in
in the
the next
next chapter.
chapter.
Episodes
Episodes of
of bipolar
bipolar disorder
disorder do not develop
do not develop overnight,
overnight, and
and how
h o w severe
severe
the
the manias
manias or
or depressions
depressions get varies greatly
get varies greatly from
from person to person.
person to person. Many
M a n y peo�
peo-
pie accelerate
ple accelerate into
into mania
mania in
in stages.
stages. Drs.
Drs. Gabrielle
Gabrielle Carlson
Carlson and
and Frederick
Frederick
G o o d w i n (1973)
Goodwin (1973) observed
observed that
that in the early
in the early stages
stages of
of mania,
mania, people feel
people feel
"wired"
"wired" or
or charged
charged up
up and
and their
their thoughts race with
thoughts race with numerous
numerous ideas.
ideas. They
They
start
start needing
needing less
less and
and less
less sleep
sleep and
and feel
feel giddy
giddy or mildly irritable
or mildly ("hypo­
irritable ("hypo-
mania"). Later
mania"). Later they
they accelerate
accelerate into
into a
a full-blown
full-blown mania,
mania, marked
marked by
by euphoria,
euphoria,
impulsive behaviors
impulsive behaviors such
such as
as spending
spending sprees,
sprees, and
and intense, frenetic periods
intense, frenetic of
periods of
activity.
activity. In
In the most advanced
the most advanced stages,
stages, the
the person
person can
can develop mental confu-
develop mental confu­
sion,
sion, delusions
delusions (beliefs
(beliefs that
that are
are irrational),
irrational), hallucinations
hallucinations (hearing
(hearing voices
voices or
or
seeing
seeing things),
things), and
and severe
severe anxiety.
anxiety. Not
Not everyone
everyone experiences
experiences these
these stages,
stages, and
and
many
m a n y people
people receive
receive treatment
treatment before they gel
before they get to
to the
the most
most advanced stage.
advanced stage.
People
People also
also spiral
spiral into
into depression
depression gradually,
gradually, although
although its
its stages
stages are less
are less
c1ear-cUl.
clear-cut. For
Forsome,
some,severe
severedepressions
depressionsarise
arisewhen
w h e n they
theywere otherwisefeeling
wereotherwise feeling
well.
well. In
In others, major depression
others, major depression develops
develops on of ongOing,
top of
on top ongoing, milder depres­
milder depres-
sions
sions called
called "dysthymias" (see Chapter
"dysthymias" (see 10).
Chapter 10).
The
The periods
periods in
in between
between manic
manic and
and depressive
depressive episodes
episodes are
are symptom-free
symptom-free
in
in some
some people.
people. For
For olhers,
others, there
there are
are symptoms left over
symptoms left over from
from the episodes,
the episodes,
such
such as
as sleep
sleep disturbance,
disturbance, ongOing
ongoing irritability,
irritability, or
or dysthymiC
dysthymic or
or hypomanic
hypomanic
disorders.
disorders. Most
Most people
people experience
experience problems
problems in their social
in their social and
and work
work life
life be­
be-
cause of
cause of the
the illness
illness (Coryell
(Coryell et al., 1993;
et aI., Goldberg et
1993; Goldberg al., 1995).
et al., 1995).
Between
Between 0.8% and 1.6%
0.8% and 1.6% of
of the
the general
general population
population has
has "bipolar
"bipolar I" disorder,
I" disorder,
marked
marked by
by swings
swings from
from extreme
extreme depression
depression to
to extreme About 0.5%
mania. About
extreme mania. 0.5% (1
(1
in 200)
in 200) has
has "bipolar
"bipolar II"
11" disorder,
disorder, in
in which
which people vary from
people vary from severely de­
severely de-
pressed
pressed to
to hypomanic,
hypomanic, a
a milder
milder form
form of
of mania
mania (Kessler
(Kessler e al., 1994;
ett aI., 1994; Regier et
Regier et
al., 1990).
al., New
1990). N e w cases
cases of bipolar disorder
of bipolar disorder have
have been
been recognized
recognized in young chil-
in young chil­
dren and
dren and in
in the
the elderly,
elderly, but
butthe
thetypical
typicalage
ageat firstonset
atfirst onsetis
isbetween
between I15 and 19
S and 19
(Goodwin &
(Goodwin Jamison, 1990).
& jamison, 1990). It
It is
is generally
generally treated
treated with
with a
a range
range of
of drugs in
drugs in
combination with psychotherapy:
combination with psychotherapy:
 WhatBiBipolar
What polar DDisorder Loob Uke
isorder looks Like 17
17

•• Mood
Mood stabilizers
stabilizers (for
(for example,
example, lithium
lithium carbonate,
carbonate, or Teg-or Teg-
Depakote,
Depakote,
retol)
retol)
•• Antidepressants
Antidepressants (for
(for eexample, Paxil or
x a m p l e , Paxil or Wellbutrin)
Wellbulrin)
•• Antipsychotics
Antipsychotics (for
(for eexample, Zyprexa or
x a m p l e , Zyprexa or Seroquel),
Seroquel), and/or
and/or
•• Antianxiety
Antianxiety agents
agents (for
(for eexample, Klonopin or
x a m p l e , Klonopin or Ativan).
Ativan).

DiKeren! Perspectives
Different Perspedives oon
n MMania
a n i a aand Depression
n d Depression

As noted,
As nOled,the
thesymptoms
symptoms associated
associated with
with bipolar
bipolar mood
mood disorder
disorder can
can be be experi­
experi-
qUite differently
enced quite
enced differently bby the person
y the person with
with the
the disorder,
disorder, bby
y aan observer, aand
n observer, n d bby
y
aa physician.
physician. T
The disorder primarily
h e disorder affects mmood
primarily affects and
ood a behavior. YYour
n d behavior. o u r moods
moods
cannot always
cannot always bbe observed bby
e observed others, although
y others, although yyou will usually
o u will usually be
be aware
aware of
of
them. Likewise,
them. Likewise, yyou
o u mmay not always
a y not always be
be aware
aware of
of your
your behavior
behavior oror its
its impact
impact
oon others, while
n others, while others
others (family,
(family, friends,
friends, or
or doctors)
doctors) are
are acutely
acutely aware
aware of
of it.
it.
WWhen people look
h e n people look at
at a
and evaluate the
n d evaluate the s
same set of
a m e set of behaviors
behaviors or
or experienc�s
experiences
different lenses,
through different
through lenses, y
you can imagine
o u can imagine h
how
o w mmuch
u c h rroom there is
o o m there is for
for inter-
inter­
pretation
pretation and
a n d misinterpretation.
misinterpretation.
You
Y may
ou m be
ay b e quite articulate in
quite articulate in describing
describing what you
what y o u are
are feeling
feehng aand think­
n d think-
ing.
ing. WWhen in a
h e n in a mmanic
a n i c phase, your thoughts
phase, your now rapidly
thoughts flow rapidly and life feels
a n d life feels exotic
exotic
and
a n d wonderful.
wonderful. You
Y o u may
m a y speak
speak more
m o r e than
than usual
usual and
a n d more
m o r e freely
freely reveal
reveal your
your
inner
inner thoughts.
thoughts. An
A n observer,
observer, such
s u c h as
as a
a family
family member,
m e m b e r , usually
usually focuses
focuses on
on
your
y o u r behavior,
behavior, which
w h i c h he
h e or
or she
she may
m a y describe
describe as
as too
too outspoken,
outspoken, boisterous,
boisterous,
verbally
verbally hostile,
hostile, dangerous
dangerous to
to yourself
yourself or
or others,
others, or
or impulSive
impulsive in
in ways
w a y s that
that
negatively
negatively affect
affect others
others (for
(for example,
example, spending
spending or
or investing
investing your
your money
m o n e y sud­
sud-
denly).
denly). Your
Y o u r doctor
doctor is
is usually
usually attuned
attuned to
to whether
w h e t h e r your
your mood
m o o d and
a n d behavior
behavior are
are
Significant
significant departures
departures from
f r o m your
y o u r normal
n o r m a l states,
states, taking
taking into
into account
account such
such
things
things as
as whether
w h e t h e r the
the symptoms
s y m p t o m s have
have lasted
lasted for
for aa period
period of
of time,
time, how
h o w intense
intense
they
they are,
are, and
a n d whether
w h e t h e r they
they cause
cause impainnent
impairment in
in your
your functioning.
functioning.
In
In the
the follOwing
following sections,
sections,IIwill
will describe
describe mania
m a n i a and
a n d depression
depression from
from these
these
three
three perspectives.
perspectives. II will
will focus
focus on
o n the
the personal
personal experiences
experiences that
that really
really define
define
episodes
episodes of
ofbipolar
bipolar disorder,
disorder,which
w h i c h are
are summarized
s u m m a r i z e d in
in the
the sidebar
sidebar on
o n page
page 18.
18.

Roller Coaster
Roller CODster Mood
MoodStates
S'D'es

"How
"How can can 1 ever
I ever make make
plans plans
or count or on
count on anything
anything or anybody? or anybody?
I never I never
k n o w how
know h o w I'm
I'm going
going to
to feel.
feel.IIcan
can be
b e up
u p and
a n d happy
h a p p y and
a n d full
fullof
ofideas,
ideas,but
but
then
then the
the littlest
htUest things
things set
set me
m e off.
off.I'll
I'lldrink
drink aa cup
c u p of
of tea
tea and
a n d it
it doesn't
doesn't
match
m a t c h my
m y expectation
expectation of
of how
h o w hot
hot ititshould
should be,
be,and
a n d I'll
I'lljust
just react-I'll
react—I'll
cuss,
cuss,scream-I'm
s c r e a m — I ' m bitterly volatile . .. .I'm
bitterlyvolatile I'm afraid
afraid ofofmy
m y own
o w n moods."
moods."
-A
— A 3D-year-old
30-year-old womanw o m a n with bipolar IIdisorder
with bipolar disorder
18
18 IHE
THE DIAGNOSIS
DIAGNOSIS AND
AND (QURSE
COURSE OF
OF BIPOlAR
BIPOIAR DISORDER
DISORDER

Experiences
Experiences of
of Manic
M a n i c and Depressive Episodes
a n d Depressive Episodes

•
• Roller-coaster
Roller-coaster mood
moodstates (euphoria,
states irritability,
(euphoria, depression)
irritability, depression)
•
• Changes
Changes in
in energy
energy or
or activity
activity levels
levels
•
• Changes
Changes in
in thinking
thinking and
and perception
perception
•
• Suicidal
Suicidal thoughts
thoughts
•
• Sleep
Sleep problems
problems
•
• lmpulsive
Impulsive or
or self-destructive
self-destructive behavior
behavior

Most people
Most people with
with bipolar
bipolar disorder
disorder describe
describe their
their moods
m o o d s as voLatile, unpre­
as volatile, unpre-
dictable,
dictable, "all
"all over
over the
the map,"
map," or
or "like
"like a
a seesaw." Mood
seesaw." M o o d states
states accompanying bi­
accompanying bi-
polar disorder can
polar disorder can be
be irritable
irritable (during
(during either
either depression
depression or
or mania),
mania), euphoric,
euphoric,
elevated
elevated or
or excessively
excessively giddy
giddy (during
(during mania),
mania), or
or extremely
extremely sad
sad (during de­
(during de-
pression).
pression).
You
Y o u may
m a y agree
agree that
thatyou
you have
have variable
variablemood
m o o d states,
states,but
butyour
yourexplanation
explanationfor
for
these
these mood
m o o d states
states may
m a y be
be quite
quitedifferent
differentthan
thanthose
thoseof
ofyour
yourdoctor,
doctor,family mem­
family mem-
bers,
bers, or
orfriends.
friends.People
Peoplewith
withbipolar
bipolardisorder
disorderoften
oftenget
getangry
angrywhen
w h e ntheir
theirdoctors
doctors
bring
bring out
out a
a list
listof
ofsymptoms
symptoms and
andask
askthem
them how
h o w many
m a n y they
theyhave
havehad
had and
andfor
forhow
how
long.
long. They
They find
find themselves
themselves reluctantly
reluctantly agreeing
agreeing that
that they
they suffer
suffer from irritable
from irritable
moods
m o o d s but
but also
also know
k n o w the
thetriggers forthese
triggersfor thesemoods
m o o d sthat
thatother
otherpeople
peoplemay
m a ynot
notsee.
see.

"When
"When I'mI'm mad,
mad, nobody
nobody better
better getin
get inmy
myface.
face. I
I feel
feellike crushing
like every­
crushing every-
thing
thing and
and everybody. Every little
everybody. Every little thing
thing will
will provoke m e . II hate
provoke me. every­
hate every-
body, II hate
body, hate my
m y life
hfe and
and want
want to
to kill
kill myself
myself in
in some really dramatic
some really dramatic way.
way.
It's like a
It's like a sharp-edged,
sharp-edged, pointed
pointed anger,
anger, like
like a
a burning feeling."
burning feeling."
— A 23-year-old
-A 23-year-old woman
w o m a n with bipolar II
with bipolar U disorder
disorder

Family
Family members,
members, when descriping the
when describing theemotional
emotionalvolatility of their
volatility of bipolar sib­
their bipolar sib-
ling,
ling, child,
child, or
or parent,
parent, tend
tend to
to emphaSize
emphasize the
the intimidation they
intimidation they feel
feel in
in the face
the face
of
of sudden
sudden outbursts
outbursts that
that they
they don't feel they've
don't feel they've provoked.
provoked. Consider
Consider this
this inter­
inter-
change between Kirsten,
change between age 2
Kirsten, age 1 , and
21, and her
her mother,
mother, after
after Kirsten
Kirsten had
had railed at
railed at
her
her mother
mother just
just minutes earlier.
minutes earlier.

KIRSTEN: II wanna
Kirsten: comeback
wanna come backand
andlive
live with
with you.
you. 1Ican
canhandle
handleit.it.
Mother: But
MOTHER: But you're
you're not
not in
in a
a good
good place
place right
right now.
n o w . Look
Look how
h o w angry
angry you just
you just
g01.
got.
 WhatBBipolar
What ipolar DDisorder ks like
isorder loo
Loob Like 19
19

KIRSTEN:ButBut
Kirsten: youyou
toldtold
me Ime I wasn't
wasn't readyready to take
to take care care of myseH!
of myself! Of course
Of course I I
exploded!
exploded!
o t h e r : AAnd
MMOTHER: you're not.
n d you're not. II can
can tell
tell because
because you're
you're overreacting
overreacting to
to mme,
e , aand
nd
that tells
that tells mme you're probably
e you're probably not
not better
better yet.
yet.

It's hard
It's hard to
to think
think of
ofyyour
o u r mmood swings as
o o d swings as evidence
evidence of
ofaan illness, especially
n illness, especially
wwhen every emotional
h e n every emotional reaction
reaction yyou have sseems
o u have perfectly justifiable,
e e m s perfectly justifiable, given
given
what's just
what's just hhappened to yyou.
a p p e n e d to o u . TTo Kirsten, her
o Kirsten, her angry
angry outburst
outburst sseemed perfectly
e e m e d perfectly
justified, because
justified, because her
her mmother
o t h e r hhad questioned her
a d questioned her competency.
competency. HHer
e r mmother
other
kknows
n o w s wwhat her daughter
h a t her daughter is
is like
like wwhen she's well
h e n she's well aand sees her
n d sees her irritability
irritability as
as aa
departure ffrom
departure this norm.
r o m this norm.
In contrast,
In contrast, the
the elated,
elated, euphoric
euphoric periods
periods of
of the
the mmanic experience feel
a n i c experience feel ex-
ex­
ceptionally ggood
ceptionally to the
o o d to the person
person with
with the
the disorder.
disorder. KKay
a y JJamison has written
a m i s o n has written ex-
ex­
tensively about
tensively about the
the w
wondrous feelings that
o n d r o u s feelings that can
can accompany
a c c o m p a n y mmanic episodes
a n i c episodes
aand
n d hhow the desire
o w the desire to
to sustain
sustain these
these feelings
feelings can
can lead
lead aa person
person to
to resist
resist taking
taking
medication Q
medication Oamison et al.,
a m i s o n et 1979; Jamison,
al., 1979; 1995). NNot
Jamison, 1995). all people
o t all people with
with bipolar
bipolar
disorder experience
disorder experience their
their high
high m
moods as euphoria,
o o d s as euphoria, however.
however. For
For example,
example,
Beth, age
Beth, age 4 2 , described
42, her mood
described her during manic
m o o d during m a n i c episodes as "the
episodes as "the sudden
sudden
awareness
awareness that I'm not
that I'm not depressed
depressed anymore."
anymore."
To
T o others, your
others, y o u r euphoria
euphoria or
or high
high mood
m o o d may
m a y seem
s e e m strange or clownish,
strange or clownish,
and
a n d they
they may
m a y not
not share
share it
it with
with you,
y o u ,but
but they
they are
are unlikely
unhkely to
to be
be as
as disturbed
disturbed by
by
it
it as
as they
they are
are by
b y your
y o u r irritability.
irritabihty. To
T o your
your relatives,
relatives, especially
especially those
those wwho
h o have
have
gone
g o n e through
through one
o n e or
or more
m o r e previous
previous episodes
episodes with
with you,
y o u , euphoric mood
euphoric m o o d is
is wor­
wor-
risome
risome to
to the
the extent
extent that
that it
it heralds
heralds the
the development
development of
ofaa full-blown
full-blown manic
m a n i c epi­
epi-
sode.
sode.
Now
N o w consider
consider how
h o w you
y o u experience
experience depression.
depression. Would
W o u l d you
y o u describe
describe it
it as
as
an
a n intense
intense sadness
sadness .. . .
a numbing
a n u m b i n gfeeling
feehng. . ...
. a feeling
a feehngofof
being
beingremoved
r e m o v e dfrom
from
others
others ....
. . a
a lack
lack of
of interest
interest in
in things
things you
y o u ordinarily
ordinarily enjoy?
enjoy? One
O n e man
m a n put it
put it
bluntly:
bluntly: "My
" M y depressions
depressions eat
eat me alive. 1I feel
m e alive. feel like
like I'm
I'm in
in aa tank
tank that
that separates
separates
me
m e from
f r o m other
other people.
people. It's
It's all
all just
just hopelessness,
hopelessness, and
a n d II don't
don't see
see any
any future
future for
for
myself.
myself.""
In
In contrast,
contrast, aa family
family member,
m e m b e r , friend,
friend, or
or lover
lover might
m i g h t see
see your
your depression
depression
as self-inflicted.
as self-inflicted.People
People who
who are
are close
close to
to you
y o u might
m i g h t feel
feelsympathetic
sympathetic at
at first
firstbut
but
then
then gel
get irritated
irritated and
a n d annoyed.
annoyed. They
T h e y may
m a y think
think you're
you're not
not tryi.ng
trying hard
hard enough
enough
or
or could
could "'make
" m a k e this
this all
all go
g o away
a w a y if
ifyou
y o u had
h a d the
the right
right mental
mental altitude."
attitude."
What
W h a t does
does the
the doctor
doctor look
look for?
for? To
T o determine
determine whether
w h e t h e r the
the diagnosis
diagnosis is
is
correct (if
correct y o u are
(ifyou are being
being diagnosed
diagnosed for
for the
the first
first time),
time), or
or whether
whether you
y o u are
are ex­
ex-
periencing
periencing aa recurrence
recurrence of
of the
the disorder
disorder (if
(if you've
you've been
b e e n diagnosed
diagnosed before)
before),,
your
y o u r doctor
doctor will
will evaluate
evaluate whether
w h e t h e r your
your mood
m o o d Slates
states are
are different,
different,in
in terms
terms of
of
degree
degree or
or intensity,
intensity, from
f r o m those
those of
of "normal"
"normal" people.
people. Do
D o your
your moods-
moods—
20
20 THE DIAGNOSIS
THE DIAGNOSISAND
ANDCOURSE Of OF
COURSE BIPOlAR
BIPOLDlSOROER
AR DISORDER

euphoric, irritable,
euphoric, irritable,or depressed-get outout
or depressed—get of hand andand
of hand staystay
out out
of hand for for
of hand
days at aa time?
days at time? Do
D o your
your mood
m o o d swings cause problems
swings cause problems in
in your
your social,
social, work,
work,
andlor
and/or family
family life?
hfe? The
T h e questions
questions listed
hsted in
in the sidebar on
the sidebar on this
this page
page will
will figure
figure
prominently
prominently in in your doctor's evaluation
your doctor's evaluation of whether your
of whether your mmood states are
o o d states are
problematic
problematic from
from a a clinical perspective.
clinical perspective.

ChDng.s in
Changes in En.rgy
EnergyDna
andActi.ity
ActivityL•••Levels
,s
If someone
If asked you
someone asked you to
to describe
describe your
your symptoms,
symptoms, you might not
you might not focus
focus on
on
your
your mood
m o o d fluctuations.
fluctuations. In Infact,
fact,many
m a n ypeople
peoplewho w h oare
areasked abouttheir
askedabout theirmood
mood
states
states answer
answer with
with descriptions
descriptions of their energy
of their energy and activity levels
and activity instead.
levels instead.
They're
They're more
more conscious
conscious of of what
what they
they dodo or
or don't
don't do do than
than of
of how
h o w they feel.
they feel.
They focus
They focus on on the
the great
great increases
increases in
in energy
energy that
that they
they experience
experience during the
during the
manic
manic oror mixed
mixed phases
phases or the decreases
or the decreases in in energy
energy theythey experience
experience during the
during the
depressive
depressive phases.
phases.
One
O n e way
w a y to
to understand
understand these fluctuations is
these fluctuations is to
tothink
think of
ofbipolar
bipolardisorder
disorderasas
aa dysregulation
dysregulation of of drive
drive states
states as
as well
well asas of
of mood.
m o o d . Changes
Changes in in nonnal
normal motiva­
motiva-
tional drives, such
tional drives, such as as eating,
eating, sleeping, sex, interacting
sleeping, sex, interacting with others, and
with others, and
achievement are
achievement are part
part and
and parcel
parcel of
of the
the bipolar
bipolar pendulum.
pendulum. T The
h e nonnal
normal drives
drives

Questions
Questions a
a Doctor
Doctor Might
M i g h t Ask
Ask
to Distinguish Bipolar
to Distinguish Bipolar Mood
M o o d Swings
Swings
from
f r o m Nonnal
N o r m a l Mood
M o o d Variability
Variability

• Do
• your mood
Do your moodswings
swingscause
causeproblems
problemsin
in your
your social
social ororfamily
family
life?
life?
•
• Do
D o your
your mood
m o o d swings
swings lead
lead to
to decreases
decreases in
in your
your work
work
productivity
productivity that
that last
last more
more than
than a
a few
few days?
days?
•
• Do
D o your
your mood
m o o d states
states last
last for
for days
days at
at aa time
time with
with lillie
little relief,
relief,or
or
do
do they
they change
change when
w h e n something good happens?
something good happens?
•
• Do
D o other
other people
people notice
notice and
and comment
c o m m e n t when
w h e n your
your mood
m o o d shifts?
shifts?
•
• Do
D o your
your mood
m o o d changes
changes go
go along
along with
with noticeable
noticeable changes
changes in
in
thinking,
thinking, perceiving,
perceiving, sleeping,
sleeping, and/or
and/or energy
energy or
or activity levels?
activity levels?
•
• Do
D o your
your mood
m o o d swings
swings ever
ever get
get so
so out
out of
ofhand
hand that
that the
the police
police
have
have to
to be
be called
called or
or a
a hospitalization
hospitalization becomes
becomes necessary?
necessary?

If your
If youranswer
answertotomost
mostofof
these questiOns
these is yes,
questions is then
yes, itthen
is likely
it isthat
likely that
your
your mood
m o o d swings
swings go
go beyond
beyond the
the nonnal range.
normal range.
 Whol
What Bipolor
BipolarDisorder
Disorderlooks
Looblike
Like 2121

that
that guide ourbehavior
guide our behavior become
become intensified
intensified in mania
in mania and diminished
and diminished in de- in de­
pression.
pression. These
T h e s e changes
changes in
in drive
drive states,
states, of
of course,
course, can
can have
have a
a tremendous
t r e m e n d o u s im­
im-
pact
pact on
o n one's
one's daily
daily life
life and
a n d productivity.
productivity.

"I" }feel
feellike
like I1 have
have aa motor
motorattached.
attached.Everything
Everythingis is moving
moving too too slowly,
slowly, and and
II want
w a n t to
to go,
go, go,
go, go.
go. 1I feel
feel like
like one
o n e of
of those
those toys
toys that
that somebody
s o m e b o d y winds
w i n d s up
up
and
a n d sends
sends spinning
spinning or
or doing
doing cartwheels
cartwheels or
or whatever
whatever ... .
. and
. a nto
d stop feels
to stop feels
like
like being
being in
in a
a cage."
cage."
— A 38-year-old
-A 38-year-old woman
w o m a n with
with bipolar I disorder
bipolar I disorder

Consider
Consider the increases
the increases in energy
in energy level
level that that accompany
accompany manic episodes.
manic episodes.
For
For Lauren,
Lauren, this
this surge
surge took
took the
the form
f o r m of
of an
a n intense
intense drive
drive to
to accomplish
accomplish a
a par­
par-
ticular
ticular activity
activity (exercising
(exercising and
a n d getting
getting in
in shape).
shape). For
For another
another patiem,
patient, Cynthia,
Cynthia,
it
it took
took the
the form
f o r m of
of a
a strong
strong desire
desire for
for social
social contact
contact and
a n d stimulation.
stimulation. When
When
manic,
m a n i c , she
she would
w o u l d call
call people
people all
all over
over the
the coumry whom
country w h o m she
she hadn't
hadn't spoken
s p o k e n to
to
in years, double-
in years, double- and
a n d triple-schedule
triple-schedule her
her social
social calendar,
calendar, and
a n d become
b e c o m e bored
bored
qUickly
quickly with
with the
the company
c o m p a n y of
of others.
others. jolene's
Jolene's took
took on
on a
a sexual
sexual quality:
quality: Accu­
Accu-
mulating
mulating as
as many
m a n y sexual
sexual partners
partners as
as possible
possible felt
felt to
to her
her like
like a
a physical
physical need.
need.
Ted
T e d felt
felt the
the drive
drive in
in relation
relation to
to food: " T h e y I[the
food: "They the nursing
nursing staff
staff at
at the
the hospital]
hospital]
put
put this
this entire
entire chicken
chicken in
in front
front of
of me
m e and I, like,
a n d I, like, inhaled it."
inhaled it."
Quite
Quite often,
often, increases
increases in
in activity
activity are
are accompanied
a c c o m p a n i e d by
b y grandiose
grandiose behavior.
behavior.
This
This is
is behavior
behavior that
that most
m o s t people
people would
w o u l d consider
consider dangerous,
dangerous, "over
"over the top,"
the top,"
unrealistic,
unrealistic, and
a n d associated
associated with
with inflated
inflated (sometimes
(sometimes delusional) beliefs about
delusional) beliefs about
one's
one's powers
p o w e r s or abilities.
or abilities.

walked
"I"Iwalked into
into a real
a real fancy
fancy restauram
restaurant withwith my mother
my mother and started
and started jump- jump­
ing
ing around
a r o u n d and
a n d running,
running, and
a n d there
there were
w e r e these
these chandeliers
chandeliers on
o n the
the ceiling.
ceiling.
II thought
thought II was
w a s Superman
S u p e r m a n or
or something, a n d II leapt
something, and leapt up
u p to
to grab
grab omo
onto one
one
of
of them
t h e m and
a n d started
started swinging
swinging on it."
o n it."
— A 21-year-old
-A 21-year-old man
m a n with
with bipolar I disorder
bipolar I disorder

Grandiosebehaviors
Grandiose behaviors usually
usually go go along
along withwith
highhigh or euphoric
or euphoric feelings,
feelings, but not
but not
invariably.
invariably. You
Y o u may
m a y experience
experience an
a n inflated
inflated sense
sense of
of self-confidence
self-confidence and
a n d then
then
feel
feel impatient
impatient and
a n d irritable
irritable because
because others
others seem
s e e m slow
slow to
to go
g o along with your
along with your
ideas
ideas or
or plans.
plans. Grandiose
Grandiose behavior
behavior is
is detrimental
detrimental not
not only
only because
because of
of its asso­
its asso-
ciated
ciated health
health risks
risks but
but also
also because
because it
it leads
leads to
to feelings
feelings of
of shame,
s h a m e , which
w h i c h can
can
c o m p o u n d your
compound y o u r depression
depression in
in the
the aftermath
aftermath of
of a
a manic
m a n i c episode.
episode. In
In the
the case
case of
of
the y o u n g man
the young m a n just
just quoted,
quoted, the
the police
police were
w e r e called
called in,
in, a
a scuffle ensued, and
scuffle ensued, and a
a
hospitalization followed.
hospitalization followed. Although
A l t h o u g h he
h e later
later related
related the
the incident with a
incident with a degree
degree
of
of bravado,
bravado, he
h e admitted
admitted to
to feeling
feeling quite
quite embarrassed
embarrassed by
b y his
his public
public behavior.
behavior.
For
F o r every
every example
e x a m p l e already
already given,
given, you
y o u can
can imagine
imagine what
what a
a coumer-
counter-
22
22 THE DIAGNOSISAND
THEDIAGNOSIS ANDCOURSE Of OF
COURSE BIPOLDISORDER
BIPOlAR AR DISORDER

example would
example would look duringthe
likeduring
look like thedepressed
depressed phase. In depression,
phase. In depression, you may
you may
become unusually slowed down, like you're " moving through molasses." The
become unusually slowed d o w n , like you're "moving through molasses." The
most mundane
most feels like
tasks feels
of tasks
m u n d a n e of requires tremendous
it requires
like it tremendous effort. Your appetite
effort.Your appetite
is usually diminished. Typically, the last thing a depressed person wants is
is usually diminished. Typically, the last thing a depressed person wants is
sex, exercise has
and exercise
sex, and has eveneven less appeal. Socializing
less appeal. an unpleasant
like an
seems like
Socializing seems unpleasant
chore
chore and requires too
and requires too much concentration and
m u c h concentration mental energy.
and mental energy.
When
W h e n drive states are
drive states heightened in
are heightened hypomania and
in hypomania mania, important
and mania, important
things can be accomplished and significant plans for personal advancement can
things can be accomplished and significant plans for personal advancement can
be into place.
put into
be pul Unfortunately, the
place. UnfoTlunately, aftermath of
depressive aftermath
the depressive these heightened
of these heightened
drive stales
drive canmake
states can plansseem
theplans
m a k e the difficultor
seem difficult impossibleto
evenimpossible
oreven toaccomplish.
accomplish.
inability to
The inability
The carry out
to carry plans that
out plans hatched while
were hatched
that were manic can
while manic can become
become a a
source
source of of despair while depressed.
despair while depressed. A bipolar man
19-year-old bipolar
A 19-year-old described the
m a n described the
switch mania to
from mania
switch from depression like
to depression this: "I'm
like this: porpoise. IIfly
like aa porpoise.
"I'm like highup
fly high upin
in
{he airand
the air then IIyell,
and then yell, 'I'm going
'I'm going d o w nagain!'
down And
again!' A n then
d thenI go underneath
1 go underneath wa­wa-
thethe
ter, and all
ter, and air,sunshine,
theair,
allthe sunshine, andthe
and breezejust
oceanbreeze
theocean justvanish."
vanish."

What Others See?

Do Others
Whot Do See?

Carol, aa 20-year-old,
Carol, 20-year-old,had had
had several
had episodes
several of bipolar
episodes disorder.
of bipolar Her older
disorder. Her older
sister described
sister manic, activated
her manic,
described her activated behavior this way:
behavior this way:

"She involved in
geLSinvolved
"Shegets these creative
in these creativeprojects thatthat
projects we want
we all 1O support,
all want to support,
like hand-painting dishes
like hand-painting or making
dishes or soap sculptures
making soap trying to
and trying
sculptures and sell
to sell
them. then she
But then
them. But seems to
she seems take it
to take too far.
it tOo She tries
far. She to sell
tries to them on
sell them the
on the
W e b , and
Web, then she
and then she gets all riled
gets all u p and
riled up and starts
frantic and
and frantic staying up
starts staying all
up all
night
night onon the computer—and then
the computer-and she crashes
then she and all
crashes and the projects
all the get
projects get
dumped."
dumped."

The The rapid

rapid changes
changes andand
in energy
in energy activity that accompany
activitythat highs and
accompany highs lows
and lows
are often
are a source
often a source of family conflicts.
of family To
conflicts. T o obselVers, your activated
observers, your behavior
activated behavior
while manic
while may
manic m look attractive
a y look attractive or encouraging at
or encouraging first, especially
at first, youwere
especiallyififyou were
formerly But i
depressed. But
formerly depressed. itt loses charm as
its charm
loses its become more
you become
as you and more
more and more
manic your behavior
and your
manic and begins to
behavior begins look frenetic
to look and purposeless.
frenetic and purposeless. What ob­
W h a t ob-
selVers (for
servers (for example, family members)
example. family are usually
members) are unaware of
usually unaware is the
of is of
feeling of
the feeling
purposefulness that
purposefulness you mmay
that you a y be Family m
experiencing. Family
be experiencing. members
e m b e r s or friends may
or friends may
become angry about
become angry your agitated,
about your agitated, "driven" quality and
"driven" quality apparent lack
and apparent lack of con­
of con-
cern for
cern others. In
for others. extreme manic
the extreme
In the family mmembers
Slates, family
manic states, e m b e r s become worried
become worried
you wiU
that you
that yourself. In
hurt yourself.
will hurt they mmay
parallel, they
In paraUel, a y become frustrated with
become frustrated with your
your
inactivity during depressed phases and give you "pep talks" that can contrib­
inactivity during depressed phases and give you "pep talks" that can contrib-
ute to your
ute to feelings of
your feelings gUilt or
of guilt inadequacy.
or inadequacy.
To a doctor, your increases in
T o a doctor, your increases in actiVity are the
activity are surest clue
the surest thathypomania
clue that hypomania
 WhotBiBipolor
polar DDisoil r looks
isordleer Loob Uke
Like 23
23

mania
ormania
or hashas
setset
in,in, but
but he he
or or
sheshe will
will probably
probably looklook for evidence
for evidence your your
that that
behavior is
behavior is consistently
consistently activated
activated across
across different
different situations.
situations. TThe
h e mmere fact
e r e fact
thatyyou
that o u hhave taken oon
a v e taken extra wwork
n extra projectsis
o r k projects isnot
not usually
usually eenough topoint
n o u g h to to
pointto
mmania. o yyour
a n i a . S$0 doctor mmay
o u r doctor ask yyou
a y ask o u hhow
o w mmany telephone calls
a n y telephone calls you've
you've mmade,
ade,
hhow many hours
o w many hours you've
you've worked,
worked, hhow much sleep
o w much sleep you've
you've gotten,
gotten, how
h o w many
many
social engagements
social engagements you've
you've arranged,
arranged, how
h o w much
much sex
sex activity
activity and
and drive you've
drive you've
had. HHe
had. or she
e or she may
may also
also base
basejudgments
judgments about
about your
your state
state on
on hhow you behave
o w you behave
in the
in the interview
interview room:
room: whether
whether you
you can
can ssit
it sstill,
till, whether
whether you
you answer
answer ques­
ques-
tions rapidly
tions rapidly or
or interrupt
interrupt aa lot,
lot. or
or whether
whether you
you wring
wring your
your hands,
hands, pick
pick at
at
things, or
things, or constantly
constantly fidget.
fidget. Likewise,
Likewise, your
your physician
physician will
will look
look for
for �psycho­
"psycho-
motor retardation"
motor retardation" (being
(being slowed
slowed down
down in
in your
your physical
physical movements)
movements) and
and
blunted facial
blunted facial expressions
expressions during
during depressions.
depressions.
A key
A key point
point to
to remember
remember here
here is
is that,
that, to
toyou,
you, the
theincreases
increasesin
inenergy
energy and
and
activity that
activity that accompany
accompany manic
manic episodes
episodes may
may feel
feel good,
good, productive,
productive, and
and pur-
pur­
poseful. To
poseful. To others,
others,including
includingyour
yourdoctor,
doctor,they may
they bebe
may seen asas
seen pOintless, unre­
pointless, unre-
alistic, or
ahstic, orsigns
signsof
ofaadeveloping
developingillness.
iUness.These
Thesedifferent
differentperceptions
perceptionswill
willcause
cause
conflict between
conflict between you
you and
and them,
them,but
butit's
it'simportant
importantto
tobe
beopen
opento
totheir
theirperspec­
perspec-
tives while also
tives while also explaining your own.
explaining your own.

Changes
Changes ininThinking
Thinkingand
and Perception
Perception

"My"My
mindmind
feels feels likeinI'm
like I'm oneinofone of postcards
those those postcards of the
of the city thatcity
are that are
taken
taken at
at night.
night, with
with the
the camera
c a m e r a moving.
m o v i n g . Lights
Lights feel
feel like
like they
they have tails,
have tails,
the
the whole
w h o l e world
w o r l d is
is zooming-l
z o o m i n g — I love
love it.
it. My
M y mind
m i n d is so fuU
is 50 full of
of thoughts
thoughts
that IIfeel
that feel like
like I'm
I'mgoing
going to
to burst."
burst."
— A 26-year-old
-A 26-year-old woman
w o m a n with
with bipolar
bipolar II disorder
disorder

Manic Manic and depressive

and depressive moods
moods almost almost
always always
involve involve
changes in yourchanges in your
thinking.
thinking. During
D u r i n g mania
m a n i a this
this involves
involves the
thespeeding
speeding up
u p of
ofmental
mental functions
functions
(racing
(racing thoughts)
thoughts) and
a n dthe
the verbal
verbal expression
expression of
ofone
o n e thought
thought after
after another in
another in
rapid-fire
rapid-fire fashion
fashion (flight
(flight of
ofideas).
ideas).Many
M a n y experience
experience the
the world
world differently:
differently: col­
col-
ors
ors become
b e c o m e brighter
brighter and
a n dsounds
s o u n d sbecome
b e c o m eintolerably
intolerablyloud.
loud.Mental
Mentalconfusion
confusion
can
can accompany
a c c o m p a n y the
the most
m o s t advanced
advanced stages
stages of
of mania:
mania: The
T h e world
world begins
begins to
tofeel
feel
like
like aaFerris
Ferris wheel
w h e e l that
that isisspinning
spinning out out ofofcomrol.
control.
During m a n i a ,your
D u r i n g mania, y o u r memory
m e m o r y can
can seem
s e e m extra
extracrisp
crispand
a n d dear,
clear,you
y o u feel
feelbril­
bril-
liantly sharp,
liantly o n eidea
sharp,one idea can
can be
b eeasily
easily related
related to
toanother,
another, and
a n dyou
y o ucan
c a nrecall
recall
events
events in
invivid
vivid detail.
detail.However,
H o w e v e r , this
thisapparent
apparent improvement
i m p r o v e m e n t in
in memory
m e m o r y is
isof­
of-
ten
tenillusory;
illusory;people
people experiencing
experiencing mania
m a n i a think
thinkthey
theyremember
r e m e m b e r better
betterthan
than they
they
actually
actually do.
d o .In
Infact,
fact,attention
attention and
a n dconcentration
concentration can
can become
b e c o m e quite
quite impaired
impaired
during
duringmania.
m a n i a .You
Y o u cannot
cannotkeep
k e e pyour
y o u rmind
m i n d on
o nanyone
any o n ething
thingat
ataatime
timebecause
because
24
24 THE
THE DIAGNOSIS
DIAGNOSISAND
ANDCOURSE
COURSEOFOF
BIPO�R
BIPOLADISORDER
R DISORDER

your
your mind
mind isistrying
tryingto to
process
processtoo many things
too many at once.
things at Your
once.attention can be­ can be-
Your attention
come
c o m e easily
easily distracted
distracted byby mundane
m u n d a n e things
things like
like random
random noises,
noises, the
the facial
facial ex­
ex-
pressions of
pressions of others,
others, or
or the
the feeling
feeling of of your
your clothing
clothing against your skin.
against your skin.
As
A s mania
mania spirals
spirals upward,
upward, youryour thoughts
thoughts can become increasingly
can become increasingly jumbled
jumbled
and
and even
even incoherent.
incoherent. Others
Others LO to whom
w h o m you
you speak
speak may
m a y be
be unable
unable LO to understand
understand
you.
you. They
They will
will probably
probably trytry to
to keep
keep you
you focused
focused andand ask
ask you to slow
you to slow down.
down.
You
Y o u will
will probably
probably find
find these
these interactions
interactions annoying
annoying and have the
and have the reaction that
reaction that
others
others seem
seem slow,
slow, dumb,
d u m b , and
and unimeresting.
uninteresting.
Some people develop
S o m e people develop hallucinations
hallucinations (perceptual experiences thal
(perceptual experiences that are
are not
not
real)
real) and
and delusions
delusions (unrealistic,
(unrealistic, mistaken
mistaken beliefs)
beliefs) during
during mania.
mania. "Grandiose
"Grandiose
delusions"
delusions" are are especially
especially common,
c o m m o n , such
such asas thinking
thinking you are exceptionally
you are tal­
exceptionally tal-
ented
ented in in an
an arena
arena in
in which
which you you have
have had
had nono formal
formal training,
training, believing
believing you
you
have
have exceptionally
exceptionally high
high intelligence,
intelligence, feeling like you
feeling like you k know
n o w what
what others are
others are
thinking,
thinking, believing
believing you
you have
havespecial
specialpowers,
powers,or or thinking
thinkingyou you are
areaamajor
major pub­
pub-
lic
lic figure
figure oror even
even God:
God:

" "[As
[As II was
was cycling
cycling into
intomania],
mania],I got thisthis
I got ideaidea
in my
in head that that
my head I should
I should
throw
throw aa party
party for
for everyone knew. As
everyone II knew. As the
the days
days wore
wore on,
on, II believed that
believed that
all
all my
m y doctors-everyone
doctors—everyone who w h o had
had ever
ever treated
treated me-were
m e — w e r e going to
going to
come. Before
come. long, II thought
Before long, thought Bruce
Bruce Springsteen
Springsteen was
was coming,
coming, and so was
and 50 was
Michael
Michael Jackson, and I
Jackson, and I heard
heard the
the voice
voice of
of God
G o d telling
telling me,
m e , 'Go
'Go to
to Dennis
Dennis
lex-boyfriend];
[ex-boyfriend]; he
he wants you."
wants you."
— A 119-year-old
-A 9-year-old bipolar
bipolar woman
woman

Delusions and
Delusions and hallucinations
hallucinations areare
particularly scaryscary
particularly to Significant others, who
to significant others, who
view
view them
them as the most
as the most concrete
concrete sign
sign of
of "craziness."
"craziness." Doctors
Doctors will
will be
be especially
especially
attuned
attuned to
to these
these symptoms
symptoms and and will
will also
also be
be on
on the
the lookout
lookout for
for less
less dramatic
dramatic
signs
signs of
of distorted
distorted thinking.
thinking. Consider
Consider the
the follOwing
following interchange between a
interchange between psy­
a psy-
chologist
chologist and
and a a 20-year-old
20-year-old man
man wwho
h o was
was coming
coming off
off the
the crest
crest of
of his
his manic
manic
high. The man
high. The m a n sal
sat with
with aa law
law book
book in
in his lap, arguing
his lap, arguing that
that he
he could
could pass the
pass the
bar without
bar without going
going to law school
to law and would
school and would suesue anyone
anyone wwho challenged him:
h o challenged him:

Have you
DOCTOR: Have
Doctor: you had
had any
any unusual
unusual thoughts
thoughtsoror
experiences thisthis
experiences week?week?
past past
Patient: No,
PATIENT: N o , not really.
not really.
Doctor: Any
DOCTOR: A n y feelings
feelings like
like you
you have
have special
special powers
powers or
or that
that you're
you're a
a famous
famous
person? Last
person? Last week
week you
you were
were thinking
thinking a
a lot
lot about
about God
G o d and
and having­
having—
Patient: (jllterrupts)
PATIENT: Well, that
{interrupts) Well, that was
was last
last week! {laughs) No,
week! (laughs) N o , II don't of
think of
don't think
myself that way,
myself that way, but
but I'm
I'm more
more like
hke aa young
young god,
god, kind
kind of
of like
like a teacher.
a teacher.
(giggles)
{giggles) II think
think II have
have a
a lot
lot to
to offer others.
offer others.
 WhatBiBipolar
What polar DDisorder
isorder Looks
Loob like
Like 2S
25

Theabove
The above client
client waswas still
still delusional.
delusional. HisHis thinking
thinking frequently
frequently got into
got him him into
troublewith
trouble with others,
others, especially
especiallyhis
hisparents,
parents, wwho
h o wwere mostlyconcerned
e r e mostly concerned about
about
hisinability
his inability to
tohold
holdaajob.
job. TThey
h e y wwere angered bby
e r e angered hisunrealistic
y his unrealisticbeliefs
beliefsin
in hhim­
im-
self aand
self his elaborate
n d his elaborate sschemes for fighting
c h e m e s for fighting the
the educational
educational system.
system.
In contrast,
In contrast, during
during depression
depression it's
it's hard
hard to
to focus
focus oon even oone
n even thing. YYou
n e thing. ou
will experience
will experience the
the slowing
slowing ddown of mental
o w n of mental functions
functions as
as aa difficulty
difficulty in
in con-
con­
centrating or
centrating or mmaking simple decisions.
a k i n g simple decisions. Colors
Colors sseem drab. Disturbances
e e m drab. Disturbances of
of
mmemory are ccommon:
e m o r y are o m m o n : YYou
o u mmay have difficulty
a y have difficulty recalling
recalling telephone
telephone nnumbers
umbers
yyou use regularly,
o u use regularly, rremembering appointments, or
e m e m b e r i n g appointments, or following
follOwing aa television
television pro-
pro­
ggram because of
r a m because of trouble
trouble holding
holding events
events in
in your
your memory.
memory.
Ruminations, in
Ruminations, in wwhich
h i c h aa person
person thinks
thinks about
about aa certain
certain event
event again
again aand
nd
again, are
again, are aa frequent
frequent aaccompaniment to depression.
c c o m p a n i m e n t to depression. Ruminations
Ruminalions during
during the
the
depressive phase
depressive phase are
are often
often self-recriminating.
self-recriminating. FFor example, Margie
o r example, Margie bbecame
ecame
preoccupied with
preoccupied with the
the thought
thought "
"Was Paul [her
W a s Paul (her boss]
boss] insulted
insulted wwhen didn't
h e n II didn't
sit next
sit next to
to hhim at the
i m at the meeting?"
meeting?" Simflarly,
Similarly, CCameron described: ""When
a m e r o n described: was
W h e n II w as
a n i c I1 jokingly
mmanic jokingly asked
asked mmy friend if
y friend if his
his wife
wife wwas 'hot,' aand
a s 'hot,' n d II couldn't
couldn't stop
stop
thinking about
thinking about hhow stupid that
o w stupid that wwas
a s wwhen
h e n II got depressed." Depressive
got depressed." Depressive ru-
ru­
minations frequently include
minations frequently indude guilt
guilt or
or shame,
s h a m e , or
or feeling worthless, hopeless,
feeling worthless, hopeless,
or
or helpless. They
helpless. T h e y can become
can b e c o m e all-encompassing
aU-encompassing aand affect one's
n d affect one's day-to-day
day-to-day
functioning.
functioning. When
W h e n Patrice became
Patrice b depressed, she
e c a m e depressed, she found
found herself
herself �rehearsing
"rehearsing
like a
like a mantra"
m a n t r a " statements
statements hlike
k e "I suck ... . 1 I hate
"I suck hate myself
myself . .. . I'm
I'msuch
sucha a
bitch.
bitch.""

SuicidD/ Thoughts
Suicidal Thoughts
Ruminations
Ruminations often
often take
take the
the form
f o r m of
of suicidal
suicidal preoccupatio ns-thoughts about
preoccupations—thoughts about
the
the various
various ways
w a y s one
o n e could
could kill
kiU oneself.
oneself. These
These ruminations
ruminations are
are most
m o s t common
common
during
during depressive
depressive or
or mixed
m i x e d episodes
episodes but
but can
can also
also be
b e present
present during
during mania.
mania.
Depending
D e p e n d i n g on
o n how
h o w desperate
desperate aa person
person feels.
feels, he
h e or
or she
she may
m a y act
act on
o n these
these
thoughts
thoughts or
or impulses,
impulses, often
often with
with dire
dire consequences.
consequences.
Friends
Friends and
a n d family
family members
m e m b e r s will
will be
b e particularly
particularly upset
upset and
a n d scared
scared by
b y your
your
suicidal
suicidal thoughts,
thoughts, if
if voiced
voiced to
to them,
t h e m , and
and w i ll do
will d o their
their best to help
best [0 help you
y o u deal
deal
with
with them,
t h e m , although
although they
they may
m a y not
not know
k n o w what
w h a t to
to say
say or
or do.
do.Your
Y o u r therapist
therapist or
or
physician
physician is
is also
also likely
hkely to
to ask
ask about
about them
t h e m (for
(for example,
example, "Are
"Are you
y o u having
having any
any
thoughts of
thoughts of hurting
hurting or
or killing
killing yourself,
yourself, as
as many
m a n y people
people do
d o when
w h e n they're
they're
down?").H
down?"). Ifyou
y o u have
have never
never had
h a d suicidal
suicidal thoughts
thoughts before
before and
a n d have
have them
t h e m now,
now,
you
y o u may
m a y feel
feelafraid
afraidto
toshare
share them.
them.You
Y o u may
m a y fear
fearthat
thatthe
thephysician
physician will
will hospi­
hospi-
talize
talize you
y o u immediately.
immediately. This
This is
is certainly
certainly one
o n e lreatment
treatment option,
option, but
but not
not the
the
only
only one.
one.Others
Others may
m a y include
include psychotherapy,
psychotherapy, modifications
modifications of
of your
your medica­
medica-
tion
tion regime,
regime, and/or
and/or various
various forms
forms of
of communilY
c o m m u n i t y or
or family
family suppon.
support.
Take
T a k e the
the chance
chance of
of discussing
discussing these
these feelings
feelings wilh
with your
your physician
physician or
or
26
26 THE
THE DIAGNOSIS
DIAGNOSISAND
ANDCOURSE Of OF
COURSE BIPO�R
BIPOLDISORDER
AR DISORDER

therapist-you
therapist—you maymayfind
find that
that some
some of of these
these thoughts
thoughts dissipate
dissipateafter you've
after you've
shared
shared them
them with
with someone
someone else.
else. You
Y o u may
m a y also learnthat
alsolearn thatmental
mentalhealth
healthprofes­
profes-
sionals
sionals are
are more
more helpful
helpful at
at such
such times
times than
than you have expected.
would have
you would expected. II will
will
discuss
discuss suicidal
suicidal feelings
feelings and
and actions
actions inin more
more detail
detail in Chapter 111.
in Chapter 1.

Sleep
Sleep Disturbances
Disturbances

Virtually
Virtuallyall allpeople
peoplewith with bipolar
bipolar disorder
disorder experience
experience disturbances
disturbances of sleep
of sleep
during
during their
their mood
m o o d swings.
swings. WhenW h e n youyou getget manic,
manic, you you maym a y feel
feel no
no need
need to to
sleep.
sleep. Sleeping
Sleeping feels
feels like
like a waste of
a waste of lime,
time, especially
especially w when
h e n so m a n y things
so many things can can
gel accomplished in
get accomplished in the middle of
the middle of the
the night! During depression,
night! During depression, sleep sleepcancanfeel
feel
like
like the
the only
only thing
thing that
that is
is welcomed.
welcomed.When W h e n you
you are depressed,you
are depressed, you may
m a y sleep
sleep
many
m a n y more hours than
more hours than usual
usual (for
(for example,
example, 16 16 hours
hours aa day)
day) andand become
become un- un­
productive
productive and and unable
unable to to function
function outside
outside of the home
of the h o m e (hypersomnia).
(hypersomnia). Alter­ Alter-
natively you mmay
natively you a y have
have insomnia
insomnia and and find
find that
that sleep eludes you.
sleep eludes you. YouY o u may lie
m a y lie
awake at
awake at night
night tOSSing
tossing and and turning,
turning, thinking
thinking aboUl
about the the same
same problems
problems over over
and over
and over again.
again. Sleep
Sleep cancan feel
feel frustratingly
frustratingly out out of your reach.
of your reach.
Are
Are sleep
sleep problems
problems a a symptom
s y m p t o m ofof bipolar
bipolar disorder,
disorder, or or dodo they actually
they actually
cause
cause problems
problems in in mood?
m o o d ? It appears that
It appears that they
they are both symptom
are both symptom and cause.
and cause.
Most
Most people,
people, bipolar
bipolar or not, have
or not, have changes
changes in in mmood
ood w when
h e n they
they have
have trouble
trouble
sleeping,
sleeping, bUl
but bipolar
bipolar people
people are are particularly vulnerable to
particularly vulnerable to changes
changes in the
in the
sleep-wake
sleep-wake cyclecycle (for
(for example,
example, W Wehr
e h r et al., 1987;
et al., 1987; Ehlers
Ehlers et al., 1993).
et al., 1993). I'll
I'll say
say
more about sleep
more about sleep disruptions
disruptions and and moodm o o d states
states inin Chapter
Chapter 5. 5.
Your doctor
Your will probably
doctor will probably ask you aboUl
ask you about sleep
sleep disturbances,
disturbances, with with empha­
empha-
sis
sis on whether the
on whether the problem
problem is is falling
falling asleep, waking up
asleep, waking up inin the
the middle
middle of the
of the
night,
night, or waking up
or waking up too early. He
too early. H e or
or she
she may
m a y ask you to
ask you to keep
keep track
track ofof your
your
sleep if
sleep if you
you have
have trouble
troublerecalling
recalling the thenature
nature of ofyour
your disturbances.
disturbances.If Ifyou
youhavehave
aa spouse,
spouse, hehe or
or she
she may
m a y be
be affected
affected by by your
your sleep
sleep patterns-when
patterns—when one one person
person
can't
can't sleep,
sleep, others
others often
often can't
can't as well! Your
as well! Your own irritability, as
o w n irritability, aswell
wellas asthat
thatof of
your
your family
family members,
members, can can bebe a function of
a function lack of
of lack of sleep
sleep or inconsistent sleep
or inconsistent sleep
habits.
habits.

Impulsive,
Impulsive, SeH.Destrudive,
Self-Destructive, or
orAddictive
AddictiveBehaviors
Behaviors

What do you
What do youusually
usually dodo when
when youyou start
start totofeel manic?
feel When
manic? Whenyou
youareareloaded
loaded
with
with energy,
energy, you
you may
m a y feel
feellike
likeyou
you have
have to have an
tohave an outlet.
outlet.Ordinary
Ordinary life
lifemoves
moves
too slowly. Perhaps
too slowly. Perhaps as as aa result,
result, wwhen people get
h e n people get manic,
manic, they
they often
often lose their
lose their
inhibitions
inhibitions and
and behave
behave impulSively.
impulsively. Many
M a n y of
of these
these impulsive
impulsive behaviors
behaviors cancan be
be
threatening
threatening to
to one's
one's life
life or
or health,
health, such
such asas driving
driving recklessly
recklessly onon the
the freeway,
freeway,
performing
performing daredevil
daredevil acts,
acts, or
or haVing
having unprotected
unprotected sexsex with
with many different
m a n y different
 Vo/hOI
WhatBipolar
BipolarDisorder LoobUke
Disorderlnoh Like 2727

partners.
partners. Martha's impulsivebehavior
Martha's impulsive behavior (Chapter
(Chapter 1) was
1) was a majora major
cause cause
of theof the
marital
marital problems
p r o b l e m s she
she had
h a d after
after herher manic
m a n i c episode.
episode.
Some
S o m e people
people make m a k e unwise
u n w i s e decisions,
decisions, like like spending
spending a a lot
lot ofof money
money
indiscriminantly.
indiscriminantly. Kevin Kevin was w a s 34
3 4 and
a n d lived
lived with
with hishis father.
father. When
W h e n manic,
manic, he he
convinced
convinced his his father
father to to liquidate
liquidate part part of of his I R A account,
his IRA account, whichw h i c h Kevin
Kevin in-in­
vested
vested wildly
wildly in in various
various commodities.
commodities. Most M o s t ofof the
the money
m o n e y disappeared.
disappeared. His His
family,
family, understandably,
understandably, was w a s livid
livid with
with him;
h i m ; his
his older
older brothers
brothers refused
refused to to talk
talk
to him
to h i m anymore.
a n y m o r e . Prior
Prior to to this
this incident,
incident, Kevin
Kevin had h a d been
b e e n making
m a k i n g plans
plans to to move
move
out
out on
o n his
his own.
o w n . But
B u t his
his father
father insisted
insisted he
h e pay
p a y the
the money
m o n e y back
back before
before he
h e agreed
agreed
to
to help
help finance
finance Kevin's
Kevin's attempts
attempts to to bbecome
e c o m e independent.
independent.
Carl,
Carl, age age 40,40, spent
spent tremendous
tremendous amounts amounts of of money
money on on home improve­
home improve-
ments.
ments. He He installed
installed elaborate
elaborate fireplaces,
fireplaces, impractical bathroom f
impractical bathroom ixtures, and
fixtures, and
eye-catching
eye-catching but but gaudy
gaudy paintings.
paintings. His His partner,
partner, Roberta,
Roberta, with with whomw h o m he he
cohabitated,
cohabitated, became became increasingly
increasingly frustrated
frustrated about about their
their dwindling finances,
dwindling finances,
and
and their
their conOicrs
conflicts intensified.
intensified. In InRoberta's
Roberta'sview, view,Carl Carlwaswasunwilling
unwillingto torecog­
recog-
nize
nize his
his mania
mania as as the
the source
source of of the
the problem.
problem.
Self-destructive
Self-destructive behavior behavior can can take
take many
many forms.
forms. Many Many people
peopletum turnto toalco­
alco-
hol
hol or
or drugs
drugs during
during manicmanic episodes.
episodes.Substance
Substanceuse useproblems
problemsand andaddictive
addictivebe­ be-
haviors
haviors areare notnot essential
essential symptoms
symptoms of of bipolar
bipolar disorder,
disorder, but butthey
theycan canbecome
become
intertwined
intertwined with with moodmood disorder
disorder symptoms
symptoms in in such
such aa way way that
that each worsens
each worsens
the
the other.
other. Alcohol
Alcoholisisoften oftensought
soughtas asaameans
meansof ofbringing
bringingoneself
oneselfdown down from
from
the high state
the high state andand quelling
quelling the the anxiety,
anxiety, confusion,
confusion,and andsleep
sleepdisturbance
disturbancethat that
typically
typically go go with
with il. it. Some
Some use use cocaine,
cocaine, amphetamine,
amphetamine, or or even marijuana to
even marijuana to
heighten and
heighten and intensify
intensify the the euphoric
euphoric experiences
experiences of of mania.
mania. During
During a depres­
a depres-
sion,
sion, alcohol
alcohol or or drugs
drugs are usually craved
are usually craved as as aa means
means of of dulling
dulling the pain, or
the pain, or
what
what w we
e call
call self-medicating.
self-medicating.More Morethan thanany anyother
otherassociated
associatedcondition,
condition,drug drug
and
and alcohol
alcohol abuseabuse makesmakes the the course
course of your bipolar
of your bipolar disorder
disorder much much worse
worse (for
(for
example,
example, Tohen Tohen et al.,1990;
etal., 1990;Strakowski
Strakowskietetal., al.,2000).
2000). Mark
Mark described
described thethe
role
role
alcohol
alcohol played
played in in his
his depressions
depressions as as follows:
follows:

"When
"When I'mdown,
I'm down,drinking
drinking for
for meme isislike· a security
like- When I'mWhen I'm
blanket.blanket.
a security
feeling
feeling mmy worst, the
y worst, bottle is
the bottle is there
there inin the
the closet,
closet, like
likeanan old
oldfriend.
friend.I I
don't
don't think
think about what it's
about what it's doing
doing to
to m my body, only
y body, only that
that I need to
I need to numb
numb
myself
myself out. Sometimes, just
out. Sometimes, justknOwing
knowing there's
there'saa bottle
bottleinin the
the cabinet
cabinet is
is
enough
enough to to make
make mme feel better.
e feel better. II just
justcan't
can'tstop myself.}Ikeep
stopmyself. keep blowing
blowing
it. "
it."

Another person
Another personwith withbipolar disorder,
bipolar Thad, was
disorder, Thad,lesswas
clearless
on why he drank
clear on why he dr
when he
when he was
was manic.
manic. While
While in
inthe
the hospital,
hospital,hehesummarized
summarizeditit like this:
like "} don't
this: "I don't
know what iittisiswith
know what withme
m eand
andbooze {smiling).I know
booze(smiling). I know it'sitnot funny,
's not but but
funny, when­
when-
ever II get
ever get that
that wayway [high,
[high, manic],
manic],IIjust
justseem
seemtotoneed
needtototietieone
oneon."
on."
28
28 THE
THE DIAGNOSIS
DIAGNOSISAND
ANDCOURSE OF OF
COURSE BIPOIDISORDER
BIPOlAR AR DISORDER

Family
Family members
members may
may be be bothered
more more bothered bydrug
by your yourand
drug and alcohol
alcohol use use
than
than your
your mood
m o o d swings.
swings. They
They may
m a y even
even define
define your
your problems
problems as as alcohol-
alcohol- oror
drug-related
drug-related and and reject
reject the
the bipolar
bipolar diagnosis,
diagnosis, thinking it is
thinking it is a w a y for
a way for you to
you to
justify continuing
justify continuing to to drink.
drink. They
They may
m a y be
be incorrect
incorrect aboUl
about this,
this, but
butyour
yourdoctor
doctor
will
will need
need to to conduct
conduct a a thorough
thorough diagnostic
diagnostic assessment
assessment to to be
be sure
sure (see
(see
Chapter 3).
Chapler 3).
Your
Your doctor
doctor will
will probably
probably be be skeptical
skeptical of of the bipolar diagnosis
the bipolar diagnosis unless
unless
there
there is
is concrete
concrete evidence
evidence that
that your
your m mood
o o d swings
swings occur
occur when
w h e n you
you do not use
do not use
drugs
drugs or or alcohol.
alcohol. Jeff,
Jeff,for
forexample,
example,had hadhadhadseveral
severalmanic episodesbefore
manicepisodes beforehehe
developed
developed problems
problems with with alcohol,
alcohol, and
and thethe bipolar diagnosis seemed
bipolar diagnosis justified.
seemed justified.
On
O n [he
the other
other hand,
hand, Kate's
Kate's alcohol
alcohol problems
problems developed well before
developed well before there
there was
was
any
any evidence
evidence of of mood
m o o d swings,
swings, and
and herher mood
m o o d episodes-allhough character­
episodes—although character-
ized
ized by typical bipolar
by typical bipolar symptoms
symptoms such such as as irritability,
irritability, sleep
sleepdismrbance,
disturbance,leth­leth-
argy,
argy, suicidality,
suicidality, andand impulsiveness-were
impulsiveness—were eventuallyeventuallyattributed
attributed to tothe
theeffects
effects
of
of alcohol intoxification.
alcohol intoxification.

Summary:
S u m m a r y : Dillerent
Different Perspectives
Perspectives

As
As you
you already
alreadyknow know or or have
havejustjustseen, people
seen, withwith
people bipolar disorder
bipolar have dis­
disorder have dis-
tinct
tinct experiences
experiences that that comprise their m
comprise their mood
o o d disorder.
disorder. Varying
Varying emotional states
emotional states
and
and changes
changes in in energy,
energy, judgment,
judgment,thinking,
thinking,and and sleep
sleep characterize
characterize thetheswings
swings
between
between the the poles.
poles. Family
Family members
members or or Significant
significant others
others are
are not
not likely
likely to un­
to un-
derstand these
derstand these widely fluctuating experiences
widelyfluctuating experiences (unless
(unless they
they have
have bipolar disor­
bipolar disor-
der themselves) and
der themselves) and are
are likely
likely to
to focus
focus on
on how your behavior
h o w your behavior affects
affects them
them and
and
other
other family
family members.
members. Most Most psychiatrists
psychiatrists will
will bebe Jess
less interested
interested inin the
the mean­
mean-
ing
ing ofof these
these experiences
experiences to to you
you than
than in
in the
the symptoms
symptoms you've
you've had
had that
that are con�
are con-
sistent
sistent oror inconsistent
inconsistent with with thethe bipolar
bipolar diagnOSiS,
diagnosis, or or that
that point
point 10 specific
to specific
treatments
treatments (see (see Chapter
Chapter 6). 6).
These different
These different perspectives
perspectives may m a y be
be aa source
source of of frustration
frustration forfor yOll,
you, be­
be-
cause
cause youyou may
m a y feel
feel like
like others
others don't
don't understand
understand you you oror aren't
aren't interested
interested in in
your inner
your inner life.
life. Likewise,
Likewise,your yourfamily
familymembers,
members,and andperhaps
perhapsyouryourdoctor,
doctor, will
will
be frustrated
be frustrated if if you
you seem
seem to to be
be oblivious
oblivious to to or
or unconcerned
unconcerned about the effects
about the effects
of your behavior
of your behavior on on others.
others. These
These disparate
disparate perceptions
perceptions can can bebe a source of
a source of
conflicts
conflicts over
over thethe treatment
treatment plan:
plan: Y You
o u may
m a y feel
feel that you've had
that you've had profound
profound ex- ex­
periences,
periences, but but others
others only
only seem
seem interested
interested in in labeling
labeling you
you asas a
a sick
sick person.
person.
Many people with
M a n y people with bipolar
bipolar disorder,
disorder, outau{ of
of frustralion
frustration over
over these
these issues,
issues, reject
reject
the
the notion
notion that
that they
they are
are having
having symptoms
symptoms and and also
also reject
reject the
the diagnosis
diagnosis and its
and its
associated
associated treatments
treatments (see Chapters 3
(see Chapters 3 and
and 4).4). Others
Others are
are fortunate
fortunate enough
enough to to
be able
be able toto communicate
communicate effectively
effectively with
with their
their doctor
doctor andand family
family members,
members,
w h o correspondingly
who correspondingly make m a k e attempts
attempts to to understand
understand thesethese private experiences.
private experiences.
 What BBipolar
What DisorderLoo
ipolar Disorder ks like
Loob Like 29
29

Thehope,
The hope,ofofcourse,
course,isis that
that you will find
you will find aa treatment
treatment regime that will
regime that will stabilize
stabilize
yyour
o u r mmood without minimizing
o o d without minimizing the
the significance
significance that
that these
these personal
personal experi-
experi­
ences have
ences have held
held for
for yyou.
ou.
WWhether
h e t h e r yyou
o u are having yyour
are having first episode
o u r first episode or
or have
have had
h a d mmany, the first
a n y , the step
first step
obtaining optimal
in obtaining
in optimal treatment
treatment for
for yourself is to
yourself is to get
get aa proper
proper diagnosis.
diagnosis.
Chapter 33 deals
Chapter deals v^dth
with this
this very
very important
important issue
issue bby answering the
y answering the following
following
questions:
questions:

How
• How• is the is the disorder
disorder actually
actually diagnosed
diagnosed by mental
by mental health health professionals?
professionals?
•• What
W h a t symptoms
s y m p t o m s and
a n d behaviors
behaviors do
d o doctors
doctors look
look for?
for?
•
• What
W h a t can
can you
y o u expect
expect during
during the
the diagnostic
diagnostic process?
process?
• How
• H o w will
will your
y o u r doctor
doctor elicit
elicitinformation
information from
f r o m you
y o u to
to determine
determine the
the diag­
diag-
nosis?
nosis?

Indescribing
In describingthe
thediagnostic
diagnostiCcriteria, Lfltouch
criteria, I'll touch on
on the
the important issue of
important issue of "bor­
"bor-
der
der conditions":
conditions":

• How•doHow
you do
knowyou
if know if you
you have havedisorder
bipolar bipolar versus
disorder versus
some othersome
psy- other psy­
chiatric
chiatric illness?
illness?
•
• Does
D o e s the
the diagnosis
diagnosis give
give aa reasonable
reasonable explanation
explanation for
for your
your behavior?
behavior?
• If not,
• If not, are
are there
there other
other diagnoses
diagnoses that
that fit
fityou
y o u better?
better?
 3
3

Into the Doctor's Court

Into the D o c t o r ' s C o u r t

WHAT
W H A T TO
T O EXPECT
EXPECT

FROM
F R O M THE DIAGNOSTIC
THE D I A G N O S T I C PROCESS
PROCESS

sonal
Y
Y
sonal and
ou're
ou're not
I o
and intense
not alone
alone in
in feeling
intense experiences.
feeling that
experiences. Nor
that mania
Nor are
mania and
are you
and depression
you alone
depression are
alone if
if you
you are
are very
are wary
very per­
wary of
per-
of any
any
stranger's
stranger's ability to understand
ability lO understand what you're going
what you're through, no
going through, matler how
no matter how
highly qualified as
highly qualified as a
a medical
medical professional.
professional. Many
Many people
peopleexperiencing
experiencingbipolar
bipolar
symptoms postpone seeing
symptoms postpone seeing a doctor for
a doctor for as
as long
long as
as possible because they
possible because they al­
al-
ready feel thoroughly
ready feel thoroughly misunderstood.
misunderstood. Olhers
Others receive
receive a
a diagnosis
diagnosis but
but reject
reject it
it
out
out of
of hand.
hand. Still
Still others
others grudgingly
grudgingly accept
accept a
a diagnosis
diagnosis of
of bipolar
bipolar disorder
disorder but
but
then
then express
express their
their resistance
resistance by refUSing to
by refusing to comply
comply with
with their
their treatment re­
treatment re-
gime. IIf
gime. you fit
f you fitinto
intoany
anyof
ofthese
thesecategories,
categories,I hope you'll
I hope reconsider
you'll the
reconsider bene­
the bene-
fits of
filS of a profesSional diagnosis.
a professional diagnosis.
No
N o diagnostiC
diagnostic label
label can
can completely
completely capture
capture your
your unique
unique situation.
situation. In
In fact,
fact,
you may
you m a y feel
feel onended
offended by
by the
the diagnostic
diagnostic label
label because
because it
it is
isincomplete,
incomplete,imper­
imper-
sonal,
sonal, or
or simply
simply doesn't
doesn'tdo
dojustice
justice to
toyour
your lire
lifeexperiences.
experiences.But
Butthese
theselabels
labelsdo
do
serve
serve a
a purpose.
purpose. First,
First,using
usingstandardized
standardizedlabels
labelsallows
allowsclinicians
cliniciansto
tocommuni­
communi-
cate with
cate with each
each other.
other. If
IfIIrerer
referaaclient
clientof
ofmine
minetotoanother
anothermental
mentalhealth
healthprofes­
profes-
sional and
sional and say
say that
that "she
"she has
has bipolar
bipolar II disorder,
disorder, mixed
mixed episode,
episode, with
with mood­
mood-
incongruent psychotic
incongruent psychotic features,"
features," there
there is
is a
a high
high likelihood
likehhood that
that this
this other
other
doctor will
doctor wifl know
k n o w what
what to
to expect.
expect. This
This common
c o m m o n language
language serves you well
serves you well
should you
should you switch
switch doctors,
doctors, as
as so
so many
m a n y of
of us
us do
do today.
today. Second,
Second, an
an accurate
accurate di­
di-
agnosis is
agnosis is importaOl
important to
to selecting
selecting the
the right
right treatment. If you
treatment. If you are
are misdiagnosed
misdiagnosed
as having
as having depreSSion
depression alone,
alone, for example, your
for example, your doctor
doctor might
might recommend a
recommend a

30
30
 Into
Intothe
theDoctor's
Doctor'sCourt:
Court:Whotto Expect
What to fromfrom
Expect the Diagnostic Process
the Diagnostic Process 31 31

standard antidepressant
standard antidepressant medication
medication (for example,
(for example, Prozac,
Prozac, Zoloft, Zoloft,
Paxil, or Paxil, or
Wellbutrin)
W e l l b u t r i n ) without
without a
a mood
m o o d stabilizer
stabilizer like
like lithium
lithium (see C h a p t e r 6).
(see Chapter If you
6 ) . If y o u are
are
actually
actually bipolar,
bipolar, this
this treatment
treatment regime
r e g i m e could
c o u l d make
m a k e you
y o u swing
s w i n g into
into mania.
mania.
Likewise,
L i k e w i s e , if
if you
y o u were
w e r e diagnosed
d i a g n o s e d as
as bipolar
bipolar when
w h e n the
the real
real problem is attention
p r o b l e m is attention
deficit
deficit disorder,
disorder, you
y o u might
m i g h t not
n o t benefit
benefit from
f r o m the
the mood
m o o d stabilizer
stabilizer regime
r e g i m e yyou
ou
would
would be
be given.
given. Notice,
Notice, then,
then, how
h o w an
an accurate
accurate diagnostic label helps
diagnostic label helps doctors
doctors
treat
treat the
the whole
whole syndrome
syndrome that
that is
is affecting
affecting you
you rather
rather than
than just the symptoms
just the symptoms
you
you are
are reponing
reporting right
right now.
now.
Diagnoses
Diagnoses also
also help
help you
you prepare
prepare for
for the
the challenges
challenges the
the future
future might
might hold.
hold.
Your
Your doctor
doctor will
will use
use the
the diagnosis
diagnosis to
to formulate
formulate your
your prognosis.
prognosis. Will you have
Will you have
another
another episode?
episode? Will
Will you
you be
be able
able to
to go
go back
back to
to work?
work? How will you
H o w will you know
know
when
w h e n you're
you're getting
getting sick
sick again?
again? Knowing
Knowing that
that you
you have
have bipolar
bipolar disorder
disorder
makes
makes you
you and
and your
your doctor
doctor privy
privy to
to all
all of
of the
the information
information that
that researchers
researchers and
and
clinicians
clinicians have
have gathered
gathered from
from the
the experiences
experiences of
of thousands
thousands of
of people
people like
like you.
you.
For
For example,
example, you
you can
can expect
expect to
to have
have another
another episode
episode soon
soon if
if you
you don't take
don't take
medication, and
medication, and you
you may
m a y need
need to
to wait
wait for
for a
a while
while after
after an
an episode
episode before go­
before go-
ing
ing back
back to
to work
w o r k full
full time.
time. Fortifying
Fortifying yourself
yourself with
with this
this information makes iit
information makes t
easier
easier to
to manage
manage your
your life
life and
and minimizes
minimizes the
the disabilities
disabilities that
that bipolar
bipolar disorder
disorder
can cause.
can cause.

The
The Crileria
Criteria for
for a
a Diagnosis
Diagnosis of
of Bipolar
Bipolar Disorder
Disorder

Psychiatrists and
Psychiatrists psychologists
and rely rely
psychologists on the
onfourth of the Diagnostic
editionedition
the fourth and
of the Diagnostic an
Statistical
Statistical Manual
Manual of Mental
of Mental Disorders
Disorders to
to make
m a k e diagnoses
diagnoses (DSM-IV;
(DSM-IV; American
American
Psychiatric Association, 1994a,
Psychiatric Association, 1994a, 2000).
2000). Note
Note the
the term
term "manual"
"manual" in the title:
in the title: A
A
clinician
clinician should
should be
be able
able to
to pick
pick up
u p the
the manual
manual and
and decide
decide whether
whether a patient
a patient
meets
meets the
the criteria
criteria for
for a
a specific
specific psychiatriC
psychiatric illness.
illness. Applying
Applying these
these diagnostic
diagnostic
criteria
criteria reliably
reliably (that
(that is,
is, being
being able
able to
to tell
tell one
one disorder
disorder from
from another)
another) cannot
cannot
be
be done
done quickly
quickly or
or haphazardly:
haphazardly: it
it requires
requires considerable
considerable training,
training, experience,
experience,
and
and skill
skill on
on the
the part
part of
of the
the mental
mental health profesSionaL
health professional.
T h e first
The first edition
edition of
of the
the DSM
D S M was
was published in 1952;
published in 1952; other
other editions
editions were
were
published in 1968,
published in 1968, 1980,
1980, 1987,
1987, and
and finally, 1994 (with
finally, 1994 (with a
a text
text revision in
revision in
2000).
2000). Each
Each version
version has
has been
been informed
informed by
by the
the research
research and
and observations of
observations of
m a n y investigators
many investigators and
and clinicians
clinicians and
and by
by experiences
experiences elicited
elicited from
from numerous
numerous
patients
patients with
with psychiatric
psychiatric disorders.
disorders. No
N o diagnostic
diagnostic manual
manual is
is perfect,
perfect, and not
and not
everyone
everyone agrees
agrees with
with the
the premises
premises of
of the
the DSM-IV
D S M - I V (e.g., Carson,1991).
(e.g., Carson, 1991).In
Inmy
my
opinion,
opinion, the
the DSM-IV
D S M - I V is
is an
an extremely
extremely useful
useful manual,
manual, and
and no
no other
other diagnostic
diagnostic
system
system exists
exists that
that provides
provides a reasonable alternative.
a reasonable alternative.
Your
Your doctor
doctor will
will first
first identify
identify which
which symptoms
symptoms you
you have
have (for
(for example,
example,
sleep
sleep disturbance,
disturbance, irritability),
irritability), how
h o w severe
severethese
thesesymptoms are,and
symptoms are, and how
h o w long
long
32
32 THf DIAGNOSISAND
THEDIAGNOSIS ANDCOURSf
COURSE BIPOLDlSORDfR
BIPOlAR
Of OF AR DISORDER

they have lasted.

they have F r o m YOUT
lasted. From particular pattern
your particular pattern of symptoms, he
of symptoms, she will
or she
he or will
then determine if
then determine if the diagnosis of
the diagnosis disorder—as outlined
bipolar disorder--as
of bipolar the DSM­
in the
outlined in DSM-
IV-fits you. If
IV—fits you. yourdoctor
does,your
Ifititdoes, doctor will
willthen
then bebeconcerned
concernedwith which
with kindofof
whichkind
bipolar disorder
bipolar you have:
disorder you isititbipolar
have: is II?
typeI Ioror
bipolartype DoD you
II? have rapid
o you have cycling?
rapid cycling?

Bipolar II Disorder
Bipolar Disorder

The sidebar on
The sidebar on this describesthe
page describes
this page subtypesofofbipolar
majorsubtypes
themajor bipolar disorder
disorder
listed in
listed DSM-IV. For
the DSM-IV.
in the For bipolar disorder, you
bipolar II disorder, have had
must have
you must least one
at least
had at one
manic or mixed episode, with elated mood and three other
manic or mixed episode, with elated m o o d and three other associated symp-associated symp­
toms of
toms of mania (grandiose thinking,
mania (grandiose decreased need
thinking, decreased need for sleep, pressured
for sleep, pressured
speech, increased activity
speech, increased energy level,
or energy
activity or thoughts,flight
racingthoughts,
level, racing flightofofideas,
ideas, dis­
dis-
tractibility,or
tractibility, behavior)that
impulsivebehavior)
orimpulsive w e e kor
lastedaaweek
thatlasted and/orrequired
moreandlor
ormore required
you be
that you
that hospitalized. If
be hospitalized. If your m o o d was
your mood and not
irritable and
was irritable four or
elated, four
not elated, or
more symptoms are
associated symptoms
m o r e associated are required. h o w these
Note how
required. Note symptoms capture
these symptoms capture
essence of
the essence
the of the
the subjective experiences of
subjective experiences mania described
of mania described in Chapter 2:
in Chapter 2: the
the
roller-coaster mood
roller-coaster increasesin
states,increases
m o o d states, and drive,
activityand
inactivity changesininthinking
drive,changes thinking
perception, and
and perception,
and impulsive or
and impulsive or self-destructive behaviors.
self-destructive behaviors.

The DSM-IV
The D Subtypes of
S M - I V Subtypes Bipolar Disorder
of Bipolar Disorder

Bipolar IIdisorder
Bipolar disorder

• At• least oneone

At least lifetimeepisode
lifetime of manic
episode of or mixed
manic or disorder
mixed disorder
•
• Although not required
Although not the diagnOSiS,
for the
required for least one
at least
diagnosis, at one lifetime
lifetime
episode of
episode depressive disorder
major depreSSive
of major disorder

Bipolar 11IIdisorder
Bipolar disorder

• At• least oneone

At least lifetime of hypomanic
episode of
lifetimeepisode disorder
hypomanic disorder
• At
• least one
At least episode of
lifetime episode
one lifetime depressive disorder
major depresSive
of major disorder

Bipolar disorderwith
Bipolar disorder withrapid cycling
rapid cycling

• Meets
• Meets criteria
criteria for I or
bipolar I
forbipolar disorder
bipolarII II
or bipolar disorder
• Four
• or more
Four or episodes of
more episodes depressive disorder,
major depressive
of major disorder, manic
manic
disorder, mixed
disorder, mixed disorder, or hypomanic
disorder, or disorder in
hypomanic disorder any one
in any one
year
year
 Intothe
Inlo theDocto(s Court:
Doctor's Whol
Court: to Expe<f
What hom the
to Expect fromDiogflosh( ProcessProcess
the Diagnostic 33 33

You
You may may
find find yourself
yourself reactingreacting negatively
negatively the symp- [he symp­
to how reductionistic
to how reductionistic
tom
t o m labels
labels are:
are: what
w h a t you
y o u see
see as as clear
clear insights
insights and a n d the
the energy
energy to get important
to get important
things
things done
d o n e may
m a y beb e labeled
labeled by b y the
the DSM-IV
D S M - I V asas grandiosity.
grandiosity. Your Y o u r reactions
reactions are are
certainly
certainly understandable.
understandable. These T h e s e symptom
s y m p t o m labels
labels areare shorthand
s h o r t h a n d for very com­
for very com-
plex
plex life
hfe experiences
experiences and a n d mood
m o o d states,
states, much
m u c h like
like the
the diagnostic
diagnostic label label itself.
itself.
The
T h e DSM-IV
D S M - I V requires
requires at at least
least one
one week
w e e k ofof manic
manic symptoms
symptoms for bipolar II
for bipolar
disorder,
disorder, unless
unless hospitalization
hospitalization was was necessary,
necessary, in in which
which case case there
there isis no
no time
time
requirement.
requirement. There must also be evidence that you showed deterioration in
There must also be evidence that you showed deterioration in
your
your workw o r k or
or family
family lifelife (for
(for example,
example, major major family
family arguments,
arguments, loss loss ofof your
your
job,
job, etc.).
etc.). InIn most
most cases,
cases,aabipolar
bipolarIIperson
personwill willalso
alsohave
havehad, had,at atsome
some point
pointin in
hfe,
life,aaminimum
m i n i m u m two-week
two-week period periodwith withfive fiveor ormore
more symptoms
symptoms of ofmajor
major de­ de-
pressive
pressive illness
illness (depressed
(depressed mood, m o o d , loss
loss ofof interests,
interests,weightweightloss lossor oraachange
change in in
appetite,
appetite, lossloss of
of energy
energy or or fatigue,
fatigue, motormotor agitation
agitationor orretardation,
retardation,loss lossofofcon­
con-
centration,
centration, feelings
feelings of of worthlessness,
worthlessness, insomnia insomnia or or hypersomnia,
hypersomnia, suicidal suicidal
thoughts
thoughts or or actions)
actions) and and during
during whichwhich therethere waswas aa deterioration
deterioration in in everyday
everyday
functioning.
functioning.
People
People withwith bipolar
bipolar II disorder
disorder can can experience
experience episodes
episodes of of mania
mania and de­
and de-
pression
pression in in different
different sequences.
sequences. Some S o m e people
people havehave manias
manias followed
followed by depres­
by depres-
sions
sions followed
followed by by periods
periods in in which
which theirtheir mood
m o o d returns
returns to to nonnal ("euthymic"
normal ("euthymic"
mood).
m o o d ) . Other
Other people
people have have depressions
depressions followedfollowed by by manias,
manias, which which areare then
then
followed
followed by by euthymic
euthymic mood. m o o d . Other
Other people
people havehave '"rapid
''rapid cycling" states, which
cycling" states, which
I'll
I'll talk
talk about
about m more later.
o r e later.
If
If you
you have
have had
had a a manic
manic episode
episode but but nono depressions,
depressions, your your doctor
doctorwillwillstill
still
diagnose
diagnose you you with bipolar II disorder.
with bipolar disorder. This This is is because
because he he oror she assumes that
she assumes that aa
depression
depression will will eventually
eventually occur occur if if the
the disorder
disorder is is not
not treated
treated adequately.
adequately. As A s II
mentioned
mentioned in Chapter 2,
in Chapter 2, people
people diagnosed
diagnosed with with bipolar
bipolar I I disorder
disorder can also
can also
have
have mixed
mixed episodes,
episodes, or or what
what some some physicians
physicians refer refer toto as
as "dysphoric mania."
"dysphoric mania."
This
This means
means thatthat you
you have
have met met the the criteria
criteria forfor major
major depressive
depressive disorder
disorder and and
mania
mania nearly
nearly every
every day
day forfor atat least
least a a week.
week. SomeS o m e people
people describe
describe mixed mixed mania
mania
as
as the
the �tired
"tired but
but wired"
wired" feeling.
feeling. You Y o u can
can feel
feel extraordinarily pessimistic and
extraordinarily pessimistic and
hopeless,
hopeless, fatigued,
fatigued, and and unable
unable to to concentrate,
concentrate, but butstill
stillfeel
feel"revved,"
"revved,"anxious,
anxious,
irritable,
irritable,driven,
driven,and andsleep
sleepdeprived,
deprived, with
with your
your thoughts
thoughts moving
movingvery very rapidly.
rapidly.

Bipo'.rII
Bipolar /I Disorder
Disorder
In bipolar
In bipolar IIII disorder,
disorder, a a person
person alternates
alternates between
between major
major depressive episodes
depressive episodes
and hypomanias. Hypomanias
and hypomanias. Hypomanias are milder forms
are milder forms of mania that
of mania that mmay not last
a y not last as
as
long as full
long as manias (the
full manias (the mminimum requirement for
i n i m u m requirement for the diagnosis is
the diagnosis is four
four days),
days),
but
but the number
the n u m b e r of symptoms required
of symptoms required is
is the same (that
the same (that is,
is, three if the
three if mood
the m is
o o d is
elated, four if
elated, four if the
the mmood is irritable).
o o d is irritable). People
People with
with hypomania experience the
hypomania experience the
first of
first ofthe
the three
threestages
stages of
ofmania
mania described
described in Chapter 2,
in Chapter 2, but
but they
they do
do not
not go
go he-
be-
34
34 THE
THE DIAGNOSIS
DIAGNOSISAND
ANDCOURSE
COURSEOFOF
BIPO�R
BIPOIADISORDER
R DISORDER

yond this: they

yond this: they have sleep
have problems,
sleep problems,irritability. increased
irritability, activity, and
increased an in­ and an i
activity,
flated
flatedsense
senseofofthemselves,
themselves,but
butnot
nottotothe
thedangerous
dangerouslevels ofthe
levelsof thefully
fullymanic
manic
person.
person. Generally,
Generally, hypomanic
hypomanic episodes
episodes dodo not
not cause
cause big
big problems
problems in
in your
your
work,
work, family,
family, or
or social life, but
socialfife, but you
you may
m a y still experience some
stillexperience some interpersonal
interpersonal
difficulties
difficulties when
w h e n in
in this
this state
state (for example, more
(for example, more arguments
arguments with your spouse
with your spouse
or
or kids).
kids). Hypomanias
Hypomanias do do not
not require
require hospitalization.
hospitalization.
Hypomanic
Hypomanic episodes
episodes cancan be
be quite
quite enjoyable
enjoyable toto the
the person
person experiencing
experiencing
them.
them. InIn general,
general, others
others will
will be
be baffled
baffled and
and put
put off
off by
by your energetic,
your energetic,
hypersexual,
hypersexual, and
and driven
driven quality
quality when
w h e n hypomanic
hypomanic (for example, they
(for example, they may tell
m a y tell
you to
you to "chill
"chill out").
out"). Your significanl others
Your significant others may
m a y also
also be
be relieved
relieved by
by what they
what they
perceive
perceive to
to be
be the
the disappearance
disappearance of the depresSive
of the depressive states often preceded
that often
states that preceded
the
the energized
energized one.
one. Consider
Consider Heather,
Heather, whow h o had
had bipolar
bipolar II disorder:
II disorder:

Heather,
Heather, 36,36,
age age waswas
a a professional conference
professional conferencecoordinator.
coordinator. She described
She described
herself
herself as as almost
almost always
always depressed.
depressed. W When
h e n she
she went
went through
through herher divorce,
divorce,
contact
contact withwith her
her soon-to-be�ex-husband
soon-to-be-ex-husband "felt "felt like drug IIneeded-it
likeaadrug needed—itwas was
the only
the only thing
thing [hat
that kept
kept mmee alive."
alive." She
She became
became suicidal
suicidal atat that
that time.
time. But
But
soon
soon after,
after, sheshebegan
beganplanning
planningaaconference
conferencefor foraagroup
group of ofarchitects,
architects,andand
started
started dating
dating oneone of
of them. The work
them. The work and
and the
the new
n e w relationship
relationship "wired
"wired
me ... II got
me... got my
m y energy
energy back.
back. II SlOpped
stopped sleeping
sleeping and
and staying
staying in
in my
m y condo so
condo so
much
m u c h ofof the
the time
time .. .. went
went walking
walking mym y dog
dog atat 2 A.M. People
2 A.M. People told told me
m e II
seemed
seemed much m u c h better,
better, like
likeIIhad
had my
m y oid
oldself
selfback,
back,butbut IIknew
k n e w IIwas
was going
going
overboard.
overboard." "

KeepKeep in mind
in mind whatwhat different
different diagnostiC subtypes
diagnostic subtypes may meanfor
may mean for your
your treat­
treat-
ment.
ment. IfIf you have bipolar
you have bipolar II instead of
II instead of bipolar
bipolar II disorder,
disorder, your
your illness
illnessis
isproba­
proba-
bly less severe.
bly less severe. But
But you
you still
still need
need to
tobe
be careful:
careful:hypomanias,
hypomanias,while
whilefun
funand
andex­
ex-
citing,
citing, can
can herald
herald the
the development
development of of aa severe
severe depresSion,
depression, or
or even
even of
of rapid
rapid
cycling,
cycling, especially
especially if you are
if you nOl protected
are not protected by by mood-stabilizing medications.
mood-stabilizing medications.

Rapid Cye/ing
Rapid Cycling

Rapid cycling
Rapid cycling can
canaccompany
accompany either
eitherbipolar I orI II
bipolar ordisorder. In rapid
II disorder. In cycling,
rapid cycling,
people
people quickly
quickly switch
switch back
back and
and forth
forth from
from mania
mania oror hypomania
hypomania or or mixed dis­
mixed dis-
order
order to
to depression,
depression, with
with four
four or
or more
more distinct
distinct episodes
episodes in
in aa single year. In
single year. In
other
other words,
words, you
you have
have many
m a n y episodes
episodes inin a
a short
short period
period of
of time.
time. Some
S o m e people
people
have �ultra-radian
have "ultra-radian cycling,"
cycling," which
which means
means switching
switching from
from one
one mood
m o o d pole to
pole to
the other within a Single 24-hour period.
the other within a single 24-hour period.
If you
If you have
have rapid
rapid cycling,
cycling, you
you may
m a y have
have to
to go
go through
through quite
quite a a bit
bit of
of [rial
trial
and error with your medications until you find something that works. Your
and error with your medications until you find something that works. Your
doctor
doctor may
m a y want
want to
to rule
rule Oul
out other
other factors
factors thal
that may
m a y contribUle
contribute to your mood
to your mood
 Into
Into the
the Docto(s
Doctor's (ouII:
Court: Whot
WhattotoExpect
Expectfrom
fromthe
theDiagnostic
Diagnostic Process
Process lS
35

swings, like
swings, like thyroid
thyroid abnormalities.
abnormalities. The The good
good news
news isis that
that rapid
rapid cycling ap�
cycling ap-
pears
pears to
to be
be a
a time�limited
time-limited phenomenon
p h e n o m e n o n (Coryell
(Coryell et al., 1992):
et al., 1992): People do not
People do not
rapidly cycle
rapidly cycle their
their whole
whole lives.
lives. I'll
I'll talk
talkmore
moreabout
aboutfrequent
frequentcycling
cyclingin
inChapter
Chapter
6
6 on
on drug
drug treatments.
treatments.

The
The Progression
Progression of
of Bipolar
Bipolar Episodes
Episodes

Many people-includingthose
Many people—including thosewhowhohavehavenot not yet
yet been
been diagnosed
diagnosed with withbipolar
bipolar
disorder
disorder andand those
those whow h o have
have but
but are
are inin doubt
doubt about
about it-find
it—find the the diagnostic
diagnostic
criteria
criteriajust
justdiscussed
discussed confusing.
confusing.Many M a n y clinicians
cliniciansdo do asaswell!
well!YouY o u may
m a y wonder
wonder
whether
whether having
having only
only one
one oror two
two of of these
these symptoms
symptoms qualifies
qualifies you
you for
for the diag�
the diag-
nosis
nosis oror what
what it
it means
means if if you
you had
had oneone symptom
s y m p t o m in
in January,
January, none
none in in February
February
and
and March.
March, andand a a different
different symptom
s y m p t o m in
in July.
July.
One
O n e of
of the
the keys
keys toto making
making the the diagnosis
diagnosis of of bipolar
bipolar disorder
disorder is is to
to think in
think in
terms
terms of of clusters
clusters ofof symptoms
symptoms that that cycle
cycle together
together in in episodes.
episodes. There
There mustmust bebe
evidence
evidence thatthat you
you have
have hadhad time�limited
time-limited periodsperiods of of mood
m o o d disorder
disorder thatthat alter­
alter-
nate with periods of functioning fairly normally or that alternate with inter­
nate with periods of functioning fairly normally or that alternate with inter-
vals
vals in
in which
which you
you experience
experience the the opposite
opposite pole pole of of the
the illness
illness (for
(for example,
example,
manic
manic episodes
episodes that
that are
are followed
followed by by depressive
depressive episodes).
episodes). Episodes
Episodes are inter­
are inter-
vals
vals when
w h e n your
your mood,
m o o d , activity
activity level.
level,thinking
thinkingpatterns,
patterns,and andsleep
sleepall allchange
changeatat
the
the same
same time.
time. AnA n episode
episode (see(see thethe figure
figure on on this
this page)
page) generally
generally has has aa
prodromal
prodromal phasephase (a(a period
period of of symptom
s y m p t o m buildup),
buildup), an an active
active phase
phase (a (a period
period ofof
severe
severe depression
depression or or manic
manic symptoms),
symptoms), and and a a recovery
recovery phase (the symptoms
phase (the symptoms
are
are abating
abating but
but are
are not
not quite
quite gone
gone yet).
yet). Consider,
Consider, Tom, Tom, a a 46-year-old
46-year-old bipolar
bipolar
patient:
patient:

1 SEVER
SEVERE -

<
z
MODERATE
MODERATE--
< ACTIVE PHASE
O
a.
LU MILD
^/IILD-•
>
PRODROMAL RECOVERY

EUTHYMIC ,
EUTHYrwilC-k"":::::__
_ "':"'===::::=-
PHASE
: ;;;;;-:::=
; =��:'::':�-----
TIME
TIME
PHASE

The
The phases
phases of
of a
a manic episode.
manic episode.
36
36 THE
THE DIAGNOSIS
DIAGNOSISAND
ANDmURSE OF OF
COURSE 8IPO�R
BIPOLDISORDER
AR DISORDER

Tom Tom described

described both both depressive
depressive episodes
episodes andand mixed
mixed episodes.AsAs
episodes. hishisde-
de­
pression developed
pression developed overover several weeks, he
several weeks, he experienced sadness and
experienced sadness and loss of
loss of
interests in his usual activities, but a mild paranoia with anxiety also de­
interests in his usual activities, but a mild paranoia with anxiety also de-
veloped. He
veloped. H e began
began to to feel
feel that
that nono one
one in
in his family was
his family was on his side
on his side and
and
that they
thal they were
were talking
talking about
about him him behind
behind his
his back.
back. As he progressed
A s he progressed into into aa
mixed episode,
mixed episode, hishis depression
depression worsened
worsened and and so
so did his anxiety
did his anxiety and para­
and para-
noia, but
noia, but he
he also
alsodeveloped
developed an an irritability
irritabilityand
and anger
anger that
thathehe expressed
expressed in­ in-
appropriately.
appropriately. In In one
one case,
case, he hebroke
brokesome
some dishes;
dishes;in inanother,
another,hehekickedkickedinin
a
a door.
door. His
His family
family members
m e m b e r s became
became scared
scared ofof him.
him. His sleep deteriorated,
His sleep deteriorated,
and
and hishis thoughts
thoughts look took on on a a rapid,
rapid, ruminating
ruminating quality
quality ("I("I think
think about
about
death and
death and that
that there's
there's no
no future--doesn'l
future—doesn't seem seem like
like there's
there's anything
anything II or or
anybody
anybody can can do").
do"). These
These periods
periods usually
usually lasted
lasted atat least
least aa week
w e e k but often
but often
longer.
longer. As As he
he recovered
recovered fromfrom hishis mixed
mixed episode-usually
episode—usually after after his
his medi­
medi-
cation
cation dosage
dosage had been increased
had been increased or or aa new
n e w medication
medication added-he
a d d e d — h e would
would
feel
feel less
less hopeless,
hopeless, hishis thoughts
thoughts would
would slow
slow down,
d o w n , and
and he became easier
he became easier
for
for others
others to to communicate
communicate with. with. Nonetheless,
Nonetheless, he he cominued
continued to to feel
feel anx�
anx-
ious,
ious, sad,
sad, and
and easily
easily irritated
irritated by by others.
others. He
H e began
began to to see
see how
h o w his
his behavior
behavior
affected his
affected his family and that
family and that at
at least
least some
some ofof his
his paranoid
paranoid feelings
feelings were
were un­
un-
founded.
founded.

Notice
Notice how,how, in Tom's
in Tom's case,a asingle
case, Single episode
episodeprogressed
progressedinin
stages. Different
stages. Different
symptoms
symptoms (his (his hopelessness
hopelessness andand paranoia)
paranoia) changed
changed moremore rapidly
rapidly than
than others
others
(his
(his sadness
sadness andand anger),
anger). The
The length
length of of bipolar
bipolar episodes
episodes varies
varies from
from person
person to to
person.
person.
It
It may
m a y not
not always
always bebe possible
possible toto tell
tell when
w h e n you
you are
are finished
finished with
with an epi­
an epi-
sode
sode oror developing
developing a a new
n e w one,
one. If
If you
you have
have had
had aa number
n u m b e r of
ofepisodes
episodes already,
already,
you
you probably
probably areare more
more attuned
attuned than
than most
most people
people toto what
what it it feels
feelslike
like to be ill
tobe ill
versus
versus well.
well. But
Butif
ifyou're
you'reon onyour
yourfirst
firstepisode,
episode, you
youmaym a be
y beunclear
unclearasas
totowhen
when
you're
you're back
back to normal or
to normal what it
or what itfeels
feelslike
liketotobe
begetting
gettingsick
sickagain.
again.As Asyou'll
you'llsee
see
when
w h e n we discuss self-managemem
w e discuss self-management techniques,
techniques, knowing
knowing your your prodromal
prodromal
symptoms
symptoms (the (the signs
signs that
that an
an episode
episode of of mania
mania or or depresSion
depression has begun) and
has begun) and
when
w h e n to
to get
get emergency
emergency treatmem helps protect
treatment helps protect you
you against
against further
further escalation
escalation
of
of the
the disorder.
disorder.

Diagnostic Self-Evaluation
Diagnostic Self-Evaluation as
as a
a Starting
Starting Point
Point or
or a
a Backup
Backup Check
Check

The self-administered
The self-administered checklist that that
checklist follows is a starting
follows point in determining
is a starting point in determinin
whether your
whether your diagnosis
diagnosis isiscorrect.
correct.IfIf
you
youhave
havenever
neverseen
seena psychiatrist but
a psychiatrist butthink
think
you might
you might need
need to,
to, the
thechecklist
checklistwill
willorient
orientyou
you to
tothe
thekinds
kindsofofsymptoms
symptoms youryour
doctor will
doctor will ask
ask about.
about.IfIfyou've
you'vealready
alreadyreceived
receivedthe diagnosis
the diagnosisof bipolar
of disorder
bipolar disorder
 Into
Intothe
theDoctoi's
Doctor's(our!: Whot
Court: to Expect
What from from
to Expect fhe Djagnos�c ProcessProcess
the Diagnostic 37 37

and are suspicious

and are suspicious ofof it, the
it, thelist
list provides yourdoctor
provides your doctor with
with a backup
a backup check.
check. The The
checklist
checklist isis not
not a
a diagnostic
diagnostic instrument:
instrument: justjust because
b e c a u s e you
y o u endorse
e n d o r s e the
the items
items does
does
not
not mean
m e a n that
that you
you have
have the the disorder,
disorder, only
onlythat
thatyou've
you'vehad had symptoms
symptoms of ofmania
mania
and
and depression
depression thatthat you
you andand your
your doctor
doctor will
will want
want to todiscuss.
discuss.likewise,
Likewise,ififnonenone
of
of the
the symptoms
symptoms soundssounds familiar,
famihar, you
you may
m a y still
stillhavehavethe thedisorder
disorderbut butyouyouand
and
your doctor
your doctor will
will want
want to to discuss
discuss other
other diagnoses
diagnoses as well.
as well.
In
In filling
filling out
out thethe checklist,
checklist, and and inin discussing
discussing the the symptoms
symptoms with with your
your
physician,
physician, keep
keep inin mind
m i n d that
that these
these symptoms
symptoms must must co-occur
co-occur during during the the same
same
period
period ofof time.
time. If
If you
you had
had sadsad mood
m o o d at
at one
one time
time in in your
your life,
life,racing
racingthoughts
thoughtsat at
another,
another, andand insomnia
insomnia duringduring another
another period,
period, that that is is not
not thethe samesame thing as
thing as
having
having an an episode
episode of of major
major depressive
depressive illness
illness or or a a manic
manic or or hypomanic
hypomanic epi- epi­
sode.
sode.

What
W h a t the
the Dodor
Doctor Will
Will Want
W a n t to
to Know:
K n o w : Steps
Steps toward
toward Diagnosis
Diagnosis
and
and Treatment
Treatment

Many
M a n y ofof my
m y patients
patients have
have come to me
c o m e to m e feeling
feeling that
that their
their initial
initial diagnosis
diagnosis waswas
made too hastily. Either they become victims of the managed care rush to
m a d e too hastily. Either they become victims of the managed care rush to
make
m a k e diagnostic
diagnostic and and treatment
treatment decisions
decisions or or they
they were
were never
never asked
asked about ele­
about ele-
ments
ments of of their
their life
life story
story that,
that, toto them,
them, seemed
seemed critical
critical toto an
an understanding
understanding of of
their
their mood
m o o d problems.
problems.
Whether
Whether you you have
have already
already been been diagnosed
diagnosed and and wish
wish toto review
review whether
whether
your
your case
case has
has been
been handled
handled correctly,
correctly,or oryou
you are
arepreparing
preparingfor foryour
yourfirst
firstevalu­
evalu-
ation,
ation, understanding
understanding the the sequence
sequence of of steps
steps inin the
the diagnostic
diagnostic and and treatment
treatment
process
process willwill help.
help. These
These steps
steps include
include the the diagnostic
diagnostic referral,
referral, reviewing
reviewing youryour
prior
prior medical
medical records,
records, andand thethe diagnostic
diagnostic interview.
interview.
As
A s II review
review the the steps
steps inin the
the diagnostic
diagnostic process,
process, keep keep inin mind
mind that
that your
your
doctor will
doctor will base
base your
your diagnosis
diagnosis largely
largely on on the
the symptoms
symptoms you you have recently ex-
have recently ex­
perienced.
perienced. How H o w you
you developed
developed these these symptoms
symptoms (also (also called
called the
the etiology
etiology ofof
your
your disorder)
disorder) is isreally
reallyaadifferent
differentquestion.
question.You Y o u may
m a y feel
feelthat
thatthese
thesesymptoms
symptoms
are
are not
not the
the product
product of of aa biochemical
biochemical imbalance
imbalance as as much
m u c h as
as current stressors
current stressors
(for
(for example,
example, having
having jusl
just broken
broken off off a
a relationship)
relationship) or or childhood
childhood issues (e.g.,
issues (e.g.,
traumatic
traumatic eventsevents suchsuch asas abuse).
abuse). If If your
your doctor
doctor is is doing
doing hishis or
or her job, he
her job, he or
or
she
she will
will address
address these
these psychological
psychological issues issues with
with youyou later
later in
in treatment, after
treatment, after
establishing
establishing the the diagnosis
diagnosis and and after
after the
the two
two ofof you
you have
have agreed
agreed onon aa medica­
medica-
tion
tion treatment
treatment plan.
plan. IfIf your
your doctor
doctor doesdoes not
not do
do psychotherapy,
psychotherapy, you you may
m a y want
want
to ask
to ask him
h i m oror her
her for
for aa referral
referral so so that
that you
you receive
receive simultaneous
simultaneous treatment
treatment
with
with a therapiSt.
a therapist.
38
38 THE
THE DIAGNOSIS
DIAGNOSIS AHO
AND[QURSE
COURSEOF
OFBlfQlAR
BIPOIARDISORDER
DISORDER

BIPOLAR
B I P O L A R SYMPTOMS:
SYMPTOMS: A
A SELF·ADMINISTERED
SELF-ADIWINISTERED CHECKLIST
CHECKLIST

1
DEPRESSION^ DEPRESSION

Has there
Has thereever
everbeen a period
been of time
a period lasting
of time two weeks
lasting two or moreor
weeks when
moreyou were
when younot your
were not your
usual
usual self
self and
and you
you experienced
experienced five
five or
or more
more of
of the
the following:
following:
Yes
Yes No
No
Felt
Felt sad,
sad, blue,
blue,or
or down
d o w n in
inthe
the dumps?
dumps?
Were
Were uninterested
uninterested in
in things?
things?
Lost
Lost or
or gained
gained more
more than 5%
than 5 % of your body
of your body weight?
weight?
Slept
Slept too
too little
little or
or too
too much?
much?
Were
Were slowed
slowed down
d o w n or
or sped
sped up
up in
in your
your movements?
movements?
Felt
Felt fatigued
fatigued or
or low
low in
in energy?
energy?
Felt
Felt worthless
worthless or
or very
very guilty
guilty about
about things?
things?
Were
Were unable
unable to
to concentrate or make
concentrate or make decisions?
decisions?
Thought
Thought about
about killing
killing yourself
yourself or
or making
making plans
plans to
to do
do so?
so?

2
MANIA
M A N I A OR
O R HYPOMANIA
HYPOMANIA^

Has
Has there
therebeen
beena aperiod of of
period lime when
time youyou
when were not not
were youryour
usual self and
usual you:
self and you:
Yes
Yes No
No
Feh
Felt so
so good
good or
or so
so hyper
hyper that
that other
other people
people thought
thought you
you were
were
not
not your normal self
your normal self or
or you were so
you were so hyper
hyper that
that you
you got into
got into
trouble?
trouble?
Were so
Were so irritable
irritable that
that you
you shouted
shouted at
at people
people or
or started fights
started fights
or
or arguments?
arguments?
Felt
Felt much
m u c h more
more self-confident
self-confident than
than usual?
usual?
Got
Got much
m u c h less
less sleep
sleep than
than usual
usual and
and found
found you
you didn't
didn't really
really miss
miss
it?
it?
Were
Were much
m u c h more
more talkative
talkative or
or spoke
spoke much
m u c h faster than usual?
faster than usual?
Had thoughts
Had thoughts racing
racing through
through your
your head
head or
or couldn't
couldn't slow
slow down
down
your
your mind?
mind?
Were
Were so
so easily
easily distracted
distracted by
by things
things around
around you
you that
that you
you had
had
trouble
trouble concentrating
concentrating or
or staying
staying on
on track?
track?
Had
Had much
m u c h more
more energy
energy than
than usual?
usual?
Were
Were much
m u c h more
more active
active or
or did
did many
many more
more things
things than
than usual?
usual?
Were
Were much
m u c h more
more social
social or
or outgoing
outgoing than
than usual;
usual; for
for example.
example,
telephoning
telephoning friends
friends in
in the
the middle
middle of
of the night?
the night?
 11110
Into the
the DodGr's
Doctor's (ourt:
Court: Whol to �ped
What to Expect hom
from the
the Diogllostic
Diagnostic Process
Process 339
9

Yes
Yes No
No
Were
W e r e much
m u c h more
m o r e interested
interested in
in sex
sex than
than usual?
usual?
Did
Did things
things that
that were
were unusual
unusual for
for you
you or
or that
that other
other people
people might
might
have
have thought
thought were
were excessive,
excessive, foolish,
foolish, or
or risky?
risky?
Spent
Spent excessive
excessive money
m o n e y thal
that got
got you
you or
or your
your family
family into
into trouble?
trouble?

If you
If you checked yes to
checked yes to more than one
more than oneof
of the
the above,
above' have several
have several
of
of these
these ever
ever happened
happened during
during the
the same period of
same period of time?
time?

How
H o w much
m u c h of
of aa problem
problem did
did any
any of
of these
these cause
cause you-like
you—like being
being unable to work;
unable to work;
having
having family.
family, money,
m o n e y , or
or legal
legal troubles;
troubles; getting
getting into
into arguments
arguments or
or fight?
fight? Please
Please check
check
one
one response
response only.
only.

No
No problem ___
problemMinor problem
Minor problem
Moderate problem ___ Moderate problem ___

Serious
Serious problem
problem ___

lAdapted
Adapted by
bypermission fromfrom
the criteria for major depressive anddepressive
manic episodes ofthe DSM-LY- Tat Rt:vision
Association,2000). 2000by
permission the criteria for major and manic episodes of the DSM-IV-T
(American
(American Psychiatric
Psychiatric Association, 2000).Copyright bythe
theAmerican
AmericanPsychiatric
PsychiatricAssociation.
Copyright 2000 American Psychiatric
Copyright2000 Association.
lAdapted
Adapted by
by pennission
permission from Hirschfeld et
from Hirschfeld et al. (2000). Copyright
al. (2000). 2000 by the American
by the Psychiatric Associa­
Associa-
tion.
tion.

Step : The
Step ,7: The Diagn051 ic Referral
Diagnostic Referral

The first
The first step in getting
step in gettinga proper a diagnosis is to find the
proper diagnosis is right
to finddoctor.theIf you
right docto
have
have private
private insurance,
insurance, you you maymay be beable
abletotoseeseesomeone
someonewho w h o specializes
specializesin in
mood
mood disorders.
disorders.If Ifititisisunclear
unclearwhether
whetheraadoctor
doctorisisaaspecialist,
specialist,you youshould
shouldfeelfeel
free
free to
toask.
ask. You
You can
canalsoalsoobtain
obtaininformation
informationabout aboutwho
w h o in
in your
your area
areatreats
treatsper­
per-
sons
sons with
with mood
mood disorders
disorders from from the
the American
American Psychiatric
Psychiatric Association's
Association's referral
referral
line
line (888-35-PSYCH)
(888-35-PSYCH) or or from
from thethe books
books inin the
the "How
"How to to Find
Find the Best Doctors"
the Best Doctors"
series
series (for
(for example, Connolly, 2000).
example, Connolly, 2000).
If
If you
you have
have aa managed
managed care care plan
plan oror no
no insurance,
insurance,you youmaymay not nothave
haveaalot lot
of
of choice
choice about
about whom
w h o m you you see.
see. Hopefully,
Hopefully,your yourplan
planwill
willdirect
directyou youtoto
aa men­
men-
tal
tal health
healthprofessional
professionalwho w h o has
hasatatleast
leastsome
some experience
experience in inmood
mood disorders.
disorders.
But
But this
this may
may reqUire
require some some detective
detective work
work on on your
your part
part. Nancy,
Nancy,for forexample,
example,
thought she might have bipolar disorder and wanted to see a psychiatrist but
thought she might have bipolar disorder and wanted to see a psychiatrist but
was
was confused
confused by by the
the number
number of of doctors
doctors listed
Hsted inin the
the Yellow
Yellow Pages
Pages who pur­
w h o pur-
portedly
portedly treated
treated mood
mood problems.
problems. She She called
called several
several but
butcould
couldreach
reachonlyonly their
their
receptionists,
receptionists,who w h o gave
gaveher herinformation
informationlike Hke"Dr.
"Dr. sees
seesmainly
mainly
adults"
adults" or or "she
"she has
has aa general
general psychiatry
psychiatry practice."
practice." She
She finally
finally discussed
discussed the the
matter
matter with
with her
her general
general practitioner,
practitioner, who w h o referred
referred her
her toto aa psychiatrist
psychiatrist in in
town
town whow h o was
was covered
covered by by her
her insurance
insurance planplan and
and was
was known
known to to have exper­
have exper-
tise
tise in
in the
the treatment
treatment of mood disorders.
of mood disorders.
40
40 lHE
THE DIAGNOSIS
DIAGNOSISANO
ANDCOURSE OF OF
COURSE BIPO�R
BIPOIDISORDER
AR DISORDER

In laday's
In today's managed
managed carecare system,
system, your
your initialdiagnostic
initial diagnostic evaluation
evaluation may
may
not
not be
be done
done by
by a
a psychiatrist. M a n y insurance
psychiatrist. Many insurance plans
plans have
have an
an intake
intake worker
worker
who
w h o determines
determines the
the need
need for
for follow-up
follow-up psychiatric
psychiatric care. However, this
care. However, this does
does
not
not mean
m e a n your
your care
care will
will be inferior. Memal
be inferior. Mental health
health professionals
professionals from
from other
other
disciplines
disciplines (e.g.,
(e.g., psychology,
psychology,social
socialwork,
work,nursing)
nursing)are
areoften
oftenwell-trained
well-trained in
in
diagnostic
diagnostic methods.
methods. There
There is
is a
a good
good chance
chance that
that this
this intake
intake worker
worker will refer
will refer
you
you to
to a
a psychiatrist,
psychiatrist, if
ifthere
thereisisany
anysuspicion
suspicionthat
thatyou
youhave
havebipolar
bipolardisorder,
disorder,
and
and he
he or
or she
she will
will almost
almost certainly
certainly do
do so
so if
ifyou
you have
have had
had prior
prior mood
m o o d disorder
disorder
episodes.
episodes. But
But if
ifyou
youdon't
don'tfeel
feelthat this
that initial
this evaluation
initial was
evaluation adequate
was oror
adequate led to to
led
appropriate
appropriate follow-up
follow-up care,
care, be
be assertive
assertivewith
with your healthcare
your health careprogram
program in
inask�
ask-
ing
ing for
for follow�up appointmems.
follow-up appointments.

Step 2:
Step 2:Reviewing
ReviewingYour
YourRecords
Records

The doctor
The you do
doctor you do see
see will
will probably
probably want
want to
to review
review any
any prior
prior medical
medical records
records
that
that other
other doctors
doctors have
have wriUen
written about
about you.
you. The
The records
records usually
usually contain previ�
contain previ-
ous
ous diagnoses (which may
diagnoses (which m a y or may
or m a y not
not include
include bipolar
bipolar disorder),
disorder), your previ­
your previ-
ous
ous medications
medications (including
(including how
h o w well
well you responded and
you responded and if
if you
you experienced
experienced
side
side effects
effects from
from them)
them),, and
and relevant
relevant information about your
information about medical, social,
your medical, social,
and
and family history.
family history.
Your
Your doctor
doctor will
will ask
ask you
you to
to sign
sign a
a "release
"release of
of information"
information" form,
form, which
which al­
al-
lows
lows him
him or
or her
her to
to gain
gain access
access to
to these
these records.
records. Of
Of course,
course, you
you can
can refuse to
refuse to
sign this
sign this release,
release,but
butrefusing
refusingis
isnot
notininyour
yourbest
bestinterest.
interest.Even
Evenif if
you feel
you your
feel your
previous
previous psychiatric
psychiatric care
care was flawed, it
was flawed, it will help your
will help your new
n e w doctor
doctor [0
to know
know
about
about these flaws, as
theseflaws, as well
well as
as what
what treatmems
treatments were
were tried
tried and
and why
w h y they
they were
were
discontinued.
discontinued. Your
Your doctor
doctor will
will not
not necessarily
necessarily recommend
recommend the
the same treat­
same treat-
ments
ments as
as you've
you've had
had in
in the past.
the past.
If
If this
thisis
isyour
yourfirst
firstvisit
visittoto
aamental
mentalhealth
healthprofeSSional,
professional,you may
you not
may have
not have
prior
prior medical
medical records. If you
records. If you have
have had
had other
other psychiatric
psychiatric consultations,
consultations, you
you
may
m a y wonder
wonder why
w h y your
your new
n e w doctor
doctor needs
needs to
to conduct
conduct a
a new
n e w diagnostic evalua�
diagnostic evalua-
tion
tion and
and can't
can't simply
simply review
review your
your medical
medical records.
records. There
There are
are many
m a n y reasons
reasons
why
w h y medical
medical charts
charts are
are inadequate
inadequate for
for determining
determining your
your diagnosis,
diagnosis, treatment,
treatment,
or prognosis.
or prognosis. First,
First, medical
medicalcharts
chartsare
areoften
oftensketchy.
sketchy.They
They contain
containcomments
comments
like
like "patiem
"patient complains
complains of
of depression" without specifying
depression" without specifying the
the severity
severity of this
of this
depreSSion,
depression, whether
whether other
other symptoms
symptoms co-occurred,
co-occurred, or
or whether
whether the
the depression
depression
occurred
occurred in
in discrete
discrete episodes.
episodes. Chan notes are
Chart notes are often
often written
written by
by professionals
professionals
focused
focused on
on other
other aspects
aspects of
of your
your medical
medical or
or psychiatric his[Ory (for
psychiatric history (for example,
example,
an
an endocrinologist
endocrinologist evaluating
evaluating thyroid
thyroid functioning)
functioning) rather
rather than
than your bipolar
your bipolar
disorder.
disorder. So
So think
think of
of the
the prior
prior medical
medical records
records as
as supplemental
supplemental information
information
that
that may
m a y help your doc[Or
help your doctor clari fy the
clarify the diagnOSiS.
diagnosis. The majority of
The majority of his
his or
or her
her
judgments
judgments will
will come
c o m e from
from the
the face�to-face diagnostic interview.
face-to-face diagnostic interview.
 Into
Into the
the Doctor's
Doctor's Court: What to
(ourt: Whot to Expect from the
Expect from Diogoostic Process
the Diagnostic Process 441
1

Sfep What10 to
Step 3:3:Whal Expecl from from
Expect the Oiagno,'ic Inlerview Interview
the Diagnostic

The diagnosis
The diagnosis of bipolar
of bipolardisorder is established
disorder through a clinical
is established through interview,
a clinicalin int
which
which you you will
will be be asked
asked whether
whether you you have
have experienced
experienced certain certain symptoms
symptoms
over
over a a given period of
given period of time.
time. IfIf your
your doctor
doctor conducts
conducts a a comprehensive
comprehensive inter- inter­
view,
view, he heororsheshewill
willask
asknot
notonly
onlyabout
aboutyour yourmoodmooddisorder
disordersymptoms
symptomsbut butalsoalso
whether you
whether you have
have ever had psychotic
ever had psychotic symptoms
symptoms (for (for example,
example, hallucinations),
haUucinations),
drug
drug oror alcohol
alcohol abuse,
abuse, anxiety
anxietysymptoms,
symptoms,eating eatingdisorder
disordersymplOms,
symptoms,or orother
other
problems.
problems.
Filling
Filling out out the
the self-administered
self-administered checklist checklist from from the the last
last section
sectionmay may helphelp
your
your doctor
doctor obtain
obtain somesome of of this
this information
information more more efficiently.
efficiently. Because
Because the the
checklist
checklist is is based
based on on the
the DSM-IV.
DSM-IV, it it may parallel some
may parallel some of of the
the questions
questions your your
doctor
doctor will
will ask.
ask. You
You cancangive
giveitit to
to him
him or orher
herat at the
the beginning
beginningof of the
the first
firstinter­
inter-
view
view as as a
a way
way of of ensuring
ensuring thatthat hehe or or she
she follows
follows up up onon certain symptoms that
certain symptoms that
may concern you.
may concern you.
During
During this this interview,
interview, youryourdoclOrdoctorwill willprobably
probablywant wantto toknow
know not notonlyonly
which
which symptoms
symptoms you've you've experienced
experienced but but also
also which
which symptoms
symptoms typicallytypically go go
together with
together with other
other ones
ones (that
(that is,
is, inin discrete
discrete episodes),
episodes), the the severity
severity of these
of these
symptoms,
symptoms, and and their
their duration.
duration. YourYour doclOr
doctor has has a a threshold
threshold in mind for
in mind for how
how
severe
severe and
and howhow impairing
impairing aa symptom
symptom must must be be before
before it it is
is considered
considered part part of of
the
the bipolar
bipolar syndrome.
syndrome. For For example,
example, when when asking
askingabout about"loss"lossof ofenergy
energy or orfa­fa-
tigue,"
tigue," your
yourdoctor
doctorwill want(0to know
willwant knowsuch suchthings
thingsasas whether
whetheryou've you'vebeenbeenun­ un-
able
able to
to gogo toto work
work because
because of of fatigue,
fatigue, or or whether
whether you you havehave trouble doing
trouble doing
housework.
housework. When W h e n asking
asking about
about insomnia,
insomnia, he heor orsheshemay
may wantwant to toknow
know how how
many
many nighlS
nights of of the
the week
week youyou have
have trouble
trouble sleeping
sleeping and and whether
whether your lack of
your lack of
sleep
sleep impairs
impairs youryour ability
ability toto drive,
drive, concentrate
concentrate at at work,
work, play play sports,
sports, or orcon­
con-
duct
duct any
any of of your
your usual
usual activities.
activities.In manyways
Inmany waysbipolar
bipolarsymptoms
symptomsare are just
justex­ ex-
aggerations of normal mental, behavioral, and emotional processes, and some
aggerations of normal mental, behavioral, and emotional processes, and some
degree
degree ofof variability
variabiHty in in mood,
mood, sleep,
sleep,or oractivity
activitylevel
levelisispartpartofofthe the human
humancon­ con-
dition. Your
dition. Yourdoctordoctorhas hastotoestablish
estabHshwhether whetheryour yoursymptoms
symptomsmeet meetaacriterion
criterion
of
of severity
severity or or impairment.
impairment.
Interviews can
Interviews can be
be quite
quite subjective,
subjective,and andthere
thereisis always
alwaysthe thepossibility
possibilitythat that
the
the way
way youryour doctor
doctor asks
asks you
you thethe questions,
questions, and and the the way
way you you answer
answer them,them,
will
win affect
affect the final diagnosis.
thefinal diagnosis.Consider
Consider the the following
following interchange
interchange that that oc­oc-
curred
curred between
between aa doctordoctor andand aa person
person with with bipolar
bipolar disorder.
disorder. Notice
Notice thatthat thisthis
doctor
doctor probes
probes carefully
carefully forfor certain
certain symptoms,
symptoms, and and the the patient,
patient, correspond­
correspond-
ingly,gives
ingly, givesuseful
usefulexamples
examplesof ofhishisexperiences
experiencesand andbehavior.
behavior.

DOCTOR: Did
Doctor: Did you
youever have
ever a week-long
have period
a week-long when when
period you felt
you very happy
felt or happy or
very
very
very irritable?
irritable?
Patient: No,
PATIENT: No, not really.
not really.
42
42 THE DIAGNOSIS
THE DIAGNOSIS AND
ANDCOURSE
COURSEOF
OFBIPOlAR
BIPOIARDISORDER
DISORDER

DOCTOR:OrOr
Doctor: when
when you you
feltfelt
veryvery grouchy
grouchy or easily
or easily provoked?
provoked?
Patient: No.
PATIENT: No.
Doctor: How
DOCTOR: H o w about
about feeling
feeling charged
charged up
up and
and full
full of
of energy?
energy?
PATIENT: Yes.
Patient: Yes.
Doctor: What
DOCTOR: W h a t was
was that like?
that like?
Patient: Well,
PATIENT: Well,in
inMarch
March IIwas
wasrunning
runningat
atfull
fulltilt, full
tilt, of,of,
full like, all sorts
like, of ideas.
all sorts of ideas.
II thought
thought II could
could develop
develop aa weather
weather monilOring
monitoring system
system that
that could
could be
be op­
op-
erated from m
erated from my
y basement.
basement.
Doctor: How
DOCTOR: H o w were
were you
you sleeping
sleeping at
at the
the time?
time?
Patient: Not
PATIENT: Not at
at alll
all! [I didn't
didn't need
need to,
to, and
and II got
got resentful
resentful when
w h e n people
people told
told me
m e II
should.
should.
Doctor: Resentful?
DOCTOR: Resentful? Tell
Tell me
m e more.
more.
Patient: Well,
PATIENT: Well,nobody
nobody appreciated
appreciatedwhat
what IIwas
was trying todo.
trying1O do. Everybody
Everybody seemed
seemed
like
like they
they were
were moving
moving slowly.
slowly. One
O n e time,
time, II practically bit this
practically bit this guy's
guy's head
head
off
off for
for knocking
knocking on
on my
m y door
door when
w h e n II was
was in
in the
the middle
middle of
of aa project.
project. And
A n d II
yelled
yelled at
at my
m y kids
kids a
a bunch
bunch ofof times
times because
because they
they kept
kept interrupting
interrupting me.me.

In this
In thisexample,
example,the
thedoctor
doctorhas found
has evidence
found of of
evidence irritable moodmood
irritable otherother
and and
manic symptoms
manic symptoms in
in this
this patient's history. Had
patient's history. H a d the
the doctor
doctor not
not done this prob-
done this prob­
ing, evidence
ing, evidence of this bipolar
of this bipolar syndrome
syndrome might
might not
not have
have emerged.
emerged.
The
The diagnostic
diagnostic interview
interview will
will take
take at
at least
least an hour or
an hour or two.
two. If
If you
you have
have aa
particularly
particularly complicated
complicated set
set of
of symptoms,
symptoms, your
your doctor
doctor may
m a y request
request several
several
sessions
sessions to
to be reasonably sure
be reasonably sure of
of the
the diagnosis.
diagnosis. A long interview
A long interview can
can be te­
be te-
dious,
dious, especially
especially if
if you've
you've been through one
been through one before,
before, but
but you'll
you'll find
find that
that your
your
and the doctor's
and the time has
doctor's time has been
been well
well spent. The information
spent. The you provide
information you will
provide will
inform
inform aa careful
careful diagnosis, which will
diagnosis, which will almost
almost certainly
certainly translate better
into better
translate into
treatment
treatment.

Does the
Does the Diagnosis
Diagnosis Fit?
Fit? Could
Could Vou
You Have
Have Another
Another Disorder
Disorder Instead?
Instead?

Whether youare
Whether you are having
haVing your
your first
firstproblems
problemswith withdepression
depression or or
mania, andand
mania,
possibly
possibly even
even if
if you
you have
have had
had numerous
numerous episodes
episodes of
of mood
m o o d disorder,
disorder, you
you will
will
probably want
probably want to
to discuss
discuss the
the accuracy
accuracy of
of the
the diagnosis with your
diagnosis with your doctor.
doctor. Does
Does
the diagnosis give a reasonable explanation for the kinds of problems
the diagnosis give a reasonable explanation for the kinds of problems you've
you've
had
had with
with your
your mood
m o o d states,
states, behavior,
behavior, and
and relationships
relationships with with other
other people?
people?
Could you have
Could you have another
another disorder
disorder instead?
instead? You
Y o u may
m a y wonder
wonder whether
whether the
the mood
mood
swings you
swings you experience are really
experience are really aa part
part of
of your
your personality
personahty (see
(see Chapter 4).
Chapter 4).
You
Y o u may
m a y believe
beheve that
that you
you have
have aa different
different psychiatric
psychiatric disorder
disorder or
or no
no disorder
disorder
 Into
Intothe
theDocto(s
Doctor'sCoUr!: Whotto
Court: WhatExpect homfrom
to Expect the DiognOSli( Process
the Diagnostic Process 43 43

at all.
at all.Alternatively,
Alternatively, you may
you may believe,
believe, rightfully,
rightfully, that
that youyou
havehave another
another psychi­
psychi-
atric
atric disorder
disorder inin addition
addition to to bipolar
bipolar disorder.
disorder.
Bipolar
Bipolar disorder
disorder canc a n be
b e difficult
difficult to to tell
tell apart
apart from
f r o m other
other disorders
disorders that that
share
share features
features inin common
c o m m o n with
w i t h it.
it. In
In this
this section,
section, II discuss
discuss the the problem of
p r o b l e m of
misdiagnosis.
misdiagnosis. II also
also discuss
discuss thethe disorders
disorders that that areare orten
often confused
c o n f u s e d with
w i t h bipolar
bipolar
disorder
disorder and
a n d how
h o w they
they differ
differ from
f r o m it.
it. Sometimes
S o m e t i m e s these
these disorders
disorders are are diagnosed
diagnosed
alongSide
alongside ofof bipolar
bipolar disorder
disorder ("comorbidity").
("comorbidity").

Wha'Can
What Can You
You Do
Do if
if You
You Think
ThinkYou've
You^veBeen
BeenMisdiagnosed?
Misdiagnosed?

There are
There are many reasons why
many reasons bipolar disorder
why bipolar disordercan bebe
can hard to distinguish
hard from from
to distinguish
other
other disorders.
disorders. First,
First, moods
m o o d s can
can vary
vary for
for any
any number
n u m b e r of
of reasons,
reasons, which
which can can
include
include hormones,
hormones, personal
personal stress,
stress, personality
personahty disturbances,
disturbances, diseases
diseases of of the
the
brain,
brain, oror ingestion
ingestion of of drugs
drugs or or alcohol.
alcohol. Second,
Second, people
people withwith thethe disorder often
disorder often
have
have trouble
trouble describing
describing theirtheir mood
m o o d states
states to to others
others and and giving
giving accurate histo­
accurate histo-
ries
ries of
of their
their disorder.
disorder. Third,
Third, mental
mental health
health profeSSionals
professionals are are not
not always
always ade­ade-
quately
quately trained
trained to to recognize
recognize the the more
more subtle
subtle forms
forms of of the
the disorder
disorder (for
(for exam­
exam-
ple,
ple, mixed
mixed states,
states, rapid
rapid cycling,
cycling, mild
mild depressions,
depressions, hypomania).
hypomania).
Diagnostic
Diagnostic confusion
confusion can can also
also occur
occur because
because of of the
the diagnostic criteria
diagnostic criteria
themselves.
themselves. Certain
Certain symptoms
symptoms are are characteristic
characteristic of of more
more than
than one disorder.
one disorder.
PsychotiC
Psychotic experiences
experiences (for (for example,
example, grandiose
grandiose delusions)
delusions) can can occur
occur in in other
other
disorders,
disorders, such such as asschizophrenia.
schizophrenia.Problems
Problemswith withdistractibility
distractibilityoccuroccur in inmania
mania
and
and inin auention-deficitlhyperactivity
attention-deficit/hyperactivity disorder disorder (ADHD).
( A D H D ) . Sleep
Sleep disturbance
disturbance and and
irritability
irritability cancan occur
occur in in recurrent
recurrent depreSSion
depression and and anxiety
anxiety disorders
disorders as well as
as well as

bipolar
bipolar disorder.
disorder. Lastly,
Lastly, mood
m o o d variability
variabilityis isaakey
keyfeature
featureof ofborderline
borderlineperson­
person-
ality
ality disorder.
disorder.
Try
Try to to be
be as
as patient
patient as as you
you cancan with
with the
the diagnostic
diagnostic process.
process. TheThe common
common
use
use of of the
the DSM-IV
D S M - I V together
together withwith improved
improved trainingtraining in in the
the recognition
recognition of of
mood
m o o d disorders
disorders makem a k e diagnosis
diagnosis moremore reliable
reliable thanthan it it used
used to to be.
be. Nonetheless,
Nonetheless,
errors
errors inevitably
inevitably occur.
occur. YourYour phYSician
physician maym a y need
need to toobserve
observeyou you during
during an an ep­
ep-
isode and once you have recovered to be sure of your diagnosis. If you have
isode and once you have recovered to be sure of your diagnosis. If you have
strong
strong doubts
doubts aboutabout thethe diagnosiS
diagnosis you you have
have beenbeen given,
given, getting
gettingaasecond
second opin­
opin-
ion
ion isis aa good idea.
good idea.
If
If you
you do do seek
seek a a second
second opinion,
opinion, be beprepared
prepared to tobebeasked
asked some
some of ofthe
thesame
same
questions
questions about about your
your symptoms
symptoms that that you
you were
were asked
asked the the first time. Tell
first time. the
Tell the
new
n e w psychiatrist
psychiatrist why w h y you
you think
think youyou have
have somes o m e disorder
disorder other
other than
than bipolar
bipolar
and,
and, speCifically,
specifically, why w h y you
you don't
don'tthink
thinkthethediagnostic
diagnosticcriteria
criteriaforforbipolar
bipolardisor­
disor-
der fit. Alternatively,
derfit. Alternatively, if if you
you think
think that
that bipolar
bipolar is is the
the correct
correct diagnOSiS
diagnosis but but
you've
you've beenbeen diagnosed
diagnosed with with something
something else,else, tell
tell the
the new
n e w physician
physician w why
h y you
you
believe
believe this.
this. Bring
Bring along
along a
a close
close family
family member,
m e m b e r , significant
significant other,
other, or
or trusted
trusted
friend. This
friend. This person
person can can offer
offer a a different
different perspective
perspective on on your
your symptoms
symptoms and life
and life
44
44 THE
THE DIAGNOSIS
DIAGNOSISAND
ANDCOURSE
COURSEOfOF
BIPOlAR DISORDER
BIPOIAR DISORDER

experiences,
experiences,which
whichmaymay be
bequite useful
quite to the
useful to mental health
the mental professional
health who
professional who
makes the diagnosis.
makes the diagnosis.
Most
Most of
of all,
all,it's
it'simportant
importanttotowork
workcollaboratively
collaborativelywith yourdoctor.
withyOUT doctor.Relate
Relate
what
what you
you can
can about
about your history and
your history and report
report events
events and symptoms as
and symptoms accu­
as accu-
rately
rately as
as possible,
possible, even
even if
ifwhat
whatyou
youare
arereponing
reportingisissometimes
sometimesembarrassing
embarrassingoror
painful
painful to
to talk
talk about.
about. Try
Try toto see
see things
things from
from the doctor's perspective.
the doctor's perspective. If
If the
the
doctor
doctor thinks
thinks you
you are bipolar, what
are bipolar, whatisisthe
therationale
rationalebehind
behindthat
thatopinion?
opinion?What
What
diagnostic
diagnostic criteria
criteria does
does the
the doctor
doctor think
think apply
apply to you? Is
to you? Is he
he or
orshe
she considering
considering
other
other diagnoses,
diagnoses, and
and if
if not,
not,why
w h y not?
not?

(omorbid
Comorbid Disorders
Disorders

The
The term
term "comorbidity"
"comorbidity"refers refersto the
to co-occurrence
the co-occurrenceof twoofor two
more orpsychiatric
more psychiatric
disorders
disorders in in the
the same
same person.
person. M Many
a n y people
people have
have more
more than
than one
one DSM-IV
D S M - I V psy­
psy-
chiatric
chiatric disorder.
disorder. InIn fact,
fact, two
two carefully
carefullydesigned
designednational
nationalsurveys
surveysof ofpsychiat­
psychiat-
ric
ric disorders in the general population—the National Comorbidity Survey and
disorders in the general population-the National Comorbidity Survey and
the
the Epidemiologic
Epidemiologic Catchment
Catchment Area Area study-concluded
study—concluded that of people
5 6 - 6 0 % of
that 56--60% people
with one
with one psychiatric
psychiatric disorder repon two
disorder report two or
or more disorders (Kessler
more disorders (Kessler et et aI.,
al.,
1994;
1994; Robins
Robins et et al.,
al., 1991).
1991). InIn clinical
clinical practice,
practice,people
peopleareareoften
oftengiven
givenmultiple
multiple
diagnoses, sometimes because
diagnoses, sometimes because theythey have
have more
more than
than one
one disorder
disorder and and some­
some-
times
times because
because thethe clinician
clinician isn't
isn't sure
sure which
which diagnosis best applies
diagnosis best applies and there­
and there-
fore diagnoses more than one.
fore diagnoses more than one.
What
W h a t does
does aa person
person withwith two
two oror more
more comorbid
comorbid disorders
disorders look
look like?
like? Con­
Con-
sider Elena, a 49-year-old woman who has been diagnosed with bipolar II dis­
sider Elena, a 49-year-old w o m a n w h o has been diagnosed with bipolar II dis-
order and ADHD.
order and ADHD.

had had
Elena
Elena several
several long-lasting depressive
long-lasting depreSSive episodes,
episodes, during which
during which hadhad
sheshe
had difficulty
had difficulty holding
holding a a job.
job.Her
Her hypomanic
hypomanic periods
periods were characterized by
were characterized by
irritability, racing thoughts,
irritability, racing thoughts, and
and sleep
sleep disturbance.
disturbance. Her Her husband, Chris,
husband, Chris,
was
was understanding
understanding of her depression
of her depression but
but became
became enraged
enraged atat the
the fact that
fact that
w h e n he
when he tried
tried to
to talk
talk to her about
to her about her
her job
job situation,
situation, Elena's
Elena's eyes
eyes would
would
glaze over and
glaze over and she
she seemed
seemed not
not to
to be
be listening.
listening. Chris
Chris also
also complained that
complained that
she
she made
made a a lot
lot of
of careless
careless mistakes:
mistakes: When
W h e n she
she sent
senther
herresume toprospec­
resume to prospec-
tiveemployers,
tive employers,there
therewas
wasoften
oftenaapage
pagemissing
missingor orthe
theprinting wasslanted.
printingwas slanted.
She
She also frequently forgot
also frequently forgot appointments
appointments withwith her
her doctors.
doctors. Her forgetful­
Her forgetful-
ness and
ness and inattention
inattention seemed
seemed toto characterize
characterize her her behavior
behavior most
most of the
of the
time, even
time, even w when
h e n she wasn't depressed.
she wasn't depressed.

In Elena's
In Elena's case, the codiagnosis
case, of bipolar
the codiagnosis of disorder
bipolar with ADHD
disorder led her
with ADHDphysician
led her physicia
to recommend
to recommend a a regimen
regimen that
that included
included a mood
am o o d stabilizer
stabUizer and dextroampheta-­
and dextroampheta
mine (Adderall),
mine (Adderafl), a
a drug
drug deSigned
designed to
to improve
improve attention
attention and
and concentration.
concentration.
 Intothe
Into the Doctor's
Dodo(sCourt:
Court:What
Whotto
toExpect
Expectfrom
homthe
theDiagnostic PIOCes:5
DiagnosticProcess 4 45
5

Psychiatric Disorders
Psychiatric Disorders Often
Often CConfused Bipolar Disorder
with Bipolar
o n f u s e d with Disorder

•• Attention-deficit/hyperactivity
Attention-deficitlhyperactivity disorder (ADHD)
disorder (ADHD)
• Borderline personality
• Borderline personality
•• Cyclothymic
Cyclothymic disorder
disorder
•• Schizophrenia
Schizophrenia or
or schizoaffective
schizoaffective disorder
disorder
•• Recurrent
Recurrent major
major depreSSive
depressive disorder
disorder
• Substance-induced
• Substance-induced mood
m o o d disorder
disorder

The
T sidebar o
h e sidebar on this page
n this page lists
lists disorders
disorders that
thatare
areoften
often comorbid
comorbid with
with bipo­
bipo-
lar disorder
lar disorder or
or confused
confused with it diagnostically.
with it ADHD,
diagnostically. A borderline personality
D H D , borderline personality
disorder,
disorder, and
and cyclothymic
cyclothymic disorder
disorder can
can all
allbe
be codiagnosed
codiagnosed with
with bipolar
bipolar disor­
disor-
der.
der. The others require
T h e others require that the clinician
that the clinician make
make a
a decision between these
decision between these diag-
diag­
noses
noses and
and bipolar disorder.
bipolar disorder.

Attention-Deficit/Hyperactivity
Attention-Deficit/Hyperactivity Disorder (ADHD)
Disorder (ADHD)

Do you have
Do you have any
any of
of the
the following
followingproblems?
problems?

• Difficulty
• Difficulty paying
paying attentionto
attention to details?
details?
•• Making
Making careless
carelessmistakes
mistakes in
inwork
w o r k or
or other
other activities?
activities?
•• Trouble
Trouble listening
listening to
to others?
others?
•• Problems
Problems with
with organization?
organization?
•• Distraction?
Distraction?
•• Forgetfulness?
Forgetfulness?

ADHDADHD is a childhood-onset
is a childhood-onset disorder
disorder characterized
characterized bybydifficulty
difficulty attending
attending
to
to tasks.
tasks.AA child
child who
w h o has
has ADHD
A D H D with
with hype�ctivity
hyperactivity or impulsivity will
or impulsivity will fidget,
fidget,
blurt
blurt out
out answers
answers to
to questions,
questions,have
havedifficulty
difficultyremaining
remainingseated.
seated,and
andtalk
talkex­
ex-
cessively
cessively (American
(American Psychiatric
Psychiatric Association,
Association, 1994;;1, 2000). Notice
1994a, 2000). Notice how
h o w simi­
simi-
lar
larthese
these symptoms
s y m p t o m s are
are to
to mania!
mania! Distinguishing
Distinguishing childhood-onset
childhood-onset bipolar
bipolar dis­
dis-
order
order from
from ADHD,
A D H D , or
or distingui�hing
distinguishing adult
adult bipolar
bipolar disorder
disorder from
from the
the
continuation
continuation of
ofan
an ADHD
A D H D first
firstdiagnosed
diagnosed in
in childhood,
childhood,is
isextremely
extremely difficult.
difficult.
And
A n d it
itis
ispossible
possible to
tohave
have both.
both.Some
S o m e studies
studieshave
have found
found that
thatas
asmany
m a n y as
as 90%
90%
of
ofchildren
childrenand 3 0 % of
and 30% ofadolescents
adolescentswith
vidthbipolar
bipolardisorder
disorder also
also have
have ADHD,
A D H D , al­
al-
though not everyone
though not everyone agrees
agrees on
on this (Geller &:
this(Geller & Luby.
Luby, 1997).
1997).
Distinguishingbipolar
Distinguishing bipolardisorder
disorderfrom
fromADHD
A D H D is
isimportant,
important,because
becausethe
thepri­
pri-
mary
mary drugs
drugs for
for treating
treating ADHD
A D H D are
are stimulants
stimulants such
such as
as methylphenidate
methylphenidate
46
46 THE
THE DIAGNOSIS
DIAGNOSISAND
ANDCOURSE OF OF
COURSE BIPO�R
BIPOLDISORDER
AR DISORDER

(Ritalin) oror
(Ritalin) Adderall. These
Adderall. drugs
These are not
drugs areusually given togiven
not usually people
towith bipolar
people with bipolar
disorder
disorder unless accompanied by
unless accompanied by a
a mood
m o o d stabilizing
stabilizing agent
agent like
like lithium
lithium or
or
Depakote. You'll
Depakote. You'll learn
learn more
more about these medications
about these medications in Chapter 6.
in Chapter Ritalin,
6. Ritalin,
like
like many
m a n y stimulating
stimulating drugs,
drugs, can
can increase
increase the
the chances
chances of
of developing
developing a
a manic
manic
or hypomantc episode
or hypomanic episode (see the case
(see the case study on page
study on 53).
page 53).
There is currently
There is currently a
a trend
trend among
a m o n g mental
mental health
health professionals
professionals to co�
to co-
diagnose
diagnose bipolar
bipolar disorder
disorder and
and ADHD,
A D H D , particularly
particularly in children. There
in children. There are
are no
no
separate
separate diagnostic
diagnostic criteria
criteria for
for bipolar
bipolar disorder in children.
disorder in children, and, unfortu·
and, unfortu-
naleiy,
nately, this
this trend
trend sometimes
sometimes leads
leads to
to imprecision. It is
imprecision. It is possible to have
possible lO both,
have both,
and
and many
m a n y people
people do,
do, but
but there
there are
are also
also ways
ways to
to tell
tell them apart.
them apart.
First,
First, the
thecognitive
cognitiveproblems
problems associated
associatedwith
withADHD
A D H D do
do not
notchange
changemuch
much
from
from day
day to
to day
day or
or week
week to week, unless
to week, unless the
the person
person is
is taking Ritalin or
taking Ritalin or a
a simi­
simi-
lar
lar drug.
drug. People
People with
with ADHD
A D H D have
have fairly constant problems
fairly constant problems with
with attention,
attention, dis­
dis-
tractibility,
tractibility,and
and organization,
organization,regardless
regardlessof
oftheir
theirmood
m o o d state.
state.In
Incontrast,
contrast,peo­
peo-
ple
ple with
with bipolar
bipolar disorder
disorder may
m a y become
become impulsive
impulsive and
and have
have difficulty
difficulty attending,
attending,
but
but mainly
mainly when
w h e n they
they are
are in
in the
the midst
midst of
of a
a manic, mixed, or
manic, mixed, or depressed epi­
depressed epi-
sode. For
sode. For example,
example, Teri, age37,
Teri, age 37,worked
worked successfully
successfullyas
asaagraphic
graphicartist
artistduring
during
her
her periods
periods of
of mood
m o o d stability.
stability. Only
Onlywhen
w h e n she
shewas
wasdepressed
depressedwas
wasshe
sheunable
unableto
to
concentrate
concentrate on
on her
her design layouts.
design layouts.
In
In addition,
addition, ADHD
A D H D is
isnot
not accompanied
accompanied by
by the
theextreme
extreme highs
highsand
and lows
lowsof
of
mood
m o o d states
states that
that are
are the
the hallmark
hallmark of
of bipolar
bipolar disorder.
disorder. It
It is
isnot
nottypical
typicalfor
forpeo­
peo-
ple with ADHD
ple with A D H D to
to experience
experience elated highs, goal-directed
elated highs, behavior, hyper-
goal-directed behavior, hyper­
sexuality,
sexuality, decreased
decreased need
need for
for sleep,
sleep, or
or grandiOSity
grandiosity (Geller
(Geller el al., 1998),
et al., 1998), or to
or to
experience
experience deep
deep depressions
depressions alternating
alternating with
with periods
periods of
of stable
stable mood.
mood.
ADHD
A D H D is
is usually
usually associated
associated with
with difficulty
difficulty in
in school
school settings. W h e n you
settings. When you
were in
were in school,
school, were
were you
you fairly
fairlyconSistently
consistently able
ableto
tokeep
keep your
your mind
mind on
on class
class
activities?
activities? Have
Have you generally functioned
you generally functioned well
well in
in tasks
tasks that
that require
require concentra­
concentra-
tion
tion and
and effort
effort since
since then?
then? If
If the
the answer
answer to
to both
both of
of these
these is yes, it
is yes, it is
isunlikely
unlikely
that you
that you have
have ADHD,
A D H D , although
although a
a thorough
thorough answer
answer to
to this
this question
question requires
requires
cognitive
cognitive testing. If you
testing. If you think
think you
you might
might have ADHD,
have A raise the
D H D , raise pOSSibility
the possibility
with
with your doctor and
your doctor and ask
ask for
for a
a separate
separate evaluation
evaluation of
of that
that condition.
condition. In
In addi­
addi-
tion
tion to
to medications
medications for ADHD,
for A there may
D H D , there m a y be
be �cognitive
"cognitive rehabilitation" pro­
rehabilitation" pro-
grams
grams in
in your
your area
area that
that you
you can
can enroll in to
enroll in to help
help you
you develop
develop strategies
strategies for
for im­
im-
proving
proving your
your attention
attention and
and concentration.
concentration.

Borderline Personality
Borderline Disorder
Personality Disorder

Do you
Do you have
have .. ..

• Difficulty
• Difficulty definingfor
defining for yourself
yourself who
who you
you are
are or
orwho
who you
you want to be?
want lO be?
•
• A
A history
history of
of very
very intense
intense and
and unstable
unstable relationships
relationships with
with people?
people?
 Into theDocto(s
Intothe Doctor'sCourt: What Expect
Whotto
Court: the Diagnostic
homfrom
to Expect Proces5
the Diagnostic Process 47 47

• A history
• A history of making making
of great to efforts
great
efforts to keep
keep people people from
from abandoning or abandoning or
leaving you?
leaving you?
• Difficulty controlling
• Difficulty angry outbursts?
controUing angry outbursts?
•
•A
A history ofimpulsive
history of behavior in
recklessbehavior
or reckless
impulsive or sex,spending
in sex, money, or
spending money, or
eating?
eating?
•A history
•A ofself�destructive
history of acts (for
self-destructive acts example,self�cutting)?
(for example, self-cutting)?

Personality
Personality disorders
disorders are long�lasting patterns
arelong-lasting disturbance
patternsofof in thinking,
disturbance in thinking,
perceiving, response, interpersonal
emotional response,
perceiving, emotional interpersonal functioning, impulse con�
and impulse
functioning, and con-
trol. The
trol. hallmarks of
The hallmarks personality disorder
borderline personality
of borderline are instability
disorder are in mood,
instability in mood,
relationships, and
relationships, and one's senseof
one'ssense ofself Peoplewith
identity.People
oridentity.
selfor borderlinedisor�
withborderline disor-
der feel
der empty and
chronically empty
feel chronically bored, have
and bored, terrible trouble
have terrible alone, and
being alone,
trouble being and
frequently make
frequently gestures or
suicidal gestures
m a k e suicidal or threats. tend to
They tend
threats. They have remarkably
to have remarkably re-re�
active m o o d s and
active moods intensely sad,
become intensely
quickly become
and qUickly anxious, or
sad, anxious, irritable in
or irritable re�
in re-
sponse to
sponse to events involving close
events involving m o o d states
These mood
relationships. These
close relationships. tend to
states tend last
to last
for only
for hours or,
few hours
only aa few most,aafew
atmost,
or, at days(American
fewdays PsychiatricAssociation,
(American Psychiatric Association,
1994a, 2000).
1994a, Borderline personality
2000). Borderline disorder generally
personahty disorder continues throughout
generally continues throughout
adulthood, unless
adulthood, seeks treatment.
individual seeks
the individual
unless the treatment.

Carla,
Carla, 27,27.
age age calledher
called herboyfriend upto
boyfriendup to 10 times a
10 times day. When
a day. When she did,
she did,
she often
she raged at
often raged h i m for
at him "not being
for "not there for
being there her" and,
for her" and, if she couldn't
if she couldn't
reach him,
reach accused him
him, accused him of being w
of being ith another
with another woman.
woman. W When alone, she
h e n alone, she
would feel
would like she
feel like was disappearing,
she was and feel
disappearing, and intolerable cravings
feel intolerable cravings toto
smoke, eat, drink
smoke, eat, vomit, or
alcohol, vomit,
drink alcohol, cut herself
or cut with glass.
herself with She tried
glass. She to
tried to
hurt herself in
hurt herself minor ways
in minor several times,
ways several but never
times, but severely enough
never severely enough to to
threaten her life.
threaten her Theseproblems
life. These had continued
problemshad forseveral
continued for years,despite
severalyears, despite
the
the fact that she
fact that was in
she was had tried
and had
psychotherapy and
in psychotherapy various forms
tried various of anti�
forms of anti-
depressant medication.
depressant medication.

There are are

There several
several parallelsbetween
parallels bipolar disorder,
and bipolar
borderline and
betweenborderline disorder,par�
par-
ticularly the rapid
ticularly the cycling forms,
rapid cycling forms, but
but there are also
there are discernible differences.
also discernible In
differences. In
borderline disorder the
borderline disorder m o o d states
changing mood
the changing usually very
are usually
states are very short-lived and
short�lived and
reaction to
a reaction
a to being or even
rejected or
being rejected slighted by
just slighted
even just people with
by people with w whom the per�
h o m the per-
son is affiliated.
son is affiliated.In fact,the
Infact, disturbances
the disturbances people
inin people with borderline
with borderline personality
personality
are most visible
are most visible w h e n one
when observes their
one observes romantic relationships.
their romantic They tend
relationships. They to
tend to
idealize
idealize and devalue those
then devalue
and then with w
those with whom they become
h o m they close, and
become close, go to
they go
and they to
great lengths
great lengths to avoid being
to avoid being what experience as
they experience
what they as abandoned.
abandoned.
with borderline
People with
People personality disorder
borderline personality disorder do become depressed
do become depressed and of�
and of-
ten meet full
ten meet for a
criteria for
full criteria depreSSive episode
major depressive
a major episode at some
at s point in
o m e point their
in their
lives. But they
lives. But do not
they do develop the
notdevelop manic or
fullmanic
the full ormixed syndrome un�
affectivesyndrome
mixed affective un-
less they
less also have
they also have a a bipolar disorder. Between
bipolar disorder. Between 1 0 % and
10% and 440%
0 % ofof people with
people with
48
48 THE DIAGNOSISAND
THE DIAGNOSIS COURSEOFOFBIPOlAR
ANDCOURSE DISORDER
BIPOLAR DISORDER

bipolardisorder
bipolar disorder also meet
also diagnostic
the the
meet diagnosticcriteria for a borderline
criteria personality
for a borderline personality
(Carpenter et al., 1995; George eL aI., 1996; Peselow
(Carpenter et al., 1995; George et al., 1996; Peselow et al, 1995). et al., 1995).
Why is it
W h y is important to
it important k n o w if
to know have borderline
you have
ifyou personality as
borderline personality well as
as well as
instead 00
(or instead
(or of) bipolar Currently, there
disorder? Currently,
bipolar disorder? are no
there arc agreed-on gUidelines
no agreed-on guidelines
for the
for treatment of
drug treatment
the drug people with
of people with borderline personality or
borderline personality those with
or those with
both borderline and
both borderline disorders. It
bipolar disorders.
and bipolar It is believed that
generally believed
is generally people with
that people with
both disorders are
both disorders are more refractory" or
"treatment refractory"
more "treatment have morc
or have trouble respond­
more trouble respond-
ing or adhering
ing or adhering to m o o d stabilizing
to mood Psychiatric Association,
(American Psychiatric
drugs (American
stabilizing drugs Association,
1994b). If
1994b). you are
If you finding the
trouble finding
having trouble
are having the right combination of
right combination of medica­
medica-
tions,and
tions, someof
and ififsome thepreceding
ofthe featuresfit
precedingfeatures fityou, youhave
possibleyou
you,ititisispossible havethis
this
complicating condition. In
complicating condition. In these cases, it
these cases, it is important for
especially important
is especially for you
you to
to
psychotherapy in
consider psychotherapy
consider addition to
in addition medication. The
to medication. The formform of therapy that
of therapy that
has the most
has the support for
research support
most research for borderline disorder is
personality disorder
borderline personality is ··dialecti­
"dialecti-
cal therapy," a
behavior therapy,"
cal behavior form of
a form cognitive-behavioral therapy,
of cognitive-behavioral therapy, in both group
in both group
and individual settings,
and individual developed by
settings, developed Linehan (1993).
Marsha Linehan
by Marsha (1993).

Cyclothymic Disorder
Cyclothymic Disorder

Do have .. ..
you have
Do you

• Short
• Short periods of of
periods feelingactive,
feeling active, irritable,
irritable, excited?
and and excited?
• Short periods
• ShOT[ mildly depressed?
feeling mildly
of feeling
periods of depressed?
•A tendency
•A to alternate
tendency to and forth
back and
alternate back the two?
between the
forth between two?

To make
To make matters eveneven
matters more
more complicated,
complicated, youyou can
can have fluctuating form
a afluctuating
have form
of mood
of marked by
disorder marked
m o o d disorder short periods
by short periods of hypomania alternating
of hypomania with
alternating with
short, periods of
mild periods
short, mild depression. To
of depression. T o have cyclothymic disorder,
have cyclothymic you must
disorder, you must
have between high
alternated between
have alternated and low
high and low periods for at
periods for at least two consecutive
least two consecutive
years and
years never be
and never without mood
be without symptoms for
disorder symptoms
m o o d disorder for more than two
more than two
months
months at time (American
a time
at a Psychiatric Association,
(American Psychiatric Association, 1994a, 2000). HHow
1994a, 2000). is
o w is
different from
this different
this 1I disorder?
bipolar II
from bipolar disorder? Consider the following
Consider the vignette:
follOwing vignette:

Katherine was was

Katherine a 30-year-old
a 30-year-old woman
woman who,
who, since
since adolescence,had
adolescence, experi­
hadexperi-
enced
enced a a panern
pattern of of alternating between three-day
alternating between periods in
three-day periods which she
in which she
cried a lot and felt sad and less interested in things, followed by another
cried a lot and felt sad and less interested in things, foflowed by another
three-day period in
three-day period which she
in which would feel
she would feel irritable, energetic, and
irritable, energetic, talk­
and talk-
ative. She had
ative. She had never been hospitalized
never been either her
for either
hospitalized for depressive or
her depressive or
hypomanic symptoms,
hypomanic symptoms, nor she been
had she
nor had unable to
suicidal, unable
been suicidal, concemrate,
to concentrate,
or lost
or amounts of
significam amounts
lost significant weight. Her
of weight. sometimes com­
boyfriend sometimes
Her boyfriend com-
plained about
plained about her moodiness and
her moodiness Although it
ragefulness. Although
and ragefulness. was more
it was diffi­
more diffi-
cult her to
for her
cult for work wwhen
to work she was
h e n she was depressed, she had
depressed, she lost aa job
never lost
had never be­
job be-
cause of
cause of it.
it.
 Into
Intothe
theDoctor's
Doctor'sCourt:
Court:Whot to to
What hpect homfrom
Expect the the
Djognos�( Process
Diagnostic Process 49 49

Katherine
Katherine received received
a diagnosisa diagnosis of cyclothymic
of cyclothymic rather disor-
rather than bipolar than bipolar disor�
der.
der. Had
H a d her
h e r depressions
depressions been b e e n worse
w o r s e and/or
and/or required
required hospitalization,
hospitalization, h her
e r diag­
diag-
nosis
nosis would
w o u l d be
b e changed
c h a n g e d to
to bipolar
bipolar II II disorder
disorder with
w i t h cyclothymic disorder. OOne
c y c l o t h y m i c disorder. ne
can
can be
be diagnosed
diagnosed with
with both!
both!
The
T h e psychiatrist
psychiatrist Hagop H a g o p Akiskal
Akiskal from from thethe University
University of of California,
California, San San
Diego
Diego School
School of of Medicine,
Medicine, views viewscyclothymia
cyclothymia as asaadisturbance
disturbance of oftemperament
temperament
that predisposes
that predisposes people people to to bipolar
bipolar disorder
disorder (Akiskal,
(Akiskal, 1996; 1996; see see also
also Chapter
Chapter
4).
4). In
In fact,
fact,cyclothymia
cyclothymiahas hasaalot lotinincommon
c o m m o n with
withbipolar
bipolar1Iand and II IIdisorders,
disorders,inin
terms
terms of of ilS
its pattern
pattern of of inheritance
inheritance and and ilS
its presumed
presumed biology.
biology. Cyclothymia
Cyclothymia is is
listed
listed inin the
the DSM�lV
D S M - I V asas aa mild
mild form
form of of bipolar
bipolar disorder.
disorder. About About one one inin every
every
three people
three people withwith cyclothymia
cyclothymia progresses
progresses to to bipolar
bipolar 1I or or II II disorder
disorder (that
(that is,
is,
they develop
they develop full-blown
full-blown manic manic episodes,
episodes, longerlongerhypomanias,
hypomanias,or ormajor
major depres­
depres-
sive episodes) over periods of two to three years
sive episodes) over periods of two to three years (Akiskal et al., 1977). (Akiskal et aI., 1977).
There
There are are very
very fewfew studies
studies on on thethe ideal
ideal treatmenlS
treatments for bipolar II
for bipolar II disorder
disorder
versus
versus cyclothymia.
cyclothymia. As As a a result,
result, psychiatrislS
psychiatrists tend tend to to treat
treat themthem in in a similar
a similar
way,
way, with
with mood
m o o d stabilizers
stabilizers like like lithium
lithium or or Depakote.
Depakote. Nonetheless,
Nonetheless, people people with
with
cyclothymia can
cyclothymia can sometimes
sometimes function without medication
function without medication because because their disor­
their disor-
der
der is
is generally
generally less less severe
severe andand less
less impairing.
impairing. For For some,
some, the the label
label cyclothymia
cyclothymia
feels
feels less
less frightening
frightening than than bipolar
bipolar 11 II disorder,
disorder, eveneven though
though they have many
they have many
similar features.
similar features.

Schizophrenia
Schizophrenia

If you
If you are
areaaperson
personwith
withschizophrenia, youyou
schizophrenia, will experience
will somesome
experience of the
of fol­
the fol-
lowing
lowing symptoms:
symptoms:

• Delusions,
• Delusions, suchsuch
as a as a feeling
feeling of being
of being followed,
followed, a belief
a belief that
that your
your
thoughts
thoughts are
are being
being controlled
controlled by
by an
an outside
outside force,
force, or
or a
a belief
belief that
that some­
some-
one
one (or
(or some
s o m e organization)
organization) wanlS
wants to
to hun
hurt you
you
•• Hallucinations,
Hallucinations,in in which
which you
you hear
hear aa voice
voice or
or see
see aa vision
vision
•• lack
Lack of
of motivation,
motivation, apathy,
apathy, and
and disinterest
disinterest in
in seeing
seeing anyone
anyone
•• Loss
Loss of
of or
or "blunting"
"blunting" of of emotions
emotions
•• Very
Very jumbled
jumbled or or confused
confused communication
communication and and thinking
thinking

It can
It can be qUite
be quite difficult to
difficult to distinguish
distinguishbipolar
bipolardisorder from
disorder schizophre­
from schizophre-
nia,
nia, especially
especially whenwhen a a person
person is first seeking
isfirst seeking treatment
treatment or
or has
has his
his or
or her
her first
first
hospitalization.
hospitalization. PeoplePeople with
with schizophrenia
schizophrenia do do not
not have
have multiple personalities,
multiple personalities,
as
as is
is commonly
c o m m o n l y believed.
believed. Instead,
Instead, they
they have
have delusions (mistaken, unrealistic
delusions (mistaken, unrealistic
beliefs)
behefs) or or hallucinations
hallucinations (sensory
(sensory experiences,
experiences, like
like voices, without a
voices, without real
a real
stimulus).
stimulus). They They cancan experience
experience severe
severe depressions,
depressions, but
but often
often their
their biggest
biggest
problem
problem is is being
being cutcut off
off from
from their
their emotions
emotions (flatness
(flatness or blunting of
or blunting affect).
of affect).
SO
50 THEDlAGHOSIS
lHE DIAGNOSISANO COURSE
AND Of OF
COURSE BIPOlAR
BIPOIOISORDER
AR DISORDER

People
People withwithbipolar
bipolar disorder
disorder can can
also also
have delusions
have delusionsand hallucinations;
and hallucinations;these these
are
are typically
typically (but
(but not
not invariably)
invariably) of of aa manic,
manic, grandiose
grandiose typetype (for
(for example,
example, "I "I
have
have a a finely-tuned
finely-tuned extrasensory
extrasensory perception")
perception") or or of
of aa depressive
depressive sort sort (for
(for ex­
ex-
ample,
ample, "The
"The devil
devil tells
tells me
m e II am
a m to
to bebe punished
punished for for my
m y bad
bad deeds").
deeds").
According
According to to DSM-IV
D S M - I V criteria,
criteria,you youhave
havebipolar
bipolardisorder
disorderinstead
insteadof ofschizo­
schizo-
phrenia
phrenia if,if,during
duringyour
yourepisodes,
episodes,you youexperience
experienceseveresevere swings
swingsofof emotion
emotionand and
energy
energy or or activity
activity levels,
levels,andandYOUT
yourdelusions
delusionsor orhallucinations
hallucinations(if (ifthey
theyoccur
occuratat
all)
all)dodonotnotappear
appearumil
untilafter
afterthe
theonset
onsetof ofyour
yourmood
m o o d swings.
swings.IfIfyouryourdelusions
delusions
and
and hallucinations
hallucinations develop
develop before
before your
your mood
m o o d swings
swings and/or
and/or persist
persist after
after your
your
depressive
depressive or or manic
manic symptoms
symptoms clear clear up,
up, you
you would
would moremore likely
likely be be diagnosed
diagnosed
with
with schizophrenia
schizophrenia or or schizoa JJective disorder,
schizoaffective disorder, a a blend
blend of of the
the schizophrenia
schizophrenia
and
and mood
m o o d disorder categories.
disorder categories.
These
These distinctions
distinctions areare very
very important
important in in relation
relation to to your
your prognosis.
prognosis. The The
long-term
long-term outcome
outcome of of schizophrenia-in
schizophrenia—in terms terms of of number
number of of hospitalizations,
hospitalizations,
ability
ability to
to work,
work, and
and other
other quality-of-life
quality-of-life indicators-is
indicators—is worse worse thanthan forfor bipolar
bipolar
or
or schizoaffective
schizoaffective disorder
disorder (Grossman
(Grossman et al., 1991).
et al., 1991). It's
It's also
alsoanan important
importantdis­ dis-
tinction
tinction forfor treatment,
treatment, because
because people
people withwith schizophrenia
schizophrenia requirerequire a a different
different
line
line ofof medications
medications than than people
people with
with bipolar
bipolar disorder.
disorder. If If your
your diagnosis
diagnosis is is
schizophrenia
schizophrenia or or schizoaffective
schizoaffective disorder,
disorder, youryour physician
physician will probably rec-
will probably rec­
ommend
o m m e n d drugs
drugs like
like olanzapine
olanzapine (Zyprexa),
(Zyprexa), c10zaril
Clozaril (Clozapine),
(Clozapine), and ris­
and ris-
peridone
peridone (Risperdal)
(Risperdal) (see(see also
also Chapter
Chapter 6). 6). These
These are are novel
novel antipsychotic
antipsychotic
drugs with mood-stabilizing
drugs with mood-stabilizing properties.
properties. If If the
the doctor
doctor feels your bipolar
feels your diag­
bipolar diag-
nosis is
nosis is accurate
accurate but
but that
thatyouyou have
have psychotic
psychotic symptoms
symptoms or orsevere
severeagitation,
agitation,he he
or she may recommend one of these drugs along with a mood stabilizing agent
or she m a y recommend one of these drugs along with a m o o d stabilizing agent
like
like lithium,
lithium, Depakote,
Depakote,or orTegretol.
Tegretol.Consider
Consider the theexperiences
experiencesof ofKurt,
Kurt,age age19:
19:

KurtKurt believed
believed there
there was
was a a"gang
"gangof of nine"
nine" that
thatroamed
roamed the
theplanet
planet andandspe­spe-
cifically was looking for him. He described his " self" as a "shell" that was
cifically was looking for him. H e described his "self as a "sheU" that was
gradually
gradually deteriorating
deteriorating and would eventually
and would eventually be taken over
be taken over byby this gang.
this gang.
When
W h e n he
he began
began toto be
be preoccupied
preoccupied with the gang
with the gang of nine, he
of nine, he would
would be-be­
come revved
come revved up,
up, irritable,
irritable, easily
easilyprovoked
provoked to totears,
tears,speak
speaka amile
mflea aminute,
minute,
and
and SLOp
stop sleeping.
sleeping. HeH e was
was hospitalized
hospitalized because his thinking
because his thinking became
became in- in­
creaSingly
creasingly bizarre and his
bizarre and parents became
his parents became afraid of him.
afraid of him. When his older
W h e n his older
brother visited him
brother visited him inin the
the hospital,
hospital, Kurt ran up
Kurt ran up to
to him, threw his
him, threw his arms
arms
around him, began
around him, began crying,
crying, and screamed, "Thanks
and screamed, "Thanks forfor saving
saving me!" After
me!" After
hospital treatment
hospital treatment with
with Haldol (an antipsychotic
Haldol (an medication), he
antipsychotic medication), he calmed
calmed
down
d o w n conSiderably
considerably andand began
began sleeping
sleeping again.
again. But
But he
he continued
continued to to believe
believe
a gang
a gang was
was follOWing
following him
him and that its
and that its members
members were
were waiting
waiting forforhim
him totobe
be
discharged from
discharged from the
the hospital.
hospitaL

Notice that
Notice thatKurt's
Kurt'sprimary disturbance
primary is in his
disturbance thinking
is in processesprocesses
his thinking rather thanrather than
mood. H
his mood.
his He continued to
e continued to be
be preoccupied
preoccupied with
with his
his delusional
delusional behefs even af-
beliefs even af-
 Into
Into the
the Doctor's
Doctor's (ourt:
Court: Whot
What to
to Expect
Expect from
from the
the Diognostic
Diagnostic Process
Process 5S1I

ler
ter his
hismood
mood and sleep problems
and sleep improved. He
problems improved. Hewas
wasgiven
giventhe
the diagnosis
diagnosis of
of
schizoaffective
schizoaffective instead
instead of
of bipolar
bipolar disorder.
disorder. These
These diagnostic distinctions are
diagnostic distinctions are
among
a m o n g the
the most
most difficult
difficult to
to make
m a k e reliably (Pope &:
reliably (Pope & Lipinski,
Lipinski, 1978). Often,
1978). Often,
people
people with
with these
these unclear
unclear patterns
patterns of of symptoms
symptoms have
have to
to be
be observed
observed across
across
several
several episodes,
episodes, and
and try
try many
m a n y different
different medications,
medications, before their diagnosis
before their diagnosis
becomes clear.
becomes clear.

Rew"ent
Recurrent Major
Major Depressive Disorder
Depressive Disorder

Have you had

Have you had major,
major, severe
severe periods
periodsof ofdepression
depression that have
that come
have comeand andgone,
gone,
but
but no
no obvious
obvious signs
signs ofof mania
mania or or hypomania?
hypomania? It It may
m a y seem
seem simple
simple to distin­
to distin-
gUish
guish people
people withwith only
only recurrent
recurrent depressions
depressions from from those
those who
w h o have both de-
have both de­
pressions
pressions and and manias,
manias, but but itit is
is actually
actually quite
quite difficult.
difficult.TheThemost
mostcommonc o m m o n situ­
situ-
ation
ation is
is aa person
person who w h o has
has hadhad repeated
repeated episodes
episodes of of major
major depreSSion,
depression, and and then
then
develops
develops a a brief
brief period
period (a (a few
few days)
days) ofof feeling
feeling "wired,"
"wired," "up,"
"up," andand "ready
"ready to to
take
take on
o n the
the world."
world." Is Is this bipolar II
this bipolar II disorder?
disorder? Or O r simply
simply thethe "high"
"high" most most ofof us
us
would
would feelfeel after
after coming
coming out out ofof aa long
long depreSSion?
depression?
A
A true
true hypomanic
hypomanic episodeepisode involves
involves an an observable
observable change
change in in functioning
functioning
from
from a a prior
prior mood
m o o d state.
state. A A hypomanic
hypomanic personpersonsleepssleepsless,
less,feels
feelsmildly
mildlyor ormod­
mod-
erately
erately elated
elated oror irritable,
irritable,and andhashasracing
racingthoughts
thoughtsor orbecomes
becomes talkative.
talkative.IfIfthisthis
state
state lasts
lasts for
for days
days atat a
a time,
time, andand others
others have
have commemed
commented on on it,
it, aa hypomanic
hypomanic
episode
episode (and(and bipolar
bipolar disorder)
disorder) is is suspected.
suspected. In In comrast,
contrast, a a person
person who w h o simply
simply
feels good
feels good after
after being
being depressed,
depressed, but but who
w h o has
has few
few oror none
none of of the other symp­
the other symp-
toms
toms inin the
the hypomanic
hypomanic cluster,cluster, is is probably
probably a a patient
patient with
with "unipolar depres­
"unipolar depres-
sion."
sion." A A history
history of bipolar disorder
of bipolar disorder in in your
your family
family provides
provides additional
additional evi- evi­
dence for the bipolar over the unipolar diagnOSiS. As mentioned earlier, ifif
dence for the bipolar over the unipolar diagnosis. A s mentioned earlier,
your
your doctor
doctor cannot
cannot be be certain
certain if if you
you have
have unipolar
unipolar depression
depression or or bipolar
bipolar
disorder,
disorder, he he oror she
she will
will probably
probably recommend
r e c o m m e n d that
that you
you take
take a
am mood stabilizer
o o d stabilizer
before
before introdUcing
introducing an an antidepressant.
antidepressant.

Substonce-Indured
Substance-Induced Mood Disorder
Mood Disorder

Are
Are all
allofofthe following
the true
following for for
true you?you?

• You
• You havehave
had had an episode
an episode of depreSSion
of depression or or mania
mania
•
• These
These symptoms
symptoms developed
developed after
after you
you took
took aa street
street drug,
drug, drank
drank aa large
large
quantity
quantity ofof alcohol
alcohol over
over several
several days
days or
or weeks,
weeks, oror began
began taking
taking an anti­
an anti-
depressant
depressant or or some
s o m e other
other medication
medication that
that affects
affects moods
moods
•
• Your
Your mood
m o o d symptoms
symptoms subsided
subsided shortly
shortly after
afteryou
you stopped
stopped drinking
drinking the
the
alcohol
alcohol oror taking
taking the
the drug
drug
• Y o u have
• You have not
not had
had previous
previous manic
manic or
or depressive
depressive episodes,
episodes,except
except those
those
brought
brought on on by
by alcohol
alcohol or or drugs
drugs
52
52 THE
THEDIAGNOSIS
DIAGNOSISAND
ANDCOURSE
COURSEOF OF
BIPOlAR
BIPOLDISORDER
AR DISORDER

Manic
Manic and depressive
and depressive symptoms
symptoms can
can be be mimicked
mimicked by certain
by certain drugsdrugs
of of
abuse.
abuse. Cocaine,
Cocaine, amphetamine
amphetamine ("speed"),
("speed"), heroin,
heroin, and
and LSD
L S D have
have all
all been
been
k n o w n to
known to create
create manic-like
manic-like Slates,
states, often
often with
with accompanying
accompanying psychosis.
psychosis. Am­
Am-
phetamine, in
phetamine, in panicular,
particular,has
hasbeen
beenknown toproduce
k n o w n to produceirritable,
irritable,hyperactivated,
hyperactivated,
delusional
delusional states.
states. It
It is
isunlikely
unlikely that
thatalcohol
alcoholabuse
abuse or dependence will
ordependence willdirectly
directly
cause
cause aa manic
manic episode,
episode, but
but it
it can
can certainly
certainly contribute
contribute lO a spiraling
to a depres­
spiraling depres-
sion.
sion.
The
The DSM·IV
D S M - I V distinguishes
distinguishes mood
m o o d disorders
disorders that
that are
are a
a function
function of
of certain
certain
substances
substances from
from those
those that
that are
are due
due to
to a
a person's
person's inherent
inherent phYSiology.
physiology. Mood
Mood
disorders
disorders that
that are
are the
the direct
direct function
function of
of substances
substances are
are usually
usually short-lived,
short-lived,dis­
dis-
appearing
appearing more
more qUickly
quickly than
than non�substance�related
non-substance-related mood
m o o d disorders,
disorders, and are
and are
usually
usually treated
treated through
through detoxification
detoxification and
and chemical
chemical dependency
dependency program.
program.
Sometimes
Sometimes they
they abate
abate without
without treatment.
treatment. However,
However, substances
substances can
can contribute
contribute
to
to the
the onset
onset of
of the
the first
first episode
episode of bipolar disorder,
of bipolar disorder, which
which then
then takes
takes on
on a
a
course
course of
of its
itsown.
own.ItItisis
not uncommon
not u n c o m m o nfor bipolar
for persons
bipolar LOto
persons say that
say their
that first
their first
manic
manic episode began shortly
episode began shortly after
after they
they began
began experimenting
experimenting with drugs.
with drugs.
As
As II talked
talkedabout
aboutin Chapter 2,
inChapter 2,you
youcan
canhave
haveboth
bothaamood
m o o dand
andaasubstance
substance
use
use disorder,
disorder, with
withone
one influencing
influencingthe
thecourse
courseof
ofthe
theother.
other.Mood
M o o d swings
swingsmake
make
you
you more likely to
more likely to take
take drugs
drugs or
or alcohol,
alcohol, and
and drugs
drugs or
or alcohol
alcohol can
can worsen
worsen
your mood
your m o o d swings. About 60%
swings. About 6 0 % of
of people
people with
with bipolar
bipolar disorder
disorder have
have had
had an al­
an al-
cohol
cohol or
or substance
substance use
use disorder
disorder at
at some
some point
point in
in Iife-a
life—a rate
rate that
that is
is much
much
higher
higher than
than the
the general
general population
population rate of 10-20%
rate of 1 0 - 2 0 % (Regier
(Regier et al., 1990;
et al., 1990; Sonne
Sonne
& Brady, 1999).
& Brady, 1999). So,
So,even
even if
ifyou
you originally
originallysought
soughttreatment
treatmentfor
foraamood
m o o d prob­
prob-
lem,
lem, your
your docLOr
doctor may
m a y still
still diagnose
diagnoseyou
you with
with aasubstance
substanceor
oralcohol
alcoholuse
usedisor­
disor-
der
der and
and recommend
recommend that
that you
you take
take part
part in
in a
a 12-step
12-step program
program (for
(for example,
example. Al­
Al-
coholics
coholics Anonymous)
A n o n y m o u s ) or
or an individual therapy
an individual therapy deSigned to help
designed to help you
you
overcome
overcome chemical dependency problems.
chemical dependency problems.
Your doctor
Your will probably
doctor will probably assess
assess the
the sequence
sequence of
of your mood
your m o o d symptoms
symptoms
and
and drinking
drinking or
or drug
drug use:
use: Do
D o you
you usually get depressed
usually get depressed and
and then drink? Does
then drink? Does
itt ever
i everhappen
happen that
thatyou
you drink
drink and
and then
then get
getdepressed?
depressed? Do
D o you
you use
use cocaine
cocaineor
or
marijuana and then get manic, or is it the reverse? Usually, he or she will not
marijuana and then get manic, or is it the reverse? Usually, he or she wiU not
be able
be able to
to tell
teh for sure if
for sure ifyou
you have
have both
both aa bipolar
bipolar and
and aa substance
substance abuse
abuse prob­
prob-
lem until
lem you have
until you remained sober
have remained sober or drug-free for
or drug-free for a period of
a period of time. Again,
time. Again,
your close
your close relatives
relatives and
and significant
significant others may
others m a y be of help
be of help here. For example,
here. For example,
your
your spouse may
spouse m be able
a y be to recafl
able to recall how
h o w and
and when your behavior
w h e n your behavior started
started to
to shift
shift
in
in relation to when
relation to you took
w h e n you certain substances.
took certain substances.
An important case
A n important of substance-induced
case of substance-induced mood disorder is
m o o d disorder is mania, hypo­
mania, hypo-
mania, or
mania, or rapid
rapid cycling that develops
cycling that develops after
after taking
taking antidepressants.
antidepressants. Karine,
Karine, in
in
the example
the below, showed
example below, showed symptoms
symptoms that
that strongly mimicked a
strongly mimicked mixed epi-
a mixed epi­
sode, but
sode, but her
her symptoms
symptoms remined
remitted once
once the
the antidepressant
antidepressant was
was withdrawn.
withdrawn.The
The
DSM-IV requires
DSM-IV requires that
that the
the bipolar
bipolar syndrome
syndrome not
not be
be diagnosed
diagnosed until
until at
at least
least one
one
 Into the Doctor'�
Intothe What toto Expect
Court:Whot
Doctor's(ourt: Expect 110m Diagnostic PrO(e5S
the Oiognosti(
from the Process 5533

manic, mixed,or
manic, mixed, orhypomanic episodehas
hypomanic episode hasoccurred withoUl
occurred provocation
without by an­
provocation by an-
tidepressants or
tidepressants substances. If
other substances.
or other If you become manic
do become
you do manic or hypomanic be­
or hypomanic be-
cause antidepressants,you
of antidepressants,
cause of m a y indeed
youmay bipolardisorder,
havebipolar
indeedhave moreevi­
butmore
disorder,but evi-
dence will
dence be required.
will be required.

Karine,
Karine, age age beenbeen
had had
48, 48, severely
severely depressed
depressed and and anxious
anxious for for
about a a
about
month after the
m o n t h after death of
the death her father.
of her She had
father. She never had
had never had a manic or
a manic or aa
hypomanic episode. Her
hypomanic episode. physician had
Her physician had put on an
her on
put her antidepressant, but
an antidepressant, but
itdid
it not make
did not her depression
m a k e her fact,her
in fact,
better; in
depression better; anxietygot
heranxiety worse.Her
gotworse. Her
physician then
physician gave her
then gave kind of
different kind
her aa different of antidepressant.
antidepressant.
"At great. II could
felt greaL.
first, 1I felt
"At first, focus on
could focus on things like never
things like before. II no
never before. no
cigarettes to
needed cigarettes
longer needed
longer keep my
to keep mind on
m y mind on my work. But
m y work. then my
But then m y mood
mood
started to
started to go u p and
go up like a
d o w n like
and down seesaw. My
a seesaw. sleep gOt
M y sleep worse and
got worse and worse-I
worse—I
woke almost every
u p almost
w o k e up hour. II felt
every hour. wired, but
felt wired, but then depression came
m y depression
then my came
back. started feeling
back. II started really irritable
feeling really worried, and
and worried,
irritable and stop my
couldn't stop
and II couldn't my
ruminations, which
ruminations, were like
which were like aa tape playing at
tape playing 78 rpms.
at 78 rpms. II hadhad toto take
take
Ambien (a sleep
A m b i e n (a medication) nearly
sleep medication) night. II couldn't
every night.
nearly every couldn't stand it."
stand it."
Her physician took
Her physician her off
took her of the
off of gradually. Her
antidepressant gradually.
the antidepressant Her mood
mood
continued tofluctuatefor a few weeks but then returned to a milder state
continued to fluctuate for a few weeks but then returned to a milder state
of depression. She
of depression. was eventually
She was treated successfully
eventually treated with oxcarbazepine
successfully with oxcarbazepine
(Trileptal, an
(Trileptal, anticonvulsive agent
an anticonvulsive agent like Tegretol) and
like Tegretol) psychotherapy. Her
and psychotherapy. Her
rapid considered an
was considered
cycling was
rapid cycling instance of
an instance of substance-induced
substance-induced m mood dis­
o o d dis-
order, although she
order, although was also
she was believed to
also believed have �uncomplicated
to have bereave­
"uncomplicated bereave-
ment," a
ment," form of
a form of major depression that
major depression that is reaction to
a reaction
is a to aa loss experience.
loss experience.
She was never
She was given the
never given diagnosis of
the diagnosis bipolar disorder.
of bipolar disorder.

* * *

hope you
II hope can see
you can important it
h o w important
n o w how
see now to obtain
is to
itis proper diagnosis
obtain aa proper diagnosis
and
and toto rule out competitive
rule out competitive diagnoses. Knowing the
diagnoses. Knowing diagnostic criteria
the diagnostic criteria forfor bi­
bi-
polar disorder and
polar disorder and h o w these
how manifest themselves
symptoms manifest
these symptoms within you
themselves within you andand
others
others is empowering. As
is empowering. A s you'll see later,
you'll see awarenessof
later, awareness ofthe symptoms that
thesymptoms thatyouyou
typically
typically experience
experience w when developing bipolar episodes will go a long way in
h e n developing bipolar episodes will go a long w a y in
helping
helping youyou to prevent these
to prevent episodes from
these episodes spiraling out
from spiraling out of control.
of control.
In the
In next chapter,
the next I'll discuss
chapter, I'll problems people
the problems
discuss the people have
have in adjusting to
in adjusting to
or coping
or coping withwith the diagnosis of
the diagnosis of bipolar disorder. Some
bipolar disorder. deny the
S o m e deny reality of
the reality the
of the
disorder
disorder and and believe that their
believe that symptoms are
their symptoms are just exaggerations of
just exaggerations of their per­
their per-
sonality. Some
sonality. S o m e overcommit
overcommit to to the diagnosis and
the diagnosis unnecessarily try
and unnecessarily try to limit
to limit
their career
their career and aspirations, and
personal aspirations,
and personal othersreluctantly
and others agree to
reluctantlyagree the diag­
to the diag-
nosis but continue
nosis but continue living lives as
their lives
living their were illness-free.
they were
as ifif they illness-free. NoN o one likesto
one likes to
believe that
believe have a
they have
that they disorder that
psychiatric disorder
a psychiatric that requires long-term treat-
requires long-term treat­
ment. C
ment. Coming to accept
o m i n g to accept the diagnosis is
the diagnosis difficult emotional
is aa difficult process.
emotional process.
 4
4

Is
I s It
It an
a n Illness
I l l n e s s or
o r Is
I s It
It Me?
M e ?

TIPS
T I P S ON
O N COPING
C O P I N G WITH
W I T H THE
T H E DIAGNOSIS
DIAGNOSIS

diagnostic
IInn Chapter
Chapter 33 we
diagnostic criteria.
criteria. What
w e discussed
discussed the
What these
thesecriteria
the rather
criteriado
rather dry
donot
dry (though
notaddress
(though useful)
addressor
useful)DSM-IV
DSM-IV
conveyisisthe
orconvey theemo­
emo-
tional
tional impact
impact of of learning
learning you
you have
have bipolar
bipolar disorder
disorder and
and acknowledging
acknowledging ilS its re­
re-
ality.
ality. Most
Mostof ofmym y patienLS
patientsgogothrough
throughpainful
painfulstruggles
strugglesin incoming
coming to toterms
terms
with
with this
this diagnosis.
diagnosis. Initially,
Initially, they
theyexperience
experienceanger,
anger,fear,
fear,sadness,
sadness,guilt, disap­
guilt, disap-
poimment,
pointment, and and hopelessness.
hopelessness. These
These are not manic-depressive
are not manic-depressive cycles bUl
cycles but
rather
rather a process of
a process of forming
forming a a new
n e w sense
sense of
of who they are,
w h o they are, aanew
n e wself-image
self-imagethat
that
incorporates
incorporates having
having biological
biological imbalances
imbalances thatthat affect
affect their
their moods.
moods. It may
It m ay
sound like
sound like I'm
I'm talking
talking about
about people
people who
w h o have
have had
had only
only one
one or
or two
two manic
manic or or
depressed
depressed episodes
episodes andand are
are surprised
surprised byby the
the diagnosis,
diagnosis, butbut rYe
I'vealso
alsoseen
seenthese
these
reactions in
reactions in people
people who
w h o have been hospitalized
have been hospitalized for
for the disorder numerous
the disorder numerous
times.
times.
W h y is
Why is the
the process
process of of acceplance
acceptance so so painful?
painful? Coming
C o m i n g to
to terms
terms with hav­
with hav-
ing the
ing the disorder
disorder may
m a y mean
m e a n admitting
admitting toto a
a new
n e w role
role for
for yourself
yourself in in your family,
your family,
in the
in the workforce,
workforce, or or in your personal
in your personal relationships.
relationships. It It may require you
m a y require you toto
make some decisions
m a k e some decisions about
about restructuring
restructuring your
your life
life and
and priorities, which may
priorities, which may
m e a n viewing
mean viewing yourself
yourself differently. For example,
differently. For example, Esteban,
Esteban, age 25, gave
age 25, u p his
gave up his
apanment
apartment and and returned
returned to to live with his
live with his parents
parents after
afterhis hospitalization.He
hishospitalization. He
then had
then had to
to deal with their
deal with their hypervigilance
hypervigilance and and increased
increased attempts
attempts to to control
control
his behavior,
his which made
behavior, which m a d e him
himfeel
feellike
likehe
hewas
wasaachild
childagain.
again.Rob,
Rob,age 38,had
age38, had
been quite
been quite successful
successful in in his work as
his work as a
a civil
civil engineer.
engineer. After his diagnosis
After his was
diagnosis was
revealed,
revealed, he found that
he found that people
people at
at work
work seemed
seemed afraid of him.
afraid of H e attributed
him. He attributed
losing his
lOSing job to
his job to the
the disclosure
disclosure of
of his illness. Nancy,
his illness. Nancy, age 44, noted
age 44, noted that after
that after

54
54
 Illnesor
IIss ItItonanIllness Is IIIsMe?
s or It Me? SS 55

learning of
learning of hher
e r diagnosis
diagnosis and telling mmany
a n d telling of her
a n y of h e r friends
friends about it, at
a b o u t it, at least
least oone
ne
"dumped m
"dumped me
e because
because I1 was
was too
too 'high
'high maintenance.'
maintenance.' "" You
Y o u can imagine the
can imagine the
pain and
pain and confusion
confusion you
you might
might feel
feel when there are
w h e n there are such
such costs to acknowledg­
costs to acknowledg-
ing
ing the disorder.
the disorder.

What's Unique
What's Unique about
about Bipolar
Bipolar Disorder?
Disorder?

People who
People have to
who have to live
livewith
withmedical
medicaldiagnoses such
diagnoses as diabetes
such or hyperten­
as diabetes or hyperten-
sion
sion go go through
through similar
similar emotions
emotions in in coping
coping with with their
their diagnoses.
diagnoses. NobodyNobody
likes
likes toto believe
believe they
they have
have a a long-term
long-term illness
illness that
that requires
requires regular treatment.
regular treatment.
But
But bipolar
bipolar disorder
disorder hashas itsits own
o w n particularities.
particularities. As A s IImentioned
mentioned in inChapter
Chapter 2, 2,
bipolar
bipolar disorder
disorder can can be be difficult
difficult to to distinguish
distinguish from from the the normal
normal ups ups and
and
downs
downs of of human
h u m a n life.
life. You
Y o u maym a y have
have always
always been been moody
m o o d y or
or temperamental
temperamental
and
and believe
believe thatthat your
your manic
manic or or depreSSive
depressive periods
periods are are just
just exaggerations
exaggerations of of
your
your natural moodiness. How
natural moodiness. H o w do do you
you know
k n o w what
what is is really
really your
your illness
illness andand
what is
what is your
your ""self
self" or
or your
your personality
personality (your (your habits,
habits, attitudes,
attitudes,and andstyles
stylesof ofre­
re-
lating
lating toto others;
others; thethe way
w a y you
you are are most
most of of the
the time)?
time)? How H o w do do you
you train yourself
train yourself
to
to know
k n o w the
the difference
difference between
between you you when
w h e n you're
you're wellwell and
and you
you when you're ill,
w h e n you're ill,
and
and not
not fool
fool yourself
yourself into
into thinking
thinking that that changes
changes in in mood,
m o o d , energy,
energy, or activity
or activity
are
are just
just "how
" h o w I've
I've always
always been"?
been"?
On
On a a practical
practical level,
level, thetheability
abilityto torecognize
recognizethese thesedifferences
differencesbetween
betweenper­ per-
sonality
sonality traits
traits and
and disorder
disorder symptoms
symptoms is is important
important so so that
that you
you and
and others
others
know
k n o w when
w h e n emergency
emergency procedures
procedures need need to to be
be undertaken.
undertaken. On O n an
an emotional
emotional
level,
level, understanding
understanding these these distinctions
distinctions can can contribute
contribute to to aa more
more stable
stable sense
sense
of
of who
w h o you
you are.
are. Maureen,
Maureen, for for example,
example, knew k n e w she
she hadhad always
always been
been extraverted
extraverted
but
but realized
reahzed she she needed
needed to to visit
visit her
her doctor
doctor whenw h e n she
she began
began staying
staying up u p late to
late to
call
caU people-all
people—aU over over the
the country-to
country—to whom w h o m sheshe hadn't
hadn't spoken
spoken in in years.
years. TheThe
requirement
requirement of of an
an increased
increased dosage dosage of of lithium
lithium did did not
not interfere
interfere with
with her ap­
her ap-
preciation
preciation of of others.
others.
The
T h e reaction
reaction of of many
m a n y ofof my
m y clients
clients upon
u p o n learning
learning of of the
the diagnosis
diagnosis is is dis­
dis-
belief
beliefor ordenial,
denial,which
whichisisonlyonlynatural.
natural.AfterAfter all,
aU,they
they have
havetoto revise
revisetheir
theirimage
image
of
of themselves,
themselves, which which is is painful
painful and and difficult
difficult to to do.
do. Others,
Others, especially
especially those
those
who
w h o were
were diagnosed
diagnosed some s o m e time
time ago,
ago, come
c o m e to
to believe
believe they they have
have thethe disorder
disorder
but
but continue
continue to to lead
lead their
their lives
lives asas if
if they
they diddid not.
not. YouY o u can
can imagine
imagine why w h y people
people
would
would reactreact this
this way;
way; inin fact,
fact,you youmaym a y even
evenrecognize
recognizethese thesereactions
reactionsin inyour­
your-
self.
self. Nevertheless,
Nevertheless,these thesestyles
stylesof ofcoping
copingcan cancause
causetrouble
troublefor foryou,
you,especially
especially
if
if they
they lead
lead toto your
your refusal
refusal to to take
take medications
medications that that would
would helphelp you
you or or to
to en­
en-
gaging
gaging in in high-risk
high-risk activities
activities (for (for example,
example, staying
staying up u p all
allnight,
night,getting
getting drunk
drunk
frequently)
frequently) that that can
can worsen
worsen your illness.
your illness.
For example,
For example, Antonio,
Antonio, age age 35,
35, behaved
behaved in in self-destructive
self-destructive ways ways to to cope
cope
56
56 THE
THEDIAGNOSIS
DIAGNOSISAND
ANDCOURSE OF OF
COURSE BIPOlAR
BIPOIDISORDER
AR DISORDER

with his
with his confusion
confusionand andpain.
pain.HeHewentwentoff hishis
off medications
medications to try
to to
tryprove to
to prove to
others
others that he wasn't
that he wasn't sick,
sick, butbutthen
thenrelapsed
relapsed and ended up
and ended back in
up back inthe
thepsychi­
psychi-
atrist's
atrist's office,
office, with
with more
more medication
medication being recommended. Rosa,
being recommended. Rosa,who
w h o had
had re­
re-
ceived
ceived her
her diagnosis
diagnosis years
years ago,
ago, of len turned
often turned toto alcohol
alcohol when
w h e n she
she experienced
experienced
the
the shame,
shame, social
social stigma,
stigma, and
and hopelessness
hopelessness she she felt
felt the
the diagnosis
diagnosis conferred
conferred on on
her.
her.
After
After they
they have
have lived
lived with
with the
the disorder
disorder forfor aa while,
while, some
some people
people begin
begin
thinking of themselves as if they were nothing more than a diagnostic label or
thinking of themselves as if they were nothing more than a diagnostic label or
aa set
set of
of dysfunctional
dysfunctional molecules.
molecules. TheyThey start
start automatically
automatically attributing
attributing all
all of
of
their
their personal
personal problems
problems to the illness,
to the illness, even
eventhose
thoseproblems
problems thatthatpeople
peoplewith­
with-
out
out bipolar
bipolar disorder
disorder routinely
routinely experience.
experience. They
They usually
usually accept
accept the
the need
need forfor
medications
medications butbut unnecessarily
unnecessarily limitlimit themselves
themselves and and avoid
avoid taking
taking advantage
advantage of of
opportunities
opportunities that
that they
they actually
actually could handle.
could handle.
By
By the
the end
end ofof this
this chapter
chapter youyou will
will have
have a a greater
greater sense
sense ofof the
the various
various
emotional
emotional reactions
reactions people
people have
have upon
upon learning
learning of of the
the diagnosis.
diagnosis. You'll feel
You'll feel
empowered
empowered knOwing
knowing that your own
that your o w n emotional
emotional reactions
reactions are
are shared
shared byby others
others
and that admitting
and that admitting to to the
the diagnosis
diagnosis doesn't
doesn't mean
m e a n giving
giving u up
p your hopes and
your hopes as�
and as-
pirations.
pirations. The
The chapter
chapterendsendswith
withsuggestions
suggestionsfor forcoping
coping with
with the
thedifficult
difficultpro­
pro-
cess
cess of
of coming
coming to to terms
terms with
with the
the illness.
illness. Bipolar
Bipolar disorder
disorder is is something
something that that
you
you have, but it
have, but it is
is not
not who
w h o you are.
you are.

The Emotional
The Fail-Out 01
Emotional Fall-Out the Diagnosis
of the Diagnosis

Most of
Most of the
thepeople
peoplewho
whoconsult
consultmemehave
havebeen
beentold by by
told someone at at
someone some time
some time
that they
that they have bipolar disorder,
have bipolar disorder, even
even if
ifthey
theydon't
don'tbelieve
beheveititthemselves.
themselves. When
When
we
w e actually
actually sitsit ddown
o w n and
and begin
begin discussing
discussing the
the disorder,
disorder, they
they experience
experience a a
wide
wide range
range ofof emotions,
emotions, including
including bewilderment,
bewilderment, anxiety,
anxiety, and
and anger.
anger. Some
Some
people
people feel
feel relief: learning that
rehef: learning that you
you have
have aa psychiatric
psychiatric disorder
disorder thatthat has
has aa
name,
name, and
and that
that explains
explains a a great
great deal
deal of
of what
what has
has happened
happened toto you,
you, can
can help al­
help al-
leviate
leviate your
your feelings
feelings ofof gUilt
guilt or
or self-blame.
self-blame. More
More often.
often, however,
however,the thediagnosis
diagnosis
raises
raises more
more questions
questions thanthan itit answers-most
answers—most of which concern
of which concern what
what the fu­
the fu-
ture
ture holds
holds for
for you
you and
and those
those close
close to you.
to you.
W h e n you
When first learned
youfirst learned that
that you
you had
had the
the disorder,
disorder, you
you may
m a y have
have asked
asked
yourself
yourself questions
questions like
like the
the following:
following:

Why Why
me? me?
Why
W h y is
is this
this happening
happening now?
now?
A m II "only
Am "only bipolar"
bipolar" now,
now, or do II still
or do stiUhave
have aaseparate
separateidentity?
identity?
Where
Where do do 1I stop
stopand
and the
thedisorder
disorderbegin?
begin?
 IsIsItItononIllness
Illnesor
s Is
orItIMe?
s It Me? 57 57

WereWere myperiods
my prior prior periods of high
of high energy, energy, creativity,
creativity, and accomplishment
and accomplishment
nothing
n o t h i n g more
m o r e than
than signs
signs of
of an
a n illness?
illness?
How
H o w much
m u c h mood
m o o d variability
variability ama m II "allowed"
"allowed" before
before people think I'm
people think I'm
getting
getting sick sick again?
again?
How
H o w responsible
responsible am a m II for
for my
m y own
o w n behavior?
behavior?
Will
Will II have
have a a normal
normal lifelife and
and achieve
achieve mym y goals?
goals?

Even
Even if if you've
you'vehad hadnumerous
numerous episodes
episodes of ofbipolar
bipolar disorder,
disorder, youyou
maymay stillstill
ask ask
yourself
yourself these
these questions.
questions. It's
It's natural
natural to to do
do so,
so, and
and healthy-to
healthy—to the the extent that
extent that
struggling
struggling withwith these
these questions
questions helpshelps youyou clarify
clarify your
your feelings
feelings and goals.
and goals.
If any
If any dose
close family
family members
m e m b e r s (for
(for example,
example, youryour spouse
spouse or parents)
or parents)
learned
learned of of your
your diagnosis
diagnosis at at the
the same
same timetime as
as you
you did,
did, they
they probably
probably hadhad ques­
ques-
tions
tions ofof their
their own.
o w n . They
They may
m a y not
not have
have voiced
voiced these
these questions
questions to to you directly
you directly
because
because they they understood
understood that that hearing
hearing their
their worries
worries might
might be be painful
painful for for you
you
and because they
and because they didn't
didn't wish
wish to to cause
cause family
family conflict.
conflict. For
For example,
example, Kyana's
Kyana's
parents worried
parents worried thatthat she
she would
would always
always be be tagged
tagged asas mentally
mentally i ill and never
ll and never
have
have a a normal
normal life.
life. They
They worried
worriedthat thatthey
theywould
would have
haveto totake
takecare
careof ofher
her for
for
the
the rest
rest ofof their
their lives
lives and
and that
that their
their hopes
hopes andand dreams
dreams for
for her
her had
had been
been dashed.
dashed.
Greg's
Greg's wife
wife wondered
wondered if if she
she had
had married
married the the wrong
wrong manm a n and whether she
and whether she
should
should leave
leave the
the relationship.
relationship. None
N o n e ofof these
these family
family members
members raised
raised their
their wor­
wor-
ries
ries until
until they
they began
began talking
talking openly
openly aboutabout the
the disorder
disorder with
with Kyana
Kyana or or Greg.
Greg.
On
O n the
the positive
positive side,
side, learning
learning more more about
about thethe disorder
disorder waswas comforting
comforting to to
Kyana,
Kyana, Greg,
Greg, and
and their
their families,
families, because
because they they learned
learned together
together that
thatthetheprog­
prog-
nosis
nosis was
was notnot as
as poor
poor as
as they
they had
had feared.
feared.

"It's No
'It's No Big
Big Deal":
Deal": Rejecting
RejectingororUnderidentilying
Underidentifyingwith thethe
with Diagnosis
Diagnosis

"I"1want
wantto
to go
go back
back to
to the
theplace
placewhere
whereI used to live
I used in Miami,
to live back before
in Miami, back before
all
all this
this mess
mess started.
started. Who knows? Maybe
W h o knows? M a y b e the
the apartment
apartment II lived in is
lived in is still
still
available.
available. People
People liked
Hked me m e there.
there. II had
had so so many
m a n y friends.
friends. II sometimes
sometimes
think
think if
if II go
go back
back there,
there, I'll
I'll find
find the
the old
old mem e sunning
sunning herseU under some
herself under some
big
big old
old palm tree."
palm tree."
-A
— A 26-year-old
26-year-old woman
w o m a n who
w h o had
had just
just been
been hospitalized
hospitalized
Jor
for her
her second
second manic episode
manic episode

Perhaps you
Perhaps you remember the first
remember the first time
timesomeone
someone told
toldyou
youthat
thatyou
youhad bipolar
had bipolar
disorder.
disorder. Did
Did any
any of
of the
the reactions
reactions in
in the
the sidebar
sidebar on
on page
page 58
58 describe
describe how
h o w you
you
felt
felt then
then or
or now?
now?
Consider
Consider the
the first
first reaction
reactionof
ofrejecting
rejectingthe
thediagnosis
diagnosisoutright.
outright.Did
Did you
you (or
(or
58
58 THE DIAGNOSIS AHO
THE DIAGHOSIS COURSE Of
AND COURSE BIPOIAR DISORDER
OF BIPOlAR DISORDER

Common Reactions to
C o m m o n Reactions Being Told
to Being Told
O n e Has
One Bipolar Disorder
H a s Bipolar Disorder

• "The diagnosis
• "The WTong:
diagnosisisis it'sit's
wrong: just just wayother
a waya for for other to
peoplepeople to
explain away
explain experiences" [re
m y experiences"
away my [rejecting the diagnosis]
jecting the diagnosis]
• "I'mjust
• ''I'm m o o d y person"
just aa moody with the
[underidentification with
person" (underidentification the
diagnosis: some credence
giving some
diagnosis: giving to it
credence (0 making few,
but making
it but if any,
few, if any,
lifestyle adaptations]
lifestyle adaptations]
• " M y illness
• "My iseverything,
illness is and IIhave
everything,and no control
have no over my
control over my
with the
[overidentification with
behavior" (overidentification
behavior" rethinking yOUT
diagnosis: rethinking
the diagnosis: your
life problems
life to blame
beginning to
and beginning
problems and or most
all, or
blame all, them, on
of them,
most of on
the disorder,
the or unnecessarily
disorder, or limiting your
unnecessarily limiting aspirations because
your aspirations because
of the illness
of the illness]J

do you now)
do you believe that
n o w ) believe the diagnosis
that the all just
was all
diagnosis was misunderstanding of
a misunderstanding
just a of your
your
behavior? Did you
behavior? Did were just
others were
think others
you think trying to
just trying you in
rein you
to rein in and weren't in·
and weren't in-
terested in
terested your private
in your Did you
experiences? Did
private experiences? get confused
you get about whether
confused about whether
your medication
your was meant
medication was to treat
meant to your mood
treat your m o o d swings or whether
swings or it caused
whether it caused
them in
them the first
in the you convinced
W e r e you
place?Were
firstplace? thatthe
convinced that diagnosiswas
thediagnosis wrong and
was wrong and
that "alternative
that treatments" were
"alternative treatments" the answer?
were the answer?
Carter, age
Carter, 49, re
age 49, jected the
rejected refused to
diagnosis, refused
the diagnosis, his doctor,
see his
to see doctor, and re­
and re-
fused to
fused take medication.
to take This obstinancy
medication. This usually surfaced
obstinancy usually he was
w h e n he
surfaced when was
manic,
manic, but he also
but he also dug his heels
in his
dug in when
heels w he had
h e n he few or
had few no
or n symptoms of
o symptoms the
of the
H e believed
disorder. He
disorder. that whatever
believed that problems arose
whatever problems be controlled
could be
arose could controlled by
by
diet (particularly
diet (particularly by limiting his
by Hmiting sugar intake)
his sugar and acupuncture
intake) and treatments.
acupuncture treatments.
He argued that
H e argued his behavior-no
that his matter how
behavior—no matter dangerous or
h o w dangerous bizarre it
or bizarre it had
had
e e n — w a s just
been-was
b misunderstood and
being misunderstood
just being and misinterpreted. He
misinterpreted. H e blamed his
blamed his
behavior on people
behavior on he thought
people he had provoked
thought had family mem­
him—typically, family
provoked him-typically, mem-
bers, employers,
bers, or romantic
employers, or romantic partners. During the
partners. During the few times in
few times which he
in which did
he did
agree to
agree take medication,
to take he mistakenly
medication, he concluded that
mistakenly concluded had caused
it had
that it his ill­
caused his ill-
ness moods
("My m
ness ("My were fine
o o d s were they gave
until they
fine until me
gave m e Depakote, now
and n
Depakote, and they swing
o w they swing
all over the place").
all over the place").
As I discussed
As I discussed in Chapter 3,
in Chapter you will
3, you to explore
want to
certainly want
wiU certainly with your
explore with your
doctor why
doctor w he or
h y he thinks the
she thinks
or she diagnosis applies
the diagnosis to you,
appHes to why
and w
you, and other possi­
h y other possi-
ble
ble diagnoses ruled out.
being ruled
are being
diagnoses are out. Second opinions are
Second opinions helpful, and
often helpful,
are often and there
there
is no substitute
is no learning as
for learning
substitute for much
as m as you
u c h as about the
can about
you can symptoms of
the symptoms the
of the
disorder, the
disorder, various medications,
of various
purposes of
the purposes medications, and strate-
self-management strate-
and self-management
 Illnes01
IsIsItItanonIllness s Is
orItIsMe?
It Me? 59 59

gies. But
gies. rejectingthe
But rejecting thediagnosis
diagnosisisisa adangerous
dangerous stance
stance to take,
to take, because,
because, as in as in
Carter's
Carter's case,case, it it can
c a n lead
lead to to the
the rejection
rejection of of treatments
treatments that that maym a yb bee life-saving.
life-saving.
People
People who w h o take
take this
this stance
stance often often go g o through
t h r o u g h several
several episodes
episodes and a n d hospitaliza­
hospitaliza-
tions
tions before
before they they admit
a d m i t that
that anything
anything is is wrong,
w r o n g , and
a n d even
e v e n then
then may distrust the
m a y distrust the
diagnosis,
diagnosis, the the doctors,
doctors, and a n d thethe medication.
medication.
Now
N o w consider
consider the the second
s e c o n d reaction,
reaction, what w h a t II call
call underidentifying
underidentifying wwith the
i t h the
diagnosis.
diagnosis. Underidentification
Underidentification is is aa very
very common
c o m m o n reaction
reaction style,style, and,
a n d , for
for many
many
people,
people, is is aa stage
stage in in coming
c o m i n g toto accept
accept haVing
having an a n illness.
illness. It It is
is similar
similar to to being
being
"in denial,"
"in denial," whichw h i c h isis not
n o t the
the same
s a m e thing
thing as as rejecting
rejecting the diagnosis. Denial
the diagnOSiS. Denial re- re­
fers
fers toto the
the process
process of of aVOiding
avoiding emotionally
emotionally painful painful problems
p r o b l e m s by p u s h i n g them
b y pushing them
out
out of of conscious
conscious awareness.
awareness. Being Being toldtold that
that youy o u have
h a v e an
a nillness
illness thatthat will
will recur
recur
a n d that
and that requires
requires rethinking
rethinking your y o u r life
life goals
goals is is extraordinarily
extraordinarily painful. painful. Who W h o
wouldn't
wouldn't want w a n t toto push
p u s h away
a w a y their
their emotional
emotional reactionsreactions to to this
this nnews
e w s and
a n d try
try toto
keep
k e e p living
living their
their life
hfe as as ifif the
the diagnOSiS
diagnosis were w e r e not
n o t true?
true?
People
People who w h o learn
learn that that theythey have
h a v e other
other medical
medical diagnoses
diagnoses also also react
react b byy
underidentifying.
underidentifying. For F o r example,
e x a m p l e , people
people who w h o have
h a v e had
h a d hean
heart attacks
attacks may m a y ac­ ac-
knowledge
k n o w l e d g e toto others
others thal that they
they needn e e d to
to make
m a k e lifestyle
lifestyle adaptations
adaptations yet yet go go o onn
smoking,
s m o k i n g , exercising
exercising little little or or not
n o t at
at all,
all, and
a n d sleeping
sleeping irregularly.
irregularly. People People with with
diabetes
diabetes or or hypertension
hypertension can c a n also
also superficially
superficially acknowledge
a c k n o w l e d g e their
their diagnoses
diagnoses
but
but go g o on
o n eating
eating sugary
sugary or or salty
salty foods.
foods.
Ellen
Ellen Frank
F r a n k and
and h her
e r colleagues
colleagues (1994) ( 1 9 9 4 ) atat the
the University
University of of Piltsburgh
Pittsburgh
have termed the emotional issues underlying the denial of bipolar disorder
have t e r m e d the e m o t i o n a l issues underlying the denial of bipolar disorder
"grieving
"grieving the the lost
lost healthy
healthy self." self." People
People with w i t h bipolar
bipolar disorder
disorder were w e r e often
often veryvery
energetiC,
energetic, popular,
popular, bright,
bright, and a n d creative
creative beforebefore they they became ill. Then,
b e c a m e ill. T h e n , once
once
their
their illness
illness is is diagnosed
diagnosed and a n d people
people around
a r o u n d them
t h e m start
start treating
treating tthem like aa
h e m like
"mental
"mental patient,"
patient," they they become
b e c o m e resentful
resentful and a n d start
start yearning
yearning for for who
w h o they
they usedused
to be. They
to be. T h e y may
m a y think
think thatthat if if they
they go g o on
o n acting
acting as as if
if nothing
nothing has h a s changed,
c h a n g e d , their
their
old
old self
self will
will comec o m e back,
back, like like a a long
long lostlost friend-the
friend—the way w a y the
the w woman
o m a n quoted
quoted
earlier
earlier dreamed
dreamed of of finding
finding her her old
old self
self back
back in in Miami.
Miami. Underlying
Underlying these these reac­
reac-
tions
tions are are deep
deep feelings
feelings of of loss
loss over
over the the dramatic
dramatic changes changes the illness has
the illness has
brought.
brought.
If
If you're
you're just just now
n o w being
being diagnosed
diagnosed for for the
the first
first time,
time, it'sit's normal
normal to to bebe inin aa
certain
certain amount
amount of of denial.
denial. But Buteven evenif ifyou
you havehavehad had thethediagnosis
diagnosisfor forsome
some time time
and
and feelfeel you've
you've accepted
accepted its its reality,
reality, you you may m a y bebeable
ableto torecall
recalltimestimeswhen w h e n youyou
were
were in in denial
denial aboutabout it. it. When
W h e n you you havehave beenbeen hypomanic
hypomanic or or manic,
manic, have have you you
found
found yourself
yourself doubting
doubting whetherwhether the the illness
illness was was real?
real? Perhaps
Perhaps thinking
thinking that that
the
the diagnosiS
diagnosis has has been
been a a mistake
mistake all all along?
along? Perhaps
Perhaps "testing"
"testing" the the diagnosis
diagnosis by by
staying
staying out out allall night,
night, drinking
drinkingaalot lotof ofalcohol
alcoholor ortaking
takingstreetstreetdrugs?
drugs? Have Have you you
found yourself "forgetting"
found yourself "forgetting" to to take
take your
your lithium,
lithium, Depakote,
Depakote, or or Tegretol?
Tegretol? Have Have
you believed you
you believed you could
could take
take your
your medication
medication without
without any
any supervision
supervision (regu­
(regu-
lar
lar doctor's
doctor's appOintments
appointments to to discuss
discuss side side effects
effects and and monitor
monitor your your blood
blood lev- lev-
60
60 THE
IHEOIAGNOSIS
DIAGNOSISAND
ANDCOURSE OF OF
COURSE BIP()�R
BIPOLDISORDER
AR DISORDER

els)? Inconsistency
els)? with
Inconsistency medication
with is a is
medication big aproblem amongamong
big problem people with bipo­
people with bipo-
lar
lar disorder,
disorder, with
with more
more than 5 0 % discontinuing
than 50% their drug
discontinuing their drug regimen
regimen at
at some
some
time
time in their lives
in their (Goodwin &
lives (Goodwin & Jamison, 1990). Frequently,
Jamison, 1990). Frequently, when
w h e n people
people
don't take
don't take their
their medications
medications it
itis
isbecause
becausethey
theyare
aremanic,
manic,hypomanic,
hypomanic,or
orother­
other-
wise
wise in
in denial
denial about their illness
about their illness (see Chapter 7).
(see Chapter 7).

"If
"If I'm
I'm Bipolar, So Is
Bipolar, So Is Everybody
Everybody Else"
Else"

"My
"My mother
mother reallygets
really getson
onmymy case
case about
about my my medications,
medications, about
about my my
visits to
visits to my
m y doctor,
doctor, about
about the
the men
m e n I'm
I'm going
going out
out with,
with, my
m y job,
job, my
my
sleep-you
sleep—you name
n a m e it.
it. She's
She's always
always asking
asking me
m e if
if I've
I've been
been drinking.
drinking. She
She
goes
goes behind
behind my
m y back
back to try to
to try to find out. She's
find out. She's always
always been
been critical
critical and dis­
and dis-
approving
approving of me.
of m think she's
e . II think she's the
the one
one who's bipolar."
who's bipolar."
— A 29-year-old
-A 29-year-old woman
w o m a n with
with bipolar II disorder
bipolar II disorder and
and alcoholism
alcoholism

Sometimes
Sometimes people
people who who
denydeny
the the disorder
disorder saysay it's because
it's becausethey're
they'reconfused
confused
abom where normal
about where normal mood variation ends
m o o d variation ends and bipolar illness
and bipolar begins. Perhaps
illness begins. Perhaps
you've
you've wondered
wondered at
at times
times whether
whether your
your emotional reactions to
emotional reactions to events
events or
or situa­
situa-
tions
tions are
are really
really any
any different
different from
from other
other people's.
people's. Have
Have you
you found
found yourself
yourself
thinking
thinking or
or saying,
saying, "People
"People around
around me
m e have
have it,
it, but
but they
they just
just don't
don't know
k n o w iit
t
yet"?
yet"? You
Y o u are
are rnosl
most like1y
likely to
to think
think this
this way
w a y when
w h e n your
your relatives
relatives or
or friends are
friends are
getting
getting increasingly
increasingly angry
angry or
or overcontrolling,
overcontroUing, accusing
accusing you
you of
of being
being sick
sick even
even
when
w h e n you're
you're in
in remission
remission and having fairly
and having fairly ordinary ups and
ordinary ups and downs.
downs.
You
You may
m a y be
be right
right that
that others
others around
around you are moody.
you are moody. We
W e do
do know
k n o w that
that bi­
bi-
polar
polar disorder
disorder runs
runs in
in families
families (see Chapter 5)
(see Chapter 5) and
and that
that bipolar
bipolar people
people tend to
tend to
find
find mates
mates who
w h o themselves
themselves have
have mood
m o o d disorders,
disorders, (called
(called ""assortative
assortative mating"
mating";;
Gershon, 1990; Merikangas
Gershon, 1990; Merikangas et
et aL, 1983), So
al., 1983). So it's
it's not
notimpossible
impossiblethat
thatolhers
othersin
in
your
your family
family context
context have
have the
the disorder
disorder or
or a
a mild
mild fonn
form of
of it.
it. Of
Ofcourse,
course,ifif
you oror
you
II asked
asked them
them why
w h y they're
they're so
so moody,
moody, they
they might
might say
say they're
they're only
only reacting
reacting to
to
your
your behavior.
behavior. In
In turn,
turn, you
you may
m a y think
think that
thatyour
yourbehavior
behavioroccurs
occursin
inreaction
reactionto
to
their
their moods.
moods.
Being aware
Being aware of
of the
the moodiness
moodiness of
of your
your close
close relatives
relatives or
or friends
friends is
is not
notnec­
nec-
essarily
essarily a
a bad
bad thing.
thing. You
Y o u can
can learn
learn to
to avoid
avoid doing
doing the
the things that provoke
things that provoke
them
them and,
and, even
even better,
better, help
help them find appropriate
them find appropriate sources
sources of
of help (for
help (for
example,
example, a support group).
a support group). Remember
R e m e m b e r that their m
that their mood nuctuations mmay
o o dfluctuations occur
a y occur
because
because of
of matters
matters that
that have
have nothing
nothing to
to do
do with
with you.
you. Chapter 12, on
Chapter 12, on commu­
commu-
nicating
nicating with
with family
family members,
members, should
should help
help you
you with
with some
some of
of these issues,
these issues.
Simply
Simply having
having moods
m o o d s that
that shift
shift doesn't
doesn't make
m a k e one
one bipolar the dis­
(recall the
bipolar (recall dis-
cussion
cussion of
of symptom
symptom thresholds
thresholds in
in making
making the
the diagnosis
diagnosis in
in Chapter
Chapter 3), But if
3). But if
you
you find
find yourself
yourself seeing
seeing bipolar
bipolar disorder
disorder in
in everyone
everyone else,
else, the
the issue
issue is
is proba-
proba-
 IIss ItItononlI100ss Is ItIsMe?
IllnessOf or It Me? 61 61

bly not
bly not that
thatyou're
you'remisunderstanding
misunderstanding the diagnostic
the diagnostic criteria.
criteria. Rather,
Rather, the issue
the issue
probably nnot
is probably
is o t wwanting to feel
a n t i n g to feel alone
alone or
or isolated.
isolated. AAdmitting that you're
d m i t t i n g that you're ill
ill and
and
different f
different from others is
r o m others is stigmatizing
stigmatizing a
and can
nd c be
an b qUite painful.
e quite painful. HHowever, as
o w e v e r , as
we'll see
we'll see later,
later, a
acknowledging the disorder
c k n o w l e d g i n g the disorder ccan also b
a n also bee eempowering and
mpowering a n d does­
does-
n't mmean
n't that life,
e a n that life, as
as y
you
o u know it, h
k n o w it, has to stop.
a s to stop.

TThe Personolity-versus-Disorder Problem

h e Personality-versus-Disorder Problem

"I"Ifeel
feel like
likeeverything
everythingI do is now
I do somehow
is now somehowconnected
connectedtotomy
my being
beingsick.
sick.
If I'm
If I'm happy,
happy, it's
it's because
because I'm
I'm manic;
manic; if
if I'm
I'm sad,
sad, it's because I'm
it's because depressed.
I'm depressed.
II don't
don't want
want to
to think
think that
that every
every time
time II have
have an
an emotion,
emotion, every
every time
time II get
get
angry
angry at
at somebody, it's because
somebody, it's I'm ill.
because I'm ill. Some
S o m e of
of my
m y feelings are justified.
feelings are justified.
People say
People I'm a
say I'm a different
different person every day,
person every but that's
day, but me!
that's m e ! I've never been
I've never been
a
a stable
stable person."
person."
-A
— A 25-year-old
25-year-old woman who
woman w h o had
had a manic episode
a manic episode
followed
followed by
by a
a six-month depression
six-month depression

Having
Having a sense
a sense of how
of how youryour personality,
personality, habits, and
habits, and attitudes
attitudes differ
differfrom
from
your
your symptoms
symptoms is
is an
an important
important part
part of
of learning
learning to
to accept
accept the disorder. Most
the disorder. Most
people want
people want to
to feel
feel that
that they
they have
have a
a sense
sense of
of self
self that
that is
is separate
separate from their
from their
symptoms
symptoms and
and biochemical
biochemical imbalances.
imbalances. They
They especially
especially feel
feel this w a y if
this way ifthey've
they've
been
been led
led to
to believe,
believe, by
by their
their doctors
doctors or
or by
by anyone
anyone else,
else, that
that their illness is
their illness a
is a
"life
"Hfe sentence."
sentence." Defining
Defining yourself
yourself in
in terms
terms of
of a
a set
set of
of stable
stable personality traits
personality traits
that
that have
have been
been with
with you
you through
through most
most of
of your
your life
lifemay
m a y make
m a k e you
you feel
feelless
lessvul­
vul-
nerable
nerable to
to the
the kinds
kinds of
of connicts
conflicts the
the young
young woman
w o m a n just
just quoted
quoted is
is experiencing.
experiencing.
Another
Another reason
reason to
to distinguish
distinguish between
between your
your personality
personality and
and your
your disorder
disorder
is
is that
that it
it will
will help
help you
you determine
determine when
w h e n you
you are
are truly
truly beginning
beginning a
a new
n e w episode
episode
rather
rather than
than just
just going
going through
through a
a rough time. For
rough time. example, if
For example, if you
you are extra­
are extra-
verted
verted by
by nature,
nature, socializing
socializing aa great
great deal
deal in
in one
one weekend
weekend may
m a y be
be less
less signifi­
signifi-
cant
cant in
in determining
determining whether
whether you
you are
are having
having a
a mood
m o o d episode
episode than
than changes
changes in
in
your
your sleep
sleep patterns,
patterns, increases
increases in
in your
your irritability,
irritabihty, or fluctuations in
orfluctuations in your
your en­
en-
ergy
ergy levels.
levels. In
In contrast,
contrast, increases
increases in
in your
your SOCializing
sociaHzing may
m a y be
be quite
quite useful
useful as
as a
a
sign
sign of
of aa developing
developing episode
episode if
if you
you are
are habitually
habitually an
an introverted
introverted person.
person.

Bipolar Disorder
Bipolar Disorderand Temperamen'
and Temperament

You
Y o u may
m a y believe-and
b e l i e v e — a n d others
others who
w h o imeract
interact with
w i t h you
y o u may
m a y believe-that
believe—that your
your
symptoms
s y m p t o m s of
of mania
m a n i a are
are just
just your
y o u r exuberant,
exuberant, optimistic,
optimistic, high-energy
high-energy self;
self; that
that
your
y o u r depression
depression is
is just
just your
y o u r tendency
t e n d e n c y to
to slide
slide into
into pessimism
p e s s i m i s m or
or overreact to
overreact to
disappointments; or
disappointments; or that
that your
y o u r mixed
m i x e d episodes
episodes or
or rapid
rapid cycling
cycling reflect
reflect your
your
62
62 THE
THE DIAGNDSIS
DIAGNOSISAND
AND(DURIE
COURSEDFOFBIPDIAR
BIPOLARDISORDER
DISORDER

natural
naturalmoodiness
moodiness or or"dark
"darktemperament."
temperament." InIn
fact, is evidence
therethere
fact, that peo­
is evidence that peo-
ple
ple with
with bipolar
bipolar disorder
disorder have
have mood
m o o d swings
swings or
or "temperamental disturbances"
"temperamental disturbances"
that
that date
date way
w a y back
back to to childhood.
childhood. A A questionnaire
questionnaire given
given toto members
m e m b e r s of
of the
the Na­
Na-
tional
tional Depressive
Depressive and and Manic-Depressive
Manic-Depressive Association
Association revealed
revealed that
that many bipo­
m a n y bipo-
Lar people report having depresSive and hypomanic periods even when they
lar people report having depressive and hypomanic periods even w h e n they
were
were children,
children, wellwell before
before anyone
anyone diagnosed them (Lish
diagnosed them (Lish etet aI.,
al., 1994).
1994).
O n e of
One of the
the more
more creative
creative thinkers
thinkers in in our
our field,
field, Hagop
HagopAkiskal,
Akiskal,has hasan anin­
in-
teresting
teresting slant
slant on on the
the whole
whole question.
question. He H e believes
believes that
that the
the behaviors,
behaviors, habits,habits,
and
and attitudes
attitudes we w e often
often refer
refer to
to as
as aa bipolar
bipolar client's
client's personality
personality are are really
really mild
mild
forms
forms ofof mmood
o o d disorder,
disorder, oror the
the bipolar
bipolar disorder
disorder in
in its
its early
early stages
stages of of develop­
develop-
ment. He
ment. H e describes
describes four four temperamental disturbances that
temperamental disturbances that hehe believes predis­
believes predis-
pose
pose people
people to to bipolar
bipolar disorder
disorder (see(see the
the sidebar
sidebar on
on this
this page).
page).He H e presents
presentsevi­ evi-
dence that
dence that people
people withwith these
these temperaments,
temperaments, even even ifif they
they have
have never
never had had a a
major
major depressive,
depressive, hypomanic,
hypomanic, mixed,mixed, or or manic
manic episode,
episode, often
often have
have a a family
family
history
history of of bipolar
bipolar disorder
disorder and and areare vulnerable
vulnerable to to developing
developing the the illness
illness
(Akiskal,
(Akiskal, 1996).
1996).
Why
W h y isis it
it important
important for for you
you to to examine
examine whether
whether one one ofof these
these tempera­
tempera-
ments
ments applies
applies toto you?
you? Because
Because if if you
you have
have them,
them, you're
you're atat risk
risk for
for aa worsening
worsening
of
of your
your disorder
disorder if if you
you are
are not
not getting
getting proper
proper treatment.
treatment. ForFor example,
example, if if you
you
had
had dysthymia
dysthymia or or cyclothymia
cyclothymia in in adolescence,
adolescence, you you are
are at
at risk for developing
risk for developing
bipolar depressive
bipolar depressive episodes
episodes earlier
earlier rather
rather than
than later
later (Akiskal
(Akiskal et et a1., 1977; Klein
al., 1977; Klein
&:
& Depue,
Depue, 1984;1984; Cassano
Cassano et et aI., 1992). Lithium
al., 1992). Lithium cancan bebe used
used to to treat
treat cyclo­
cyclo-
thymia
thymia as as well
well asas bipolar
bipolar disorder.
disorder. If If you
you had
had dysthymia
dysthymia or or hyperthymia
hyperthymia as as a
a
child
child or
or adolescent,
adolescent, you you are
areatatrisk
riskfor
fordeveloping
developing hypomanic
hypomanic episodes,
episodes,espe­
lt�neously
espe-
cially
cially if
if you
you take
take an an antidepressant
antidepressant medication
medication andand are not simu
are not simultaneously

Akiskal's F o u r Temperamental
Akiskal's Four T e m p e r a m e n t a l Disturbances
Disturbances

• Hyperthymic:chronically
• Hyperthymic: chronicallycheerful, overly
cheerful, optimistic,
overly exuberant,
optimistic, exuberant,
extraverted,
extraverted, stimulus
stimulus seeking,
seeking, overconfident,
overconfident, meddlesome
meddlesome
• Cyclothymic: Frequent
• Cyclothymic: Frequent mood
m o o d shifts
shifts from
from unexplained
unexplained tearfulness
tearfulness
to
to giddiness,
giddiness, with
with variable
variablesleeping
sleepingpatterns
patternsand
and changing
changing levels
levels
of self-esteem
of self-esteem
• Dysthymic: chronically
• DysthymiC: chronically sad,
sad, tearful,
tearful,joyless,
joyless,lacking
lackingininenergy
energy
• Depressive mixed: Simultaneously anxious, speedy,
• Depressive mixed: simultaneously anxious, speedy, irritable, irritable,
restless,
restless, and
and sad,
sad,with
with fatigue
fatigueandand insomnia
insomnia

SOUTce;
Source: Akiskal
Akiskal (1996)
(1996)
 IIss lIon
It onIllness
Illnesor Is IIIsMe?
s or It Me? 63 63

taking aa mood
taking mood stabilizer
stabilizer such
such as lithium
as lithium (Akiskal,
(Akiskal, AkiskalAkiskal
1996; 1996; &: Akiskal,
& Akiskal,
1992). If you
1992). If you have any of
have any of the
the four
four temperaments,
temperaments, you
you m
may still experience
a y still experience
mood
m variability even
o o d variability once you
even once you return
return to your "baseline"
to your "baseline" after a manic
after a manic or
or de-
de­
pressive episode.
pressive episode. The notion is
T h e notion is that
that these
these temperaments are relatively
temperaments are relatively con-
con­
stant and
stant and reflect a biologically
reflect a biologically based
based vulnerability
vulnerability to
to your
your disorder.
disorder. They
They come
come
before the
before onset of
the onset of the disorder and
the disorder remain present
and remain present even
even after
after the
the worst the
of the
worst of
symptoms have ceased.
symptoms have ceased.
So, in
So, in one
one sense,
sense, when
w h e n people
people with
with bipolar
bipolardisorder
disorder say
say that
thatthey
they have
have al­
al-
ways been
ways moody,
been m o o d y , they're right. But
they're right. But the
thekey
key point
pointis
isthat
thatyour
your moodiness
moodiness may
may
reflect
reflect the
the biochemical imbalances underlying
biochemical imbalances underlying the
the disorder
disorder rather than charac-
rather than charac­
ter
ter or
or personality.
personality. What
W h a t can
can look like personality
look like personality traits
traits can really be
can really be ongOing
ongoing
symptoms
symptoms of your disorder
of your disorder that require more
that require more aggressive medical or
aggressive medical or psycho-
psycho­
logical treatment.
logical treatment.

AA Self-Administered
Self-AdministeredChecklist
Checklist
It is
It isperhaps
perhapsimpossible
impossibletototell
tellfully
fullywhat
whatisisyour
yourpersonality
personalityand
andwhat
whatisis
your
your
disorder,
disorder, particularly
particularly if
if you've
you've had
had aa number
n u m b e r of
ofepisodes
episodes and
and you've
you've become
become
accustomed
accustomed to
to the
the wide
wide mood
m o o d swings
swings and
and the
the changes
changes in
in energy
energy and
and behavior
behavior
that
that go with them.
go with them. The
T h e following
following exercise
exercise may
m a y clarify
clarify your thinking about
your thinking about
these
these matters.
matters. In
In filling
filling out
out this
this exercise,
exercise, compare
compare your
your personality
personality traits to
traits to
the
the symptoms
symptoms you
you have
have when
w h e n you
you get
get manic
manic or
or depressed.
depressed. Under "personal­
Under "personal-
ity,"
ity," try
try to
to think
think of
of the
the way
w a y you
you are
are most
most of
of the
the time,
time, not
not just
just when
w h e n you're
you're
having
having mood cycles.
m o o d cycles.
Does
Does your
your personality
personality consist
consist of
of a
a group
group of
of traits
traits that
that"hang
"hang together"
together"(for
(for
example,
example, sociable,
sociable, optimistic,
optimistic, affectionate,
affectionate, open)?
open)? See
See if
if you
you can
can distinguish
distinguish
the
the cluster
cluster of
of traits
traits that
thatdescribe
describeyou
you throughout
throughoutyour
your life
lifefrom
fromthose
thosethat
thattyp­
typ-
ify
ify the
the way
w a y you
you feel,
feel,think,
think,or
orbehave
behavewhen
w h e n you
youare
aremanic
manicor
ordepressed.
depressed.How
How
do
do you
you usually
usually relate
relate to
to other
other people,
people, and
and does
does this
this change
change when
w h e n you
you get
get into
into
high
high or
or low
low mood
m o o d states?
states? When
W h e n you're
you're racing
racing and
and charged
charged up,
up, are
are you really
you really
"affectionate
"affectionate and
and open"
open" or
or just
just physical
physical with
with many
m a n y different
different people
people and talk­
and talk-
ative
ative across
across the
the board?
board? Would
W o u l d people
people describe
describe you as boisterous,
you as boisterous, assertive,
assertive, or
or
energetiC
energetic even
even when
w h e n you're
you're not
not cycling
cycHng into
into aa manic
manic episode?
episode? Are
Are you pessi­
you pessi-
mistic
mistic and
and withdrawn
withdrawn when
w h e n you're
you're not
not feeling
feeling depressed?
depressed?
If
Ifyou're
you'renot
notsure
sureabout
aboutwhether
whetheryou
you have
have certain
certainpersonality
personality traits,
traits,check
check
with
with others
others to
to see
see if
if they
they would
would describe
describe you
you with
with these
these trait
trait terms.
terms. Fre­
Fre-
quently,
quently, those
those close
close to you will
to you will have
have different
different ideas
ideas than
than you
you do
do about
about what
what
your
your personality
personality is
is like
like and
and how
h o w it
it differs
differs from
from your
your mood
m o o d disorder
disorder symp­
symp-
toms.
toms. Of
O f course,
course, you
you may
m a y feel
feel uncomfortable
uncomfortable approaching
approaching certain
certain close rela­
close rela-
tives
tives with
with these
these questions,
questions,especially
especially if
ifyou
you feel
feelthese
thesefamily
familymembers
m e m b e r s have
havean
an
agenda, such
agenda, such as
as getting
getting you
you to
to take
take more
more medication.
medication. For
For now,
n o w , try
try to
to select
select
64
64 THE
THE DIAGNOSIS
DIAGNOSIS AND
AND COUR<iE
COURSE OF
OF BIPOlAR
BIPOIAR DISORDER
DISORDER

WHAT'S
WHAT'S ME
M E AND
A N D WHAT'S
WHAT'S MY
M Y ILLNESS?
ILLNESS?
Check as
Check as many off the
many o following as
the following as apply.
apply.

Your
Your personality
personality traits
traits Your
Your manic
manic or
or depressive
depressive symptoms
symptoms
Reliable
Reliable __ Euphoric
Euphoric
Conscientious
Conscientious Grandiose
Grandiose
__ Dependable
Dependable __ Depressed
Depressed
Indecisive
Indecisive Loss
Loss of interest
of interest
Assertive
Assertive _ Sleeping
Sleeping too
too much
much
__ Open
Open __ Sleeping 100
Sleeping too linle
little
__ Optimistic
Optimistic __ Racing
Racing thoughts
thoughts
Sociable
_ _ _ Sociable __ Full
Full of
of energy
energy
Withdrawn
Withdrawn __ Doing
Doing too
too many things
many things
Ambitious
Ambitious __ Highly distractible
Highly distractible
Aloof
Aloof __ Feeling suicidal
Feeling suicidal
__ Critical
Critical __ More
More easily
easily fatigued
fatigued
Intellectual
Intellectual Unable
Unable to concentrate
to concentrate
Affectionate
Affectionate Irritable
Irritable
__ Spirited __ Feeling worthless
Feeling worthless
unusual risks
Spirited
Passive
Passive __ Taking hig
Taking big or
or unusual risks
Talkative
Talkative Wired
Wired
__ Seeking novelty
Seeking novelty __ Highly
Highly anxious
anxious
__ Spontaneous
Spontaneous Slowed
Slowed down
down
Boisterous
Boisterous __ Sped
Sped up
up
Fearful
Fearful __ Overly
Overly goal-driven
goal-driven
Pessimist ic
Pessimistic __ Aggressive
Aggressive impulses
impulses
Erratic
Erratic __ Hopeless
Hopeless
Rebellious
Rebellious __ Unusually passive
Unusually passive

someone
someone you
you think
think is
is not
not invested
invested in
in (he
the outcome
outcome of
of the discussion (that
the discussion (that is,
is,
whether
whether you
you conclude
conclude that
that certain
certain behaviors
behaviors are
are your
your illness
illness rather
rather than
than your
your
personality,
personality, or
or vice versa). A
vice versa). A close,
close, trusted
trusted rriend
friend may
m a y be
be a good choice.
a good choice. Per�
Per-
haps
haps rrame
frame the
the question
question like
like this:
this: ''I'm
"I'm trying
trying to
to figure
figure out
out why
w h y I've
I've had so
had so
m a n y mood
many m o o d changes.
changes. II want
want to
to know
k n o w whether
whether I've
I've really
really changed or whether
changed or whether
I've
I've always
always been
been like
like this.
this. Can
C a n you help me
you help m e with
with a simple exercise?"
a simple exercise?"

"Won't
"Won't Bipolar
Bipolar Disorder
Disorder Change
Change My Personality?"
M y Personality?"

The flip side

Theflip side of
of this
this Mpersonality
"personality versus
versus disorder"
disorder" question is whether
question is whether one or
one or
more
more episodes
episodes of
of mania
mania or
or depression
depression can
can actually
actually change
change your
your personality or
personahty or
 IsIsItItanonIllness s Is
Illnesor orIIIsMe?
It Me? 65 65

character.
character. This Thisisisa averyverycomplicated
complicated question.
question. There There
is someisresearch
some research
evi- evi­
dence
d e n c e that
that very
very painful
painful events
events canc a n change
c h a n g e the
the fundamental
f u n d a m e n t a l character
character of of aa per­
per-
s o n (the
son (the "scar
"scar hypothesis";
hypothesis"; see see Just
Just et et al.,
al., 2001).
2 0 0 1 ) . Many
M a n y people,
people, particularly
particularly
those
those who w h o have
h a v e had
h a d many
m a n y bipolar
bipolar episodes,
episodes, feel feel that
that the the disorder
disorder and a n d the ex­
the ex-
periences
periences of of hospitalization,
hospitahzation, medications,
medications, psychotherapy,
psychotherapy, and painful life
a n d painful life
events
events have have fundamentally
fundamentally changed changed who w h o they
they are.
are. People
People who w h o have just been
have just been
diagnosed
diagnosed may m a y not
not worry
worry so so much
m u c h that
that their
their personality
personahty will wiH be be changed
changed by by
the diagnosis
the diagnosis as as that
that people
people will
wfll relate
relate to to them
them differently
differently becausebecause of of it-and
it—and
that
that they
they maym a y start
start acting
acting differently
differently as as a result.
a result.
Certainly,
Certainly, a a longstanding
longstanding mood m o o d disorder-especially
disorder—especially if if it
it has
has notnot been
been
rreated--can
treated—can profoundly
profoundly affect affect your
your attitudes,
attitudes, habits,habits,and and styles
stylesof ofrelating
relatingto to
others.
others. It It can
can also
also require
require lifestyle
lifestyle changes
changes that that areare a a lot
lot like
like changes
changes in per­
in per-
sonality.
sonality. But But ifif you
you were
were really
really free
free ofof your
your moodm o o d disorder
disorder symptoms
symptoms for for aa
long period
long period of of time,
time, would
would you you gogo back
back to to being
being the the wayw a y you
you were before the
were before the
illness
illness began?
began?
We
W e really
really don't
don't know
k n o w whether
whether there there are are fundamental
fundamental changes changes in in a per­
a per-
son's character
son's character as as a
a result
result ofof long-term
long-term bipolarbipolar illness.
illness. It It is
is possible
possible thatthat what
what
look like changes in personality (for example, becoming less sociable, acting
look like changes in personality (for example, becoming less sociable, acting
more
more aggresSively)
aggressively) following
following repeated
repeated episodes
episodes of of bipolar
bipolar disorder
disorder are really
are really
just "subsyndromal
just "subsyndromal symptoms"-depressive
symptoms"—depressive or or man
manic ic symptoms
symptoms that that have
have not
not
fully
fully disappeared
disappeared after after the
the last
last major
major episode.
episode. But But no no oneone doubts
doubts thatthat the ex­
the ex-
perience
perience of of bipolar
bipolar moodm o o d swings
swings is is very
very profound
profound and and can can change
change thethe way
w a y you
you
view
view yourself
yourself and and those
those around
around you.you.

"I Am
"I MyDisorder":
Am My Disorder": Overidentifying
Overidenlilying as
as a
a Coping Style
Coping Style

"I've become
"I've very worried
become very worried about
about having
having another
another episode.
episode.I keep thinking
I keep thinking
that
that even
even the
the smallest
smallest thing
thing will
will push
push mem e over
over the
the edge-a
e d g e — a glass
glass of wine,
of wine,
traveling,
traveling, eating
eating a
a rich
rich dessert,
dessert, even
even just
just going
going toto the
the store.
store. MMyy husband
husband
wants
wants me m e to
to do
do more,
more, like
like go
go with
with him to restaurants
h i m to restaurants or or shows, hut I'm
shows, but I'm
afraid
afraid going
going out
out will
will make
m a k e me
m e manic.
manic. I'm
I'm now
n o w leading
leading a a pretty
pretty sheltered
sheltered
life,
life, IIguess."
guess."
-A
— A 58-year-old
58-year-old woman
w o m a n iin
naa depressed
depressed phase
phase o bipolar II disorder
f bipolar
of disorder

Some Some
peoplepeople deal
deal with thewith the emotional
emotional pain
pain of the of theby
disorder disorder by giving them­
giving them-
selves
selves over
over to to it.
it. They
T h e y "overidentify"
"overidentify" with
w i t h the
the illness,
illness,viewing
viewing all
allof
of their
their prob­
prob-
lems,
lems, eemotional
m o t i o n a l reactions,
reactions, viewpoints,
viev^qjoints, attitudes,
attitudes, and
a n d habits
habits as
as pan
part of of their
their
disorder.
disorder. If If your
y o u r last
last period
period ofof illness
illness was
w a squite
quite traumatic
traumatic forfor you
y o u (for
(for exam­
exam-
ple,
ple, your
y o u r life
life oror health
health was
w a s threatened,
threatened, you y o u experienced
experienced public
public shame
s h a m e or
or hu­
hu-
miliation,
miliation, or or you
y o u lost
lost aa great
great deal
deal of
of money
m o n e y or
orstatus),
status), you
y o umay
m a y have
h a v e become
become
66
66 THE DIAGNOSIS
THE DIAGNOSISAND
ANDCOURSE
COURSEOFOF
BIP{)�R DISORDER
BIPOIAR DISORDER

fearful ofof
fearful thethe
disorder's powerpower
disorder's over you,
overand placed
you, and severe
placedrestrictions on your
severe restrictions on you
life
life as
as a a way
w a y of
of warding
warding off off future
future damage.
damage. If If this
this coping
coping style
style does
does not not de-
de­
scribe
scribe you you n now, perhaps you
o w , perhaps you can recall periods
can recall periods of time w
of time when
h e n itit did.
did.
There are
There are many
m a n y reasons
reasons for for overidentifying
overidentifying with with the the illness.
illness. First,
First, youyou
may
m a y have
have received
received inaccurate
inaccurate information
information from from your
your dOClOTS
doctors or or other
other mental
mental
health sources.
health sources. You Y o u may
m a y have
have been
been told told that
that your
your illness
illness is is quite
quite grave,
grave, thatthat
you
you shouldn't
shouldn't have have children,
children, thatthat youyou can't
can't expect
expect a a satisfying
satisfying career,
career, that thatyouyou
may
m a y end
end up up spending
spending a a considerable
considerable amount amount of of Lime
time in in hospitals,
hospitals, that that your
your
marital problems will
marital problems will worsen,
worsen, and and thatthat there
there isis liule
little you
you cancan do do to to control
control
your
your raging
raging biochemical
biochemical imbalances.
imbalances. If If you've
you've beenbeen given
given thisthis kind
kind of infor­
of infor-
mation,
mation, it's it'snot
notsurprising
surprisingthat thatyou
you would
would give giveupup control
controlto tothis
thisaffliction
afflictionthat that
destroys
destroys everything-or
everything—or so so you've
you've been told.
been told.
Being
Being given
given thisthis kind
kind of of "life
"life sentence"
sentence"by by your
your doctor
doctormay m a y make
m a k e you
you stan
start
reinterpreting
reinterpreting your your lifelife in
inthe
thecontext
contextof ofthe
thelabel.
label.You Y o umay
m a ystart
startthinking
thinkingback back
on
on normal
normal developmental
developmental experiencesexperiences you you hadhad (for(for example,
example, being being upsetupset
about
about breaking
breaking up with your
up with your high
high school
school boyfriend
boyfriend or girlfriend) and
or girlfriend) andlabeling
labeling
them
them as as yOUT
your first
first bipolar
bipolarepisode.
episode.You You maym a y start
starttoto think
think that
thatyou
you can canaccom­
accom-
plish
plish little
littlewith
withyOUTyour life,
life,belieVing,
believing, "All
"AllI am
I ais
m bipolar,
is bipolar, andandI can't change.
I can't It's It's
change.
all
all biochemical
biochemical and and II can't
can't take responsibility for
take responsibility for myself."
myself." ThisThis wayw a y of think­
of think-
ing
ing may
m a y lead
lead you
you to to avoid
avoid going
going backback to work, withdraw
to work, withdraw from from social
social relation­
relation-
ships,
ships, and and rely
rely more
more and and more
more on on thethe caretaking
caretaking of of your
your family members.
family members.
In
In case
case itit isn't obvious,IIdisagree
isn'tobvious, disagreewith with this
thisway
w a y ofofcharacterizing
characterizing bipolarbipolar
disorder.
disorder. Many-in
M a n y — i n fact,
fact, m most-of
o s t — o f my m y patients
patients are are productive
productive people people who who
have successful
have successful interpersonal
interpersonal relationships.
relationships. They They havehave adjusted
adjusted to to the neces­
the neces-
sity
sity ofof taking
taking medication,
medication, but they don't
but they don't feel
feel controlled
controlled by their illness
by their illness or or its
its
treatments.
treatments. They They havehavedeveloped
developed strategies
strategiesfor formanaging
managing their theirstress
stresslevels
levelsbut but
don't
don't completely
completely avoid avoid challenging
chahenging situations
situations either.
either. II have been amazed
have been amazed by by
how
how m many
a n y of
of my
m y mOSt
most severely
severely i ill
ll clients
clientscallcallmem e years
yearslater
latertototell
tellme m e they've
they've
gotten
gotten married,
married, had had kids,
kids, and/or
and/or started
started an an eXCiting
exciting new n e w job.
job. ButBut without
without
knOWing
knowing the the future,
future, some some people
people "overarm"
"overarm" themselves
themselvesand and gogo too
toofarfarin inny­
try-
ing to
ing to protect
protect themselves
themselves from from thethe world.
world.
Vou
You may find that
m a y find that you're
you're more
more likely
Hkely to to underidentify
underidentify with with the the disorder
disorder
h e n in
when
w in the
the manic
manic pole pole ofof the
the illness,
illness, whereas
whereas you you maym a y overidentify
overidentify with with itit
h e n experiencing
when
w experiencing the the depressive
depressive pole. This is,
pole. This in part,
is, in because depression
part, because depression
dampens
dampens your yOUT motivation
motivation to to initiate
initiate certain
certain activities,
activities, like work, socializing,
like work, socializing,
or
or sexual
sexual contract.
contract. Vou You maym a y have
have subtle
subde problems
problems in in memory
m e m o r y oror concentra­
concentra-
tion
tion as aswell,
well,rendering
rendering the theworld
world aa confUSing,
confusing,blurry blurry place
place that
thatdemands
demands lOa too
much. The
much. The illness
illness cancan seem
seem like
like an
an incredible
incredible burden
burden that that erases
erases anyany hopes
hopes forfor
the
the future.
future. W When
h e n youyou feel
feel this
this way,
way, you you may,
may, understandably,
understandably, begin begin to to merge
merge
the illness with
the illness your sense
with your sense of of who
w h o youyou areare and
and w who
h o you
you will
wiH become.
become.
 IsIs lIon
It anIllness
Illnesor
s Is
orItIMe?
s It Me? 67 67

If you
If you have have symptoms
symptoms of depression,
of depression, it's important
it's important not to takenot to take on more
on more
than
than you
you can
can handle,
handle, andand toto "stick
"stick to
to your
your guns"
guns" about
about what
what you
you do
do and don't
and don't
feel able to do (even when others want you to do more). But remember also
feel able to do (even w h e n others want you to do more). But remember also
that
that your
your depression
depression is is likely
likely to
togo
go away,
away,with
with the
theproper
proper combination
combination of
ofmed�
med-
ication, psychotherapy,
ication, psychotherapy, family family and
and friendship
friendship support,
support, and time. So,
and time. So, it's a
it's a
good idea
good idea to
to set
set some
s o m e limited
limited goals
goals for
for what
what youyou can
can accomplish
accomplish even
even while
while
you're
you're depressed,
depressed, to to help
help you
you become
become more
m o r e energized.
energized. Maintaining
Maintaining a certain
a certain
level
level of
of "behavioral
"behavioral activation"
activation" can can protect
protect youyou against
against a
a worsening
worsening mood
mood
state
state (see
(see Chapter 10).
Chapter 10).

"WhalIs
"What Is the
Ihe Best
Besl Way for Me
Way for 10 Think
Meto Think about
aboul the
lhe Diagnosis?"
Diagnosis?"

Getting into
Getting into debates
debates with
with yourself
yourselfororothers about
others whether
about whetheryour
yourbehavior
behavior
stems
stems from
from your
your personality
personality or or your
your disorder
disorder can
can be
be quite
quite discouraging.
discouraging. You'llYou'll
find
find yourself
yourself intensely
intensely disagreeing
disagreeing with
with your
your friends
friends oror family
family m members
e m b e r s about
about
whether
whether youyou really
really have
have changed
changed or
or whether
whether you're
you're just
just being
being yourself
yourself and re�
and re-
acting
acting toto circumstances.
circumstances. Alternatively,
Alternatively, you
you may
m a y disagree
disagree with
with others
others w who ex�
h o ex-
pecl
pect you
you toto be
be "up
"up and
and rolling"
rolling" when
w h e n you
you feel
feel like
like you're
you're not
not back
back toto full
full ca�
ca-
pacity.
pacity. But
Butififunderidentifying
underidentifyingand and overidentifying
overidentifyingare areboth
bothproblematic,
problematic,what what
is
is a
a helpful
helpful view?
view? Is Is there
there an accurate and
an accurate and empowering
empowering way w a y to
to think
think about
about thethe
disorder?
disorder? Keep
Keep inin mind
m i n d several
several "mantras"
"mantras" about
about the
the diagnosis
diagnosis ofof bipolar disor�
bipolar disor-
def.
der.

1. Bipolar
1. Bipolar disorder
disorder is not is nor a
a life life sentence.
sentence. As I've As I've discussed,
discussed, underiden-underiden­
tifying
tifying and a n d overidentifying
overidentifying are are based
b a s e d in
in painful
painful experiences
experiences from f r o m the
the past
past aandnd
understandable
understandable fears fears and
a n d uncertaimies
uncertainties about a b o u t the
the future.
future. But B u t having
having a a bipolar
bipolar
illness
illness doesn't
doesn't mean m e a n you
y o u have
h a v e toto give
give up u p your identity, hopes,
y o u r identity, h o p e s , and aspirations.
a n d aspirations.
Try
Try to to think
think of of bipolar
bipolar disorder
disorder in in the
the same
s a m e way
w a y you
y o u would
w o u l d think
think of of diabetes
diabetes
or
or high
high blood
b l o o d pressure.
pressure. ThatT h a t is,
is, you
y o u have
have a a chronic
chronic medical
medical illnessiUness thatthat re-
re�
quires
quires you y o u toto take
take medication
medication regularly.
regularly. TakingT a k i n g medication
medication over over thethe long
long term
term
markedly
m a r k e d l y reduces
reduces the the chances
c h a n c e s that
that your illness will
y o u r illness w i H interfere
interfere with with your
y o u r life.
Hfe.
There
T h e r e are
are also
also certain
certain lifestyle
lifestyle adaptations
adaptations you y o u will
w i U need
n e e d totomake
m a k e (such
(such as as vis�
vis-
iting
iting regularly
regularly with with a a psychiatrist
psychiatrist or or therapist,
therapist, arranging
arranging blood b l o o d tests,
tests, keeping
keeping
your
y o u r sleep-wake
s l e e p - w a k e cycles
cycles regulated,
regulated, moderating
m o d e r a t i n g your
y o u r exposure
e x p o s u r e to
to stress,
stress, choos�
choos-
ing
ing work
w o r k thal
that helps
helps you
y o u maintain
maintain a a stable
stable mood).
m o o d ) . None
N o n e of of these
these changes,
changes,
however,
h o w e v e r , requires
requires that that you
y o u give
give upu p your
y o u r life
life goals,
goals, including
including having having a a success­
success-
ful
ful career,
career, maintaining
maintaining good g o o d friendships
friendships and a n d family
family relationships,
relationships, having having ro� ro-
mance,
m a n c e , or
or getting
getting married
married and a n d having
h a v i n g children.
children.
2. Many
2. M a n y creative,
creative, productive
productive people people have have lived
lived with
with thisthis illness.
illness. Bipolar
Bipolar dis-dis�
61
68 THE
THE DiAGNOSIS
DIAGNOSISAND
ANDCOURSE
COURSEOfOF
BIPOlAR DISORDER
BIPOIAR DISORDER

order is
order isone
oneofof
a very small
a very set of
small illnesses
set that maythat
of illnesses an upside
havemay have anto upside
it: peo­ to it: pe
ple
ple who
w h o have
have it
it are
are often
often highly
highly productive
productive and
and creative.
creative. This
This is
is because,
because, in
in
part, when
part, w h e n you're
you're not
not actively
actively cycling
cycling in
in and
and out
out of episodes of
of episodes of the
the disorder,
disorder,
your
your innate
innate mental
mental capabilities,
capabilities, imagination,
imagination, artistic
artistic talents,
talents, and
and personality
personality
strengths
strengths come
c o m e to
to the
the fore.
fore. In book Touched
her book
In her Touched with
with Fire,
Fire, Kay
Kay Jamison dis­
Jamison dis-
cusses
cusses the
the link
link between
between manic-depression
manic-depression and
and artistic
artistic creativity.
creativity. In
In reading
reading
her
her work,
work, you will discover
you will discover that
that you
you are
are not
not alone
alone in
in your
your struggles.
struggles. Some of
S o m e of
the
the most
most influential
influential people
people in
in art,
art, literature,
literature, business,
business, and
and politics
politics have
have had
had
the
the disorder
disorder and
and have
have produced pieces of
produced pieces of work
work that
that have
have had
had lasting
lasting effects
effects on
on
OUf society.
our society.
3. Try
3. Try to
to maintain
maintain a
a healthy
healthy sense
sense of
of who
who you
you are
are and
and think
think about
about how
how your
your
personality
personality strengths
strengths can
can be
he drawn
drawn on
on in
in dealing
dealing with
with the
the illness.
illness. As
A s you reflect
you reflect
on
on who
w h o you
you were
were before
before you
you were
were diagnosed
diagnosed (and
(and after
after completing
completing the
the check­
check-
list
list in
in the
the exercise),
exercise), you
you will
will probably
probably recall
recall many
m a n y of
of your personality
your personality
strengths.
strengths. Perhaps
Perhaps you
you are
are assertive,
assertive, sociable,
sociable,or
orintellectual.
intellectual.How
H o wcan
canyou
yoube
be
appropriately
appropriately assertive
assertive in
in getting proper
getting proper medical
medical treatment?
treatment? Can
C a n you
you use
use your
your
natural
natural sociability
sociability to
to call
call on your friends,
on your friends, family, and neighbors
family, and neighbors lO
to help
help you
you
through
through rough
rough times?
times? Can you use
Can you use your
your natural
natural intellectual
intellectual inclinations to
inclinations to
read
read up
up on
on and
and learn
learn as
as much
m u c h as you can
as you can about
about your
your illness?
illness? DOing
Doing so
so may
may
generate
generate a
a feeling
feeling of
of continuity
continuity between
between who you used
w h o you used to
to be
be and
and who
w h o you
you are
are
now.
now.
4. The
4. The way
way you
you fed
feel right
right now
now is
is nor
notnecessarily
necessarilythe
theway
way you
youwillf ul ininthree
will feel three
months,
months, six
six months,
months, or
oraa year.
year.You
Youmay
m a ybe
befeeling
feelingbad
badabout
aboutyour
yourdiagnosis
diagnosisand and
unable
unable to
to function
function at the level
at the level that
that you
you know
k n o w you're
you're capable
capable of.
of. This
Thisrough
roughpe­
pe-
riod
riod may
m a y make
m a k e you
you feel
feel like
like you
you have
have to
to give
give up
up control
control to
to your
your family,
family, your
your
doctors,
doctors, and,
and,worst
worstof
ofall,
all,your
yourillness-a prospect
illness—a that
prospect feels
that highly
feels distasteful.
highly distasteful.
But
But in
in all
all likelihood,
likelihood, with
with proper
proper treatment,
treatment, you
you will
will return
return to
to a
a state
state that
that is
is
close
close to
to where you used
where you used to
to be,
be, or
or at
at least thatis
leastthat ismore
moremanageable
manageable(see
(seeChapter
Chapter
6 on
6 on medication
medication treatment).
treatment). In
In the
the same
same way
w a y that
that someone
someone who
w h o has
has had
had aa bad
bad
viral flu has
viralflu has to
to stay
stay in
in bed
bed for
foranother
another few
few days
days after
after the
theworst
worst symptoms
symptoms have
have
cleared, you m
cleared, you may
a y need
need a
a period
period of
of convalescence
convalescence before you can
before you can get
get back to
back to
your
your ordinary
ordinary routines and functioning.
routines and functioning.
5. There
5. There are
are things
things you
you can
can do
do in
in addition
addition to
to taking medications to
taking medications to control
control
the cycling
the cycling of your
of your mood
mood states.
states. Coming
Coming toto terms
terms with
with the
the diagnosis
diagnosis of
of bipo­
bipo-
lar
lar disorder
disorder also
also means
means learning
learning certain
certain strategies
strategies for
for mood
m o o d regulation. Later
regulation. Later
chapters (8-1
chapters 1) describe
(8-11) describe these
these in
in more
more detail.
detail. Knowing
Knowing the
the practical self­
practical self-
management
management strategies will keep
strategies will keep you
you from
from feeling
feeling victimized
victimized by
by the disor­
the disor-
der.
der.

* * *
 IsIsItItonanIllness
Illnesor
s Is
orItIMe?
s It Me? 69 69

Hopefully,
Hopefully, thechapters
the last last chapters haveyou
have given given youofa sense
a sense of the challenges
the challenges the the
disorder can
disorder c a n bring
bring to to your self-image, and
y o u r self-image, a n d how,
h o w , when
w h e n you're
you're challenged
challenged inin
this way,
this w a y , it
it is
is natural
natural to to want
w a n t to
to reinterpret
reinterpret thethe evenLS
events that
that have
h a v e occurred
occurred inin
w a y s that
ways that feel
feel more
m o r e acceptable.
acceptable. Your Y o u r reactions
reactions to to the
the illness
illness label
label are
are shared
shared
by
by others
others with
with thethe disorder.
disorder.You Y o u may
m a y be
be able
ableto
tomake
m a k e even
even more
more sense
sense of
ofyour
your
disorder
disorder when w h e n you
you think
think aboUl
about the biological imbalances
the biological imbalances of of the
the brain
brain that cre­
that cre-
ate
ate different
different moodm o o d states,
states, andand how
h o w certain
certainstressful
stressfulcircumstances
circumstancesin in your life
your life
can
can trigger
trigger these
these imbalances.
imbalances. Becoming
Becoming familiar
familiar with
with the
the causes
causes of dis­
bipolar dis-
of bipolar
order
order willwill help
help assure
assure that
that you
you askask for,
for, and
and get,
get, the
the right
right treatmenLS.
treatments.
This page intentionally left blank
P A RT I I
P A R T I

Causes
C a u s e s and
a n d Treatments
T r e a t m e n t s
This page intentionally left blank
 5
5

Where
W h e r e Does
D o e s Bipolar
B i p o l a r Disorder
Disorder

Come
C o m e From?
F r o m ?

GENETICS,
G E N E T I C S , BIOLOGY,
B I O L O G Y , AND
A N D STRESS
STRESS

Stacy,
Stacy,38, 38,had
hadtwotwoyoung
youngdaughters
daughtersand andworked
workedpart partlime
timeforforananaccount�
account-
iog
ing firm.
firm. She
She had
had carried
carried the bipolar II diagnosis
the bipolar diagnosis forfor at least I15
atleast S years
years and
and
took
took Depakote
Depakote on on a a regular
regular basis.
basis. Although
Although she she agreed
agreed thatthat she'd
she'd had
had se­se-
vere
vere mood
m o o d swings,
swings, her her interpretations
interpretations of of their
their causes
causes tended
tended toward
toward the the
psychological rather
psychological rather than
than the
the biological.
biological. She
She often
often doubted
doubted that that she
she hadhad
bipolar
bipolar disorder:
disorder: SheShe was
was scientifically
scientifically trained
trained and
and fell
felt that
that the absence of
the absence of
a
a definitive
definitive biological
biological test test meant
meant thatthat the
the diagnosis
diagnosis should
should remain
remain in in
doubt.
doubt. Her Her psychiatrist
psychiatrist frequently
frequently reminded
reminded her her of
of her
her family
family history:
history: HerHer
uncle
uncle had had been
been diagnosed
diagnosed withwith bipolar
bipolar illness
illness and
and alcoholism.
alcoholism, and and herher
mother
mother suffered
suffered fromfrom major
major periods
periods of depression. Bm
of depression. But she
she remained
remained un- un­
convinced
convinced and and continued
continued to to wonder
wonder whether
whether sheshe really
really needed
needed medica­
medica-
tion.
tion. After
After all,
all, she
she had
had been
been feeling
feeling fine
fine for
for more
more than
than a a year.
year. SheShe toyed
toyed
with
with thethe idea
idea of
of discontinuing
discontinuing her her Depakote
Depakote but but was
was talked out of
talked out it, time
of it, time
and time again, by her psychiatrist.
and time again, by her psychiatrist.
Over
Over thethe course
course of ofaayear,
year,Stacy
Stacywenl
went through
through aaseries
seriesof oflife
lifechanges,
changes,
including
including divorcing
divorcing her her husband.
husband. Other
Other than
than some
s o m e mild
mild depression,
depression, she she
made
m a d e it
it through
through the the initial
initial marital
marital separation
separation reasonably
reasonably well.well. 1tIt wasn't
wasn't
until
until she
she and
and her
her children
children hadhad toto undergo
undergo a a child
child custody
custody evaluation
evaluation that that
she
she began
began to to show
s h o w symptoms
symptoms of of mania.
mania. AsA s the
the evaluation
evaluation proceeded,
proceeded, she she
found
found that
that calls
calls from
from her
her lawyer
lawyer made
m a d e her
her spring
spring into
into action:
action: She
She would
would
rush
rush offoff to
to the
the library
library and
and copy
copy every
every legal
legal precedent
precedent that that was
was even
even re-re-

73 73
74
74 CAUSES
CAUSESAND
ANDTREATMENTS
TREATMENTS

mOlely
motely pertinent
pertinent to to
herher case, call
case, call friends
friendsall all
overover
the country to asktothem
the country ask them
to speak
to speak toto lawyers
lawyers theythey knew,
knew, andand fax
fax numerous
numerous documents
documents to to her
her law­
law-
yer's
yer's and
and doclor's
doctor's offices.
offices. SheShe often
often called
called her
her estranged
estranged husband
husband and and
screamed
screamed threats
threats into
into the
the phone.
phone. Her Her lawyer
lawyer assured
assured her
her that
that the
the divorce
divorce
and
and custody
custody agreement
agreement would would be be comfortable
comfortable for for her
her and
and her
her children,
children,
but
but his
his assurances
assurances did did liale
little to
to SlOp
stop her
her from
from working
working harder
harder and
and harder
harder
and
and sleeping
sleeping less
less and less.
and less.
When
W h e n her
her psychiatrist
psychiatrist suggested
suggested to to her
her that
that she
she was
was getting
getting manic,
manic,
she
she shrugged
shrugged and and said
said ""probably,"
probably, " adding
adding that
that she
she needed
needed toto spend
spend every
every
minute
minute preparing
preparing for for her
her upcoming
upcoming courtcourt dale.
date. As
A s her
her mania
mania escalated,
escalated,
her
her doctor
doctor convinced
convinced her her toto ny
try an
an increased
increased dosage
dosage ofof Depakote
Depakote andand toto
add
add a a major
major tranquilizer
tranquilizer (Zyprexa)
(Zyprexa).. SheShe reluctantly
reluctantly agreed
agreed to
to these
these modi­
modi-
fications
fications but
but still
still maintained
maintained that that her
her problems
problems werewere stress-related.
stress-related.
The
The divorce
divorce andand custody
custody arrangement
arrangement werewere eventually
eventually settled
settled out
out of
of
court
court (and
(and inin Stacy's
Stacy's favor)
favor).. Perhaps
Perhaps duedue to
to the
the additional
additional medication
medication and and
the
the removal
removal of of this
this life
life stressor,
stressor,her hermania
maniagradually
graduallyremitted
remittedandanda amajor
major
crisis
crisis was
was averted.
averted.

Two Two
majormajor questions
questions plague
plague virtually
virtually everyone
everyone diagnosed
diagnosed with
with bipolar
bipolar
disorder:
disorder: "How did II get
" H o w did getthis?"
this?"and
and "What
"What triggers
triggersan
an episode
episode of
ofmania
mania or
orde­
de-
pression?"
pression?" As
As you
you read
read this
this chapter,
chapter, you'll
you'll make
m a k e distinctions
distinctions between factors
between factors
that cause the
that cause the onset
onset of the disorder
of the and factors
disorder and factors that
that affect the course
affect the course of the
of the
disorder
disorder once
once it
it is
ismanifest.
manifest.These
Thesefactors
factorsare
arenot
notnecessarily
necessarilythe
thesame.
same.Alter­
Alter-
natively, the same
natively, the factors may
same factors m a y carry
carry different weight in
different weight in the onset than
the onset in the
than in the
course of
course of the
the disorder. Specifically, the
disorder. Specifically, theinitial
initialcause
cause of
ofthe disorderis
thedisorder isstrongly
strongly
influenced by genetic
influenced by genetic factors
factors (having
(having a
a family
family history
history of bipolar disorder
of bipolar disorder or
or at
at
least
least depreSSive
depressive illness). In contrast,
illness). In new
contrast, n e w episodes
episodes that
that develop after the
develop after first
the first
one appear
one appear toto be
be heavily
heavily influenced
influenced by
by environmental
environmental stress,
stress, sleep
sleepdisruption,
disruption,
alcohol
alcohol and
and substance
substance abuse,
abuse, noncompliance
noncompliance with
with drug
drug treatmenlS,
treatments, and other
and other
genetic, biological, or
genetic, biological, or environmental factors.
environmental factors.
If you
If you have
havehad
had the
thedisorder
disorderfor
forquite
quitesome
sometime,
time,you
youmay
m a ybe
beaware
awarethat
thatyour
your
mood swings have
m o o d swings have a
a strong
strong biochemical
biochemical basis.
basis. You
You may
m a y also
alsobe
beaware
aware that
thatbipo­
bipo-
lar disorder
lar disorder runs
runs in
in families.
famihes.You
Youmay
m a y know
k n o wseveral
severalother
otherpeople
peoplein yourfamily
inyour family
tree who
tree w h o have
have had
had it
itor
orversions
versionsof
ofit.
it.IfIf
you areare
you learning about
learning bipolar
about disorder
bipolar disorder
for the
for first time,
the first time, you
you may
m a y not
not have
have been
been told
told that
that the
the cycling
cycling of
of the
the disorder
disorderisis
influenced by
influenced by disturbances
disturbances inin the
the activity
activity of
of receptors
receptors on
on your
your nerve
nerve cells and
cells and
the production
the production or
or breakdown
breakdown of
of certain
certain neurotransmitters,
neurotransmitters, hormones, and
hormones, and
other chemicals
other chemicals in
in your
your brain.
brain. Medications
Medications are
aredesigned
designed to
tocorrect
correct these
theseimbal­
imbal-
ances. In
ances. Ineither
eithercase,
case,ititisis
useful toto
useful know
k n oabout the
w about genetic
the and
genetic biological
and origins
biological origins
of the
of the disorder,
disorder,because
becausethis
thisknowledge
knowledgewill
wiHhelp
helpyou
youaccept
acceptthe
theillness
illnessand
andedu­
edu-
cate others
cate others close
close to
to you
you about
about what
what you
you are
are going
going through
through (see
(seealso Chapter12).
alsoChapter 12).
Also, knowing
Also, knOWing about
about the
the biological
biological bases
bases of
of your
your disorder
disorder wiH
will probably
probably make
make
taking medications feel more reasonable to you.
taking medications feel more reasonable to you.
 Where
Where Does
DoesBipolar
BipolarDisorder (orne
Disorder ComeFrom?
From? 7575

But genetics
But genetics and biology
and biology aregoing
are not not going to be
to be the the story.
whole whole As
story. As Stacy's
Stacy's
case
case reflects,
reflects, a
a major
major life
Hfe stressor,
stressor, such
such as
as going
going through
through a
a divorce,
divorce, can
can serve
serve
as
as a
a catalyst
catalyst for
for the
the cycling
cycling of
of mood
m o o d states.
states. Everybody
E v e r y b o d y gets
gets mad,
m a d , sad,
sad, or
or happy,
happy,
depending
depending on
o n the
the nature
nature of
of the
the things
things that
that happen
h a p p e n to
to them.
them. People with bipo-
People with bipo­
lar disorder,
lar disorder, because
because of
of the
the nature
nature of
of their
their biology,
biology, can
can develop
develop extreme
extreme
moodiness
m o o d i n e s s in
in reaction
reaction to
to events
events in
in their
their environment.
environment. We
W e don't
don't know
k n o w whether
whether
stress
stress causes
causes people
people to
to have bipolar disorder
have bipolar disorder in
in the first place,
thefirst but we're
place, but we're fairly
fairly
certain
certain that
that it
it makes
m a k e s the
the course
course of
of the
the illness
illness worse
w o r s e in
in people
people wwho
h o already
already
have it.
have it.

Vulnerability
Vulnerability and
a n d Stress
Stress

needn't
Weneedn't
We think
think ofofbipolar
bipolar disorder
disorder asas"only
�only
a abrain
brain disease"oror"only
disease" "onlya apsy-
psy­
chological
chological problem."
problem." It
It can be both
can be both of
of these
these things,
things, and
a n d each influences the
each influences the
other.
other. Most profeSSionals think
M o s t professionals think of
of the
the cycling
cycling of bipolar disorder-and,
of bipolar for
disorder—and, for
that
that matter,
matter, the
the waxing
w a x i n g and waning
and w a n i n g of
of most
m o s t illnesses-as
illnesses—as reflecting
reflecting a
a complex
complex
interplay
interplay b e t w e e n biological
between biological agents
agents (for
(for example,
example, reductions
reductions in
in the
the activity
activity of
of
dopamine
d o p a m i n e in your
in y brain), psychological
o u r brain), psychological agents
agents (for
(for example,
example, your
your expectations
expectations
about
about things), a n d stress
things), and stress agents
agents (things
(things that
that bring
bring about
about changes, whether pos­
changes, whether pos-
itive
itive or
or negative,
negative, such
such as
as transitions
transitions in your job
in your job or
or living
living situation,
situation, financial
financial
problems,
problems, family
family conflicts,
conflicts, or
or a
a new
n e w romantic
romantic relationship).
relationship). Think
T h i n k of it this
of it this
way: You
way: Y o u have
have underlying
underlying biochemical
biochemical disturbances
disturbances ("vulnerabilities")
("vulnerabilities") with
with
which
w h i c h you
y o u may
m a y have been
have b e e n born.
born. These
These disturbances
disturbances can
can include your brain's
include your brain's
over-
over- or
or underproduction
underproduction of
of neurotransmitters
neurotransmitters (such
(such as
as norepinephrine,
norepinephrine,
dopamine,
d o p a m i n e , or
or serotonin)
serotonin) and
a n d abnormality
abnormality in
in the
the structure
structure or
or function
function of
of
your
your nerve
nerve cell
cell receptors.
receptors. Much
M u c h of
of the
the time
time these
these disturbances
disturbances are
are "dormant"
"dormant"
and
and have
have little
little effect
effect on
o n your
your day-to-day
day-to-day functioning,
functioning, though
though they still
they still
make
m a k e yyou
o u more
m o r e susceptible
susceptible to
to experiencing bipolar episodes.
experiencing bipolar When
episodes. W h e n stressors
stressors
reach
reach a
a certain
certain level,
level, these biological vulnerabilities
these biological vulnerabilities or
or predispositions get ex­
predispositions get ex-
pressed
pressed as
as the
the symptoms
s y m p t o m s you're
you're already
already familiar with-irritable m
familiar with—irritable mood,
o o d , racing
racing
thoughts,
thoughts, paralyzing
paralyzing sadness,
sadness, and/or
and/or sleep
sleep disturbance.
disturbance. In
In other
other wwords,
o r d s , your
your
biological
biological predispositions
predispositions affect
affect your
your psychological
psychological and
a n d emotional
emotional reactions
reactions
to
to stress
stress (and
(and in
in all
all likelihood,
likelihood, vice
vice versa).
versa). Likewise,
Likewise, when
w h e n the stress agent
the stress agent is
is
removed,
r e m o v e d , your biochemical imbalances
y o u r biochemical imbalances may become
may b e c o m e dormant
d o r m a n t again
again (as hap­
(as hap-
pened
p e n e d for
for Stacy).
Stacy).
Some
S o m e psychiatriSts
psychiatrists and
a n d psychologists
psychologists use
use a
a vulnerability-stress
vulnerability-stress model
model
(Zubin &
(Zubin Spring, 1977)
& Spring, 1 9 7 7 ) to
to explain
explain a
a person's bipolar symptoms.
person's bipolar s y m p t o m s . Look
L o o k at
at the
the
graph
graph on page 76.
o n page 76. If you
If y o u are
are born with a
b o r n with a great
great deal
deal of
of genetiC
genetic vulnerability­
vulnerability—
for example,
for e x a m p l e , the
the disorder
disorder is
is present
present across
across multiple
multiple past
past generations
generations of
of your
your
family-a
f a m i l y — a relatively
relatively minor
m i n o r stressor
stressor (for
(for example,
example, a
a change in your
change in your job
job shift
shift
hours) may
hours) be
may b e enough
e n o u g h to
to elicit
elicit your bipolar symptoms.
your bipolar s y m p t o m s . If
If you have less
y o u have ge-
less ge-
76
76 CAUSES
CAUSES AND
ANDTREATMENTS
TREATMENTS

Maximum
Maximum ,---

(0 Illness
Illness
(0
(D Threshold-...-
Threshold-
*^

WeI/ness
Wellness

Minimum
Minimum I:;;;--::===========��;��==
L
low
Low •... High
> High
Vulnerability
Vulnerability

A
A vulnerability-suess
vulnerability-stress model for
for understanding
understanding periods
periods of
of illness
illness and wellness.
and wellness.
Copyrigh.t
Copyright by
by the
the American
American Psycholog ical Association.
Psychological Association. Adapted
Adaptedby
bypennission
permissionfrom
from
Zubin
Zubin and
and Spring
Spring (1977).
(1977).

netic vulnerability
netic vulnerability (for (for example,
example, onlyonly one
o n e extended
extended relative,
relative, like
likean a nuncle,
uncle,had had
bipolar disorder,
bipolar disorder, or or aa few
few relatives
relatives had
h a d depression,
depression, but but no n o one
o n e was
w a s bipolar),
bipolar), it it
may
m a y take
take a a relatively
relatively severe
severe stressor
stressor (for
(for example,
example, the the death
death of of aa parent)
parent) to to
evoke
evoke your your bipolar
bipolar symptoms.
symptoms.
In this
In this chapter,
chapter, you'll
you'll seesee examples
examples of of what
w h a t is
is meant
m e a n t by
b y genetic
genetic anda n dbio­
bio-
logical
logical vulnerability
vulnerability and and a a way
w a y to
to determine
determine whether
whether your your family
family tree
tree puts you
puts you
at
at greater
greater or or lesser
lesser risk.
risk. You'll
You'll also
also see
see examples
examples of of the
the kinds
kinds of of stressors that
stressors that
have
have beenbeen shown
s h o w n in
in research
research studies
studies to bee important
to b important in in triggering
triggering mood cy­
m o o d cy-
cling.
cling. Recognizing
Recognizing that that you
you m may
a y be
be biologically
biologically and a n d genetically
genetically vulnerable
vulnerable and and
that certain
that certain factors
factors areare stressful
stressful for you
for y is [he
o u is the first
first step
step inin learning
learning skills
skills for
for
managing your disorder. By [he chapler's end, you should have a general idea
m a n a g i n g your disorder. B y the chapter's end, y o u should have a general idea
of
of hhowo w geneticS
genetics and a n d biology
biology answer
answer thethe question
question "How did 1I get
" H o w did get this?" and
this?" and
h o w these
how these factors
factors combine with stress
c o m b i n e with stress toto bring
bring about
about new n e w episodes
episodes (recur­
(recur-
rences) of
rences) of your
your bipolar
bipolar disorder.
disorder. Later chapters provide
Later chapters practical suggestions
provide practical suggestions
for
for minimizing
minimizing the the impact
impact of of stressful
stressful events
events or or circumstances.
circumstances.

''How Did
"How Did II Get
G e t This?":
This?": The
T h e Role
Role of
of Genetics
Genetics

We
W e have
have known
k n o w n for
for many
m a n y years
years that
that psychiatric
psychiatric disorders
disorders are genetically heri­
are genetically heri-
table
table and
a n d run
r u n in
in families.
famihes. In In the
the 1960s
1960s anda n d 1970s,
1970s, studies
studies of schizophrenic pa­
of schizophrenic pa-
tients
tients who
w h o had been adopted
h a d been adopted away
a w a y from
from their
their natural
natural parents
parents showed that
s h o w e d that
 Where
Where Does
DoesBipolar
BipolarDisorder
Disorde(orne
r ComeFrom?
From? 7777

schizophrenia occurred
schizophrenia occurred atathigher
higher than
than average
average rates
rates ininthethebiological
biologicalrelatives
relatives
of the
of the patients,
patients, eveneven when
w h e n these
these relatives
relatives had h a d played
played no n o role
role inin raising
raising the the
patients
patients (Heston,
(Heston, 1966;1966; Kety,
Kety, 1983;
1983; Rosenthal,
Rosenthal, 1970).1970). ldemical
Identical twin twin studies
studies
have also
have also supported
supported the the idea
idea that
that genes
genes can can predispose
predispose aa personperson lO to develop­
develop-
ing schizophrenia,
ing schizophrenia, probably probably in in combination
combination with with environmental
environmental triggers triggers
(Gottesman,
(Gottesman, 1991). 1 9 9 1 ) . Genetic
Genetic studies
studies of of persons
persons with with bipolar
bipolar disorder
disorder (re- (re­
viewed in
viewed in the
the next
next section)
section) have
have led
led lOto similar
similar conclusions
conclusions (Gershon,
(Gershon, 1990). 1990).
As
A s wew e discussed
discussed in in Chapter
Chapter 3, 3, family
family history
history is is often
often aa partpart of of the initial
the initial
diagnostic
diagnostic evaluation.
evaluation. Stacy,
Stacy, asas it
it turned
turned out,out, had
had a a mother
m o t h e r and
a n d an
a n uncle
uncle who who
showed
s h o w e d signs
signs of
of mood
m o o d disorder,
disorder, although
although it it was
w a s only
only her
her uncle
uncle whow h o hadh a d bipo­
bipo-
lar
lar disorder.
disorder. It It is
is not
not unusual
unusual for for bipolar
bipolar disorder
disorder to to "co-segregate"
"co-segregate" or or be
b e asso­
asso-
ciated
ciated inin family
family trees
trees with
with other
other kinds
kinds of of mood
m o o d disorders,
disorders, particularly
particularly variousvarious
forms of
fonos of depression
depression (Gershon,
(Gershon, 1990, Nurnberger &.
1 9 9 0 , Nurnberger & Gershon,
G e r s h o n , 1992)
1 9 9 2 ) ..
How
H o w do d o we
w e know
k n o w that
that bipolar
bipolar disorder
disorder runs runs in in families?
families? Geneticists
Geneticists usu­ usu-
ally
ally establish
establish that
that an a n illness
illness is
is heritable
heritable through
through familyfamily studies,
studies, twin studies,
twin studies,
and
and adoption studies. II discuss
adoption studies. discuss eacheach of of these
these briefly
briefly anda n d offer
offer additional
additional
sources
sources for for reading
reading more m o r e about
about these
these topics.
topics.

Fomily, Twin,
Family^ Twin, ond
and Adoption Studi.s
Adoption Studies

Familyhistory
Family historystudies
studiesexamine
examine people
people whowho
havehave an illness
an illness and and
then then
find find
out out
who
w h o inin their
their family
family ··pedigree'·
"pedigree" or or family
family tree tree also
also has
has thethe disorder
disorder or or some
some
fonn
form of of it
it (recall
(recall from
f r o m earlier
earlier chapters
chapters that that bipolar
bipolar disorder
disorder can can look
look quite
quite
variable).
variable). We W e know that when
k n o w that w h e n one
o n e person
person has has thethe disorder,
disorder, often often a a brother,
brother,
sister,
sister, parent,
parent,or or aunt
aunt or or uncle
uncle will
willalso
alsohavehave it.it.WeW e also
alsoknow
k n o w that
thatsome
s o m erela­
rela-
tives
tives ofof bipolar
bipolar people
people willwill have other mood
have other m o o d disorders,
disorders, such such as major depres­
as major depres-
sive
sive disorder
disorder or or dysthymic
dysthymic disorder
disorder (long-term,
(long-term, mild mild depression).
depression). TThey h e y may
may
also
also bebe affected
affected by b y alcoholism,
alcoholism, drug drug abuse,
abuse, panic
panic or or other
other anxiety
anxiety symplOms,
symptoms,
or
or an
a n eating
eating disorder
disorder (for (for example,
example, obeSity
obesity with with binge
binge eating),
eating), wwhich,
h i c h , while
while
not
not mood
m o o d disorders
disorders themselves,
themselves, are are problems
problems that co-occur with
that co-occur with a and
n d some­
some-
times
times mask
m a s k underlying
underlying depresSive
depressive or or manic
m a n i c symptoms.
s y m p t o m s . The figure pictures
T h e figure pictures
Stacy's
Stacy's family
family pedigree.
pedigree. The T h e circles
circles represent
represent women, w o m e n , and
a n d the
the squares repre­
squares repre-
sent men.
sent m e n . Notice
Notice that
that s some
o m e of her relatives
of her relatives had h a d mmood
o o d disorders
disorders and and s some
o m e did
did
not.
not.
The
T h e rate
rate of
of mmood
o o d disorder
disorder (major
(major depression,
depression, dysthymia,
dysthymia, or bipolar disor-
or bipolar disor­
der)
der) among
a m o n g first-degree
first-degree relatives
relatives (siblings,
(siblings, parents,
parents, and a n d children)
children) of of bipolar
bipolar
persons
persons averages about 20%. That is, one of every five first-degree relatives of
averages about 2 0 % . T h a t is, o n e of every five first-degree relatives of
a
a bipolar
bipolar person
person hashas a a mood
m o o d disorder.
disorder. On O n average,
average, about
about 8% 8 % of
of aa person's first­
person's first-
degree relatives have
degree relatives bipolar disorder,
have bipolar disorder, and a n d about
about 12% 1 2 % have major depressive
have major depressive
episodes without mmania
episodes without a n i a oror hhypomania.
y p o m a n i a . TThese
h e s e nnumbers are averages:
u m b e r s are averages: Some Some
people have
people have mmanyany m more relatives wwho
o r e relatives h o have
have mmood o o d disorders
disorders aand n d ssome
o m e have
have
78
78 CAUSES
CAUSES AND
AND TREATMENTS
TREATMENTS

Mother,
Uncle,
Uncle,
Uncle, Father,
Fatlier, age 65
.,,
,,,64
age
age 71
71 age 66
66 (major depres&lor1) (bipolar disorder,
alcohol dependence)

s...", Sister,
Brolher.
Brother,
oge '" 3B .ge 34
age 41
41 (bipolat Ihorder)

Stacy's
Stacy's family pedigree.
family pedigree.

fewer.
fewer. Also,
Also, these
these numbers
numbers are
are "age-corrected,"
"age-corrected," meaning
meaning that
that older first­
older first-
degree relatives,
degree relatives,because
becausethey
theyhave
havehad
had more
more time
timeto
todevelop
developaamood
m o o d disorder,
disorder,
are given
are given more weight in
more weight in the
the calculations
calculations than
than are
are younger
younger first-degree rela­
first-degree rela-
tives. If
tives. If you would like
you would like to
to read
read funher
further about
about these
these family
family history slUdies,
history studies,
check
check out
out two
two excellent
excellent chapters
chapters authored
authored or
or coauthored
coauthored by
by Eliot
Eliot Gershon
Gershon
(1990; Nurnberger &
(1990; Nurnberger Gershon, 1992).
& Gershon, 1992).
Another
Another way to establish
w a y (0 establish heritability
heritability is
is to
to ask
ask [his
this question:
question: When
W h e n one
one
identical
identical twin
twin has the disorder,
has the disorder, what
what is the probability
is the probability (percentage)
(percentage) that the
that the
other idemicai
other identical lwin
twin has
has it
it also?
also? Identical
Identical twins,
twins, as
as you
you probably
probably know,
know, share
share
1 0 0 % of
100% of their
their genes.
genes. Fraternal
Fraternal twins
twins (from
(from two
two different
different eggs)
eggs) share only 50%
share only 50%
of
of their
their genes,
genes, just
justlike
likebrothers
brothersand
and sisters.
sisters.IfIfwe
w ethink
thinkaadisorder
disorderisisheritable,
heritable,
we
w e would
would expect
expect that
that the identical twin
the identical twin pairs
pairs will
will have
have higher "concordance"
higher "concordance"
or
or agreement
agreement rates-when
rates—^when one
one twin
twin is
is bipolar,
bipolar, the
theother
othershould
should be
bealso---than
also—than
fraternal
fraternal twin pairs.
twin pairs.
One
O n e review
review of
of the
the genetic literature found
genetic literature found that concordance rates
that concordance rates for
for bi­
bi-
polar
polar disorder
disorder among
a m o n g identical twins averaged
identical twins 57%
averaged 5 7 % and
and between fraternal
between fraternal
twins, 14%
twins, 1 (Alda, 1997).
4 % (Aida, 1997). Stated
Stated another way, when
another way, w h e n one
one identical
identical twin
twin has
has bi­
bi-
polar
polar disorder,
disorder, there
thereis
ismOfe
more than
thanaaone-in-two
one-in-twochance
chance that
thatthe otheridentical
theother identical
twin does
twin does also.
also. When
When a
a fraternal
fraternal twin
twin has
has bipolar
bipolar disorder,
disorder, there is about
there is a
about a
one-in-seven
one-in-seven chance
chance that his or
that his or her
her twin
twin has
has it
it. This
This suggests
suggests that
that bipolar dis­
bipolar dis-
order
order has
has a
a strong
strong genetic
genetic component.
component. If
If the
the illness were entirely
Ulness were genetic, the
entirely genetic, the
idemical
identical twin
twin rate
rate would
would be
be 100%.
100%. Because
Because it
it is only 57%,
is only 5 7 % , we
w e know there
k n o w there
must be
must be nongenetic, environmental causes
nongenetic, environmental as well,
causes as well, and
and these
these are
are discussed
discussed
later in
later in the
the chapter
chapter (DeRubeis
(DeRubeis et
et ai.,
al., 1998).
1998).
Twin
Twin studies
studies have
have been
been criticized
criticized because identical twins
because identical twins tend to be
tend to be
treated
treated as more alike
as more alike by
by their
their parents than do
parents than do fraternal
fraternal twins.
twins. If
If environmental
environmental
 Where
Where Does
DoesBipolar
BipolarDisorder
DisorderCome From?
Come From? 7979

factors do
factors do play
play aa role,
role,Lhen
then the
thedifferences
differencesfound
found between identical and
between identical and frater-
frater­
nal twins
nal twins cannot
cannot necessarily
necessarily be
b e attributed to genetics.
attributed 10 genetics. To
T o eliminate
ehminate the envi­
the envi-
ronmental
ronmental factor,
factor, researchers
researchers look
look for
for identical
identical twins
twins who
w h o have been
have b e e n raised
raised
separately.
separately. Few
F e w studies
studies have
have been
b e e n done
d o n e on
o n this
this topic
topic because they are
because they are very
very
hard
hard toto do.
do. Two
T w o such
such studies
studies found
found thatthat identical
identical twins
twins raised
raised from binh in
f r o m birth in
two
t w o different
different households
households had
h a d concordance
concordance rates rates for
for major
major mood
m o o d disorders
disorders
that
that were
w e r e similar to the
similar 10 the rates
rates for
for identical
identical twins
twins raised
raised in
in the
the same
s a m e household
household
(McGuffin &:
(McGuffin & Katz, 1989; Price,
Katz, 1989; Price, 1968).
1968).
Finally,
Finally, geneticists can find out
geneticists can find out if if bipolar
bipolar disorder
disorder runsruns in families
in families
through
through adoption
adoption studies.
studies. Adoption
Adoption studies
studies are are another
another wayw a y to begin to
to begin sepa­
10 sepa-
rate "nature
rate "nature fromfrom nurture"
nurture" byby examining
examining whether
whether the the biological
biological parents or
parents or
Siblings
siblings of of bipolar
bipolar adoptees
adoptees are
are themselves
themselves ill, ill,even
evenififthey
theynever
nevershared
sharedan anen­
en-
vironment
vironment with with the
the bipolar
bipolar adoptee.
adoptee. Two researchers, Mendlewicz
T w o researchers, Mendlewicz and and Rainer
Rainer
(1977), examined
(1977), examined the the biological
biological relatives
relatives of of bipolar
bipolar people
people w who had been
h o had been
adopted.
adopted. TheseThese biological
biological relatives
relatives had
had thethe same
same rate
rate of
of mood
m o o d disorder (bipo­
disorder (bipo-
lar
lar or
or major
major depressive
depressive illness)
illness) asas the
the biological
biological relatives
relatives ofof bipolar
bipolar persons
persons
who
w h o had
had notnot been
been adopted
adopted (about 2 6 % ) . The
(about 26%). T h e adoptive
adoptive parenlS
parents of of these
these bipolar
bipolar
persons
persons did did not
not show
show a a higher
higher than
than average
average raterate of
of mood
m o o d disorder.
disorder. OnceOnce
again,
again, ititseems
seems that
thatbipolar
bipolardisorder
disorderrunsrunsin infamilies,
families,even
evenwhenw h e nscientislS
scientistsare
are
able
able 10to rule
rule out,
out, or
or at least limit,
at least limit, the
the influences
influences of of the
the person's upbringing.
person's upbringing.

WhatExactly
What Exactly Is
Is Inhe,ited?
Inherited?

Weknow
We know
thatthat inheriting
inheriting bipolar
bipolar disorder
disorder can'tcan't
be asbe as simple
simple as inheriting
as inheriting
brown
b r o w n hair
hair oror blue
blue eyes.
eyes. Too T o o many
m a n y people
people with
with bipolar
bipolar disorder
disorder have
have nono
mood
m o o d disorder
disorder in in their
their families,
families, or or the
the last
last time
time itit occurred
occurred in the family
in the family wwas
as
several
several generations
generations ago. ago. This
This means
m e a n s that
that the
the way
w a y the
the disorder
disorder is inherited has
is inherited has
to
to be
b e more
m o r e complicated.
complicated. It It may
m a y beb e that
that the
the tendency
tendency to to become
b e c o m e "emotionally
"emotionally
dysregulated"-extremely
dysregulated"—extremely moody-runs m o o d y — r u n s inin families.
families. ItIt may
m a y be that people
b e that in­
people in-
herit
herit a a mild
mild form
f o r m of
of bipolar
bipolar disorder
disorder (for (for example,
example, bipolar
bipolar IIII disorder)
disorder) or per­
or per-
haps
haps just
just a a moody
m o o d y temperament,
t e m p e r a m e n t , but
but develop
develop thethe full
full bipolar
bipolar condition
condition only if
only if
other
other predisposing
predisposing conditions
conditions occur. occur. Some
S o m e of
of these
these conditions
conditions may m a y include
include
inheriting genes
inheriting genes for
for bipolar
bipolar disorder
disorder from
f r o m both
both sides
sides of
of the
the family,
family, being "in
being "in
utero"
utero" when
w h e n the
the mother
m o t h e r contracted
contracted a a virus,
virus, undergOing
undergoing a a difficult,
difficult, compli­
compli-
cated
cated birth,
birth, taking
taking street
street drugs
drugs when
w h e n growing
growing u up,
p , sustaining
sustaining aa head injury, or
head injury, or
some
s o m e traumatic
traumatic environmental
environmental circumstance.
circumstance.
The
T h e hypotheSiS
hypothesis that
that a
a person's
person's genetiC
genetic inheritance
inheritance interacts
interacts with
with specific
specific
environmental
environmental conditions
conditions to
to produce
p r o d u c e bipolar disorder is
bipolar disorder is just
just that,
that,aa hypothe­
hypothe-
sis.
sis. To
T o test
test this
this hypotheSiS
hypothesis in
in aa research
research study,
study, we
w e would
w o u l d have
have toto determine
determine
whether
whether children
children born
b o r n wiLh
with a
a genetic
genetic history
history of
of bipolar
bipolar disorder
disorder and
a n d affected
affected
by these predispOSing
b y these predisposing environmental
environmental conditions
conditions are
are more
m o r e likely
likely to develop hi-
to develop bi-
80
80 CAUSES
CAUSESAND
ANDIREAIMENIS
TREATMENTS

polar
polar disorder
disorderinin
adulthood than
adulthood children
than withwith
children a similar genetic
a similar historyhistory
genetic who who
have
have not
not been
been affected
affected by
by these
these environmental
environmental conditions.
conditions. These
These long-term
long-term
studies,
studies, which
which would
would take
takemany
m a n y years
yearsto
tocomplete
complete and
and are
areextremely
extremely difficult
difficult
to
to execute,
execute, have not been
have not been done.
done.
Current
Current advances
advances in
in modern
modern genetics
genetics now
n o w allow
allow researchers
researchers to
to examine
examine
regions
regions of
of the
the chromosomes
chromosomes in
in an
an attempt
attempt to locale genes
to locate genes for
for bipolar disorder.
bipolar disorder.
To
T o date,
date, no
no Single
singlegene
gene of
oflarge
largeeffect
effecthas
has been
been found,
found,leading
leading researchers
researchersto
to
suspect
suspect that many
that m a n y genes---each with quite
genes—each with quite small
small effect-contribute
effect—contribute lO the
to the
genetic
genetic vulnerability
vulnerability to
to bipolar
bipolar disorder.
disorder. Several
Several investigations
investigations have re·
have re-
ported
ported a
a vulnerability
vulnerability gene
gene on chromosome 18
on chromosome 18 (for
(for example,
example, the
the research of
research of
MacKinnon
MacKinnon and associates, 1998),
and associates, 1998), but
but pinpointing
pinpointing the
the exact
exact gene
gene has
has been
been
elusive.
elusive. At
At this
thisstage,
stage,there
thereis
isaalot
lotwe
w e don't
don'tknow
k n o w about
abouthow
h o w bipolar
bipolardisorder
disorder
is inherited,
is inherited,but
butscientists
scientistsare
areworking
workingvery
veryhard
hardtotosolve
solvethe
thepuzzle.
puzzle.Once
Oncethe
the
genes
genes are
are located,
located, more
more accurate
accuratediagnoses
diagnoses and
and better
bettertreatments
treatmentsare
arelikely
likelyto
to
follow.
follow.

"Do
" D o II Have
Have a
a Genetic
Genetic Vulnerability?":
Vulnerability?": Examining
Examining Your
Your Own
O w n Pedigree
Pedigree

Before we
Before we gel
getinto thethe
into issue of what
issue the genetic
of what data might
the genetic datamean formean
might yourfor
ownyour own
life,
life, let's
let'stake
takeaalook
lookat
atwhether
whetherbipolar
bipolardisorder
disorderruns
runsin
inyour
yourfamily.
family.Are
Areyou
you
genetically
genetically predisposed
predisposed to the disorder?
to the disorder? In part II of
In part of this
this exercise, fill out
exercise, fiH out the
the
table
table on page 81
on page 81 to the best
to the of your
best of your knowledge.
knowledge. Confine
Confine yourself to your
yourself to your own
own
children,
children, your
your Siblings
siblings(note
(notein
inthe
thetable
tableif
ifthe
theperson
personisisa a
full sibling
full oror
sibling aahalf
half
Sibling)
sibling),, your
your parents,
parents, grandparents,
grandparents, aunts,
aunts, and
and uncles. Leave out
uncles. Leave cousins,
out cousins,
nephews
nephews and
and nieces
nieces (the
(the information people have
information people have on
on these
these relatives
relatives tends to
tends to
be
be unreliable).
unreliable). Consult
Consult your
your relatives
relatives if
if you
you want
want more
more information.
information. II have
have
fill
ed inin
filled the first
the four
first lines
four from
lines Stacy's
from family
Stacy's asas
family examples.
examples.
Next, place
Next, place a
a star
star nexL
next LO
to anyone you think
anyone you think may
m a y have
have had
had (or
(or still
stiU has)
has)::

1. Full
1. FuH bipolar
bipolar I orI or bipolarII
bipolar II disorder,
disorder, or
oreven
evena a
milder form
mflder bipolar
of of
form bipolar
disorder, such
disorder, such as
as cyclothymia
cyclothymia (mild
(mild and
and short
short depressed
depressed periods that
periods that
alternate
alternate with
with short
short hypomanic
hypomanic periods)
periods)
2.
2. Major
Major depressive
depressive episodes
episodes or long+term periods
or long-term periods of
of milder
milder depression
depression
(dysthymia)
(dysthymia)
3. Any
3. A n y other
other psychiatric
psychiatric problem
problem that
that is
is not
not a
a mood
m o o d disorder
disorder but that
but that
may
m a y be
be masking
masking changes
changes in
in mood
m o o d (for
(for example,
example, drinking
drinking or
or drug prob+
drug prob-
lerns,
lems, panic
panic aLtacks,
attacks, or
or eating
eating disorders)
disorders)

Answers
Answers toto the
the following
followingquestions
questionswill
willgive youyou
give clues as to
clues asyour relative's
to your relative's
health or illness:
health or illness:
 Where
Where Does
Does Bipolar
Bipolar Disorder
Disorder (orne From?
Come From? 81
81

COLLECTING
COLLECTING INFORMATION
INFORMATION TO
TO DRAW
D R A W YOUR
YOUR PEDIGREE
PEDIGREE
Age now
toyOll
Age now
Name
N a m e of
of relative
reljitive Relationshi
p to
Relationship you (or
(or at
at How
H o w did
did be/she die?
he/she die?
death)
death)
1.
1. Roben
Robert Father
Father 66
66 Heart
Heart attack
attack
2.
2. Isabelle
Isabelle Mother
Mother 64
64 (Still
(Still alive)*
alive)*
3.
3. Mark
Mark Brother
Brother 4
411 (Still
(Still alive)
alive)
4.
4. Valerie
Valerie Sister
Sister 344
3 (Still
(Still alive)
alive)
5. ___

6.
fi ___

7.
7 ___

8.
8 ___

9.
Q ___

10.
in ____

• How
H o w did
did the
the relative
relative die
die (if
(if deceased)?
deceased)? Was
W a s it
it an
a n accident,
accident, suicide,
suicide, or
oran
an
illness?
illness?
• Was
W a s the
the person
person ever
ever unable
unable to
to work
w o r k for
for a
a period
period of time, or
of time, or did he
did h or
e or
she
she constantly
constantly switch
switch jobs?
jobs?
• Did
D i d he
h e or
or she
she jump
j u m p from
f r o m one
o n emarriage
marriage or
or relationship
relationship to
to another?
another?
• Are
A r e there
there family
family stories
stories about
about the
the person
person being
being drunk,
d r u n k , hurting
hurting him- or
h i m - or
herself
herself or
or others,
others, or
or having
having a
a "nervous
"nervous breakdown"?
breakdown"?
• Are
A r e there
there stories
stories about
about how
h o w this
this relative
relative was
wasaa recluse,
recluse, shutting him-
shutting h or
i m - or
herself
herself away
a w a y in
in a
a room
r o o m for
for days
days at
at a
a time?
time?
• Did
D i d he
h e or
or she
she ever
ever take
take medication?
medication? What
W h a t kind?
kind?
• Was
W a s the
the relative
relative ever
ever in
in a
a psychiatric
psychiatric hospital?
hospital?

Now
N o w assemble
assemble your
y o u r information
information into
into the
the pedigree.
pedigree. Again.
Again, circles
circles refer to
refer to
female
female relatives
relatives and
a n d squares
squares to
to males.
males. Fill
Fill in
in the
the circle
circle or
or square
square of
of any
a n y relative
relative
you
y o u think
think may
m a y have
h a v e had
h a d bipolar
bipolar disorder.
disorder. Fill
FiU in
in only
only half of the
half of the circle or
circle or
square if
square if the
the person
person had
h a d major
m a j o r depression,
depression, dysthymia,
dysthymia, cyclothymia,
cyclothymia, or
or any of
a n y of
the
the other
other problems
p r o b l e m s mentioned
m e n t i o n e d that
that can
c a n mask
mask a
a mood
m o o d disorder
disorder (for
(for example,
example,
alcoholism,
alcoholism, drug
d r u g abuse,
abuse, eating
eating disorders).
disorders). Put a n "s"
P u t an " S " above
above anyone
a n y o n e who
w h o com­
com-
mitted
mitted suicide.
suicide. Put
Put a
a question
question mark
m a r k in
in the
the circles
circles or
or squares
squares of
of any
a n y relatives
relatives
you're
you're not
not sure
sure about.
about.
Next,
N e x t , examine
e x a m i n e the
the pedigree
pedigree (paying
(paying particular
particular attention
attention to
to the
the solid
soHd aand
nd
half-solid
half-solid circles
circles or
or squares)
squares) and
a n d ask
ask yourself
yourself the
the following
foUowing questions:
questions: How
How
many
m a n y of
of your
y o u r relatives
relatives have
h a v e bipolar
bipolar disorder?
disorder? If
If none,
n o n e , are
are there members
there m in
e m b e r s in
your
your family
family tree
tree who
w h o are/were
are/were depressed,
depressed, alcoholic, drug-addicted or
alcoholic, drug-addicted or have had
have h ad
 82
82 CAUSES
CAUSES AND
AND TREATMENTS
TREATMENTS

Grandlather
Grandfather Grandmother
Grandmother Grandfather Grandmolhef

A ^ .
( Aunt J Uncle f Aunt J D,d
Dad IWom ) Uncle Aunt ) Uncle

ME
M E -,- Spouse
^
( Sister ) Brother Sister Brother

Daughter! Son (Daughter) Son

locating relatives
Locating relatives with
with mood
m o o d disorders
disorders in
in your
your family pedigree.
family pedigree.

an
an eating
eating disorder?
disorder? If If so,
so, consider
consider whether
whether the the alcoholism,
alcoholism, eating
eating problem,
problem, or or
panic
panic symptoms
symptoms may m a y have
have hidden
hidden an an underlying
underlying depressed
depressed or or bipolar condi­
bipolar condi-
tion.
tion. For
For example,
example, if if the
the person
person hadhad bursts
bursts of of rage
rage even
even w when
h e n not
not drunk,
drunk, and
and
became
became withdrawn
withdrawn for for periods
periods of of lime
time even
even when
w h e n "on
"on the
the wagon,"
wagon," he he or
or she
she
may
m a y have
have had
had an an underlying
underlying mood m o o d disorder
disorder as as well
well asas alcoholism.
alcoholism.
Disorders
Disorders likelike alcoholism
alcoholism or or drug
drug abuse
abuse lendtend lOto affect
affect males
males moremore than
than fe­
fe-
males,
males, whereas
whereas majormajor depressive
depressive episodes
episodes afrecl
affectmore
more females
females than than males
males (for
(for
example,
example, Kessler
Kessler et al., 1994).
et al., 1994). Does
Does thisthis pattern
pattern help help you
you determine
determine whether
whether
the
the male
male versus
versus the the female
female relatives
relatives in in your
your family tree had
family tree had psychiatric condi­
psychiatric condi-
tions? Did
tions? Did any
any relative
relative spendspend time
time inin a a psychiatric
psychiatric hospital
hospital or or take
take psychiatric
psychiatric
medications
medications for for aa long
long period
period of time? Did
of time? Did anyone
anyone commit suicide? Although
commit suicide? Although
we
w cannot k
e cannot know
n o w for
for sure,
sure, there
there isis aa possibility
possibility that that a a suicidal
suicidal relative
relative had
had a a
mood
m o o d disorder
disorder and/or
and/or an an alcohol
alcohol oror substance
substance dependence
dependence disorder.
disorder.
H
If you
you have
have children,
children, you you may
m a y know
k n o w whether
whether one one oror more
more of them has
of them has a a
psychiatric
psychiatric disorder
disorder and and cancan fill
fill in
in those
those circles
circles or or squares.
squares. Of Of course,
course, your
your
children
children maym a y not
not yet
yet havehave reached
reached an an age
age when the disorder
w h e n the disorder is is recognized­
recognized—
bipolar disorder can
bipolar disorder can be be diagnosed
diagnosed at at any
any age,
age, butbut most
most frequently
frequently starts
starts be­
be-
tween
tween ages
ages J15 and 19.
5 and 19. Be Be sure
sure to
to fill
fillin inany
any psychiatric
psychiatricinformation
information relevant
relevantto to
your children's
your children's mother
mother (if (if you
you are
are their
their father)
father) or father (if
or father (if you
you are their
are their
mOlher),
mother), and and draw
draw in in "tree
"tree branches"
branches" to to any
any affected
affected or or unaffected
unaffected relatives
relatives in in
his
his or
or her
her family
family of of origin.
origin. As you know,
As you know, i itt is
is possible that your
possible that your children in­
children in-
herited
herited mood
m o o d disorders
disorders from from thethe other
other parent's
parent's side side ofof the
the family,
family, or or from
from
both
both sides
sides ofof the family.
the family.
 Where
Where Does
Does Bipolor
Bipolar Disorder
Disorder (orne
Come From?
From? 883
3

"What Does the

"What Does the Genetic
GeneticEvidence Mean
Evidence lorfor
Mean Me?"
Me?''

P,actical
Practical lmplications of Genetics
Implications of Genetics

It
It isis
not yetyet
not possible to assign
possible a number
to assign to a person's
a number geneticgenetic
to a person's vulnerability to
vulnerability to
bipolar
bipolar disorder.
disorder. Instead,
Instead, vulnerability
vulnerability is
is usually
usually described
described iin
n general
general terms
terms
like
like "low,"
"low," "medium,"
"medium," or
or "high."
"high." One
O n e way
w a y of
of assessing
assessing your
your family
family tree
tree is to
is to
ask
ask whether
whether the
the number
n u m b e r of
of late-teenage
late-teenage or
or adult first-degree relatives
adultfirst-degree relatives in
in your
your
pedigree
pedigree who
w h o have
have bipolar
bipolar disorder
disorder exceeds
exceeds the
the average
average rate
rate o
off 8
8% (20%
% ( 2 0 % if
if you
you
include
include persons
persons with
with depressive
depressive disorders).
disorders). If
If your
your family
family tree
tree is
is ""dotted"
dolted� with
with
people
people who
w h o have
have bipolar
bipolar disorder
disorder or
or some
s o m e other
other mood
m o o d disorder
disorder (more
(more people
people
are
are affected
affected than
than unaffected),
unaffected), your
your vulnerability
vulnerability is
is high.
high. Likewise, if bipolar
Likewise, if bipolar
disorder
disorder or
or other
other mood
m o o d disorders
disorders are
are present
present in
in several
several generations
generations (for
(for exam­
exam-
ple,
ple, in
in your
your Siblings,
siblings, parents,
parents,and
andgrandparents),
grandparents),then
thenyour
yourgenetic
geneticvulnerabil­
vulnerabil-
ity is
ity is higher
higher than
than for
for a
a person
person with
with bipolar
bipolar disorder
disorder in
in only
only one
one generation.
generation. If
If
only
only one
one of
of your
your first-degree
first-degree relatives
relatives had
had a
a mild
mild dysthymiC
dysthymic depreSSion and no
depression and no
one
one had
had bipolar
bipolar disorder,
disorder, your
your genetic
genetic vulnerability
vulnerability is
is probably
probably on the low
on the low
end
end of
of the
the continuum.
continuum.
Now,
N o w , what
what do
do you
you do
do with
with the
the information
information if
if you
you have
have concluded
concluded that
that bi­
bi-
polar
polar disorder,
disorder, or
or at
at least
least depreSSion,
depression, runs
runs in
in your
your family?
family? Genetic
Genetic evidence
evidence
has
has practical
practical implications
implications for
for your
your life.
life. First,
First,the
thefact that
fact the
that thedisorder
disorderruns
runsinin
your
your family
family should
should make
m a k e you
you feel
feel less
less ashamed
ashamed of
of having
having the
the illness.
illness. None of
N o n e of
us
us can control the
can control the genes
genes with
with which
which we
w e come
c o m e into
into this
this world.
world. As you'll see
A s you'll in
see in
later chapters,
later chapters, there
there are
are things
things you
you can
can do
do to
to control
control the
the cycling
cycling of
of your disor­
your disor-
der.
der. But
But getting
getting the
the disorder
disorder in
in the
the first
first place
placeis
is heavily
heavily influenced
influenced by
by your
your ge­
ge-
netic
netic makeup.
makeup. We
W e don't
don't know
k n o w how
h o w to
to engineer
engineer the
the environment to prevent
environment to prevent
the
the original
original onset
onset of
of the
the disorder.
disorder. In
In other
other words, it isn't
words, it isn't your fault-a fact
your fault—a fact
that
that your
your family
family members
m e m b e r s may
m a y also
also need
need to
to hear
hear (see Chapter 12).
(see Chapter As the
12). As the fa-
fa­
ther
ther of
of one
one young
young man
m a n with
with bipolar
bipolar disorder
disorder put
put it,
it, "For
"For a
a long
long time
time we
we
thought
thought he
he was
was just
just a
a screw-up.
screw-up. He
H e seemed
seemed able
able to
to screw
screw up
u p everything.
everything. But
But
eventually
eventually we
w e realized
realized there
there was
was an
an illness,
illness, and
and that
thatthere
therewas
was something
something re­
re-
ally
ally wrong with his
wrong with his brain.
brain. He
H e had
had a
a real
real problem
problem that
that had
had a chemical basis,
a chemical basis,
and
and it
it was
was probably
probably something
something he
he got
got from
from me
m e or
or from
from my
m y wife's
wife's side
side of the
of the
family.
family. He
H e wasn't
wasn't doing
doing all
all that
that stuff
stuff to
to hurt
hurt us.
us. That's
That's when we
when w e came to some
came to some
understandings
understandings as
as a
a family."
family."
Having
Having a
a family
family history
history of
of bipolar
bipolar disorder
disorder may
m a y also
also help
help confirm
confirm your
your
diagnosis, if
diagnosiS, if you
you still
still have
have doubts
doubts (see
(see also Chapter 3).
also Chapter If bipolar
3). If bipolar disorder
disorder
clearly
clearly runs
runs in
in your
your family,
family, this
this fact
fact will
will sway
sway your
your doctor
doctor toward
toward a bipolar
a bipolar
diagnOSiS
diagnosis rather
rather than,
than, say,
say, attention-deficitlhyperactivity
attention-deficit/hyperactivity disorder,
disorder, depression,
depression,
or
or schizophrenia.
schizophrenia. A
A family
family history
history of
of bipolar
bipolar disorder
disorder is
is not
not a
a conclusive piece
conclusive piece
of but it
evidence, but
of evidence, it provides
provides one
one piece
piece of
of the
the diagnostic
diagnostic puzzle.
puzzle.
84
84 CAUSES
CAUSESAND
ANDTREATMENTS
TREATMENTS

ThisThis is not
is not to to saythat
say that genetic
genetic evidence
evidenceisis
thethe
keykey
to why youyou
to why have mood
have mood
swings.
swings. We W e believe
believe genetics
genetics play
play a
a big
big role
role inin who
w h o has
has bipolar
bipolar disorder,
disorder, hut
butwe we
know
k n o w that
that genetics
genetics alone
alone do
do not
not explain
explain when
w h e n and
and why
w h y your
your mood
m o o d swings oc­
svnngs oc-
cur.
cur. Even
Even if if bipolar
bipolardisorder
disorder TUns
runs in
inyour
your family,
family,you youprobably
probablyfeel feelthat
thatyour
your
mood
m o o d swings
swings areare aa product
product ofof more
more than
than just
just your
your genes
genes oror some
some chemicals
chemicals in in
your
your brain
brain that
that have
have gone
gone haywire.
haywire. Stacy
Stacy certainly
certainly felt
felt this
thisway.
way.That's
That'swhy
w h yit's
it's
very
very important
important lO to think
think of
of genetics
genetics asas providing
providing only only a a background
background for prob­
for prob-
lems you
lems you may
m a y have
have in regulating your
in regulating your emotions, thinking, and
emotions, thinking, and activity
activity levels.
levels.
It's
It's the
the same
same way with high
w a y with blood pressure:
high blood pressure: It It certainly
certainly runs
runs in in families,
families, but
but
not
not everyone
everyone in in aa genetically
genetically susceptible family ends
susceptible family ends upup with
with high
high blood pres­
blood pres-
sure,
sure, andand certainly
certainlynot noteveryone
everyone with
with aa family
family history
history ofofhean
heartdisease
diseaseends
endsup up
dying
dying of of a heart attack.
a heart attack. What
W h a t people
people eat,
eat, whether
whether theythey smoke, their weight,
smoke, their weight,
their
their levels
levels ofof stress,
stress, and
and aawhole
whole host
hostof ofother
otherfactors
factorscome
c o m e imo
intoplay.
play.Again,
Again,
there
there isis an
an imponam
important distinction
distinction totobe
be made
m a d e between
between thetheoriginal
originalcauses
causesofofthe
the
disorder
disorder and and triggers
triggers of episodes.
of episodes.

"Wha' If
''What IfI Don', Have
I Don't a Family
Have His'ory
a Family 01 'heof
History Disorder?"
the Disorder?''

Somepeople
Some people with
with bipolar
bipolardisorder
disorderexamine their
examine family
their pedigrees
family and see
pedigrees andnosee no
evidence
evidence ofof any
any illness,
illness, mood
m o o d or
orotherwise.
otherwise.This This isisunusual,
unusual,but but ititdoes
doeshap­
hap-
pen. The
pen. thing to
The thing to ask yourself is
ask yourself is whether
whether you you know
k n o w enough
enough about
about thethepeople
people
in
in your
your pedigree
pedigree to to say
say that
that they
they hadhad no illness. Could
no illness. Could the the "exhaustion"
"exhaustion" that that
your
your mother
mother describes
describes about
about herher own
o w n mother
mother havehave reflected
reflected a a depression?
depression? If If
your
your grandfather
grandfather is is described
described as as"dominating,"
"dominating," "angry,"
"angry,"or or "aggressive,"
"aggressive,"could
could
he have also
he have also been
been manic?
manic? If If not,
not,could
could bipolar
bipolar illness
illness have
have occurred
occurred in in some­
some-
one
one several
several generations
generations back?back?
Often,
Often, your
your older
older relatives
relatives will
will know
k n o w more
more about
about your
your family
family pedigree
pedigree
than you do, in which case you can enlist their help in filling out your pedi-
than you do, in which case you can enlist their help in filling out your pedi­
gree
gree chart.
chart. Your
Your parents,
parents, if if they
they areare alive, will almost
alive, will almost cenainly
certainly know
k n o w more
more
about
about the
the lives
lives of
of their
their parents,
parents, Siblings,
siblings, and and other
otherrelatives.
relatives.Consider
Consider asking
asking
your doctor
your doctor to to perform
perform a a family
family history
history interview
interview withwith oneone oror more
more of of your
your
relatives, if such an evaluation was not done as pan of your initial evaluation
relatives, if such an evaluation was not done as part of your initial evaluation
(see Chapter 3).
(see Chapter 3).
Nonetheless,
Nonetheless, you you may
m a y not
not bebe able
able to
to identify
identify anyany relatives
relatives inin your pedi­
your pedi-
gree
gree who
w h o have
have had
had mood
m o o d disorders.
disorders. We W e believe
believethere
thereareareother
other triggers
triggersforforthe
the
onset of bipolar
onset of bipolar disorder,
disorder,but butwew e aren't
aren'tcertain
certainwhatwhatthese
theseare.
are.It's
It'pOSSible
s possible that
that
prolonged
prolonged drugdrug abuse
abuse cancan bring
bring onon bipolar
bipolar disorder
disorder in in some people. An
some people. A n injury
injury
to
to the
the head
head oror aa neurological
neurological illness
illness such
such as as encephalitis
encephahtis or or muhiple
multiple sclerosis
sclerosis
can
can bring
bring onon mood
m o o d swings
swings that look just
that look just like
like those
those of of bipolar disorder. Per­
bipolar disorder. Per-
haps
haps we
w e will
will find
find that
that the
the onset
onset ofof bipolar
bipolar disorder
disorder can can bebe attributed
attributed in in some
some
people
people to to complications
complications that that occurred
occurred during
during their binh or
their birth or to
to viruses their
viruses their
 Where
Where Does
DoesBipolar
BipolarDisorder
Disorder(orne
ComeFrom?
From? 8585

mothers contracted
mothers contracted during
during pregnancy,
pregnancy, as hasas been
has beenfound found for schizophrenia
for schizophrenia
(for
(for more
m o r e information
information about about this this possibility,
possibility, see see ana n excellent
excellent review
review of of the
the
schizophrenia
schizophrenia Hterature literature by b y Barbara
Barbara Cornblatt
Cornblatt and a n d her
her associates (1999). It
associates (1999). is
It is
unlikely
unlikely that that environmental
environmental stress stress or or traumatic
traumatic experiences
experiences alone alone cancan make
make a a
person develop bipolar disorder if he or she has no
person develop bipolar disorder if h e or she has n o genetic predisposition, but genetic predisposition, but
this
this topic
topic hashas never
never been b e e n studied.
studied.
Even
E v e n if
if your
your disorder
disorder doesn't
doesn't have have ana n obvious
obvious genetic
genetic basis,
basis, youy o u may still
m a y still
respond
respond to to the
the medications
medications that that areare used
used to to treat
treat bipolar
bipolar disorder
disorder (see (see Chapter
Chapter
6), just
6), just asas environmental
environmental stress stress cancan cause
cause a a headache
headache that that aspirin
aspirin can can alleviate.
aHeviate.
Some
S o m e studies
studies indicate
indicate that that ififyou
y o u have
have aa high
high prevalence
prevalence of ofbipolar
bipolar disorder
disorder in in
your
your family
family tree,
tree, youy o u may
m a y respond
respond betterbetter to to lithium
lithium than than if if you have a
y o u have a low
low
prevalence (Abou-Saleh &:
prevalence (Abou-Saleh & Coppen, 1986; Aida
C o p p e n , 1986; Alda el et al., 1997; Grof
al, 1997; Grof et et al., 1993;
al., 1993;
Maj
M a j etet al., 1 9 8 4 ; Prien
al., 1984; Prien et et al., 1973). You
al., 1973). Y o u may
m a y respond
respond better better to anti­
to anti-
convulsants
convulsants (for (for example,
example, Tegretol)
Tegretol) than than to to lithium
lithium if if you
y o u have
have little
little or
or no
no
family
family history
history (Post (Post et et al., 1987). But
al., 1987). But thethe evidence
evidence for for this
this isis not
not strong
strong
enough
e n o u g h to
to gUide
guide our our choice
choice of of treatments.
treatments. Given G i v e n our
our current
current state
state ofof knowl­
knowl-
edge,
edge, your
your physician
physician will will probably
probably place place greater
greater emphasis
emphasis on o n your
your current
current andand
past
past symptoms
s y m p t o m s anda n d pattern
pattern of of mood
m o o d cycling
cycling in in making
m a k i n g his
his or her drug
or her drug treat-
treat­
ment
m e n t recommendations,
r e c o m m e n d a t i o n s , rather
rather than than ono n your
your family
family history.
history.

"Wh.,about
"What .boulHaving
Having Chiltlren?"
Children?"

As indicated
As indicated above,
above,if
if you havebipolar
you have bipolardisorder,
disorder,your
yourchances
chancesof of passing
passing thethe
disorder
disorder on o n to
to your
y o u r kids
kids average
average about
about 8% ( 2 0 % if
8 % (20% if you
y o u include
include majormajor depres­
depres-
sion).
sion). These
These probabilities
probabilities are are relatively
relatively lowl o w and
a n d are
are comparable
comparable to to other
other psy­
psy-
chiatric
chiatric disorders.
disorders. For For example,
example, if if you
y o u have
have schizophrenia,
schizophrenia, your your chances
chances of of
passing
passing itit on
o n to
to your
y o u r children
children are are about
about 13% 1 3 % (Gottesman,
(Gottesman, 1991). 1991). So, So, the
the odds
odds
are
are in
in your
your anda n d your
your child's
child's favor.
favor. OfO f course,
course, thethe question
question of of whether
whether to to have
have
children
children goes
goes well
well beyond
b e y o n d statistics.
statistics. Whether
W h e t h e r you
y o u are
areaawoman
w o m a n oror aa man,
m a n ,your
your
answer
answer to to this
this question
question shouldshould be be based
based on o n considerations
considerations such such as as whether
whether
you
y o u are
are clinically
clinically stable
stable enough
e n o u g h to
to take
take care
care ofof aa child,
child, whether
whether y you
o u are physi­
are physi-
cally
cally healthy
healthy in in other
other ways,
w a y s , and,
and, where
w h e r e applicable,
applicable, whether
w h e t h e r you
y o u are
are satisfied
satisfied
with
with your
your relationship
relationship with vdth your
y o u r partner.
partner.

Genes AreNot
Genes Are NolDestiny
Desliny
Despite the
Despite the relatively
relatively small
small chance that bipolar
chance that bipolar disorder
disorder will
willbe
be passed
passed geneti­
geneti-
cally
cally from parent to
from parent to child,
child, many
m a n y people
people feel
feel doomed
d o o m e d by
b y the
the evidence
evidence that
that they
they
may
m a y have
have those
those genes.
genes. They
T h e y assume
a s s u m e that
that having
having the the associated
associated genes
genes means
means
that
that they a n d their
they and their children
children have
have nothing
nothing to to look
look forward
forward toto but a lot
but a lot of
of mood
mood
cycling, doctors, medications, and hospitals.
cycling, doctors, medications, a n d hospitals.
86
86 CAUSES
CAUSES AND
ANDTRfATMENTS
TREATMENTS

Being Being geneticallyprone

genetically proneororvulnerable
vulnerable to to aadisorder
disordermeans meansthat,
that,by by
meansmeans
of
of your
your biology,
biology, you
you aTe
are more
more likely
likely toto get
get anan illness
illness than
than someone
someone withom
without
the
the same
same genetic
genetic susceptibility.
susceptibility. But But being
being genetically
genetically vulnerable
vulnerable does does notnot
mean
m e a n that
that you
you will
will necessarily
necessarily getget ill
ill within
within aa certain
certainstretch
stretch of oftime;
time;ititdoes
does
not tell
not tell you
you the
the probability
probability or the timing
or the timing of of your
your recurrences.
recurrences. It It also
also does not
does not
mean
m e a n that
that there
there is
is nothing
nothing youyou can
can dodo toto control
control youryour cycling.
cycling. High
High blood
blood
pressure,
pressure, highhigh cholesterol.
cholesterol, and
and diabetes
diabetes are are all
all heritable,
heritable, but but exercise,
exercise, diet,
diet,
and appropriate
and appropriate medications
medications go go aa long
long way
w a y in
in controlling
controlling thesethese diseases.
diseases. Like­
Like-
wise,
wise, lifestyle
lifestylemanagement
management and and medications
medicationsare arecrilicai
criticallo tocontrolling
controllingepisodes
episodes
of bipolar
of bipolar illness
illness (see Chapters 6-10).
(see Chapters 6-10).
Being
Being genetically
genetically susceptible
susceptible doesn't
doesn't mean
m e a n that
that your first-degree relatives,
your first-degree relatives,
including
including your your children,
children, will
will necessarily
necessarily get get the
the illness,
illness, even
even ifif they
they are
are at a
at a
higher
higher than
than average
average statistical
statistical risk.
risk. Illnesses
Illnesses skip
skip generations
generations or or can
can be trans­
be trans-
mitted
mitted to to your
your children
children inin a
a milder form. Nonetheless,
milder form. Nonetheless, ififyou youdo dohave
haveaafamily
family
history of
history of bipolar
bipolar disorder and you
disorder and you also
also have
have children,
children, you you may
m a y be
be concerned
concerned
about how
about h o w you
you can protect them.
can protect There are
them. There are ways
ways toto determine
determine whether
whether one one oror
more
more of of your
your children
children are
are showing
showing signssigns ofof disturbance
disturbance that that suggest
suggest thethe begin­
begin-
nings
nings of bipolar disorder.
of bipolar disorder. These
These cancan include
include irritability,
irritability, aggreSSiveness,
aggressiveness,sleep sleep
disturbance,
disturbance, nightnight terrors,
terrors, school problems, inappropriate
school problems, inappropriate sexuality,
sexuality, drug
drug oror
alcohol
alcohol abuse,
abuse, extreme
extreme andand rapid
rapid switches
switches in in mood,
m o o d , sadness, lethargy, or
sadness, lethargy, or
withdrawal
withdrawal from from others.
others. There
There areare steps
steps you
you can take to
can take to gel
get your
your child treat­
child treat-
ment if these signs are present, even if you're not really sure that he or she has
ment if these signs are present, even if you're not really sure that he or she has
bipolar
bipolar disorder.
disorder. IfIfyou'd
you'd like
liketotolearn
learnmore
more about
aboutbipolar
bipolar disorder
disorder in inchildren,
children,
I'd suggest reading The Bipolar Child by Demitri and Janice Papolos (1999).
I'd suggest reading The Bipolar Child by Demitri and Janice Papolos (1999).

What Is a
W h a t Is a Biochemical
Biochemical Imbalance?
Imbalance?

Stacy
Stacy hadhad been
been told
told that
that her
her illness
illness was
was probably biochemical. However,
probably biochemical. However,
no linkage had
no linkage had ever
ever been made
been m a d e for her between
for her between her her biochemistry
biochemistry andand her
her
medications. She
medications. understood that
She understood that haVing
having a a biochemical
biochemical imbalance
imbalance meant
meant
that
that her
her illness
illness was
was not
not fuHy under her
fully under her control,
control, butbutshe
shewas unclearwhat
was unclear what
else
else itit meant.
meant. WasW a s the
the biochemical
biochemical imbalance
imbalance something
something that could be
that could be
measured?
measured? Why W h y was
was there
there no
no blood
blood test
test for it? Was
for it? W a s the
the imbalance there
imbalance there
only
only when
w h e n she
she was
was manic
manic oror depressed?
depressed? What were the
W h a t were medications doing
the medications doing
to
to it?
it? Were
W e r e the
the medications
medications creating
creating a a different
different kind
kind of biochemical im­
of biochemical im-
balance?
balance? Could the imbalance
Could the imbalance be be corrected
corrected byby diet?
diet? She
She became frustrated
became frustrated
that
that her
her doctor
doctor didn't
didn't give
give clear
clear answers
answers to to these
these questions,
questions, even
even though
though
he
he seemed
seemed quitequite knowledgeable
knowledgeable otherwise.
otherwise. SheShe felt
felt that
that she
she was being
was being
asked
asked to to accept
accept a a lot
lot of things on
of things on faith,
faith, and
and her
her scientific
scientific background
background
made
m her feel
a d e her doubtful.
feel doubtful.
 Where
Where Does
Does Bipolar
Bipolar Disorder
Disorder (orne
Come From?
From? 887
7

Bio'ogico'
BiologicalV.'nerobili/i.s
Vulnerabilities

Given that genetic

Given that genetic background
backgroundsosostrongly strongly influences
influences the onset of bipolar
the onset dis­
of bipolar dis-
order,
order, surely
surely anatomical
anatomical and/orand/or physiological
physiological faclOrs factors play
play a a role
role asas well.
well. A As s I1
discussed
discussed in in the
the preceding
preceding sections,
sections, aabiological
biologicalvulnerability
vulnerabilitycan can bebe dormant
dormant
and
and then
then become
b e c o m e activated
activated by by a a trigger,
trigger, such suchas asenvironmental
environmental stress stressor ordrug
drug
abuse.
abuse. Defining
Defining the the nature
nature of of this
this biological
biological predisposition
predisposition is is mmuch trickier,
u c h trickier,
however.
however. If If you
you have
have been
been lOld
told that
that you
you have
have a a "biochemical imbalance in
"biochemical imbalance the
in the
brain,"
brain," youyou maym a y feel
feel that
that this
this explanation
explanation raises raises as as many
m a n y questions
questions as as it an­
it an-
swers,
swers, as as it
it did
did for Stacy.
for Stacy.
You
Y o u may
m a y find
find you're
you're more
more willing
willing to to accept
accept the the neceSSity
necessity of of aa medication
medication
regime
regime if if you
you understand
understand what what your
your doctors
doctors mean
m e a n by
by aa biological vulnerability
biological vulnerability
or
or biochemical
biochemical imbalance.
imbalance. They They areare usually
usually referring
referring to to something
something that that is part
is part
of you
of you even
even when
w h e n you're
you're notnot having
having any any symptoms.
symptoms. To T o use
use the
the blood
blood pressure
pressure
analogy,
analogy, people
people withwith hypertension
hypertension always always havehave a a vulnerability
vulnerability to to an
an attack
attack of of
high
high blood
blood pressure,
pressure, even even when
w h e n they're
they're doing
doing fine.
fine. Their
Their system
system is is such
such thatthat
their
their blood
blood pressure
pressure is is above
above normal
normal even even when
w h e n they
they are
are relatively stress-free
relatively stress-free
and eating well, and stress causes their blood pressure
and eating well, and stress causes their blood pressure to rise even higher. lo rise even higher.
Likewise,
Likewise, we w e think
think that
thatininbipolar
bipolardisorder,
disorder,certain
certainchemicals
chemicals or or molecules
molecules in in
the
the brain-notably
brain—notably neurotransmitters-are
neurotransmitters—are produced produced at at levels
levels that
that are loO high
are too high
or
or too
too low.
low. The
T h e cells'
cells' receptors
receptorsfor forthese
theseneurotransmitters-along
neurotransmitters—along with with vari­
vari-
ous enzymes
ous enzymes or or neurohormones-may
n e u r o h o r m o n e s — m a y be
be altered
altered in in their
their molecular
molecular structure
structure
and
and function.
function. In In bipolar
bipolar disorder,
disorder, biological
biological vulnerabilities
vulnerabilities involving
involving these these
chemicals
chemicals may m a y be
be evoked
evoked by by stress
stress agents
agents (for(for example,
example, a a sudden
sudden change
change such such
as
as loss
loss ofof aa job),
job), alcohol
alcohol or or street
street drugs,
drugs, or or for
for some
some people,
people, antidepressants
antidepressants
(see Chapter 6).
(see Chapter 6). When
When a a stressor
stressor brings
brings vulnerabilities
vulnerabilities to to the foreground, the
the foreground, the
symptoms
symptoms of of bipolar
bipolar disorder
disorder are are most
most likely
likely to to appear.
appear.
To
T o gel
get technical
technical for for aa moment,
m o m e n t , we
w e strongly
strongly suspect
suspect thatthat people
people withwith bipo-
bipo­
lar
lar disorder
disorder have have disturbances
disturbances in in the
the production
production and and catabolism
catabolism (chemical
(chemical
breakdown)
breakdown) of of the
the neurotransmitters
neurotransmitters norepinephrine,
norepinephrine, dopamine, acetylcho­
dopamine, acetylcho-
line,
line,serolOnin,
serotonin,and and GABA
G A B A (gamma-aminobutyric
(gamma-aminobutyric acid). acid).We W e believe
believethatthatsomesome
of
of these
these neurotransmitters
neurotransmitters are are over-
over- or or underproduced
underproduced during during different
different phases
phases
of
of the
the illness,
illness, then
then notnot broken
broken down d o w n quickly
quickly enough,
enough, or or broken
broken downd o w n tooloO
quickly.
quickly. We W e also
also know
k n o w that
that people
people with with bipolar
bipolar disorder
disorder and and unipolar depres­
unipolar depres-
sion
sion have
have an an abnormal
abnormal production
production of hormones (for
of hormones (for example,
example, glucocorticoids
glucocorticoids
such
such as as cortisol)
Cortisol) produced
produced by by the
the adrenal
adrenal glands
glands whenwhen a a person
person is is under
under
stress.
stress. Long-term
Long-term stress stress and
and glucocorticOid
glucocorticoid overproduction
overproduction may m a y damage
damage or or
destroy
destroy cells
cells in
in the
the hippocampus,
hippocampus, a a brain
brain structure
structure thatthat isis an
an important
important com­ com-
ponent
ponent of of the
the limbic
limbic system,
system, whichwhich regulates
regulates emotional
emotional states,
states, sleep,
sleep, and and
arousal (Sapolsky, 2000;
arousal (Sapolsky, Manji, 2001).
2000; Manji, 2001).
Measuring
Measuring biochemical
biochemical imbalances
imbalances gives gives us us incomplete
incomplete information.
information. For For
88
88 CAUSES
CAUSESAND
ANDTREATMENTS
TREATMENTS

example, many
example, people with
many people with bipolar
bipolardisorder have
disorder lowlow
have levels of the
levels ofmetabolite
the metabolite
(the
(the breakdown
breakdown product)
product) of of norepinephrine
norepinephrine when w h e n they
they are
are in
in the
the depressed
depressed
phase
phase andand higher
higher levels
levels when
w h e n inin the manic phase
the manic (Manji &
phase (Manji & POlLer, 1997;
Potter, 1997;
Man
Manji, 2001). Generally
ji, 2001). Generally in in these
these studies,
studies, levels
levelsofofthe breakdown product
thebreakdown productin inaa
bipolar person's
bipolar person's urine,
urine, blood,
blood,or orcerebrospinal
cerebrospinalfluid fluid(which
(which requires
requiresaaspinal
spinal
tap) are
tap) are measured.
measured. Such Such procedures
procedures may tell us
m a y tell us that
thatsomething
something is iswrong
wrong in inthe
the
production
production of of norepinephrine,
norepinephrine, but but we w e don't
don'thave
have thetheprecision
precision to topoint
point to tothe
the
area
area in
in the
the brain
brain where
where this
this misfiring
misfiring is is occurring.
occurring. Eventually,
Eventually, thethe ""neural
neural cir�
cir-
cuits" (brain pathways)
cuits" (brain pathways) most most associated
associatedwith withbipolar
bipolarsymptoms
symptoms may m a y be
be identi­
identi-
fied,
fied, perhaps
perhaps through
through brain
brain imaging
imaging techniques
techniques such such as as fMRls
fMRIs (functional
(functional
magnetic resonance imaging)
magnetic resonance imaging).. Identifying
Identifying these these brain
brain circuits
circuits may help us
m a y help us rec+
rec-
ognize
ognize persons
persons at at risk
risk for
for the
the disorder,
disorder, even evenwhenw h e n they
theyarearesymptom+free,
symptom-free,and and
hopefully develop
hopefully develop moremore effective treatments.
effective treatments.
New
N e w research
research withwith bipolar
bipolar persons
persons has has found
found problems
problems in in their second
their second
messenger
messenger systems (also k
systems (also known
n o w n as
as "Signal
"signal transducers"),
transducers"), which which areare molecules
molecules
inside
inside brain
brain nerve
nerve cells.
cells. When
W h e n oneone nerve
nerve cellcell "fires,"
"fires," itit sends neurotrans+
sends neurotrans-
millers (the
mitters (the "first
"first messengers")
messengers") to to the
the next
next nerve
nerve cell.
cell.Then
Thenaasecond
secondmessen­
messen-
ger system informs
ger system informs the the second
second nerve
nerve cellcell that
that the first nerve
the first nerve cell
cell has
has fired.
fired. InIn
other words, second
other words, second messengers
messengers help help to to determine whether a
determine whether a cell
cell communi­
communi-
cates messages to
cates messages to other
other parts
parts ofof the same cell
the same cell and
and to to nearby
nearby cells.
cells. One
O n e part of
part of
the
the second
second messenger
messenger system,
system, called G-proteins (guanine
called G-proleins (guanine nucleotide-binding
nucleotide-binding
proteins),
proteins), may
m a y bebe present
present at at abnormally
abnormally high high levels
levels inin the
the blood
blood platelets
platelets of of
people with
people with bipolar
bipolar disorder,
disorder, even
even when
w h e n they
they are
are free of symptoms
free of symptoms (Mitchell
(MitcheU
et al.,
et al., 1997).
1997). Lithium
Lithium probably
probably changes G-protein function
changes G-protein function (Avissar
(Avissar et al.,
et al,
1988;
1988; ]ope,
Jope, 1999;
1999; Risby
Risby etet aI.,
al., 1991).
1991). Lithium
Lithium and and Depakote
Depakote alsoalso slow
slow down
down
activity
activity of the protein
of the protein kinase
kinase C C signaling
signaling cascade,
cascade, an an important
important mediator
mediator of of
Signals
signals within
within the the cells
cells when
w h e n their
their receptors
receptors are are stimulated
stimulated by neuro­
by neuro-
transmitters
transmitters (Manji, 2001). This
(Manji, 2001). This exciting
exciting research
research suggests
suggests that
that changes
changes in in
second
second messenger
messenger systems
systems maym a y constitute
constitute one one form
form of of biological
biological vulnerability
vulnerabihty
to
to bipolar
bipolar disorder--one
disorder—one that that m may
a y be partially correctable
be partially correctable by medications.
by medications.

The Lack
The Lackof
ofa aDefinitive Te.t Test
Definitive
,

Despite
Despite this
this promising
promising research,
research,therethere
is no definitive biologicalbiological
is no definitive or genetiC test
or genetic t
for chemical
for chemical imbalances
imbalances in bipolar disorder.
in bipolar disorder. Most
Most professionals,
professionals, patients,
patients,andand
families wish there
families wish there were,
were, because
because that
that would
would make
m a k e diagnOSiS
diagnosis and
and treatment
treatment
planning
planning m much
u c h easier.
easier. Most
Most of
ofususbelieve
beheve that
thatsuch
suchaatest
testwill
wiHbebefound
foundeventu­
eventu-
ally, but for now it's a long way off.
ally, but for n o w i t's a long w a y off.
The
The absence
absence of of a
a definitive
definitive test
test makes
makes ititeasy
easy to
to forget
forgetthat
that you have aa bio­
you have bio-
chemical imbalance and even easier to believe that you never had one in the
chemical imbalance and even easier to believe that you never had one in the
first
first place.
place. Notice
Notice thatthat Stacy,
Stacy, wwho had been
h o had free of
been free of symptoms
symptoms forfor quite
quite some
some
Lime,
time, started
started to
towonder
wonder whether
whether sheshe really
reallyhad
had aabiological
biologicalpredisposition.
predisposition.ItIt is is
 Where
Where Does
DoesBipolar
BipolarDisorder
Disorder(orne
ComeFrom?
Fram? 8989

understandable
understandable totohave have this
this question.
question. Could
Could youryourmanicmanic or depressive
or depressive epi- epi­
sodes
sodes have
have beenb e e n one-time
one-time occurrences
occurrences that
that were
w e r e set
set off
off byb y unpleasant
unpleasant life cir­
life cir-
cumstances?
cumstances? Many M a n y people
people start
start to
to believe
believe that
that "I "I had
h a d this
this illness
illness once,
once, but
but
now
n o w it's
it's under
u n d e r my
m y control,"
control," especially
especially when
w h e n they've
they've been
b e e n well for a
well for a while.
while. But
But
bipolar
bipolar symptoms
s y m p t o m s have
have aa way
w a y of
of recurring
recurring when
w h e n you
y o u least
least expect
expect them.
them. We W e
believe
believe this
this is is because
because biological
biological vulnerabilities
vulnerabilities are are still
still present,
present, even
even when
when
your
your symptoms
s y m p t o m s are
are controlled
controlled by
b y medications
medications and
a n d psychotherapy.
psychotherapy.

WhatTurns
What Turns a Biological
a Biological Vulnerability
Vulnerability intointo an Episode?
an Episode?

Learningthat
Learning thatyou
you probably
probably havehave a biological
a biological imbalance,
imbalance, although
although perhapsperhaps
frightening,
frightening, should should help help to to arm
a r m you
y o u against
against recurrences
recurrences of of your
your illness.
illness. Like
Like
the
the diabetic
diabetic who w h o knows
k n o w s heh e or
or she
she must
m u s t avoid
avoid ice ice cream,
cream, or or the
the person
person with with
high
high blood
blood pressure
pressure who w h o must
m u s t avoid
avoid extreme
extreme distressdistress and
a n d be
be sure
sure to
to exercise,
exercise,
you
y o u can
can exert
exert a a degree
degree of of control
control over over youryour bipolar
bipolar disorder
disorder b by
y learning
learning to to
avoid
avoid triggers
triggers that that influence
influence the the expression
expression of of your
your chemical
chemical imbalance.
imbalance.
When
W h e n people
people who w h o do d o not
not have
have biochemical
biochemical imbalances
imbalances experience
experience these trig­
these trig-
gers
gers (for
(for example,
example, they they take
take drugs
drugs or or alcohol
alcohol or or intentionally
intentionally rake take on
o n high lev­
high lev-
els
els of
of stress),
stress), they
they may m a y experience
experience changeschanges in in mood
m o o d but
but not
not to the degree
to the degree thatthat
characterizes
characterizes a a person
person with with bipolar
bipolar disorder.
disorder.
Some
S o m e triggers
triggers may m a y directly
directly impinge
impinge on on a a person's
person's chemical
chemical imbalances
imbalances
and
a n d set
set them
t h e m off,
off, kind
kind of of like
like lighting
lighting a a fuse
fuse connecting
connecting a a string
string ofof firecrack­
firecrack-
ers.
ers. For
For example,
example, LSD L S D stimulates
stimulates the the action
action of of certain
certain serotonin
serotonin receptors
receptors in in
the
the brain,
brain, which
w h i c h produces
produces other other biochemical
biochemical events events that
that will
will increase
increase your your
risk of developing a manic episode. Studies of laboratory animals as well as
risk of developing a m a n i c episode. Studies of laboratory animals as well as
humans
h u m a n s find
find thatthat amphetamine
a m p h e t a m i n e (speed)
(speed) stimulates
stimulates the the release
release and
a n d prolongs
prolongs
the
the activity
activity of of dopamine
d o p a m i n e inin the
the brain,
brain, which
w h i c h can
can also
also result
result inin aa Slate
state of of high
high
arousal,
arousal, paranoid
paranoid thinking,
thinking, irritability,
irritability, and a n d increases
increases in in energy
energy or or mmotor activ­
o t o r activ-
ity.
ity. Caffeine
Caffeine usage usage blocks
blocks a a receptor
receptor for for thethe neurotransmitter
neurotransmitter adenosine,
adenosine,
which
w h i c h may
m a y result
result in in greater
greater release
release of of dopamine,
d o p a m i n e , norepinephrine,
norepinephrine, and acetyl­
a n d acetyl-
choline.
choline. Alcohol
Alcohol inhibits
inhibits the the activity
activity of of your
your central
central nervous
nervous system
system (for(for ex­
ex-
ample,
ample, it it increases
increases the the effects
effects of of the
the inhibitory
inhibitory neurotransmiLter
neurotransmitter GABA G A B A on its
o n its
receptors)
receptors) and, and, likelike caffeine
caffeine and a n d other
other substances,
substances, interferes
interferes with your sleep­
with your sleep-
wake
w a k e rhythms.
rhythms. When W h e n youy o u stop
stop drinking,
drinking, your your brain
brain circuits
circuits become
become m more
o r e ex­
ex-
citable,
citable, muchm u c h like
like they
they do d o in
in mania.
mania.
Environmental stress can augment
Environmental stress can a u g m e n t your
your biochemical
biochemical imbalances,
imbalances, but but the
the
mechanisms
m e c h a n i s m s byb y which
w h i c h this
this happens
h a p p e n s are
are notnot wellwell understood
understood b by scientists.
y scientists.
Stress
Stress cannot
cannot be b e avoided
avoided in in thethe same
s a m e way
w a y thatthat alcohol
alcohol or or drugs
drugs can can be be
avoided,
avoided, but but knowing
k n o w i n g what
w h a t kinds
kinds of of stress
stress agents
agents willwill be
be particularly
particularly trouble­
trouble-
s o m e wiD
some will help
help you y o u know
k n o w when
w h e n you
y o u are
are most
m o s t atat risk
risk for
for bipolar
bipolar recurrences
recurrences
and
a n d plan
plan preventively
preventively in in the
the ways
w a y s that
that areare covered
covered in in the
the next
next few
few chapters.
chapters.
90
90 CAUSES
CAUSESAND
ANDTREATMENTS
TREATMENTS

Stress and
Stress and Bipolar
Bipolar Episodes
Episodes

Can bipolar
Can bipolar disorder
disorder be
be caused
caused by
by environmental
environmental factors,
factors,such as as
such a highly
a highly
conflictive
conflictive marriage,
marriage, problems
problemswith with parents,
parents,life lifechanges,
changes, a adifficult
difficult job,
job,oror
be­be-
ing
ing abused
abused as as a
a child?
child? These
These areare extremely
extremely important
important questions
questions that that arc
are not
not
fully
fully answerable.
answerable. As As II mentioned
mentioned earlier,
earlier,mostmostofofus usdoubt
doubtthatthatenvironmental
environmental
factors
factors alone
alone can cause bipolar
can cause bipolar disorder
disorder without
without the the contributing
contributing influences
influences of of
genetics
genetics andand biology.
biology. However,
However,we w e are
arereasonably
reasonablycenaincertainthat
thatstress
stressaffeclS
affectsthe
the
course of your illness, or increases the chances that you
course of your illness, or increases the chances that you will have anepisode will have an episode
of
of mania
mania or depreSSion if
or depression if you
you already
already have have bipolar
bipolar disorder.
disorder. YourYour level
level ofof
stress
stress may
m a y also
also affect
affect how
h o w long
long itit lakes
takesyou you totoget
getover
overaabipolar
bipolarepisode.
episode.That
That
is,
is, the
the level
level and
and type
type ofof stress
stress you
you experience
experience is is a
a "prognostic
"prognostic factor"
factor" that
that
helps
helps determine
determine youryour likelihood
likelihood of of getting
getting better
better or or worse within a
worse within a certain
certain
lime
time frame.
frame. Psychiatrists
Psychiatrists and and psychologists
psychologists are are interested
interested in in knOwing
knowing about about
the
the role
role ofof stress
stress in
in your
your life
life because
because it it can help them
can help them inin treatment
treatment planning,
planning,
such as
such as deciding
deciding what
what type
type of therapy to
of therapy to recommend
recommend to to you.
you.
What
W h a t kinds
kinds ofof environmental
environmental stress stress areare particularly
particularly impacting?
impacting? If If you
you
have
have bipolar
bipolar disorder,
disorder, encountering
encountering a a major
major life
life change-whether
change—^whether positive positive oror
negative-increases
negative—increases your your likelihood
likelihood of of having
having a a bipolar
bipolar recurrence.
recurrence. Stacy's
Stacy's di­
di-
vorce
vorce hadhad relatively
relatively little
little immediate
immediate effect effect on
on herher mood
m o o d state,
state, but
but the child
the child
custody
custody evaluation
evaluation played
played a major role
a major role in her manic
in her manic episode.
episode. Other kinds of
Other kinds of
stress
stress include
include sleep-wake
sleep-wake cyclecycle disruptions
disruptions and and conflicts
conflicts with
with Significant oth­
significant oth-
ers.
ers. I'll
I'll be
be talking
talking about
about eacheach of these and
of these and giving
giving examples.
examples. I I'll
'll also
also discuss
discuss
some
some of the currenl
of the current lhinking
thinking about
about mechanisms
mechanisms by by which
which biochemical imbal­
biochemical imbal-
ances
ances might
might be be affected
affected by stress.
by stress.

Mojor Life
Major LifeChanges
Changes

Changes are
Changes are a
a part
part of
oflife, andand
life, sometimes they
sometimes are are
they quite welcome.
quite SomeSome
welcome. of of
them are positive
them are positive and
and some
some quite
quite negative.
negative. Examples
Examples of
of positive
positive life
life changes
changes
include
include getting
getting married,
married, having
having a
a child, buying a
child, buying annew
e w house,
house, making
making money
money
from
from anan investment,
investment, oror getting
getting a job promotion.
a job promotion. Negative
Negative life
life changes include
changes include
the
the death
death of
of a
a loved
loved one,
one, the loss of
the loss of a
a relationship,
relationship, thetheloss
lossofofaajob,
job,aacar
caracci­
acci-
dent,
dent, or
or the
the development
development of of a
a medical
medical illness
illness in
in yourself
yourself or or another family
another family
member.
member.
Manic
Manic and
and depressive
depressive episodes
episodes often
often follow
follow major
major life
life changes,
changes,bothbothposi­
posi-
tive and
tive and negative. Sheri Johnson,
negative. Sheri Johnson, PhD,
PhD, a a psychology
psychology professor
professor at at the
the Univer­
Univer-
Sity
sity of
of Miami,
Miami, has
has written
written extenSively
extensively about
about life
life events
eventsin inbipolar
bipolardisorder
disorder(for
(for
example, Johnson &
example,Johnson 62 Roberts, 1995). She
Roberts, 1995). She points
points out
out that
that it
itisisnot
notalways
alwaysclear
clear
whether
whether life
life events
events are
are a
a cause
cause or
or an
an effect
effect of
of the
the mood
m o o d episode.
episode. A client with
A client with
 Where
WhereDoes
DoesBjpolar
BipolarDjsorder
DisordeCome flom?
r Come From? 9191

bipolar disorder, Patrick,

bipolar disorder, Patrick, age age 36, providesananillustration.
36, provides illustration. When When he hewaswascy- cy­
cling
cling into
into mania,
m a n i a , he
h e would
w o u l d become
b e c o m e overconfident
overconfident and a n d frequently
frequently "tell off" his
"teH off' his
employers.
employers. He H e often
often lostlost jobs
jobs as as aa result.
resuh. When W h e n discussing
discussing his his history,
history, he he
would
w o u l d argue
argue thatthat hishis pattern
pattern was w a s toto lose
lose jobs
jobs and then become
a n d then b e c o m e manic-when
manic—when
the
the reality
reality wasw a s probably
probably the the other
other way w a y around.
around. But But eveneven whenw h e n considering
considering
only
only events
events that that couldn't
couldn't have have been
b e e n brought
brought about about by b y the
the illness
illness itself
itself (for
(for ex­
ex-
ample,
ample, the the death
death of of aa parent;
parent;losing
losing one's
one's job job at at aa plant
plant [hat
that closed
closed down),
d o w n ) , re­
re-
searchers
searchers still still find
find that
that life
life events
events play play aa role
role in in the
the onset
onset of of manic
m a n i c and
a n d depres­
depres-
sive
sive episodes (Johnson &:
episodes Oohnson & Roberts,
Roberts, 1995). 1995).
All
A H ofof us
us are
are emotionally
emotionally affectedaffected by b y stress,
stress, but but notnot everyone
everyone has has the
the se­
se-
vere
vere mood
m o o d swings
swings that that bipolar
bipolar people
people have have whenw h e n under
u n d e r stress.
stress. Are A r e people
people
with
with bipolar
bipolar disorder
disorder somehow
s o m e h o w more
m o r e sensitive
sensitive to to life
life events?
events? Johnson
J o h n s o n and
a n d her
her
coHeagues (2000)
colleagues (2000) pointpoint out out that
that thethe kinds
kinds of of events
events thatthat precede
precede manic m a n i c epi­
epi-
sodes
sodes are are often
often goal-
goal- or or achievement-oriented.
achievement-oriented. Examples E x a m p l e s of
of these
these kinds
kinds of of
events
events include
include job job promotions,
promotions, new n e w romantic
romantic relationships,
relationships, financial invest­
financial invest-
ments,
ments, and a n d athletic
athletic successes.
successes. She S h e and
a n d her
her colleagues
coHeagues think think that
that these
these kinds
kinds of of
events
events activate
activate aa circuit
circuit in in the
the brain
brain known
k n o w n as as the
the behavioral
behavioral activation
activation system,
system,
which
w h i c h regulates
regulates the the activity
activity of of the
the brain
brain whenw h e n "cues"
"cues" or or stimuli
stimuli indicating
indicating re- re­
ward
w a r d are
are present
present (for (for example,
example, investments
investments that that Signal
signal the the pOSSibility
possibility of of great
great
financial
financial gain).
gain). In In contrast,
contrast, otherother kindskinds of of events
events causecause people
people to to shut
shut downdown
and
a n d withdraw,
withdraw, as as they
they do d o when
w h e n they
they get get depressed.
depressed. These These events,
events, whichw h i c h usu­
usu-
ally
ally involve
involve loss,loss, grief,
grief, or or rejection,
rejection, may m a y activate
activate a a different
different set set ofof neural
neural cir-cir­
cuits,
cuits, called
called thethe behavioral
behavioral inhibition system. This
inhibition system. This system
system motivates
motivates the the person
person
to avoid stimuli that Signal punishment. For example, the loss of a relation­
to avoid stimuli that signal p u n i s h m e n t . For example, the loss of a relation-
ship
ship maymay m make
ake a a person
person withdraw
w i t h d r a w from
f r o m others
others as as aa way
w a y of
of avoiding
avoiding further
further re- re­
jection.
jection.
The
T h e behavioral
behavioral activation
activation and a n d inhibition
inhibition systemssystems probably
probably involveinvolve dopa­dopa-
mine
m i n e and
a n d serotonin activity, wwhich,
serotonin activity, h i c h , as
as mentioned
m e n t i o n e d earlier,
earlier, may m a y bbee abnormal in
a b n o r m a l in
the
the brains
brains of people with
of people with bipolar
bipolar disorder.
disorder. People People with with bipolar
bipolar disorder
disorder might might
therefore
therefore b bee mmore biologically sensitive
o r e biologically sensitive to to events
events that that areare goal-oriented
goal-oriented or or
loss/rejection-oriented. Johnson's
loss/rejection-oriented. hypotheSiS is
Johnson's hypothesis is an
a n intriguing
intriguing one, one, a and she has
n d she has
supported it
supported it in
in her
her research
research bby y shOwing that, aamong
s h o w i n g that, people with
m o n g people with bipolar
bipolar II
disorder,
disorder, m manic
a n i c episodes
episodes are often preceded
are often preceded bby y events
events that stimulate goal-
that stimulate goal­
directedness QOohnson
directedness o h n s o n et al., 2000).
et al., 2000).

Slressful Events:
Stressful Events: E.amining
Examining Your Hislary
Your History

Havestressful
Have events played
stressful events playedaa role
role in
in your previous episodes?
your previous episodes?IfIf you
youhave
havehad
had
mmore than oone
o r e than clear-cut episode,
n e clear-cut episode, yyou
o u mmay find the
a y find the following
following exercise
exercise useful.
useful.
Fill out
Fill out the dates of
the dates of three
three or
or mmore of your
o r e of your previous
previous mmanic!hypomanic or de-
a n i c / h y p o m a n i c or de­
pressive episodes
pressive episodes aand see if
n d see if yyou can determine
o u can determine wwhether life events
h e t h e r life events occurred
occurred
92
92 CAUSESAND
CAUSES ANDTREATMENTS
TREATMENTS

WHAT
W H A T ROLE
ROLE HAS
HAS STRESS
STRESS PLAYED
PLAYED IN
IN YOUR
Y O U R ILLNESS?
ILLNESS?

ApprOximate dale
Approximate date
of
of eepisode
pisode Type of
Type of eepisode
pisode
(or
(or your
your age
age at
at the
the (manic,
(manic, hypomanic,
hypomanic,
time)
time) depressed,
depressed, mixed)
mixed) Stressful
Stressfulevents
events(describe)
(describe)

before
before (or
(or during)
during) any
any or
or all
all of
of them.
them. If
If yOUT
your previous
previous episodes
episodes have
have been
been
mainly
mainly mixed,
mixed, indicate
indicate this
this in the table
in the table so
so that
that you
you can keep them
can keep them separate
separate
w h e n evaluating
when evaluating the
the exercise.
exercise. Currently,
Currently, we
w e don't know
don't k n o w whether
whether mixed
mixed epi­
epi-
sodes
sodes have
have different
different environmental
environmental stress
stress triggers
triggers from manic or
from manic or depreSSive
depressive
episodes.
episodes.
Include
Include major
major events
events (for
(for example,
example, a
a move
m o v e to
to a
a new
n e w state,
state, new
n e w romantic
romantic
relationships
relationships or
or relationship
relationship breakups,
breakups, car
car accidents,
accidents, job
job changes,
changes,deaths
deaths in
in
the family)
the family) as
aswell
wellas
asevents
eventsthat,
that,by
bycomparison,
comparison,are
areless
lesssevere
severeorordisruptive
disruptive
(for
(for example, buying a
example, buying a new
n e w pet,
pet, getting
getting the flu, taking
theflu, vacation, changing
taking aa vacation, changing
your job
your job hours).
hours). Include
Include both
both positive
positive and
and negative
negative life
life events.
events.
Try
Try to take a
to take a somewhat
somewhat removed
removed stance
stance when
w h e n examining
examining the
the role
role of
of life
Hfe
stress
stress in yOUT own
in your o w n illness.
illness. Are
Areparticular
particulartypes
typesof
ofevents
eventsconsistently relatedto
consistentlyrelated to
yOUT
your episodes? Has an
episodes? Has an event
event involving
involving loss
loss or
or grief
grief ever
ever preceded
preceded one or more
one or more
of
of your
your depressive
depressive episodes? How
episodes? H o w many
m a n y of
of your
your prior
prior manic
manic or
or mixed epi­
mixed epi-
sodes were related
sodes were related to
to romantic
romantic relationships, evenif
relationships, even ifpositive
positive(such as,fmding
(suchas, finding
a
a new
n e w partner)?
partner)? Do
D o events
events that
that involve
involve achievement
achievement (for
(for example,
example, an
an increase
increase
in your work
in your w o r k aSSignments)
assignments) often
often precede your manic
precede your manic or hypomanic episodes?
or hypomanic episodes?
How
H o w many
m a n y of
of these
these events might have
events might have resulted
resulted in changes in
in changes in when
w h e n or
or how
how
 WRere
Where Does
DoesBipolar
BipolarDisorder
Disorde(orne
r ComeFrom?
From? 9393

much
much you youslept?
slept?More More generally,
generally, do do these
these events
events occur
occur independemly
independently of yourof your
mood
m o o d disorder?
disorder? Or O r does
does your
your manic
m a n i c or
or depressive
depressive behavior
behavior play play a a significant
significant
role
role in in causing
causing these these events?
events?
Don't
Don't be be disappoimed
disappointed if if you
y o u have
have difficulty
difficulty answering
answering these these questions.
questions.
Many
M a n y people
people with with bipolar
bipolar disorder
disorder have have trouble
trouble recalling
recalling when w h e n their
their episodes
episodes
started
started and a n d ended
e n d e d and
a n d when
w h e n certain
certain stressful
stressful events
events occurred.
occurred. If If you
y o u are
are hav­
hav-
ing
ing trouble,
trouble, try try consulting
consulting aa family family member
m e m b e r oror your
your doctor
doctor if if he
h e oror she
she has
has
seen you through several episodes. Take him or her
seen y o u through several episodes. T a k e h i m or her through the exercise a n d through the exercise and
see if
see if he
h e oror she
she cancan help
help jogjog your
y o u r memory
m e m o r y about
about when w h e n certain
certain eventsevents oc­ oc-
curred,
curred, whether
w h e t h e r these
these events
events came
c a m e before
before or or after
after an a n episode,
episode, and a n d what
w h a t type
type of
of
episode
episode you y o u had.
had.
The
T h e temporal
temporal relationship
relationship between
between a a life
life event
event and and a a resulting
resulting mood m o o d state
state
can
can bebe quite
quite complicated.
complicated. For For example,
example, Annie,Annie, a a 27-year-old,
27-year-old, become b e c o m e mildly
mildly
depressed
depressed after after she
she broke
broke up u p with
with her her live-in
live-in girlfriend
girlfriend but but did
did notnot develop
develop a a
full
full bipolar
bipolar depression.
depression. However,
H o w e v e r , when
w h e n her
her physician
physician staned started herher on on a a regime
regime
of
of antidepressam
antidepressant medication,
medication, she she developed
developed aa mixed m i x e d episode.
episode. In In this
this case,
case, the
the
environmental
environmental stressor stressor (the(the relationship
relationship ending)ending) was w a s related
related to to the
the outcome
outcome
(the
(the mixed
m i x e d episode)
episode) only only through
through the the avenue
avenue of of aa change
change in in her
her medication.
medication.
Remember
R e m e m b e r that
that discovering
discovering aa linkagelinkage between
b e t w e e n life
life events
events and a n d your
your moodmood
disorder
disorder episodes
episodes does does notnot mean
m e a n that
that you
y o u are
are somehow
s o m e h o w at at fault
fault forfor causing
causing
your
your owno w n illness.
illness. ManyM a n y life
life events
events are are unavoidable.
unavoidable. Some S o m e of
of these
these events
events can can
become
b e c o m e more likely to
m o r e likely to occur
occur when w h e n you
y o u get
get manic
m a n i c or
or depressed,
depressed, but that still
but that still
doesn't
doesn't meanm e a n youy o u are
are fully
fully inin control
control of of their
their occurrence.
occurrence. For For example,
example, you you
may
m a y have
have lost
lost certain
certain jobsjobs once
once youry o u r mood
m o o d cycled
cycled into into irritability
irritability or or depres­
depres-
sion,
sion, but
but that
that doesn't
doesn't m mean
e a n you
y o u should
should have have been
b e e n able
able to to control
control thesethese mood
mood
states
states oror their
their effects
effects on o n others,
others, particularly
particularly without
without havinghaving any any tools
tools to to do so.
d o so.

TIre Role
rhe Role of
of the
the Sleep-Wake
Sleep-Woke Cycle
Cycle

We've
W e ' v e already
already talked
talked about
about one o n e mechanism
m e c h a n i s m byb y which
w h i c h stress
stress can affect bipolar
can affect bipolar
symptoms-the
s y m p t o m s — t h e behavioral
behavioral activation
activation and a n d inhibition
inhibition systems.
systems. Another
Another mecha­mecha-
nism
nism is is sleep.
sleep. If If you
you r remember
e m e m b e r back
back to to your
your first
first episode
episode or or any other epi­
any other epi-
sodes,
sodes, you y o u will
will probably
probably agreeagree thatthat sleep
sleep played
played some s o m e role
role in in them. Perhaps it
them. Perhaps it
is
is simply
simply that that when
w h e n you
y o u were
w e r e manic
m a n i c you
y o u slept
slept less,
less, and
a n d when
w h e n you
y o u were de­
w e r e de-
pressed
pressed you y o u slept
slept more.
m o r e . But
But changes
changes in in sleeping
sleeping and a n d waking
w a k i n g are
are important
important in in
another
another way. w a y . Researchers believe that
Researchers believe that bipolar
bipolar people
people are are very
very sensitive
sensitive to to even
even
minor
m i n o r changes
changes in in sleep-wake
sleep---wake rrhythms, such as
h y t h m s , such as when they go
w h e n they to bed,
g o to bed, �henwhen
they
they actually
actually faU fall asleep,
asleep, and a n d when
w h e n they
they w wake
a k e upu p (Wehr
( W e h r etet al.
al. 1 9 8 7 ; FFrank
1987; et
r a n k et
aI.,
al, 2000;
2 0 0 0 ; Malkoff-Schwartz
Malkoff-Schwartz et
et al.,
al., 1998).
1998). If
If so,
so, events
events that
that change
change your
your sleep--
sleep- ­
wake cycle will
w a k e cycle will also
also affect
affect your
your m mood.
o o d . Stacy
Stacy became
b e c a m e quite
quite manic
m a n i c wwhen she be-
h e n she be­
gan
g a n the
the child
child custody
custody proceedings,
proceedings, possibly because the
possibly because the preparations
preparations were were
94
94 CAUSES
CAUSESAND
ANDTREATMENTS
TREATMENTS

stressful
stressful and forced
and forcedher her
to stay
to up
staylater
up at night.atDarryl,
later night.age 24, became
Darryl, manic
age 24, became mani
shortly
shortly after
after his
his graduate
graduate school
school finals,
finals, during
during which
which hehe had stayed up
had stayed later
u p later
and later. losing
and later. Losingeven
evenaasingle
singlenight's
night'ssleep
sleepcan
canprecipitate
precipitateaamanic
manic episode
episodein in
people with
people bipolar disorder
with bipolar disorder whow h o have
have otherwise
otherwise been
been stable
stable (Malkoff­
(Malkoff-
Schwartz
Schwartz et al., 1998).
et aI., 1998). In In parallel,
parallel, sleep
sleep deprivation
deprivation can
can improve
improve the
the mood
mood
of
of aa person
person with
with depression,
depression, although
although only briefly (Barbini
only briefly (Barbini et
et aI., 1998;
al., 1998;
Liebenlufi &:.
Liebenluft W e h r , 1992).
& Wehr, 1992).

What Affects
What Affects OurOur
Sleell-Woke Regularity?,
Sleep-Wake Sodol Zeitgebers
Regularity?: Socialand Zeitstorers and Zeitstorers
Zeitgebers

Unless you
Unless you speak
speak German,
German, you've
you've probably
probablynever
neverheard these
heard terms
these hefore­
terms before—
nor
nor had
had II until
until II started
started reading
reading about
about the the social
social rhythm
rhythm stabilit
stabilityy hypothesis
hypothesis of of
Cindy
Cindy Ehlers
Ehlers and and her
her associates
associates at at the
the University
University of of Pittsburgh
Pittsburgh Medical
Medical Center
Center
(Ehlers et al., 1988; et al., 1993).
(Ehlers et al., 1988; Ehlers et al., 1993). This model helps us understand why
Ehlers This model helps us understand why
lire
life events
events might
might affect
affect bipolar
bipolar people's
people's mood cycles.
m o o d cycles.
Ehlers'
Ehlers' theory
theorystates
statesthatthatthethecore
coreproblem
problem in inbipolar
bipolardisorder
disorderis isone
one of
ofin­
in-
stability.
stability. Usually,
Usually,people
peoplemaintain
maintainregularregularpatterns
patternsof ofdaily
dailyactivity
activityand andsocial
social
stimulation,
stimulation, such such as as when
w h e n they
they gogo to to bed,
bed, when they get
w h e n they gel up
up and
and gogo toto work,
work,
how
h o w many
m a n y people
people theythey ordinarily
ordinarily socialize
socialize with,
with, or or where
where theythey gogo after
after work.
work.
These
These "social
"social rhythms"
rhythms" are are important
important in in maintaining
maintaining OUT our "circadian rhythms,"
"circadian rhythms,"
which
which are are the
the more
more biologically
biologically drivendriven cycles
cycles such
such as as when
w h e n you
you actually
actually faU fall
asleep,
asleep, thethe production
production of of hormones
hormones like like melatonin
melatonin (which (which is is produced
produced when when
you
you areare approaching
approaching sleep),sleep), or your pattern
or your pattern of rapid eye
of rapid eye movement activity
m o v e m e n t activity
during sleep.
during sleep.
Social
Social rhythms
rhythms stay stay stable,
stable, in inpart,
part,because
becauseofofsocialsocialZeitgebers,
Zeitgebers, which
which are
are
persons
persons or or events
events that
that function
function as as anan external
external time
time clock
clock toto regulate
regulate youryour hab­
hab-
its. Your
its. Yourdog dogcancanbebeaasocial
socialZeitgeber
Zeitgeberififshe sheor orheheneeds
needstotobe walkedatata acer­
bewalked cer-
tain time
tain time of of the
the morning.
morning. If If you
you have
have aaspouse,
spouse,he heor orshe
shealmost
almostcertainly plays
certainly plays
a
a role
role inin organizing
organizing your your eating
eating and and sleeping
sleeping schedules
schedules and and probably
probably affects
affects
how
h o w much
m u c h stimulation
stimulation you you have
have fromfrom other
other people
people during
during the the day.
day. IfIf you
you
were to
were to split
split up with your
up with your spouse,
spouse, or or even
even if he or
if he or she were to
she were to go
go away
away forfor aa
period
period of of time,
time, your
your daily
daily and
and nightly
nightly routines
routines would
would be be disrupted.
disrupted. Your job
Your job
also
also keeps
keeps youyou on on a a regular routine.
regular routine.
In
In contrast,
contrast, a a social Zeitstorer (time
social Zeitstorer (time disturber)
disturber) is is aa person
person or or a a social de­
social de-
mand
m a n d that
that throws
throws everything
everything off off balance.
balance. WhenW h e n you
you start
start aa new relationship,
n e w relationship,
your patterns of
your patterns of sleeping,
sleeping, waking,
waking,and and SOCializing
socializingchange.
change.The The same thingwill
same thing will
happen
happen if you have
if you have a a baby.
baby. In In these
these cases, the n
cases, the new
e w romantic
romantic partner
partner or or your
your
baby
baby is
is a
a Zeitstorer.
Zeitstorer. If
If you
you take
take on on employment
employment thatthat has
has constantly shifting
constantly shifting
work hours or
work hours or requires
requires that
that you
you travel
travel across
across different
different time
time zones, your social
zones, your social
and
and circadian
circadian rhythms
rhythms will
will be
be disrupted
disrupted conSiderably.
considerably.
What
W h a t does
does all
all of
ofthis
thismean
m e a n for
foraaperson
person with
with bipolar
bipolardisorder? Events that
disorder? Events that
 DoesBipolar
WhereDoes
Whefe DisordeCome
BipolarDisorda From?
r Come From? 9595

bring about
bring changesininsocial
about changes rhythms,either
social rhythms, eitherby Zeitstorersororre-
introducingZeitstorers
byintroducing re­
moving Zeitgebers, alter
m o v i n g Zeilgebers, rhythms. You
circadian rhythms.
alter circadian are particularly
Y o u are vulnerable to
particularly vulnerable to
aa manic episode after
m a n i c episode after you experienced aa social
have experienced
y o u have social rhythm-disrupting
rhythm-disrupting life life
event (for
event (for example, Malkoff-Schwartz et
e x a m p l e , Malkoff-Schwartz et al.,
al., 1998).
1998).
Let me
Let give you
m e give example. Debra,
a n example.
y o u an 36-year-old woman
Debra, aa 36-year-old bipolar II
with bipolar
w o m a n with II
disorder, lived
disorder, lived withwith her her husband, Barry. During
h u s b a n d , Barry. session with
therapy session
During aa therapy with the the
couple,
couple, Debra complained that
D e b r a complained Barry had
that Barry changed the
h a d changed schedule for
the schedule for feeding
feeding
their two
their cats. He
t w o cats. h a d begun
H e had feeding them
b e g u n feeding both in
t h e m both in the instead of
m o r n i n g instead
the morning of the
the
evening, and
evening, result one
as aa result
a n d as o n e or both of
or both of the cats were
the cats into the
c o m i n g into
w e r e coming the couple's
couple's
r o o m in
room in the middle of
the middle the night,
of the crying for
night, crying food. Debra
for food. w a n t e d to
Debra wanted feed the
to feed the cats
cats
before she
before she and Barry went
a n d Barry w e n t to bed, but
to bed, but he saying it
refused, saying
h e refused, it would m a k e the
w o u l d make the
cats overweight. After
cats overweight. consecutive nights
three consecutive
After three nights of of poor sleep, she
poor sleep, she became irri­
b e c a m e irri-
table, experienced mental
table, experienced confusion at
mental confusion at work, developed racing
a n d developed
w o r k , and racing thoughts.
thoughts.
Finally, Barry
Finally, agreed to
Barry agreed the new
to the n e w evening schedule, which
feeding schedule,
evening feeding w h i c h alleviated
alleviated
the with the
p r o b l e m with
the problem cats. As
the cats. D e b r a got
A s Debra back on
got back o n aa regular sleep-wake cycle
regular sleep-wake cycle
and experienced several
and experienced nights of
several nights restorative sleep,
of restorative sleep, her started to
h y p o m a n i a started
her hypomania to
d o w n . In
settle down.
settle Debra's case,
In Debra's case, a episode was
major episode
a major averted by
w a s averted b y reestablishing
reestablishing
routines that
routines that had disrupted by
b e e n disrupted
h a d been relatively minor
b y aa relatively m i n o r event.
event.
Miriam, a
Miriam, 47-year-old woman
a 47-year-old w o m a n withwith bipolar reported that
disorder, reported
bipolar II disorder, that she she
developed manic
developed m a n i c oror mixed s y m p t o m s the
m i x e d symptoms m o r n i n g or
the morning afternoon after
or afternoon after drinking
drinking
alcohol, even if only in
alcohol, even if only in small
small quantities.
quantities. II
It wasn't
wasn't entirely
entirely clear
clear to
to me
m why a
e why a
small a m o u n t of
small amount alcohol would
of alcohol w o u l d make her manic
m a k e her considered her
until II considered
m a n i c until her sleep
sleep
alcohol was
cycle: alcohol
cycle: acting as
w a s acting as a Zeitstorer. She
disruptive Zeitstorer.
a disruptive S h e had m u c h more
h a d much diffi­
m o r e diffi-
culty falling asleep
culty falling asleep after drinking. Once
after drinking. she stopped
O n c e she drinking (or
stopped drinking (or limited
limited her- her­
self to
self o n e beer,
to one beer, usually early in
c o n s u m e d early
usually consumed in an evening), she
a n evening), she had less trouble
h a d less trouble
sleeping
sleeping and shifts in
fewer shifts
a n d fewer her mood
in her stales.
m o o d states.
In Chapter 8,
In Chapter "Practical WWays
8, "Practical a y s to to Maintain Wellness," I'll
Maintain Wellness," tell yyou
I'll tell about aa
o u about
method for keeping
m e t h o d for keeping y o u r social
your social routines regulated even
routines regulated even wh w h �n events conspire
2n events conspire
to
to change
change t them
h e m (the social rrhythm
(the social stability method;
h y t h m stability method; F r a n k et
Frank et al., 0 0 0 ) . This
al., 22000). This
self-monitoring
self-monitoring technique technique can help yyou
can help o u keep your mmood
keep your ood a and sleep-wake cy-
n d sleep-wake cy­
cles stable.
cles stable.

Conflicts SignificantOthers
with Significant
Conflicts with Others

So far,
So talked about
we've talked
far, we've Single life
about single and changes
events and
life events in your
changes in routine. The
yourroutine. The
other major
other type of
major type to ddo
has to
stress has
of stress o with your ongOing
with your relationships. Chapter
ongoing relationships. Chapter
12 is
12 devoted to
is devoted dealing with
to dealing family mmembers,
with family so I'll
e m b e r s , so give it
I'll give brief mention
only brief
it only mention
here. There
here. is nno
There is evidence that
o evidence in family
disturbances in
that disturbances relationships (for
family relationships (for exam­
exam-
ple, ppoor
ple, parenting wwhen
o o r parenting o u wwere
h e n yyou child) cause
e r e aa child) disorder in
bipolar disorder
cause bipolar first
the first
in the
place. But
place. or marital
family or
high-conflict family
But high-conflict can increase
situations can
marital situations increase your likeli­
your likeli-
hhood having aa recurrence
of having
o o d of of bipolar
recurrence of once yyou
disorder once
bipolar disorder o u have it.
have it.
96
96 rAUSES
CAUSESAiD
ANDIREAIMEHIS
TREATMENTS

I conducted
I conducted my dissertationresearch
my dissertation researchon
onthis
this topic
topicatat
UCLA
UCLA with
withmy
my for­
for-
mer
mer mentor,
mentor, Michael
Michael Goldstein
Goldstein (Miklowitz
(Miklowitz et al., 1988).
et aI., 1988). In In this
this study,
study, we we
worked
worked with bipolar II manic
with bipolar manic adults
adults who w h o lived
lived primarily
primarily with with theirtheir parenlS.
parents.
We
W e examined
examined the the level
level of of conflict
conflict between
between these these patients
patients and and their
their parents
parents
while
while the the patients
patients were were in in the
the hospital
hospital and and onceonce theythey got
got out.
out. Not surpris­
Not surpris-
ingly,
ingly, those
those who w h o returned
returned to to high-conflict
high-conflict families
families had had mOTe
more manic
manic and and de­de-
pressive
pressive episodes
episodes (recurrences)
(recurrences) within within ninenine months
months after after their
their hospitalization
hospitalization
than
than those
those who w h o returned
returned to to low-conflict
low-conflict families.
families. Though
T h o u g h all
all of
of the
the people
people in in
our
our study
study were
were hospitalized,
hospitalized, many m a n y people
people with with bipolar
bipolar disorder
disorder nevernever enter
enter a a
hospital.
hospital. Nevertheless,
Nevertheless, other other researchers
researchers have have found
found similar
similar associations
associations be- be­
tween
tween family
family relationships
relationships and and the the outcome
outcome of of bipolar
bipolar disorder,
disorder, whether
whether or or
not
not thethe patients
patients had had been
been hospitalized
hospitalized (O'Connell
(O'Connell et al., 1991;
et al., 1991; Priebe
Priebe et et al.,
al.,
1989;
1989; Honig
Honig el al., 1997).
et aI., 1997).
We
W e don't
don't know
k n o w exactly
exactly why w h y conflict-ridden
conflict-ridden family family environments
environments make bi­
m a k e bi-
polar
polar people
people moremore recurrence-prone
recurrence-prone (though (though it it makes
makes sense),
sense), but butwe w e do
do know
know
that
that family
family environments
environments affect affect the the course
course of of many
m a n y other
other psychiatric
psychiatric disor- disor­
ders,
ders, including
including schizophrenia,
schizophrenia, depreSSion,
depression, alcoholism,
alcoholism, and and eating
eating disorders
disorders
(Butzlaff &
(Butzlaff Hooley, 1998).
& Hooley, 1998). We W e also
also suspect
suspect thatthat i itt is
is not
not only
only conflicts
conflicts withwith
family
family members
members or or a a spouse
spouse that that cancan affect
affect thethe cycling
cycling of of your
your disorder
disorder but but
also
also conflicts
conflicts withwith other
other Significant
significant people
people in in your
your life,
life,such
suchas asyour
youremployer,
employer,
coworkers,
coworkers, or or friends.
friends. In In Stacy's
Stacy's case,
case, her
her conflicts
conflicts withwilh herher ex-husband
ex-husband may may
have
have played
played a role in
a role in her
her escalating
escalating mania.
mania. H Had
a d she
she been
been able
able to
to sit
sit down
d o w n with
with
him
him and and work
work things
things out out with
with civility,
civility, her
her chances
chances of of staying
staying stable
stable might
might
have been beuer.
have been better. But But she
she really
really didn't
didn't have
have that option.
that option.
For
For now,
n o w , lel's
let's simply
simply recognize
recognize that
that family
family and
and interpersonal
interpersonalconflictsconflictscan can
be
be risk factors in
risk factors in the
the course
course of of your
your illness. Begin thinking
illness. Begin thinking aboutabout whatwhat rolerole
family or
family or marital
marital conflict
conflict has has played
played in your disorder.
in your disorder. Do your episodes
D o your episodes typi-typi­
cally coincide
cally coincide with with Significant
significant familyfamily or or marital
marital arguments?
arguments? Do these conflicts
D o these conflicts
come
c o m e before
before the the episode,
episode, after after thethe episode
episode has begun, or
has begun, or is
is it
it impossible
impossible to to
tell? M
tell? Many
a n y ofof my
m y clients
clients say that the
say that the family
family conflicts
conflicts camecame before
before their epi­
their epi-
sodes; others
sodes; others say say that
that the
the conflicts
conflicts arise once they've
arise once they've become
become manic, mixed, or
manic, mixed, or
depressed-but
depressed—but also also make it harder
m a k e it harder to to get better. Some
get better. S o m e report that family
report that con­
family con-
flicts that
flicts that have
havebeenbeenthere there allaHalong
alongget getworse
worsewhen w h e nthey
theybecome
becomeill,iH, ororthat
that
"buried" issues
"buried" issues c come
o m e out
out in in their
their dealings
dealings withwith family
family members.
members. W When you
h e n you
are becoming ill, it can be difficult to "edit" the things you want to say to your
are becoming ifl, it can be difficult to "edit" the things you want to say to your
members, and
family members,
family and these
these family
family members
members mmay have similar
a y have similar difficulties
difficulties in in
their communication with you (see Chapter 12).
their communication with you (see Chapter 12).
WWhen thinking through
h e n thinking through these these issues,
issues, trytry 1O avoid blaming
to avoid blaming others
others for for their
their
role in your illness-in most cases family members are trying their best to be
role in your illness—in most cases family members are trying their best to be
helpful and
helpful and often
often don't
don't kknow what to
n o w what lO do
do or or say.
say. As
As you'H
you'll see
see inin Chapter
Chapter 12, 12,
 Where
Where Does
Does Bipolor
BipolarDisorder
Disorde(orne
r ComeFrom?
From? 9797

there
there are
are good andbad
good and bad ways
ways to to deal
deal withwithyouryour family
family members
members regarding
regarding is- is­
sues
sues surrounding
surrounding your
your disorder.
disorder. Managing
M a n a g i n g your
your family
family relationships is an
relationships is im­
a n im-
portant
portant element
element of
of maintaining
maintaining wellness.
wellness.

* * *

Bipolar
Bipolar disorder
disorder does does not
not have
have clear-cut
clear-cut causes,
causes, but
but wew e know
k n o w enough to
e n o u g h to
say
say that
that it
it involves
involves biological
biological brain
brain imbalances
imbalances that that are
are partly
partly under
u n d e r genetic
genetic
controL
control. These
T h e s e biological
biological vulnerabilities
vulnerabilities can can beb e set
set off
off byb y various
various kindskinds of of
stressors,
stressors, conflicts,
conflicts, or or life
life changes,
changes, whether
w h e t h e r positive
positive oror negative.
negative. Stacy's
Stacy's expe­
expe-
riences
riences with
with life
life stress,
stress, family
family conflict,
conflict, anda n d sleep-wake
sleep-wake disturbances
disturbances may m a y mir­
mir-
ror
ror some
s o m e of
of your
your own.
own.
Medications
Medications are are deSigned
designed to to correct
correct thethe underlying
underlying biological imbalances.
biological imbalances.
The next
The next chapter
chapter describes
describes the the available
available medications,
medications, what what we w e think
think they
they do,
do,
their
their side
side effects,
effects, and
and the the role
role of
of psychotherapy
psychotherapy as as an
an adjunctive treatment.
adjunctive treatment.
Later chapters
Later chapters describe
describe lifestyle
lifestyle management
management techniques.
techniques. Usually
Usually these tech­
these tech-
niques
niques areare recommended
r e c o m m e n d e d alongSide
alongside medication
medication as as a
a way
w a y of
of improving
improving your your
ability to cope
ability (Q cope with stress. As
with stress. A syou
you read
readon, on,trytryto
tothink
thinkofofbiology
biologyand and environ­
environ-
ment as interacting with each other-you'll have an easier time making
ment as interacting with each other—you'll have an easier time making
choices
choices about
about treatments
treatments if if you
you can
can keep
keep thesethese mult iple causes
multiple causes of bipolar dis-
of bipolar dis­
order
order in
in mind.
mind.
 6 6
WhatC Can
W h a t a n MMedication
e d i c a t i o n

a and
n d P Psychotherapy
s y c h o t h e r a p y D Doo f for
o r MMe?
e ?

treatment
treatment
W
w . e ehave
forfor
haveknown
bipolar
bipolar
knownfor
disorder.
fora along
disorder.WWe
long
e know
time
timethat
knowthat
thatmedication
medicationisisthe
thataaperson
personwith withbipolar
thefirfirst-line
st-line
bipolardisorder
disorder
remains
remains well longer if he or she lakes medication regularly. Butwe
well longer if he or she takes medication regularly. But wealsoalsoknow
know
that medication requires careful monitoring by you and
that medication requires careful monitoring by you and your phYSician and your physician and
sometimes
sometimes demands
demands that
thatyouyoutolerate
tolerate unpleasant
unpleasant side
sideeffects.
effects.
People have strong feelings about taking
People have strong feelings ahoUl taking mood stabilizing mood stabilizing medications
medications
and sometimes don't take them even when they would
and sometimes don't take them even when they would clearly benefit-often clearly benefit—often
because
becausethey they lack
lackinformation
information about
about the medications
the medications andandtheir
theirside
sideeffects.
effects.
The overview of the medications used to treat bipolar
The overview of the medications used to treat bipolar disorder presented disorder presented in in
this chapter
[his chapler willwillallow
allowyou youtototake
takeonon a much
a much more
more powerful
powerful role
roleinindealing
dealing
with
with your disorder. Knowing what these medications do, which sideeffects
your disorder. Knowing what these medications do, which side effects
are
are common and which are rare, and how you can deal with them, as well as
common and which are rare, and how you can deal with them, as well as
what
what the most
the most recent
recentresearch
research teltells
ls ususabout
aboutthethe"track
"trackrecord"
record"ofofthese
thesemedi-
medi­
cations,
cations, will
willhelp
helpyouyouplanplanyour
your medication
medication regimen
regimen with
withyour
your doctor
doctor and
and
manage it over
manage it over time.time.
I strongly
I strongly believe
believe that
thatpeople
peoplewith withbipolar
bipolardisorder
disorderdo dobest
bestwhen
whenthey theyareare
taking medications and simultaneously working with
taking medications and Simultaneously working with a therapist. Although a therapist. Although
psychotherapy
psychotherapy isisnot
nota asubstitute
substitutefor formedication,
medication,there therearearethings
thingsyou youcancanac-ac­
complish
complish in therapy that won't be accomplished by medication. For thisrea-
in therapy that won't be accomplished by medication. For this rea­
son
sonI Ialso
alsotalk
talkabout
aboutthetherole
roleofofpsychotherapy
psychotherapyas asan
anadjunct
adjuncttotomedication
medicationin in
this chapter.
this chapter.

9898
 Whot
What (on
Can Medication
Medication and
andPsycholheropy
PsychotherapyDo
DoforforMe?
Me? 9999

Knowing
Knowing the about
the facts facts about medication
medication is a crucial
is a crucial foundation
foundation for adhering
for adhering
to
to a a medication
medication regimen.
regimen. The T h e reasons
reasons that that people
people withwith bipolar
bipolar disorder
disorder
commonly
c o m m o n l y refuse
refuse to
to take
take medication
medication range range from
f r o m suffering
suffering uncomfortable
uncomfortable
side
side effects
effects toto having
having trouble
trouble remembering
r e m e m b e r i n g to
to take
take the
the medication,
medication, disagree­
disagree-
ing with the diagnosis, disliking having one's moods controlled, or having
ing with the diagnosis, disHking having one's m o o d s controlled, or having
strong
strong feelings
feelings about
about what
w h a t the
the medication
medication represents.
represents. Any A n y of these factors
of these factors
can
can lead
lead to to a patient's refusal
a patient's refusal to to take
take medication
medication consistently
consistently or or at
at all.
all. Be­
Be-
cause
cause it it is
is so
so important
important to to take
take medication
medication consistently,
consistently, I'veI've devoted
devoted Chap­
Chap-
ter
ter 77 to
to exploring
exploring the
the factors
factors that
that impede
impede a a person's
person's adherence
adherence with
with a a given
given
medication
medication regimen.
regimen.

"What
"What Can
Can Medication
Medication Do
Do for
for Me?"
Me?"

You'll recall
You'll recall from fromearlier chapters
earlier that bipolar
chapters that disorder
bipolar follows
disorder a relapse!
follows a rel
remission
remission course.
course. Research
Research by by Michael
Michael Gitlin
Gitlin and
and his
his colleagues
colleagues at at UCLA
UCLA
found
found that
that aa person
person who w h o has
has had
had aa manic
manic or or depreSSive
depressive episode
episode hashas aa6 60%
0%
chance
chance of of having
having another
another one one within
within twotwo years
yearsand
and aa 73%
7 3 % chance
chance over
over an
an av­
av-
erage
erage ofof four
four and
and aa third
third years
years (Gitlin
(Gitlin et aL, 1995).
et al, 1995). Likewise,
Likewise, the theNational
NationalIn­ In-
stitUle
stitute of
of Mental
Mental Health
Health Collaborative
Collaborative Program
Program on on the
the Psychobiology
Psychobiology of of De­
De-
pression
pression found
found thatthat 81-91%
81-91% of of people
people withwith manic
manic or or mixed
mixed episodes
episodes of of
bipolar
bipolar disorder
disorder had had recurrences
recurrences within
within five
five years
years(Keller
(Kelleret etaI.,
al.,1993).
1993).Many
Many
people
people have
have significant
significant symptoms
symptoms even even when
when they
they aren't
aren't having
having major epi­
major epi-
sodes
sodes (Harrow
(Harrow et et aL,
al, 1990;
1990; Gitlin
Gitlinet etaI.,
al,1995).
1995).
The
The good
good news
news is is that
that virtually
virtuallyeveryone
everyonesuffering
sufferingfromfrom thethedisorder
disorderfinds
finds
that
that medication
medicationmakes makes recurrences
recurrencesless lesslikely.
likely. Across
Across a number
a numberofof studies,
studies,thethe
average
average relapse
relapse rate
rate on lithium is
on lithium is 34%
3 4 % over
over periods
periods of of treatment
treatment ranging from
ranging from
five
five months
months to to4040months.
months.The The relapse
relapserate
rateisis81%
8 1 %ononplacebo
placebo pills
pills(Goodwin
(Goodwin
&:.
& Jamison,
Jamison, 1990)!
1990)!
Even
Even more
more important,
important,long-term
long-termtreatment
treatmentwithwithmood
mood stabilizing
stabilizingmedica­
medica-
tions
tions (notably
(notably lithium)
lithium) decreases
decreases the the chances
chances thatthat any
any person
person withwith bipolar
bipolar
disorder
disorder willwill commit
commit suicide
suicide (Baldessarini
(Baldessarini et et aL,
al, 1999;
1999; Tondo
Tondo et et aL, 1998).
al, 1998).
One
One only
only has
has toto read
read autobiographical
autobiographical accounts
accounts of ofpeople
people with
with bipolar
bipolar or
or de­
de-
pressive
pressive disorders
disorders to to know
know the the pOSitive
positive impact
impact that
that medication
medication has has had
had onon
their
their lives,
lives,including
includingthe theremoval
removalofofsuicidal
suicidal thoughts,
thoughts, impulses,
impulses, andand
attempts
attempts
(for
(for example,
example,]amison,
Jamison,1995; 1995;Wurtzel,
Wurtzel,1994;1994;Solomon,
Solomon,200l). 2001).Sadly,
Sadly,many
manyof of
the
the people
people whow h o committed
committed suicide
suicide had
had little
little or
orno
noaccess
accessto topsychiatric
psychiatrictreat­
treat-
ment.
ment. They
They diddid not
not receive
receive the
the appropriate
appropriate medicat
medication ion oror psychiatric
psychiatric care,
care, or or
their illnesses
their illnesses were
were notnot even
even detected
detected by by mental
mental health
health profeSSionals
professionals in the
in the
first
first place
place Oamison,
(Jamison,2000a;2000a;Jamison,
Jamison,2000a,
2000a,b).b).
100
100 CAUSES AND
CAUSES AND TREATMENTS
TREATMENTS

Acute versus
Acute versus Preventative
PreventativeTreatment
Treatment

For the
For the purposes
purposesofof
medication treatment,
medication think
treatment, of your
think of disorder as having
your disorder as an
having an
�acute phase"
"acute (treating an
phase" (treating an existing
existing Ulness
illness episode)
episode) and
and aa "maintenance
"maintenance phase"
phase"
(preventing future
(preventing future episodes).
episodes). The medication you
The medication you take
take during
during the
the two
two phases
phases
may
m be different.
a y be different. Your
Your regime
regime during
during the
theacute
acute phase
phase is
islikely
likelyto
toinvolve
involve more
more
medications at
medications at higher dosages than
higher dosages than your
your regime
regime during the maintenance
during the maintenance
phase.
phase.
The acute
The acute phase involves bringing
phase involves bringing you down
you d from a
o w n from a severe manic high
severe manic or
high or
up from a
up from depreSSive low.
a depressive low. Acute
Acute phase
phase treatment
treatment is usually done
is usually done on on an inten­
an inten-
sive outpatient basis
sive outpatient basis through regular psychiatry
through regular psychiatry appoimments,
appointments, or or through
through in- in­
patient hospitalization. On
patient hospitalization. average, the
O n average, the acute phase of
acute phase of treatment
treatment lastslasts up to
up to
three months,
three months, although
although nowadays
nowadays only about a
only about week of
a week of this
this (if
(if any)
any) would
would be be
spent
spent inin the
the hospital. The length
hospital. The length of the acute
of the acute phase
phase m may
a y bebe shorter
shorter or longer,
or longer,
depending
depending on your response
on your response to to the medications.
the medications.
In
In contrast,
contrast, thethe maintenance
maintenance phase phase involves
involves keeping
keeping you you well
well and
and pre-pre­
venting
venting youyou from
from developing
developing more more severe
severe symptoms.
symptoms. This This is also called
is also " pro­
called "pro-
phylactic"
phylactic" (preventative)
(preventative) treatment.
treatment. The The maintenance
maintenance phasephase does does not
not have
have a a
prescribed length, although
prescribed length, althoughsome some doctors
doctorssay saythat
thatatatleast
leastsixsixmonths
months of ofstable
stable
medication is
medication is necessary
necessary after
after the
the acute
acute phase
phase to to help
help prevent
prevent recurrences
recurrences of of
the disorder
the disorder (Fawcett
(Fawcett et et aI.,
al, 2000).
2000). As A s you'll
you'll see
see in
in Chapter
Chapter 7. 7, many
m a n y people
people
take
take their
their medications
medications duringduring the the acute
acute phase
phase butbut mistakenly
mistakenly want want to to drop
drop
them
them during
during the the maintenance
maintenance phase,phase, thinking
thinking theythey no
no longer
longer needneed them.
them. The The
result
result isis often
often that
that they
they have
have rapid
rapid recurrences
recurrences of of the
the disorder,
disorder, eveneven though
though
they
they were
were better
better atat the
the point
point when
w h e n they
they discontinued
discontinued the the medications.
medications.
The
The two
two graphs
graphs on on page
page 101101 show
show how h o w acute
acute and
and maintenance
maintenance treatment
treatment
works.
works. Two T w o patterns
patterns areare described
described in in each:
each: one
one inin which
which a a bipolar
bipolar person
person
takes
takes medication
medication (solid (solid line),
line), and
and oneone in in which
which he he or
or she
she does
does notnot (dOlled
(dotted
line).
line). In
In the
the first
first figure,
figure, Alben,
Albert, aa 32-year-old
32-year-old with with bipolar disorder, devel­
bipolar II disorder, devel-
oped
oped a a severe
severe manic
manic episode.
episode.JustJustbefore
beforethe themania
mania would
would havehavecrested,
crested,he hebe­
be-
gan
gan taking
taking two two medications,
medications, lithium
lithium and and anan antipsychotic
antipsychotic drug. drug. TheThe dotted
dotted
line
line shows
shows whatwhat would
would likely
likely have
have happened
happened if ifhe
he hadn't
hadn'ttaken
takenmedications
medicationsat at
that
that point
point in in time.
time.
The
The second
second figure
figure shows
shows whatwhat Albert's
Albert's longer-term
longer-term coursecourse of of illness
illness
looked
looked likelike with
with medications,
medications, and and what
what it it would
would have
have looked
looked like like without
without
them.
them. Notice
Notice thatthat for
for Alben,
Albert, medications
medications do do not
not eliminate
eliminate his m o o d cycling,
his mood cycling,
but
but they
they dodo slow
slow itit down
d o w n and
and prevent
prevent full full recurrences.
recurrences.The periodsofofwellness
Theperiods wellness
are
are longer,
longer,his hisepisodes
episodesare areshaner
shorterand andlesslesssevere,
severe, and
andhishissymptoms
symptoms between
between
episodes
episodes are are milder.
milder. Thus,
Thus, in in the
the best-case
best-case scenario,
scenario, aa medication
medication regime regime
should
should do do three
three things
things forfor you:
you:
 What (on
Con Medimtion
Medication and
and Psychotherapy
Psychotherapy Do lor Me?
Do for Me? 101
101

SEVERE
SEVERE MANIA
MANIA-- .................................

HYPOMANIA
HYPOIVIANIA --

BASELINE MOOD
BASELINE MOOD -tC:�----�---=::::�:
DAY 1 DAY 7 DAY 12 DAY 21
DAY 21

DEPRESSION
DEPRESSION V

The
The effects
effects of
of medication
medication on on Albert's
Albert's acute
acute manic
manic episode.
episode. The
The arrow
arrow indicates
indicates the
the point
point at
at which
which
Albert
Albert began
began taking lithium and
taking lithium and anan antipsychotic
antipsychotic drug.
drug. The
The dOlled
dotted line
line indicates what might
indicates what might have
have
happened
happened toto his
his mood
m o o d had
had he
he not
not taken
taken these
these medications
medications..

.. . . . ...
/
.. .
. ... .. .\
. .. . .....
.. ...
' .
.................. ...
../ \
... . .
...
.
/
/ . ..

/ .....
' .•

.......
I \
//
/ :
HYPOMANIA - -

\ /'
/
/ �
' ============�,.;;;;��====�'�"'<==='7��==��,,====��>====t--
h��
i:
�UN£
t.l000- 996 1997 1998 1999

\
t.lOOEFlATE
MODERATE
DEPReSSION \
. . . .. . . . .
\...... . .. . ..'
/' /
.. . . ....
DEPRESSION

SEVERE
SEVERE
DEPRESSION
DEPRESSION

Albert's longer-tenn
Albert's longer-term mood
m o o d cycling,
cycling, as
asititwould
wouldappear
appearon
onappropriate
appropriatemedications
medications(solid
(solidlines)
lines)and
andoff
off
medications
medications (dotted
(dotted lines).
lines).
 102
102 CAUSES AND
CAUSES ANDIREAIMENIS
TREATMENTS

1 . Control
1. Control and and
helphelp resolve
resolve anan episodethat
episode that has
has already
already developed;
developed;
2. Delay
2. Delay future
future episodes and minimize
episodes and minimize the
the severity
severity of
of those
those that do occur;
that do occur;
3. Reduce
3. Reduce the
the severity
severity of
of the
the symptoms
symptoms you
you experience
experience between
between episodes.
episodes.

More globally,
More globally, when
whenyour
yoursymptoms
symptoms are
arewell-controlled,
well-controlled,you you
can can
expect to be to be
expect
more in
more in cootTol of your
control of your life
life and have an
and have an easier time pursuing
easier time pursuing your
your goals. Hav­
goals. Hav-
ing more
ing more control
control increases the chances
increases the chances that you'll be
that you'H be able
able to
to function
function beueT
better at
at
work and
work and in
in your
your family
family and
and social
social life.
life.

"Do II Have
''Do Have to
to lake
Take Medication
Medication Forever?"
Forever?"

This
This is
isa aquestion
questionmany
manypeople
peoplewith
withbipolar illness
bipolar ask. It
illness is an
ask. Itunderstand­
is an understand-
able
able and very important
and very important question.
question. As
As you
you know
k n o w from Chapter 5,
from Chapter 5,bipolar
bipolardisor­
disor-
der is
der is associated with underlying
associated with biological imbalances
underlying biological imbalances involving the activity
involving the activity
of
of brain neurotransmitters and
brain neurotransmitters and their associated Signaling
their associated systems. These
signaling systems. These im­
im-
balances are
balances are inherited
inherited in
in many
m a n y cases.
cases. We
W e also believe that
also believe that medications
medications help
help
correct
correct biochemical imbalances in
biochemical imbalances in some
some of
of the
the ways
ways described
described below.
below. For this
For this
reason,
reason, most
most people
people with
with bipolar
bipolar disorder
disorder must
must take
take medication indefinitely,
medication indefinitely,
especially
especially if
if the
the diagnosis
diagnosis seems
seems definite,
definite, if
if they
they have
have had
had more
more than
than one
one
major episode,
major episode, and
and if
if they
they have
have aa family
family history
history of
ofbipolar
bipolar illness.
illness.Much
M u c h like
like
diabetes
diabetes or
or high
high blood
blood pressure,
pressure, bipolar
bipolardisorder
disorder involves
involvesbiological
biologicalvulnera­
vulnera-
bilities that require
bilities that require long-term treatment.
long-term treatment.
There
There are exceptions lO
are exceptions to this rule, such
this rule, such as
as if
if a
a woman
w o m a n wants
wants to
to become
become
pregnant
pregnant (mood
(mood stabilizers
stabilizers can
can increase
increase the
the risk
risk to
to the
the fetus
fetus of
of hean
heart and cen­
and cen-
tral
tral nervous
nervous system
system defects).
defects). In
In the
the case
case of
of pregnancy,
pregnancy, the
the solution
solution is
is usually
usually
to
to gradually
gradually discontinue
discontinue medication
medication prior
prior to
to conception
conception and
and then
then reintroduce
reintroduce
it
it later
later in
in (or
(or after)
after) the
the pregnancy,
pregnancy, or
or find
find a
a different
different class
class of
of medication
medication
rather
rather than
than stopping
stopping altogether
altogether (Cohen
(Cohen et al, 1994;
et aL, 1994; Kahn
K a h n et al, 2000).
et al., 2000). ¥ou
You
may
m a y also
also have
have to
to stop
stop medication
medication if
ifyou
you develop
develop aamedical condition that
medicalcondition thatpre­
pre-
vents
vents you
you from
from taking
taking mood
m o o d stabilizers
stabilizers (for
(for example,
example, certain diseases of
certain diseases of the
the
liver
liver or
or kidney).
kidney). Fortunately,
Fortunately, your
your mood
m o o d stabilizing
stabilizing medications
medications are not ad­
are not ad-
dictive
dictive or
or habit-forming: You will
habit-forming:You willnot
notcrave
cravethem
them when
w h e n they
theyare
arewithdrawn.
withdrawn.
If
Ifyou
you have
have had
had only
only one
one episode,
episode,your
your doctor
doctor may
m a y recommend thatyou
recommend that you
take medication
take medication for
for one
one year
year and
and then
then reassess
reassess your
your need
need for
for it.
it.But
Butthat
thatrec­
rec-
ommendation
ommendation will
will vary
vary from
from doctor
doctor to
to doctor
doctor and
and will
will depend
depend on
on how
h o w stable
stable
your
your mood
m o o d remains
remains over
over the
the year.
year. It's
It'saagood
goodidea
ideato
toask
askyour
yourdoctor
doctorhow
h o w long
long
,
he
he or
or she
she expects
expects you
you to
to be
be taking
taking medicines.
medicines.
Needless
Needless to
to say,
say, accepting
accepting aa long-term
long-term drug
drug regime
regime is
is aa very
very Significant
significant
decision.
decision. I'll
I'llsay
saymore
more about
aboutthe
theemotional
emotionalSignificance
significanceof
oftaking
takingmedications
medications
 Whot
WhatCon
CanMedication
Medicationand
andP�(hotheropy
PsychotherapyDoDo
lor fMe?
or Me? 103103

in Chapter
in Fornow,
Chapter 7.7.For now, let'sfocus
let's focus
on on
thethe mechanics
mechanics of medications:
of medications: which which
ones
ones you
y o u are
are likely to be
likely to b e prescribed,
prescribed, in in what
w h a t dosages,
dosages, their
their likely
likely side effects,
side effects,
and
a n d how
h o w long
long before
before they
they take effect.
take effect.

What
W h a t Is
Is a
a Mood
M o o d Stabilizer?
Stabilizer?

Mood stabilizers are

Mood stabilizers are usually
usually given given during
duringthe theacute
acutephase
phase and
and continued
continued dur-dur­
ing the
ing the maintenance
m a i n t e n a n c e phase
phase of of treatment.
treatment. To T o be
b e defined
defined as as aa mood
m o o d stabilizer,
stabilizer, a a
medication
medication has has to to be
b e effective
effective in in treating
treating manic,
m a n i c , mixed,
m i x e d , or
or depressive
depressive episodes
episodes
of bipolar
of bipolar disorder,
disorder, andlorand/or must m u s t prevent
prevent new n e w episodes
episodes duringduring long-term
long-term main­ main-
tenance.
tenance. Some S o m e mood
m o o d stabilizers
stabilizers do d o both.
both. The T h e medication
medication must m u s t not
not worsen
w o r s e n the
the
bipolar
bipolar disorder
disorder or or cause
cause rapid
rapid cycling
cycling (four (four or or more
m o r e episodes
episodes in in one
o n e year;
year; seesee
Chapter
Chapter 3). 3 ) . As
A s you'll
you'll soons o o n see,
see, antidepressants
antidepressants like like fiuoxetine
fluoxetine (Prozac)
(Prozac) are are not
not
considered
considered mood m o o d stabilizers
stabilizers because
because they they impact
impact only only depreSSion,
depression, not not mania,
mania,
and
a n d because
because they they can can cause
cause rapid
rapid cycling.
cycling. N Note
o t e that
that medications
medications have have at at least
least
two
two names:
names: a a generic
generic name n a m e that
that reflects
reflects theirtheir chemistry
chemistry (which (which I'll I'll give first)
give first)
followed
followed by by a a specific
specific brand b r a n d name
n a m e created
created by b y the
the pharmaceutical
pharmaceutical company company
that
that developed
developed the the generic
generic drug d r u g for
for commercial
c o m m e r c i a l use
use (given
(given in in parentheses).
parentheses).
Doctors
Doctors and a n d pharmacies
pharmacies usually usually refer refer to to drugs
drugs by b y their
their brand
brand name.
n a m e . The
T h e main
main
mood
m o o d stabilizers
stabilizers in in use
use today
today are are lithium carbonate and
lithium carbonate a n d the anticonvulsants:
the anticonvulsants:
typically,
typically, divalproex
divalproex sodium sodium (Depakole)
(Depakote) or carbamazepine (TegretoI).
or carbamazepine (Tegretol). CertainCertain
newer
n e w e r agents---for
agents—for example, lamotrigine (LamictaI),
e x a m p l e , lamotrigine (Lamictal), topiramale
topiramate (Topamax)( T o p a m a x ) ,,
and
and gabapentin
gabapentin (Neurontin)-although
( N e u r o n t i n ) — a l t h o u g h less
less proven,
proven, benefit
benefit some s o m e people.
people.
Your
Y o u r mood
m o o d stabilizing
stabilizing medications
medications are are likely
likely to to change
change over over time,
time, both both in in
type
type anda n d in
in dosage.
dosage. The T h e need
n e e d toto change
c h a n g e medications
medications doesn't doesn't mean m e a n you're
you're get­ get-
ting
ting worse.
worse. Typically,
Typically, no n o Single
single medication
medication works w o r k s to alleviate bipolar
to alleviate bipolar symp­symp-
toms
t o m s over
over the the person's
person's entireentire lifespan.
Hfespan. It's It's also
also likely
likelythatthatyou'll
you'll be b e treated
treated with with
more
m o r e than
than one o n e mood
m o o d stabilizing
stabilizing medication
medication at at some
s o m e point
point or or perhaps
perhaps even even on on
an
an ongOing
ongoing basis basis (for(for example,
e x a m p l e , lithium
lithium and a n d Depakote
D e p a k o t e together).
together). Many M a n y people
people
with
with bipolar
bipolar disorder
disorder experience
experience an a n additive
additive therapeutic
therapeutic benefit benefit f from
r o m taking
taking
more
m o r e than
than one m o o d stabilizer.
o n e mood stabihzer. Perhaps
Perhaps this this is is because
because agents agents likeHke H lithium
t h i u m and
and
Depakote
Depakote have h a v e different
different but b u t complementary
c o m p l e m e n t a r y effects
effects on o n brain
brain mechanisms,
mechanisms,
such
such as as the
the protein
protein kinase
kinase C C signaling
signaling pathway (Manji, 2001;
p a t h w a y (Manji, 2 0 0 1 ; see Chapter 5).
see Chapter 5).
Taking
Taking more m o r e than
than one o n e medication
medication doesn't doesn't mean m e a n that
that you are sicker
y o u are sicker than than
the
the next
next person
person with with bipolar
bipolar disorder-it
disorder—it just just maym a y mean
m e a n that
that your
y o u r unique
unique
physiology
physiology doesn't doesn't respond
respond as well as
as well as that
that person's
person's to to ana n individual
individual com­ com-
pound.
p o u n d . People
People vary vary in in their
their response
response to to medications
medications in in part
part because
because of of their
their
patterns
patterns of of symptoms,
s y m p t o m s , such
s u c h asas whether
w h e t h e r they
they havehave purepure manic highs versus
m a n i c highs versus
mixed
m i x e d episodes.
episodes.
104
104 CAUSES
CAUSESANO
ANDIREAIMENIS
TREATMENTS

Types of
Types of Mood Stabilizers
Mood Stabilizers

Lithium
LithiumCarbonate
Carbonate

The most well

The most well known
known mood mood stabilizer is
stabilizer is lithium,
lithium, which
whichisis dispensed
dispensed underunder
brand
brand names
names likelike Eskalith,
Eskahth, Lithobid,
Lithobid, Lithonate.
Lithonate, or or Cibalith-S.
Cibalith-S. A A naturally
naturally oc- oc­
curring
curring element
element that that you'll
you'll findfind inin the
the periodic
periodic table,
table, lithium
lithium was was the first
the first
medication proven
medication proven to to stabilize
stabilize moodm o o d inin bipolar
bipolar disorder
disorder and and also
also toto prevent
prevent
manic
manic or or depressive
depressive episodes
episodes from from returning.
returning. Although
Although various
variousformsforms of of"lith­
"lith-
ium
ium bromide"
bromide" were were used
used during
during the the late
late 18005
1800s to to quell
quell agitation
agitation or overexcite­
or overexcite-
ment,
ment, thethe discovery
discovery of of lithium
lithium as as aa treatment
treatment for for bipolar
bipolar disorder
disorder is usually
is usually
anribuled
attributed to to John
John CadeCade (1949).
(1949). CadeCade was was an an Australian
Australian phYSician
physician who w h o theo­
theo-
rized
rized that
that there
there were
were toxic
toxic compounds
compounds in in the
the urine
urine of of patients
patients with what was
with what was
then
then called
called manic-depressive
manic-depressive illness. illness. HeH e happened
happened upon u p o n lithium
lithium by accident.
by accident.
His
His experiment
experiment involvedinvolved injecting
injecting uric acid mixed
uric acid mixed with with lithium
lithium into into the the
bloodstream
bloodstream of of guinea
guinea pigs.
pigs. Injection
Injection withwith lithium
lithium calmed
calmed down d o w n the
the guinea
guinea
pigs
pigs and
and made
m a d e them
them lessless active.
active. Cade
Cade thenthen thought
thought to to try
try lithium
lithium with
with oneone of of
his most severely
his most severely illill manic
manic patients,
patients,a aS 51-year-old
l·year-old man. m a n .The
Thepatient
patientresponded
responded
very
very well
well andand for
for the
the fi rst time
first time waswas able
able to to function
function outside
outside of of a
a hospital.
hospital. This This
story
story ofof sciemific
scientific serendipity
serendipity is is somewhat
somewhat tempered
tempered by by the fact that
the fact that this pa­
this pa-
tient
tient took
took himself
himself off off the
the medication,
medication, againstagainst medical
medical advice
advice sixsix months
months later,later,
perhaps
perhaps foreshadowing
foreshadowing the the wide-ranging
wide-ranging problem problem of of med\cation
medication nonad­ nonad-
herence
herence by by people
people treated
treated for for bipolar
bipolar disorder.
disorder. Nonetheless,
Nonetheless, lithium lithiumcame came intointo
general
general useuse inin the
the 1960s
1960s and and hashas been
been used
used regularly
regularly in in the
the United
United States
States since
since
1970,
1970, toto the
the great
great benefit
benefit of of many
m a n y people
people withwith the illness.
the illness.
Lithium
Lithium is is usually
usually givengiven in in 300-
300- or or 4S0.milligram
450-milligram (mg) (mg) tablets,
tablets, and and peo­
peo-
ple usually
ple usually taketake between
between one one andand eight
eight of of these
these per
per day
day (300-2400
(300-2400 mg). m g ) . Some
Some
people take
people their lithium
take their lithium in in divided
divided doses,
doses, several
several times
times a a day,
day, and
and some
some onlyonly
once-this
once—this is is one
one ofof the
the decisions
decisions you you andand your
your doctor
doctor can can m make
a k e when trying
w h e n trying
to
to figure
figure outout how
h o w best
best toto control
control youryour side
side effects.
effects.A A correct
correctdosage
dosageis isone
onethatthat
brings your
brings your blood
blood level into aa "therapeutic
level into "therapeutic range."
range." The
The therapeutic
therapeutic rangerange youryour
doctor
doctor targets
targets forfor you
you during
during treatment
treatment of of your
your acute
acute episode
episode may m a y be
be higher
higher
than
than the
the one
one he he oror she
she targets
targets during
during your your ongoing
ongoing maintenance treatment,
maintenance treatment,
which
which is is usually
usually between
between 0.8 0.8 and
and 11.2. 2 mill equivalents per
millequivalents per liter
liter (a(a chemical
chemical
measure
measure of of lithium
Hthium concentration
concentration in in the blood). Children
the blood). Children with with bipolar disor­
bipolar disor-
der
der or
or persons
persons over over the
the age
age of of 65
65 can
can often
often bebe maintained
maintained on on lower
lower dosages
dosages of of
lithium
lithium andand still
still show
show good responses.
good responses.
How
H o w well
well does
does lithium
Hthium work? work? Studies
Studies indicate
indicate that
that 60-70%
6 0 - 7 0 % of
of people
people withwith
bipolar
bipolar disorder
disorder show show a a remission
remission of of symptoms
symptoms when w h e n treated with lithium
treated with lithium
(Goldberg,
(Goldberg, 2000; Goodwin &
2000; Goodwin & lis,
Zis, 1979).
1979). EvenEven at at appropriate
appropriate blood levels,
blood levels,
however,
however, people
people can can have
have "breakthrough"
"breakthrough" episodes episodes of mania or
of mania depression.
or depression.
 What
What(on
Con Medication
Medication and
and Psychotherapy Do for
Psychotherapy Do for Me?
Me? lOS
105

Lithium
Lithium does doesa abetter
betterjob jobofofpreventing
preventing manic
manic episodes
episodes and and controlling
controlling manicmanic
symptoms
s y m p t o m s than
than it it does
d o e s preventing
preventing depreSSive
depressive episodes,
episodes, but b u tititcan
c a nstill
stiH beb e effec­
effec-
tive
tive as as an
a n antidepressant
antidepressant when w h e n used
used alone ( K e c k &:
alone (Keck & McElroy,
McElroy, 1 1996; Prien et
9 9 6 ; Prien et
aI.,
al, 1984; Zornberg &
1984; Zornberg & Pope,
Pope, 1993).
1993).
When
W h e n youy o u begin
begin taking
taking lithium,
lithium, you y o uwon't
won't feel
feel its
itsbenefit
benefit right Itwill
a w a y . It
right away. will
probably
probably take take at at least
least a a week
w e e k and
a n d often
often a a few
f e w weeks
w e e k s before
before you y o u start
start seeing
seeing iim­m-
provement
p r o v e m e n t inin your
y o u r manic
m a n i c or
or depressive
depressive symptoms.
symptoms.
The
T h e table
table on o n this
this page
p a g e lists
lists the
the symptoms
s y m p t o m s anda n d course
course patterns
patterns that that gogo
along with
along with a a good
g o o d response
response to to lithium,
lithium, and a n d the
the factors
factors thatthat gog o along
along withwith a a less
less
favorable
favorable response
response to to lithium
lithium and and a a better
better response
response to to the
the anticonvulsants
anticonvulsants
(Depakote
(Depakote and a n d TegretoD.
Tegretol). It It is
is useful
useful for y o u lO
for you to know
k n o w about
about these factors,
these factors,
which
w h i c h function
function as as predictors.
predictors. They T h e y may
m a y help
help explain
explain why w h y your doctor has
y o u r doctor has rec­
rec-
ommended
o m m e n d e d anticonvulsants
anticonvulsants over over lithium,
lithium, or or the
the reverse.
reverse. In In general,
general, the the more
more
your illness
your illness reflects
reflects the the "textbook"
"textbook" description
description of of bipolar
bipolar disorder
disorder (euphoric,
(euphoric,
grandiose,
grandiose, manic m a n i c highs
highs followed
followed by b y deep
d e e p depreSSions,
depressions, combinedc o m b i n e d with
with a a family
family
history
history of of bipolar
bipolar disorder
disorder in in one
o n e oror more
m o r e ofof your
y o u r first-degree
first-degree relatives),
relatives), the the
more
m o r e likely
likely you y o u are
are toto respond
respond to to lithium.
lithium. The T h e more
m o r e "atypical"
"atypical" your y o u r disorder
disorder
is
is (for
(for example,
e x a m p l e , characterized
characterized by b y mixed
m i x e d episodes,
episodes, psychosis,
psychosis,or orrapid
rapid cycling),
cycling),
the
the more
m o r e likely
likely youy o u will
will dod o better
better on o n the
the anticonvulsams.
anticonvulsants.
We
W e don't
don't knowk n o w exactly
exactly why w h y lithium
lithium is is effective
effective in in controlling
controlling manic manic a and
nd
(to
(to a a lesser
lesser extent)
extent) depreSSive
depressive episodes,
episodes, but b u t we
w e suspect
suspect it it has
has effects
effects on the
o n the
underlying
underlying biological
biological vulnerabilities
vulnerabilities discusseddiscussed in in Chapter
Chapter 5. 5. You'll
You'll recall
recall that
that
componems
c o m p o n e n t s of
of the
the second
s e c o n d messenger
m e s s e n g e r system
system (for (for example,
e x a m p l e , calcium,
calcium, protein
protein

Predictors of Response
Predictors to Lithium
of Response vc:rsus versus
to Lithium Anticonvulsants
Anticonvulsants

A
A good
good response
response to
to lithium
lithium A good
good response
response to
to amiconvuisants
anticonvulsants
·Pure."
"Pure," euphoric
euphoric manias
manias Mixed
Mixed episodes
episodes (depression
(depression and mania
combined)
combined)
A
A cycling
cycling pattern
pattern marked
marked by
by manias
manias followed A cycling
cycling pattern
pattern marked
marked by
by depressions
by
by depressions,
depressions, followed
followedby
bynonnal
normalmood
mood followed
followedby
bymanias
manias
periods
periods
High
High prevalence of bipolar disorder in
in the
the No
No (or
(or low)
low) prevalence
prevalence of
of bipolar
bipolar disorder in
in
family
family tree
tree (he
the family
family tree
tree
Absence
Absence of
of rapid
rapid cycling
cycling Rapid
Rapid cycling
cycling (four
(four or
or more episodes/year)
more episodes/year)
A
A good
good respo�
response to
to lithium
lithium previously
previously Very
Very severe
severe manias
manias wilh
with psychosis
psychosis (delusions/
(delusions/
hallucinations)
hallucinations)
Fewer,
Fewer, rather
ratherthan
thanmore,
more,previous
previousepisodes
episodesofof Co-occurringsusubstance
Co.occuning bstance abuse
abuseororanxiety
anxiety
illness
iUness disorders
disorders
Clear-cut episodes
episodes with
with relatively symptom-free Mani
a symptoms
Mania symptoms that
that occur
occur after
after aa
intervals
intervals in
in between
between neurological
neurological illness
illness or
orbrain
braininjury
injury

Sources:
Sources: Calabr� et al.
Calabrese et al. (1996);
(1996); Grof
Grof et (1993); McDonald
al. (1993):
et a1. McDonald (2000).
(2000).
106
106 CAUSES
CAUSESAND
ANDIREAIMENIS
TREATMENTS

kinase
kinase C)C) are
are responsible
responsiblefor forcommunicating chemicalmessages
communicatingchemical messagestotovarious
various
parts of
parts of the
the cell,
cell,such
suchas asthe
thecell
cellnucleus,
nucleus,which
which determines
determineswhen
w h e n aacell
cellcom­
com-
municates
municates messages
messages toto other
other cells.
cells. Through
Through its
its effects
effects on
on signal
signal transduction
transduction
pathways,
pathways, lithium
lithium may
m a y affect
affect whether
whether chemical
chemical messages
messages are
are sent
sent from
from the
the
brain
brain to
to parts
parts of
of the
the body
body oror from
from one
one pan
part of
of the
the brain
brain to
to another.
another.

Side
SideEffects of Lilhium
Effects of Lithium

When
W h e n you
you take
take any
any medication,
medication, it's it's important
important to toknow
k n o w its
itspossible
possiblesidesideeffects
effects
so that changes
so that changes in in your
your body
body will
will notnot come
c o m e as
as aa surprise
surprise to to you,
you, andand you'll
you'H
k n o w La
know to report them LO
report them your doctor.
to your doctor. All All mood
m o o d stabilizing
stabilizing agents
agents have
have some
some
side
side effects.
effects. InInfact,
fact,be beskeptical
skepticalofof"namral"
"natural"oror"homeopathic"
"homeopathic"mood m o o dremedies
remedies
that
that presumably
presumably have have nono adverse
adverse effects.
effects. There
Thereis isnonoevidence
evidencethat thatanyanynatural
natural
substance
substance is is both
both free
free ofof side
side effects
effects and effective as
and effective as aa mmood stabilizer.
o o d stabilizer.
Your
Your doctor
doctor will
will usually
usually include
include any any side
side effects
effects youyou repon
report as as an
an impor­
impor-
tant source
tant source of of information
information for for planning
planning your your treatment.
treatment. Side Side effects
effects can often
can often
be
be controlled
controlled in in some
some of of the
the ways
ways described
described below.
below. In In Chapter
Chapter 7 7 you'll
you'll find
find a a
side-effect
side-effect recording
recording sheet
sheet thatthat will
will help
help youyou communicate
communicate with with your
your doctor
doctor
about
about complications
complications associated
associated with with youryour medication.
medication.
People
People withwith bipolar
bipolar illness
illness generally
generally have have some
some predictable
predictable side effects
side effects
with
with lithium,
lithium, but butwhich
which ones onesaaperson
persondevelops
developsand and their
theirseverity
severityvaryvaryaagreat
great
deal
deal from
from person
person to to person.
person. Common
C o m m o n side
side effects
effects ofof lithium
lithium include
include thirst,
thirst,re­re-
taining water, frequent urination, fatigue, diarrhea, andlor a metallic taste
taining water, frequent urination, fatigue, diarrhea, and/or a metallic taste in
in
the
the mouth.
mouth. More More troublesome
troublesome side side effects
effects include
include weight
weight gain,
gain, mental slug­
mental slug-
gishness
gishness or or problems
problems with with memory,
memory, shaky hands, development
shaky hands, development or fiareup of
orflareup of
skin conditions
skin conditions (such(such as as acne
acne or or psoriasis),
psoriasis), andlor
and/or stomach discomfort or
stomach discomfort or
pain. Some people also develop hypothyroidism, a condition in which the thy­
pain. S o m e people also develop hypothyroidism, a condition in which the thy-
roid
roid gland
gland does not produce
does not produce enough
enough hormone.
hormone. Kidney
Kidney functioning
functioning (the (the ability
abihty
of
of the
the kidney
kidney to to clear
clear substances
substances like like urea
urea or or creatinine
creatinine out out of
of the blood) can
the blood) can
also
also bebe affected
affected if if lithium
lithium is is taken
taken overover a a long
long period
period of time.
of time.
The side effects of lithium can be related to the dosage you
The side effects of lithium can be related to the dosage you take.
take. Many
Many
doctors
doctors adopt
adopt thethe "start
"start low,
low, gogo slow"
slow" approach
approach in in which
which you you stan
start the
the medi­
medi-
cation on a low dosage and gradually increase to the therapeutic dosage, as
cation on a low dosage and gradually increase to the therapeutic dosage, as aa
way
w a y of
of keeping
keeping youryour side
side effects
effects inin check.
check. If Ifyou
you arearealready
already being
being maintained
maintained
on
on a a cenain
certain dosage
dosage of of lithium
lithium but but have
have unpleasant
unpleasant side side effects, your doctor
effects, your doctor
may
m a y decide
decide to to reduce your dosage,
reduce your dosage, although
although this carries the
this carries the risk
risk of making the
of making the
medication less
medication less effective
effective for for you.
you. In In other
other words,
words, treatment
treatment with with lithium
Hthium can can
be
be aa bit of a
bit of a balancing
balancing act act in
in which
which you you and
and your
your doctor
doctor collaborate
collaborate to to find the
find the
blood level that
blood level that stabilizes
stabilizes youryour mood
m o o d (for
(for example,
example, keeps keepsyou episode-freefor
you episode-free for
at least
at least a a year)
year) butbutalso
alsoallows
allowsyou you to tofunction
functionwith with thetheleast
leastannoying
annoyingside sideef­ef-
fects
fects (for
(for example,
example, not not haVing
having to to deal
deal with
with slowed-down
slowed-down thinking).
thinking).
 Whot
What Con
CanMedication
Medicationond
andPsychotherapy
PsychotherapyDoDolorfo
Me?
r Me? 107107

Other
Other side side effects
effects require
require more more creative
creative solutions:
solutions: frequent
frequent urination,
urination, for for
example,
e x a m p l e , can
c a n be
b e reduced
reduced by
b y taking
taking lithium
lithium once
o n c e during
during the day
the d a y instead of sev­
instead of sev-
eral
eral times
times a
a day;
day; thirst
thirst can
can be
b e controlled
controlled by
b y drinking
drinking more
m o r e water, chewing
water, c h e w i n g on
on
ice
ice chips,
chips, or
or using
using sugarless
sugarless cough
c o u g h drops.
drops. Stomach
S t o m a c h irritation
irritation can
can bbe helped by
e helped by
taking
taking lithium
lithium after
after a
a full
full meal.
meal. In
In other
other cases,
cases, your
y o u r side
side effects
effects may
m a y require
require
additional
additional medications,
medications, such
s u c h as
as thyroid
thyroid supplements
supplements (for
(for example,
e x a m p l e , levo­
levo-
thyrOXine
thyroxine (Synthroid))
[Synthroid]) or
or beta-blockers
beta-blockers for
for hand
h a n d tremors
tremors (for
(for example,
example,
propranolol
propranolol [Inderal)).
[Inderal]). Kidney
K i d n e y functioning
functioning is
is usually
usually monitored
monitored during lith­
during Hth-
ium
i u m treatment
treatment through
through a
a variety
variety of
of blood
blood tests
tests (for
(for example,
e x a m p l e , your
y o u r creatinine
creatinine
level)
level).,

Lilhium Blood
Lithium BloodTests
Testsand
andToxicity
Toxidty

People who
People whotake
takelithium
lithium must
must have
have their
their blood
blood drawn
drawn regularly
regularly to make
to make sure sure
they
they are
are getting
getting a
a proper
proper dosage.
dosage. If
If you
y o u are
are starting
starting lithium
lithium for
for the
the first
first time
time
and
and are
are being
being stabilized
stabilized from
from a
a manic
m a n i c or
or depressive
depressive episode,
episode, you
y o u will
will probably
probably
have
have to
to get
get your
y o u r blood
blood tested
tested every
every week
w e e k or
or two
t w o for
for the
the first one
first o n e or
or two
two
months
m o n t h s of
of treatment,
treatment, then
then every
every month
m o n t h for
for about
about three
three months.
m o n t h s . If
If all
all has
has gone
gone
well
well up
u p to
to that
that pOint,
point, your
y o u r doctor
doctor will
will probably
probably recommend
r e c o m m e n d you
y o u get it tested
get it tested
every
every three
three months
m o n t h s or
or so.
so. The
T h e purpose
purpose is to make
is to m a k e sure
sure you
y o u have
have the
the proper
proper
level
level of
of lithium
lithium in
in your
y o u r bloodstream.
bloodstream. Generally,
Generally, your
your physician
physician will
will check
check
your
your blood
blood level about 10-14
level about 1 0 - 1 4 hours
hours after
after your
your last
last lithium
lithium dosage.
dosage.
Getting
Getting your
y o u r blood
blood tested
tested regularly
regularly helps prevent lithium
helps prevent lithium toxicity. in
toxicity, in
which
w h i c h your
y o u r body
b o d y accumulates
accumulates lithium
lithium at
at very
very high
high levels.
levels. The
T h e signs of toxicity
signs of toxicity
include problems
include p with balance
r o b l e m s with balance and
a n d coordination,
coordination, severe
severe diarrhea,
diarrhea, abdominal
abdominal
discomfort,
discomfort, blurry
blurry vision,
vision, slurring
slurring of
of speech,
speech, extreme
extreme shakiness
shakiness of
of the
the hands,
hands,
severe
severe nausea
nausea or
or vomiting,
vomiting, and
a n d mental
mental confusion
confusion or disorientation. Because
or disorientation. Because
this
this toxic
toxic state
state isis extremely
extremely dangerous
dangerous and a n d even potentially deadly,
even potentially deadly, it is impor­
it is impor-
tant
tant toto know
k n o w the signs (and
the signs (and infonn
inform your
y o u r dose
close relatives
relatives as
as well) so that
well) so you
that y o u can
can
get
get in
in to
to see
see your
y o u r doctor as soon
doctor as soon as as possible,
possible, toto have
have your
y o u r blood level checked
blood level checked
and
a n d in
in most cases to
m o s t cases to have
have your
y o u r lithium
lithium adjusted
adjusted or
or stopped
stopped temporarily.
temporarily.
Your
Y o u r lithium blood levels
lithium blood levels can
can increase
increase in
in reaction
reaction to
to dehydration
dehydration or
or from
from
taking
taking over-the-counter
over-the-counter medications
medications such
s u c h as
as ibuprofen.
ibuprofen. Your
Y o u r levels can also
levels can also
be
be too
too low
l o w or
or even
even non therapeutic, especially
nontherapeutic, especially if
if you
y o u are
are getting
getting an
a n inadequate
inadequate
dosage
dosage or
or have
h a v e been
b e e n Laking
taking the
the medication
medication inconSistently. It is
inconsistently. It is helpful
helpful 10
to
know
k n o w these
these facts
facts and
a n d to
to become
b e c o m e familiar
familiar with
with the
the blood
blood level
level scale
scale so
so that
that you
you
can
can become
b e c o m e an
a n active
active participant
participant in
in your
y o u r lithium
lithium treatment.
treatment. Ask
A s k your
your doctor
doctor
which
w h i c h blood
blood level
level he
h e or
or she
she is
is targeting
targeting for
for you,
y o u , so
so that
that you'll
you'll know
k n o w when
when
your
your levels
levels are
are getting
getting too
too low
l o w or
or too
too high.
high. If
If you
y o u decide
decide to
to see
see another
another doctor,
doctor,
he
h e or
or she
she will
will want
w a n t to
to know
k n o w what
w h a t therapeutic
therapeutic blood
blood levels
levels you
y o u are
are currently
currently
maintaining, and
maintaining, a n d which levels have
w h i c h levels have been
b e e n problematic
problematic for
for you
y o u in the past.
in the past.
108
108 (lUSIS
CAUSESAND
ANDIRIAIMINIS
TREATMENTS

You You
may may
find find blood
blood testing
testing difficult: No
difficult: No one
one likes
likesto to
be bestuck withwith
stuck a nee­
a nee-
dle,
dle, and having one's
and having one's blood
blood tested
tested can
can remind
remind youyou of
of being
being ill.
ill.But
Butititisisaavery
very
important
important aspect
aspect of
of your
your care.
care. If
If you
you find
find it
it particularly
particularly unpleasant,
unpleasant, discuss
discuss it it
with
with your
your doctor.
doctor. He
H e or
or she
she may
m a y choose
choose toto put
put you
you onon a
a mood
m o o d stabilizer that
stabilizer that
requires less
requires less frequent
frequent blood testing.
blood testing.

Oi••lproex Sodium
Divalproex Sodium

Divalproex
Divalproex sodium, which is
sodium, which is also
also called
called valproate
valproate or or valproic
valproic acid
acid (brand
(brand
names Depakote and Depakene), is an anticonvulsant medication that has
names Depakote and Depakene), is an anticonvulsant medication that has
been
been used
used for
for decades
decades toto treat
treat epilepsy
epflepsy and and other
other seizure
seizure disorders
disorders (Kahn
(Kahn etel
al, 2000).
aL, 2000). ForFor reasons
reasons that
that aren't
aren't entirely
entirely clear,
clear, some
some anticonvulsams
anticonvulsants also also
have
have mood stabilizing properties.
m o o d stabilizing Divalproex is
properties. Divalproex is a
a fatty
fatty acid
acid that
that is
is similar
similar toto
other
other compounds
compounds found found inin animal
animal fats
fats and
and vegetable
vegetable oils. Divalproex proba�
oils. Divalproex proba-
bly
bly works
works in in several
several ways,
ways, including
including reducing
reducing activity
activity of
of the
the protein kinase
protein kinase
C
C pathway
pathway and and enhancing
enhancing the the action
action of of the
the inhibitory
inhibitory neurotransmilter
neurotransmitter
GABA (Manji, 2001;
G A B A (Manji, Goldberg, 2000).
2001; Goldberg, 2000). Low L o w levels
levels ofof GABA
G A B A have
have been
been found
found
in
in blood
blood samples
samples andand spinal fluids of
spinal fluids people with
of people with depression
depression (Petty(Petty &: &
Sherman, 1984).
Sherman, 1984).
Charles
Charles Bowden,
Bowden, a a researcher
researcher at at the
the University
University of of Texas
Texas Health
Health Science
Science
Center
Center inin San Antonio, and
San Antonio, and his
hisassociates
associateshave have found
found that
thatdivalproex
divalproexis isat
atleast
least
as
as efrective
effective as lithium in
as lithium in controlling
controlling episodes
episodes of mania and
of mania and may
m a y be
be even better
even better
than
than lithium
lithium in controlling mixed
in controlling mixed manic
manic episodes
episodes (Bowden
(Bowden et et aI.,
al, 1994,
1994, 2000;
2000;
Swann
Swann et al, 1997).
et aI., 1997). Divalproex
Divalproex is is also
also reasonably
reasonably effective
effective inin treating bipolar
treating bipolar
depressions,
depressions, although
although many
m a n y experts
experts view
view it it as
as aa second
second choice
choice to lithium for
to lithium for
this purpose
this purpose (Kahn
(Kahn et al, 2001).
et aI., The evidence
2001). The evidence for
for its
its effectiveness
effectiveness in prevent�
in prevent-
ing future
ing future episodes
episodes ofof bipolar
bipolar disorder
disorder is is based
based largely
largely onon physicians'
physicians' opinions
opinions
rather
rather than
than the
the outcomes
outcomes of of long�term
long-term research
research studies.
studies. Nonetheless,
Nonetheless, dival�
dival-
proex has
proex has come
come into
into wide
wide use use as
as aa long�term
long-term preventative
preventative agent,
agent, much like
m u c h like
lithium.
lithium.
There
There are
are at
at least
least three
three reasons
reasons why w h y your
your physician
physician might
might give
give you
you
divalproex rather than lithium (see the table on page 105). First, if you have
divalproex rather than lithium (see the table on page 105). First, if you have
mixed
mixed episodes
episodes oror rapid
rapid cycling,
cycling, iitt may
m a y be
be more
more effective
effective for
for you.
you. Second,
Second, it it
seems
seems toto work
work aa bit
bit more
more quickly,
quickly, even
evenwithin
withinasasfew
fewas asthree
threetotofive
fivedays
daysafter
after
the onset of
the onset of a
a major
major manic
manic episode.
episode. Unlike
Unlike lithium,
lithium, your
your dosage
dosage can usually
can usually
be
be raised
raised rather
rather quickly
quickly without severe side
without severe side effects.
effects. Third, there is
Third, there is evidence
evidence
that
that people
people have
have less
less severe
severe side
side effects
effects with
with divalproex
divalproex than
than with
with lithium
lithium
(Bowden, 1996;
(Bowden, 1996; Weiss
Weiss et al, 1998).
et al., 1998). These
These advantages must be
advantages must be weighed
weighed
against
against the
the greater
greater abundance
abundance of of supportive
supportive research
research onon lithium,
lithium, perhaps be­
perhaps be-
cause
cause it
it has
has been around for
been around longer.
for longer.
 What
what (on
ConMedication
Medicationond
andPsychotherapy
PsychotherapyDoDoforfo
Me?
r Me? 109109

PeoplePeople usually
usually are given
are given divalproex
divalproex in 250-into250- 500-mg to tablets,
500-mg and tablets,
they and they
typically
typically taketake from
f r o m 11,500
,500 mgm g toto 3,000
3,000 mg m g per
per day.
day. Three
T h r e e times
times a a day
day is is aa typi­
typi-
cal
cal dosing
dosing pattern.
pattern. Your
Y o u r doctor
doctor willwill want
w a n t to
to achieve
achieve a a therapeutic
therapeutic serums e r u m level
level
which
w h i c h is
is usually
usually between
b e t w e e n 45
4 5 and
a n d 125
1 2 5 micrograms per milliliter
m i c r o g r a m s per milliliter (the
(the measure
measure
used
used to to indicate
indicate divalproex
divalproex concentration
concentration in in the
the blood).
blood). As A s with lithium, reg-
with lithium, reg­
ular
ular blood
blood tests
tests can
c a n tell
tell you
y o u and
a n d your
y o u r doctor
doctor whether
w h e t h e r you
y o u are
are geuing
getting the the
proper
proper dosage
dosage ofof divalproex.
divalproex.

Side Efterts
Side Effects01 Divalproex
of Divalproex

Because divalproexisisbroken
Because divalproex broken down
down by theby the liver,
liver, youyou cancan develop
develop an elevation
an elevation
in
in liver
liver enzymes,
e n z y m e s , which,
w h i c h , in
in rare
rare instances,
instances, can can leadlead to to liver
liver inflammation.
inflammation.
Divalproex
Divalproex can can also
also affect
affect the the production
production of of blood
blood platelets.
platelets. For F o r this
this reason,
reason,
your doctor
your doctor should
should conduct
conduct liver liver enzyme
e n z y m e tests
tests anda n d blood
blood platelet
platelet counts
counts at at
regular
regular intervals
intervals (Kahn ( K a h n etet aL,
al, 2000).
2 0 0 0 ) . When
W h e n you y o u start
start taking
taking divalproex,
divalproex, you you
m a y feel
may feel nauseous,
nauseous, sleepy sleepy or or sedated,
sedated, or or have
h a v e indigestion,
indigestion, and a n d you
you m may have a
a y have a
hand
h a n d tremor
tremor (as (as can
can occur
occur withwith lithium).
lithium). These T h e s e side
side effects
effects usually
usually disappear
disappear
relatively
relatively soon. soon. SomeS o m e people
people also also develop
develop hair hair lossloss oror hair
hair thinning.
thinning. More More
worrisome
w o r r i s o m e is
is significant
significant weight weight gain, gain, which
w h i c h can
can contribute
contribute to to other
other medical
medical
problems (for example, high blood pressure, hean disease, or diabetes). Gen­
problems (for e x a m p l e , high blood pressure, heart disease, or diabetes). Gen-
erally,
erally, youry o u r doctor
doctor will will treat
treat these
these side side effects
effects by b y changing
changing the the schedule
schedule of of
your
your pills
pills or or adjusting
adjusting your y o u r dosage
dosage (for (for example,
e x a m p l e , dropping
dropping the the dosage
dosage may may
help
help youy o u feel
feel less
less sedated).
sedated). Your Y o u r doctor
doctor may m a y also
also recommend
r e c o m m e n d certain
certain drugs
drugs as as
adjuncts
adjuncts to to divalproex,
divalproex, such s u c h asas ranitidine
ranitidine (Zantac)(Zantac) for for nausea,
nausea, or or vitamins
vitamins
containing
containing seleniumselenium and a n d zinc
zinc for for preventing
preventing hair hair loss.
loss.
New
N e w formulations
formulations of of divalproex
divalproex help help people
people who w h o are
are very
very sensitive
sensitive to to the
the
side
side effects
effects of of the
the 500-mg
5 0 0 - m g tablets.
tablets. Depakote
D e p a k o t e 125-mg
1 2 5 - m g sprinkles-a
sprinkles—a popular popular al- al­
ternative
ternative for for children
children and a n d many
m a n y adul t s — ca
a d u lts---c ann be
b e put
put on o n food
food toto reduce
reduce stomach
stomach
irritation.
irritation. ThereT h e r e is
is also
also ana n extended-release
extended-release 500-mg 5 0 0 - m g tablet
tablet (Depakote
(Depakote ER) E R ) that
that
may
m a y beb e less
less likely
likely to to cause
cause stomach
s t o m a c h distress
distress or or significant
significant weight gain.
weight gain.
There is a concern that women who take divalproex can develop an
T h e r e is a concern that w o m e n w h o take divalproex can develop illness
a n illness
called polycystic ovary
called polycystic ovary disease,
disease, in in which noncancerous cysts
w h i c h noncancerous develop on
cysts develop o n the
the
ovaries.
ovaries. But B u t the
the jury
jury is is still
still out
out on o n whether
w h e t h e r this
this isis aa significant problem; stud­
significant problem; stud-
ies
ies now
n o w in in progress
progress may m a y help
help to to answer
a n s w e r this
this question
question (Sachs,
(Sachs, 1998).
1998).
The
T h e anticonvulsants
anticonvulsants like like divalproex
divalproex and a n d carbamazepine
carbamazepine often "interact"
often "interact"
with
with other
other medications,
medications, meaning m e a n i n g that
that side
side effects
effects or or medical
medical complications
complications
can
can occur
occur when w h e n these
these drugs
drugs are are used
used together
together with with other
other drugs.
drugs. For this
F o r this
reason,
reason, you y o u should
should be b e sure
sure to to tell
tell your
y o u r physician,
physician, especially
especially if if he
h e or
or she
she isis
new
n e w to to you,
y o u , about
about any a n y other
other drugsdrugs you y o u are
are taking
taking for for any
a n y other
other medical
medical
conditions.
conditions.
110
no CAUSES
CAUSES AND
AND TREATMENIS
TREATMENTS

Ca,lIomalepine
Carbamazepine

less popular
The less
The popular of
ofthe
the"big three"
"big mood
three" stabilizers
mood is carbamazepine
stabilizers (Teg­ (Teg-
is carbamazepine
retal,
retol, CarbatTol,
Carbatrol or or Atretol).
Atretol). Carbamazepine
Carbamazepine was was quite popular as
quite popular as aa treatment
treatment
in the 19805,
in the 1980s, especially
especially whenw h e n used
used in in combination
combination with with lithium.
lithium. But But it it can
can bebe
difficult
difficult lO find the
to find the appropriate
appropriate dose dose with
with carbamazepine.
carbamazepine, and and difficult
difficultside sideef­ ef-
fects can
fects can occur,
occur, somesome of which don't
of which don't occur
occur withwith divalproex. Nonetheless,
divalproex. Nonetheless,
some
some doctors
doctors willwill recommend
recommend carbamazepine
carbamazepine if if you
you have
have a a difficult
difficult time
time withwith
the
the side
side effects
effects ofof divalproex.
divalproex.
Like
Like divalproex,
divalproex, carbamazepine
carbamazepine is is an
an anticonvulsant
anticonvulsant used used to to treat
treat seizure
seizure
as
as well
well as as mood
m o o d disorders.
disorders. ThereThere isis aa substantial
substantial amount
amount of of research support­
research support-
ing its
ing its effectiveness
effectiveness in in the
the treatment
treatment of of acute mania (Ketter
acute mania (Ketter et al, 1998).
et al., 1998).
About
About as as many
m a n y people
people withwith bipolar
bipolar disorder
disorder respond
respond to lO carbamazepine
carbamazepine as to
as to
lithium
lithium (two-thirds),
(two-thirds), but but different
different kinds
kinds of of people
people may m a y respond
respond to to these
these two two
medications.
medications. Like Like divalproex,
divalproex, carbamazepine
carbamazepine seems seems 1O work well
to work well forfor people
people
with
with bipolar
bipolar disorder
disorder who don't respond
w h o don't respond wellwell toto lithium, including those
lithium, including those withwith
mixed episodes,
mixed episodes, rapidrapid cycling,
cycling,or orpsychotic
psychoticmaniasmanias(Post(PostetetaI.,al,1987).
1987).Among Among
people who
people w h o don't
don't respond
respond 1O to lithium,
lithium, aboutabout one-third
one-third will will respond
respond to to
carbamazepine
carbamazepine within within a a month. Although i
month. Although itt seems
seems to to work
work better
better for for manic
manic
symplOms
symptoms than than depressive
depressive symptoms,
symptoms, about about oneone in three people
in three people who w h o have
have notnot
benefited
benefited from from other
other treatments
treatments for for depression
depression will will respond
respond well well to carba­
to carba-
mazepine
mazepine (Post (Post et al, 1986).
et al.. 1986).
Carbamazepine
Carbamazepine probably probably worksworks by by affecting
affecting the the movements
movements of of sodium
sodium
and
and calcium
calcium ionsions across
across the
the membranes
membranes of of the nerve cells.
the nerve cells. This
Thisnow flowof ofions
ionsaf­af-
fects whether
fects whether cells cellsfire
fireorornot-whether
not—whetherthe theelectrical
electricalchanges
changesoccur occurthat that allow
aHow
cells
cells toto communicate
communicate with with other
other cells.
cells. By
By adjusting
adjusting the now of
the flow of these ions,
these ions,
carbamazepine
carbamazepine probably probably slowsslows down
d o w n the
the rate
rate atat which
which cells
cells fire
fire and therefore
and therefore
the
the overall
overall rate of activity
rate of activity oror eXcitability
excitability of of nerve
nerve pathways.
pathways.
Your doctor
Your doctor willwill probably
probably startstart you
you on on a a dosage
dosage of of 200-400
200-400 mg m g per
per dayday
and
and increase
increase it by 200
it by 200 mgm g (one
(one tablet)
tablet) every
everytwo twoto tofour
fourdays.
days.Typical
Typicaldosages
dosages
are between 400
are between 400 mg and 11,600
m g and ,600 mg per day,
m g per day, given
given in in 200 -
200-mg mg tablets.
tablets. As As with
with
lithium
lithium or or divalproex,
divalproex, your your physician
physician willwill probably
probably start start low
low and
and go slowly
go slowly
upward to
upward to minimize
minimize your your sideside effects.
effects. However,
However, unlike unlike these
these other
other medica­
medica-
tions,
tions,carbamazepine
carbamazepinedoes doesnotnothave
havea aspecific
specificbloodbloodlevel
levelthatthatwe w eknow
k n o wwill
wiH
give you
give you the best response.
the best response. Usually,
Usually, youryour doctor
doctor willwill choose
choose your your dosage
dosage
based
based on on balancing
balancing its its effectiveness
effectiveness for for your
your moodm o o d stability
stabHity against
against its side ef­
its side ef-
fects,
fects, rather
ratherthanthanyouryour blood
blood levels
levels(Ketter
(Ketteret al, 1998).
etaI., 1998).Typical
Typicalbloodblood levels
levels
for people who take carbamazepine are between 4 and 12 micrograms per mil­
for people w h o take carbamazepine are between 4 and 12 micrograms per mil-
Hliter (Goldberg, 2000).
liliter (Goldberg, 2000). Because
Because the the liver
liver breaks
breaks down carbamazepine more
d o w n carbamazepine more
qUickly over
quickly over time,
time, your
yourdoctor
doctor maym a y have
have totoincrease
increaseyour your dosage
dosageafterafterthe thefirst
first
 What(on
What Medicationand
CanMedicotion DofOIforMe?
PsychotherapyDo
andPsydJotheropy Me? 1
1 1Ill

four to six
four to weeks
six weeks of of treatment-and
treatment—and periodically
periodically thereafter—to maintainmaintain
thereafter-to a a
therapeutic level
therapeutic level.

Side Efferts
Side Effects Corbomozepine
01 of Carbamazepine

The
The mostmost common
common side effects
side effects of carbamazepine
of carbamazepine are sedation,are sedation,
nausea, and nausea, and
mild i m p a i r m e n t (for
m e m o r y impairment
m H d memory (for example, finding words).
difficulty finding
e x a m p l e , difficulty T h e s e side
w o r d s ) . These side
effects are
effects related to
usually related
are usually to the dose you
the dose take and
y o u take a n d often disappear after
often disappear after a a few
few
w e e k s or
weeks m o n t h s of
or months treatment. Some
of treatment. S o m e people experience blurry
people experience vision, consti­
blurry vision, consti-
pation, or
pation, loss of
or loss coordination. There
m u s c l e coordination.
of muscle T h e r e is less of
is less with weight
p r o b l e m with
of aa problem weight
gain on
gain carbamazepine, which
o n carbamazepine, w h i c h is is why people prefer
s o m e people
w h y some prefer it. Usually, your
it. Usually, your
doctor will
doctor treat side
will treat effects by
side effects adjusting your
b y adjusting y o u r dosage.
dosage.
People
People taking carbamazepine, even
taking carbamazepine, even more often than
m o r e ohen than for divalproex, can
for divalproex, can
develop a
develop elevation in
mild elevation
a mild in liver w h i c h can
e n z y m e s , which
liver enzymes, can be identified through
b e identified through
regular liver
regular function tests.
liver function tests. Your doctor will
Y o u r doctor will probably discontinue your
probably discontinue your
carbamazepine if
carbamazepine develop signs
y o u develop
if you signs of hepatitis, such
of hepatitis, such as feeling sluggish,
as feeling sluggish,
pain, or
s t o m a c h pain,
stomach other gastrointestinal
or other gastrointestinal problems. problems. About 1 0 - 1 5 % of
A b o u t 10-15% people de­
of people de-
velop skin
velop rashes. This
skin rashes. This side should be
effect should
side effect reported to
be reported y o u r doctor
to your doctor immedi­
immedi-
ately because it
ately because progress into
can progress
it can into a serious, potentially
a serious, life-threatening skin
potentially life-threatening skin
condition called
condition Stevens-Johnson syndrome
called Stevens-johnson s y n d r o m e (a blistering or
(a blistering burning of
or burning of the
the
tissue or
skin tissue
skin lining of
or lining the mucous
of the m e m b r a n e s ) ..
m u c o u s membranes)
T h e most
The serious side
m o s t serious effect of
side effect carbamazepine is
of carbamazepine is aa bone m a r r o w reaction
b o n e marrow reaction
agranulocytosis, which
called agranulocytosis,
called w h i c h is quiterare,
isquite affectingabout
rare,affecting aboutone o n ein every100,000
inevery 100,000
persons. It
persons. dramatic drop
involves aa dramatic
It involves white blood
in white
d r o p in doctorshould
Y o u rdoctor
cells.Your
blood cells. shouldbe be
monitoring your
monitoring y o u r blood c o u n t regularly
blood count regularly to detect the
to detect beginning of
the beginning this condition.
of this condition.
Let your
Let doctor know
y o u r doctor k n o w if develop aa fever,
y o u develop
ifyou infection,sore
fever,infection, throat,sores
sorethroat, soresinin your
your
mouth,
m o u t h , or bruising or
easy bruising
or easy bleeding, all
or bleeding, all ofof which can be
w h i c h can signs of
b e signs of aad drop in your
r o p in y o ur
white
white blood (Ketter et
c o u n t (Ketter
blood count aL, 1998).
et al, N o n e of
1 9 9 8 ) . None adverse reactions
these adverse
of these reactions is, b y it­
is, by it-
self, reason to
self, reason ruleout
torule carbamazepine at
outcarbamazepine atthe especiallybecause
outset,espeCially
theoutset, because it canbe
itcan be
prevented
prevented throughthrough regular monitoring by
regular monitoring y o u r doctor.
b y your doctor.
A new
A medication that
n e w medication that is chemically related
is chemically related to to carbamazapine,
carbamazapine, called called
(Trileptal), has
oxcarbazepine (Trileptal),
oxcarbazepine has recently
recently c o m e on
come scene. Its
the scene.
o n the Its side effects in-
side effects in­
fatigue and
clude fatigue
clude and a a possible decrease in
possible decrease in s o d i u m levels,
sodium levels, butbut it it is easier to
is easier to take
take
than carbamazepine
than carbamazepine a n d does
and does not carry the
not carry the ssame risk of
a m e risk of liver
liver or blood dys­
or blood dys-
function.
function. M More research on
o r e research Trileptal is
o n Trileptal n e e d e d to
is needed see if
to see if it will wwork
it will o r k as well as
as well as
carbamazepine in
carbamazepine controlling mood
in controlling disorder symptoms.
m o o d disorder symptoms.
The
T table on
h e table page 11 11 2
o n page s u m m a r i z e s some
2 summarizes s o m e of the information
of the information you've you've just just
read. You
read. m a y want
Y o u may w a n t to refer to
to refer 1O it time to
f r o m time
it from time, to
to time, to see
see if side effects
y o u r side
if your effects
for aany
for given medication
n y given medication are consistent with
are consistent with those listed and
those listed a n d if o u r dosages
if yyour dosages
and
a levels are
blood levels
n d blood within the
are within expected range.
the expected range.
112
112 CAUSES
CAUSES AND
AND lREA1MEN1S
TREATMENTS

Mood
M o o d Stabilizing Agents

Drug
Drug Dosage Blood level Common
Common side effects
side
Lithium
Lithium 300-2,400 mg
300....2,400 mg 0.8-1.2 mEqIL
0.8-\2 mEq/L • Weight gain
per day
day • Fatigue,
Fatigue, sedation
sedation
• Stomach
Stomach irritation,
irritation, diarrhea
diarrhea
• Thirst
Thirst and
and frequem
frequent urination
urination
• Melallic
Metallic taste
taste in
in mouth
mouth
• Hand tremor
Hand tremor
• Thyroid dysfunction
Thyroid dysfunction
• Acne or psoriasis
Acne or psoriasis
• Menial sluggishness or memory
Mental sluggishness or memory
problems
•
problems
Kidney clearance problems
Kidney clearance problems
D ivalproex sodium
Divalproex sodium 1,500-3,000
1,500-3,000 45-- 125 meg!
45-125 meg/ • Nausea, stomach
stomach pain
(Depakole)
(Depakote) mg
m g per
per day
day ml
ml • Faligue,
Fatigue, sedalion
sedation
• Hand
Hand Iremor
tremor
• Hair loss,
Hair loss, curlier
curlierhair
hair
• Dizziness
Dizziness
• Headaches
Headaches
• Weight
Weight gain
gain
• Elevated liver enzymes
Elevated liver enzymes
• Drop in platelet count
Drop in platelet count
Carbamazepint
Carbamazepine 400-1600 mg
mg 4-12 mcg/ml
t-12 mcg/ml • Fatigue,
Fatigue, sedation
sedation
(Tegretol)
(Tegretol) per
per day
day • Nausea,
Nausea, stomach
stomach pain
pain
• Mild
Mild memory
memory m iimpairment
pairmem
• Constipation
Constipation
• Diuiness,
Dizziness, lightheadedness
lightheadedness
• Blurred
Blurred vision
vision
• IWh
Rash
• Problems with physical coordinalion,
Problems with physical coordination,
unsu�adinc.ss
unsteadiness
• Elevaled liver enzymes
Elevated liver enzymes
• Drop in white blood cell count
•
Drop in white blood cell count
Drop in sodium levels
Drop in sodium levels
NOIe.
Note. mEqIl.
mEq/L,millequivalcnts
millequivalentsper
perliter;
liter;mcglml. micrograms
mcg/ml, perper
micrograms milliliter. I wish
milliliter. \0 thto
1 wish anthank
k loriLori
Altshuler. MD. M
Altshuler, and
D, and
GaT)' Sachs, MD.
Gary Sachs. M D ,for
forproviding
providingthe
themedicol
medicalinformation
informationfor
forthi.�
thistable_
table.

Newer
Afeiver MMood
o o d St.bilizers
Stabilizers

One welcomeadvance
One welcome advance in in the
the past
pastfewfewyears hashas
years been the increased
been availability
the increased availability
of
of alternatives
alternatives to
to traditional
traditional mood
m o o d stabilizers.
stabilizers. Most
Most of these new
of these drugs are
n e w drugs are
amiconvulsants like divalproex
anticonvulsants like divalproex oror carbamazepine,
carbamazepine, butbut they
they vary
vary inin terms of
terms of
their
their side-effect
side-effect profiles
profiles and
and how
h o w effective
effective they
they are
are for
for the manic versus
the manic versus the
the
depressive
depressive pole
pole ofof the
the disorder.
disorder. They
They are
are mostly used in
mostly used in combination
combination with the
with the
traditional
traditional mood
m o o d stabilizers
stabilizers toto create
create aa stronger
stronger response
response (in of mood
terms of
(in terms mood
stability), rather than substituting for them.
stability), rather than substituting for them.
One
O n e new
n e w option
option isis lamotrigine
lamotrigine (Lamictal).
(Lamictal). The
The limited research on
limited research on
lamolrigine indicates that
lamotrigine indicates itt is
that i is reasonably
reasonably effective,
effective, especially
especially for
for bipolar de­
bipolar de-
pressions
pressions and
and rapid
rapid cycling.
cycling. The
The response
response rates
rates for
for people
people during de-
bipolar de-
during bipolar
 Can Medicotion
Whot(on
Whot and Psy(hotherapy
Medicationand Do for
Psychotherapy 00 forMe?
Me? III
113

pressionswere
pressions higher
werehigher for lamotrigine
forlamotrigine than forfor
than placebo
placebo pills
piHs in one
in one seven-week
seven-week
study, w h e n the
especially when
study, especially w a s 200
dosage was
the dosage m g per
2 0 0mg (Calabrese et
d a y(Calabrese
perday al, 1999).
etal., 1999).
Lamotrigine may
Lamotrigine successfully treat
m a y successfully people with
treat people m a n i c or
with manic episodes who
m i x e d episodes
or mixed who
haven't responded
haven't w e H to
r e s p o n d e d well medications, either
other medications,
to other w h e n used
either when or in
itself or
b y itself
used by in
combination with other
combination with (Goldberg, 2000).
stabilizers (Goldberg,
m o o d stabilizers
other mood 2000).
T h e r e are
There s o m e concerns
are some about this
concerns about d r u g because,
this drug with carbamazepine,
as with
because, as carbamazepine,
about 6-10%
about of people
6 - 1 0 % of skin rash
develop aa skin
people develop within two
rash within to eight
t w o to of treat­
w e e k s of
eight weeks treat-
ment. mild rash
usually mild
This usually
m e n t . This can, in
rash can, instances (about
rare instances
in rare (about 0.3%), to more
lead to
0 . 3 % ) , lead more
serious skin
serious as Stevens-
s u c h as
conditions, such
skin conditions, Stevens-Johnson (described ear­
s y n d r o m e (described
Johnson syndrome ear-
lier). Your
lier). doctor can
Y o u r doctor prevent rashes
to prevent
try to
c a n try y o u r dosage
increasing your
b y increasing
rashes by (to
dosage (to
y o u up
bring you
bring to aa therapeutic
u p to very slowly.
level) very
therapeutic level) lamotrigine's side
Otherwise, lamotrigine's
slowly. Otherwise, side
effects are
effects mild and
relatively mild
are relatively transient, and
usually transient,
a n d usually a n d can include problems
c a n include problems
with physical
with coordination, dizziness,
physical coordination, vision, nausea,
dizziness, vision, a n d head­
vomiting, and
nausea, vomiting, head-
(Currier &
aches (Currier
aches Goodnick, 1998;
& Goodnick, et aI.,
K a h n et
1998; Kahn al, 2000).
2000).
A n even
An agent, topiramate
newer agent,
even newer (Topamax), is
topiramate (Topamax), an anticonvulsant
is an that
anticonvulsant that
appears
appears to be helpful
to be the manic
alleviating the
in alleviating
helpful in side of
manic side the illness,
of the leastwhen
atleast
illness, at when
combined with other
combined with other mood stabilizers, but
m o o d stabilizers, possibly even
butpOSSibly by itself.
even by m a y be
Itmay
itsellIt be
useful for
useful people with
for people (McElroy &
cycling (McElroy
rapid cycling
with rapid Keck, 2000).
& Keck, Unlike most
2000). Unlike most
other
other mood stabilizers, iit
m o o d stabilizers, can cause
t can cause weight rather than
loss rather
weight loss gain. For
weight gain.
than weight For
this reason, many
this reason, people want
m a n y people want to substitute it
to substitute for lithium
it for divalproex, but
or divalproex,
lithium or but
there
there is research on
enough research
not enough
is not it yet
on it to justify
yet to substitution. This
this substitution.
justify this drug has
Thisdrug has
side effects
side effects in people, such
s o m e people,
in some as blurred
such as vision or
blurred vision pain, concentration
eye pain,
or eye concentration
or
or memory problems (for
m e m o r y problems (for example, trouble finding
example, trouble finding words), tingling feelings
words), tingling in
feelings in
the hands or
the hands fatigue,feeling
face, fatigue,
or face, d o w n ,tremors,
sloweddown,
feelingslowed nausea,
tremors, and
nausea, dizziness
and dizziness
(Chengappa et
(Chengappa aL, 1999;
et al, Marcotte, 1998).
1999; Marcotte, 1998).
S o m e physicians
Some to recommend
like to
physicians like drug called
a drug
recommend a called gabapentin (Neu­
gabapentin (Neu-
rontin) which has
rontin),, which become popular
has become popular because it can
because it be combined
can be with other
combined with other
mood without the
stabilizers without
m o o d stabilizers effects or
negative effects
the negative interactions that
or interactions that have to be
have to be
considered when
considered w adding drugs
h e n adding like carbamazepine.
drugs like But the
carbamazepine. But research on
the research on
gabapentin not consistently
does not
gabapentin does consistently support its effects
suppon its as a
effects as mood
a m o o d stabilizer. In
stabilizer. In
fact, in a
fact, in large study
a large of people
study of with bipolar
people with bipolar disorder who
disorder w were taking
h o were tradi­
taking tradi-
tio!.1al
tional m mood
o o d stabilizers not doing
but not
stabilizers but adding gabapentin
well, adding
doing well, no better­
was no
gabapentin was better—
and perhaps even
and perhaps less effective�than
even less placebo tablets
effective—than placebo in treating
tablets in mania (Pande
treating mania (Pande
et aL,
et 2000). Other
al, 2000). Other research indicates that
research indicates gabapentin is
that gabapentin at least
is at ef­
modestly ef-
least modestly
fective as
fective an antidepressant
as an antidepressant during depressions (Young
bipolar depressions
during bipolar (Young et aL, 1997).
et al, 1997).
Gabapentin may
Gabapentin m be most
a y be most useful treating the
in treating
useful in the anxiety panic symptoms
and panic
anxiety and symptoms
that often
that accompany bipolar
often accompany mood
bipolar m o o d swings (McElroy &
swings (McElroy & Keck, 2000). Its
Keck, 2000). Its most
most
common side effects
c o m m o n side include oversedation,
effects include dizziness, and,
oversedation, dizziness, in some
and, in people,
some people,
overactivation (Schaffer
overactivation & Schaffer,
(Schaffer & Schaffer, 1997).
1997).
o n e of
None
N of these
these newer has the
medications has
newer medications proven track
the proven track records of the
records of stan­
the stan-
dard "big three"
dard "big mood
three" m stabilizers. But
o o d stabilizers. But you may
you m a y want to discuss
want to agents
these agents
discuss these
114
114 CAUSES
CAUSESAND
ANDTRfATMENTS
TREATMENTS

with
with your
your doclor,
doctor,if you are are
if you having unpleasam
having reactions
unpleasant to the standard
reactions mood
to the standard mood
stabilizers
stabilizers or
or if
if they
they are
arenot
not working
working as
as well
wellas
asthey
they should
should in
instabilizing
stabilizingyour
your
moods.
moods.

"Add-On" Medications:
''Add-On" Medications: Antidepressants,
Antidepressants, Antipsychotics,
Antipsychotics,
and
and Other
Otiier Agents
Agents

Moodstabilizers
Mood stabilizers are often
are given
often with
given medications
with whose
medications primary
whose purpose
primary is is
purpose
to
to combat
combat a panicular symptom,
a particular symptom, such
such asas anxiety, insomnia, agitation,
anxiety, insomnia, agitation, or
orpsy­
psy-
chosis.
chosis. The
The different
different medications
medications in
in your regimen will
your regimen make
will m mOTe sense
a k e more sense if
ifyou
you
think
think of
of each
each of
of them as belonging
them as belonging to
to aa certain
certain class
class (for
(for example,
example, amidepres­
antidepres-
sams)
sants) and
and having
having a a unique
unique purpose
purpose (for
(for example, improving sleep).
example, improving sleep).

Antidepress.nts
Antidepressants

Standard mood
Standard mood stabilizers
stabilizers areare
generally more more
generally effective in preventing
effective the manic the manic
in preventing
pole
pole than
than the
the depressive
depressive pole
pole of the illness.
of the illness. For
For this
this reason,
reason, at some point
at some point
your doctor
your doctor may
m a y discuss
discuss with
with you
you the
the option
option of
of combining your mood
combining your stabi­
m o o d stabi-
lizer with
lizer with an
an antidepressant
antidepressant medication.
medication.You Y o u have
have probably
probably heard
heard much
m u c h ininthe
the
past years about
past years about thethe type
type of of antidepressants
antidepressants called
called thethe selective
selective serotonin
serotonin
reuptahe inhibitors (SSRls).
reuptake inhibitors (SSRIs). These
These include fluoxetine (Prozac),
include fluoxetine sertraline
(Prozac), sertraline
(Zolofl), paroxetine (Paxil)
(Zoloft), paroxetine (Paxil),, fluvoxamine
fluvoxamine (Luvox),
(Luvox), and and citalopram
citalopram (Celexa).
(Celexa).
An
A n older
older line
line ofof antidepressants,
antidepressants, calledcalled the tricyclics, include
the tricydics, include imipramine
imipramine
(Tofranil),
(Tofranil), amitriptyline
amitriptyline (Elavin,
(Elavil), nortriptyhne
nortriptyline (Pamelor),
(Pamelor), and and deSipramine
desipramine
(Norpramin).
(Norpramin). Still another class,
Still another class, called
called the monamine oxidase
the monamine inhibitors
oxidase inhibitors
(MAOIs),
(MAOIs), include tranylcypromine (Pamale)
include tranylcypromine (Parnate) andand phenelzine
phenelzine (Nardil).
(Nardil). A set
A set
of
of novel
novel antidepressants
antidepressants is is also
also available,
available, including
including venlafaxine (Effexor),
venlafaxine (Effexor),
bupropion
bupropion (Wellbutrin),
(Wellbutrin), trazodone
trazodone (Desyrel),
(Desyrel), nefazadone (Serzone), and
nefazadone (Serzone), and
mirtazapine
mirtazapine (Remeron).
(Remeron).
These
These agents
agents can
can bebe effective
effective inin alleviating
alleviating thethe unpleasant
unpleasant symptoms
symptoms of of
bipolar
bipolar depression,
depression, suchsuch asas sadness,
sadness, loss
loss of
of interests,
interests, insomnia,
insomnia, fatigue,
fatigue, andand
suicidal
suicidal feelings.
feelings. Some
S o m e are more effective
are more effective than
than others,
others, and
and some have more
some have more
easily
easily tolerated
tolerated side
side effects.
effects. Unfortunately,
Unfortunately, they they all
all have
have a a major
major side
side e ffect in
effect in
bipolar
bipolar disorder:
disorder: They
They cancan bring
bring on
on hypomanic,
hypomanic, manic,
manic, or or mixed affective
mixed affective
states
states and
and can
can cause
cause rapid
rapid cycling. For this
cycling. For this reason,
reason, antidepressants
antidepressants are are usually
usually
recommended
recommended only only when
w h e n necessary,
necessary, and and then
thenonly
onlyin incombination
combination withwithmood mood
stabilizers.
stabilizers. These
These necessary
necessary conditions include going
conditions include going forfor at least 1-2
at least 1-2 months
months
with
with aa severe
severe and
and persistem
persistent depression
depression that
that has
has not responded well
not responded well to to mood
mood
stabilizers
stabilizers alone,
alone, haVing
having severe
severedepressive
depressive symptoms
symptoms with with few
few or no accompa­
orno accompa-
nying
nying manic
manic of of hypomanic
hypomanic symptOms
symptoms (e.g.,
(e.g., aadecreased
decreased needneed for
forsleep,
sleep,racing
racing
 What
What(on
ConMedico�on
Medicationand
andPsychotherapy
PsychotherapyDoDoforfo
Me?
r Me? 115115

thoughts), and
thoughts), andhaving
having severe
severe suicidalimpulses
suicidal impulses (Dubovsky
(Dubovsky &:. Buzan,
& Buzan, 1999).1999).
If If
y o u do
you d o take
take antidepressants,
antidepressants, you'll
you'H have
have to
to be
b e monitored
monitored carefully and
carefully a n d proba­
proba-
bly will
bly will need
n e e d to
to see
see your
y o u r doctor
doctor more
m o r e often.
often.
You
Y o u should not be
should not he taking
taking an
a n antidepressant
antidepressant by
by itself,
itself, without
without aa mood
m o o d stabi­
stabi-
lizer. Doing
lizer. so will
Doing so will greatly
greatly increase
increase the
the chances
chances of
of developing
developing mania
mania or in­
or in-
creased
creased moodm o o d cycling.
cycling. The T h e mood
m o o d stabilizer/antidepressant
stabiHzer/antidepressant combination combination de- de­
creases this risk but doesn't erase it.
creases this risk but doesn't erase it.
Most
Most psychiatrists
psychiatrists do do recommend
r e c o m m e n d that
that their
their patients
patients trytry an antidepres­
an antidepres-
sant
sant atat some point in
s o m e point in their
their illness.
illness. SomeS o m e antidepressants
antidepressants seem seem safer
safer than
than
others
others in in terms
terms of of their
their likelihood
likelihood of of provoking
provoking manic manic or rapid cycling
or rapid cycling
states.
states. ItIt is
is useful
useful forfor you
you to to know
k n o w about
about the the medical
medical "decision
"decision tree"tree" that
that
physicians
physicians sometimes
sometimes follow follow in in recommending
recommending antidepressants
antidepressants to to you,
you, so so
that
that his
his oror her
her recommendations
recommendations don't don't seemseem random
random or or haphazard.
haphazard. A A panel
panel
of
of experts
experts (Frances
(Frances et et aI.,
al, 1996)
1996) has has recommended
recommended that that when
w h e n bipolar
bipolar people
people
have
have severe
severe depressions,
depressions, it's it's often
often bestbest if if they
they start
start with
with thethe drug
drug Well­
Well-
butrin,
butrin, which
which seems
seems to
to have
have aa lower
lower risk
risk of
of indUcing
inducing mania
mania (for
(for example,
example,
Sachs
Sachs el et aI.,
al, 1994),
1994), or or with
with oneone of of the
the selective
selective serotonin
serotonin inhibitor
inhibitor drugs
drugs
(for
(for example,
example, Paxil)Paxil) or or the
the novel antidepressant Effexor.
novel antidepressant Effexor.
If you
If you have
have notnot responded
responded well well to to these
these medications
medications or or have had bad
have had side
bad side
effects,
effects, your
your doctor
doctor may m a y recommend
recommend a a monoamine
m o n o a m i n e oxidase
oxidase inhibitor.
inhibitor. ManyMany
people
people do do quite
quite well
well onon MAOIs,
M A O I s , but
but they
they are
are difficult
difficult to to take
take inin that they re-
that they re­
quire
quire you
you to to avoid
avoid foods
foods thatthat are
are high
high in in the
the amino
amino acidacid tyramine
tyramine (for (for exam­
exam-
ple,
ple, aged
aged cheeses,
cheeses, sausage,
sausage, chianti
chianti wines).
wines). The The tricyclics
tricyclics areare usually
usually recom­
recom-
mended
mended last last because
because of oftheir
theirside
sideeffects,
effects,and andare areusually
usuallyavoided
avoidedaltogether
altogetherin in
people
people whow h o have
have experienced
experienced mania mania or or hypomania
hypomania while while onon antidepressants
antidepressants
(Goldberg &
(Goldberg & Kocsis,
Kocsis, 1999).
1999).
About
About one one inin three
three people
people develop
develop sexualsexual sideside effects
effects on
on SSRIs
SSRIs or or MAO
M A O I Is.
s.
These
These cancan include
include a a lower
lower sexsex drive
drive and and ""ejaculatory
ejaculatory delay"delay' (difficulty reach­
(difficulty reach-
ing
ing orgasm).
orgasm). If If these
these side
side effects
effects become
become Significant,
significant, your yourdoctor
doctor maym a y recom­
recom-
mend
mend a a different
different antidepressant
antidepressant or or advise
advise youyou to to take
take breaks
breaks from
from thethe medica-
medica­
tion.
tion. For
Forsome
s o m e people,
people,sexual
sexualsidesideeffects
effectsarearereason
reasonenough
enoughtotostopstoptaking
takingthethe
antidepressant,
antidepressant, but but as
as with
with any
any side
side effect,
effect, youyou should
should discuss
discussthisthiswith
withyour
your
physician
physician before
before discontinuing
discontinuing the the drug.
drug. Going
Going off off an
an antidepressam
antidepressant qUickly
quickly
has
has been
been known
k n o w n toto increase
increase a a person's
person's risk risk of
of developing
developing maniamania or or rapid cy­
rapid cy-
cling.
cling. Other
Other sideside effects
effects ofof antidepressants
antidepressants can can include
include weight gain, insomnia,
weight gain, insomnia,
headaches,
headaches, and and daytime
daytime sedation.
sedation.

Antipsychotic
Antipsychotic Medic./ions
Medications

The
T h e notion
notion of taking an
of taking a n antipsychotic
antipsychotic medication
medication is
is scary
scary to
to many
m a n y people
people be­
be-
cause they
cause they equate
equate the
the use
use of
ofthese
these drugs
drugs with
with having
having severe
severe delusions,
delusions,halluci­
halluci-
nations,
nations, and
a n d even
even schizophrenia.
schizophrenia. Antipsychotic
Antipsychotic medications
medications areare not
not to
to be
be
116
116 CAUSES
CAUSESAND
ANDIREAIMEHIS
TREATMENTS

taken lightly,
taken lightly, but they
but have
they broader
have applicability
broader than just
applicability than the treatmen(
just of
the treatment of
schizophrenia.
schizophrenia.
Antipsychotics
Antipsychotics are are used
used in in bipolar
bipolar disorder
disorder for for several
several purposes.
purposes. First, First,
some
some people
people withwith bipolar
bipolar disorder
disorder do do have
have severe disturbances in
severe disturbances in thinking
thinking
and
and perception
perception (psychosis)
(psychosis) that that are
are notnot fully
fully controlled
controlled by by the traditional
the traditional
mood
m o o d stabilizers.
stabilizers. ForForexample,
example,during
during the theperiod
period in inwhich
which theytheyare areescalating
escalating
into
into mania
mania or or during
during the manic episode
the manic episode itself,
itself,they
theymaym a y hear
heartheir
theirname
n a m ebeing
being
called
called or or music
music being
being played
played (even
(even though
though no no one
one else
else isis around),
around), see see move­
move-
ment OUl of the corner of their eyes (even though nothing
ment out of the corner of their eyes (even though nothing is there), or believe is there) , or believe
they
they areare being
being followed.
followed. These
These symptoms
symptoms can can bebe alleviated
alleviated by by antipsychotic
antipsychotic
medicines. Second,
medicines. Second, antipsychotic
antipsychotic drugs,
drugs, particularly
particularly the thenewer
newer ones
onesknown k n o w n as
as
the
the atypical antipsychotics, have
atypical antipsychotics, have antimanic
antimanic properties.
properties. They They may m a y augment
augment the the
effects
effects of of traditional
traditional mood
m o o d stabilizers
stabilizers and and cancan even
even be be substituted
substituted if if you
you
haven't
haven't responded
responded wellwell to to lithium
lithium or or the
the anticonvulsants.
anticonvulsants. They They work fairly
work fairly
rapidly
rapidly in in stabiliZing
stabilizing an an acute
acute manic
manic or or mixed
mixed episode
episode and and are
are sometimes
sometimes rec- rec�
ommended
o m m e n d e d for
for rapid
rapid cycling.
cycling. Lastly,
Lastly, anti psychotics can
antipsychotics can be be used
used as astranquiliz­
tranquiliz-
ers,
ers, to relieve anxiety,
to relieve anxiety, restlessness,
restlessness, or or problems
problems with with sleep.
sleep. In In other words,
other words,
your
your doctor
doctor maym a y recommend
recommend these these medications
medications even even if ifhehe or
orshe
she doesn't
doesn'tthink think
you are psychotic.
you are psychotic.
Ten
Ten years
years ago,
ago, doctors
doctors werewere recommending
recommending a a traditional
traditional line line of anti­
of anti-
psychOlics
psychotics that that you
you may
m a y have
have heard
heard of, of, such
such as chlorpromazine (Thorazine)
as chlorpromazine (Thorazine)
and
and haloperidol
haloperidol (Haldol).
(Haldol). These
These drugs have severe
drugs have long-term side
severe long-term side effects,
effects, in­ in-
cluding
cluding a a serious
serious motor
motor movement
m o v e m e n t disorder
disorder called
called tardive
tardive dyskinesia.
dyskinesia. The The
newer
newer atypical
atypical antipsychotics
antipsychotics have have lessless severe
severe side
side effects
effects andand appear
appear to to bebe
less
less likely
likely to to cause
cause tardive
tardive dyskinesia.
dyskinesia. The The newer
newer drugs drugs include
include clozapine
clozapine
(Clozaril),
(Clozaril), risperidone
risperidone (Risperdal),
(Risperdal), olanzapine
olanzapine (Zyprexa),
(Zyprexa), quetiapine
quetiapine (Sero- (Sero­
quel) , and
quel), and ziprasidone
ziprasidone (Zeldox,
(Zeldox, Geodon).
Geodon). It's It'snot
notclear
clearyetyetwhether
whether these theseatyp­
atyp-
ical antipsychotics
ical antipsychotics qualify
quahfy as as mood
m o o d stabilizers
stabilizers (that
(that is,is, whether
whether they they control
control
acute
acute episodes,
episodes, decrease
decrease the the vulnerability
vulnerabihty to to future
future episodes,
episodes, and and do do notnot
worsen
worsen the the course
course of illness) or
of illness) whether they
or whether they just
just have
have short*term,
short-term, sedatingsedating
effects
effects on existing manic
on existing manic or or mixed episodes.
mixed episodes.
Clozapine
Clozapine used used toto be
be the
the most
most widely
widely preSCribed
prescribed novel antipsychotic, but
novel antipsychotic, but
many
m a n y doctors
doctors no no longer
longer recommend
recommend it it because
because aasmalls m a H number
number of ofpeople (less
people (less
than 1%)
than 1%) develop
develop agranulocytosis
agranulocytosis (definition
(definition on page 1111).
on page 1 l ). Currently,
Currently, the the
most
most popular
popular of these drugs
of these drugs is
is probably
probably olanzapine,
olanzapine,which
whichhashasFood
Foodand andDrug
Drug
Administration approval for
Administration approval the treatment
for the treatment of
of mania.
mania. AA study
study done
done by
by Mauricio
Mauricio
Tohen
Tohen andand his
his associates
associates of
of the
the Lilly
Lilly Research
Research Laboratories (Tohen et
Laboratories (Tohen al.,
et al,
1999)
1999) found
found that
that over
over a
a four-week
four-week period,
period,acutely
acutelymanic
manic or
ormixed
mixed episode
episodepa*pa-
tients
tientsrecovered
recoveredmoremoreqUickly
quicklyandandmore
morefully
fullyononolanzapine
olanzapinethan
thanthey
theydid
didonon
placebo
placebo pills.
pills. Olanzapine
Olanzapine diddid have
have more
more side
side effects
effects than placebo, including
than placebo, including
greater
greater weight
weight gain
gain and
and feeling
feeling sleepy
sleepy or
or sleeping
sleeping too
too much.
much.
 Whot Medicationond
ConMedicotion
What(on Psychotheropv
and Psychotherapy 101fMe?
DoDo or Me? 1 1 7117

If these
If these medications
medications are recommended to you byto
are recommended youdoctor,
your doesn't it doesn't
it doctor,
by your
necessarily
necessarily mean illness is
y o u r illness
that your
m e a n that getting worse.
is getting It may
worse. It your pro­
that your
m e a n that
m a y mean pro-
fileof
file ofsymptoms
s y m p t o m s (for agitation,thinking
e x a m p l e ,agitation,
(forexample, disturbances,restlessness,
thinkingdisturbances, restlessness,
cycling) will
rapid cycling)
rapid better to
respond better
will respond medications than
these medications
to these than to m o o d stabiliz­
to mood stabiHz-
ers alone.
ers Often, antipsychotic
alone. Often, medications are
antipsychotic medications given for
are given period of
for aa period time and
of time and
then gradually once
discontinued gradually
then discontinued has stabilized.
person has
o n c e aa person stabilized.

Thyroit/ Supplements,
Thyroid Benzot/iazepines,
Supplements, Benzodiazepines, ant/
and Other
Other Options
Options

Your may
doctormay
Yourdoctor severalseveral
recommend
recommend other medications
other medications as adjuncts to your to your
as adjuncts
mood stabilizers. For
m o o d stabilizers. e x a m p l e , it
F o r example, is not
it is unusual for
not unusual doctors to
for doctors to recommend
recommend
supplements such
thyroid supplements
thyroid s u c h as Synthroid. Certain
as Synthroid. Certain mood stabilizers, such
m o o d stabilizers, as lith­
s u c h as Hth-
ium, tend to
i u m , tend suppress thyroid
to suppress thyroid hormones. This is
h o r m o n e s . This useful to know
is usefuho k n o w if are feel­
y o u are
ifyou feel-
fatigued or
ing fatigued
ing slowed down
or slowed d o w n on o n lithium-a thyroid supplement
l i t h i u m — a thyroid m a y help
s u p p l e m e n t may help
bring you
bring to a
b a c k to
y o u back a normal energy level.
n o r m a l energy level. You benefit from
m a y benefit
Y o u may thyroid supple­
f r o m thyroid supple-
ments
m e n t s even if y o u h a v e a n o r m a l thyroid test result because they can be help­
even if you have a normal thyroid test result because they can be help-
ful in treating
ful in depression or
treating depression or rapid (Bauer &
c y c H n g (Bauer
rapid cycling & Whybrow, 1 9 9 0 ) . Discuss
W h y b r o w , 1990). Discuss
this option with
this option with your particularly if
doctor, particularly
y o u r doctor, y o u are
ifyou female:Women
are female: W o m e n are are partic­
partic-
p r o n e to
ularly prone
ularly to hypothyroidism.
hypothyroidism.
Many people with
M a n y people with bipolar disorder also
bipolar disorder take one
also take of the
o n e of benzodiazepines, a
the benzodiazepines, a
class of
class of drug that may
d r u g that c a l m you
m a y calm d o w n , help
y o u down, anxiety or
m a n a g e anxiety
help manage panic symp­
or panic symp-
toms,
toms, anda n d help with sleep.
help with R e m e m b e r Valium?
sleep. Remember D r u g s like
V a l i u m ? Drugs d i a z e p a m (Valium)
like diazepam (Valium)
and alprazolam (Xanax)
and alprazolam w e r e prescribed
( X a n a x ) were prescribed quite readily in
quite readily in the 1970s as
the 1970s as a w a y of
a way of
managing stress and
m a n a g i n g stress tension. Other
a n d tension. Other drugs drugs in this class
in this include clonazepam
class include clonazepam
(Klonopin) and
(Klonopin) lorazepam (Ativan).
a n d lorazepam (Ativan). These drugs need
T h e s e drugs n e e d to b e taken
to be taken with cau­
with cau-
tion,
tion, however, because unlike
h o w e v e r , because unlike the other drugs
the other discussed so
drugs discussed far, the
so far, the ben­
ben-
zodiazepines can be addictive. People may need higher and higher dosages
zodiazepines can b e addictive. People m a y n e e d higher a n d higher dosages
over
over timetime to get the
to get the s same (they develop
effects (they
a m e effects tolerance) and
develop tolerance) a n d can have with-
can have with­
drawal y m p t o m s when
drawal ssymptoms t h e m — i n c l u d i n g seizures.
stopping them-including
w h e n stopping seizures. But But if o u are
if yyou are
considerable pproblems
having considerable
having r o b l e m s getting
getting to sleep or
to sleep or staying asleep at
staying asleep night, or
at night, if
or if
you chronically anxious
feel chronically
y o u feel anxious during during the these medications
day, these
the day, medications mmay help yyou.
a y help ou.
Your doctor may
Y o u r doctor m a y also
also r ecommend a
recommend benzodiazepine instead
a benzodiazepine instead of of aan atypical
n atypical
antipsychotic
antipsychotic to quell yyour
help quell
to help a n i c or
o u r mmanic m i x e d symptoms.
or mixed symptoms.
A n u m b e r of
A number other alternative
of other medications have
alternative medications have come o n the
c o m e on scene in
the scene the
in the
past few
past years and
few years are in
a n d are the process
in the process of of being evaluated in
being evaluated in research studies.
research studies.
Physicians vary
Physicians vary in in their enthusiasm for
their enthusiasm for these agents. FFor
these agents. or e example, tiagabine
x a m p l e , tiagabine
(Gabitril),, aan
(Gabitril) n agent
agent that inhibits the
that inhibits the reuptake
reuptake of A B A into
of GGABA into thethe nerve celis, is
nerve cells, is
used
used bby y s some doctors to
o m e doctors rapid cycling.
treat rapid
to treat cycling. It It has not come
has not into wwide
c o m e into i d e use be­
use be-
cause
cause of of the lack of
the lack of supportive
supportive evidenceevidence for for its effectiveness.
its effectiveness.
One
O increaSingly popular
n e increasingly popular alternative
alternative is the omega-3
is the omega-3 fatty fatty acidacid plan (fish
plan (fish
oil). TThe
oil). use of
h e use fish oil
of fish exciting to
is exciting
oil is to mmany
a n y people because it
people because it is
is a "natural" sub-
a "natural" sub-
118
118 CAUSES
CAUSESAND
ANDTREATMENTS
TREATMENTS

stance.
stance.ItIt hashasbeen found
been in onc
found in study to do to
one study bener than placebo
do better tablets intablets
than placebo pro­ in pro
longing periods
longing periods of of wellness
wellness among
a m o n g people
people with
with bipolar
bipolar disorder
disorder whow h o were
were also
also
getting
getting mood
m o o d stabilizers
stabilizers (Stoll
(StoH el al, 1999).
et al., 1999). There
There is also a
is also a class
class of
of drugs
drugs
known as calcium
k n o w n as calcium channel
channel blockers.
blockers. Although
Although thesethese are
are mainly
mainly usedused for the
for the
treatment
treatment of of heart
heart diseases
diseases and
and blood
blood pressure,
pressure, they
they may have mood-stabiliz-
m a y have mood-stabiliz­
ing
ing properties.
properties. These
These drugs include verapamil
drugs include verapamil (Calan,
(Calan, Isoptin),
Isoptin), nimoclipine
nimodipine
(Nimotop),
(Nimotop), and and other
other agents.
agents. They
They are recommended for
sometimes recommended
are sometimes treat­
for treat-
ment-resistant
ment-resistant mania
mania butbut only
only rarely
rarely given
given their
their questionable efficacy.
questionable efficacy.
More
More research
research isis needed
needed onon all
allof
ofthese
theseagents.
agents.Right
Rightnow,
n o w ,they
theyare
arerecom­
recom-
mended mainly
mended mainly asas add-cns
add-ons to traditional mood
to traditional m o o d stabilizers
stabilizers or
or as
as alternatives
alternatives for for
people
people w who
h o can't tolerate the
can't tolerate the side
side effects
effects of
of any
any of
of the
the first-line
first-line medicat
medicationion
choices.
choices.

Electroconvulsive Therapy:
Ele<troconvulsive Therapy: What
W h a t Is and Isn't
Is and Isn't True
True about It?
about It?

Josh,
Josh, a 35-year-old
a 35-year-old manman
withwith bipolar
bipolar I Idisorder,
disorder, was
was hospitalized
hospitalized for fora a
manic
manic episode
episode andand then
then returned
returned home
h o m e on
on a a combination
combination of of lithium
lithium andand
haloperidol,
haloperidol, an an antipsychotic
antipsychotic medication.
medication. Shorrly
Shortly after his discharge
after his discharge he he
swung
swung into
into a
a severe
severe depression,
depression, which
which was was characterized
characterized by by sleeping
sleepingmost
most
of
of the
the day,
day, suicidal
suicidalthoughts,
thoughts,lowlow energy,
energy,mental
mentalslowness,
slowness,and andloss
lossofofin­
in-
terest
terest in
in his
his family and work.
family and work. He
H e began
began to to have
have unusual
unusual thoughts,
thoughts, suchsuch asas
fearing
fearing that
that his
his body
body was
was rotting.
rotting. His
His physician
physician waswas unwilling
unwilling to to give
give him
him
an
an antidepressant
antidepressant because he'd had
because he'd had several
several badbad reactions
reactions to antidepres­
to antidepres-
sants
sants before,
before, including
including periods
periodsofofrapid
rapid cycling
cyclingandand mixed
mixed symptoms.
symptoms.In­ In-
creasing
creasing his
his dosage
dosage of lithium did
of lithium did not
not help
help his
his depression,
depression, and and gave
gave him
him
more side
more side effects-and
effects—and "more"more toto be
be depressed
depressed about"
about" (his
(his words).
words).
Josh
Josh eventually
eventually asked
asked to
to be
be admitted
admitted to to the
the hospital
hospital again.
again. Although
Although
he
he had
had been
been quite
quite frightened
frightened of
of electroconvulsive
electroconvulsive therapy
therapy (ECT)
(ECT) thethe first
first
time
time he
he had
had it,
it, this
this time
time he
he asked
asked forfor it,
it, thinking
thinking itit was
was the
the only
only option
option
that would help.
that would help. HeH e was staned on
was started on aa course
course of of ECT
E C T three
three times
times a a week.
week.
He
H e responded
responded to to this
this treatment
treatment within
within three
three weeks
weeks andand was
was discharged
discharged
from
from the
the hospital,
hospital, his
his depreSSion
depression largely
largely lifted.
lifted. He
H e felt brighter, mentally
felt brighter, mentally
sharper,
sharper, and
and more
more able
able to
to engage
engage with
with his
his wife
wife and
and children. His suicidal
children. His suicidal
thoughts
thoughts hadhad diminished.
diminished.

ECT,ECT, or what
or what is oftendisparagingly
is often disparagingly labeled
labeledasas
"shock treatment,"
"shock isofone of
is one
treatment,"
the
the more
more powerful
powerful treatment
treatment options
options available
available forfor people
people withwith bipolar disor­
bipolar disor-
der.
der. ECT
E C T works
works qUickly
quickly and
and effiCiently.
efficiently. ItItisismainly
mainlyan anacute
acutetreatment, de­de-
treatment,asas
fined earlier: ItItisisone
fined earlier: oneofof
the most
the mosteffective
effective methods
methods we w ehave
havefor pulling
for some­
pulling some-
one
one out
out of
of aa severe
severe depreSSion
depression or mixed episode.
or mixed episode. ECT can also
E C T can also be used to
be used to

bring
bring aa person
person down
d o w n from
from aa manic
manic high,
high, although
although it itisisrarely used
rarely usedfor that
for pur-
that pur-
 What
What (an
ConMedication and
Medication andPsychotherapy
PsychotherapyDoDoforfo
Me?
r Me? 119119

pose, giventhe
pose, given therapid
rapid effects
effects of of medications
medications such such
as theasatypical
the atypical antipsy­
antipsy-
chotics.
chotics.
What
W h a t happens
h a p p e n s during
during ECT?
E C T ? Typically, first you
Typically,first y o u stop
stop taking
taking your
your regular
regular
medications,
medications, including
including lithium
lithium oror amiconvulsams.
anticonvulsants. OnceO n c e these
these drugs are
drugs are
washed
w a s h e d out
out ofofyour
y o u r system
system (which
( w h i c h can
c a ntake
take aa week
w e e k or
ortwo),
t w o ) , an
a n appointment
appointment is is
scheduled.
scheduled. During this session,
D u r i n g this session, you y o u are
are given
given a a general
general anesthetic
anesthetic (for (for exam­
exam-
ple,
ple, sodium
s o d i u m pemothal)
pentothal) and a n d another
another medication
medication (succinyl
(succinyl choline)
choline) to to help re­
help re-
lax
lax your
y o u r muscles
muscles and a n d prevent
prevent a a full
full body
b o d y seizure.
seizure. These
T h e s e drugs
drugs willwill m make
a k e yyou
ou
unconscious
unconscious while while you y o u are
are undergoing
undergoing the the treatment.
treatment. The T h e doctor
doctor thenthen admin­
admin-
isters
isters an a n electrical
electrical pulsepulse that
that creates
creates a a mild
mild seizure
seizure in in your
your brain.
brain. Usually,
Usually, be­ be-
tween 4
tween a n d 1122 treatments
4 and treatments are are needed,
needed, or or upu p to
to three
three limes
times a awweek
e e k for
for about
about
one month.
one month.
The
The theory
theory behind
behind ECT E C T is is that
that this
this pulse
pulse and and resulting seizure "jump­
resulting seizure "jump-
starts"
starts" the the brain's
brain's production
production of of neurotransmitters.
neurotransmitters. It It may
m a y also
also temporarily
temporarily re- re­
duce the
duce the activity
activity of of the
the fromal
frontal lobelobe of of the
the brain,
brain, which
which is isthought
thought to tobebe impor­
impor-
tant
tant in
in modulating
modulating mood m o o d states
states (Sackheim
(Sackheim et al, 1992).
et aI., Because ECT
1992). Because E C T isis gener-
gener­
ally
ally not
not considered
considered a a maintenance
maintenance (preventative)
(preventative) treatmem,
treatment, you you will usually
will usually
continue
continue with with your
your mood m o o d stabilizer,
stabilizer,antidepressant,
antidepressant,or orantipsychotic
antipsychoticregimen regimen
after
after the
the course
course of of ECT
E C T is
is over.
over.
Because
Because of of the
the difficult
difficult andand turbulent
turbulent history
history of of ECT,
E C T , people
people withwith bipolar
bipolar
disorder
disorder and and their
their family
family members
m e m b e r s often
often don't
don't want
want to to consider
consider it it even
even in in the
the
most
most dire
dire of of circumstances.
circumstances. This This is is unfortunate
unfortunate because
because ECT E C T is life-saving in
is life-saving in
many
m a n y cases.
cases. It It can
can pullpull people
people out out ofof serious
serious depressions
depressions from which they
from which they
might
might havehave otherwise
otherwise committed
committed suicide.suicide.
Many
M a n y physicians
physicians recommend
r e c o m m e n d ECT
E C T only
only reluctantly
reluctantly because
because one one of its side
of its side
effects
effects isis aa loss
loss ofof memory.
m e m o r y . The
T h e memory
m e m o r y loss
loss is
is usually
usually most
most noticeable
noticeable forfor
events
events that
that occurred
occurred during
during the the treatmem
treatment itself
itself (that
(thatis,
is,during
duringthe thefour
fourweeks
weeks
or
or soso when
w h e n the
the treatments
treatments were were given)
given).. But
But some
s o m e people
people also
also forget
forget events
events
that
that occurred
occurred priorprior toto the
the ECT
E C T procedure.
procedure. This This isis probably
probably because
because E EeT
C T can
can
affect
affect the
the transfer
transfer ofof information
information usually usually held
held inin short-term
short-term memory
m e m o r y (the
(the kind
kind
of
of memory
m e m o r y that
that encodes
encodes and and holds
holds information
information in in your mind for
your mind for aa brief
brief period
period
of
of time,
time, such
such asas when
w h e n you
you first
first hear
hear people's
people's names
names andand phone
phone numbers)
numbers) to to
long-term
long-term memorym e m o r y storage.
storage. It It is
is not
not clear
clear that
that memories
memories are are lost
lost for
for good,
good,
however. In fact, memories for events that occurred before the EeT usually
however. In fact, memories for events that occurred before the E C T usually
come
c o m e back
back several
several momhs
months after after the
the treatment
treatment (Mondimore,
(Mondimore, 1999; 1999; Squire
Squire etet
al.,
al, 1981).
1981). It It appears
appears thatthat about
about two-thirds
two-thirds of of people
people who
w h o receive
receive E ECT experi­
C T experi-
ence
ence problems
problems in in memory
m e m o r y functioning,
functioning, but but the
the problems
problems seemseem to be tempo­
to be tempo-
rary
rary and
and usually
usually disappear
disappear with time.
with time.
Nowadays,
Nowadays, EeT E C T is
is aa safe
safe and
and effective
effective treatment
treatment that
that is
is fairly routine in
fairly routine in its
its
administration. It
administration. It can
can be
be done
done on on anan outpatiem
outpatient basis.
basis. Because
Because of of its
its side ef­
side ef-
fects
fects and high economic
and high economic cost,
cost, ititis
istypically
typicallyconsidered
consideredwhen
w h e n aaperson
person has
has not
not
170
120 CAUSES
CAUSESAND
ANDTREATMENTS
TREATMENTS

responded adequately
responded adequately to
tomood
mood stabilizers
stabilizers or antidepressants and isand
or antidepressants incapaci­
is incapaci-
tated
tated byby depresSion,
depression, psychosis,
psychosis, or or sUicidality.
suicidality. ItIt is
is also
also considered
considered for for women
women
who
w h o arc
are pregnant
pregnant andand severely
severely depressed
depressed or or manic.
manic. Most
Most mood
m o o d stabilizers
stabilizers and
and
antidepressants
antidepressants carry carry some
some risk
risk of
of harm
harm to to the
the unborn
unborn baby,
baby, but
but ECT
E C T docs
doesnot
not
when
w h e n administered
administered under
under standard
standard medical
medical conditions.
conditions. ECTE C T will
will not
not be
be done
done
against
against your wishes. Like
your wishes. Like any psychiatriC treatment,
any psychiatric treatment, receiving
receivingECTE C T is
isbased
basedon on
aa joint
joint decision
decision between
between youyou and
and your
your doctor.
doctor.
An
A n ahernative
alternative toto ECT, called rapid
E C T , called rapid transcranial
transcranial magnetiC
magnetic stimulation,
stimulation, has
has
recently
recently been
been developed.
developed. The The procedure
procedure is is a
a simpler
simpler andand less
less invasive
invasive way
way to[0
stimulate
stimulate thethe cerebral
cerebral cortex.
cortex. ItIt does
does not
not require
require you
you to(0 have
have general anesthe­
general anesthe-
sia
sia and
and has
has relatively
relatively minimal
minimal cognitive
cognitive side
side effects
effects (George
(George et
et al.,
al, 1997).
1997). BU[
But
it does not
it does not appear
appear to to be
be as
as effective
effective as
as ECT
E C T for
for depressed
depressed people
people w who
h o are not
are not
responding
responding to to antidepressant
antidepressant medications.
medications. Perhaps
Perhaps as as a
a result,
result, transcranial
transcranial
magnetic
magnetic stimulation
stimulation has has not
not yet
yet come into wide
c o m e into wide useuse in
in clinical
clinical practice
practice
(Nahas
(Nahas et al, 1999;
et aI., Thase &:
1999; Thase Sachs, 2000).
& Sachs, 2000).

Light
Light Treatment
Treatment

You mayhave
You may have noticed
noticed that
thatyouryourmoods
moods vary
varyconSiderably
considerably with
withthethe
season of of
season
the
the year.
year. Some
S o m e people
people do do have
have seasonal
seasonal bipolar
bipolar disorders,
disorders, which
which usually
usually
means
means theythey have
have mania
mania or hypomania in
or hypomania in the
the spring
spring or or summer
s u m m e r and
and depression
depression
in the fall
in the fall or
or winter.
winter. ItIt may
m a y be
be that
that changes
changes in exposure to
in exposure to light
light during
during the
the
different
different seasons
seasons mediate
mediate changes
changes in in people's
people's mood
m o o d states.
states. Sitting
Sitting in
in front of
front of
full-spectrum bright white lights for half an hour to two hours per day can
full-spectrum bright white lights for half an hour to two hours per day can
improve mood
improve m o o d and
and selVe
serve as
as an
an alternative
alternative to to traditional
traditional antidepressant
antidepressant medi­
medi-
cations for some (Terman &. Terman, 1999). But like the antidepressants,
cations for some (Terman & Terman, 1999). But like the antidepressants,
light treatment
light treatment can can lead
lead to
to switches
switches into
into mania
mania oror hypomania
hypomania or interfere with
or interfere with
your sleep. Its recommended use in bipolar depressions is not clear because
your sleep. Its recommended use in bipolar depressions is not clear because
no
no systematic,
systematic, controlled
controlledstudies
studieshave
have been
been done
done among
a m o n g bipolar peopletaking
bipolarpeople taking
mood stabilizers (Thase &. Sachs, 2000). Nonetheless, if you think
m o o d stabilizers (Thase & Sachs, 2000). Nonetheless, if you think your
your de­
de-
pressions
pressions have
have seasonal
seasonal triggers,
triggers, discuss
discussthisthisalternative
alternativewithwithyouryourphysician.
physician.

"Do
" Need P.y,hotherapy?"
D o II Need Psychotherapy?"

"I"I cannot
cannot imagine
imagine leading
leading aanormal
normal life without
life both
without taking
both lithium
taking andand
Hthium
having had
having had the
the benefits
benefits of of psychotherapy
psychotherapy.. ... .
. ineffably, psychotherapy
. ineffably, psychotherapy
heals. It
heals. It makes
makes some
some sense
sense ofof the
the confusion,
confusion, reins
reins in
in the
the terrifying
terrifying
thoughts
thoughts and
and feelings,
feeHngs, returns
returns some
some control
control and
and hope
hope and
and possibility of
possibihty of
learning
learning from
from it
it all.
all. .. .. It
It is
is where
where II have
have believed-or
believed-or have
have learned to
learned to
 What
What (on
Can Medication
Medicationend
andPsychotneropy
PsychotherapyDo
Dofor
forMe?
Me? 121
121

believe-that
beheve—that I might
I might someday
someday be ablebe
to able to contend
contend with allwith all ofNothis.
of this. pillNo pill
can
can help
help me
m e deal
deal with
with the
the problem
p r o b l e m of
of not
not wanting
wanting to
to take
take pills; likewise,
pHls; likewise,
no
n o amount
a m o u n t ofof psychotherapy
psychotherapy alone
alone can
can prevent
prevent my
m y manias
m a n i a s and depres­
a n d depres-
sions.
sions. II need
n e e d both."
both."
-Jamison
— J a m i s o n (1995, pp. 88-89)
(1995, pp. 88-89)

Many Many doctors

doctors will recommend
will recommend that you
that you combine combine
your medicalyour medical treatment
treatment
with
with some
s o m e form
f o r m of
of psychotherapy.
psychotherapy. ForF o r example,
e x a m p l e , Clarence,
Clarence, a a 19-year-old
19-year-old manman
who
w h o had
h a d been
b e e n hospitalized
hospitalized during
during aa manic
m a n i c episode
episode (see(see more
m o r e details
details inin Chap­
Chap-
ter 7),
ter 7 ) , came
c a m e toto some
s o m e important
important decisions
decisions about about his his illness
illness and
a n d his
his need
need for
for
medication
medication as as aa result
result ofof psychotherapy.
psychotherapy. He H e originally
originally refused
refused medication,
medication, butbut
through
through the the support
support of of his
his therapist
therapist he
h e eventually
eventually agreedagreed toto aa trial
trial of
of lithium.
lithium.
In
In turn,
turn, his his combination
combination of of psychotherapy
psychotherapy and a n d lithium
lithium helped
helped him h i m recover
recover
from
from a a relatively
relatively intractable illness.
intractable illness.
Learning
Learning to to accept
accept medication
medication is is only
only oneo n e reason
reason to to seek
seek psychotherapy.
psychotherapy.
Many
M a n y people
people with with bipolar
bipolar disorder
disorder say say that therapy is
that therapy is an
a n essential
essential part
part of
of their
their
recovery
recovery fromf r o m episodes,
episodes, on on a a par
par with
with medication.
medication. Psychotherapy
Psychotherapy can't can't cure
cure
you
y o u of
of bipolar
bipolar disorder,
disorder, nor nor is is it
it a
a substitute
substitute for for medication.
medication. Nonetheless,
Nonetheless, psy­
psy-
chotherapy
chotherapy can can help
help you
y o u learn
learn to to recognize
recognize the the triggers
triggers for
for your
your m mood
o o d swings
swings
and
a n d what
w h a t to
to do
d o about
about t them.
h e m . If
If you
y o u can
can afford
afford it,
it, and
a n d if
if you
y o u can
can find
find aa good
good
therapist
therapist in in your
y o u r community
c o m m u n i t y who
w h o knows
k n o w s about
about bipolar
bipolar disorder,
disorder, II would
would
highly
highly recommend
r e c o m m e n d that
that you
y o u pursue
pursue it. it. In
In my
m y experience,
experience, mostm o s t people
people are sat­
are sat-
s
i fied with
isfied with weekly,
weekly, hour-long
hour-long visits visits toto an
a n individual,
individual, couple,
couple, family, or group
family, or group
therapist.
therapist.

WhyTry
Why TtyPsychotherapy?
Psychotherapy?
There
There are are several
several compelling
compelling reasons reasons to to seek
seek psychotherapy
psychotherapy (see (see thethe sidebar
sidebar
on page 122).
o n page 122). A A major
m a j o r reason
reason is is to
to get
get some
s o m e guidance
guidance in in managing
m a n a g i n g yyour
o u r disor­
disor-
der.
der. You
Y o u may
m a y want
w a n t toto discuss
discuss the the role
role of of stressful
stressful events
events in in eliciting
eliciting youryour
mood
m o o d cycling,
cycling, the the wayw a y you
y o u feel
feel "set
"set off'
o f f byb y certain
certain interactions
interactions with with your
your
spouse
spouse or or other
other family
family members,
m e m b e r s , your
y o u r difficulties
difficulties accepting
accepting the the illness
iHness or its
or its
stigma,
stigma, or or your
y o u r ambivalence
ambivalence about about medications.
medications. You Y o u may
m a y wish
w i s h toto discuss
discuss thethe
impact
impact thatthat your
y o u r illness
illness is is haVing
having on o n your
y o u r work
w o r k life,
life, social
sociallife,
life,or or family
family rela­
rela-
tionships,
tionships, or or how
h o w to to talk
talk about
about it it with
with other
other people.
people.These are all
T h e s e are allgood
g o o d reasons
reasons
to
to seek
seek therapy
therapy to to help
help youy o u cope
cope with
with and a n d manage
m a n a g e your
y o u r disorder.
disorder.
You
Y o u may
m a y also
also wish
w i s h to
to try
try therapy
therapy in in order
order to to address
address longstanding
longstanding per­ per-
sonal
sonal problems
p r o b l e m s that
that maym a y be
b e unrelated
unrelated to to your
y o u r disorder
disorder or or that
that seem to con­
s e e m to con-
tinue,
tinue, whether
w h e t h e r your
y o u r mood
m o o d isis stable
stable oror not.
not. These
T h e s e issues
issues areare probably
probably not not being
being
addressed
addressed in in your
y o u r medication
medication monitoring
monitoring sessionssessions with with your
y o u r psychiatrist.
psychiatrist. For For
example,
example, some s o m e people
people with with bipolar
bipolar disorder
disorder feel feel that
that they've
they've nevernever had had a a suc-
sue-
177
122 CAUSES
CAUSESAND
ANDlREA1MENlS
TREATMENTS

The
T h e Ob jectives of
Objectives of Psychotherapy
Psychotherapy
for
for Persons with Bipolar
Persons with Bipolar Disorder
Disorder

•
• To
To help
help you
you make sense of
make sense ofyour
your current
currentoror
past episodes
past of of
episodes
illness
illness
•
• To
T o discuss
discuss long-term
long-term planning,
planning,given
given your
your vulnerability to future
vulnerability [0 future
episodes
episodes
•
• To
T o help
help you
you accept
accept and
and adapt
adapt to
to aa long-tenn
long-term medication
medication regimen
regimen
•
• To identify and develop strategies for coping with
T o identify and develop strategies for coping with stress stress
•
• To
T o improve
improve your
your functioning
functioning in
in school
school or or the
the workplace
workplace
•
• To
T o deal
deal with
with the
the social
social stigma
stigma of
of the
the disorder
disorder
•
• To
T o improve
improve family
family or
or maritaVromantic
marital/romantic relationships
relationships

cessful
cessful romantic
romantic relationship.
relationship. Some
S o m e have
have been abused as
been abused as children
children andand need
need toto
talk
talk about
about past
past traumatic
traumatic experiences.
experiences. SomeS o m e feel
feel chronically
chronically suicidal,
suicidal, even
even
when
w h e n they
they are
are not
not in
in an
an episode
episode of of depression.
depression. Some
S o m e experienced
experienced painful
painful
childhood losses (for
childhood losses (for example,
example, thethe suicide
suicide of
of aa parent)
parent) and
and need
need to tomake
m a k e sense
sense
of
of their
their feelings
feelings of
of abandonment
abandonment and and rejection.
rejection. Even
Even ififthese
thesepsychological
psychologicalis­ is-
sues
sues are not aa primary
are not primary cause
cause of
of your
your bipolar
bipolar disorder,
disorder, they
they may
m a y become
become more more
salient
salient toto you
you when
w h e n your
your mood
m o o d cycles.
cycles. Gaining
Gaining insight
insight into
into the
the nature
nature ofof these
these
conflicts
conflicts andand developing
developing skills
skills for
for coping with them
coping with have the
them have the potential
potential to to
make
m a k e you
you less
less vulnerable
vulnerable to to new
new m mood episodes.
o o d episodes.

Esther,
Esther, a 27-year-oldwoman
a 27-year-old woman withwith bipolarII11 disorder,
bipolar disorder, also alsosuffered
suffered from from
obsessive--compulsive
obsessive-compulsive symptoms,symptoms, whichwhich had
had become
become bad bad enough that she
enough that she
had
had quit her job
quit her job as as a
a court
court reporter.
reporter. She
She was
was bothered
bothered by intrusive
by intrusive
thoughts
thoughts thatthat she
she might
might stab
stab her
her husband,
husband, Carl,
Carl, also
also age
age 27.
27. These
These
thoughts
thoughts were
were especially
especially disturbing
disturbing toto her
her because
because "I "I deeply
deeply love
love him ...
him ...
he's
he's the
the best
best lhing
thing that's
that's ever
ever happened
happened to to me,
m e , maybe
m a y b e the
the only really good
only really good
thing."
thing." WWhen
h e n she
she had
had these
these violent
violent thoughts,
thoughts, shesfie often
often cycled
cycled into de­
into de-
pressive, suicidal
pressive, suicidal episodes.
episodes. SheShe was
was consistem
consistent in in taking her regimen
taking her regimen of of
Depakote and Zoloft (an SSRI antidepressant), but her thoughts caused
Depakote and Zoloft (an SSRI antidepressant), but her thoughts caused
her
her Significant
significant distress.
distress. Carl was aware
Carl was aware of
of her
her impulses
impulses but but said
said he
he wasn't
wasn't
worried
worried about
about them.
them. SheShe had
had never
never acted
acted on
on them,
them, andand "besides,
"besides, I'd
I'drather
rather
she
she had fantasies about
had fantasies about killing
killing me
m e than
than somebody
somebody off off the street."
the street."
During
During a a course
course of of interpersonally
interpersonally oriented
oriented therapy
therapy (see
(see next sec­
next sec-
tion),
tion), Esther
Esther came
came to to realize
realize that
that she
she was
was quite
quite angry
angry at at her
her husband
husband for for
what
what she
she termed
termed his his "treating
"treating mem e like
Hke his
his little
Htde doll."
doH." SheShe recounted
recounted how how
her
her various
various attempts
attempts at at independence
independence were were met
met with
with vitriolic
vitriolic tirades
tirades from
from
 What
What Con
CanMedimtion
Medicationond
andPsychotherapy
PsychotherapyDoDolorfoMe?
r Me? 173
123

Carl,Carl, in which
in which he wouldhe would
assert assert
"being "being the boss."
the boss." In one In one particularly
particularly emo- emo­
tional session she
tional session she reahzed
realized that that herher violent
violent thoughts
thoughts usually
usually appeared
appeared
within
within a a few
f e w hours
h o u r s of
of having
having a a frustrating
frustrating discussion
discussion with with Carl
Carl regarding
regarding
her
her desire
desire to to get
get a a job
job oror gog o back
b a c k to
to school.
school. Later
Later inin therapy,
therapy, sheshe became
became
more
m o r e comfortable
comfortable with with thethe idea
idea that
that she
she had
h a d legitimate
legitimate reasons
reasons to to beb e an­
an-
gry
gry with
with Carl
Carl anda n d decided
decided to to work
w o r k on
o n her
her assertiveness
assertiveness skills skHls in her inter-
in her inter­
actions
actions with w i t h him.
h i m . Whereas
W h e r e a s Carl
Carl continued
continued to to oppose
o p p o s e her
her working
w o r k i n g full
fuH
time,
time, he
h e did
did finally
finally agree
agree to
to support
support her
her applying
applying for
for aa part-time
part-time job
job at
at a
a
health
health clubclub anda n d enrolling
enroHing in in an
a n evening
evening course.
course. Her
H e r violent
violent thoughts
thoughts grad­ grad-
ually
ually receded.
receded.

Esther's
Esther's problems
problems with
with her her husband
husband did not
did not stem stem from
directly directly
her from
bipo- her bipo­
lar
lar disorder,
disorder, although
although they
they contributed
contributed to
to her
her cycling
cycling patterns. Notice that
patterns. Notice that her
her
improvement
i m p r o v e m e n t stemmed
s t e m m e d from
f r o m two
t w o factors:
factors: her insight into
her inSight into the
the reasons
reasons behind
behind
her
her violent
violent thoughts,
thoughts, and
a n d her
her decision
decision to
to do
do something
something differently in her
differently in rela­
her rela-
tionship.
tionship. Most
M o s t therapists
therapists nowadays
n o w a d a y s believe
believe that
that psychotherapy
psychotherapy is
is most effec­
m o s t effec-
tive
tive when
w h e n people
people combine
c o m b i n e inSight
insight with
with learning
learning the
the needed
n e e d e d skills
skills for
for changing
changing
their
their thinking
thinking patterns
patterns or behaviors.
or behaviors.

Choosingthe
Choosing IheRight
RighITherapy
Theropy

Like medication,
Like medication,psychotherapy
psychotherapy comes
comes in different
in different sizes,
sizes, shapes,
shapes, andand dosages.
dosages.
Depending
D e p e n d i n g on
o n your
y o u r community,
c o m m u n i t y , you
y o u may
m a y be
b e able to locate
able to locate professionals
professionals who
who
practice
practice individual
individual therapy
therapy from
from a
a number
n u m b e r of
of different
different theoretical viewpoints.
theoretical viev^^points.
You
Y o u may
m a y also
also have
h a v e access
access to
to family
family therapy,
therapy, couple
couple therapy,
therapy, or
or self-help
self-help
groups.
groups. If
If you
y o u live
live in
in a
a rural
rural or
or mountain
m o u n t a i n setting,
setting, you m a y be
y o u may limited to
b e limited to the
the
orientation
orientation and
a n d type
type of
of practice
practice available
available in
in your
y o u r immediate
i m m e d i a t e locale.
locale.
Almost
A l m o s t all
all therapy
therapy goes
goes better
better if
if you're
you're with
with a
a therapist
therapist whom you
whom y re­
o u re-
spect
spect and
a n d trust,
trust, with
with whom
w h o m you
y o u have
have a
a good
g o o d relationship,
relationship, and
a n d who
w h o you feel
y o u feel
genUinely
genuinely cares
cares about
a b o u t you.
y o u . But
B u t it
it is also important
is also important to
to find
find a therapist who
a therapist who
understands
understands the
the syndrome
s y n d r o m e of
of bipolar
bipolar disorder.
disorder. Avoid
A v o i d being in the
being in the position
position
of
of educating
educating your
y o u r therapist
therapist about
a b o u t your
y o u r bipolar
bipolar symptoms,
s y m p t o m s , or
or having
having him
h i m or
or
her
her label
label your
y o u r behavior
behavior as
as "acting
"acting out"
out" or
or "low
"low self-esteem"
self-esteem" when
w h e n the real
the real
issues
issues have
h a v e to
to do
d o with
with unresolved
unresolved manic
m a n i c or
or depressive
depressive symptoms.
s y m p t o m s . Good
Good
questions
questions to
to ask
ask your
y o u r intended
intended therapist
therapist include
include whether
w h e t h e r her
her or she (1)
or she (1)
works
w o r k s regularly
regularly with
with persons
persons with
with bipolar disorder, (2)
bipolar disorder, (2) will
will integrate
integrate his
his or
or
her
her knowledge
k n o w l e d g e of
of the
the disorder
disorder into
into the
the treatment,
treatment, and
a n d in
in what w a y s , (3)
w h a t ways, (3)
places
places importance
importance on
o n understanding
understanding the
the illness
illness and
a n d its
its effects
effects on
o n your rela­
y o u r rela-
tionships, (4)
tionships, (4) will
will communicate
c o m m u n i c a t e regularly
regularly with
with the
the physician
physician who
w h o is
is manag­
manag-
ing
ing your
y o u r medications
medications and
a n d develop
develop an
a n integrated
integrated treatmeOl
treatment plan,
plan, and
a n d (5) will
(5) will
focus
focus on
o n the
the present
present as well as
as well as the past. You
the past. Y o u also should ask
also should how
ask h long your
o w long your
124
124 CAUSES
CAUSESAND
ANDTREATMENTS
TREATMENTS

therapy is
therapy islikely to last,
likely although
to last, your therapist
although may notmay
your therapist be not
ablebe
to able
give you
to give you
a
a precise
precise answer.
answer. It It is
is reasonable
reasonable to to expect
expect weekly
weekly or or biweekly
biweekly sessions
sessions forfor
about
about sixsix months
months 1O to a a year
year after
after anan illness
illness episode,
episode, with
with anan agreement
agreement to to
evaluate
evaluate youryour progress
progress from
from time
time to time.
to time.
Avoid agreeing
Avoid agreeing to to open-ended,
open-ended, long-term
long-term contracts
contracts with
with no
no clearly
clearly articu­
articu-
lated
lated goals.
goals. Avoid
Avoid therapy
therapy approaches
approaches in in which
which allall disorders-whether
disorders—whether bipo- bipo­
lar
lar disorder,
disorder, depression, anxiety problems,
depression, anxiety problems, or or substance/alcohol
substance/alcohol abuse-are
abuse—are
ascribed
ascribed to to traumatic
traumatic "repressed
"repressed memories"
memories" (that(that is,
is, memories
memories of of negative
negative
childhood
childhood experiences
experiences that that are
are buried
buried andand presumably
presumably must must bebe uncovered).
uncovered).
Despite
Despite the the fact
fact that
that these
these treatments
treatments have been around
have been around forfor some
some time,
time, they
they
are
are largely unproven by
largely unproven by research
research andand have
have notnot been
been evaluated
evaluated systematically
systematically
in
in bipolar
bipolar disorder.
disorder. What's more, they
What's more, tend to
they tend to downplay
downplay or or even deny the
even deny the im­
im-
portance
portance of of the
the biological
biological andand genetiC origins of
genetic origins of the
the disorder
disorder and
and the
the need for
need for
medication.
medication. This This is
is not
not toto say
say that
that examining
examining painful
painful childhood
childhood events
events will
wiU
not
not help
help you,
you, but itt should
but i should be done in
be done in the
the context
context o fa
of a tlierapy
therapy tliat acknowl­
that acknowl-
edges
edges the
the biological
biological bases
bases ofofyour
your disorder,
disorder,educates
educatesyouyouabout
abouthowhowtotocope withit,it,
copewith
and
and deals
deals wit
withIi present
present di fficulties as
difficulties well as
as well past.
as past.
In
In the
the next
next section,
section, IItalk
talkabout
aboutdifferent
differentkinds
kindsof ofindividual
individualpsychothera­
psychothera-
py that
py that may
m a y be available in
be available in your
your community,
community, theirtheir assumptions
assumptions and purposes,
and purposes,
and
and research
research evidence
evidence for for their
their effectiveness
effectiveness in in stabilizing
stabilizing the
the cycles
cycles of of your
your
bipolar
bipolar disorder
disorder w when
h e n combined
combined with with medication.
medication.

Individual Psychotherapy
Individual Psychotherapy

Individual therapy
Individual therapyis is
most often
most recommended
often recommendedonce
onceyou
youhave
havestaned to re·
started to re-
cover
cover from
from anan episode
episode of of bipolar
bipolar disorder.
disorder. Therapy
Therapy is is primarily
primarily a a maintenance
maintenance
treatment rather
treatment rather than
than anan acute
acute episode
episode treatment.
treatment. When
W h e n you
you are beginning to
arebeginning to
stabilize
stabihze on on your
your medication,
medication, you you may
m a y still
still have
have Significant
significant mood
m o o d symptoms,
symptoms,
disturbances
disturbances in in your
your thinking
thinking patterns,
patterns, and
and behavior
behavior patterns that can
patterns that inter·
can inter-
fere
fere with
with your
your long.term
long-term stability.
stability. Consider finding a
Consider finding psychotherapist who
a psychotherapist who
can work
can work with you cognitively
with you cognitively or or interpersonally.
interpersonally. These
Thesearearethe
the two
two types
typesof ofin·
in-
dividual
dividual therapy
therapy that have the
that have the most
most research
research support
support in terms of
in terms of improving
improving
the course of
the course of bipolar
bipolar disorder
disorder when
w h e n given
given alongSide medications (Miklowitz
alongside medications (Miklowitz
& Craighead, 2001;
& Craighead, Craighead &
2001; Craighead Miklowitz, 2000).
& MiklowilZ, 2000).
Cognitive·behavioral
Cognitive-behavioral therapy therapy (CBT),
(CBT), a a treatment
treatment designed
designed byby Aaron
Aaron Beck,
Beck,
MD,
M D , is
is perhaps
perhaps thethe most
most well·established
well-established psychotherapy
psychotherapy for for depreSSion
depression (Beck(Beck
et al, 1979;
et aI., DeRubeis et
1979; DeRubeis al, 1998).
et aI., There are
1998). There are few
few published
published studies
studies ofof CBT for
C B T for
bipolar
bipolar persons,
persons, butbut the few that
the few that do
do exist find that
exist find that people
people who
w h o do
do CBT
C B T while
while
on
on medication
medication havehave fewer
fewer relapses
relapses of of their
their disorder
disorder (Cochran,
(Cochran, 1984;
1984; Perry
Perry etet
al, 1999;
al., 1999; Lam
L a m e1 al, 2000).
et aI., 2000). If If your
your therapist
therapistspecializes
speciahzesin in CST,
C B T ,he
he or
orshe
shewill
wiU
 What
Whot (on
Con Medi{O�on
Medicationand PsychotherapyDoDoforfoMe?
andPsychotheropY' r Me? 125
125

encourage you
encourage you to to focus
focus on on patterns
patterns of negative
of negative thinking
thinking about
about yourself,
yourself, your your
world,
world, and
a n d your
y o u r future.
future. By
B y keeping
keeping a
a daily
daily thought
thought record
record (see
(see Chapter
Chapter 110),
0),
y o u can
you c a n learn
learn to
to identify
identify your
y o u r assumptions
assumptions about
about certain
certain critical
critical events,
events, par­
par-
ticularly
ticularlyany
a n y self-defeating
self-defeatingstatements-"hot
s t a t e m e n t s — " h o tcognitions"-that
cognitions"—thatspontaneously
spontaneously
arise in
arise in reaction
reaction to
to these
these events
events (for
(for example,
e x a m p l e , "I
"1 lost
lost my
m y job
job because
because I'm
I'm just
just
not capable
not capable of
of holding
holding one").
o n e " ) . Your
Y o u r CBT
C B T therapist
therapist will
w i H encourage you
encourage y o u to
to recog­
recog-
nize
nize the
the impact
i m p a c t of
of such
s u c h assumptions
assumptions on
o n your
y o u r mood
m o o d states
states and to conduct
a n d to c o n d u c t "ex­
"ex-
perimentsn
periments" in
in your
y o u r day-to-day
day-to-day life
life to
to detennine
determine if
if your
y o u r assumptions
assumptions are
are valid.
vahd.
As
A s therapy
therapy proceeds,
proceeds, he
h e or
or she
she will
will encourage
encourage you
y o u to
to consider
consider more
m o r e adaptive
adaptive
and
a n d balanced
balanced interpretations
interpretations of
of events
events and
a n d record
record these
these new
n e w cognitions
cognitions on
on
your
your thought
thought record
record (for
(for example,
e x a m p l e , "Maybe
" M a y b e 1I lost
lost this
this job because II was
job because w a s still re­
stHl re-
covering
covering from
f r o m my
m y depression
depression and
a n d couldn't
couldn't function
function at
at the
the level
level II know
k n o w I'm ca­
I'm ca-
pable
pable of,"
of," or
or "This
"This last
last job
job taught
taught me
m e that
that II need
n e e d to
to work
w o r k in
in an
a n environment
environment
that
that will
w i H allow
allow me
m e to
to stay
stay stable
stable and
a n d still
stiH use
use my
m y skills").
skills"). Chapter 1 0 offers
Chapter 10 offers a
a
more
m o r e thorough
t h o r o u g h discussion
discussion of
of the
the CBT
C B T approach
a p p r o a c h and
and a
a selection
selection of
of cognitive
cognitive
restructuring
restructuring exercises
exercises you
y o u can
c a n try
try out
out on
o n your
y o u r own.
own.
A
A second
second individual
individual approach
a p p r o a c h is
is interpersonal therapy. This
interpersonal therapy. This therapy is
therapy is
geared
geared toward
t o w a r d helping
helping you
y o u understand
understand the
the role
role that
that your
y o u r illness
illness is playing in
is playing in
your
your close
close relationships
relationships or
or work
w o r k life,
life, and
a n d in
in turn,
turn, how
h o w your
y o u r relationships
relationships or
or
work
w o r k life
life is
is affecting
affecting your
y o u r bipolar
bipolar disorder.
disorder. This
This therapy
therapy was
w a s shown to work
s h o w n to work
as
as well
well as
as cognitive-behavioral
cognitive-behavioral therapy
therapy in
in a
a large
large study
study of
of major
m a j o r depreSSive
depressive
disorder
disorder (Elkin
(Elkin et
et aI., 1 9 9 5 ; Weissman
a l , 1995; W e i s s m a n et
et aI., 2 0 0 0 ) . Interpersonal
al, 2000). Interpersonal therapists
therapists
encourage
encourage you
y o u to
to focus
focus on
on a
a particular
particular interpersonal
interpersonal problem in your
p r o b l e m in life and
y o u r life and
consider
consider how
h o w it
it relates
relates to
to your
y o u r mood
m o o d disorder.
disorder. For
F o r example,
e x a m p l e , some
s o m e people de­
people de-
velop
velop a
a manic
m a n i c or
or depreSSive
depressive episode
episode after
after a
a loss
loss or
or grief
grief experience
experience (e.g.,
(e.g., the
the
death
death of
of a
a parent)
parent);; some
s o m e after
after a
a life
life transition
transition such
s u c h as
as lOSing
losing a
a job
job or
or a
a divorce;
divorce;
some
s o m e after
after significant
significant disputes
disputes with
with family
family members
m e m b e r s or
or panners;
partners; and
a n d some af­
s o m e af-
ter
ter a
a series
series of
of ongOing
o n g o i n g problems
p r o b l e m s in
in maintaining
maintaining relationships
relationships with
with other
other peo­
peo-
ple.
ple. Interpersonal
Interpersonal therapy
therapy focuses
focuses on
o n your
y o u r habits
habits in
in close
close relationships
relationships and
and
how
h o w to
to alter
alter them
t h e m to
to help
help stabilize
stabilize your
y o u r mood.
mood.
A
A new
n e w fonn
f o r m of
of interpersonal
interpersonal therapy,
therapy, called
called interpersonal
interpersonal and
and social
social
rhythm therapy (IPSRT;
rhythm therapy (IPSRT; Frank
F r a n k et
et aI., 1 9 9 4 ; Frank
al, 1994; F r a n k et
et al., 2 0 0 0 ) , includes
al, 2000), a new
includes a new
element:
element: monitoring your
monitoring y o u r sleep-wake
sleep-wake rhythms,
r h y t h m s , patterns
patterns of
of daily
daily activity,
activity, and
and
levels
levels of
of daily
daily social
social stimulation
stimulation (for
(for example,
e x a m p l e , the
the amount
a m o u n t of
of high-
high- versus
versus
low-intensity
low-intensity contact
contact you
y o u have
h a v e with
with friends
friends or
or family
family members).
m e m b e r s ) . This
This method
method
is
is discussed
discussed further
further in
in Chapter 8 (in
Chapter 8 (in particular,
particular, see
see the
the self-rated
self-rated Social
Social
Rhythm
R h y t h m Metric).
Metric). Working
W o r k i n g with
with a
a therapist
therapist who
w h o specializes
specializes in
in this interper­
this interper-
sonal
sonal model
m o d e l may
m a y be
b e qUite
quite helpful
helpful to
to you
y o u in
in implementing
i m p l e m e n t i n g sleep-wake
sleep-wake and
and
other
other strategies
strategies for
for stabilizing
stabUizing social
social rhythms.
r h y t h m s . In
In one
o n e carefully
carefully designed
designed study,
study,
IPSRT
I P S R T was
w a s shown
s h o w n to
to decrease
decrease the
the amount
a m o u n t of
of time
time that
that people
people with
with bipolar dis-
bipolar dis-
126
126 CAUSES
CAUSESAND
ANDTREATMENTS
TREATMENTS

order
order spem
spentin
indepressive episodes
depressive episodesandand
to increase their their
to increase time in stable
time in mood
stable mood
states (Frank, 1999; Frank et al., 1999).
states (Frank, 1999; Frank et al, 1999).

FGmily
Family Gnd
andCouple
CoupleThe'GPY
Therapy

Sometimes bipolar
Sometimes bipolar disorder
disorderis is
best treated
best in a family
treated or couple
in a family context.context.
or couple The The
advantage
advantage of of therapy
therapy with
with youryour close
close relatives
relatives isis that
that they
they can
can bebe educated
educated
about your
about your disorder
disorder andand taught
taught coping
coping skills
skills for
for managing
managing stress
stress at
at the
the same
same
time
time as
as you.
you. People
People with
with bipolar
bipolar disorder often have
disorder often have significant
significant family
family oror rela­
rela-
tionship
tionship problems
problems (see Chapter 5).
(see Chapter Family treatments
5). Family treatments can can provide
provide ways
ways ofof im­
im-
proving
proving your
your communication
communication with with your
your spouse,
spouse, parents,
parents,or or kids
kids (see
(seethe
thecom­
com-
munication
munication strategies
strategies described
described in in Chapter
Chapter 12).12).
The
The family!couple
family/couple approach
approach that that II developed
developed with with Michael Goldstein,
Michael Goldstein,
PhD, called family-focused
PhD, called family-focused therapy
therapy (FFT),
(FFT), is is a
a nine�month-long
nine-month-long educational
educational
therapy.
therapy. In In FFT,
FFT, bipolar
bipolar persons
persons andand their
their spouses
spouses or or parents
parents are
are acquainted
acquainted
with the
with the facts
facts about
about the
the disorder:
disorder: itsits symptoms,
symptoms, causes,
causes, prognosis,
prognosis, and and treat­
treat-
ment. Later stages
ment. Later stages ofof FFT
F F T focus
focus on
on family
family oror couple
couple communication
communication and prob­
and prob-
lem-solving
lem-solving strategies,
strategies, including
including how h o w to
tolisten,
listen,negotiate,
negotiate,andand solve
solveconflicts
conflicts
(to
(to learn
learn more
more about
about this therapy, see
this therapy, see the book by
the book Miklowitz &
by Miklowitz & Goldstein,
Goldstein,
1997).
1997). In
In two
two different
different studies
studies wew e have
have found
found that
that people
people with
with bipolar disor­
bipolar disor-
der
der who
w h o get
get medication
medication and lake pan
and take in FFT
part in have better
F F T have better outcomes
outcomes of their
of their
disorder over
disorder over the
the one-
one- toto two-year
two-year period
period follOWing
following an an episode
episode thanthan those
those
who
w h o get
get medication
medication and and supportive
supportive individual
individual therapy
therapy or or case
case management
management
(Miklowitz
(Miklowitz et al, 2000;
et aL, 2000; Rea
Rea et al, 2001).
et al., 2001).
Cognitive, interpersonal,
Cognitive, interpersonal, and and family
family educational
educational treatments
treatments maym a y be
be hard
hard
to find
to in your
find in your community,
community, but but look
look for
for them
them anyway.
anyway. Check
Check outout lhe
the website
website
for
for the
the Systematic
Systematic Treatmem
Treatment Enhancement
Enhancement Program Program for Bipolar Disorder,
for Bipolar Disorder,
which includes referral
which includes referral information
information for for sites around the
sites around the coumry
country that offer
that offer
these
these specialty
specialty therapies
therapies in in the
the context
context of of aa National Institute of
National Institute of Mental
Mental
Health-sponsored
Health-sponsored program (www.stepbd.org).
program (www.stepbd.org).

Sell-Help
Self-HelpG,oups
Groups

Manypeople
Many peoplebenefit
benefit from
from support
support groups (Bauer62&McBride,
groups(Bauer 1996).InIn
McBride,1996).
groups, people
groups, people with
with bipolar
bipolar disorder
disorder get
get together
together and
and discuss
discuss their feelings,
their feelings,
attitudes, and
attitudes, and experiences
experiencesrelated
relatedto
tothe
thedisorder.
disorder.Many
M a n y people
peoplefeel
feelthat
thatolhers
others
with bipolar
with bipolar disorder
disorder are
are the only ones
the only ones who
w h o can
can truly
truly undersland them and
understand them and
give
give them
them viable
viable solutions.
solutions. People
People in
in bipolar
bipolar support
support groups
groups lalk about medi­
talk about medi-
cations
cations they've tried and
they've tried which have
and which have worked,
worked, which
which therapies
therapies they've
they've had,
had,
how
h o w they
they have
have dealt
dealt with problems in
with problems in the
the work, family, or
work, family, orsocial settings,and
socialsettings, and
what
what they
they do
do to
to prevem
prevent themselves
themselves from
from getting
getting ill again.
iH again.
 Whot
What Con
CanMedimtion
Medicationond
andPsychotheropy
PsychotherapyDoDoforfoMe?
r Me? 127
127

Ofmore
Of the the than
more than
2,000 2,000 respondents
respondents to the
to the National NationalandDepressive and
Depressive
Manic
M a n i c Depressive
Depressive Association
Association (NDMDA)
( N D M D A ) Support
Support Group
G r o u p Compliance
C o m p l i a n c e Survey
Survey
(1998;
(1998; Lewis,
Lewis, 2000)-all
2 0 0 0 ) — a H of
of whom
w h o m had
had been
been active
active in in local
local NDMDA
N D M D A groups-
groups—
95%
9 5 % said
said that
that their
their group
group experience
experience helped them become
helped them become more more willing
wilHng to to
take medication,
take medication, communicate
communicate with with their
their doctors,
doctors, and and cope
cope with their side
with their side ef­
ef-
fects.
fects. II used
used toto run
run a a support
support group
group forfor people
people with
with bipolar
bipolar disorder
disorder and and was
was
continually
continually impressed
impressed with with howh o w effective
effective the
the members
m e m b e r s were
were at at helping
helping eacheach
other.
other.
Sometimes
Sometimes thesethese groups
groups have have leaders
leaders who
w h o are
are mental
mental health profession­
health profession-
als,
als, and
and sometimes
sometimes theythey are are leaderless
leaderless andand contain
contain onlyonly people
people with with the dis­
the dis-
order
order ("mutual
("mutual support
support groups").
groups"). NotNot everyone
everyone feels
feels comfortable
comfortable in in a a group
group
sening,
setting, however.
however. If If you
you havehave doubts,
doubts, try try going
going for for one
one session
session and and see if
see if
you can relate to the other people in the group. Can
you can relate to the other people in the group. C a n you imagine feeling you imagine feeling
supported
supported and and understood
understood by by them
them when
w h e n talking
talking about
about youryour own o w n problems?
problems?
Do
D o they
they seem
seem toto have
have had had thethe kinds
kinds of of life
life difficulties
difficulties or or illness
illness manage­
manage-
ment
ment problems
problems you've
you've had?had? To T o see
see ifif there
there areare groups
groups available
available in in your
your
community,
community, try try calling
calling thethe local
local mental
mental health
health center
center in in your
your city city or town,
or town,
local
local psychiatrists
psychiatrists whow h o specialize
specialize in in mood
m o o d disorders,
disorders, or or the
the phone
phone numbersnumbers
listed
listed in in the
the next
next paragraph.
paragraph.

Family Support
Family SupportG,OUpS
Groups

Your spouse
Your spouse or
or parents
parents may
may also
also want
want to
toanend
attenda support group.
a support They
group. may
They may
benefit
benefit from
from a a group
group in in which
which theythey can
can commiserate
commiserate with with other
other relatives of
relatives of
persons
persons with
with bipolar
bipolar disorder.
disorder. GoodG o o d options
options for
for your
your relatives
relatives include the De-
include the De­
pression
pression andand Bipolar
Bipolar Support
Support Alliance
Alliance (800-826-3632;
(800-826-3632; www.ndmda.org),
www.ndmda.org), the the
National
National Alliance
Alliance forfor the Mentally III
the Mentally 111 (800-950-NAMI;
(800-950-NAMI;www .namLorg), or
www.nami.org), orthe
the
Child
Child and
and Adolescent
Adolescent Bipolar
Bipolar Foundation
Foundation (847-256-8525;
(847-256-8525; www.bpkids.org).
www.bpkids.org).
These
These organizations
organizations usually
usually proVide
provide informative
informative lectures,
lectures, group
group discussions,
discussions,
and
and educational
educational materials
materials for relatives.
for relatives.
Try
Try not
not to
to be
be anxious
anxious about
about your
your spouse's
spouse's oror your
your parent's
parent's desire
desire to join
to join
such
such a a group.
group. YouY o u may
m a y fear
fear that
that these
these groups
groups will
will be
be composed
composed of of angry rela­
angry rela-
tives
tives who
w h o will
will badmouth
badmouth you you and and encourage
encourage youryour relatives
relatives to
to give
give up
up and
and
leave.
leave. In
In my
m y experience,
experience, this this is
is not
not thethe case.
case. Rather,
Rather, these
these groups
groups provide
provide use­
use-
ful
ful information
information and and support
support and and help
help relatives
relatives feel
feel less
less isolated
isolated in
in their at­
their at-
tempts
tempts to to understand
understand and and cope
cope with
with bipolar
bipolar disorder.
disorder. IfIf you are uncomfort­
you are uncomfort-
able,
able, ask
ask your
your relative
relative to to take
take you
you with
with them.
them. InIn most
most cases,
cases, these
these groups are
groups are
open
open to to persons
persons withwith the the disorder
disorder as as well
well as
as their relatives. And,
their relatives. usually,
And, usually,
they're free.
they're free.

* * *
128
128 CAUSES
CAUSESANO
ANDIRfAlMENIS
TREATMENTS

As you
As you can can
see,see, thereare
there arenumerous
numeroustreatments
treatments for
for bipolar
bipolardisorder. None
disorder. None
of these
of these treatments
treatments is is perfect,
perfect,but butmany
m a n ycan
caneffectively
effectivelytreat youracute
treatyour acutesymp­
symp-
toms
toms and,
and, in in all
all likelihood,
likelihood, eveneven outout thethe course
course ofof your
your illness
illness over time.
over time.
Adding psychotherapy
Adding psychotherapy or or support
support groups
groups to to your
your medication
medication regimen
regimen helpshelps
ensure
ensure that
that your "person" is
your "person" is treated
treated as well as
as well as your
your disorder,
disorder, and
and that
thatyouyou de­
de-
velop strategies
velop strategies for
for coping
coping withwith stress triggers.
stress triggers.
Y o u and
You and your
your doctor
doctor maym a y need
need toto experiment
experiment with with aa number
number of of different
different
medication
medication and and therapy
therapy options
options before
before youyou find
find aa combination
combination thatthat isis effective
effective
and also
and also minimizes
minimizes your
your side
side effects.
effects. This
Thistrial
trialand errorprocess
and error processmay m a y be
befrus­
frus-
trating at
trating at times. There is
times. There is every
every reason
reason to to be
be hopeful
hopeful that,
that, with
with time,
time,you you will
wiU
find
find aa regimen
regimen thatthat is
is optimal
optimal for for you.
you. Of Of course,
course, committing
committing to to aa long-term
long-term
program
program of of medication
medication is is an
an important
important personal
personal decision.
decision. You
Y o u may
m a y have sig­
have sig-
nificant
nificant doubts
doubts about
about whether
whether you you should
should take any of
take any of these
these medications.
medications, even even
if
if you
you areare suffering
suffering from
from mood
m o o d swings
swings thatthat interfere
interfere with
with your
your functioning.
functioning.
These
These reactions
reactions areare understandable.
understandable. But But w when
h e n people with bipolar
people with bipolar disorder
disorder
stop taking medication,
stop taking medication, particularly
particularly if if they
they dodo so
so abruptly,
abruptly, they
they often
often endend up
up
relapsing and
relapsing and worse
worse offoff than
than they
they were
were before
before they
they stopped.
stopped. To T o hear
hear more
more
about
about how
h o w patients have resolved
patients have this dilemma,
resolved this dilemma, readread on: Chapter 7
on: Chapter 7 is
is devoted
devoted
to
to the
the issues
issues involved
involved inin coming
coming to to accept
accept a a long-term
long-term program
program of of medication.
medication.
 7
7

Coming
C o m i n g tot o Terms
T e r m s

with
w i t h Your
Y o u r Medication
Medication

"Accusing
"Accusing me m e of
of mania,
mania, my m y elder
elder sister's
sister's voice
voice has
has an
an odd
odd manic quality.
manic quality.
'Are
'Are you
you taking
taking your
your medicine?'
medicine?' A A low
low controlled
controlled mania,
mania, the
the kind
kind of coo­
of con-
trol
trol in
in furious
furious questions
questions addressed
addressed toto children,
children, such
such as
as 'Will you get
'Will you get
down
d o w n from
from there?'
there?' ... .. .
MAs
"As if
if by
by going
going off
offlithium
lithium IIcould
could erase
erase the
the past,
past,could
could prove
prove itithad
had
never happened,
never happened, could
could triumph
triumph over
over and
and contradict
contradict my m y diagnoses;
diagnoses; thisthis
way
w a y II would
would bebe right
right and
and they
they would
would be wrong. It
be wrong. It had
had always
always been
been the the
other
other way;
way; they
they were
were right
right and
and II was
was wrong.
wrong. Of O f course
courseIIhadhad only
only to
to take
take
the
the lithium
lithium inin order
order to
to be
be accepted
accepted back
back ....
. . on
on lithium
lithium II would
would he be 'all
all
right'
right'. ... .But I amI never
. But all right,
a m never just just
all right, in remission.
in remission.If I could win win
If I could this this
gamble
gamble.. ...."
.

—Millet (1990,
-Millet (1990, p.p. 32)
32)

The
The nature
nature of ofbipolar disorder
bipolar is such
disorder that even
is such that when
even you
whenfeel
youbetter, you still you still
feel better,
have
have anan underlying
underlying biological
biological predisposition
predisposition to to the
the illness.
illness.This
Thispredisposition
predisposition
requires
requires youyou toto take
take medication
medication eveneven when
w h e n you're
you're feeling
feeling well.
well. Often,
Often, though,
though,
when
w h e n you
you feel
feel beuer,
better, you
you will
will be
be tempted
tempted toto stop
stop your
your medication,
medication, because
because
you
you won't
won't see
see the
the need
need for
for it.
it. That's
That's anan understandable
understandable reaction.
reaction. Unfortu­
Unfortu-
nately,
nately, stopping
stopping your
your medications
medications against
against medical
medical advice-and
advice—and sometimes
sometimes
even just
even just laking
taking inadequate
inadequate dosages
dosages or
or missing
missing dosages
dosages regularly-pulS
regularly—puts you at
you at
aa much
m u c h higher
higher risk
risk of
of having
having aa recurrence
recurrence ofof your
your bipolar
bipolar disorder.
disorder.

129
129
130
130 CAUSES
CAUSESAND
ANDTREATMENTS
TREATMENTS

In experience,
In my my experience, people
people arearemost
mostlikely
likely to
to consider
considerstopping their
stopping medi­
their medi-
cations
cations onceonce they
they have
have recovered
recovered from from a manic or
a manic depressive episode.
or depressive episode. During
During
this
this phase
phase they they m may
a y feel
feel good
good or or even
even hypomanic,
hypomanic, but but are
are more
more in in control
control of of
theiT
their moods
m o o d s than
than during
during the height of
the height of theiT
their illness.
illness. Taking
Taking medication
medication feels feels
like
like spoiling
spoiling a a good
good party.
party. These
These reactions
reactions are are especially
especially truetrue ofof younger
younger peo- peo­
ple who
ple w h o have
have hadhad only
only a a few
few episodes.
episodes. Inconsistency
Inconsistency with with medication
medication some- some­
times
times stems
stems from
from feelings
feelings of of "youthful
"youthful invulnerability"
invulnerability" or or just plain denial
just plain denial of of
the
the disorder.
disorder. But But II have also worked
have also worked with with middle-aged
middle-aged and and older
older adults
adults who who
have
have hadhad many,
many, m many
a n y bipolar
bipolar episodes
episodes and and still
still doubt
doubt that
thatthey
theyneed
need medica­
medica-
tion,
tion, even
even if they do
if they do acknowledge
acknowledge having having thethe disorder.
disorder. Understandably,
Understandably, they they
want
want to to know what life
k n o w what life would
would be like without
be like without the pills.
the pills.
In
In the
the last
last chapter,
chapter, II talked
talked about
about the the various
various drugdrug treatments
treatments available
available to to
people
people withwith bipolar
bipolar disorder.
disorder. In In this chapter, II talk
this chapter, talk about
about the the various
various reasons
reasons
that
that people
people withwith bipolar
bipolar disorder
disorder give give for
for discontinuing
discontinuing their their drug regimens.
drug regimens.
Many
M a n y ofof these reasons have
these reasons have been
been offered
offered by by mym y own
o w n clients,
clients, including
including those those
who
w h o have
have been
been stable
stable for
for quite
quite some
some time but question
time but question whether
whether the the medica-
medica­
tion is
tion is really
really working.
working. Sometimes
Sometimes the the issues
issues surrounding
surrounding inconsistency
inconsistency or or
"nonconcordance"
"nonconcordance" are are related
related to to feelings
feelings or or beliefs
beliefs about
about the the disorder,
disorder, such suchas as
disagreeing
disagreeing with with the
the diagnosis
diagnosis or or missing
missing the the pleasure
pleasure of the high
of the high periods.
periods. in­ In-
conSistency
consistency can can also
also bebe aa response
response to to unpleasant
unpleasant side side effects
effects (for
(for example,
example,
weight gain
weight gain on on divalproex),
divalproex), difficulty
difficultyrelating
relatingto toaaparticular
particularphYSician,
physician,or ordis­
dis-
like
like ofof having
having one's
one's blood
blood drawn.
drawn. Sometimes
Sometimes people people just
just forget
forget to to take their
take their
medicine. People also go off medication because of practical matters like pre-
medicine. People also go off medication because of practical matters like pre·
scriptions
scriptions that that lapse
lapse (and
(and difficulties
difficulties getting
getting a annew
e w appointment)
appointment) and and thethe high
high
costs
costs of of paying
paying for for medication
medication (for (for example,
example. Keck Keck et et aI.,
al, 1997;
1997; Lewis,
Lewis, 2000).
2000).
In
In this
this chapter,
chapter, II suggest
suggest some
some tips tips for
for making
making medication
medication feel feel more
more ac- ac­
ceptable to you, as well as ideas for discussing side effects with your
ceptable to you, as well as ideas for discussing side effects with your physi­
physi-
cian.
cian. Y You
o u may
m a y recognize
recognize youryour own o w n experiences
experiences in in the
the illustrations
illustrations of of issues
issues
that people commonly struggle with when ttying to accept a long-term pro-
that people commonly struggle with w h e n trying to accept a long-term pro­
gram
gram of of medication.
medication.

W h a t Is
What Medication Concordance?
Is Medication Concordance?

"Concordance'· with
"Concordance" with medication
medication isis
"a "a
congruence between
congruence thethe
between planplan
mademade
withwith
the
the physician
physician and
and the
the plan
plan carried
carried outout by the patiem"
by the patient" (Sachs,
(Sachs, 2000).
2000).
"Nonconcordance"
"Nonconcordance" meansmeans that
that you
you have
have nOInot followed
foHowed the
the physician's
physician's recom­
recom-
mendations
mendations inin taking
taking your
your medication
medication or or have
have stopped
stopped altogether, againsthis
altogether, against his
or
or her
her advice. But people
advice. But can become
people can become nonconcordant
nonconcordant in in any
any number
number ofof ways.
ways.
For example,
For example, some
some people
people take
take their
their medications
medications correctly
correctly for
for several
several weeks
weeks
and
and then
then stop
stop all
aH of them abruptly.
of them abruptly. Some
S o m e stop
stop only
only one
one medication
medication inin a
a "cock-
"cock-
 (oming toTerm�
Coming10 Termswith Your
with Medicotion
Your Medication III
131

tail"
taU" of of medications:
medications: they theyare areon onHthium,
lithium, Depakote,
Depakote, and and Zyprexa,
Zyprexa, and decide
and decide
to
to discominue
discontinue everything
everything but b u t the
the Depakote
D e p a k o t e (and
(and sometimes
s o m e t i m e s even
even taketake a a
higher
higher dosage
dosage of of this
this medication
medication than than prescribed).
prescribed). Other O t h e r people
people drop drop their
their
dosages
dosages or or take
take medications
medications intermittemly
intermittently (for (for example,
e x a m p l e , take
take onlyonly half
half ofof
their
their recommended
r e c o m m e n d e d Tegretol
Tegretol tablets,
tablets, missmiss their
theirevening
evening dosages,
dosages,skip skipSaturday
Saturday
nights).
nights). For F o r others,
others, nonconcordance
n o n c o n c o r d a n c e takes
takes the the form
f o r m of
of substituting
substituting unprovenunproven
remedies
remedies (for (for example,
e x a m p l e , medicinal
medicinal herbs herbs likelike Sl.
St. John's
John's won w o r t or
orkava
kava kava)
kava) forfor
mood
m o o d stabilizers,
stabilizers, or or trying
trying to to use
use alcohol
alcohol or or marijuana
marijuana to to control
control their their mood
mood
states.
states.
Why
W h y thethe term concordance! Many
term concordance? M a n y alternative
alternative terms terms have have beenb e e n proposed
proposed in in
the
the medical
medical literature,
literature, the the most
m o s t common
c o m m o n of of which
w h i c h are adherence and
are adherence a n d compli­
compli-
ance. In
ance. In my
m y experience,
experience, persons persons with with bipolar
bipolar disorder
disorder don't don't usually
usually like H k e either
either
of
of those
those terms. Nonadherence either
terms. Nonadherence either feels
feels critical
critical or or judgmental
judgmental or or isis associated
associated
in
in the
the mind
m i n d with
with tapetape or or glue.
glue. It It implies
implies that that the
the person
person with with the the disorder
disorder is is
unwilling
unwilling or or unable
unable to to stick
stick to to ana n agreed-upon
agreed-upon program. program. Even E v e n worse i the
s
w o r s e is the
term noncompliance, which
term noncompliance, w h i c h implies
implies a a paternalistic
paternalistic stance: stance: The T h e client with bi-
client with bi­
polar
polar disorder
disorder is is not
not going
going along with what
along with w h a t others
others insist
insist thatthat heh e or
or she
she must
m u s t do.
do.
II prefer
prefer thethe term concordance because
term concordance because it itunderlines
underlines the theimportance
importance of of the
the
alliance
alliance between
b e t w e e n the
the physician
physician and a n d the
the person
person with with bipolar
bipolar disorder.
disorder. Stopping
Stopping
medications
medications or or taking
taking them t h e m inconsistently
inconsistently can can often
often be b e attributed,
attributed, in in pan,
part, to to
the
the phYSiCian,
physician, who w h o maym a y not
not have
h a v e articulated
articulated the purposes of
the purposes of the various medi­
the various medi-
cations
cations in in the
the regimen,
regimen, may m a y not
n o t have
have alerted
alerted you y o u to
to the
the possible
possible side effects,
side effects,
or
or may
m a y not
n o t have
h a v e been
b e e n understanding,
understanding, respectful,respectful, or or communicated
communicated a a sense
sense of of
caring
caring for for your
y o u r individuality.
individuality.

How
H o w (ommon
C o m m o n Is
Is Nonconcordance?
Nonconcordance?

Frequently, people
Frequently, peoplewith
withbipolar
bipolardisorder discontinue
disorder their
discontinue medication.
their Esti­ Esti-
medication.
mates vary,
mates but the
vary, but the consensus
consensus seems
seems to be that
to be that more
more than half of
than half of those
those with
with
bipolar disorder
bipolar disorder quit taking their
quit taking their medications
medications at
at some point in
some point in their
their lives
lives
(Colom
(Colom et et aI., 2000). A
al, 2000). A study
study by
by Stephen Strakowski and
Stephen Strakowski and colleagues
colleagues atat the
the
University
University of of Cincinnati
Cincinnati College
College of Medicine (1998)
of Medicine (1998) found
found that 59%
that 5 of pa-
9 % of pa­
tients
tients with
with mmood
o o d disorder were "partially
disorder were "partially nonadherent"
nonadherent" (took
Ctook medications
medications in-in­
consistently) or
consistently) or "fully nonadherent" (quit
"fully nonadherent" (quit taking
taking them altogether) during
them altogether) during the
the
year
year after their first
after their first hospitalized
hospitalized episode.
episode. Y You are more
o u are more likely
likely to
to become
become
nonconcordaot if
nonconcordant if you
you are
are male,
male, younger
younger rather
rather than
than older,
older, severely
severely iill with
ll with
mood disorder, recently
m o o d disorder, recently hospitalized,
hospitalized,prone
pronetotoalcohol
alcoholor
orsubstance
substanceabuse
abusedis­
dis-
orders, and
orders, and lack
lack a supportive family
a supportive family structure,
structure, a a spouse, or friends
spouse, or friends to
to rely
rely onon
(Colom et
(Colom et aI., 2000; G
al, 2000; Goodwin
oodwin & &. Jamison,
Jamison, 1990).
1990).
Not all
Not all medications
medications lead lead to the same
to the same rate of nonconcordance.
rate of nonconcordance. For For exam-
exam-
132
132 CAUSES ANDTREAIMENIS
CAUSESAND TREATMENTS

pie, Weissand
RogerWeiss
pie,Roger andcolleagues
colleagues (1998) found
(1998) foundthat only
that 21%21%
only of people
of peoplewithwith
bipolar disorder who were taking lithium were consistent with it all
bipolar disorder w h o were taking lithium were consistent with it all the lime. the time.
rate was
The rate
The a m o n g people
5 0 % among
was 50% Depakote, possibly
taking Depakote,
people taking possibly because side ef­
its side
because its ef-
fects easier to
are easier
fects are tolerate.
to tolerate.
People with
People disorder are
bipolar disorder
with bipolar not the
are not only ones
the only have trouble
w h o have
ones who trouble ac­
ac-
cepting aa long-term
cepting program of
long-term program medication. Those
of medication. with diabetes,
Those with heart dis­
diabetes, hean dis-
ease,hypertenSion,
ease, glaucoma,or
hypertension,glaucoma, orany chronic medical
otherchronic
anyother conditionthat
medicalcondition thatre­
re-
quires
quires ongOing medication are
ongoing medication against the
up against
are up same challenge
the same are. People
you are.
challenge you People
are even inconsistent
are even taking antibiotics
with taking
inconsistent with and birth
antibiotics and control pills!
birth control You'renOl
pills! You're not
alone in
alone type of
this type
in this of struggle.
struggle.

What Are the

W h a t Are of Nonconcordance?
Consequences of
the (onsequences Nonconcordance?

People with
People bipolardisorder
with bipolar disorder often
areare often to medication
to take
told told take medication being being
withoutwithout
given compelling
given doing so
for doing
reasons for
compelling reasons or a
so or understanding of
full understanding
a full what might
of what might
happen
happen if they don't.
if they The main
don't. The that sLopping
reason that
main t'eason stopping your medication is
youI' medication is inad­
inad-
visable is that
visable is it is
that it with a
associated with
is associated a high of t'ecurrence
risk of
high risk (for example,
recurrence (for example,
Strober el
Strober et aI., 1990; Keck
al, 1990; et al.,
Keck et al, 1998). It also
1998). It increases the
greatly increases
also gt'eatly ofsui­
riskof
therisk sui-
cide. fact, not
In fact,
cide. In medications,as
takingmedications,
nottaking thegreatest
prescribed,isisthe
aspreSCribed, singlefactot'
greatestSingle factor
contributing to
contributing when and
to when often bipolat'
how often
and how bipolar people have t'ecurrences
people have recurrences (Colom et
(Colom et
al., 2000). As
al, 2000). stated by
As stated by Jamison
Jamison (1995), owed my
"That lI owed
(1995), "That m y life pills was
to pills
life lO not,
was not,
however, obvious lO
however, obvious for a
m e for
to me a long time; my
long time; lack of
m y lack judgement about
of judgement about the ne­
the ne-
cessity to
cessity to take proved to
lithium proved
take lithium be an
to be an exceedingly
exceedingly costly one" (p.
costly one" (p. 89).
89).
When medications are
W h e n medications discontinued very
are discontinued (which is
abruptly (which
very abruptly is usually
usually thethe
case),
case), the chances of
the chances relapsing—or of
of relapsing--or suicide—are higher
committing suicide-are
of committing than
higher than
w h e n medications
when medications are discontinued slowly
are discontinued slowly (for example, Suppes
(for example, Suppes et et aI., 1993;
al, 1993;
Tondo &:
Tondo Baldessarini, 2000).
& Baldessarini, 2000). It take a
will take
It will before your
while before
a while your medication
medication
reaches
reaches a a stable blood level
stable blood if you
level if suddenly and
stop suddenly
you stop restart. If
then restart.
and then you take
If you take
medication inconSistently. you
medication inconsistently, you can also end
can also end upup with inadequate blood
with inadequate levels
blood levels
that lead to
that lead same negative
the same
to the results.
negative results.
a n y people
Many
M people wantwant to lO go
go on holidays," thinking
"drug holidays,"
on "drug thinking that if they
that if get
they get
worse, they
worse, they can always go
can always back on
go back the drug
on the drug and return to
and return normal-just like
to normal—just Hke
that. Because
that. Because the consequences of
theconsequences ofdiscontinuing medication is
discontinuing medication always im­
not always
isnot im-
mediate (that
mediate (that is, can feel
you can
is, you temporarily,after
better,temporarily,
feelbetter, stopping your
afterstopping your medica­
medica-
tion), you
tion), you maym a y feel thatyou
feel that you are "in the
are "in and can
clear"and
the clear" can go go on your life
livingyOUT
on living Hfe
without medication.
without Unfortunately, your
medication. Unfortunately, your good feelings can
good feelings can be due to
be due the
to the
hypomania that
hypomania often develops
that often shortly after
develops shortly medication is
after medication withdrawn. This
is withdrawn. This
hypomania is
hypomania often the
is often stage in
first stage
the first in the evolution of
the evolution manic episode.
serious manic
ofaa serious episode.
If you
If you go go off such as
drug such
off aa drug as lithium then have
and then
lithium and relapse of
have aa relapse your illness,
of yOUT illness,
there is
there is aa very real possibihty
very real you won't
that you
possibility that respond as
won't respond as wwell
eH w when you resume
h e n you resume
 Coming
Coming to
toTerms
Termswith
withYour Medicotion
Your Medication 133
133

taking it (Post,
taking it (Post, 1993).
1993). In
In fact,
fact,starting
startingand
and stopping
stopping medication canlead
medication can leadtotoa a
pattern
pattern of
of continuous
continuous cycling
cycling in
in which
w h i c h illness
illness episodes
episodes beget
beget other
other illness
illness epi­
epi-
sodes,
sodes, and
a n d the periods of
the periods of feeling
feeling well
w e H between
b e t w e e n periods
periods of
of illness
illness get
get shorter
shorter
and
a n d shorter
shorter (the
(the "kindling
"kindling effect";
effect"; Post,
Post, 1992).
1992). On O n the
the positive
positive side,
side, getting
getting
medical
medical treatment
treatment early
early in
in the
the course
course of of your
y o u r disorder
disorder (that
(that is,
is, when
w h e n it is first
it is first
diagnosed),
diagnosed), anda n d staying
staying with
with itit can
c a n prevent
prevent thesethese patterns
patterns of
of continuous
continuous cy- cy­
cling.
cling.

Why
W h y Do
D o People
P e o p l e Stop
Stop Taking
Taking Their
Their Medicotion­
Medication—
and
and Why
W h y Should
Should You You Resist
Resist Doing
Doing So?
So?

Clarence,
Clarence, a 19-year-old
a 19-year-old man,
man, hadhadhis hisfirst
first manic
manic episode
episode while
while aastudent
student
at
at a
a West
W e s t Coast
Coast statestate university.
university. He H e became
became belligerent,
belligerent, inappropriately
inappropriately
sexual,
sexual, giddy,
giddy, and and grandiose,
grandiose, claiming
claiming that that his
his artwork
artwork and and writing
writing
were
were soon
soon to to make
m a k e him
h i m millions.
millions. His His thoughts
thoughts raced
raced andand he he became
became
hyperverbal.
hyperverbal He H e was
was given
given lithium
lithium and and anan antipsychotic
antipsychotic medication
medication while while
an
an inpatient
inpatient at at the
the university's
university's hospital.
hospital. He H e showed
showed a a partial
partial response
response but but
was
was still
stillhypomanic
hypomanic when w h e n he
hereturned
returnedto tohis
hisparents'
parents'house
houseafter
afterdropping
dropping
out
out ofof school.
school. He H e abruptly
abruptly stopped
stopped his his medications without telling
medications without his
telling his
parents.
parents. He H e sank
sank into
into a a deep
deep depression,
depression, markedmarked by by insomnia, lethargy,
insomnia, lethargy,
slowed
slowed thinking,
thinking, suicidality,
suicidality, and and thoughts
thoughts such such as "I suck
as "I suck ..... . II don't de­
don't de-
serve
serve to
to live
live ... .. I've done
. I've donenothing
nothing forfor
anyone
anyone in this universe."
in this universe." HeHeventu­
e eventu-
ally
ally agreed
agreed to to see
see a a therapist,
therapist, rather
ratherthanthanaapsychiatrist,
psychiatrist,underunderthe theproviso
proviso
that
that ""whoever
whoever he he is
is needs
needs to to know
k n o w that
that I'm
I'm philosophically
philosophically and spiritually
and spiritually
opposed
opposed to to medications
medications of of any sort."
any sort."
Clarence
Clarence did did not
not rule
rule out
out the
the pOSSibility
possibility thatthat he
he had
had bipolar disorder.
bipolar disorder.
He
H e made
m a d e it
it clear,
clear, however,
however,that thatthe
thetherapist
therapistshould
shouldaddress
addressClarence's
Clarence'sin­ in-
dividual struggles with identity, sexuality, moral values, and family rela­
dividual struggles with identity, sexuality, moral values, and family rela-
tionships,
tionships, rather
rather thanthan treating
treating himhim as as a a umanic--depressive
"manic-depressive case." case." The
The
therapist
therapist spent
spent a a number
n u m b e r of
of sessions
sessions developing
developing an an alliance with Clarence
alliance with Clarence
and
and helping
helping him him understand
understand the the onset
onset of of the
the depreSSion
depression from
from two two stand­
stand-
points:
points: its
its psychosocial
psychosocial triggers
triggers (events
(events in in college,
college,suchsuchas asrejection
rejectionby by his
his
girlfriend)
girlfriend) and and its biological and
its biological and genetiC
genetic bases,
bases, including
including a history of
a history sui­
of sui-
cide
cide and
and bipolar
bipolar disorder
disorder in in his
his maternal
maternal grandfather.
grandfather. The The therapist
therapist did did
not
not challenge
challenge the idea that
the idea that Clarence's
Clarence's depreSSion
depression was was ""existential
existential and and
spiritualn
spiritual" butbut gradually
gradually introduced
introduced the the notion
notion thatthat it
it might
might have
have a a chemi­
chemi-
cal
cal basis
basis as as well.
well. HisHis father
father and
and stepmother
stepmother were were brought
brought in in for
for conjoint
conjoint
educational sessions where the treatment options were discussed and
educational sessions where the treatment options were discussed and
Clarence
Clarence explained
explained his his position.
position. OverOver the the next
next two
two months,
months, Clarence's
Clarence's
m o o d improved
mood improved somewhat,
somewhat, but but hehe remained
remained moderately depressed and
moderately depressed and
complained
complained of of insomnia.
insomnia.
After
After he he and
and Clarence
Clarence had had developed
developed a a solid
solid alliance,
alliance, the
thetherapist
therapistre- re-
134
134 CAUSES
CAUSESAND
ANDTREAIMENIS
TREATMENTS

introduced
introduced the the
ideaideaof of tryinglithium.
trying lithium. Clarence
Clarence agreed
agreed toto retry
retryit it
forfor
an an
agreed-upon interval
agreed-upon interval (three
(three months).
months). The The therapist
therapist referred
referred Clarence
Clarence to a
to a
psychiatrist,
psychiatrist,whow h o took
took time
timetotodevelop
developaarapport
rapportwithwithhim
him and
andlisten
listento
tohis
his
story.
story. The
Thepsychiatrist
psychiatristrecommended
recommended he he try
trylithium
lithiumat at1,200
1,200 mg.
m g .Clarence
Clarence
responded quickly:
responded quickly: HisHis depression
depression lifted,
lifted, his suicidal thoughts
his suicidal disap­
thoughts disap-
peared,
peared, and
and his
his sleep
sleep improved.
improved.
After
After six
six months
months of of twice
twice weekly
weekly individual
individual plus
plus family
family therapy,
therapy, and
and
regular maintenance
regular maintenance lithium
lithium treatment,
treatment, he he decided
decided to to return
return lO college.
to college.
He
H e remained
remained on on medication
medication onceonce back
back in in college,
college,where
wherehishistreatment
treatmentwaswas
managed
managed by by aa psychiatrist
psychiatrist at the student
at the student health
health service.
service. Contact
Contact with the
with the
therapist
therapist several years later
several years later revealed
revealed that his mood
that his m o o d disorder
disorder was
was stable,
stable,hehe
remained
remained in in school,
school, andand he
he was
was still
still taking
taking lithium.
lithium.

Accepting
Accepting a program
a program of of medication
medication tototreat
treat bipolar
bipolardisorder is ais
disorder long-term
a long-term
commitment
commitment and and thus
thus a
a very
very important
important personal
personal decision.
decision. Naturally
Naturally you
you will
wiU
have
have questions.
questions. IfIf you
you have
havejust
justbeen
been diagnosed
diagnosed with
with bipolar
bipolar disorder
disorder or
orare
areat
at
an
an early
early point
point in its course,
in its course, questions
questions about
about committing
committing to to a
a medication regi­
medication regi-
men
m e n may
m a y be
be particularly
particularly salient
salient for
for you,
you, as they were
as they were for
for Clarence. But you
Clarence. But you
may have strong
m a y have strong feelings
feelings about
about medication,
medication, even
even if if you have been
you have taking
been taking
mood
m o o d stabilizers
stabilizers for
for a
a long
long time.
time. In section, 1I discuss
this section,
In this discuss some
some of the reasons
of the reasons
people stop taking
people stop their medications,
taking their medications, andand some
some counterargumems
counterarguments to con­
to con-
sider,
sider, if
if you
you find
find yourself
yourself agreeing
agreeing with
with these
these reasons.
reasons.

UI
"I Miss
MissMy
My High
HighPeriods"
Periods"

"Doesa afish
"Does fish know whenit's
know when it's wet?
wet?Hypomania
Hypomania felt
feltgood
goodtoto
me. I felt
me. like Ilike I
I felt
was
was finally
finally getling
getting there
there inin my
m y life.
life. ItItdidn't
didn'tfeel
feelatatall
alllike
likethere
therewas wasany­
any-
thing
thing wrong
wrong toto me,
m e , it
it felt
feltgreat,
great,and andI'dI'dbeen
beenfeeling
feelingbadbadforforsosolong.
long.SoSoI I
went
went off
offmy
m y medication,
medication,and andthen
thenI Istarted
startedgetting
gettinghigher
higherand andhigher.
higher. Peo­
Peo-
ple
ple told
told me
m e to
to go
go back
back on,on, but
but itit felt patronizing.I Iresented
feltpatronizing. resentedtheirtheirlack
lackofof
recognition that
recognition that II was
was accomplishing
accomplishing things. things. II told
told them,
them, 'You
'You don't
don't un­
un-
derstand,
derstand, you've
you've got
got me
m e inin aa box,
box, you're
you're sticking
sticking mem e in
in one
one ofof your cate­
your cate-
gOries." But
gories.' But then
thenIIcycled
cycledintointoaa depression
depressionand and got
gotsuicidal.
suicidal.IIwentwent back
back
to
to my
m y doc
doc and-wouldn't
and—wouldn't you you know it?-back on
k n o w it?—back on lithium."
Hthium."
-A 38-year-old man with bipolar
— A 38-year-old m a n with bipolar II disorder,
disorder,
reviewing
reviewing hishis most
most recent
recent mood cycle
mood cycle

Kay Kay Jamison

Jamison makes
makes clear,
clear, from
from her
her researchas
research as well
well as
asher
herpersonal expe­
personal expe-
riences
riences with
with bipolar
bipolar disorder,
disorder, that
that many
m a n y people
people enjoy
enjoy their
their high periods
high periods
Qamison, 1995;
Oamison, 1995; Jamison
Jamison el al, 1979).
etal., 1979). The
The highs,
highs,especially
especially if
ifthey
theyare
areaccom­
accom-
panied
panied by
by euphoria
euphoria and
and grandiosity,
grandiosity, feel
feel quite
quite good.
good. WWhen
h e n in
in this state you
this state you
 Coming toTerms
Coming 10 Termswith Your
with Medicotion
Your Medication 135135

feel
feel productive,
productive, driven, driven,onontoptOp of of things,
things, cheerful,
cheerful, andand invulnerable.
invulnerable. Who Who
wouldn't
wouldn't enjoy enjoy this this state,
state, anda n d why
w h y spoil
spoil it it with
with medication?
medication?
One
O n e ofof my
m y c1iems
clients compared
c o m p a r e d mania
m a n i a toto being
being in in love.
love. When people fall
W h e n people fall in
in
love,
love, it it can
c a n resemble
resemble mania: mania: You Y o u feel
feel giddy,
giddy, happy,
h a p p y , and
a n d driven,
driven, and a n d you
y o u sleep
sleep
less; you feel more confident, attractive, and sexual; you
less; y o u feel m o r e confident, attractive, a n d sexual; y o u w a n t to talk to m o r e want to talk to more
people
people and a n d do
d o more
m o r e things.
things. My M y client
client said,
said, "If"If you
y o u were
w e r e in
in love,
love, and
a n d someone
someone
c a m e along
came along with
with a a tablet
tablet that
that would
w o u l d cure
cure you y o u of
of the
the feeling,
feeling, where
where w would
o u l d you
you
teU
tell that
that person
person to to go?"
go?"
Not
N o t everyone
everyone experiences
experiences mania m a n i a asas a a happy
h a p p y state.
state. It It can
can also
also be be a a wired,
wired,
pressured,
pressured, irritable
irritable state.
state. ButB u t even
even whenw h e n people
people experience
experience mania m a n i a negatively,
negatively,
they
they resem
resent thethe idea
idea that
that their
their moods
m o o d s areare under
u n d e r the
the control
control of of aa substance.
substance. As As
I've
I've said
said inin earlier
earlier chapters,
chapters, no n o one
o n e likes
likes thethe feeling
feeling of of being
being under the control
u n d e r the control
of
of another
another person
person or or thing,
thing, anda n d inin my
m y experience
experience people people with with bipolar
bipolar disorder
disorder
are
are particularly
particularly sensitive
sensitive to to this
this issue.
issue. TheyT h e y often
often havehave a a 10veJhate
love/hate relationship
relationship
with
with their
their m moods:
o o d s : They
T h e y hate
hate thethe fact
fact that
that their
their moods fluctuate so
m o o d s fluctuate so wildly,
wildly, and and
particularly
particularly resent resent the the lows,
lows, but but mood
m o o d variations
variations are are also central to
also central to who
w h o they
they
are
are and
a n d how
h o w they
they experience
experience life. life.
There
There is is no
n o mincing
m i n c i n g words
w o r d s about
about it: it: Medication
Medication does does taketake away the high
a w a y the high
periods.
periods. When W h e n people
people take take lithium,
lithium, Depakote,
Depakote, or or TegretOl,
Tegretol, theirtheir moods
m o o d s are
are
more
m o r e stable.
stable. SomeS o m e people
people complain
complain that that they
they are are tootoo stable.
stable. Stability
Stability putsputs youyou
in
in the
the driver's
driver's seatseat anda n d gives
gives you y o u more
m o r e control
control over over your
y o u r fate
fate than
than the the illusion
illusion
of
of control
control thatthat mania
m a n i a gives
gives you.
y o u . But
But stability
stability also also means
m e a n s giving
giving u upp the
the intensity
intensity
of the roller-coaster ride that bipolar disorder provides. In other words,, taking
of the roller-coaster ride that bipolar disorder provides. In other w o r d s taking
medication can
medication can meanm e a n increased
increased stability
stability at at the
the cost
cost of of the
the exciting,
exciting, positive
positive
features
features of of the
the disorder.
disorder.
Nonetheless,
Nonetheless, the the excitemem
excitement and a n d drama
d r a m a ofof the
the high
high periods
periods oftenoften bring
bring
debilitating
debilitating depressions
depressions in in their
their wake.
w a k e . The
T h e 38-year�0Id
38-year-old man m a n just quoted expe�
just quoted expe-
rienced
rienced an almost immediate
a n almost i m m e d i a t e crash
crash afterafter hishis mania
m a n i a crested.
crested. ThisThis is is also
also true if
true if
you
y o u have
h a v e the
the bipolar
bipolar II II form
f o r m ofof the
the disorder:
disorder: Even E v e n if
if your
y o u r hypomania
h y p o m a n i a isis not
not
particularly
particularly destructive
destructive in in itself,
itself,preventing
preventing hypomanich y p o m a n i c episodes
episodes can can help
help pre­
pre-
vent the
vent the severe
severe depressions
depressions that that often
often follow
follow (see (see also
also Chapter
Chapter 99). ).

"/ Feel
"I Fin. Now,
F••/ Fine Why
$0Why
Now, So Do Do / N.ed
I Need Medicin.?"
Medicine?"

Many
M a n y people
people with with bipolar
bipolar disorder
disorder realize
realize that
that they
they needn e e d medication
medication when when
they're
they're cycling
cycling intointo an a n episode,
episode, butbut don't
don't see
see the
the need
n e e d for
for prophylaxis-the
prophylaxis—the
use
use ofof medication
medication when w h e n they're healthy to
they're healthy to prevent
prevent future
future episodes
episodes (Colom et
( C o l o m et
aL, 2 0 0 0 ) . When
al, 2000). W h e n their
their manic
m a n i c or
or depreSSive
depressive episode
episode has has resolved,
resolved, theythey wonder,
wonder,
"Why
" W h y should
should II keepk e e p taking
taking medication
medication and a n d dealing
d e a H n g with
with the the side effects?"
side effects?"
Some
S o m e people
people thinkthink of of mood
m o o d stabilizers
stabilizers in
in the
the same
s a m e way
w a y they
they m might
i g h t think
think of of
painkillers: You
painkillers: Y o u take
take themt h e m only
only when
w h e n you're
you're hurting,
hurting, and a n d you
y o u stop
stop taking
taking
136
136 CAUSES
CAUSESAND
ANDTREATMENTS
TREATMENTS

them once the

them once the pain
paindisappears.
disappears.h'sIt's
the same logic logic
the same peoplepeople
use when
usethey're on
when they're on
diets.
diets. Once
Once they
they have met their
have met their initial
initial goal
goal of
of losing,
losing, say,
say,1515 pounds,
pounds,theytheysee
see
no
no reason
reason toto continue
continue dieting,
dieting, even
even though
though continuing
continuing toto diet
diet is the key
is the to
key to
weight
weight maintenance.
maintenance.
This
This confusion
confusion is is understandable,
understandable, butbut remember
remember oncone of
of the
the key
key points in
points in
Chapters 5
Chapters 5 and
and 6:
6: People
People with
with bipolar
bipolar disorder
disorder have
have underlying
underlying chemical pre­
chemical pre-
dispoSitions
dispositions that
that require them to
require them to take
take medicine
medicine onon an ongoing basis
an ongoing basis for pre­
for pre-
ventative purposes.
ventative purposes. There
There is
is no
no guarantee
guarantee that
thatyou'll
you'llbe
befree
freeof
ofepisodes
episodeseven
evenifif
you
you do take m
do take mood
o o d stabilizers,
stabilizers, antidepressants,
antidepressants,andlor
and/oranti psychotics. SUl
antipsychotics. Butthe
the
chances that
chances that you'll
you'H remain
remain well
well over
over long
long periods
periods and
and have less severe
have less epi­
severe epi-
sodes are greatly improved.
sodes are greatly improved.

"Medication rake,
"Medication TakesAway
AwayMy
My Creativity"
Creativit/'

One of the
O n e of the most
most fascinating
fascinating aspects
aspects of of bipolar
bipolar disorder
disorder is is its
its association
association with with
artistic
artistic creativity.
creativity. ManyM a n y famous
famousartists,
artists,writers.
writers, poets,
poets, and musicians
and musicians probably
probably
had bipolar
had bipolar disorder
disorder or or aa variant
variant of of it.
it. Examples
Examples may m a y include
include Sylvia Plath,
Sylvia Plath,
Anne Sexton, Roben
A n n e Sexton, Lowell, Ernest
Robert Lowell, Ernest Hemingway,
Hemingway, Delmore Delmore Schwartz.
Schwartz, Vincent
Vincent
van Gogh,
van Gogh, andand Ludwig
Ludwig van van Beethoven.
Beethoven. Jamison
Jamison (1993)
(1993)has has written
writtenextensively
extensively
about this
about this issue
issue in in her book Touched
her book Touched withwith Fire:
Fire: Manic�Depressive
Manic-Depressive Illness Illness and
and
the
the Artistic
ArtisticTemperament.
Temperament.IIcan canalso
alsorecommend
recommend aathoroughthoroughreviewreviewof ofthe
thestud­
stud-
ies
ies in
in this
this area
area byby Teresa
Teresa Carreno
Carreno and and Paul
Paul Goodnick
Goodnick of of the
the UniverSity
University of of Mi­
Mi-
ami
ami School
School of of Medicine
Medicine (1998).
(1998).
The
The link
link with
with creativity
creativity can can put
put the
the person
person with
with bipolar
bipolar disorder
disorder in a
in a
bind.
bind. What
W h a t if
if you
you pride
pride yourself
yourself on on your
your writing,
writing, artistic
artistic talent,
talent, oror musical
musical
ability,
ability, and
and fear
fear that taking medication
that taking medication will will destroy
destroy your
your product?
product? If If having
having
mood
m o o d swings
swings can can improve
improve the the quality
quality ofof your
your artart by
by investing
investing it it with
with emotion
emotion
and
and passion,
passion, why w h y take
takethese
theseaway?
away? Benson
Benson (1975)
(1975)reported
reported that thatof
of12 12patiems
patients
who stopped their lithium,
w h o stopped their lithium, one-third
one-third did
did so
so because
because they
they thought it damaged
thought it damaged
their creatiVity.
their creativity.
Does
Does mood
m o o d stabilizing
stabilizing medication
medication actually
actually interfere
interfere with creativity? We
with creativity? We
can
can certainly
certainly point
point to to people
people likelike Kay
Kay Jamison,
Jamison, who w h o has produced excellent
has produced excellent
writing
writing eveneven when
w h e n taking
taking lithium.
lithium. W What
h a t does
does the
the broader
broader research
research say say about
about
this
this topic? Not many
topic? Not m a n y research
research studies
studies have been done,
have been done, andand most
most are
are case
case stud­
stud-
ies that have
ies that have examined
examined a a select group of
select group of artistic
artistic people
people to to observe
observe what effect
what effect
lithium
lithium had had on their work.
on their work. NoneN o n e of these studies
of these studies onon creat involve people
ivity involve
creativity people
on Depakote or Tegretol, so we don't know if those medications are better or
on Depakote or Tegretol, so w e don't k n o w if those medications are better or
worse.
worse.
Marshall
MarshaH and and colleagues
coHeagues (1970) (1970) found
found thatthat ofof six
six recognized artists and
recognized artists and
businessmen
businessmen who w h o had
had bipolar
bipolar disorder,
disorder, five
five reported
reported higher
higher productivity
productivity and and
better
better quality
quality of of work
work output
output while
while onon lithium
lithium thanthan while
while not
not onon it.
it.InInMogens
Mogens
 Coming
Coming to Termswitb
toTerms Your
with Medication
Your Medication 137
137

Schou's report
(1979)report
Schou's (1979) onon
24 24 anisLS
artists andand writers
writers with
with bipolar
bipolar disorder,
disorder, 12 re­
12 re-
ported
ported that
that the
the drug
d r u g improved
i m p r o v e d their
their creativity
creativity and
a n d productivity, 6 said
productivity, 6 said it
it de­
de-
creased
creased their
their productivity,
productivity, and 6 said
and 6 said it
it had
h a d no
n o effect.
effect. Lithium prevented all
Lithium prevented all
2 4 people
24 people from
f r o m developing
developing recurrences
recurrences of
of their
their bipolar
bipolar disorder.
disorder.
Do
D o people
people with
w i t h bipolar
bipolar disorder
disorder become
b e c o m e more
m o r e creative
creative when
w h e n they
they stop
stop
their
their medication?
medication? The
T h e literature
literature does
does not
not provide
provide a
a clear
clear answer
a n s w e r to
to this
this ques­
ques-
tion, at
tion, at least
least where
w h e r e lithium
H t h i u m is
is concerned.
concerned. Shaw
S h a w and
a n d associates (1986) found
associates (1986) found
that bipolar
that bipolar people
people did
did better
better in
in "associational
"associational processing"
processing" (prodUCing
(producing a
a cre­
cre-
ative
ative stream
stream of
of ideas)
ideas) when
w h e n they
they were
w e r e off
off lithium
lithium than
than on it. Kocsis
o n it. Kocsis and asso­
a n d asso-
ciates ( 1 9 9 3 ) tested
ciates (1993) tested 46
4 6 people
people with
with bipolar
bipolar disorder
disorder who
w h o were on
were o n long-term
long-term
lithium
lithium treatment
treatment and
a n d who
w h o were
w e r e discontinued
discontinued from
f r o m it
it in
in the
the context
context of
of their
their
study.
study. They
T h e y found
f o u n d that
that patients'
patients' scores
scores on
o n memory,
m e m o r y , associative
associative productivity,
productivity,
and
a n d motor
m o t o r speed
speed (finger
(finger lapping)
tapping) improved
i m p r o v e d once
o n c e they
they went
w e n t off lithium. T
off lithium. The
he
people
people who
w h o improved
i m p r o v e d the
the most
m o s t on
o n these
these measures
m e a s u r e s were
w e r e those who
those w h o had the
h a d the
highest
highest levels
levels of
of lithium
lithium in
in their
their bloodstream
bloodstream before
before going
going off the drug,
off the drug, sug­
sug-
gesting
gesting that
that higher
higher dosages
dosages may
m a y lead
lead to
to more
m o r e interference
interference with
with menlal
mental func­
func-
tioning.
tioning.
W h a t do
What d o these
these findings
findings mean
m e a n for
for people
people who
w h o have
h a v e anistic
artistic talent? First,
talent? First,
lithium
lithium can
can have
h a v e effecLS
effects on
o n your
y o u r cognitive
cognitive or
or motor
m o t o r performance, but it
performance, but it isn't
isn't at
at
all
all certain
certain that
that it
it interferes
interferes with
with your
y o u r creativity.
creativity. In
In fact,
fact, the
the opposite
opposite may
maybbe
e
true.
true. Most
M o s t professionals
professionals believe
believe that
that bipolar
bipolar people
people do
d o better
better in
in their
their art,
art, mu­
mu-
sic,
sic, or
or writing
writing when
w h e n they're
they're in
in remission
remission from
f r o m their
their disorder,
disorder, or
or perhaps
perhaps
slightly
slightly hypomaniC
h y p o m a n i c but
b u t not
n o t fully
fully manic
m a n i c or
or depressed.
depressed. It's
It's interesting
interesting that
that
among
a m o n g eminent
e m i n e n t writers,
writers, the
the bipolar
bipolar II
II form
f o r m of
of the
the disorder
disorder (depression
(depression with
with
hypomania)
h y p o m a n i a ) is
is more
m o r e common
c o m m o n than
than the
the full
full bipolar
bipolar disorder,
disorder, suggesting that
suggesting that
milder
milder manic
m a n i c states
states may
m a y be
b e more
m o r e clearly
clearly linked
linked to
to creativity
creativity than
than full
full manic
manic
states
states (Andreasen,
(Andreasen, 1987; Richards &
1987; Richards & Kinney, Carreno &
1989; Carreno
Kinney, 1989; & Goodnick,
Goodnick,
1998). In
1998). In this
this sense,
sense, medication
medication may
m a y even
even be
be helpful
helpful to
to your
your work
work if
if it suc­
it suc-
cessfully
cessfully controls
controls your
your more
m o r e severely
severely manic Swings.
manic swings.
If
If you
you do
do think
think that
that your lithium or
your lithium or your
your anticonvulsant
anticonvulsant is
is affecting
affecting your
your
creativity,
creativity, talk
talkto
toyour
yourdoctor
doctorabout
aboutreducing
reducing the
thedosage
dosagebefore
beforeyou
you decide
decide to
to
go
go off
off it.
it. Perhaps
Perhaps he
he or she will
or she will think
think it's
it's safe
safe for
for you
you to
to experiment
experiment with
with a
a
lower
lower dosage,
dosage, especially
especially if
if you
you have
have been
been stable
stable for
for a while.
a while.

"MedicationGives
"Medication GivesMeMe Unacceptable
Unacceptable SideSide Effects"
Effects"

As II talked
As talkedabout
about in Chapter
in Chapter 6, all6,ofall
theofmajor
the mood
major mood stabilizers,
stabilizers, anti- anti­
psychotiCS,
psychotics, and
a n d antidepressants
antidepressants have
h a v e side
side effecLS,
effects, which
w h i c h can
c a n range from
range f the
r o m the
mild (for
mild (for example,
e x a m p l e , thirst
thirst on
o n lithium)
lithium) to
to the
the severe
severe (toxic
(toxic reactions,
reactions, kidney
kidney
functioning problems,
functioning p r o b l e m s , rapid
rapid cycling,
cycling, agranulocytosis).
agranulocytosis). In
In many
m a n y cases,
cases, medica­
medica-
tion side effecLS
tion side effects are
are transient
transient and
a n d will
will disappear
disappear or
or at
at least
least become
b e c o m e milder
milder after
after
138
138 CAUSES
CAUSESAND
ANDIREAIMENIS
TREATMENTS

you've
you've been
beenon onthethemedication
medication forfor
a while. OtherOther
a while. side effects are not soare
side effects easy to so easy t
not
ignore
ignore and
and cancan bebe continuous.
continuous.
Many
M a n y people
people go go off
off their
their medication
medication becausebecause they they find the side
find the side effects
effects tootoo
unpleasant
unpleasant and and disruptive.
disruptive. This This is is also
also true
true when
w h e n people
people areare prescribed
prescribed medi­medi-
cations for
cations for traditional
traditional medical
medical conditions.
conditions. BloodBlood pressure
pressure medications,
medications, for for ex­
ex-
ample,
ample, cancan m make
a k e people
people fatigued.
fatigued. Allergy
Allergy medications
medications can can make
m a k e people
people feelfeel
sleepy
sleepy oror "dried
"dried up."up.n Even
Even "natural»
"natural" or "herbal" substances
or "herbal" substances have have side
side effects.
effects.
For
For example,
example, Sl. St.John's
John'swort,
wort,an analternative
alternativeantidepressant,
antidepressant,can cangive
giveyouyoustom­
stom-
achaches,
achaches, makem a k e you
you sun-sensitive,
sun-sensitive, and, and,ififnotnottaken
takenalongSide
alongsideof ofaamood
m o o dstabi­
stabi-
lizer,
lizer, callse
cause switches
switches intointo mania
mania (Nierenberg
(Nierenberg et et al.,
al, 1999).
1999).
Taking
Taking a a medication
medication is is aa cost-benefit
cost-benefit decision.
decision. ThereThere areare clearly benefits
clearly benefits
to
to mood
m o o d stabilizers.
stabilizers. Bm But they
theyalso have costs,
alsohave costs,including
includingside sideeffects
effectsandandactual
actual
financial
financial outlays
outlays (see the self-rated
(see the self-rated cost-benefit
cost-benefit exerciseexercise at at the end of
the end this
of this
chapter).
chapter). MostMost people
people withwith bipolar
bipolar disorder,
disorder, if if able
able to to weigh
weigh the the costs
costs andand
benefits
benefits objectively,
objectively, come c o m e down
d o w n onon the
the side
side ofof continuing
continuing to to take
take their
their medi­
medi-
cation,
cation, especially
especially if if they've
they've beenbeen through
through some some painful
painful mood
m o o d disorder
disorder epi-epi­
sodes.
sodes. But that doesn't
But that doesn't m mean
e a n you
you should
should havehave to to live
live with
with terrible
terrible medication
medication
side
side effects
effects asas a a trade-off
trade-off for for health
health andand mood stability.
m o o d stability.
First,
First, managing
managing your your side
side effects
effects should
should be be a a collaborative
collaborative process
process be- be­
tween
tween youyou andand your
your physician.
physician. Don't Don't trytry toto adjust
adjust youryour medication
medication on on your
your
own.
own. Instead,
Instead,keep keepaarecord
recordof ofwhich
whichside sideeffects
effectsyou youexperience
experienceeach eachday,
day,and and
tell
tell your
your physician
physician aboutabout them.
them. The The exercise
exerciseon on page
page 139139 will
willhelp
help you
you orga­
orga-
nize
nize your
your thoughts
thoughts aboutabout which
which side side effects
effects you
you experience
experience from from which
which medi­
medi-
cations.
cations. Copy
Copy the the completed
completed record,record, bring
bring i itt to
to your
your next
next medication
medication visit,visit,
and
and gogo over
over it it with
with your
your doctor.
doctor.
Ask
Ask your
your physician
physician what what can can bebe done
done to to control
control youryour side
side effects.
effects. Many
Many
can
can be
be managed
managed with with a a simple
simple dosage
dosage adjustment
adjustment (for (for example,
example, dropping
dropping the the
number of
number of lithium
lithium tablets
tablets soso that you feel
that you feel less
less sluggish
sluggish mentally)
mentally) or or by
by taking
taking
your
your pills
pills in
indifferent
differentdosing
dosing pauerns.
patterns.For For example,
example,if ifyou
youtake
takelithium
lithiumin inone
one
dosage
dosage rather
rather than
than several,
several, you you may have less
m a y have less need
need to to urinate frequently. If
urinate frequently. If
you
you take
take the
the extended-release
extended-release form form of of Depakote,
Depakote, you you may
m a y have less gastroin­
have less gastroin-
testinal
testinal distress.
distress. Other
Other side
side effects
effects cancan bebe controlled
controlled with with additional side-ef­
additional side-ef-
fect
fect medications.
medications. For For example,
example, hand hand tremors
tremors can can be be helped
helped by by adding
adding a beta
a beta
blocker,
blocker, propranolol
propranolol (lnderan,
(Inderal),to toyour
yourmedication
medication regimen.
regimen.The The hair
hairthinning
thinning
associated
associated withwith Depakote
Depakote can can sometimes
sometimes be be managed
managed with with zinc
zinc oror selenium
selenium
supplements.
supplements.
Your doctor
Your doctor maym a y also
also decide
decide to to switch
switch youyou to to another
another medication entirely.
medication entirely.
For
For example,
example, if ifyou
you have
have problems
problems with with memory
m e m o r y or ormotivation
motivation on lithium,he
on lithium, he
or
or she
she may
m a y switch
switch you you toto Depakote,
Depakote, which which is is less likely 1O
less likely to produce
produce these side
these side
effects
effects (Stoll
(StoH et et aI.,
al, 1996).
1996). If If you
you have
have problems
problems with withweight
weight gaingain onon DepakOle,
Depakote,
 ComillQ to Terms
Coming 10 withYOUI
Termswith YourMedicO�Ofl
Medication 139
139

KEEPING
KEEPING TRACK
TRACK OF
O F YOUR
Y O U R SIDE
SIDE EFFECTS
EFFECTS
Date/day
Date/day Side
Side effects
effects
of
of week
week Medications
Medications taken
taken Dosage experienced""
experienced* i

Weight
Weight at
at beginning
beginning of
of week
week ____ End
End of
of week
week ___

*Examples:
*Examples: dry
dry mouth,
mouth, urinating
urinating frequently,
frequently, rash,
rash,acne,
acne,stomachaches,
stomachaches,nsomnia,
i insomnia,
headaches, fatigue,
headaches, hair
fatigue, hair
loss, problemswith
loss,problems withconcentration,
concentration,hand
handtremor.
tremor.IfIfyou're
you'renot
notsure
surewhich
whichmedication
medicationcauses
causeswhich
whichside
sideef­ef-
fect,
fect,Simply
simply list
listeach
eachsside
ide effect
effectyou
you experience
experienceand
and put
put aa�?� nextto
"?" next toeach
eachone.
one.
140
140 CAUSES
CAUSESAND
ANDlRUTMEN1S
TREATMENTS

then Tegretol,
then Tegretol,oror
thethe
newer anticonvulsant,
newer Topamax,
anticonvulsant, be alternatives
maymay
Topamax, for
be alternatives for
you. New
you. N e w drugs
drugs for
for bipolar
bipolar disorder
disorder are
are being
being developed
developed all
all of the time,
of the time, and
and it
it
m a y be
may be that
that easily tolerated medications
easily tolerated medications that that work
w o r k just
just asas well
well asas the "Big
the "Big
Three"
Three" willwill eventually
eventually become available.
become available.
The
The decision
decision to to switch
switch medication
medication willwiH notnot be
be decided
decided solely
solely onon the basis
the basis
of your side effects, of course. Hopefully, this decision wiH c o m e out of adis­
of your side effects, of course. Hopefully. this decision will come out of a dis-
cussion
cussion between
between you you and
and your
your physician
physician concerning
concerning the the pros
pros andand cons
cons ofof cer­
cer-
tain medications
tain medications from from the
the vantage
vantage point
point ofof effectiveness
effectiveness versus
versus adverse
adverse effeclS.
effects.
You
Y o u may
m a y feel
feel angry
angry atatyour
yourdoctor
doctorififyouyoufeel
feelheheororshe
sheshould
shouldhavehavealerted
alerted
you
you ahead
ahead of time to
of time to the
the side effects you're
side effects you're experiencing.
experiencing. Your Your anger
anger isis under­
under-
standable,
standable, but butkeep
keep ininmind
mind that
thathehe or
orshe
shemaym a y not
notbe beable
ableto topredict
predictyour
yourpar­
par-
ticular
ticular profile
profile of
of adverse
adverse effects
effects ahead
ahead of time. If
of time. If you
you are
are feeling
feelingangry,
angry,discuss
discuss
this with
this with him
him oror her
her rather than not
rather than not showing
showing up up for
for your
your next
next session.
session. There
There
is
is little
littleheheor
orshe
shecan
candodototohelp
helpyou
youifif
you
youaren't
aren'tcoming
cominginin on ona a
regular
regular basis.
basis.
The
The most
most important
important pointpoint is that side
is that side e ffects represent
effects represent a a problem
problem for for
which
which there
there are
are solutions
solutions other
other than
than simply
simply stopping
stopping youryour medication.
medication. In- In­
forming
forming youryour doctor
doctor onon a regular basis
a regular basis about
about your
your side
side effects
effects will
willhelp
help him
him or or
her consider
her consider andand discuss
discuss with
with you
you the
the alternatives
alternatives to to your
your treatmem plan.
treatment plan.

17aking Medication
"Taking MedicationIsIs
a Sign 01 Personal
a Sign Weakness,
of Personal Sickness,
Weakness, Sickness,
and Lack of
and Lack of Con',o/"
Control"

"Forme,
"For me,it's
it's all
allabout comro!.
about I have
control. always
I have had had
always trouble with with
trouble authOrity
authority
figures,
figures, and medication feels
and medication feels like
like just
just one
one more authority figure.
more authority figure. Some­
Some-
one
one comes
comes along
along and
and says, 'Here, just
says, 'Here, justtake
take this
thissalt
saltand
and you'll
you'llfeel
feelbener
better
and
and be
be like
like the
the rest
rest of us.' IIthink
of us.' thinkit's garbage, and it makes me realize thethe
it's garbage, and it makes m e realize
person
person doesn't
doesn't know
k n o w me
m e very
very well.
well. II can
can handle
handle things
things by
by myself just
myself just
fine, thank you."
fine, thank you."
— A 19-year-old
-A 19-year-old mallm a n shortly
shortly after
after his
his hospitalization
hospitalization for
for mania
mania

ManyMany people
people feelfeel that
that takingmedication
taking medication is
is aasign ofof
sign personal weakness.
personal It
weakness. It
feels
feels like
likeadmitting
admitting thatthatyou're
you'resick,
sick,defective,
defective,orormentally
mentally ill.illCertainly,
. Certainly,taking
taking
medication
medication daily
daily can
can remind
remind youyou of
of your
your troubles
troubles andand make
m a k e you resent the
you resent the ill­
ill-
ness
ness even
even more
more than
than you
you dodo already.
already. But
But many
m a n y people
people take
take thisthis perspective
perspective
further
further and
and claim
claim that
that they
they can
can get
get along
along without
without medication
medication just by exerting
just by exerting
self-control. tr
self-control. Ifyou
youareareininaahypomaniC
hypomanicphase,
phase,you're
you'reparticularly
particularlylikelylikelytotofeel
feel
this
this way. Unforlunately, bipolar
way. Unfortunately, bipolar disorder cannot be
disorder cannot be controlled
controlled by by sheer will­
sheer will-
power.
power. Neither
Neither cancan other
other biologically
biologically based illnesses.
based illnesses.
There
There are
are many
m a n y ways
ways toto think about control.
think about control In In some
some people's minds, con-
people's minds, con-
 Coming
Coming to
toTerms
Termswith
withYour Medi(otion
Your Medication 141141

trol
trol isisabout
about not needinghelp
not needing helpfrom
from anyone
anyone or anything.
or anything. For others,
For others, control comrol
means
m e a n s availing
availing yourself
yourself of of opportunities
opportunities to to further
further your
y o u r life
life goals.
goals. It
It is
is true
true
that taking
that taking aa medication
medication now n o w means
m e a n s giving
giving up up a a certain
certain amoum
a m o u n t of
of control
control in in
the
the short
short run.
run. But
B u t taking
taking care
care of
of yourself
yourself in in this
this way
w a y can
can also give yyou
also give o u more
more
control in
control in the
the long
long run.
run. Achieving
Achieving mood m o o d stability
stability on o n an
a n ongoing
ongoing basis trans­
basis trans-
lates
lates into
into aa greater
greater likelihood
likelihood of of staying
staying outout of of the
the hospital,
hospital, not not having
having to to
schedule
schedule so so many
m a n y doctor
doctor visits,
visits, saving
saving money
m o n e y on
o n additional
additional treatments,
treatments, beingbeing
able
able toto plan
plan ahead
ahead for for things
things you
y o u want
w a n t to
to do,
d o , better
better family
family and a n d romantic
romantic rela-rela­
tionships,
tionships, and
and a a more
m o r e productive
productive workw o r k life.
life. In
In other w o r d s , taking
other words, taking medication
medication
can
can give you
give y o u the
the kind
kind of
of control
control you
y o u crave,
crave, rather
rather than
than eliminating
eliminating it.
it. Not
N o t tak­
tak-
ing medication,
ing medication, inin contrast,
contrast, can
can mean
m e a n giving
giving up
u p control
control if
if it
it leads
leads to
to becoming
becoming
ill
ill again.
again.
Later
Later chapters
chapters talk talk about
about self-management
self-management strategies
strategies such
such as
as sleep-wake
sleep-wake
monitoring,
monitoring, mood m o o d charting,
charting, cognitive
cognitive restructuring,
restructuring, anda n d coping with family
coping with family
stress.
stress. Implementing
I m p l e m e n t i n g these
these behavioral
behavioral strategies
strategies can
can contribute
contribute toto yyour
o u r feeling
feeling
of
of control
control over
over your
y o u r fate.
fate. But
B u t these
these strategies
strategies will
will work
w o r k much
m u c h better
better if
if you
y o u are
are
being
being Simultaneously
simultaneously protected protected by b y medications.
medications.

"MeaicalionCarries
"Medication Ca"i..aaStigma
SligmaininOur
OurSociety"
Sociely"
Bipolar disorder
Bipolar disordercarries
carries the
thestigma
stigmaofofmental
mental illness,andand
illness, taking
taking medication
medication
can
can become
become a a proxy
p r o x y for
for this
this stigma.
stigma. You Y o u may
m a y worry
w o r r y about
about what w h a t employers,
employers,
friends,
friends, and
a n d romantic
romantic partnerspartners will will think
think if if they
they know
k n o w you're
you're on o n medication.
medication.
This
This is is not
not an a n easy
easy issue,
issue, and a n d itit is
is aa very
very real
real concern
concern for for many people.
m a n y people.
There
There maym a y be
b e jobs
jobs you y o u can't
can't taketake because
because of of being
being on o n medication
medication (for (for exam­
exam-
ple,
ple, aa job
job that
that requires
requires fine fine motor
m o t o r control
control over over your
y o u r hands).
h a n d s ) . Upon
U p o n learning
learning of of
an
an employee'S
employee's disorder,
disorder, employers
employers have have beenb e e n known
k n o w n to to react
react withwith anything
anything
from
from complete s y m p a t h y to finding w a y s to fire the person (although such
complete sympathy to finding ways to fire the person (although such
discrimination
discrimination is is illegal,
illegal, as as discussed
discussed in in Chapter
Chapter 12). 12). ButBut the the situation
situation is is im­
im-
proving.
proving. My M y impression,
impression, especiallyespecially over over the the last 1 0 years,
last 10 years, has has been
b e e n that
that our so­
our so-
ciety
ciety is
is becoming
b e c o m i n g more
m o r e and
a n d more
m o r e understanding
understanding of of the
the biological
biological bases bases of of psy­
psy-
chiatric
chiatric disorders
disorders and a n d thethe need
n e e d forfor psychiatriC
psychiatric medications.
medications. More M o r e and
a n d more
more
people
people are are admitting
admitting to to being
being on o n mood
m o o d stabilizers
stabilizers and a n d antidepressants.
antidepressants. Few Few
people
people would
w o u l d reflexively
reflexively "dump" "dump" a a potential
potential romantic
romantic partner partner or or employee
employee
simply because that
simply because that person
person admits admits to to taking
taking moodm o o d medication.
medication.
Of
O f course,
course, you y o u are
are notnot obliged
obliged to to tell
tell your
y o u r employer
employer or or other
other Significant
significant
people about your mood disorder or its treatments. You may also want
people about y o u r m o o d disorder or its treatments. Y o u m a y also w a n t to
to be
be
selective in
selective in what y o u tell
w h a t you tell them.
t h e m . As
A s I1 discuss
discuss in in Chapter
Chapter 12, 12, there
there areare construc­
construc-
tive
tive ways to educate
w a y s to educate othersothers aboutabout your your needn e e d for
for medications
medications so so that the stigma
that the stigma
is
is minimized.
minimized.
142
142 CAUS£S
CAUSES AND
AND TREATM£NTS
TREATMENTS

17be
"The Medication
MedicationDoesn't
Doesn'tWork"
Work"

Some people
Some people with
with bipolar
bipolardisorder
disordercomplain that
complain their
that medication
their is just
medication isnot
just not
effective.
effective. They
They wonder
wonder why
w h y they
they should
should take
take one
one or mOTe mood
or more stabilizers
m o o d stabilizers
when
w h e n they
they don't
don't feel
feel that
thatthe
themedication
medication is
is really
reallycontrolling
controlling their
theirsymptoms.
symptoms.
The
The reality
reality isis that
that your
your bipolar
bipolar disorder
disorder is is only
only partially
partially controllable
controllable by by
medicines
medicines (see (see Chapter
Chapter 6). 6). Bm
But almost
almost everyone
everyone with with the
the disorder
disorder does better
does better
on
on medication
medication than than offoff it. Y o u will
it. You will continue
continue to to experience
experience mood fluctuations
m o o d fluctuations
on
on medication,
medication, but but ifif you
you examine
examine the course of
the course of your
your illness
illness carefully,
carefully, you'll
you'll
probably
probably find that there
find that there has
has been
been somesome improvement.
improvement. Keeping
Keeping a ammood
o o d chan
chart
(Chapter
(Chapter 8) 8) will
will help you determine
help you determine h howo w your
your medication
medication is is affecting
affecting YOUTyour
sleep
sleep andand m moods
o o d s in
in aa relatively
relatively objective
objective way.way.
A question
A question to to ask
ask yourself
yourself is, is, "Is
"Is my
m y medication
medication truly
truly ineffective,
ineffective, or ordoes
does
it
it just
just not
not work
work as as well
well asas II would
would like like it
it to?"
to?" Depending
Depending on on your
your answer,
answer, you you
may
m a y want
want to to discuss
discuss the the maner
matter with with your
your doctor.
doctor. ItIt is
is pOSSible-especially
possible—especially if if
you
you are
are trying
trying m mood
o o d stabilizers
stabilizers for for the
the first
first time-that
time—that you you are not improving
are not improving
as much
as m u c h as
as you
you could,
could, andand you
you should
should notnot hesitate
hesitate to tell your
to tell your doctor
doctorif if that
thatisis
what you
what you believe.
believe. He H e or she mmay
or she a y agree with you
agree with you and
and suggest
suggest a a different
different moodmood
stabilizer
stabilizer or or various
various adjunctive
adjunctive medications
medications to to enhance
enhance your your current
current regimen
regimen
(Chapter
(Chapter 6). 6).
Try
Try toto be
be objective
objective about
about whether
whether there there has
has been
been anyany improvement.
improvement. Ask Ask
relatives
relatives forfor their
their opinions
opinions aboutabout the the impact
impact of of the
the medication
medication on on your func­
your func-
tioning. They may
tioning. They m a y have
have seen
seen effects
effects that
that you
you aren't
aren't aware
aware of of (for
(for example,
example, be­ be-
ing
ing less
less easily
easily provoked
provoked to to anger,
anger, smiling
smiling moremore often,
often, being
being less
less irritated
irritated by by
changes
changes in in your
your environment,
environment, seeming seeming like likeyour
your old
old seiO.
self).Sometimes
Sometimesthe theben­
ben-
efits
efits aren't
aren'tas asstraightforward
straightforward as asmood
m o o d stability.
stability.For Forexample,
example,Neil,Neil,age age18,18,diddid
not
not think
think hishis Tegretol
Tegretol had had anyany effect
effect on
on hishis moods.
moods. He H e did
did believe,
believe, however,
however,
that he
that he was
was gelling
getting along
along better with his
better with parents and
his parents and friends
friends since
since starting
starting it. it.

"MyProblems
"My Problems Are
Are Psy,hologi,.I,
Psychological, NotNot
Biologi,.I"
Biological"

If you
If youfeel
feelthatthat
youryour
problems are only
problems are of a psychological
only origin (for
of a psychological example,
origin (for example,
related to
related to childhood
childhood trauma
trauma or
or disturbed
disturbed family
family relationships, problemsrelat­
relationships, problems relat-
ing
ing to
to authority
authority figures),
figures), then
then itit may
m a y not
not bebe obvious
obvious to
to you
you what
what role medica­
role medica-
tion
tion has
has in
inyour
your treatment.
treatment.YouY o u may
m a y feel
feelthat
thatyour underlying vulnerabilities
your underlying vulnerabihties
have
have more
more toto do
do with
with a negative view
a negative view of of yourself
yourself than to biological
than to biological or genetiC
or genetic
factors.
factors.
Take
Take aa look
look again
again at
at Chapler
Chapter 5, 5, in
in which
which II talk
talk about
about the vulnerability­
the vulnerability-
stress
stress model.
model. Psychological stress, such
Psychological stress, suchas asinterpersonal
interpersonalor orfamily
familyconflicts
conflictsoror
loss
loss experiences,
experiences, cancaninteract
interactwith
withaaperson's
person'sbiological
biologicaland
and psychological
psychologicalvul­vul
nerabihties (for
nerabilities (for example,
example, a a low
low opinion
opinion of of your
your intellect
intellect or your abihties).
or your abilities).
 Comingtto
Coming o Terms
Termswirfl
withYour
YourMedica�oo
Medication 143
143

This is one
Thisis oneofofthe
thereasons
reasonswewe recommend
recommend medication
medication and psychotherapy
and psychotherapy in in
rather than
combination, rather
combination, than as
as substitutes
substitutes for
for each
each other.
other. RRemember, your prob-
e m e m b e r , your prob�
lems needn't
lems needn't bbe biological or
e biological psychologicaL TThey
or psychological. can bbe
h e y can both.
e both.
Medication mmay
Medication actually mmake
a y actually a k e yyour psychotherapy mmore
o u r psychotherapy successful. M
o r e successful. Most
ost
psychotherapists say
psychotherapists say that
that they
they can't
can't accomplish
accomplish mmuch
u c h wwhen
h e n aa person
person with
withbi-
bi­
polar disorder
polar disorder is in aa severely
is in severely depressed,
depressed, mmanic, or mmixed
a n i c , or state. If
i x e d state. medication
If medication
mmakes
a k e s yyour
o u r mmood stable, or
o o d stable, or at
at least
least stable
stable eenough that yyou
n o u g h that can mmake
o u can it to
a k e it to reg-
reg­
ular appointments
ular appointments aand carry through
n d carry through oon therapy hhomework
n therapy assignments,
o m e w o r k assignments,
you'll benefit
you'll benefit aa great
great deal
deal mmore
o r e ffrom the psychotherapy.
r o m the psychotherapy. You'll
You'll bbe able to
e able deal
[0 deal
mmore productively with
o r e productively with the
the underlying
underlying issues
issues that
that mmay
a y bbe contributing to
e contributing to
unhappiness or
your unhappiness
your or distress.
distress.

'7.ki.gMedication
"Taking Medic./io. Me••
Means s I'm
I'm Givi.g
Giving i. My
in to /0 My P.re./s
Parents (orSpouse)"
(or My My Spouse)"

"I'm
"I'm a product
a product of what
of what I learned
I learned from from my parents,
my parents, but
but I've I've
also also learned
learned
things from
things other people,
f r o m other people, in
in college,
college, after
after college, in various
college, in various wwork situa­
o r k situa-
tions,
tions, relationships,
relationships, and the hard
a n d the hard knocks
k n o c k s of
of life. If II go
life. If g o on medication, it
o n medication, it
can't be
can't their decision.
b e their decision. Whether I go
Whether I g o back
b a c k on it, when
o n it, I go
when I back, how
g o back, how
u c h II go
mmuch g o back
b a c k on
o n it,
it, and
a n d who
w h o will
w i H be
b e my
m y doctor,
doctor,are
are all
allthings
things I've
I've gOl
got to
to
decide
decide by
b y myself.
myself. If
If they
they make
m a k e the
the decision
decision for
for me,
m e , even if 1I agree
even if with it,
agree with it,
II won't
won't be
b e able
able to
to follow
f o H o w through."
through."
-A
— ^ A 23-year�old
23-year-old woman
w o m a n with bipolar II disorder
with bipolar disorder

As woman
As this this woman says,
says, and as and
Kate as Katesays
MHlet Millet
in says in the
the quote atquote at the beginning
the beginning
of
of this
this chapter,
chapter, taking
taking medication
medication cancan mean
m e a n feeling
feehng like
like you're
you're giving
giving in
in to
to
your
your family's
family's demands.
d e m a n d s . If
If you
y o u are
are aa young
y o u n g adult
adult and
a n d live
live with
with your
your parents,
parents,
you
y o u can
can quickly
quickly get
get tired
tired of
of hearing
hearing them
t h e m nag
n a g you
y o u to
to take
take your
y o u r medication,
medication, in­
in-
terpret
terpret your
y o u r emotional
emotional responses
responses to
to everyday
everyday things
things as
as signs
signs that
that you
y o u need
need
more
m o r e medicine,
medicine, or
or remind
r e m i n d you
y o u that
that you're
you're the
the sick
sick one
o n e in
in the
the family.
family. You
Y o u may
may
believe
believe that
that others
others in
in the
the family
family also
also have
have the
the disorder
disorder and
a n d that
that they
they should
should be
be
the
the ones
ones taking
taking medicine,
medicine, not
not you.
you.
Most
M o s t people
people want
w a n t independence
independence from
f r o m their
their parents.
parents. Taking
Taking medication
medication
can
can feel
feel like
H k e giving
giving up
u p your
y o u r independence:
independence: Swallowing
S w a H o w i n g pills,
pills, seeing
seeing doctors,
doctors,
and
a n d getting
getting your
y o u r blood
blood level
level tested
tested may
m a y feel
feel like
H k e you
y o u are
are under
u n d e r your
your parents'
parents'
thumb.
t h u m b . The
T h e reality
reality is
isthat
that taking
taking medication,
medication, while
while perhaps
perhaps initially
initially reflecting
reflecting
your
your acquiescence
acquiescence to
to your
y o u r parents'
parents'plans,
plans,greatly
greatly increases
increases your
y o u r chances
chances of
of in­
in-
dependence
d e p e n d e n c e from
f r o m them
t h e m later.
later. If
Ifyour
y o u r mood
m o o d is
is stable,
stable,there
there is
is aa greater
greater chance
chance
that
thatyou'll
you'H be
b e able
able to
to function
function away
a w a y from
f r o m home.
h o m e . But
But it's
it'shard
hard to
to take
take this
this long­
long-
term
term view
v i e w when
w h e n taking
taking medicine
medicine makes
m a k e s you
y o u feel
feel like
like you're
you're aa child
c h d d again.
again.
If
Ifyou're
you'remarried
marriedor
orpartnered,
partnered,you
y o u may
m a y have
have the
thesame
s a m e feelings
feeHngs about
aboutyour
your
144
144 CAUSES
CAUSESAND
ANDIREAIMEHIS
TREATMENTS

spouse. Your
spouse. Your spouse
spouse may
may be
be taking
takinga ahard line
hard with
line some
you;you;
with of my
some of diems'
my clients'
spouses
spouses havehave even
even threatened
threatened to to leave
leave if if their bipolar partner
their bipolar partner didn't
didn't remain
remain
consistent in
consistem in taking
taking his
his oror her
her medication.
medication. Your spouse's insistence
Your spouse's insistence that that you
you
take medication can make the option feel all the more unappealing to you.
take medication can m a k e the option feel all the more unappealing to you.
How
H o w dodo people
people resolve
resolve this
this dilemma?
dilemma? Many M a n y of
of my
m y clienlS have eventually
clients have eventually
come
come around
around to to realizing
realizing thethe neceSSity
necessity of of mood
m o o d stabilizers
stabilizers notnot only
only for their
for their
own
o w n mood
m o o d stability but also
stability but also for
for their
their relationships
relationships with with their family members.
their family members.
But
But itit is
is important
important thatthat you
you feel
feel the
the decision
decision to to take
take the
the medicine
medicine is largely
is largely
your
your own.
own. Chapter
Chapter 12 12 gives
gives you
you some
some tips
tips onon how
h o w to
to communicate
communicate with with fam�
fam-
ily members
ily members on on problems
problems related
related to to your
your illness,
illness, including
including h how
o w toto negotiate
negotiate
the
the sometimes volatile issue
sometimes volatile issue of of medication-taking.
medication-taking.
Perhaps
Perhaps even even more
more important,
important, try try to
to make
make a a distinction
distinction between
between the the way
way
you
you feel
feel about
about your
your medicine
medicine and and the
the w way
a y everyone
everyone else else seems
seems to to feel
feel about
about it.
it.
Do
D o you
you think
think the
the medication
medication helps helps you,
you, even
even ifif it's
it's less
less than
than you'd
you'd like?
like? Does
Does
taking
taking medicine
medicine havehave toto mean
m e a n feeling
feeling like
like a a child?
child? If If so,
so, what
what do do wew e make
make of of
the
the many successful people
m a n y successful people who w h o have
have hadhad this
this illness
illness and
and took medication?
took medication?
Many
M a n y of
of my
m y clients
clients have
have reported
reported feeling
feeling beuer
better abom
about laking
taking medicine
medicine once once
they
they began
began to to view
view drug
drug treatment
treatment as as important
important for for maintaining
maintaining their health
their health
status
status and
and furthering
furthering their
their personal
personal life life goals.
goals. Some
S o m e have
have made the transition
m a d e the transition
from
from engaging
engaging in in power
power struggles
struggles withwith their
their parents
parents or or spouse
spouse to to take
take more
more
responsibility
responsibility for for managing
managing theirtheir own
o w n medication
medication (for (for example,
example, keeping
keeping to to the
the
regular
regular dosing
dosing schedule
schedule so so that
that reminders
reminders from from others
others become
become unnecessary,
unnecessary,
monitoring
monitoring their their side
side effects,
effects, arranging
arranging their their own doctor visits
o w n doctor visits and
and blood
blood
tests).
tests). This
This transition
transition helped
helped themthem to to feel
feel that
that medication
medication was less of
was less of a threat
a threat
to
to their
their independence
independence and and sense
sense of identity.
of identity.

HI
"I Can't
Can'tRemember
Remember to
toTake
TakeMy
MyMedication"
Medication"

This is
This isaavery
veryreal problem
real and
problem one
and that
one phYSicians
that oftenoften
physicians underestimate. In
underestimate. In
fact,
fact, one
one factor
factor that
that predisposes
predisposes people
people with
with bipolar
bipolar disorder
disorder to to noncon­
noncon-
cordance
cordance is is haVing
having toto remember
remember a a greater number of
greater number of medication
medication dosages
dosages
(Keck
(Keck et et aI., 1997; Sachs,
al, 1997; 2000). Sometimes
Sachs, 2000). Sometimes people
people forget
forget whether
whether theythey have
have
taken
taken a a morning
morning or or an
an afternoon
afternoon dosage,
dosage, and
and then
then end
end up
up taking
takingan an extra
extradose
dose
in
in the
the evening,
evening, which
which can
canincrease
increasetheir chancesof
theirchances ofgetting
getting too
toomuch
m u c h of
ofaamed­
med-
ication.
ication.
If
If you
you are
are using
using alcohol
alcohol oror street
street drugs
drugs regularly,
regularly, including
including marijuana,
marijuana,
you're
you're going
going toto have
have particular problems remembering
particular problems remembering to to take
take your
your medica­
medica-
tion. This
tion. Thisisisprobably
probablyoneoneofofthe
thereasons
reasonsthat
thatsubstance
substanceabuse
abuseisisso sohighly
highlycor­
cor-
related
related with medication nonconcordance
with medication nonconcordance (e.g.,
(e.g.,Strakowski
Strakowskiet etaI., 1998).IfIfyou
al,1998). you
are
are able
able toto get
get your
your substance
substance useuse problem
problem under
under control
control (see
(see Chapter 8),
Chapter 8),
 Coming
Coming to Termswith
toTerms Your
with Medko�on
Your Medication 145145

you'll havea amuch

you'H have much easier
easier timetime remembering
remembering to taketo take
your your medication.
medication. Also, Also,
the
the medication
medication will
will almost
almost certainly
certainly be b e more
m o r e effective!
effective!
If
If you
y o u are
are having
having trouble
trouble remembering
r e m e m b e r i n g to
to take
take your
y o u r tablets,
tablets, ask
ask your
y o u r phy­
phy-
sician
sician whether
w h e t h e r you
y o u can
c a n be
b e given
given the the medication
medication in in its
its least
least complex
c o m p l e x dosing
dosing
pattern.
pattern. Some S o m e medication,
medication, including
including lithium,
lithium, can c a n be
b e taken
taken all all in
in one
o n e dosage.
dosage.
Sometimes
S o m e t i m e s the
the regime
regime can c a n be
b e simplified
simplified to to morning
m o r n i n g and
a n d evening
evening dosages
dosages only.only.
Don't
Don't be b e ashamed
a s h a m e d of
of forgetting-it's
forgetting—it's a a more
m o r e common
c o m m o n problem
p r o b l e m than
than y you
o u think.
think.
There
T h e r e are
are also
also ways
w a y s to
to remind
r e m i n d yourself.
yoursell Some S o m e people
people use use pill
pill boxes
boxes withwith
morning,
m o r n i n g , afternoon,
afternoon, and a n d evening
evening dosesdoses laid
laid out
o u t at
at the
the beginning
beginning of the day.
of the day.
Some
S o m e people
people have h a v e key
k e y chains
chains with
with an a n attached
attached container
container with with room
r o o m for
for aa day's
day's
dosage.
dosage. You Y o u can
c a n usually
usually get get these
these at at a a drug
d r u g store.
store. Other
O t h e r people
people use use watch
watch
alarms
alarms or or palm
p a l m pilots
pilots to to alert
alert them
t h e m when
w h e n they
they need
n e e d another
another dosage. Others try
dosage. Others try
to
to time
time their
their dosages
dosages around
a r o u n d events
events that that will
will "cue"
"cue" them,
t h e m , like
like meals
meals oror waking
waking
uplbedtime
up/bedtime routines.
routines. Some S o m e people
people keep k e e p spare
spare pills
pills in in their
their desk
desk drawers
drawers at at
work
w o r k in
in case
case they
they forget
forget to to bring
bring them.
t h e m . Others
Others acquaint
acquaint their their spouse
spouse with
with thethe
medication
medication routines
routines and a n d ask
ask for
for reminders.
reminders. If If you
y o u are
are comfonable
comfortable with with youryour
spouse
spouse taking
taking thisthis role,
role, itit may
m a y beb e helpful
helpful to to you
y o u in
in staying
staying on o n schedule.
schedule.
In
In the
the next
next chapter
chapter on o n maintaining
maintaining wellness,wellness, you'llyou'll be b e introduced
introduced to to the
the
daily self-rated
daily self-rated moodm o o d chart.
chart. On O n thethe chart
chart you'll
you'll seesee places
places to to record
record thethe num­
num-
ber of
ber of tablets
tablets of of each
each medication
medication you've you've taken.taken. Keeping
K e e p i n g track
track of of your
y o u r moods
moods
and
a n d medication
medication on on a a daily
daily basis
basis will
will n not
o t only
only remind
r e m i n d you
y o u to
to take
take yyour
o u r medi­
medi-
cine b u t will
cine but will also
also help
help you y o utotosee
seethetherelations
relations between
b e t w e e n your
y o u r medication
medication con� con-
sistency and
sistency a n d the
the stability
stability of of your
y o u r mood
m o o d states.
states. OneO n e of of mym y clients
clients related
related the the
follOwing:
following: "Breakfast
"Breakfast and a n d medications
medications were w e r e always
always connected
connected for for mme.
e . But
B u t then
then
when
w h e n II got
got mym y new
n e wjob,
job,IIforgot
forgot to toeateat breakfast
breakfast and a n dalso
also missed
missed my m y morning
morning
medication
medication dose-l d o s e — I took
took it it to
to work
w o r k with
with me m e and
a n d would
w o u l d completely
completely forgetforget
about
about it.it. When
W h e n mym y mood
m o o d started
started dropping
dropping and a n dIIstarred
startedkeeping
keeping aamoodm o o d chan,
chart,
II discovered
discovered II wasn't
wasn't taking
taking my m y morning
m o r n i n g dose
dose as as frequently
frequently as as II thought
thought II was.
was.
Keeping
Keeping tracktrack made
made me m e more
more conscious
conscious of of remembering
remembering my m y morning
morning dose dose
and
and also
also helped
helped me m e make
make breakfast
breakfast more more of of aa priority."
priority."

SummarizingthethePros
Summarizing Pros
andand Cons
Cons of 01 Medication:
Medication: A Se/l·Rated
A Self-Rated ChartChart

After you've
After you've thought
thoughtthrough
through some
some of the
of the issues
issues just
just discussed,
discussed, it may
it may be use­
be use-
ful
ful to
to summarize
s u m m a r i z e the
the costs a n dbenefits
costsand benefits of
ofmedication
medication in inyour
y o u r own
o w n terms.
terms.The
The
exercise
exercise on o n page 1 4 6 will
p a g e 146 will help
help you
y o u organize
organize your
y o u r thinking
thinking about
about pros
pros aand
nd
cons
cons anda n d about
about things
things you
y o u can
c a n do
d o to
to make
m a k e medication
medication feel feel more
m o r e acceptable to
acceptable to
you.
you. This
This is is another
another page
p a g e that
that you
y o u may
m a y want
w a n t to
to copy
c o p y and
a n d bring
bring with you
with y to
o u to
your
y o u r doctor's
doctor's office-it
office—it canc a n provide
provide a a format
format for for discussing
discussing issuesissues of
of concern
concern
to
to you.
y o u . It
It may
m a y also
also be
b e helpful
helpful to to review
review this
this list
list if
if you
y o u have
h a v e the
the impulse to dis-
impulse to dis-
146
146 CAUSES
CAUSES AND
ANDTREATMENTS
TREATMENTS

THE
THE PROS
PROS AND CONS
AND C O N S OF
O F TAKING
TAKING MEDICATION
MEDICATION

REASONS
R E A S O N S TO
T O TAKE
T A K E MOOD
M O O D MEDICATION
MEDICATION

(Examples: helps
(Examples: control
helps my manic
control my symptoms, helps with
manic symptoms, my depressed
helps with mymood, improves
depressed mood, impro
my
m y sleep,
sleep,makes
makesme
m ebener
betterable
abletoto
focus, decreases
focus, mymanxiety,
decreases improves
y anxiety, mymrelating
improves withwith
y relating
other
other people,
people, decreases
decreases my
m y conflict
conflict with
with family
family members, improves my
members, improves m y energy level,
energy level,
makes me
makes m e feel
feel more
more confident,
confident, makes
makes me
m e concentrate
concentrate better at work.
better at work, keeps
keeps me from
m e from
spending
spending too
too much
much money,
money, helps
helps me
m e avoid
avoid traffic
traffic tickets)
tickets)
1I.
. __
_ _
____
____
____
____________
____
____
___

2.
2. __
____
____
____
____
____
____
____
____
____
____
__

3.
3. __
____
____
____
____
__ __
__ __
____
____
______
____

4.
4. ------

5.
5. __
____
____
____
____
____
____
____
____
____
____
__

DISADVANTAGES
DISADVANTAGES OF
O F MOOD
M O O D MEDICATION
MEDICATION

(Examples: side
(Examples: sideeffects [give
effects specifics].
[give missing missing
specifics], my high my
periods. cost of medication
high periods, and
cost of medication and
psychiatry
psychiatry visits,
visits, disliking
disliking having
having my
m y moods
moods controlled,
controlled, disliking
disliking my
m y doctor,
doctor, disliking
disliking
making
making medical
medical appointments,
appointments, makes
makes me
m e feel
feel less
less sexual
sexual or
or less
less creative,
creative, medications
medications
carry
carry a
a stigma,
stigma, medications aren't
medications aren't that
that effective)
effective)
11.
. __
________
__________
____
________
____
___

2.
2. __
________
__________
________
____
_______

3.
3. __
______
____
______
__________
___________

4.
4.
5. -------
5. __
________
______
__________
______
____
___

THINGS
T H I N G S II CAN
C A N DO
D O TO
T O IMPROVE
I M P R O V E THE
T H E SITUATION
SITUATION

(Examples: discuss
{Examples: discussside
sideeffects
effectswith physician,
with consider
physician, otherother
consider medications or dosing
medications or dosing
strategies.
strategies, take
take more
more responsibility
responsibiUty for
for my
m y own
o w nregime,
regime,change
change my
m y doctor, change m
doctor,change myy
insurance
insurance plan,
plan, educate
educate others
others about
about mmy
y disorder,
disorder, create
create reminders
reminders to take medication,
to take medication,
cut
cut down
d o w n my
m y use
use of
of alcohol
alcohol or
or drugs)
drugs)
1. __
______
______
1. ______
____
____
___________

2.
2. __
_ _________________

3.
3. __
_ _________________

4.
4. __
_ _________________

5
5.. __
____________
__________
________ __
____ _
 Coming
Coming to
toTerms withYour
lermswith Medication
Your Medication 147147

continue yourmedication,
continue your medication, to to remind
remind yourself
yourself of of your
your reasons
reasons for for taking
taking themthem
in the first place and the other alternatives available
in the first place a n d the other alternatives avaflable to you. to you.
Try
Try to
to individualize
individuahze thisthis exercise
exercise as as much
m u c h as
as possible:
possible: You
Y o u may
m a y know
k n o w of
of
advantages
advantages and a n d disadvantages
disadvantages of of the
the medications
medications thatthat II have
have not listed here.
not listed here.
Once
O n c e again,
again, your
y o u r family
family members
m e m b e r s may
m a y be
b e able to help
able to help you
y o u identify
identify the
the costs
costs
and
a n d benefits
benefits of
of your
y o u r medication.
medication.

• • •

The
T h e decision
decision to to commit
c o m m i t to to aa long-term
long-term program
p r o g r a m of of medication
medication is is aa very
very
difficult
difficult one.one. As A s you
y o u can
can see see from
f r o m this
this chapter,
chapter, peoplepeople with with bipolar
bipolar disorder
disorder
struggle
struggle with with many
m a n y practical
practical and a n d emotional
emotional issuesissues when
w h e n coming
c o m i n g to terms with
to terms with
their
their need
n e e d for
for medication.
medication. You Y o u are
are not
not alone
alone in in your
y o u r struggles
struggles to to accept
accept the the
disorder
disorder and a n d its
its required
required treatments.
treatments.
New
N e w drugs
drugs for for bipolar
bipolar disorder
disorder are are being
being developed
developed and a n d tested
tested allall of
of the
the
time.
time. In In all
all likelihood,
likelihood, some s o m e will
will prove
prove successful
successful and a n d others
others will will come
c o m e into
into
vogue
vogue for for a a while
while and a n d then
then disappear.
disappear. But But there
there is is good
g o o d reason
reason to to believe
believe that that
you
y o u will
will find
find a a medication
medication regimen regimen that that will
will work
w o r k for
for you
y o u over
over thethe long
long termterm
and
and won't
won't require
require you y o u toto tolerate
tolerate debilitating
debilitating side side effects.
effects.
A b o v e all, r e m e m b e r the m e a n i n g of the term concordance: aa collaborative
Above all, remember the meaning of the term concordance: collaborative
process
process between
b e t w e e n you
y o u and
a n d your
y o u r physician.
physician. It It is
is very
very important
important to to communicate
communicate
your
your concerns
concerns to to your
y o u r physician
physician and a n d see
see ifif anything
anything can can be be done
d o n e toto adjust
adjust
your
your regimen
r e g i m e n so
so that
that it it is
is maXimally
maximally effective
effective as as well
well as as more
m o r e easily
easily tolerated.
tolerated.
Most
M o s t physicians
physicians are are open
o p e n to
to this
this kind
kind ofof communication
c o m m u n i c a t i o n and
a n d even
even w welcome it,
e l c o m e it,
particularly
particularly if if you
y o u talk
talk toto them
t h e m before
before youy o u decide
decide to to stop
stop or or make
m a k e your
your own own
decisions
decisions about about changing
changing your y o u r medicine.
medicine. The T h e exercises
exercises in in this
this chapter
chapter can can
help
help youy o u organize
organize information
information about about youry o u r drug
drug treatmem
treatment so that yyou
so that o u cancan
work
w o r k with
with youry o u r physician
physician more m o r e efficiently
efficiently within
within the the limited
limited time time blocks
blocks that that
managed
m a n a g e d care
care allows.
allows.
Fortunately,
Fortunately, managing m a n a g i n g bipolar
bipolar disorder
disorder is is not just about
not just about takingtaking medica­
medica-
tion.
tion. In In addition
addition to to medication
medication to to help
help control
control your disorder, there
y o u r disorder, there are self­
are self-
management
m a n a g e m e n t strategies
strategies you y o u can
can useuse during
during periods
periods of of wellness
wellness (Chapter
(Chapter 88), ),
when
w h e n experiencing
experiencing the the beginning
beginning signs signs of of mania
m a n i a (Chapter
(Chapter 9), 9 ) , and
and w when
h e n de­
de-
pressed
pressed or or suicidal
suicidal (Chapters
(Chapters 110 0 and 1 ). Try
a n d 111). Try to to think
think of medication as
of medication as one el­
o n e el-
ement
e m e n t in
in a a collection
collection of of strategies
strategies for for managing
m a n a g i n g your
y o u r disorder.
disorder.
This page intentionally left blank
P A RT I I I
P A R T I I I

Self-Mana
S a ement
e l f - M a n g g e m e n t
This page intentionally left blank
 8
8

How
H o w Can
C a n I
I Manage
M a n a g e My
M y Disorder?
Disorder?

PRACTICAL
P R A C T I C A L WAYS
W A Y S

TO
T O MAINTAIN
M A I N T A I N WELLNESS
WELLNESS

Amy,
Amy, ageage 33,
33, had
had aa six-year
six-year history
history ofof bipolar
bipolar disorder.
disorder.ThreeThreeyears
yearsafter
after
being
being diagnosed,
diagnosed, she she began
began aa period
period of of rapid
rapid cycling that seemed
cycling that seemed to to be
be
provoked,
provoked, in in part,
part, by
by anan on-again,
on-again, off-again
off-again relationship
relationship withwith her boy­
her boy-
friend.
friend. When
W h e n she
sheabruptly
abruptlyrelocated
relocatedOUl-Or-Slate
out-of-statedue dueto tohis
hisbusiness,
business,her her
rapid
rapid cycling
cycling intensified.
intensified.She Sheobtained
obtainedpart-time
part-timeworkworkin inher
hernewnewcity
cityandand
sought
sought psychiatric
psychiatric treatment.
treatment. Her psychiatrist gave
Her psychiatrist gave her
her aa combination
combination of of
lithium
lithium andand Depakole,
Depakote,which which helped
helpedevenevenoutoutherhercycles,
cycles,but butsheshestill
stilex­
l ex-
perienced
perienced unpleasant
unpleasant ups ups and
and downs.
downs. Her Her sleep
sleep was
was quite
quite variable
variable from
from
night
night toto night.
night.
Her
Her psychiatrist
psychiatrist suggested
suggested that
that she
she supplement
supplement her her medication
medication treat­
treat-
ment
ment with
with therapy
therapy from
from aa psychologist
psychologist with with whom
w h o m she
she (the psychiatrist)
(the psychiatrist)
worked.
worked. The The psychologist
psychologist encouraged
encouraged her her to
to start
start aamood
mood chart,
chart,ininwhich
which
she
she kept
kept track
track ofofher
her moods
moods on on aadaily
dailybasis,
basis,thethenumber
numberofof hours
hours ofof
sleep
sleep
she
she had
had each
each night,
night,her hermedication,
medication,and andany anyevents
eventsthat
that she
shefound
foundstress­
stress-
ful,
ful,whether
whetherpositive
positiveorornegative.
negative. AtAtfirst she
firs found
t she foundthis aSSignment
this assignment to beto abe a
hassle.
hassle.SheShetold
toldher
hertherapist
therapistthat
thatitit
took
took time
time and
andsheshedidn't
didn'tlike being
like being re­re-
minded
minded of of her
her illness
illness soso frequently.
frequently. HerHer therapist
therapist acknowledged
acknowledged the the dis­
dis-
comfort
comfort of of the
the assignment
assignment but but reminded
reminded her her that
that tracking
tracking herher moods
moods was was
a
a first
firststep
steptoward
towardgaining
gainingmoremorecontrol
controloveroverthem.
them.After
Aftersome
somediscussion
discussion
she agreed to
she agreed to try
try it
itbutbutmade
made nono commitment
commitment to tokeeping
keeping the thechart
charton on aa
regular basis.
regular basis.

151 lSI
IS2
152 Sm-MANAGEMENT
SELF-MANAGEMENT

Amy and Amy and her therapist

her therapist began examining
began examining her chartsher charts
during during their
their
weekly
weekly meetings.
meetings. OverOver a a period
period of
of several
several momhs,
months, theythey began
began to identify
to identify
certain
certain behavioral
behavioral pauerns
patterns associated
associated withwith Amy's
Amy's mood
m o o d swings.
swings. For ex·
For ex-
ample,
ample, Amy A m y learned
learned that
that her
her mixed
mixed mood
m o o d states often began
states often with a
began with rejec­
a rejec-
tion
tion byby herher boyfriend
boyfriend (such(such as
as being
being ignored
ignored or or slighted
slighted by by him
him inin the
the
company of
company of others). Rather than
others). Rather directly confronting
than directly confronting him him about
about these ex­
these ex-
periences,
periences, she she would
would usually
usually go
go out
out drinking
drinking withwith her
her female
female friends that
friends that
night
night or or the
the next
next night.
night. Her
Her sleep
sleep would
would then then become
become more more disturbed,
disturbed,
and
and herher mood
m o o d would
would taketake on
on an irritable, anxious
an irritable, anxious quality.
quaHty. Her
Her mood
mood
would
would usually
usually stabilize
stabilize once
once she
she had
had reestablished
reestablished a a regular
regular bedtime
bedtime and and
wake time.
wake time.
She
She asked
asked herher friends
friends whether
whether they
they would
would feelfeel any
any differently
differently about
about
her
her if
ifsheshe went
went outoutwith
with them
them but
but didn't
didn'tdrink.
drink.None
N o n e seemed
seemed particularly
particularly
bothered by
bothered by this.
this. Although
Although she she did not stop
did not stop drinking
drinking entirely,
entirely. Amy did
A m y did
find that
find thatlimiting
limitingherheralcohol
alcoholintake
intakehelped
helped her hersleep
sleepbeuer,
better,which
whichinintumturn
made
m a d e her
her feel
feel less
less irritable,
irritable, anxious,
anxious, andand depressed
depressed the the next
next day.
day. SheShe
made clear to
m a d e clear to her
her therapist
therapist that
that she
she had
had nono intention
intention of of giving
giving upup her
her
"outrageous
"outrageous side." But with
side." But with time,
time, she
she has
has become
become moremore consistent
consistent with
with
these
these lifestyle
lifestyle habits,
habits, pleasantly
pleasantlysurprised
surprisedby by the
thebeneficial
beneficialeffects
effectsthey've
they've
had
had on on her
her mood stability.
m o o d stability.

WhatWhat can you

can you domaximize
do to to maximize your
your intervalsof
intervals of wellness
wellness and
andminimize
minimizethe
the
time you
time you spend
spend ill?
ill? Many
M a n y people
people go
go for
for long
long periods
periods of time without
of time without having
having
Significant
significant symptoms,
symptoms, but virtually everyone
but virtually everyone with
with the
the disorder
disorder has recur­
has recur-
rences
rences of illness at
of illness at some
some pOint.
point. In
In my
m y experience,
experience, the
the people
people who
w h o do
do the best
the best
over time are
over time are those
those who not only
w h o not only take their medication
take their medication regularly
regularly and
and see their
see their
doctors
doctors bm
but also
also successfully
successfully implement
implement self-management strategies.
self-management strategies.
What
W h a t does itt mean
does i m e a n to
tomanage
manage bipolar
bipolardisorder
disordersuccessfully?
successfully? In
In Chapter
Chapter 55
w e talked
we talked abom
about the
the risk factors in
risk factors in bipolar
bipolar disorder
disorder (things
(things that
that make
m a k e your
your ill­
ill-
ness worse).
ness There are
worse). There are also
also protective
protective factors:
factors: things
things that
that keep
keep you
you well
well when
when
you
you are
are vulnerable to mood
vulnerable to m o o d Swings.
swings. You
Y o u are
are already
already familiar
familiar with
with some of
some of
these
these protective factors from
protective factors from earlier
earlier chapters-for
chapters—for example, consistency with
example, consistency with
medication
medication and
and having
having social suppOrts.
social supports.
In
In essence,
essence, maintaining
maintaining wellness
wellness means
means minimizing
minimizing the
the risk
risk factors
factors and
and
maximizing the
maximizing protective facrors
the protective factors (see
(see the
the table
table on
on page 153). Sometimes
page 153). risk
Sometimes risk
and
and protective
protective factors
factors are
are simply
simply opposite
opposite sides of the
sides of the same
same coin.
coin. For
For exam­
exam-
ple,
ple, steep
sleepdeprivation
deprivationis
isaarisk
riskfactor,
factor,whereas
whereasstaying onon
staying a regular sleep-wake
a regular sleep-wake
rhythm is
rhythm is aaprotective
protectivefacLOT.
factor.InInother
othercases,
cases,protection
protectioninvolves introducing
involves aa
introducing
new
n e w element
element into
into your
your daily
daily life,
life,such
such as
askeeping
keeping aamood
m o o d chart.
chart.
Minimizing
Minimizing risk
risk and
and maximizing
maximizing protection
protection will
will almost
almost certainly
certainly improve
improve
your
your course
course of
of illness
illness and
and the
the quality
quality of
of life.
life. But
But doing
doing so
socan
canbe difficult.lrIt
bedifficult.
can
can require
require giving
giving up
up things
things that
that you
you have
have come
c o m e to depend on
to depend (for example,
on (for example,
 How
How (on
Can IIManage
ManageMy
MyDisorder?
Disorder? 153
153

drinking alcoholtotorelax,
drinking alcohol relax,staying
stayingupup lateatatnight).
late night).It
It will
will probably
probably beheimpossi-
impossi­
ble for you
ble for y o u to
to avoid
avoid every
every risk
risk factor
factor and
a n d take
take full
full advantage
advantage of every protec­
of every protec-
tive
tive factor
factor in
in the
the table.
table. For
F o r example,
e x a m p l e , some
s o m e people
people are are able
able to
to stay
stay scrupulously
scrupulously
close
close to
to their
their medication
medication regimen
r e g i m e n and
a n d have
h a v e learned
learned to to avoid
avoid alcohol
alcohol bbut
u t find it
find it
impossible
impossible to to prevent
prevent sleep
sleep disruption.
disruption. Others O t h e r s are
are able
able to
to keep relatively con­
k e e p relatively con-
sistent
sistent daily
daily and
a n d nightly
nightly routines
routines but b u t find
find it
it difficult
difficult to to regulate their exposure
regulate their exposure
to
to family
family stress
stress oror other
other interpersonal
interpersonal conflicts.
conflicts. IfIf you
y o u know
k n o w yourself
yourself well,well, you
you
may
m a y beb e able
able to to decide
decide which w h i c h risk
risk factors
factors you
y o u can
c a n and
a n d cannot
c a n n o t realistically
realistically
avoid,
avoid, anda n d which
w h i c h self-management
s e l f - m a n a g e m e n t strategies
strategies are
are possible
possible to to implement
i m p l e m e n t within
within
your
y o u r current lifestyle.
current lifestyle.
This
This chapter
chapter will
will acquaint
acquaint you
y o u with
w i t h practical
practical self-management
s e l f - m a n a g e m e n t strategies
strategies
that
that fall
fall into
into four
four broad
b r o a d categories:
categories:

• Tracking
• Tracking your
your mood mooda through
through a daily chan
daily chart
•
• Maintaining
Maintaining regular
regular routines
routines and
a n d sleep-wake
s l e e p - w a k e cycles
cycles
•
• Avoiding
A v o i d i n g alcohol
alcohol and
a n d other
other mood-altering
mood-altering substances
substances
•
• Developing
D e v e l o p i n g and
a n d maintaining
maintaining social
social supports
supports

Risk
Risk and
and Protective
Protective Factors
Factors in
in Bipolar
Bipolar Disorder
Disorder

Risk factors
Risk factors that increase yourthat increaseof
chances your chances ill
becoming of becoming ill

Risk factors
Risk factors Examples Examples

Stressful
Stressful life
life changes
changes Loss
Lossof
ofaajob,
job,gaining
gainingororlosing
losinga anew
newrelationship, birth
relationship, ofof
birth
a
a child
child
Alcohol
Alcohol and
and drug
drug abuse
abuse Drinking
Drinking binges,
binges, experiment ing with
experimenting withcocaine,
cocaine,LSD,
LSD,oror
Ecstasy,
Ecstasy,excessive
excessivemarijuana
marijuanause use
Skep
Sleep deprivation
deprivation Changing
Changing time
time zones,
zones, cramming
cramming for forexams,
exams,sudden
sudden
changes
changes in
in sleep-wake
sleep-wake habits
habits
Family
Family distress
distress or
or OIher
other n
iinterpersonal
terpersonal High
High levels
levels of
of criticism
criticism from
from aa parem,
parent, spouse,
spouse,ororpartner;
partner;
conflicts
conflicts Provocative
Provocative or
or hostile
hostile imerchanges
interchanges withwith fam ily members
family members oror
coworkers
coworkers
Inconsistency with medication Suddenly stopping your mood stabilizu; regularly missing
Inconsistency with medication Suddenly stopping your mood stabilizer; regularly missing
one or more dosages
one or more dosages
Protective factors Protective
that helpfactors that you
protect help from
protect you from ill
becoming becoming ill

Protective factors
Protective factors Examples Examples

Observing
Observing and
and monitoring your
your own
own Keepi
ng a
Keeping a daily
daily mood
mood chan
chart or
or social
social rhythm
rhythm chart
moods
moods and
and triggers
triggers for
for fluctuations
fluctuations
Maintaining
Maintainingregular dailydaily
regular and nightly Going
and nightly to bed
Going to and
bedwaking up at the
and waking up same time;
at the having
same a
time; having a
routines
routines predictable
predictable social
social schedule
schedule
Relying
Relyingononsocial and family
social supports
and family Clear
supports communication
Clear with relatives;
communication asking yourasking
with relatives; Significant
your signific
others
others for
for help
help in
in emergencies
emergencies
Engag ing in
Engaging in regular
regular medical
medical and
and Staying
Staying on
on aa consistent
consistent medication
medication regime,
regime, obtaining
obtaining
psychOSOCial
psychosocial treatment
treatment psychotherapy,
psychotherapy, attending
attending support
support groups
groups
154
154 SElF-MANAGEMENT
SELF-MANAGEMENT

The
The strategies
strategiesyou'll learnlearn
you'll will bewill
of most
be help whenhelp
of most you are feeling
when well feeling
you are or expe­ well or e
riencing
riencing only
only mild
mild mood
m o o d swings.
swings. They
They can
can also
also help
help protect
protect you
you from
from more
more se-se­
vere
vere bipolar
bipolar episodes.
episodes. Throughout
Throughout the the chapter,
chapter, II show
s h o w you
you how
h o w other
other people
people
with
with bipolar
bipolar disorder
disorder have
have used
used these
these strategies
strategies in
intheir
theirdaily
dailylives
livesand
andhow
h o wthey
they
have
have avoided
avoided some
some ofof the
the pitfalls
pitfallsassociated
associatedwith
with implementing
implementing them. them.Chapters
Chapters
9, 10, and
9, 10, 11 give
and 11 give you
you 100is
tools to
to use
use w when
h e n you want to
you want to stop
stop aa developing
developing manic,
manic,
depressive,
depressive, or
orsuicidal
suicidalepisode
episodefrom
from spiraling
spirahngbeyond
beyond your yourcontrol.
control.

Maintaining
Maintaining Wellness
Wellness Tip
Tip Na. : Keeping
N o . 11: Keeping a
a Maad
M o o d Chart
Chart

If you've
If you'vebeen
beenseeing a psychiatrist
seeing for a for
a psychiatrist longa time,
long you're
time, probably familiar familiar
you're probably
with some
with some form
form of
of mood
m o o d chart.
chart.If
Ifthis
thisisisyour
yourfirst episode,
first your
episode, psychiatrist
your or or
psychiatrist
therapist
therapist mmay
a y not
not have
have introduced
introduced this this assignment
assignment yet yet. AA mood
m o o d chart
chart isis sim­
sim-
ply
ply a
a daily
daily diary
diary of
of your
your mood
m o o d states,
states, with
withdates
datesindicating
indicatingwhenw h e n these
thesemoods
moods
start
start and
and stop.
stop. The
The chart
chart cancan also
also incorporate
incorporate information
information about your sleep,
about your sleep,
medication,
medication, andand life
life stressors.
stressors.
Why
W h y should
should you
you keep
keep a a mood
m o o d chart?
chart? First,
First,becoming
becoming aware
awareof ofeven
evensubtle
subtle
changes
changes in your mood
in your and activity
m o o d and levels will
activity levels help you
will help you recognize
recognize if if you
you areare
having
having a a mood disorder relapse
m o o d disorder relapse andand determine
determine whether
whether you you should
should contact
contact
your
your doctor to see
doctor lO see if
if aa change
change in in medication
medication wouldwould be be helpfu1.
helpful.Many
M a n y bipolar
bipolar
people
people have been able
have been able toto "head
"head offoff at
at the
the pass"
pass" their
their episodes
episodes by by observing
observing the the
minor fluctuations on
minorfluctuations their m
on their mood charts, which
o o d charts, which often
oftenherald
herald the
theonset
onset ofofma­
ma-
jor
jor manic,
manic, mixed,
mixed, or or depressive
depressive episodes.
episodes. A A picture
picture is is worth
worth a a thousand
thousand
words!
words!
Second,
Second, your doctor will
your doctor will find
find the
the chan
chart useful,
useful, in
in that
that he
he oror she
she will
will bebe
able
able to
to see
see how
h o w well
well your
your medication
medication is is working
working or,or, alternatively,
alternatively, when
w h e n it
it is
is
making
making youyou feel
feel worse
worse (such
(such as as when
w h e n antidepressants
antidepressants bring
bring about
about rapid
rapid cy-cy­
cling).
cling). HHe
e or she m
or she may
a y also
also want
want to to monitor
monitor symptoms
symptoms otherother than mania or
than mania or de­
de-
pression, such
pression, such as
as your
your anxiety,
anxiety, sleep
sleep disturbance,
disturbance, or irritability.
or irritability.
Third, you
Third, you can
can use
use your
your mood
m o o d chan
chart information
information to
to identify
identify environmen­
environmen-
tal
tal triggers
triggers of
of your
your mood
m o o d cycling,
cycling, which
which can
can then
then lead to stress-management
lead to stress-management
strategies
strategies toto lessen
lessen the
the impact
impact of
of these
these triggers.
triggers. With
With time
timeand practice,many
and practice, many
of
of my
m y clients
clients have
have become
become effective
effective at
at identifying
identifying stress
stress triggers, such as
triggers, such the
as the
onset
onset ofof their
their menstrual
menstrual cycle,
cycle, arguments with particular
arguments with particular family
family members,
members, oror
work stress.
work stress. Amy,
A m y ,for
forexample,
example,came
came to
torecognize
recognizethrough
throughmood
m o o d charting
chartingthat
that
conflicts
conflicts with
with her
her boyfriend
boyfriend were
were a a trigger
trigger for
for her
her mood
m o o d cycling.
cycling. She also
She also
found
found that
that her
her usual
usual strategy
strategy for
for coping
coping with
with distress-going
distress—going outout drinking­
drinking—
was
was contributing
contributing to
to her
her irritable mood
irritable m o o d stales
states for
for several
several days
days later.
later. This real­
This real-
ization
ization did
did not stop her
not stop her from
from drinking
drinking altogether,
altogether, but it did
but it did make her weigh
m a k e her weigh
the
the pros
pros and
and cons
cons of
of alcohol
alcohol as
as aa means
means of of self-medicating
self-medicating her
her emotions.
emotions.
 How (on
How I Manage
Con I ManageMyMyDisorder?
Disorder? ISS
155

The The
chart chart on page
on page 156 is156used
is usedin thein theNIMH NIMH Systematic
Systematic Treatment
Treatment En- En­
hancement
hancement Program Program for for Bipolar
Bipolar Disorder
Disorder (Sachs, (Sachs, 1993,
1993, 1998).
1998). ThereThere is is aa
version of
blank version
blank of this
this chart
chart atat the
the endend ofof the
the book
book that you can
that you can copy
copy for for your
your
own
o use, or you can download it from v.rww .manicdepressive.org.
w n use, or you can download it from www.manicdepressive.org. T h e website The website
also contains
also instructions for
contains instructions for filling
filling outout the
the chart,
chart, which
which are are also
also detailed
detailed be­ be-
low. Each
low. chart allows
Each chart allows you you to track your
to track your m moods for up
o o d s for up toto one month. So,
one month. So, ifif
you have started
you have started the chart in
the chart in the middle of
the middle of the month, continue
the month, continue to 1O useuse the
the
same sheet
same until the
sheet until the middle
middle of of the next month,
the next month, and then begin
and then begin a a nnew sheet. In
e w sheet. In
other words,
other words, "day "day 1" 1" need
need notnot bebe the first of
the first the month.
of the month. It It could
could be be the
the 10th,
10th,
and
and dayday 110 0 could
could be be the 20th.
the 20th.
People with
People with bipolar
bipolar disorder
disorder find find this
this toto bebe a a "user-friendly"
"user-friendly" method method of of
recording
recording the the cycling
cycling of of their
their moods
m o o d s over
over time,
time, even
even though
though it it looks
looks intimi-
intimi­
dating at
dating at first.
first. Once
O n c eyou
yougetgetused
used to toit,
it,youyoucan canusually
usuallyfill filit
l out
it out inina few
a fewmin­
min-
utes
utes each
each day.
day. I1 usually
usually suggest
suggest thatthat people
people keep keep thethe chart
chart on on an indefinite ba-
an indefinite ba­
sis,but
sis, butififthis
thisseems
seemsdaunting
daunting then thentrytryititfor
foraamonth
m o n t h or
ortwo
two to tosee
seeif ifititproves
proves
useful.
useful. After that, you
After that, you maym a y decide
decide to tochan
chartyouryour moods
m o o d s in
inaadifferent
differentway w a y (or
(or
your
your doctor
doctor may m a y have
have another
another chartchart for
for youyou to to use).
use).
For
For now,
n o w , let's
let's consider
consider Amy's
Amy's mood m o o d chan,
chart, which
which she she completed
completed during during aa
month
month in in which
which she she experienced
experienced Significant
significant mood fluctuations. Her
m o o d fluctuations. Her "X""X"
marks
marks indicate
indicate her her mood
m o o d states
states on on any
any given
given day.day. Notice
Notice thatthat on on some
some days days
she
she has
has made
m a d e twotwo ratings,
ratings, oneone forfor mania
mania and and one one for
for depression
depression (her (her mixed
mixed
mood states)
m o o d states). .
Amy
A m y identified
identified some s o m e of
of the
the factors
factors thatthat contributed
contributed to to her
her mood swings,
m o o d swings,
including life events such as the illness of her dog. Her mood had been rela-
including life events such as the illness of her dog. Her m o o d had been rela­
tively
tively stable
stable (note
(note the the absence
absence of of "peaks"
"peaks" between
between the the argument
argument with with herher dad
dad
and
and the
the rejecting
rejecting event event with
with herher boyfriend)
boyfriend), , but
but then
then sheshe stayed
stayed out late at
out late at aa
concert
concert andand experienced
experienced aa hypomanic
hypomanic period. period. By By day
day 16 16 of
of the
the month,
month, she'd she'd
had
had seven
seven consecutive
consecutive nights nights of of poor
poor sleep
sleep and and began
began to to experience
experience mixed mixed
mood
m o o d symptoms.
symptoms. Her Her medication
medication was was notnot changed
changed duringduring this this interval,
interval, bUl but
she
she hadhad been
been inconsistent
inconsistent with with her her regimen
regimen during during daysdays 10 10 and
and 111. 1 . So
So she
she
identified
identified fourfour things
things thatthat may
m a y have
have correlated
correlated with with her her mood
m o o d shifts
shifts during
during
this
this particular
particular month:
month: eventsevents involving
involving her her pet,
pet, problems
problems with with herher boyfriend,
boyfriend,
sleep
sleep deprivation,
deprivation, and and medication
medication inconsistencies.
inconsistencies.
We
W e don't
don't know
k n o w for
for sure
sure whether
whether these
these variables
variables would
would have
have affected
affected
Amy's
Amy's moods
m o o d s during
during aa different
different month.
month. This
This is
is one
one of
of the
the reasons it is
reasons it is im­
im-
portant
portant to
to keep
keep the
the chart
chart on
on an
an ongOing
ongoing basis-to
basis—to detennine
determine whether
whether you
you
have
have aa predictable
predictable set
set ofof "mood
" m o o d triggers"
triggers" (for
(for example,
example,arguments
arguments with
with fam­
fam-
ily
ily members, final exams,
members, final exams, changing
changing time
time zones,
zones, aa specific
specific pattern
pattern of
of sleep
sleep
deprivation).
deprivation). Identifying
Identifying moodm o o d triggers
triggers is
is an
an important
important step
step in
in gaining
gaining con­
con-
trol
trol over
over your
your moods,
m o o d s , as
as you'll
you'll learn
learn more
more about
about in
in this
this and
and subsequent
subsequent
chapters.
chapters.
 Psyctiotic Symptorrs
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If
f

Strange Ideas, Hallucinations

a;
......

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�� H
af
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,-

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,-
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g ra •§ Significant Impairment
'a.s 5 ABLE TO W O R K
^ 2 Wittiout significant
...

XXXXXXXXX XX
fi

o ^ impairment
0 indicate best_

CM CO in CD CO O)0 OJc^Ti-10(Dr^CO CJ)0 CM CVJ CO d (§Is^ m 'cm 8 CO

SYMPTOMS
. � NO SYMPTOMS

indicate Menses
""_
ElEVATED OR
Q£PREsseOR

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o.

to
date \0
OEANlTElY
NOT

X XX X XX
DEFINITELY

CM CM CM
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MOOD ""

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ELEVATED
-
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""'"

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Q
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MOOD

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s
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"'"

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X XX X X X X X X XX X
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c Q. 5 ABLE TO W O R K
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SeU-Rated Mood Chart.
Hours Slept Last Night tvtoOSto^0^0tS-o0 into tointo(0^ tototo•0r^l>r--iN® IStoto to inin «
{
i
l
•
g

X
u
T3
Anxiety - - Q 0 0 0 0 0 - - 0 0 0 0 0 INCM egCM CM Q 0 0 0 0 0 0 0 0 0 Q 0
I

0
I g�

, 19'"
illi Irritability - - Q 0 0 0 0 0 c 0 0 - 0 0 0 CJ- - - - - - - - - - - 0 0 - - T3
� •
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U
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u^
•| V
E 0 1/1

Amy's
2000
August -

to
Chart
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Mood CI'I&�

y
""""'-

"" -

1 1 1 p
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•s

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�
•

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•

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156
 How Can IIManage
How (an ManageMy
My Disorder?
Disorder? 157
157

Step Raling
Step 1:1: VourYour
Rating MoodMood
Each Each
Day Day

The
The first
first stepstep in learning
in learningto fill out toa fiHmood outchart is to become
a mood chart is familiar with a familia
to become
numerical
numerical scale scale that that corresponds
corresponds to to various
various levels
levels of of your
your mood
mood disturbance.
disturbance.
The
The sidebar
sidebar gives gives you you guidelines
guideHnes for for making
making judgments
judgments about about your daily
your daily
mood,
mood, using
using aa scale from -3
scale from -3 (severe
(severe depression)
depression)to to+3+3(severe
(severemania).
mania).ItIt givesgives
examples
examples of of how people with
h o w people with bipolar
bipolar disorder
disorder feel feel and
and think
think (and what they
(and what they
say) when
say) when they're
they're in in these
these various
various states
states (see
(see also
also Young
Young et et aI.,
al, 1978).
1978). Not Not ev-
ev­
ery example
ery example or or descriptive
descriptive label label inin the
the table
table need
need apply
apply to to you
you inin order
order to to use
use
the
the corresponding
corresponding scale scale number.
number. Rather,
Rather, try try to
to figure
figure outout which
which category
category of of
depression
depression or or elevation
elevation best best describes
describes how how you you feel
feel onon aa given day.
given day.
Mood
Mood charting
charting requires
requires aa bit bit ofof practice.
practice.You Youmay maybe beaaperson
personwho w h o isis nat­
nat-
urally
urally able
able to to judge
judge for for yourself
yourself whether
whether you you areare feeling
feeling manic
manic or depressed,
or depressed,
and
and you
you maymay be be easily
easily able
able toto describe
describe the the experience
experience to to others.
others. Alternatively,
Alternatively,
the
the descriptive
descriptive label label "manic'·
'"manic" or or "depressed"
"depressed" may may not not fully
fully capture
capture the the way
way
you feel. If this is the case, take time to learn the mood chart and numerical
you feel If this is the case, take time to learn the mood chart and numerical
scales
scales andand try try to to see
see ifif you
you cancan equate
equate the the terms
terms used
used inin the
the chart with your
chart with your
particular
particular way way of of describing
describing mood mood stales.
states.For Forexample,
example, depressed
depressed cancan mean
meanthe the
same
same thing
thing as "crashed"; elevated
as "crashed"; elevated can can mean
mean the the same
same thing
thing as "wired."
as "wired."
Practice
Practice by by seeing
seeing if if you
you cancan apply
apply aa mood descriptor La
mood descriptor to your mood today
your mood today
and
and yesterday,
yesterday, using usingthe the-3 -3--++33scale.scale.I fIfyouyouareare unsure
unsureasastotowhether
whetheryour your
rating is
rating is reasonable,
reasonable, ask ask someone
someone who w h o knows
knows you you well
well (perhaps
(perhaps a family
a family
member
member or or your
your partner)
partner) ififhe heor orshe
shewould
wouldagreeagreewithwithyour
yourrating.
rating.IfIfyou youfeel
feel
that
that your
your mood mood varies varies conSiderably
considerably during during the the day,
day, make
make a a "best"
"best" and and a a
"worst"
"worst" rating
rating (for (for example,
example, you you maymaybe beat ataa-2-2in inthe
themorning
morningand and aa-1 -1 oror00
by
by evening).
evening). If If your
your moodmood has has been
been bothboth elevated
elevated and and depressed
depressed on on the
the same
same
day,
day, make
make two two ratings,
ratings, indicating
indicatingthe thehighest
highestand andlowest
lowestpoints.
points.
In
In choosing
choosing your your level,
level,try tryto tothink
thinkabout
aboutthe theleast
leastand
andmost
mostdepressed
depressedor or
manic
manic you've
you've ever ever beenbeen in in your
your life
lifeandanddetermine
determinewhere wherethese
thesestates
statesfitfiton onthe
the
scale.
scale.For Forsome somepeople,people,their their worst
worst period
period ever
evermight
might have
have been
been a- a 1-1;
; for
foroth­
oth-
ers
ers it
it might
might have have beenbeen a a -3.
-3. IfIf your
your moodmood has has never
never gone
gone above
above or or below
below a 2,
a 2,
use
use these
these as as benchmarks
benchmarks for for judging
judging your your mood
mood todaytoday andand throughout
throughout the the
week.
week.
Compare
Compare your your depression
depression level level today
todayagainst
againstaatypical
typicaldayday(your
(yourbaseline,
baseline,
or
or how
how you you feel feel most
mostof ofthethetime,
time,whichwhichwouldwouldrate ratea a0).
0).Then
Thencompare
compareyour your
mood
mood to to other
other days days when
when you you felt
felt blue
blueor oroutoutof ofsorts
sortsbut
butnot
notimpaired
impaired (-1), (-1),
days
days when
when you you have have felt
feltimpaired
impairedbut butcould
couldstill
stillfunction
functionwithwithsignificant
significantdif­ dif-
ficulty
ficulty (-2),
(-2), and,and, if if applicable,
applicable,days dayswhenwhenyou youfeltfeltsosodown
downthat that you
youcouldcould notnot
work
work at at all
all or orinteract
interactwith others(-3).
withothers (-3).These
These comparisons
comparisonsshould should help help youyou
determine
determine today's today's rating.rating. likewise,
Likewise, try try toto think
think of of the
the most
most manic manic or or
hypomanic you've
hypomanic you've ever ever felt.
felt. IfIfyou
youwerewereevereverseverely
severelymanicmanicand andin inthethehospi-
hospi-
158
158 Sm-MANAGEMENl
SELF-MANAGEMENT

Mood
M o o d Descriptors
Descriptors

(0) "WNL"
(0) (within normal
"WNL" (within normallimits). ThisThis
limits). is your
is baseline: Your mood
your baseline: Yourismood is
not elevated
not elevated or
or depressed,
depressed,your
yourenergy levelis
energylevel isnormal
normalfor
foryou,
you,sleep
sleepisis
normal, and you're
normal, and you're able to carry
able to carry out
out your
your daily
daily work
w o r k and
and other
other tasks
tasks
with
with little
little or
or no
no difficulty.
difficulty. You
Y o u have
have no
no other
other obvious
obvious symptoms of
symptoms of
your
your mood
m o o d disorder.
disorder.

Elevated Mood
Elevated Mood

(+ 1) Mildly
(+1) Mildlyelevated.
elevated.YouYou
areare
feeling giddy,giddy,
feeling cheerful, or energized,
cheerful, or
or energized, or
somewhat
somewhat more
more irritable
irritable or
or anxious
anxious or
or nervous
nervous than
than usual.
usual, but
but you
you
are
are nol
not really
really impaired;
impaired; you
you have more energy
have more energy and
and more
more ideas,
ideas, and
and
you feel
you feel more
more self-confident but have
self-confident but been able
have been able to
to work effectively
w o r k effectively
and relate normally
and relate normally to
to others.
others. ''I'm
"I'm more
more restless/animated/talkative
restless/animated/talkative
today
today than
than usual,"
usual," "I'm
"I'm making
making more
more phone
phone calls,"
calls," ''I'm
"I'm getting
getting by
by
with
with a
a little
little less
less sleep"
sleep" (for
(for example,
example, one
one or
or two
two hours
hours less
less than
than
usual).
usual), "I'm
"I'm more
more easily
easily distracted
distracted today,"
today," "I'm snapping at
"I'm snapping at people
people
more. n"I'm more
more," "I'm more frustrated
frustrated by
by little
little things,"
things," "I'm
"I'm somewhat
somewhat revved
revved
up
up or
or wired,"
wired," "My mind is
" M y mind is clicking
clicking along
along a
a little
little faster,"
faster," "I'm feeling
"I'm feeling
sexier,"
sexier," ''I'm
"I'm more
more optimistic,"
optimistic," '''I'm
"I'm hypomanic."
hypomanic."

(+2) Moderately
(+2) Moderatelyelevated.
elevated."High" or moderately
"High" manic;
or moderately youryour
manic; mood is is
mood
euphoric
euphoric or
or very
very irritable
irritable and
and 'anxious,
anxious, and
and people have told
people have told you it
you it
seems
seems inappropriate;
inappropriate; you
you feel
feel like breaking things;
like breaking things; you
you feel
feel heavily
heavily
goal�driven
goal-driven and
and hypersexual
hypersexual and your thoughts
and your thoughts are
are going
going very fast;
very fast;
you
you have
have Significant
significant difficulty
difficulty fOCUSing
focusing on
on your
your work;
work; you
you are
are having
having
run-ins with people
run-ins with (they seem
people (they seem to
to be moving and
be moving and talking
talking too
too slowly);
slowly);
people are
people are complaining
complaining that
that you
you seem
seem angry
angry or
or grouchy
grouchy or
or are
are
moving
moving way
w a y too
too fast;
fast; you
you yelled
yelled at
at others
others inappropriately.
inappropriately. You
Y o u are
are
sleeping
sleeping as
as little
Httle as
as four
four hours
hours per
per night
night and
and not
not feeling
feeling tired.
tired. "I'm
"I'm
feeling
feeling very
very impatient
impatient today," "I think
today," "1 think 1I can
can get
get by
by with
with a
a lot less
lot less
sleep,"
sleep," "I'm
"I'm very
very preoccupied
preoccupied with
with sex,"
sex," "My
" M y mind
mind is
is working faster
working faster
than
than ever,"
ever," "I
"I have
have so
so much
m u c h to
tosay
say and
and IIhate
hatebeing
beinginterrupted."
interrupted,""I'm
"I'm
feeling
feeling irritated,
irritated, angry
angry at
ateverything."
everything."

(+3) Severely
(+3) Severelyelevated/manic. Euphoric
elevated/manic. or aggresSive;
Euphoric you are laughing
or aggressive; you are laughing
constantly
constantly or
or your
your irritability
irritability is
is out
outof
ofcontrol;
control;you
youhave
havehad
hadloud
loudver­
ver-
bal or
bal physical fights
or physical fights with
with people;
people; you
you feel
feel like
like you
you are
are exceptionally
exceptionally
 How
How (on
Can IIManage
ManageMy
MyDisorder?
Disorder? 1St
159

talented
talented or
or have
h a v e special
special powers
p o w e r s (for
(for example,
e x a m p l e , the
the ability
ability to read peo­
to read peo-
ple's
ple's minds,
m i n d s , to
to change
c h a n g e the
the weather),
weather), you
y o u are
are constantly
constantly moving
m o v i n g about
about
and
a n d cannot
cannot sit
sit still;
still; you
y o u are
are unable
unable to
to work
w o r k or
or get
get along
along with others;
with others;
you
y o u have
h a v e gotten in trouble
gotten in trouble in
in public,
public, have
h a v e been
b e e n stopped
stopped by the police
b y the police
or
or have
h a v e been
b e e n taken
taken to
to the
the hospital;
hospital; you
y o u are
are sleeping
sleeping little
little or
or not
not at
at all.
aU.

Depressed
Depressed Mood
Mood

( 1) Mildly
-
(-1) Mildly depressed.
depressed.You
Youare feeling
are slightly
feeling slowed
slightly down
slowed or sad;
down or sad;
you
you have
have trouble
trouble keeping
keeping certain
certain negative
negative thoughts
thoughts out
out of
of your
your head;
head;
you feel
you feel more
m o r e self-critical,
self-critical,you
youwant
wanttotosleep
sleepmore
moreor
orare
arehaving
havingslight
slight
trouble
trouble falling
falling or
or staying
staying asleep,
asleep,and
andyou
you feel
feelsomewhat
somewhatmore
morefatigued
fatigued
than
than usual;
usual; you
you wonder
wonder if
iflife
lifeisisworth
worthliving;
living;things don't
things seem
don't seemasas
in­
in-
teresting
teresting as
as they
they usually
usually do;
do; you
you are
are still
still able
ableto
towork
w o r k effectively
effectivelyand
and
are
are relating
relating nonnally
normally to
to others,
others, even
even though
though you
you may
m a y feel
feel less
less effec­
effec-
tive;
tive; your
your depression
depression is
isnot
not obvious
obvious to
toothers.
others.

(-2) Moderately
(-2) Moderately depressed.
depressed.You
You are
are feeling
feelingvery
verysad, down
sad, down in
in the
the
dumps,
d u m p s , hopeless,
hopeless, moderately
moderately slowed
slowed down,
d o w n , or
or uninterested
uninterested in
in things
things
for
for most
most of
of the
the day;
day; you
you are
are sleeping
sleeping more
more or
or having
having a
a lot
lot of
of trouble
trouble
falling asleep or
falling asleep or staying
staying asleep
asleep (for
(for example,
example, waking
waking up
u p regularly in
regularly in
the
the middle
middle of
of the
the night)
night);; fewer
fewer and
and fewer
fewer things
things are
are of
of interest to you;
interest to you;
you
you are
are ruminating
ruminating a
a lot
lot about
about current
current or
or past
past failings;
failings;you
you are
arefeeling
feeling
grouchy
grouchy and
and irritable;
irritable; you
you have
have significant
significant difficulty
difficulty getting
getting your
your
work
w o r k done
done (missing
(missing days
days at
at work or school
w o r k or school or
or being
being less
less productive);
productive);
your
your concentration
concentration is
is impaired;
impaired; others
others comment
c o m m e n t that
that you
you seem
seem mo­
mo-
rose
rose or
or slowed
slowed down
d o w n or
or that
that you're
you're speaking
speaking slowly;
slowly;you
you have
have consid­
consid-
ered
ered suicide
suicide and
and have
have thought
thought of
of various
various methods.
methods.

(-3) Severely
(-3) Severelydepressed.
depressed.You feel
You deeply
feel sad sad
deeply or numb; youyou
or numb; have lostlost
have
interest
interest in
in almost
almost eVerything;
everything; you
you are
are experiencing
experiencing severe suicidal
severe suicidal
feelings,
feelings, you
you wish
wish to
todie
dieor
orhave
have made
m a d e an
an attempt
attempt on
on your
your life;
life;you
you
feel
feel extremely
extremely hopeless;
hopeless; you
you believe
believe you
you have
have sinned
sinned terribly
terribly and
and
should
should be
be punished;
punished; you
you are
are unable
unable to
to work,
work, concentrate, interact
concentrate, interact
with
with others,
others, or
or complete
complete self-care
self-care tasks
tasks (for
(for example,
example, bathing,
bathing, wash­
wash-
ing
ing clothes);
clothes); you
you stay
stay in
in bed
bed most
most of
of the
the day
day andlor
and/or cannot
cannot sleep
sleep and
and
have
have severe
severe problems
problems with
with lack
lack of
of energy.
energy.

Sources: Sachs(1998);
Sources:Sachs (1998);Young
Youngctet
al.al.
(1978); Will
(1978); iams (1988)
Williams (1988)
166
160 SElf-MANAfiEMENl
SELF-MANAGEMENT

tal, your
tal, yourrating at thal
rating lime time
at that would have have
would a +3. aIf+3.
been been you If youever
have been
have ele­been ele-
ever
vated to
vated to the
the extent
extent that
that you
you were
were having
having trouble
trouble functioning
functioning at work,your
at work, your rat­
rat-
ing would
ing would be a +2.
be a +2. If
If you
you have
have been
been "wired"
"wired" and
and ""upbeat,"
upbeat," but
but this
thisstate
state did
did
not cause
not cause run-ins
run-ins with
with olhers
others or
or make
m a k e it
it difficult
difficult to
to sleep,
sleep, a
a+ 1 (hypomanic)
+1 (hypomanic)
probably
probably applies.
applies. In
In other
other words,
words, think
think in
in terms
terms of your own
of your o w n personal
personal
benchmarks.
benchmarks.

Slep 2:
Step 2:Recording
RecordingYour Anxiety
Your .ndand
Anxiety Irrit.bility
Irritability

You'll notice
You'll noticethat thethe
that mood chart
mood alsoalso
chart asks asks
you to rate
you to your
rateanxiety and irri­and irri-
your anxiety
tability
tability levels
levels on a 0-3
on a 0-3 scale.
scale. There
There are
are two
two reasons to do
reasons La do this.
this. First,
First, anxiety
anxiety
and
and irritability
irritability can
can be
be the
the first
first signs
signs of
of a
a new
n e w manic
manic or mixed episode.
or mixed episode. Sec­
Sec-
ond, some medications
ond, some medications may
m a y produce
produce these
these symptoms
symptoms as
as side
side effects
effects (for ex­
(for ex-
ample, the SSRI
ample, the SSRI antidepressants). So, it's
antidepressants). So, it's a
a good
good idea
idea to track these
to track these symp­
symp-
toms, even
toms, even if
if you're
you're not
not sure
sure how
h o w they
they are
are related
related to the cycling
to the of your
cycling of your
bipolar disorder.
bipolar disorder.
Examples of "1"
Examples of "1" levels
levels of
of irritability
irritability include
include feeling
feeling somewhat
somewhat snappish or
snappish or
grumpy,
grumpy, but
but not
not to
to the
the extent
extent that
that you
you can't
can't function
function alongside
alongside people. A "r
people. A "2"
would
would mean
m e a n moderate
moderate irritability
irritability that
that causes
causes problems
problems for
for you
you at
at work
work or at
or at
home.
home. A "3" would
A "3" mean
would m e a n that
that you
you were
were severely
severely irritable
irritable and angry to
and angry to the
the ex­
ex-
tent
tent that
that you
you were
were having
having real
real trouble
trouble functioning. Likewise, aa"1"
functioning. Likewise, "1" anxiety
anxietyrat­
rat-
ing
ing would
would mean
m e a n feeling mildly jittery,
feeling mildly jittery, apprehensive,
apprehensive, and
and perhaps
perhaps scared
scared but
but
able
able to
to get
get along with minimal
along with minimal extra
extra effon. A "2"
effort. A "2"would
would mean
m e a n moderate
moderateanxi­
anxi-
ety
ety that
that makes
makes it
it difficult
difficult to
to work,
work, read,
read, socialize,
socialize, or
or perform
perform daily chores;
daily chores;
however, you're still
however, you're still able
able to function with
to function with extra
extra effort. A "3"
effort. A "3" would
would mean
mean
overt
overt panic
panic and
and severe,
severe, incapacitating
incapacitating anxiety.
anxiety.

Slep 3:
Step 3:Recording
RecordingYour Hours
Your of Sleep
Hours of Sleep

Along with
Along with your
your mood
mood rating,
rating,make
makea a
daily rating
daily of how
rating of many hours
how many of sleep
hours of sleep
you
you had
had the
the previous
previous night.
night. If
Ifyou're
you're rating
rating your
your mood
m o o d for,
for,say, Thursday,re­
say,Thursday, re-
cord the hours
cord the hours you
you slept
slept Wednesday
Wednesday night
night to
to Thursday
Thursday morning.
morning. If
Ifyour
your sleep
sleep
is
is intermittent,
intermittent, try
try to
to estimate
estimate the
the actual
actual number
number of
of hours
hours you
you were asleep.
were asleep.
Your recall
Your recall of
of your prior night's
your prior night's sleep
sleep may
m a y be
be most
most accurate
accurate when you ffirst
w h e n you irst
wake up in
wake up in the
the morning.
morning.
If you
If you take
take naps
naps regularly,
regularly, separately
separately recording
recording nighttime and daytime
nighttime and daytime
sleep
sleep will
will allow you to
allow you to investigate
investigate whether
whether napping
napping in
in the
the afternoon
afternoon makes
makes
it
it harder
harder to
to sleep
sleep that
that night
night or
or makes
makes your
your mood
m o o d worse
worse by
by the
the end
end of the
of the
day_
day.
After
After a
a week
week or
or more
more of
of doing
doing this
this charting,
charting, you
you may
m a y begin
begin to
to see
see how
how
your
your sleep
sleep and
and mood are related.
m o o d are related. Many
M a n y people
people are
are surprised
surprised at
at the result.
the result.
 How
How(an
CanI Manoge My My
I Manage Disorder?
Disorder? 161161

Amy, for example,

Amy, for example, had always assumed
had always that lack
assumed that lack of
of sleep
sleepcaused
causedher
hertotogetget
more
more depressed,
depressed, yet
yet she
she found
found from
from her
her mood
m o o d chaning
charting that
that sleep
sleep loss
loss was
was
more
more consistently
consistently associated
associated with
with her
her hypomanic
hypomanic periods
periods (note
(note the shift on
the shift on
day 10
day 10 of
of her
her chan).
chart).

Step 4:
Step 4:raking
TakingDai/y
DailyNot., on on
Notes LifeLife
Events and Soci./
Events Stresso"
and Social Stressors

If you
If youfeel
feelthat your
that mood
your hashas
mood been influenced
been by one
influenced by or more
one eventsevents
or more or inter­
or inter-
actions with
actions with others,
others, record
record these
these onon your
your chart
chart under
under "Daily
"Daily Notes."
Notes." S Some
o m e of
of
these
these may
m a y be
be Significant
significant (for
(for example,
example, breaking
breakingup up with
withyour
your partner,
partner,quitting
quitting
your
your job)
job) and
and others
others may
m a y seem
seem minor
minor (having
(having a a change
change in in work
work hours; racing
hours; racing
to the
to the airport
airport to
to catch
catch a
a plane;
plane; getting
getting stuck
stuck in
in a
a traffic
trafficjam).
jam). Record
Record all
allevents
events
that
that you
you feel
feel may
m a y be
be important,
important, eveneven if
ifthey
theyseem
seem asasif
ifthey
theywould
wouldbe beinconse­
inconse-
quential
quential for
for many
m a n y people. For example,
people. For example. Amy
A m y found
found that
that even relatively rou-
even relatively rou­
tine
tine quarrels
quarrels with
with her
her father
father were
were associated
associated with
with a a mild
mild drop
drop in
in her
her mmood (lO
o o d (to
a -1). The
a -1). The purpose
purpose here
here isis to
to observe
observe thethe connection
connection between
between specific
specific events
events
and
and specific
specific mood
m o o d changes.
changes. WhenW h e n reviewing
reviewing the the day
day and
and filling out your
filling out your
chart,
chart, consider
consider questions
questions such
such asas the
the following:
following:

• What
• What happened
happened right right before
before I last
I last feltirritable
felt irritable ororhypomanic?
hypomanic?
•
• What
W h a t happened
happened right
right after
after my
m y irritable
irritable mood
m o o d set
set in?
in?
•
• What
W h a t happened
happened right
right before
before my
m y mood
m o o d spiraled
spiraled downward?
downward?

WhenWhen
you'reyou're recording
recording stressors,
stressors, recallthe
recall theissue
issue raised
raised in Chapter5:5:it it
inChapter
can
can be
be difficult to tell
difficult lO tellwhether
whether stress
stresswas
was the
thecause
cause ororthe
theeffect
effectof
ofyour
your mood.
mood.
Over
Over time,
time, mood
m o o d chaning
charting maym a y help
help you
you determine
determine thethe timing
timing of events in
of events in re­
re-
lation
lation to
to changes
changes in in your
your mood.
m o o d . For
For example,
example, did
did you
you race
race to
to the airport and
the airport and
then
then feel
feel an
an increase
increase in in your
your energy
energy level
level and
and mood,
m o o d , or
or were
were you feeling
you feeling
speedy
speedy before
before you
you raced
raced toto the
the airport?
airport? Did
Did you
you get
get into
into an
an argument
argument with with
your
your father
father and
and then
then feel
feel down
d o w n about
about yourself,
yourself, or
or were
were you
you feeling
feeling down be­
d o w n be-
fore you
fore you got
got into
into the
the argument?
argument? Don'tDon't wony for now
worry for n o w if
ifyou're
you're not
not sure
sure which
which
caused which.
caused which. Instead,
Instead, just
just try
try to
to identify
identify the
the factors
factors that
that coincide:
coincide:stressful
stressful
events,
events, mood
m o o d states,
states, and
and sleep patterns.
sleep patterns.
The
The "Daily
"Daily Notes"
Notes" section
section isis also
also aa good
good place
place to
to record your alcohol
record your alcohol or
or
drug use. If
drug use. If you
you drank on aa specific
drank on specific day,
day,record
record that
thatinformation
information as
as an
an event
event
even
even if
if your
your intake
intake seemed
seemed trivial
trivial (for
(for example,
example, "drank
"drank one
one beer"
beer" or
or "had
"had aa
margarita").
margarita"). Then
T h e n you
you can
can observe
observe forfor yourself
yourself whether,
whether, and
and to
to what degree,
what degree,
alcohol
alcohol or
or drug
drug usage
usage affects
affects your
your mood
m o o d the
the next
next day.
day. You
You mmay also learn
a y also learn
whether
whether you
you areare using
using substances,
substances, in in part, to alleviate
part, lO alleviate a
a negative
negative mood state
m o o d state
from
from the
the previous
previous days days or
or week.
week.
162
162 SElF-MANAGfMENT
SELF-MANAGEMENT

Step 5:
Step 5:Recording
RecordingYour Treatments
Your Treatments

Record all
Record allofof
thethe
medications andand
medications dosages you you
dosages are supposed to take
are supposed to at the top
take at the top
of
of the left columns
the left columns of ofthe
the chart,
chart,including
includingmedications
medicationsthat thatare
arenotnotspecifically
specifically
for
for your bipolar disorder
your bipolar disorder (for(for example,
example, blood pressure pills).
blood pressure pills). InIn the boxes cor-
the boxes cor·
responding
responding to to the
the day
day ofof the
the month
m o n t h you're
you're rating,
rating, record
record the the number
n u m b e r you ac­
you ac-
mally took.
tually This will
took. This will help
help you,
you, your
your physician,
physician, and and other
other members
members of of your
your
treatment team
treatment team toto know if inconsistencies
k n o w if inconsistencies in your use
in your use of of medication
medication is is affect­
affect-
ing your
ing your day-ta-day
day-to-day mood.mood. Amy A m y missed
missed her her evening
evening dosages
dosages on on the night she
the night she
went
went to to the
the coneen
concert andand thethe next
next evening
evening as as well,
well, which
which probably
probably comributed
contributed
to her
to her mood
m o o d instability.
instability. As As IItalk
talkabout
aboutin inChapler
Chapter7, 7,most
mostpeople
peoplemissmissaamedi­
medi-
cation
cation dosage
dosage once
once in in a
a while,
while, butbut it's
it's important
important to to keep track of
keep track these seem­
of these seem-
ingly minor inconsistencies.
ingly minor inconsistencies. likewise,
Likewise, placeplace aa check
check markmark nextnext to to any
any days
days
when you attended
w h e n you attended a a psychotherapy
psychotherapy session.session. As A swith
with medication,
medication,some some people
people
are
are quite
quite regular
regular andand others
others areare quite
quite irregular
irregular inin their
their therapy altendance.
therapy attendance.
You
Y o u may
m a y be
be taking
taking some
some of of your
your medications
medications "as "as needed."
needed." For For example,
example,
some
some people
people take
take a a medication
medication like like Klonopin
Klonopin only only when
w h e n they
they can't
can't get
get toto
sleep.
sleep. Indicate
Indicate "as"as needed"
needed" on the top
on the top left
left column
column of of your
your mood
m o o d chart
chart next
next toto
medications
medications that that f fit
it this
this description.
description. Some S o m e people
people findfind that
that their
their mood
m o o d isis
lower
lower on on the
the day
day after
after they
they have
have taken
taken an an as-needed
as-needed medication.
medication. OthersOthers findfind
that
that cenain
certain as-needed
as-needed medications
medications (for (for example,
example, the the allergy
allergy medication
medication
pseudoephedrine) make them feel temporarily energized, wired, or
pseudoephedrine) m a k e them feel temporarily energized, wired, or even
even
hypomanic.
hypomanic.
Your physician will
Your physician will bebe able
able toto use
use your
your medication
medication records
records in in aa number
number of of
ways.
ways. Let's
Let's imagine
imagine thatthat hehe or
or she
she has
has prescribed
prescribed Depakote
Depakote and and an an SSRI anti­
SSRI anti-
depressam. Let's also imagine that your chart indicates improvements in your
depressant. Let's also imagine that your chart indicates improvements in your
mood
m ood a week or
a week or two
two after
after you
you staned
started the the SSRI,
SSRI, but then you
but then you began
began to report
to report
"roller-coastering"
"roller-coastering" or or rapid
rapid cycling
cycling of of your
your emotions
emotions and and energy
energy levels.
levels. IfIf all
aU
of this is
of this is documented
documented on on your
your chan,
chart, your
your physician
physician may m a y decide
decide to discon­
to discon-
tinue
tinue thethe antidepressant
antidepressant or or adjust
adjust your
your dosage
dosage as as aa way
w a y of stabilizing your
of stabilizing your
mood.
mood.

Step 6: Recording
Step 6: Recording Your
Your Weight
Weight and
and Menses
Menses

Twoother
Two other pieces
pieces of
ofinformation will
information help
will round
help out out
round youryour
mood chart.
mood First,First,
chart.
record
record your weight at
your weight at least
least once
once during
during the month. It's
the month. It's best
best to
to weigh
weigh yourself
yourself
on
on the
the same
same day
day each
each month
m o n t h so
so that
that you
you can see whether
can see your medication,
whether your medication,
stress,
stress, or
or mood
m o o d cycling
cycling isis connected with changes
connected with changes in
in your
your weight. For exam­
weight. For exam-
ple,
ple, if you are
if you are gaining
gaining weight
weight on on an
an atypical
atypical antipsychotic (for example,
antipsychotic (for example,
Zyprexa), your
Zyprexa), your physician
physician maym a y choose
choose toto switch
switch you
you toto a
a different
different medication
medication
within
within the
the same
same class
class (for
(for example,
example, Risperdal)
Risperdal) or
or adjust your dosage.
adjust your If you
dosage. If you
 How
How (an
Con IIManoge
ManageMyMyDisorder?
Disorder? 163
163

are
are a
a woman, circlethe
woman, circle thedaysdaysonon which
which youyou
had had
your your period.
period. Youyour
You and and your
doctor
doctor may
m a y wish
wish to
to examine
e x a m i n e whether
whether your
your mood
m o o d cycles
cycles begin
begin before,
before, during,
during,
or after
or after the
the onset
onset of
of your
your menses.
menses.

E.a/uating Yaur
Evaluating Your Mood Chart
Mood Chart

Share your
Share yourcompleted
completed mood
mood chartchart
with with
your your therapist
therapist or physician
or physician during during
each visit.
each visit. Together,
Together, you y o u can
can evaluate
evaluate thethe influence
influence of of certain
certain stressors
stressors onon
your
your mood,
m o o d , the
the influence
influence of of sleep
sleep disturbances,
disturbances, and a n d the
the effects
effects of of various
various
medications
medications and a n d your
your consistency
consistency with
with them.
them. Even
E v e n if
ifyou're
you're not
not meeting
meeting regu­
regu-
larly
larly with
vidth your
your doctor
doctor oror therapist,
therapist, make
make a a point
point of of examining
examining thethe chart
chart at
at the
the
end
end ofof each
each week
w e e k to
to see
see if
if any
any patterns
patterns jump
j u m p out
out at at you.
you. Keeping
Keeping the the chart
chart
over a
over a year
year or m o r e will
or more will enable
enable you
y o u to
to develop
develop longer-range hypotheses about
longer-range hypotheses about
which
which biological
biological or or social
social factors
factors are
are provoking
provoking shiftsshifts inin your
your m mood
o o d (for
(for ex­
ex-
ample,
ample, periods
periods of of greater
greater alcohol
alcohol oror marijuana
marijuana usage,
usage, the the onset
onset ofof winter,
winter, the
the
onset
onset ofof spring,
spring, thethe Christmas
Christmas holidays,
holidays, periods
periods of of increased
increased work
w o r k or
or school
school
stress).
stress).

Prohlemswith
Problems with Mood
MoodCharting
Charting
Moodcharting
Mood chartingcan
can feelreductionistic:
feel reductionistic: It
It does
does nm
not do
do justice
justiceto
tothe
themany
many var­
var-
ied
ied experiences
experiences youy o u have
have on
on a a daily
daily basis.
basis. ItIt is
is also
also very
very present-focused.
present-focused. Some
Some
people
people feel
feel that
that their
their mood
m o o d shifts
shifts are
are related
related to to factors
factors that
that can't
can't be
be eaSily re­
easily re-
corded
corded ono n the
the chart
chart (for
(for example,
example, traumatic
traumatic events
events inin the
the recent past or
recent past in
or in
childhood).
childhood). Even
E v e n with
with these
these limitations,
limitations, however,
however, moodm o o d charting is a very ef­
charting is a very ef-
ficient
ficient way
w a y of
of summarizing
summarizing a a great
great deal
deal ofof information
information veryvery SUCcinctly
succinctly for
for
yourself
yourself and
and your doctor. If
your doctor. If you
y o u are
are using
using mood
m o o d charting
charting asas a
a supplement
supplement to to
your
your personal
personal psychotherapy,
psychotherapy, think think of
of it
it as
as a point of
a point of departure
departure for
for exploring
exploring
larger issues
larger issues that
that affect
affect your
your mood.
m o o d . For
For example,
example, events
events such
such as
as minor
m i n o r dis­
dis-
agreements
agreements with
with a
a partner
partner can
can have
have profound
profound effects
effects on
o n your
your mood
m o o d if
if they
they
trigger
trigger fears
fears of
of separation
separation or
or loss.
loss. You
Y o u may
m a y wish
wish to
to explore
explore these
these larger
larger issues
issues
with
with your therapiSt.
your therapist.
Mood
M o o d charting
charting can
can also
also be
be difficult
difficult to
to remember
r e m e m b e r to
to do
d o every
every day.
day. Try
Try to
to
pick
pick one
one time
time each
each day
day to
to complete
complete your
your chart,
chart, and
and stick
stick to
to this
this time
time on
on a
a day­
day-
to-day
to-day basis.
basis. Some people fill
S o m e people fill it
it out
out right
right before
before getting
getting ready
ready forfor bed;
bed; others
others
tie
tie mood
m o o d charting
charting to to aa specific
specific daily
daily activity
activity (for
(for example:
example: justjust after
after finishing
finishing
dinner,
dinner, afterafter walking
walking the the dog,
dog, before
before watching
watching the the evening
evening news).
n e w s ) . Avoid
Avoid
choosing
choosing the the worst
worst moment
m o m e n t of
of the
the day to fill
day to fill out
out the
thechart
chartif ifthat
thatmoment
m o m e n t does
does
not
not represent
represent how h o w you've
you've felt
felt for
for the
the whole
w h o l e day.
day. SoSo if
if you
y o u usually
usually feelfeel quite
quite
u n h a p p y when
unhappy y o u first
w h e n you first wake
w a k e up
u p but
but feel
feelbetter
better within
within half
halfanan hour
h o u r or
or so,
so, pick
pick
another,
another, more m o r e representative
representative time time ofof day.
day. Avoid
Avoid trying
trying toto fill out a
fill out a month's
month's
164
164 SHf-MANAG£M£NI
SELF-MANAGEMENT

worth
worth of
of mood
m o o d charts
charts just
just before
before your
your doctor
doctor appointments,
appointments, as
as people
people some­
some-
times
times do.
do. The
The more:
more accurate
accurate the
the information
information you
you convey
convey to
to your
your doctor,
doctor, the
the
better
better the
the treatment
treatment decisions you and
decisions you your doctor
and your can make.
doctor can make.

Maintaining Wellness
Maintaining Wellness Tip
Tip No.
N o . 2:
2: Maintaining
Maintaining Regular
Regular Daily
Daily
and
and Nightly
Nightly Routines
Routines

really feel
"I"Ireally feelthat I benefited
that from from
I benefited psychoanalysis. I was in
psychoanalysis. I it
wasfour
in times a times a
it four
week. But II don't
week. But don't think
think itit was
was all
all that
that learning
learning about
about mym y childhood.
childhood.
There
There was
was something
something very therapeutic about
very therapeutic about always
always having
having aa place
place to
to go
go
to in the
to in the morning,
morning, seeing
seeing the
the same
same therapist
therapist every
every day,
day, seeing
seeing the
the same at­
same at-
tendant
tendant inin the
the parking
parking lot,
lot, getting
getting back
back in
in my
m y car
car at
at [he
the same
same time . . II
time ....
found
found all
all of
of that
that structure
structure very
very comforting."
comforting."
-A
— A 40-year-old
40-year-old woman
w o m a n with bipolar II
with bipolar II disorder
disorder

In Chapter
In Chapter I talkabout
5, I5, talk aboutthe
the beneficial
beneficialeffects on your
effects mood
on your stability
mood of
stability of
external
external "time keepers," and
"time keepers, and the
n the potentially
potentially negative
negative effects
effects of
of events
events or social
or social
demands
demands that
that disrupt yOUT daily
disrupt your daily routines
routines and
and sleep-wake cycles (Ehlers
sleep-wake cycles (Ehlers et
et aL,
al,
1988, 1993). Actively
1988, 1993). Actively maintaining
maintaining daily
daily and
and nightly
nightly routines
routines is
is one
one of the
of the most
most
important
important behavioral
behavioral changes
changes you
you can
can undertake---aside
undertake—aside fromfrom regularly
regularly taking
taking
your
your medication-to help keep
medication—to help keep you
you in
in the
the driver's
driver's seat
seat in
in managing
managing your disor­
your disor-
der.
der. In
In this
this section,
section, II discuss
discuss the
the Msocial
"social rhythm
rhythm stability"
stability" approach
approach to main­
to main-
taining well ness.
taining wellness.

Keeping
Keeping a
a Social
Social Rhythm
Rhythm Char'
Chart

The Social
The Social Rhythm
Rhythm Metric
Metric (SRM) is aamore
(SRM) is more time-consuming
time-consuming device
devicethan
thanthe
the
mood
m o o d chan, but it
chart, but it is
is also
also potentially
potentially more
more informative
informative (Monk
( M o n k et
et aL, 1990,
al, 1990,
1991). In
1991). In this
this chart,
chart, you
you keep
keep track
track ofofwhen
w h e n you
you eat,
eat,sleep.
sleep,exercise,
exercise,andand so­
so-
cialize,
cialize, and
and make
m a k eratings
ratingsof
ofyour
yourdaily
dailymood.
mood.WithWith lime,
time,you
youcancanwork
workon onsta­
sta-
bilizing your
bilizing yOUT daily
daily routines
routines as
as a
a means
means of of stabilizing
stabilizing your
your mood. This involves
mood. This involves
planning yOUT regular
planning your regular activities
activities for
for predictable
predictable times
times of
of the
the day
day or night.
or night.
The
The S SRM
R M was
was developed
developed as as aa central
central part
part of
of Ellen
Ellen Frank's
Frank's andand David
David
Kupfer's
Kupfer's work
work on on interpersonal
interpersonal andand social
social rhythm
rhythm therapy
therapy (IPSRT).
(IPSRT). As As II
talked
talked about
about inin Chapler
Chapter 6,
6, Frank
Frank and
and her
her colleagues
colleagues have
have shown
s h o w n that
that the
the com­
com-
bination
bination of IPSRT and
of IPSRT medication is
and medication is effective
effective in
in improving
improving the course ofbipo­
the course of bipo-
lar
lar disorder
disorder (Frank, 1999; Frank
(Frank, 1999; Frank et al, 2000).
et aL, 2000). II was trained in
was trained in Frank's social
Frank's social
rhythm
rhythm therapy approach some
therapy approach some years
years ago
ago and
and have
have become
become convinced
convinced of of the
the
 How (on
How Can I ManageMyMyDisorder?
I Manoge Disorder? 165
165

value of
value ofdaily
dailyrhythm tracking
rhythm andand
tracking srabilization for persons
stabilization with bipolar
for persons with disor­
bipolar disor
der.
der.
The
T purpose of
h e purpose of social
social rhythm
rhythm tracking
tracking is is to
to allow
allow youyou to to discover
discover the the rela-
rela­
tionship between changes
tionship between changes in in your
your daily
daily routines,
routines, levels
levelsof ofinterpersonal
interpersonal stimu­stimu-
lation, sleep-wake
lation, sleep-wake cycles, cycles,and and mood.
m o o d . Over
Over several
severalweeks
weeks or ormonths,
months,you you will
will
begin
begin to to see cerrain patterns
see certain patterns emerge
emerge (as (as A Amy did). For
m y did). For example,
example, you you maym a y find
find
that changes
that changes in in your
your activity
activity levels
levels or sleep patterns
or sleep patterns presage
presage the the development
development
of new
of n e w episodes.
episodes. In In the
the beginning
beginning phasesphases of of mania
mania you you maym a y observe
observe a a gradual
gradual
decrease in
decrease in the
the time
time you
you spend
spend sleeping
sleeping and and an increase in
an increase in the time you
the time you spend
spend
exerCising. likewise, you
exercising. Likewise, you m may
a y find
find that
that as you recover
as you recover from from a a manic
manic or or de-
de­
pressive
pressive episode,
episode, your your activity
activityand and sleep
sleep patterns
patterns naturally
naturallygo go back
back toto the
thewayway
they were before
they were before you became ill
you became ill. In
In other words, your
other words, your sleep
sleep and activity pat-
and activity pat­
terns can
terns can be be a a sign
sign of of whether
whether your your moodm o o d problems
problems are are getting better or
getting better or
worse.
worse.
As
A s with
with thethe m mood
o o d chart,
chart, it'sit'sbest
bestto tofill
fillOuloutthe
theSRMS R M every
everyday dayand
andreview
review
it
it each
each week
w e e k byby yourself
yourself and with your
and wdth your therapist
therapist or or psychiatrisl. Keeping the
psychiatrist. Keeping the
social
social rhythm
rhythm chart chart on on a a regular,
regular, ongOing
ongoing basis basis will
will enable
enable you you to spot shifts
to spot shifts
in
in your
your daily
daily routines
routines and and sleep-wake
sleep-wake cycles cycles that
that may
m a y be
be ofof subtle
subtle importance
importance
in
in determining
determining your your mood.
mood.
The
The chart
chart on on page
page 166 166 waswas completed
completed by by Leslie,
Leslie, a a 40-year-old
40-year-old woman woman
with
with bipolar
bipolar II disorder
disorder (a (a blank
blank Social
Social Rhythm
R h y t h m Metric
Metric formform is is provided
provided at the
at the
end
end ofof the
the book).
book). FirstFirst notice
notice the the upper
upper left-hand
left-hand corner,
corner,wherewhere she shehashas made
made
aa daily
daily mood
m o o d rating
rating on on aa -5-5 - +5 scale.
- +5 scale.In Inthis
thisrespect
respectititisislikelikethe
themood
m o o d chan.
chart.
But
But notice
notice that
that there
there areare 117 7 activities
activities listed
Hsted on on the
the left
left side;
side; most
most people will
people will
do
do some
some ponion
portion of of these
these every
every day.
day. Indicate
Indicate in in the
the boxes
boxes what time you
what time you did
did
these
these activities:
activities: what what timetimeyou you woke
w o k e up,
up,had had your
yourfirst
firstcupcup of ofcoffee,
coffee,wentwenttoto
work,
work, went
went to to school
school or or did
did some
s o m e other
other daily
daily activity,
activity, ate ate lunch,
lunch, exercised,
exercised,
came
came home,
h o m e , ate
ate dinner,
dinner, and and went
went to to bed.
bed. These
These daily
daily routines,
routines, in inpart,
part,"drive"
"drive"
your
your sleep-wake
sleep-wake habits habits (Frank
(Frank et et aI.,
al, 2000).
2000). For For example,
example, if if you
you have
have a shift­
a shift-
ing
ing work
work schedule
schedule that that demands
demands that that youyou work
work fromfrom 8 a.m. to
8 A.M. to 4 p.m. one
4 P.M. one day
day
and
and then
then 4 p.m. to
4 P.M. to 112
2 A.M.
a.m. thethe next,
next, your
your bedtime
bedtime and and wake
w a k e time
time will
wiH be corre­
be corre-
spondingly
spondingly altered
altered fromfrom day day to
to day,
day, and
and your
your mood
m o o d may
m a y change
change (up (up oror down)
down)
in
in the
the days
days that
that follow.
foHow. In In contrast,
contrast, if if you
you eat,
eat, exercise,
exercise, work,work, andand interact
interact
with
with others
others at at fairly
fairly regular
regular times
times of of the
the day
day or or evening,
evening,you you willwiH come
c o m e to
to ex­
ex-
pecl
pect sleep
sleep at at aa cerrain
certain time.
time.
The
The SRM
S R M also
also asks
asks youyou toto record
record who w h o did
did each
each oof f these
these activities
activities with
with you
you
and
and how
how stimulating
stimulating they were. The
they were. T h e degree
degree to to which
which your your interchanges
interchanges with with
others
others areare provocative,
provocative, conflict-ridden,
conflict-ridden, or or otherwise
otherwise stimulating,
stimulating, versusversus low­
low-
key
key oror "laid
"laid back,"
back," can can bebe important
important determining
determining factors factors in in the
the degree
degree of of sta­
sta-
bility
bility you experience in
you experience in your
your emotional
emotional states states and
and possibly
possibly even even your
your sleep.
sleep.
Say
Say you
you ate
ate dinner
dinner withwith youryour wife
wife or or husband
husband but but had
had anan argument,
argument, and and then
then
 166
166 SElF-MANAGEMENT
SELF-MANAGEMENT

THE
T H E SOCIAL
SOCIAL RHYTHM
R H Y T H M METRIC (SRM)
METRIC (SRM)
MacArthur
MacArthur Foundation
Foundation Mental
Mental Health
Health Research Network II
Research Network

PleasePlease
Fill Fill This
This OutAt
Out At The
The End
End Of
Of The
The Day
Day

Day
Day of
ofWeek:
Week: Sun
Sun Date:
Date 5-28
5-2&

MOOD
M O O D RATING
RATING (Choose
(Choose one): .:1.- TIME
= Just
Just Present
one): -2 TIME PEOPLE

_3�_1
Scale 1t ,;:

= ACtivelr �V;fved
Scale Present
-5 .
2 =

= Others
Others J
-5 -4
-4 -3 (-2]-^ 00 ,1 22 33 ,4 5 , 2 Actively Involved

�
3
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A ocial rhythm
A ssocial rhythm chart.
chart. Copyright 1991 by
Copyright 1991 by Elsevier
Elsevier Sdence. by permission from Monk
Science. Reprinted by et at.
M o n k eI al.
(1991).
(1991).
 How Can IIMonoge
How (on ManageMyMyDisorder?
Disorder? 167
167

the two
the two of youwent
of you opposite
wenttotoopposite ends
ends of ofthethe house
house (rated
(rated a "3"
a "3" on stimula­
on stimula-
tion); w o u l d probably
y o u would
tion); you have more
probably have falling asleep
trouble falling
m o r e trouble night. Com­
that night.
asleep that Com-
pare that
pare night to
that night another night
to another y o u and
w h e n you
night when had a
spouse had
your spouse
a n d your relaxing din­
a relaxing din-
ner together
ner might be
(which might
together (which rated aa "1
be rated "-"others just
"1"—"others just present").
present").
High levels of
H i g h levels of stimulation from other
stimulation from people can
other people can feel positive hut
quite positive
feel quite but
still
StiH affect your mood
affect your sleep-wake cycle
or sleep-wake
m o o d or Deborah, age
negatively. Deborah,
cycle negatively. 26, found
age 26, found
that her evening
that her waitressing job at
evening waitressingjob w h i c h she
bar, which
at aa bar, great deal,
enjoyed aa great
she enjoyed deal, con­
con-
tained highly stimulating
tained highly bursts of
stimulating bursts activity (usually
of activity blocks in
three-hour blocks
(usually three-hour in
which she
which she was in great
w a s in b y the
d e m a n d by
great demand patrons). She
the patrons). consistendy had
She consistently had more
more
trouble after getting
asleep after
falHng asleep
trouble falling than she
h o m e than
getting home she did nights when
o n nights
did on she was­
w h e n she was-
n't working.
n't She had
working. She easier time
a n easier
h a d an she was
w h e n she
time when w a s assigned early evening
the early
assigned the evening
shift.
shift.
Katherine, age
Katherine, enjoyed the
4 2 , enjoyed
age 42, contact with
intensive contact
the intensive with people she had
people she had
her job
through her
through in the
job in section of
clothing section
the clothing department store.
of aa department H o w e v e r , the
store. However, the
social rose to
stimulation rose
social stimulation to almost intolerable levels
almost intolerable during the
levels during w e e k e n d s prior
the weekends prior
to
to the holidays, and
Christmas holidays,
the Christmas a n d she found herself
she found b e c o m i n g increasingly
herself becoming irrita­
increasingly irrita-
ble. She
ble. learned not
She learned not 10 schedule any
to schedule any social activities on
social activities o n the w e e k e n d evenings
the weekend evenings
following these
following as a
w o r k d a y s as
these workdays a way modulating her
of modulating
w a y of exposure to
her exposure stress and
to stress and
stimulation.
stimulation.

Leslie's E••
Leslie's mple: EEvaluating
Example: ••I••,ing •aSoci.1 Rhythm Ch.rl
SocialRhythm Chart

Although onlyone
Althoughonly shown
isisshown
day
oneday in in
Leslie's example
Leslie'sexample on on page
page 166,
166, de- de­
can can
we we
velop some
velop hypotheses about
s o m e hypotheses factors that
about factors affected her
that affected m o o d states.
her mood her, a
For her,
states. For a
mixed m o o d state
mixed mood is a
state is day of
a day of depresSion, agitation, nervousness,
with agitation,
along with
depression, along nervousness,
and irritability.
and N o t e that
irritability. Note though the
even though
that even sample day
the sample day occurred
occurred during the
during the
spring,
spring, wwhen w e r e longer,
hours were
daylight hours
h e n daylight still had
she still
longer, she had a a relatively short day
relatively short day
(woke
(woke upu p at
at 9:30 A.M. and
9:30 a.m. w e n t to
and went bed at
to bed 10 P.M.).
at 10 w a s sleeping
She was
p.m.). She sleeping too100 much.
much.
She
She also h a d several
also had high-stimulation interactions
several high-stimulation during the
interactions during day (including
the day (including
an argument over
an argument the telephone
over the telephone with with her ex-husband about
her ex-husband about their
their child, and a
child, and a
confrontation with
confrontation with a r o o m m a t e whom
a roommate felt was
she felt
w h o m she inconsiderate). She
being inconsiderate).
w a s being She
had at
had least one
at least alcoholic drink
o n e alcoholic drink w alone. In
h e n alone.
when addition to
In addition to her
her biological pre­
biological pre-
dispositions,
dispositions, thesethese factors m a y have
factors may determined her
partially determined
have partially her agitated, de­
agitated, de-
pressed mood.
pressed mood.
It is
It possible that
is possible events and
these events
that these a n d activities resulled from
activities resulted from her
her m mood state
o o d state
(for example, she
(for example, might have
she might have been anxious and
been anxious irritable and
and irritable therefore more
a n d therefore more
prone to
prone confrontations). To
to confrontations). help determine
T o help caused which,
w h i c h caused
determine which Leslie col­
which, Leslie col-
lected social
lected r h y t h m and
social rhythm mood
and m information on
o o d information herself over
o n herself over a period of
a period several
of several
months. She
months. began to
She began see h
10 see how interactions with
provocative interactions
o w provocative certain people,
with certain people,
sleep
sleep patterns,
patterns, a n d alcohol
and alcohol ccombined change her
to change
o m b i n e d to her m mood, as well
o o d , as as hhow
well as her
o w her
mood states affected
m o o d states affected the the timing
timing a and frequency of
n d frequency events aand
these events
of these habits. She
n d habits. She
168
168 Sm-MANAGEMENT
SELF-MANAGEMENT

became increasingly certain

became increasingly certainthat
that alcohol before
alcohol bedtime
before bedtime sleeping
andand moremore
sleeping
than
than nine
nine hours
hours combined
combined to
to make her nervous
m a k e her nervous and irritable and
and irritable more prone
and more prone
to
to run-ins
run-ins w ith people.
with people.

"HowCan
"How Can I' Regu'ate
Regulate My
My Doily
DailyRoutines?"
Routines?"

The
The next step is
next step is to
to devise
devise strategies
strategies that help you
that help you regulate
regulate youryour daily
daily routines.
routines.
Keeping
Keeping regular routines sounds
regular routines sounds straightforward,
straightforward, bUl but ififyou've
you'veeverever tried
triedto tododo
it,
it, you
you know
k n o w that
that significant
significant challenges
challenges are are likely
likely toto arise.
arise. YouY o u can
can do this
do this
alone,
alone, butbutaatherapist
therapistmay m a y bebeable
ableto tohelp
helpyou you develop
develop and and keep
keep "target
"targettimes�
times"
for
for various
various activities
activities suchsuch as as sleep
sleep and exercise.
and exercise.
The
The first,
first,most
mostimportant
importantingredient
ingredientisistotogo golOtobed
bedatatthethesame
sametime timeevery
every
night
night andand wake
wake up up atat the
the same
same timetime every
every morning.
morning. Try Try to to maintain
maintain this this pat­
pat-
tern
tern onon weekends,
weekends, even even w when
h e n you'd
you'd rather
rather sleep
sleep late.
late. Of
O f course,
course, there
there will
will be
be
times when
times w h e n geuing
getting to to bed
bed at at your
your target
targethour
hour or or waking
waking up up atataaspecific
specifictime
timeisis
impossible,
impossible, such such as as when
w h e n you
you travel,
travel, have
have social
social plans
plans on on aa weekend,
weekend, have have a a
sick
sick child,
child, oror need
need to to get
get upup extra
extra early
early toto pick
pick up up someone
someone at at the
the train
train sta­
sta-
tion.
tion. Some
S o m e of these events
of these events willwill bebe controllable
controllable by by you
you (for
(for example,
example, whether
whether
to
to go
go toto the
the early
early or or late showing of
late showing of aa certain movie) and
certain movie) and some
some will will not (for
not (for
example,
example, the the timing
timing of of anan airline flight). If
airlineflight). Ifyour
yourschedule
scheduleisisshifted
shiftedby byananhour
hour
or
or two
two on on aa given
given night,
night, trytry to reinstate your
to reinstate your original
original sleep-wake
sleep-wake target target times
times
as
as soon
soon as possible.
as possible.
Try
Try to to maintain
maintain your your sleep
sleep patterns
patterns eveneven if if events
events conspire
conspire to to make
m a k e you
you
change
change them.them. ForFor example,
example, if ifyou
you have
have lost
lostyour
yourjob,job,try
tryto toget
getupu p at
atthe
thesame
same
time
time youyou would
would havehave gotten
gotten up up when you were
w h e n you were going
going in in toto work.
work. If If your
your new
new
job
job requires
requires different
different hourshours (say,
(say, getting
getting to to work
work by by 8 A.M. instead
8 A.M. instead of of 99 A.M.),
A.M.),
adjust
adjust your
your bedtime
bedtime to to anan hour
hour earlier.
earlier. ll's
It'sbest
besttotoease
easeinto
intoyour
yournew n e wschedule
schedule
gradually
gradually rather
rather than
than suddenly.
suddenly.
You
You cancan also
also work
work with with your
your therapist
therapist to to anticipate
anticipate events
events that will change
that will change
your
your daily
daily routines,
routines,and andplanplanwayswaysto toregulate
regulateyourself
yourselfonceoncethese eventsoccur.
theseevents occur.
For example, if you know that you may be changing jobs soon or traveling
For example, if you k n o w that you m a y be changing jobs soon or traveling
more in
more in the
the near
near future,
future, you you can
can anticipate
anticipate that thatyour
your sleep
sleep will
willbebe disrupted.
disrupted.
Make plans, in advance, to go to bed and wake up at consistem times, even
M a k e plans, in advance, to go to bed and wake up at consistent times, evenaf­af-
ter these disruptive
ter these disruptive events
events have have occurred.
occurred.
Second, if you have been having trouble
Second, if you have been having troublesleeping
sleeping (see(seethethesection
sectionon on sleep,
sleep,
below),
below), try try to
to avoid
avoid Msleep
"sleep hingeing,"
bingeing," in in which
which you you calch
catch up from all
up from all the lost
the lost
sleep during
sleep during the week by
the week by sleeping
sleeping more more on on weekends.
weekends. You'll You'll probably
probably findfind
that
that sleep
sleep bingeing
bingeing has has a a negative
negative impact
impact on on your
your mood (typically depression;
m o o d (typically depression;
see,
see, for
for example,
example, a a study
study of of sleep
sleep disturbance
disturbance by Wolfson &.
by Wolfson & Carskadon,
Carskadon,
1998). It
1998). It also makes it
also makes it harder
harder to sleep the
to sleep next night.
the next night.
Third, try
Third, try toto see
see if if you
you cancan maintain
maintain the the same
same hours
hours eacheach dayday at work or
atwork or
 How (on
How CanI Manoge MV My
I Manage Disordef?
Disorder? 169169

school.For
school. Forexample,
example,try to take
try classes
to take during
classes the same
during theinterval each day.each
same interval Try day. Try
to
to avoid
avoid having
having all
all of
of your
your classes
classes on
on one
one or
or two
two days
days and
and none
none on
on the
the other
other
three. T
three. To parallel your
o paraHel regular job
your regular job hours,
hours, try
try to
to exercise
exercise atat the
the same
same time
time (for
(for
example, just after work) rather than late in the evening on one night and
example, just after work) rather than late in the evening on one night and
then early in
then early in the
the morning
morning the
the next
next day. Try to
day. Try to have
have a regular period
a regular to unwind
period to unwind
before going to
before going to bed.
bed. Avoid having your
Avoid having your most
most stimulating
stimulating interactions with
interactions with
partners, friends,
panners, friends, or
or coworkers
coworkers right
right before
before you try to
you try to go
go to sleep.
to sleep.

Prodi,a' Challenges
Practical ta Maintaining
Challenges Regu'a,
to Maintaining Routines
Regular Routines

There are
There are practical
practicalproblems to to
problems be solved, of course.
be solved, The courses
of course. you want
The courses youtowant to
take may
take m a y be
be offered
offered at
at all
all different
different times
times of
of the
the day
day or
or night.
night. You
Y o u may have aa
m a y have
job
job that
that requires
requires a
a lot
lot of
of travel,
travel, necessitates
necessitateslong
longshifts
shiftson
on weekends,
weekends,requires
requires
work
work at at home
h o m e in
in the
the evening
evening on on some
s o m e nights
nights but not others,
but not others, or or involves
involves
changing
changing shifts.
shifts. AnA n example
example is isaacontract
contractnursing
nursingjob,job,ininwhich
which people
people are areof­
of-
ten called
ten called for
for aa full
full eight-hour
eight-hour shift shift only
only anan hour
hour before
before thethe shift
shift isis to
to start.
stan.
Restaurant
Restaurant jobsjobs often
often have
have shifting
shifting schedules
schedules as as well.
well. InIn Chapter
Chapter 12, 12, you'll
you'll
find
find some
some suggestions
suggestions for for negotiating
negotiating work w o r k hours
hours with
with your
your employer
employer in light
in light
of
of the
the limitations
limitations youryour disorder
disorder can can impose.
impose.
Here
Here areare examples
examples of of how
h o w some
s o m e of
of my
m y patients
patients have
have kept
kept regular social
regular social
rhythms
rhythms eveneven when
w h e n faCing
facing thethe demands
demands of of school
school or or job.
job. Walter
Walter had had an an open
open
discussion
discussion withwith his
his employer
employer about about his his mood
m o o d disorder.
disorder. HisHis employer
employer agreed agreed
to
to keep
keep himhim on on the 8-5 daily
the 8-5 daily shift
shift atat his
his computer
computer programming
programming job, rather
job, rather
than
than the
the constantly
constantly variable
variable shifts
shifts that
that were
were typical.
typical.Juanita,
Juanita,who w h otraveled
traveledfre­ fre-
quently,
quently, always
always tried
tried toto get
get the
the same
same number
n u m b e r of
of hours
hours of of sleep
sleep each night,
each night,
even
even when
w h e n she
she was
was inin aa new
n e w time
time zone.
zone. Maintaining
Maintaining her her sleep
sleep habits
habits required
required
aa degree
degree of of assertiveness,
assertiveness,given giventhat
thatsheshewaswasoften
oftenencouraged
encouragedby byher
hertraveling
traveling
coworkers to stay out
coworkers to stay out late. late.
Candace
Candace (discussed
(discussed more m o r e on
on page 179-180) found
page 179-180) found that
that her
her weekends
weekends in- in­
volved
volved long
long periods
periods with
with little
Htde contact
contact withwith others,
others, andand her
her depressions
depressions usu­ usu-
ally became worse
allybecame worse then.
then.Scheduling
ScheduHng low-key low-key activities
activitieswith
with friends
friendsor oracquain­
acquain-
tances
tances during
during weekend
weekend days days gave
gave her her aa greater
greater feeling
feeling of of consistency
consistency in in
routines from the
routines from the week
w e e k to
to the
the weekend
weekend and and helped
helped improve
improve her her mood. Like­
m o o d . Like-
wise,
wise, Wesley,
Wesley, who w h o became
became depressed
depressed after after breaking
breaking up with his
up with his girlfriend,
girlfriend,
found that scheduling
found that scheduHng activities
activities with
with other
other people
people eacheach morning,
morning, or or at
at mini­
mini-
mum,
m u m , taking
taking trips
trips toto aa coffee
coffee shop
shop by by himself,
himself,helped
helped get
get him
him out out ofof bed
bed byby a a
certain time.
certain time.
The
The SRMS R M can
can help
help youyou design
design aa daily
daily schedule
schedule of of sleeping,
sleeping,eating,
eating,exercis­
exercis-
ing,
ing, and
and SOCializing
sociaHzing that that isis comfortable
comfortable and and feasible,
feasible, given
given thethe demands
demands of of
your
your current
current social,
social, family,
family, andand work
w o r k life.
life.Try
Tryto toset
setgoals
goals[orforwhen
w h e nyou
youplanplan
to
togo
go to
to bed
bed and
and when
w h e n you
you want
want to to wake
w a k e up,
up, and
and try
try not
not toto deviate from these
deviate from these
170
170 SElF·MANAGEMENT
SELF-MANAGEMENT

plans
plans by bymore
more than
than3030minutes
minutestotoan an
hour, even
hour, when
even there
when are rewarding
there ac­ ac-
are rewarding
tivities
tivities (for
(for example,
example, parties.
parties, late-night
late-nightmovies)
movies)that you feel
thatyou feelwould
would improve
improve
your
your mood.
mood. Other members of
Other members of your
your family,
family, if
if living
living with
with you
you (for
(for example,
example,
your
your spouse
spouse or or partner),
partner), may
m a y be
be able
able to
to help
help you
you design
design this
this program
program and
and
stick to it.
stick to it.

Resislonees
Resistances10to
T,oeking andand
Tracking Keeping Reguloted
Keeping Roulines
Regulated Routines

Some
S o m e people
people complain
complain that that social
social rhythm
rhythm tracking
tracking is is tedious
tedious and and reminds
reminds
them
them of of doing
doing homework
h o m e w o r k assignments
assignments for for school.
school. Like most treatment
Like most treatment and and
self-management
self-management techniques,
techniques, the the SRM
S R M isis not
notwithout
without its itscosts
costsin interms
termsof oftime
time
and
and effort.
effort. But Butasasyou
you getgetused
used to toit,
it,you
youwillwillfind
findthat
that you
youcan cando doititat at
the end
the end
of
of the
the day
day in about five
in about five minutes.
minutes. With With time,
time, you you may
m a y find
find that
thatcertain
certainitemsitems
on the
on the chan
chart areare morc
more imponam
important to to record
record than others. For
than others. Forexample,
example,your yourbed­bed-
time,
time, wake
wake time,time,jobjobhours,
hours,and andexercise
exercisetimestimesmay m a ybebecritical
criticalin indetermining
determining
your
your moodm o o d stability,
stability, butbutyouryour mealtimes
mealtimes or orTV T V habilS
habitsmay m a y bebe less
lesscentral.
central.
In
In mym y and
and other
other clinicians'
clinicians' experience,
experience, the the bigger
bigger issue
issue that
that people
people withwith
bipolar
bipolar disorder
disorder faceface is the trade-off
is the trade-off involved
involved in in regulating
regulating their their daily rou­
daily rou-
tines:
tines: ItIt means
means giving
giving up up aa degree
degree of of spontaneity.
spontaneity. PeoplePeople sometimes
sometimes wonder,wonder,
"Why
" W h y can't
can't II have
have thethe same
same kindkind of of 'devil
'devil may care' altitude
m a y care' attitude thatthatothers
othershave?have?
If
If everyone
everyone else else is
is staying
staying up up until
until 2 a.m. to
2 A.M. to party,
party, why can't n"
w h y can't I?"
If
If you're
you're haVing
having these
these reactions,
reactions,that'sthat'sunderstandable.
understandable. For For Amy,
A m y , keeping
keeping
aa regulated
regulated routine
routine made
m a d e her
her feel
feel that
that she
she was
was different
different fromfrom everyone
everyone else. else.
On
O n the
the other hand, she
other hand, she came
came to to realize
realize that
that the
the unpredictability
unpredictability and social
and social
stimulation
stimulation she she craved
craved was was likelike a a drug.
drug. She usually had
She usually had a m o o d hangover"
a ""mood hangover"
the next day.
the next day.
There
There is is comfort
comfort in in knowing
knowing that that you
you areare doing
doing something
something proactive
proactive to lO
manage
manage your your disorder.
disorder. You Y o u will
will almost
almost certainly
certainly see see benefilS
benefits in in terms
terms of of your
your
o o d stability
mood
m stability and productivity when
and productivity w h e n you
you structure
structure your your days
days and nights.
and nights.
With
With time,time, a a regulated routine will
regulated routine will give
give youyou a a sense
sense of of security
security and and control
control
over
over your fate.
your fate.
Even
Even apart
apart from
from thethe issue
issue of of mood
m o o d stabilization,
stabilization, some some of of mym y clients find
clients find
that social
that social rhythm
rhythm tracking
tracking helps
helps themthem manage
manage their their disorder
disorder and and lifestyle
lifestyle in in
ways
ways they they hadn't
hadn't expected.
expected. For For example,
example. Cannen,
Carmen, age 29, found
age 29, found thatthat SRMSRM
tracking
tracking helped
helped remind
remind her her toto take
take her
her medication,
medication, which which until
untd that
thatpoint
pointhad had
been
been haphazard
haphazard and and unpredictable.
unpredictable. After After filling
filling outout his
his chart
chart forfor several
several
weeks, Arthur, 35,
weeks, Arthur, 35, observed that "I
observed that "I have
have a a habit
habit ofof jamming
jamming inin too
too many
many
things
things to
to avoid
avoid depression,
depression, but
butthen
then IIget
getlike
likeaacar
carthat's
that'srun
runout
outof
ofgas.
gas.I 1
want
want
contaC[
contact with
with people, but II can
people, but can get
get to
to the
the poim
point where
where I'mI'm doing
doing too much. II
too much.
need
need some
some more
more conSistency, and I1 need
consistency, and need not
not toto be
be constantly
constantly overstimulated
overstimulated
and running away
and running from myself."
away from myself."
 How Con
How CanI I
Manage MV My
Manage Disordel?
Disorder? 171171

It is
It is notnot only
only people
people with
with mood
mood disorders
disorders who
who have
have to to stay
stay onon regular,
regular,
regimented schedules. Parents
regimented schedules. Parents usually
usually need
need to
to follow very predictable
follow very rou­
predictable rou-
tines to manage
tines to manage the
the daily
daily activities
activities of
of their
their children.
children. Athletes
Athletes need
need to
to stick
stick to
to
well-regulated training
well-regulated training schedules.
schedules. People
People w who become expert
h o become expert performers,
performers,
such as accomplished
such as accomplished professional
professional musicians,
musicians, have
have often developed highly
often developed highly
regimented routines
regimented routines to
to help
help them
them accomplish
accomplish their
their craft (for example,
craft (for example, Krampe
Krampe
&
& Ericsson,
Ericsson, 1996).
1996).
Nonetheless,
Nonetheless, if if you're
you're finding
finding a regimented routine
a regimented too stifling,
routine too discuss
stifling, discuss
this with your
this with your doctors.
doctors. There
There may
m a y be
be compromises
compromises that that can
can be made. Perhaps
be made. Perhaps
you can
you can identify
identify the point at
the point at which fluctuating routines
whichfluctuating routines negatively
negatively affect your
affect your
mood. For
mood. For example,
example, a a 30-minute
30-minute departure
departure from your bedtime
from your bedtime m may
ay mmake
a k e no
no
difference,
difference, but
but 9090 minutes
minutes might
might make
m a k e aabig
bigdifference.
difference.Try tosee
Try to seeif
ifyou
youcan
can
identify
identify the
the range
range of fluctuation in
offluctuation in routines
routines within
within which
which you
you can
can function
function
and
and still
still feel stable.
feel stable.

"OK,
"OK, Now
N o w Tha'
That I'm
I'm Going
Going '0
to Bed
Bed on
on Time,
Time, How
H o w 00
D o II F."
Fall Asleep?"
Asleep?"

"I"I toss
toss and
and turn,
turn, look
look at
at the
the clock,
clock,sneer
sneerand
and snort
snortthrough
throughmy
my nose,
nose,
walk
walk around
around the the house
house .... . . do
do my
m y yoga,
yoga, do
do my
m y meditation,
meditation, turn on Ameri­
turn on Ameri-
can
can Gladiators
Gladiators ... . . , but I still
., but can't
I still sleep.
can't It irks
sleep. It me
irkstom no end
e to no that
end my
thatwife
m y wife
can
can just
just lie
lie down
d o w n and
and she's out.IIalmost
she'sout. almostwant
wanttotowake
wakeher herup
uptotomake
m a k eher
her
suffer Hke II am,
suffer like a m , but
but II don't.
don't. ..... . It
It goes
goes like
Hke this
this every
every night,
night, and then, of
and then, of
course, I'm a wreck at work the
course, I'm a wreck at w o r k the next day."next day."
-A
— A 51 -year-old man
51-year-old m a n with
with rapid
rapid cycling
cycling bipolar
bipolar disorder
disorder

For For
somesome
bipolarbipolar people,
people, getting
getting totobed
bedatatthe
the right
right time
time isn't
isn'tthethe
main
main
problem.
problem. TheT h e problem
problem is is falling
falHng asleep
asleep and
and staying
staying asleep.
asleep. There
There is
is nothing
nothing
more
more frustrating
frustrating than than lying
lying awake
awake and
and trying
trying to
to fall
fall asleep.
asleep. Sleep
Sleep disturbance
disturbance
is
isaakey
key symprom
s y m p t o m of
ofbipolar
bipolardisorder
disorderand
and sometimes
sometimescan canbe
beaaside
sideeffect
effectofofan­
an-
tidepressant
tidepressant medications.
medications. I tIt
can also
can bebe
also due
duetotosubstances
substances like
likecaffeine,
caffeine,exces­
exces-
sive sugar, tobacco, or alcohol, espeCially if these are ingested close ro your
sive sugar, tobacco, or alcohol, especially if these are ingested close to your
bedtime.
bedtime.
Your
Your docror
doctor may
m a y decide
decide toto give
give you
you medications
medications for
for sleep,
sleep, such
such asas
Klonopin
Klonopin oror zolpidem
Zolpidem (Ambien).
(Ambien). Although
Although these
these medications
medications often
often work
work
well,
weH, not
not everyone
everyone likes
likes to
to take
take them
them because
because you
you can
can become
become addicted
addicted or tol­
or tol-
erant
erant (that
(that is,
is,you
youmay
m a yneed
needaabigger
biggerdosage
dosageover
overtime
timero
toachieve
achievethe
thesame
sameef­ef-
fect)
fect).. But
Butyou
you and
andyour
yourphYSician
physicianmay m a y decide
decidethat
thataasleeping
sleepingmedication
medicationis isthe
the
best
best alternative
alternative inin order
order to
to keep
keep sleep
sleep disturbance
disturbance from
from contributing
contributing to
to your
your
worsening
worsening moodm o o d state.
state.
Fortunately, there
Fortunately, there is is aa literature
literature onon behavioral
behavioral interventions
interventions for
for sleep
sleep
172
172 Sm-MANAGEMENT
SELF-MANAGEMENT

Ways
W a y s to
to Combat
C o m b a t Sleep
Sleep Disturbance
Disturbance

• Keep stress out

Keep stress outofof
the bedroom
the bedroom
• Give
Give yourself
yourself time
time to
to unwind
unwind before
before sleep
sleep
• Never
Never "compete"
"compete" to
to get
get to
to sleep
sleep
• Use
Use muscle
muscle relaxation
relaxation techniques
techniques
• Adjust
Adjust your
your sleep
sleep cycle
cycle before travel
before travel

Souru: OttoctetaLal.(1999
Source:Dtw )
(1999)

problems.
p r o b l e m s . Michael
M i c h a e l Otto
Otto and
a n d his
his colleagues
colleagues at
at the
the Harvard
H a r v a r d Medical
M e d i c a l SchooV
School/
Massachusetts
Massachusetts General
General Hospital ( 1 9 9 9 ) have
Hospital (1999) h a v e developed
developed rrecommendations
e c o m m e n d a t i o n s for
for
ways
w a y s to
to improve
i m p r o v e sleep if you're
sleep if suffering [rom
you're suffering f r o m bipolar
bipolar disorder
disorder (see
(see the
the
sidebar
sidebar on this page),
o n this p a g e ) . Some
S o m e of
of these
these sleep
sleep techniques
techniques would bee applicable
would b to
applicable to
people
people without
w i t h o u t bipolar
bipolar disorder
disorder as well.
as well.
EExamples
x a m p l e s of
of "stress in the
"stress in the bbedroom"
e d r o o m " include
include having
having arguments
a r g u m e n t s wwith
i t h your
your
spouse, preparing
spouse, preparing wwork aSSignments for
o r k assignments the nnext
for the e x t dday while in
a y while in bbed,
e d , examining
examining
yyour next day's
o u r next day's wwork
o r k schedule, checking the
schedule, checking the stock
stock mmarket pages, checking
a r k e t pages, checking
yyour
o u r e-mail one
e-mail o n e last
last time,
time, eating
eating in
inbed,
b e d , and
a n dmaking
m a k i n g last-minute
last-minute phone
p h o n e calls.
calls.
TThese activities should
h e s e activities should b
be avoided right
e avoided right before
before bbedtime.
e d t i m e . MMore generally, try
o r e generally, try to
to
kkeep the last
e e p the last hhour just before
o u r just before sleep
sleep free
free of stressful activities
of stressful activities sso that y
o that you
o u can
can
uunwind and
nwind a relax. If
n d relax. If possible,
possible, try
try to
to arrange
arrange yyour
o u r bbedroom
e d r o o m ssuch that noise
u c h that noise is
is
blocked o
blocked out (for eexample,
u t (for the telephone
x a m p l e , the telephone is
is (Urned
turned off,
off,no
n o radios
radios are
are playing)
playing)
or wwear
or earplugs.
e a r earplugs.
Paradoxically, activities
Paradoxically, activities that
that people
people often
often take
take for
for granted
granted as
as necessary
necessary for
for
falling asleep
falling asleep mmay actually contribute
a y actually contribute to
to sleep
sleep disturbance.
disturbance. FFor
o r eexample,
x a m p l e , many
many
people wwatch
people the evening
a t c h the evening nnews in bbed
e w s in before turning
e d before turning oout the Hghts,
u t the lights, bbut the news
u t the news
overstimulates tthem
overstimulates h e m aand cranks tthem
n d cranks h e m uup. likewise, mmany
p . Likewise, people feel
a n y people feel they
they can't
can't
fall asleep
fall asleep wwithout reading a
i t h o u t reading a bbook, yet ssometimes
o o k , yet reading, eeven
o m e t i m e s reading, if it's
v e n if only aa
it's only
novel, ccan
novel, get the
a n get thebrain
brain rrunning in aall
u n n i n g in sorts of
H sorts ofdifferent
different directions.
directions. If
If you've
you've been
been
reading a
reading a good
good murder
murder mystery,
mystery, it
it may
m a y be
be hard
hard to
to put
put down
d o w n and
and stop
stop thinking
thinking
about! Likewise,
about! likewise, most
most people
people believe
believe that
thatregular
regular exercise
exercise contributes
contributes to
to good
good
sleep because
sleep because it
it tires
tires you
you out
out and
and relaxes
relaxes your
your muscles.
muscles.But
Butititcan
canalso keepyou
alsokeep you
awake if
awake ifyou
you exercise
exercise right
rightbefore
beforebedtime-try
bedtime—tryto togive
giveyourself
yourself m u c hasasthree
asasmuch three
hours between finishing your exercises and going to bed.
hours between finishing your exercises and going to bed.
If you
If you want
want to
to investigate
investigate which
which activities
activities are
are contributing
contributing toto your sleep
your sleep
problems, try
problems, try nights
nights with
with and
and without
without these
these activities
activities and
and record
record the
the changes
changes
 How Can I1 Monoge
How (on ManageMy
MyDisorder?
Disorder? 173
173

on your mood
on your mood chart
chart oror SRM
SRM (for(for example,
example, writewrite
"no "no
TV" TV" on Thursday
on Thursday night,night,
and
and "yes
"yes T TV"
V" oon Friday night,
n Friday night, a and
n d record your sleep
record your sleep forfor each). Try to
each). Try to see
see if if
o u can
you
y detect whether
can detect whether doingdoing or or not
not doing certain activities
doing certain affecLS your
activities affects your sleep
sleep
and
and mood.
mood.
Some
S people feel
o m e people that falling
feel that falling asleep
asleep is is like
like an athletic competition,
an athletic competition, like like
running a
running race in
a race in aa certain
certain time.
time. Being
Being unable
unable to to sleep
sleep makes
makes themthem feel
feel inade­
inade-
quate
quate or or incompetent,
incompetent, and and ·'performance
"performance anxiety"anxiety" begins
begins to to accompany
accompany their their
altempts to
attempts to sleep. Try not
sleep. Try not to
to think
think of your ongoing
of your ongoing sleep
sleep disturbance
disturbance as as some-
some­
thing you're
thing you're doing
doing to to yourself,
yourself, but butrather
ratheras asaabiological
biologicalsign signofofyour
your disorder.
disorder.
Rather
Rather than wrestling with
than wrestling yourself about
with yourself about being unable to
being unable to sleep,
sleep, instead
instead expe­
expe-
rience
rience the physical sensations
the physical sensations of of being
being in bed, including
in bed, including how your body
h o w your body feels,
feels,
how
h o w you
you experience
experience the the covers
covers over
over you,
you, oror how
h o w the
the pillow
pillow feels against your
feels against your
head. If you have access to a relaxation tape or meditation exercises,
head. If you have access to a relaxation tape or meditation exercises, you
you may
may
wish to
wish to use
use these
these toto help
help you
you experience
experience the the physical
physical sensations
sensations that lead to
that lead to
sleep
sleep (Otto
(Otto et et al.,
al., 1999).
1999).
Many
M a n y people
people have
have trouble
trouble sleeping
sleeping whenw h e n they
they travel.
travel. IfIf you fly from
you fly from the the
West
West Coast
Coast of of the
the United
United States
States to to the
the East
East Coast,
Coast, youyou may
m a y arrive
arrivewhen
w h e n every­
every-
one
one else
else is
is going
going to to sleep,
sleep, but
but forfor you
you it it is
is three
three hours
hours earlier. Transatlantic
earlier. Transatlantic
travel
travel (for
(for example,
example,flyingflying from
from Chicago
Chicago to to Paris)
Paris)is isparticularly
particularly difficult
difficult forfor
people
people withwith bipolar
bipolar disorder
disorder because
because therethere is is such
such a a dramatic
dramatic shift
shift in circa­
in circa-
dian
dian rhythms.
rhythms. But But travel
travel is
is often
often unavoidable.
unavoidable.
One
O n e way
w a y to
to combat
combat thisthis travel
travel disruption
disruption is is to
to gradually
gradually adjust your inter-
adjust your inter­
nal
nal time
time clock
clock toto the
the new
n e w place
place you're
you're going,
going, before
before you
you actually
actually leave. So,
leave. So,
over
over the
the course
course of of the
the week
w e e k before
before you
you travel
travel toto a
a later
later time
time zone,
zone, go
go to
to bed
bed anan
hour
hour earlier
earlier than
than usual,
usual, then
then anan hour
hour andand a a half,
half, and
and then
then two
two hours earlier,
hours earlier,
and
and so
so forth.
forth. ByBy the
the time
time you
you arrive,
arrive, ititmay
m a y be
beeasier
easiertotoadjust
adjustto tothe
thehours
hours ofof
the
the new
n e w time
time zone.
zone. This
This procedure
procedure usually
usually works
works best
best if
if you'll
you'll be
be in
in the
the new
new
time zone for more than a few
time zone for m o r e than a few days. days.
There
There areare other
other strategies
strategies youyou can
can useuse toto improve
improve your
your sleep,
sleep, some
some of of
which
which go go beyond
beyond our our scope.
scope. If If you've
you've been
been having
having difficulties,
difficulties, consider
considerread­
read-
ing
ing self-help
self-help books
books specifically
specifically oriented
oriented toward
toward sleep
sleep issues,
issues, such
such asas William
Wilham
Dement
Dement and and Christopher
Christopher Vaughan's
Vaughan's (1999)(1999) TheThe Promise
Promise of of Sleep
Sleep or
or Peter
Peter
Hauri
Hauri and
and colleagues' (1996) No
colleagues' (1996) N o More
More Sleepless Nights.
Sleepless Nights.

Maintaining
Maintaining Well ness Tip
Wellness Tip No.
N o . 3:
3: Avoiding
Avoiding Alcohol
Alcohol
and
and Recreational
Recreational Drugs
Drugs

Ruth,
Ruth, a 32-year-old
a 32-year-old woman
woman who who had just
had just beenbeen diagnosed
diagnosed withwith bipolar
bipolar 1 I
disorder,
disorder,had
hadaasevere
severeproblem
problemwith
withdrinking
drinkingthat
thatusually
usuallybegan
beganwhen
w h e n she
she
174
174 SElF�MANAGEMENr
SELF-MANAGEMENT

was was relativelyfree

relatively free of
of bipolar
bipolarsymptoms.
symptoms.Typically,
Typically, romantic
romantic relationships
relationships
with
with m men
e n or
or conflict-ridden
conflict-ridden business
business entanglements
entanglements were were thethe background
background
of
of these
these episodes.
episodes. HerHer drinking
drinking binges
binges were
were so so severe
severe that
that she
she often
often had to
had to
be
be hospitalized
hospitalized and and detoxified.
detoxified. She She went
went through
through an an Antabuse
Antabuse program,
program,
in
in which
which she she was required to
was required to come
c o m e inin twice
twice a week to
a week to take
take a a medication
medication
which
which madem a d e her
her vomit
vomit if if she
she drank.
drank. But But she
she quit
quit this
this program
program and and wentwent
back
back 10 to drinking.
drinking.
Her
Her owno w n view
view was
was thatthat her
her bipolar
bipolar disorder
disorder was was making
making her her drink.
drink.
Many
M a n y observers,
observers, including
including her her doc lOTS and
doctors and family
family members,
members, felt felt that
that iit
t
was
was thethe other
other w way around: that
a y around: that her
her drinking
drinking came came first
first and
and ledled to to her
her
mood
m o o d cycling.
cycling. SheShe constantly
constantly complained
complained of of the
the pain
pain ofof the
the mood
m o o d swings
swings
and
and their
their associated
associated anxiety,
anxiety, but but herher symptoms
symptoms co-occurred
co-occurred so consis­
so consis-
tently with
tently with drinking
drinking thatthat itit was
was difficult
difficult to to tell
tell which
which were were duedue totothethebi­
bi-
polar
polar disorder
disorder andand which
which to to the alcohol.
the alcohol.
During
During one one interval,
interval, RuthRuth became
became convinced
convinced that thatshesheshould
shouldgive giveup up
alcohol
alcohol and and stayed
stayed abstinent
abstinent for for almost
almost six six months.
months. Her Her bipolar
bipolar swings
swings
were
were much
m u c h improved
improved during
during this this interval:
interval: She She still
still had
had aa mild
mild depression
depression
but
but nono mania
mania or mixed symptoms.
or mixed symptoms. She She was was ableable toto obtain
obtain a a regular
regular
waitressingjob
waitressing job and and began
began functioning
functioning betterbetter than
than sheshe had
had inin aa long time.
long time.
During
During thisthis period
period of ofrecovery,
recovery,however,however,Ruth Ruthcame cameto tothe
theconclusion
conclusion
that
that she
she hadhad nono real
real problem
problem with with drinking.
drinking. She She began
began to to reinterpret
reinterpret her her
past almost
past almost exclUSively
exclusively in terms of
in terms of her
her n new
e w bipolar
bipolar diagnosis,
diagnosis, denying
denyingany any
causal
causal influence
influence of of alcohol.
alcohol. For For example,
example, she she labeled
labeled her her past
past alcohol
alcohol
binges
binges as as -rapid
"rapid cycling"
cycling" and and ··self-medicating."
"self-medicating." She She reasoned
reasoned that that she
she
wouldn't
wouldn't againagain lose
lose control
control of of her
her drinking
drinking since since herher m mood
o o d disorder
disorder had had
become stable.
become stable.
About
About fivefive months
months intointo her
her period
period of of abstinence,
abstinence, she shetraveled
traveledto toPalm
Palm
Springs
Springs for for aa weekend
weekend with with her
her newn e w boyfriend.
boyfriend. QuiteQuite deliberately,
deliberately,she shedis­
dis-
continued
continued her her Antabuse
Antabuse program
program five five days
days before
before the the trip.
trip. Within
Within one one
week
week sheshe was
was back
back inin the
the hospital
hospital in in need
need of of detoxification.
detoxification. Her depres­
Her depres-
sion
sion was
was much
m u c h more
more severe
severe uponupon her hospital discharge,
her hospital discharge, and and she en­
she en-
rolled,
rolled, once
once again,
again, inin the
the Antabuse
Antabuse program.
program.

Alcohol
Alcohol and
and Drugs:
Drugs: What
What Are
Are the
the Risks?
Risks?

Most psychiatrists and

Most psychiatrists psychologists
and psychologists agree that that
agree if youifhave
you bipolar disorder,
have bipolar disorder,
you
you should
should avoid
avoid alcohol
alcohol and
and recreational
recreational drugs ahogether. As
drugs altogether. A s IItalk aboutin
talkabout in
Chapter 5, alcohol
Chapter 5, alcohol and
and drugs
drugs interfere
interfere with
with the
the effects
effects of
of your
your medication
medication and and
worsen
worsen the course of
the course of your
your illness
illness (for
(for example, Sonne &
example, Sonne & Brady, 1999;
Brady, 1999;
Strakowski et
Strakowski et aI., 2000). If
al., 2000). If you
you use
use alcohol
alcohol and
and drugs,
drugs, you
you are
are likely
likely to be­
to be-
come
come inconsistent
inconsistent with
with your
your medicat ion regimen
medication regimen and will have
and will more trouble
have more trouble
becoming
becoming stable
stable as
as aa result
result (Keck
(Keck et
et aI., 1998; Strakowski
al., 1998; Strakowski et etaI., 1998).Worst
al.,1998). Worst
 How
How(on
CanI Manage My Disorder?
I Manage My Disorder? 175175

of
of all,
all,alcohol and
alcohol drug
and useuse
drug puts youyou
puts at aatmuch greater
a much risk risk
greater for committing
for committing
suicide
suicide Oamison,
(Jamison, 2000b;
2000b; see
see also
also Chapter
Chapter 111).
1).
Some
S o m e doctors
doctors will
will tell
tellyou
you that
thatyou
you can
candrink
drinkalcohol
alcoholin
invery
very small
smallquanti­
quanti-
ties
ties (for
(for example,
example, a
a single
single glass
glass of
of wine
wine with
with dinner).
dinner). There
There may be people
m a y be people
with bipolar
with bipolar disorder
disorder who
w h o can
can do
do this
this and
and stay
stay stable,
stable, but,
but, to
to be honest, II
be honest,
k n o w very
know very few.
few. II tend
tend to
to take
take the
the more
more extreme
extreme view
view that
that not drinking at
not drinking at all
all
and
and not
not using
using any
any drugs
drugs (including
(including marijuana)
marijuana) is
is one
one of
of the
the best ways to
best ways to main­
main-
tain wellness. People
tain wdlness. People with
with bipolar
bipolar disorder
disorder are
are quite
quite strongly
strongly affected-in
affected—in
terms
terms of
of their
their mood
m o o d stability
stability and
and behavior-by
behavior—by even
even small
small amounts
amounts of certain
of certain
substances
substances (see
(see ChapLer 5). This
Chapter 5). This is
is especially
especially the
the case
case if
if they
theyindulge
indulge in
in alco­
alco-
hol
hol or
or drugs
drugs when
w h e n their
their mood
m o o d states
states are
are already
already starting
starting to
to fluctuate.
fluctuate.
Many
M a n y bipolar
bipolar people,
people, like
like Ruth,
Ruth, have
have a
a codiagnosis
codiagnosis of
of alcohol
alcohol or
or drug
drug
abuse
abuse or
or dependence
dependence (the
(the "dual
"dual diagnosis"
diagnosis" situation).
situation). People with dual
People with diag­
dual diag-
noses
noses must
must learn
learn to become abstinent,
to become abstinent, because
because the
thetwo
two disorders
disorderscan
can worsen
worsen
each
each other,
other, much
m u c h as
as they
they did
did for
for RUlh.
Ruth. If
If you
you have
have previously
previously had
had problems
problems
with
with alcohol
alcohol or
or drugs,
drugs, consider
consider joining
joining a
a 12-step
12-step program
program such as Alcoholics
such as Alcoholics
Anonymous
A n o n y m o u s (as
(as Ruth
Ruth did)
did) or
or Narcotics
Narcotics Anonymous.
A n o n y m o u s . These
These groups
groups can
can serve
serve
as
as powerful
powerful resources
resources in
in helping
helping people
people maintain
maintain abstinence.
abstinence. If
If you
you don't
don't like
like
groups,
groups, 12-step
12-step and
and other
other programs
programs for
for addictive
addictive behavior
behavior (for example, moti­
(for example, moti-
vational
vational interviewing; Miller &
interviewing; Miller & Rollnick,
Rollnick, 2002)
2002) can
can often
often be
be obtained
obtained on
on an
an
individual
individual therapy basis.
therapy basis.
Spencer,
Spencer, age 45, fought
age 45, fought his
his desire
desire to
to drink
drink for
for many
m a n y years.
years. However,
However,
through
through couples'
couples' educational
educational therapy
therapy sessions
sessions about
about his
his disorder and through
disorder and through
mood
m o o d charting,
charting, he
he learned
learned to
to recognize
recognize his
his signs
signs of
of mood
m o o d cycling:
cycling: subtle in­
subtle in-
creases
creases in
in irritability
irritabihty and
and anger,
anger, lethargy,
lethargy, and
and insomnia.
insomnia. During
During these cycling
these cycling
intervals,
intervals, he
he learned
learned to
to drink
drink nonalcoholic
nonalcoholic beer
beer when
w h e n he
he was with his
was with his wife
wife
and
and friends
friends who
w h o were
were drinking.
drinking. He
H e eventually
eventually gave
gave up
u p drinking.
drinking. He
H e summa­
summa-
rized
rized his
his experience
experience this
this way:
way:

usedto
"I�lused to be
be aa two-drink-a-night
two-drink-a-nightperson, every
person, night,
every for many
night, years.
for many I fi­ I fi-
years.
nally
nally came
came to
to the
the conclusion
conclusion that
that II just
just couldn't
couldn't do
do it.
it. It
It wasn't
wasn't some
some
moral
moral thing,
thing, ititwas
wasactually
actuallyjust
justaasimple
simpledecision
decisionthat
thatdrinking
drinkingcreated
createdaa
state
state in
in me
m e that
that was
was miserable.
miserable. For
For two
two days
days after
after drinking
drinking even just
even just
small
small amounts
amounts II would
would feel
feel irritated
irritated with
with everybody,
everybody, emotionally ex­
emotionally ex-
hausted,
hausted, and
and want
want to
to sleep
sleep all
all day.
day. The price 1I was
The price was paying
paying was
was too high.
too high.
But
But before
before II could
could quit, had
quit,1 I hadtoto
have hard
have evidence
hard that
evidence alcohol
that was
alcohol waswors­
wors-
ening
ening my
m y life,
Hfe, that
that it
itwas something IIdidn't
was something didn'tneed
needtotodo myself.1 Ifinally
dototomyself. finally
saw
saw alcohol
alcohol as
as a
a big
big contributor
contributor to
to my
m y anger
anger and
and my
m y problems with peo­
problems with peo-
ple.
ple. Without
Withoutalcohol,
alcohol,I I
can decide
can ifif
decide I want to work
I want to w o ron mymanger;
k on it'siwith­
y anger; t's with-
in
in my
m y power
power to
to do
do so.
so. With
With alcohol,
alcohol, the
the anger
anger just
just takes
takes me over."
m e over."
176
176 SHHMNAGEMENT
SELF-MANAGEMENT

B./i.,s about
Beliefs aboutOri.ki." Drug
Drinking, Abuse,
Drug a.d Bipo/ar
Abuse, Disorder
and Bipolar Disorder

People often
People oftenhave
havemistaken
mistakenbeliefs
beliefsabout alcohol,
about drug drug
alcohol, substances, and bipo­
substances, and bipo-
lar
lar disorder.
disorder. SomeS o m e of
of these
these areare listed
listed inin the
the sidebar
sidebar on on this page.
this page.
I've
I've heard
heard people
people with
with bipolar
bipolardisorder
disorder claim
claim that
thatmarijuana
marijuana or cocaineis
or cocaine is
just
just asas effective
effective as as aa mood
m o o d stabilizer
stabilizer suchsuch as as Depakote
Depakote in in controlling
controlling theirtheir
mood
m o o d states.
states. They
They argue
argue that
thatalcohol
alcoholcalmscalmsthem
them down,
d o w n ,or orreduces
reducestheirtheiranxi­
anxi-
ety,
ety, oror improves
improves their their depression;
depression; they they argue
argue thatthat marijuana
marijuana boosts their
boosts their
mood
m o o d when
w h e n they
they areare depressed.
depressed. One O n e patient
patient said,
said, "For
"For me, m e , alcohol
alcohol is is like
like the
the
ropes that keep
ropes that keep the hot air
the hot air balloon
balloon from from going
going up up .. .. .. and
and on the other
on the other side
side isis
like
like aa disguise
disguise covering
covering over over thethe depreSSion."
depression."
Some
S o m e people
people do do drink
drink or or use
use drugs
drugs to to make
m a k e themselves
themselves feel feel better,
better, but
but
whether
whether these these substances
substances are are really
really doing
doing thethe trick-as
trick—^as opposed opposed to to making
making
their
their mmoods
o o d s worse-is
worse—is anotheranother question.
question. We W e know
k n o w that
that alcohol
alcohol worsens
worsens de- de­
pression
pression (as (as in
in the
the examples
examples given given above)
above).. People
People who w h o havehave both
both bipolar dis­
bipolar dis-
order
order and
and alcohol
alcohol problems
problems also also have
have more
more rapid
rapid cycling,
cycling, mixedmixed symptoms,
symptoms,
and
and anxiety
anxiety or or panic
panic than
than those
those who w h o do not drink
do not drink. Alcohol
Alcohol can can also interfere
also interfere
with
with sleep, which can
sleep, which can worsen
worsen mania.mania.
People
People often
often assume,
assume, as as Ruth
Ruth did,did, that
that their
their depression
depression came came first
first and
and that
that
they
they use
use alcohol
alcohol or or drugs
drugs for
for thethe purpose
purpose of of self-medicating
self-medicating this depression.
this depression.
For
For many
m a n y people
people withwith bipolar
bipolar disorder,
disorder, however,
however, the the alcohol
alcohol abuseabuse precedes
precedes
the
the depression
depression ratherrather than
than thethe reverse
reverse (Strakowski
(Strakowski et et aI., 2000). For
al., 2000). For some,
some, a a
vicious
vicious cycle
cycle lakes
takes over:
over: They
They drink
drink heavily
heavily andand get
get depressed
depressed and anxious,
and anxious,
then stop
then stop drinking
drinking and and experience
experience a a recurrence
recurrence of of depression
depression or or panic
panic symp­
symp-
toms
toms that
that isis attributable
attributable to to the
the alcohol
alcohol withdrawal.
withdrawal. Then T h e n they
they try
try to self­
to self-
medicate
medicate thesethese mood
m o o d symptoms
symptoms with with more
more alcohol.
alcohol. This pattern makes
This pattern makes the the
course
course of both disorders
of both disorders muchm u c h worse.
worse.
Marijuana,
Marijuana, although
although perhaps
perhaps not not asas toxic
toxic forfor bipolar
bipolar persons
persons as alcohol,
as alcohol,
can also
can also be
be detrimenlal
detrimental to to your
your moodm o o d stability.
stability. In InStrakowski
Strakowskiand andcolleagues'
colleagues'

Mistaken Beliefs
Mistaken about Bipolar
Beliefs about Bipolar Disorder
Disorder
and Alcohol or
a n d Alcohol or Drug
D r u g Abuse
Abuse

• Alcohol
• Alcohol or
or drugs
drugscan
canbebeused
usedasas
mood
moodstabilizers
stabilizers
• Hard
• Hard drugs
drugs like
like amphelamine,
amphetamine, LSD,
LSD, or
or cocaine
cocaine can
can be
be used
used
as
as antidepressants
antidepressants
• Substances
• Substances cannot
cannot worsen
worsen your
your disorder
disorder if
if your
your mood
m o o d has
has
been stable
been stable
 How Con
How CanI Manage My My
I Manage Disorder?
Disorder? 177177

study (2000), marijuana

study (2000), marijuana use
use was
was associated
associatedwith
withmanic symptoms, whereas
manicsymptoms, whereas
alcohol
alcohol use
use was
was associated
associated with
with depressive
depressive symptoms.
symptoms. One
O n e patient put it
patient put it this
this
way:
way: "Marijuana
"Marijuana makes
makes me
m e think
think and
and think
think and
and think,
think, and
and then
then it keeps me
it keeps me
from
from sleeping.
sleeping. It'sIt's like
likeaacatalyst
catalystfor forsomething
something in inme."
me."Marijuana
Marijuana can can also
also in­
in-
terfere
terfere with
with your
your attention
attention and and concentration
concentration as as well
well as as your
your ability to remem­
ability to remem-
ber
ber toto take
take your
your medication.
medication. Some S o m e people
people findfind it it makes
makes them them lethargic
lethargic and and
unmotivated.
unmotivated.
Rationalizing
Rationalizing their their heavy
heavy drugdrug use,
use, some
s o m e people
people claimclaim that
that L LSD ("acid"),
S D ("acid"),
amphetamines
amphetamines (speed), (speed), cocaine
cocaine (or (or "crack"),
"crack"), and and "Ecstasy"
"Ecstasy" are are really antide­
really antide-
pressants.
pressants. TheyThey argue
argue that
that these
these drugs
drugs cancan help
help their
their depression
depression more more thanthan a a
standard
standard antidepressant
antidepressant such such asas Prozac.
Prozac. SomeS o m e even
even know
k n o w about
about studies
studies show­
show-
ing
ing that
that LSD
L S D stimulates
stimulates the the action
action of of certain
certain serotonin
serotonin receptors
receptors or or that
that am­
am-
phetamine
phetamine stimulates
stimulates and and prolongs
prolongs dopamine
dopamine activity,
activity, as as some antidepres­
some antidepres-
sants do. But they are misinterpreting the
sants do. But they are misinterpreting the clinical implications of clinical implications of these
these
studies.
studies. Even
Even though
though many m a n y street
street drugs
drugs do do affect
affect thethe same
same neurotransmitter
neurotransmitter
systems
systems as as antidepressants,
antidepressants, street street drugs
drugs do do notnot produce
produce true true mood stability.
m o o d stability.
Instead,
Instead, they
they tend
tend to to produce
produce short-term
short-term burstsbursts of neuronal activity
of neuronal activity accompa­
accompa-
nied
nied by
by elation
elation or or irritability
irritability (much
( m u c h like
like mania
mania or or hypomania),
hypomania), rather rather thanthan
truly
truly alleviating
alleviating depression.
depression.
Some
S o m e people
people with
with bipolar
bipolar disorder
disorder use use substances
substances to to intenSify
intensify the elated
the elated
and
and grandiose
grandiose aspects
aspects of of their
their hypomanic
hypomanic or or manic
manic states.
states. TheyThey feel
feeldriven
drivento­ to-
ward further stimulation
ward further stimulation and and novelty.
novelty. Cocaine
Cocaine and and amphetamine
amphetamine are espe­
are espe-
cially
cially likely
likely toto be
be used
used in in this
this way.
way. The result is
The result is often
often a a severe increase in
severe increase in
manic
manic or or mixed
mixed symptoms,
symptoms, or or the
the initiation
initiation of of rapid
rapid cycling
cycling states
states leading
leading to to
hospitalization.
hospitalization.
You
Y o u may
m a y believe
believe thatthat taking
taking alcohol
alcohol or or drugs
drugs is is fine
fine as as long
long as as you
you have
have
been
been feeling
feeling well
well for
for aa period
period of of time.
time. This
This was
was Ruth's
Ruth's logiC,
logic, andand sheshe tested
testeditit
frequently
frequently by by going
going "off
"off the
the wagon"
wagon" whenever
whenever she she had
had a a period
period of of mood sta­
m o o d sta-
bility.
bility. For
Forher,
her,ordinary
ordinarylife lifeseemed
seemedvery verydrab.
drab.The The up u p and
and down
d o w n periods
periodsthatthat
alcohol
alcohol brought
brought werewere somehow
s o m e h o w preferable
preferable to to feeling
feeling that
that life
lifehad
had become
become ordi­ordi-
nary
nary and
and boring.
boring. Many
M a n y people
people whose
whose bipolar
bipolar disorder
disorder is is stable report that
stable report that al­
al-
cohol
cohol and
and drugs
drugs provide
provide a a relief
relief from
from their
theirfeelings
feelingsof ofemptiness.
emptiness.But But ititisisonly
only
aa temporary
temporary relief,
reHef,as asthese
thesesubstances
substancestriggertriggernegative
negativemood m o o d states
statesthat
thatarearefarfar
more
more unpleasant
unpleasant than than boredom.
boredom.
The
The exercise
exercise on on page 178 may
page 178 m a y help
help you
you identify
identify whatwhat makes
makes you you want
want to to
drink
drink oror use
use drugs
drugs (after
(after McCrady,
McCrady, 2001). 2001). ItsIts purpose
purpose is istotohelp
helpyouyouidentify
identify

• Triggers
• Triggers forfor
useuse (forexample,
(for example, being
being with
with people
peoplewhom you want
whom you want to
to im­
im-
press)
press)
•
• The
T h e feelings
feelingsyou
you want
want to
to alleviate
alleviate (for
(formany
m a n y people
people with
with bipolar
bipolar disor­
disor-
der,
der, depression
depression or
or anxiety)
anxiety)
178
178 SElF-MANAGEMENT
SELF-MANAGEMENT

A
A MAINTAINING
M A I N T A I N I N G WELLNESS
W E L L N E S S EXERCISE:
EXERCISE:
IDENTIFYING
IDENTIFYING TRIGGERST R I G G E R S FOR
F O R ALCOHOL
A L C O H O L AND
A N D DRUG
D R U G ABUSE,
ABUSE,
YOUR
Y O U R RESPONSES
R E S P O N S E S TO
TO T THOSE
H O S E TRIGGERS,
TRIGGERS, A AND
ND T THE
H E CONSEQUENCES
CONSEQUENCES

List
List the
thetype
typeofofalcohol or or
alcohol thethe
drug you
drug use
you most
use mostfrequently (examples:
frequently beer,beer,
(examples: wine,wine,
marijuana,
marijuana, cocaine).
cocaine).

List
List the situations in
the situations in which
which you
you are
are most likely [0
most likely to get
get drunk
drunk or
or high (examples: being
high (examples: being
alone;
alone;being
being out
outwith
withfriends;
friends;parties;
parties;Friday afternoon
Friday after
afternoon work;
after with
work; specific
with people).
specific people).

List
List the feelings you
the/eelings you ordinarily
ordinarily have
have right
right before
before you
you drink/get
drink/get high (examples: depressed,
high (examples: depressed,
anxious,
anxious, irritable,
irritable, excited).
excited).

Describe your expectations

Describe your expectations about
about what
what this
this drink/drug
drink/drug will
will do
do for
for you
you (examples:
(examples: it
it will
will
make me
make m e relax
relax and
and ease
ease up
up with
with people;
people; help
help me
m e deal
deal with
with difficult
difficult situations;
situations; decrease
decrease
my
m y depression;
depression; help
help me sleep; make
m e sleep; make me
m e think
think more
more clearly),
clearly).

Describe
Describe the actual consequences
the actual consequences of
of your
your drinking/drug
drinking/drug use
use the
the last
last few
few times.
times. Try to
Try to
distinguish (1)
distingUish (1)what
whathappens
happensimmediately
immediatelyafter
afteryou
youdrink/get
drink/gethigh (examples:relaxed
high(examples: relaxedme,
me,
got
got me
m e into
into an
an argument,
argument, alleviated
alleviated my
m y depression,
depression, made
made me
m e feel
feelmore
moresocial)
social)versus
versus(2)
(2)
the
the delayed
delayed effects (made
effects (made me
m e feel
feelmore
more depressed
depressed the
thenext
nextday,
day,had
hadhangover,
hangover,got
gottoto
work
work
late).
late).

Immediate
Immediate effects:
effects:

Delayed effects:
Delayed effects:

-------� -----
•r)fSS-WKW>5WJ«8aM
 How
How (on
Can I I
Manage MyMy
Manage Disorder?
Disorder? 179
179

• Your
• Your expectations
expectations
•
• The
T h e immediate
immediate consequences
consequences of
of using
using the
the drug/alcohol
drug/alcohol (for
(for example,
example,
feeling
feeling relaxed,
relaxed, feeling
feeling more
more confident,
confident, forgening
forgetting your
your medications)
medications)
•
• The
T h e extended
extended or
or delayed
delayed consequences
consequences ofof use
use (for
(for example,
example, sleep
sleep dis­
dis-
turbance,
turbance, missing
missing work
w o r k the
the next
next day,
day, feeling
feeling irritable,
irritable, drowsy,
drowsy, or
or anx­
anx-
ious
ious several
several days later)
days later)

In
In other
otherwords,
words,think
thinkofof drinking
drinking or or
drugdruguseuse as one
as oneevent in a in
event sequence of of
a sequence
events rather
events rather than
than aa singular,
singular,isolated
isolatedact.
act.Then
T h e nyou'll
you'Hbe beinina aposition
positiontotothink
think
about
about changing
changing this
this sequence.
sequence. For
For example,
example. Amy A m y learned
learned to toavoid
avoid certain
certain situ­
situ-
ations
ations and
and people
people who,
w h o , she
she believed,
believed, made
m a d e her
herdrink
drinkmore.
more.Earl,
Earl,whow h osmoked
smoked
marijuana
marijuana heavily,
heavily, learned
learned toto plan
plan things
things forfor times
times of
of the
the day
day when
w h e n he
he was
was
most
most likely
likely to
to get
get high
high (typically
(typically late
late afternoons
afternoons afterafter he finished his
hefinished classes).
his classes).
Bethany
Bethany learned
learned to
to challenge
challenge her
her belief
behef that
that alcohol
alcohol alleviated
alleviated her depressions.
her depressions.
When
W h e n she
she systematically
systematically evaluated
evaluated the
the results
results of of her
her drinking,
drinking, she she concluded
concluded
that
that she
she felt
felt bener
better at
atfirst
firstbut
butmore
moreirritable
irritableandanddepressed
depressedlater.
later.SheShebegan
begantoto
think
think ofof alcohol
alcohol asas aa cause
cause rather
rather than
than an
an effect
effect ofof her
her mood problems.
m o o d problems.

Maintaining
Maintaining Wellness
Wellness Tip
Tip No.
N o . 4:
4: Relying
Relying on
on Social
Social Supports
Supports

Candace,
Candace, a 49-year-old
a 49-year-old woman
woman withwith bipolar
bipolar II IIdisorder,
disorder, suffered
sufferedfrom froman an
ongOing
ongoing depreSSion
depression that that was
was notnot alleviated
alleviated by by antidepressants
antidepressants or or mood
mood
stabilizers.
stabilizers. After
After becoming
becoming frustrated
frustrated withwith the
the myriad
myriad of of medications
medications she she
had
had tried,
tried, she
she consulted
consulted a a psychotherapist,
psychotherapist, who w h o observed
observed that
that she
she waswas
quite
quite SOcially
socially isolated:
isolated: SheShe had
had broken
broken up u p with
with her
her boyfriend
boyfriend two
two months
months
earlier,
earlier, sheshe had
had few
few newn e w friends
friendsor oreven
even acquaintances,
acquaintances,and and she
she had
had be­
be-
come
c o m e disconnected
disconnected from from herher parents
parents andand her
her two
two sisters.
sisters.Her
Her therapist
therapisten­ en-
couraged
couraged her her to
to try
try some
s o m e new
n e w social
social activities,
activities,which
whichshe shestrongly
stronglyresisted
resisted
doing.
doing. HerHer weekends
weekends were were largely
largely spent
spent alone
alone inin her
her apartment,
apartment, where
where
"my
" m y thoughts
thoughts eat eat me alive."
m e alive."
Candace
Candace had had few
few hobbies
hobbies in in her
her current
current life
life but
but had
had played
played soccer
soccer in in
college.
college. With
With some
s o m e reluctance,
reluctance, she she joined
joined a a group
group who w h o played
played soccer
soccer on on
weekends.
weekends. She She felt
felt awkward
awkward at at first.
first."They're
"They're notnot mym y kind
kind of people," she
of people," she
observed.
observed. At At the
the beginning
beginning she she had
had to to force
force herself
herself to to go.
go. little
Little by little,
by little,
however,
however, she she found
found that
that herher weekends
weekends became
became more more structured
structured because
because
of
of the
the soccer
soccer practices.
practices. Although
Although she she never
never admitted
admitted to to enjoying
enjoying the the
members
m e m b e r s of
of the
the team,
team, sheshe did
did notice
notice that
that her
her mood
m o o d brightened
brightened w when
h e n she
she
participated
participated in in an
an activity
activity with
with them.
them. At At first
first she
she thought
thought this
this was
was duedue toto
physical
physical exercise,
exercise, but butshe
she found
found thatthatherher mood
m o o d also
alsobrightened
brightened when
w h e n she
she
went
went to to pot-luck
pot-luck dinners
dinners or or movies
movies at at the
the team
team members' houses. She
members' houses. She
eventually
eventually disclosed
disclosed her her illness
illness toto aa few
few ofof her
her teammates,
teammates, who w h o "weren't
"weren't
180
180 SElF-MANAGEMENT
SELF-MANAGEMENT

fazed
fazed like
like thoughtthey'd
I Ithought they'd be.
be."With
n Withtime,
time,thethe
group became
group becamelikelike
a second
a second
family
family to
to her,
her, and
and she
shebegan
began dating
dating one
one of
ofthe
themen.
m e n .After
After playing
playingwith
with the
the
learn
team for
for six
six months,
months, she acknowledged in
she acknowledged in one
one of
of her
her therapy
therapy sessions that
sessions that
her
her chronic
chronic depression,
depression, while still presem,
while still present,was
was nOl
not as
asbad
bad as
asitithad
hadbeen
been
before
before she
she had
had made
m a d e these
these connections.
connections.

Social
Social support-feeling
support—feeling emotional
emotional connections
connections with
with people
people with
with whom
whom
one
one regularly
regularly interacts-is
interacts—is an
an important
important protective
protective factor against depression.
factor against depression.
Sheri Johnson and
Sheri Johnson and her
her colleagues
colleagues found
found that
that after
after an
an episode
episode of
of depreSSion,
depression,
people
people with
with bipolar
bipolar disorder
disorder who
w h o had
had good
good social
social support
support systems
systems recovered
recovered
more
more qUickly
quickly and had less
and had less severe
severe depression
depression symptoms
symptoms over
over a
a six-month pe­
six-month pe-
riod
riod than
than those
those with
with small
small or
or nonexistent
nonexistent support
support systems Oohnson et
systems Qohnson et al.,
al.,
1999). Similar
1999). Similar findings
findings have
have come
c o m e from
from studies
studies of
of people
people with
with major depres­
major depres-
sion
sion (for
(for example, Brown &
example. Brown 61 Harris, 1978). In
Harris, 1978). In other
other words, having a
words, having a group
group of
of
people
people you
you know well, whom
k n o w well, w h o m you
you trust
trustwith
with knowing
knowing abom
aboutyour
your bipolar
bipolardis­
dis-
order,
order, and whom
and w h o m you
you see
see with some regularity
with some regularity will
will help
help you
you do bener in
do better in
terms
terms of
of the
the cycling
cycling of
of your
your disorder.
disorder.
You
You may
m a y be
be a
a person
person who
w h o seeks
seeks our
out others
others naturally,
naturally, or
or you
you may prefer
m a y prefer
spending
spending time
time by
by yourself.
yourself. Either way, when
Either way, w h e n you're
you're depressed,
depressed, it
it is
is hard to
hard to
interact
interact with
with anybody.
anybody. Unless
Unless you
you have
have a
a social
social support
support system
system in
in place
place when
when
you're
you're well,
well, you
you may
m a y find
finditithard
hardto
toreach
reachout
outfor
forthe
thevery
veryhelp
helpyou
youneed
needwhen
when
depression
depression strikes.
strikes. Likewise,
Likewise, maintaining
maintaining regular
regular contact with your
contact with social
your social
support
support group
group when
w h e n you're well will
you're well will do much
do m u c h to
to prevent future depression.
prevent future depression.
When
W h e n you
you encounter
encounter the
the inevitable
inevitable conflicts
conflicts that
that come
c o m e up
u p with
with family
family mem­
mem-
bers or
bers or coworkers, your friends
coworkers, your friends and
and supportive
supportive relatives
relatives can
can be
be like
like a
a landing
landing
pad
pad for
for comfort
comfort and
and steadiness.
steadiness. They
They provide
provide a
a counterpart
counterpart to,
to, and
and minimize
minimize
the impact of,
the impact of, stressful conflicts.
stressful conflicts.
1I don't
don't want
want 1Oto overSimplify things
oversimplify things by
by implying
implying that
that just
just having
having people
people
around you is
around you is all
all that
that counts.
counts. As
As II discussed
discussed in
in Chapter 5, high
Chapter 5, high levels
levels of con­
of con-
flict
flict with
withcertain members
certain membersofof
your
yourcore circle,
core particularly
circle, family
particularly members,
family members,
can
can be
be associated
associated with
with a
a more
more difficult
difficult course
course of
of your
your illness.
illness. It
It is
is empathiC,
empathic,
give-and-take
give-and-take relationships
relationships with
with members
members of
of your
your core
core circle,
circle, and
and just plain
just plain
low-key social
low-key time, that
social time, that will best protect
will best protect you
you from
from depression.
depression. Needless to
Needless to
say, that won't always be possible. Chapter 12, on family and work relation­
say, that won't always be possible. Chapter 12, on family and work relation-
ships,
ships, will
will acquaint
acquaint you
you with
with skills
skills to
to help
help you
you maximize
maximize the positive influ-
the positive influ­
ences
ences of
of your
your social
social support
support system.
system.

Your Core
Your Core CCircle
ircle

As
As you'll
you'll see in the
see nextnext
in the chapters, your social
chapters, your supports can be critical
social supports can be keep­
in critical in kee
ing
ing your
your illness
illness from cycling out
from cycling out of
of control.
control. But first, let's
Butfirst, let's identify
identify who
w h o these
these
people are.
people arc.
 How
How Can
Con IIMonaga MyDiSOfdet?
ManageMy Disorder? 181
181

Complete
Complete the exercise
the exercise that follows,
that foUows, " Identifying
"Identifying Your
Your Core Core Circle."
Circle." You You
may
m a y be
b e surprised
surprised at
at your
y o u r list!
list! For
For some people, the
s o m e people, the core
core circle
circle consists
consists of
of
members
m e m b e r s of
of a
a church
church or
or synagogue,
synagogue, or
or a
a group
group devoted
devoted to
to a
a particular
particular hobby
hobby
(as
(as was
w a s the
the case
case for
for Candace).
Candace). Other
Other people
people regularly
regularly rely
rely on and
on a n d socialize
socialize
with just a
with just a few
few friends
friends or
or family
family members.
m e m b e r s . IIt
t isn't
isn't simply
simply the
the number
n u m b e r of
of people
people
in your
in your life
Hfe that
that protects
protects you
y o u from
from a
a drop
drop in
in your
your mood
m o o d but the quality
but the quaHty of
of
these
these relationships
relationships and
a n d the
the regularity
regularity of
of the
the contact.
contact.

IDENTIFYING
IDENTIFYING YOUR
Y O U R CORE
C O R E CIRCLE
CIRCLE

List
Listallall
of the
of people you consider
the people friends-those whom you
you consider/riends—those whomfeel
youyou canyou
feel confide
can in (talk in (talk
confide
to,
to,get
getemotional
emotionalsupport
supportfrom)
from)and
andwho
w h o you
yousee
seeor
orhave
havephone
phonecontact
contactwith
withat
atleast
leastonce
once
a
a week.
week. List
List their
their phone
phone numbers
numbers in
in the
the second
second column.
column.

List
List which family members
which/amily members you
you see
see regularly
regularly and
and feel
feel comfortable
comfortable confiding
confiding in.
in. List
Listtheir
their
phone numbers in
phone numbers in the
the second
second column.
column.

If
If you
you were
were ever
ever in
in trouble
trouble (for
(for example,
example, having
having a
a medical
medical emergency)
emergency) and
and needed
needed
somebody
somebody to
to help
help you,
you, whom
w h o m would
would you
you be
be most
mostlikely
likelyto
tocontact
contactand
and in
inwhat
what order
order (list
(list
them
them in
in order
order of
ofpreference,
preference,from
fromfirst
firsttotofourth)?
fourth)?List
Listtheir phone
their phonenumbers
numbersininthe
thesecond
second
column.
column.

Are
Are there any groups
there any groups of
of people
people who
w h o could
could help
help you
you feel
feel less
less lonely
lonely or assist you
or assist if you
you if you
were
were having
having any
any kind
kind of emergency (examples:
of emergency (examples: church
church or
or synagogue
synagogue groups,
groups, support
support
groups
groups like
like Alcoholics
Alcoholics Anonymous,
Anonymous, groups
groups dedicated
dedicated to
to certain
certain activities-art, cooking,
activities—art, cooking,
foreign
foreign languages,
languages, or
or sports)
sports)
182
182 SElF-MANAGEMENI
SELF-MANAGEMENT

Maintaining
MaintainingFriendships
FriendshipsWhile Avoiding
While Alcohol
Avoiding or Drugs
Alcohol or Drugs

What
What if if your
your social
socialcircle is one
circle is that
one relies heavily heavily
that relies on alcohol on or drugs?orDis­
alcohol drugs? Dis-
pensing with
pensing with alcohol,
alcohol, marijuana,
marijuana, or or hard
hard drug
drug useuse can
can indeed
indeed have negative
have negative
social
social implications.
implications. For For example,
example, some
some people
people find
find it
it hard
hard toto go out with
go out their
with their
friends
friends without
without drinking (this was
drinking (this was the
the case
case for
for Amy).
A m y ) . Some
S o m e say
say [hat their
that their
friends
friends devalue their efforts
devalue their efforts to
to Slay
stay sober.
sober. If these problems
If these problems apply apply toto you, con­
you, con-
sider
sider discussing
discussing your
your dilemma
dilemma with one or
with one or more
more trusted
trusted friends.
friends. D Doo they
they un­
un-
derstand
derstand abomabout your
your disorder
disorder andand the
the likely
likely impact
impact of of alcohol
alcohol or or drug
drug use?
use?
If
If you're
you're not
not comfortable
comfortable disclosing
disclosing the
the disorder
disorder to to any
any of of your friends,
your friends,
consider
consider giving
giving other
other justifications
justifications for
for why
w h y you
you don't
don't want
want to to drink.
drink. Many
Many
people
people today
today respect
respect any measure taken
any measure taken to to improve physical and
improve physical and mental
mental
health
health andand fitness,
fitness, soso saying
sayingyou're
you're trying
trying totolose
loseweight,
weight,or or that
thatdrinking
drinking atat
night discourages
night discourages you you from
from getting
getting up
up and
and working
working out out when
w h e n you
you want
want to, or
(0, or

that
that when you drink
w h e n you drink youyou don't
don't have
have the
the mental
mental sharpness
sharpness you you need
need atat work
work
the
the next
next day,
day, might
might keep
keep them
them from
from pushing
pushing you further.
you further.
Many
M a n y of
of my
m y clients
clients repoTl
report lhat
that giving
giving upup alcohol
alcohol or or drugs
drugs does
does make so­
m a k e so-
Cializing
cializing with
with cenain
certain people
people more
more awkward.
awkward. Very Very few, however, experience
few, however, experience
outright
outright rejection
rejection ifif their
their friends
friends understand
understand theirtheir motivations:
motivations: They They are ab­
are ab-
staining
staining outout of
of a
a desire
desire toto take
take care
care of
of their
their health-rather
health—rather than than to
to judge
judge oror
place
place themselves
themselves above others.
above others.

* * *

Think
Think about
about managing
managing your
your disorder
disorder in
in stages.
stages. Some
S o m e techniques
techniques are best
are best
applied when
applied w you're well
h e n you're well (this
(this chapter),
chapter), and
and olhers,
others, during
during various
various phases
phases of
of
your illness (Chapters
your illness (Chapters 9-11).9-11). In previous chapters
In previous chapters II emphaSize
emphasize the impor­
the impor-
tance of maintaining consistency with your medication regimen and with your
tance of maintaining consistency with your medication regimen and with your
psychotherapy
psychotherapy sessions.
sessions. TheThe strategies
strategies covered
covered inin this
this chapter
chapter for
for maintaining
maintaining
wellness-mood
wellness—mood chaning, keeping regular
charting, keeping regular sleep-wake
sleep-wake routines,
routines, avoiding al­
avoiding al-
cohol
cohol and
and drugs,
drugs, andand relying on social
relying on social supports-can
supports—can enhance
enhance the
the effects of
effects of
your psychiatric treatments in keeping your mood stable. In the next three
your psychiatric treatments in keeping your m o o d stable. In the next three
chapters you'll see
chapters you'll see how
h o w the
the lifestyle
lifestyle management
management techniques
techniques discussed
discussed here
here
can be adjusted when you feel your moods stan to spiral upward or
can be adjusted w h e n you feel your m o o d s start to spiral upward or down­
down-
ward.
ward.
 9
9

What
W h a t Can
C a n I I Do
D o IfIf II Think
T h i n k

I'm
I ' m Getting
G e t t i n g Manic?
M a n i c ?

Robert, 45,
Roben, 45, managed
managed a a successful
successful landscape
landscape architecture
architecture firm. He'd had
firm. He'd had
three
three manic
manic episodes
episodes in in the
the four
four years
years since
since hehe had
had been
been dating
dating his cur­
his cur-
rent girlfriend,
rent girlfriend,Jessie,
Jessie,with
withwhom
w h o mhehewas
wasnown o wliving.
living. Two
T w oofofhis
hisepisodes
episodes
involved
involved hospitalizations.
hospitalizations. He H e maintained
maintained closeclose contact
contact with
with hishis two kids
two kids
from
from a a previous
previous marriage,
marriage, IS-year-old
18-year-old Angie
Angle andand 22-year-old Brian. Jessie
22-year-old Brian. Jessie
had
had no children.
no children.
His
His most
most recent
recent manic
manic episode,
episode, which
which hadhad led
ledtotoaahospitalization,
hospitalization,in­ in-
volved
volved an an identifiable
identifiable setset of
of warning
warning Signs.
signs. The
The first
firstsign
sign he reported was
he reported was
becoming
becoming disimerested
disinterested in in his
his job
job and
and irritable
irritable with
with his
his coworkers,
coworkers, about
about
whom
w h o m hehe had
had become
become mistrustful.
mistrustful. ThisThis was
was a a difficuil
difficult lime
time toto become
become dis- dis­
interested;
interested; his his business
business was flourishing due
was flourishing due toto aa new
n e w housing develop­
housing develop-
ment
ment project
project he he had
had been
been involved
involved in in planning.
planning. During
During the the earliest
earliest stages
stages
of
of his
his manic
manic episode,
episode, he he described
described being
being aware
aware thatthat something
something was was
wrong:
wrong: His His thoughts
thoughts began
began to to race
race and
and he
he was
was full
full of
of great
great ideas.
ideas. HeH e had
had
still
stillbeen
beenable
abletotosleep
sleepmost
most ofofthe
thenight,
night,however,
however,and andsaw sawnononeed
needto tocall
call
his psychiatrist.
his psychiatrist.
According
According to to jessie,
Jessie,Robert
Robert became
became "overly
"overly expressive"
expressive" and and "took
"took on on
this
this physical
physical dominance
dominance stance"
stance" during
during thethe one-week
one-week interval
interval prior
prior toto his
his
hospitalization.
hospitalization. For For example,
example, he he attended
attended Angie's
Angle's basketball
basketball g game
a m e and
and
Mwas
"was thethe loudest
loudest oneone in
in the
the bleachers.
bleachers. At At some
some point
point the
the coach asked him
coach asked him
to
to leave."
leave." OnO n another
another evening
evening jessie
Jessie and
and Robert
Robert hadhad gone
gone toto a fast-food
a fast-food
restaurant
restaurant in
in which
which he
he had
had "barked"
"barked" his
his order
order at
at the
the waitress.
waitress. He later
H e later
apologized to
apologized to the
the waitress.
waitress. jessie
Jessie andand Robert
Robert discussed
discussed his his escalating
escalating

183 183
184
184 SElF-MANAGEMENI
SELF-MANAGEMENT

behavior
behavior and andRobertRobert admiued
admitted thatthathe he was was
being being "hyper"
"hyper" but butalsoalso feltfelt
good:
good: "I'm
"I'm seeing
seeing things
things more
more clearly
clearly than
than ever before."
ever before."
They finally agreed
Theyfinally agreed to to call
call his doctor, whom
his doctor, w h o m he he hadn't
hadn't seen face-to­
seen face-to-
face
face in almost aa year.
in almost Robert's doctor
year. Robert's doctor talked with him
talked with him by by phone
phone but but didn't
didn't
really
really ask
ask questions
questions about
about his
his m mood
o o d state,
state, fOCUSing
focusinginstead
insteadon onhis hisfeelings
feelings
about
about hishis work
work situation.
situation. She She concluded
concluded that that "you
"you need
need some
some rest.rest. You
You
sound exhausted."
sound exhausted." No N o changes
changes were were recommended
recommended in his medication
in his medication re- re­
gime,
gime, which
which consisted
consisted of of relatively
relatively low low dosages
dosages of of Depakote
Depakote and vera­
and vera-
pamil
p a m d (Isoptin,
(Isoptin, a a calcium
calcium channel
channel blocker),
blocker).
Things
Things took took aa turn
turn for
for the
the worse
worse when
w h e n Roben,
Robert, irritated
irritated that
that his
his son
son
Brian had
Brian had notnot returned
returned his his calls,
calls, went
went downd o w n 1O
to the
therecord
record storestorewhere
where
Brian
Brian worked.
worked. He H e and
and Brian
Brian had
had a a verbal
verbal show-down
show-down next next toto the
the cash reg­
cash reg-
ister,
ister, involving
involvingmuch m u c h profanity.
profanity.Brian's
Brian'sbossbossangrily
angrilytoldtoldRobert
Robertand andBrian
Brian
to
to "take
"take it it somewhere
somewhere else."else."Brian
Brian waswas quite
quiteupset
upset andand told
toldRobert
Robert never
never
to
to come
c o m e see
see him
him atat work again.
work again.
In
In the
the next
next few
few days,
days, Robert's
Robert's behavior
behavior escalated
escalated dramatically.
dramatically. His His
movements
movements became became rapidrapid and
and frenetic.
frenetic. He H e became
became angry,
angry, paranOid,
paranoid, and and
fixated
fixated on on grandiose
grandiose notions
notions about
about a a music
music career,
career, even
even though
though he he had
had
been
been playing
playing the the guitar only occaSionally,
guitar only occasionally, as as a a hobby.
hobby. He H e bought
bought an ex­
an ex-
pensive
pensive Fender
Fender Stratocaster
Stratocaster guitar
guitar butbut then
then impulSively
impulsively tradedtraded it it at
ataagui­
gui-
tar
tar show
show for for an
an instrument
instrument worth worth muchm u c h less
less money.
money. He and Jessie
H e and Jessie began
began
to have bitler
to have bitter arguments
arguments in in which,
which, according
according to to Robert,
Robert, "she
"she took
took on this
on this
angry,
angry, resentful,
resentful, removed
removed tone tone but also got
but also got controlling
controlling and and know-il-all.�
know-it-aH."
He
H e impulSively
impulsively moved m o v e d oul
out ofof their
their apartment
apartment and wenL to
and went to live
live atat his of­
his of-
fice.
fice. He
H e called
called her,
her, inin tears,
tears, one
one night
night to to say
say hehe had
had begun
begun to to paniC
panic be-be­
cause
cause he he thought
thought he he was
was dying
dying or or that he might
that he might killkill himself.
himself.JessieJessiecalled
called
the
the police,
police, who w h o found
found himhim in inhis
hisoffice
officestaring
staringfixedly
fixedlyat atthe
theceiling.
ceiling.They
They
escorted
escorted him him toto aa local
local state
state hospital.
hospital. He H e stayed
stayed there
there for
for two
two weeks
weeks be-be­
fore being discharged
fore being discharged on on a a new
n e w regime
regime of of Depakote
Depakote (at (at aa higher
higher dosage)
dosage)
and
and Zyprexa
Zyprexa (an (an antipsychotic).
antipsychotic).

A manic
A manic episode
episode can wreak
can wreak havochavoc
with with a person's
a person's life.ItItcan
life. candrain
drain fi-
fi­
nances, ruin
nances, ruin marriages
marriages andand long-term
long-term relationships,
relationships, destroy
destroy a a person's physi­
person's physi-
cal
cal health,
health, produce legal problems,
produce legal problems, and and lead
lead toto loss
loss of employment. h
of employment. It can
can
even
even lead
lead toto loss
loss of
of life.
life. The
The fall-out
fall-outcan
canbebelong-lasting:
long-lasting:William Coryelland
William Coryell and
his colleagues
his colleagues at at the
the University
University of of Iowa
Iowa Medical
Medical Center (1993) found
Center (1993) that the
found that the
social
social and
and job-related
job-related effects
effects ofof a
a manic
manic episode
episode areare observable
observable forfor up
up to five
to five
years
years after
after the
the episode
episode has has resolved itself.
resolved itself.
If
Ifyou
you think
think back
back totoyour
your last
lastmanic
manic episode,
episode,you youwill
willprobably recallthat
probablyrecall that
it was
it was quite
quiteexhilarating
exhilaratingat atthe
thetime.
time.There
There may
m a y be
be aa pan
partofofyou
you that
thatwants
wants toto
re-create
re-create the
the manic
manic phases
phases forfor the
the euphoric,
euphoric, energized,
energized, confident
confident feelings that
feelings that
accompany
accompany them them (see
(see also
also Chapter
Chapter 7).7). When
W h e n your
your mood
m o o d was escalating,your
was escalating, your
thought
thought processes
processes probably
probably seemed
seemed very
very purposeful
purposeful and and brilliant
brilliant to you, even
to you, even
 CanIIDoDoIf IIfThink
What(an
What I'm GettMani(?
I'm Gening
I Think ing Manic? 18S 185

ifothers
if others found
found them bizarre.You
thembizarre. probably
Youprobably enjoyed
enjoyed the the feeling
feeling of being
of being highly
highly
energized a n d goal-driven.
energized and Perhaps you
goal-driven. Perhaps k n e w you
e v e n knew
y o u even getting manic
w e r e getting
y o u were manic
but didn't
but w a n t to
didn't want shut off
to shut off the feeHngs. This
intoxicating feelings.
the intoxicating This was the case
w a s the for Rob­
case for Rob-
ert, as it
ert, as is for
it is m a n y bipolar
for many people with
bipolar people with whomw h o m I'veI'veworked.
worked.
In retrospect, you
In retrospect, probably feel
y o u probably that, if
feel that, it had
if it possible to
b e e n possible
h a d been to prevent
prevent oror
at m i n i m i z e the
least minimize
at least associated with
d a m a g e associated
the damage y o u r manic
w i t h your episodes, you
m a n i c episodes, y o u would
would
have done
have After his
so. After
d o n e so. hospitalization, Robert
his hospitalization, expressed aa great
Robert expressed of re­
deal of
great deal re-
at the
m o r s e at
morse toll his
the toll episodes were
m a n i c episodes
his manic Jessie was
taking: Jessie
w e r e laking: w a s threatening
threatening to to
leave h i m , and
leave him, his son
a n d his Brian was
s o n Brian talking to
n o t talking
w a s not h i m . His
to him. relationships with
His relationships his
with his
employees were
employees damaged as
were damaged as well.
well.
If you have
If you have not not hadhad full manic or
full manic or mixed episodes but
mixed episodes only hypomaniC
but only hypomanic
ones (that
ones is,you
(that is, youhave disorder),little
bipolarIIIIdisorder),
havebipolar damagemay
Htdedamage m a y have beendone
havebeen done
during your
during activated states.
your activated Nonetheless, you
states. Nonetheless, you may have found
m a y have that hypo­
found that hypo-
episodes—much like
manic episodes-much
manic their more
like their counterparts—bring on
severe counterparts-bring
more severe on major
major
depressions in
depressions aftermath. The
their aftermath.
in their adage that
The adage "what goes
that "what goes up must come
up must come
down" applies only
d o w n " applies only too well to
too well involved in
processes involved
the processes
to the in bipolar disorder.
bipolar disorder.
Because of
Because bases, you
biological bases,
their biological
of their fully prevent
can't fully
you can't prevent future manic or
future manic or
hypomanic episodes
hypomanic episodes from occurring altogether.
from occurring altogether. But Butyou youmay m a y be ableto
be able tocontrol
control
how severe they
how severe and limit
get and
they get damage they
the damage
limit the You can
cause. You
they cause. can learn to "head
learn to "head
them
them off at the
off at recognizing when
by recognizing
pass" by
the pass" they are
w h e n they starting to
are starting and then
occur, and
to occur, then
putting into motion
putting into plans for
motion plans preventing yourself
for preventing from spiraling
yourself from upward even
spiraling upward even
further. In
further. Robert's case,
In Robert's was a
there was
case, there a brief of opportunity
w i n d o w of
brief window opportunity in which his
in which his
early signs were
warning signs
early warning and more
apparent and
were apparent could have
more could been done
have been to prevent
done to prevent
his
his escalation into a
escalation into episode. You'll
full-blown episode.
a full-blown more about
learn more
You'll learn about h o w Robert
how Robert
and Jessie learned
and Jessie to antiCipate
learned to derail his
and derail
anticipate and worst manic
his worst symptoms
manic symptoms later
later in
in
this chapter.
this chapter.
If can successfully
you can
If you implement a
successfully implement a plan to prevent
plan to or decrease
prevent or decrease the sever­
the sever-
of your
ity of
ity manic episodes,
your manic your family,
then your
episodes, then job, and
family,job, socialfunctioning
and social functioning willwill
almost
almost certainly improve. Some
certainly improve. of this
aspects of
S o m e aspects plan will
this plan involve things
will involve you do
things you do
on your own.
on your S o m e will
o w n . Some involve the
will involve actions of
the actions of your family members
your family m e m b e r s and sig­
and sig-
nificant
nificant others. Still other
others. Still aspects will
other aspects will involve
involve your doctor and
your doctor and therapist (if
therapist (if
you have
you one). When
have one). mania is
W h e n mania escalating, you
is escalating, willneed
you will the help
need the others be­
ofothers
help of be-
cause itt will
cause i will be hard to
be hard to rein in yoursel
rein in yourself.f It's best to
It's best to m a k e relapse
make prevention
relapse prevention
plans when
plans w h e n you're because w
well because
you're well when
h e n you you will
escalating, you
are escalating,
you are have aa diffi­
willhave diffi-
cult time recognizing
cult time recognizing the the potential dangers associated
potential dangers your behavior
with your
associated with behavior and
and
what
what to to do to curtail
do to curtail the cycle.
upward cycle.
the upward
II think
think ofof a developing manic
a developing episode as
manic episode as like leaving a
train leaVing
like aa train station.
a station.
When
W the train
h e n the train is m o v e out
to move
starting to
is starting of the
out of the station someone wants
and someone
station and get
to get
wants to
off, the
off, the conductor still has
conductor still time to
has time stop the
to stop before i
train before
the train itt reaches speed.
full speed.
reaches full
But if
But if he waits too
he waits train will
the train
long, the
too long, on its
be on
will be w n trajectory
own
its o trajectory and passengers
and passengers
will stuck on
be stuck
will be train until
the train
on the it stops
until it crashes on
or crashes
stops or its oown.
on its episodes
Manic episodes
w n . Manic
186
186 Sm-MANAGEMENT
SELF-MANAGEMENT

can
can feel
feel like
Hke this
this (rain.
train. The
The key
key is
is to
to be
be able
able to
to tell
teH when the train
w h e n the train has
has staned
started
La move and to try to get off of it before it's barreling down the tracks.
to m o v e and to try to get off of it before it's barreling d o w n the tracks.

The
The Relapse
Relapse Prevention Drill
Prevention Drill

Howimportant
How importantis
is it
it totoknow
know when you are
when you are getting
gettingmanic?
manic? One
One study
study indi­
indi-
cated
cated that
that there
there were
were twO
two predictors
predictors of of rehospitalization
rehospitalization in in bipolar disorder:
bipolar disorder:
nOl
not taking
taking medications,
medications, and and failing
failing to to recognize
recognize the the early
early signs
signs ofof relapse
relapse
(Joyce, 1985). On
Qoyce, 1985). On aa more
more hopeful
hopeful note,
note, people
people with bipolar disorder
with bipolar disorder who re­
w h o re-
ceive
ceive educational
educational interventions,
interventions, such such as as learning
learning to to identify
identify earlyearly warning
warning
signs
signs ofof mania
mania and and then
then seeking
seeking mental
mental health
health services,
services, are areless
lesslikely
likelyto tohave
have
full
full recurrences
recurrences of ofmania
mania andand have
have better
bettersocial
socialandand workwork functioning
functioning over over 18 18
months
months than than those
those who
w h o do
do not
not receive
receive thisthis kind
kind of of education
education (Perry(Perry et al.,
et al,
1999). As
1999). As Roben
Robert said,
said, once
oncehe heand
andJessie
Jessiehadhadbegun
begun (0 toimplement
implementaasuccessful
successful
relapse
relapse prevention
prevention plan,plan, "I
"I used
used to to think
think II was
was inin the
the driver's
driver's seat w h e n II was
seat when was
manic,
manic, but but that
thatwas
was just
justthe
theillness
iHness talking.
talking.Now N o w I Ithink
think I'm
I'minin the
thedriver's
driver's seat
seat
when
w h e n II can
can stop
stop myself
myself from getting manic."
from getting manic."
In
In this
this chapter,
chapter, you'll
you'll learn
learn a a three-step
three-step strategy
strategy forfor getting
getting offoff the train
the train
before mania
before mania takes you for
takes you for aa harrowing
harrowing ride. The method,
ride. The method, calledcalled a a "relapse
"relapse
drill,"
driH," was
was developed
developed by by Alan
Alan Marlatt
Marlatt andand Judith
Judith Gordon
Gordon (1985)(1985) for for the
the treat­
treat-
ment
ment of of alcoholism relapses. The
alcoholism relapses. The relapse
relapse drilldrill waswas used
used successfully
successfully in in
our
our studies
studies of of family-focused
family-focused treatment
treatment for for people
people with with bipolar
bipolar disorder
disorder
(Miklowitz &.
(MiklowilZ & Goldstein, 1997; Rea
Goldstein, 1997; Rea etet aL, 2001;see
al., 2001; seeChapter
Chapter6). 6).AArelapse
relapsepre­pre-
vention method is
vention method is also
also a central part
a central part ofof the
the "collaborative
"collaborative care" care" program
program for for
patients
patients in in NIMH's
NIMH's Systematic
Systematic Treatment
Treatment Enhancement
Enhancement Program Program for for Bipolar
Bipolar
Disorder (Sachs,
Disorder 1998; Otto
(Sachs, 1998; Otto etet aI.,
al., 1999).
1999).
A
A relapse
relapse drill
drill is
is like
like the
the fire
fire drills
drills you
you took
took partpart in
in back
back in in schooL
school. like
Like
fire
fire drills,
drills,relapse
relapsedrills
drillsare
areformulated
formulatedwhen w h e n everything
everythingis issafe
safeand goingwell
andgoing weH
so
so that you know
that you k n o w exactly
exactly what
what to to do
do should
should a a disaster
disaster occur.
occur. Like fire drills,
Like fire drills,
the
the relapse
relapse drill
drill involves
involves a a series
series ofof steps
steps toto take
take toto try
try to
to prevent
prevent the the damage
damage
done
done by by anan anticipated event:
anticipated event:

• Identify
• Identify your
your prodromal
prodromal symptoms
symptoms
•
• List
List preventative
preventative measures
measures
•
• Create
Create aa writlen
written plan
plan or
or contract
contract detailing
detailing prevention
prevention procedures
procedures

In the
In the firststep,
first step, identifying
identifying your
yourprodromal
prodromal symptoms,
symptoms, you
you make
make aa list
list
(usually
(usually with
with the
the help
help of
of others)
others) of
of early
early warning
warning signs that Signal
signs that signal the begin­
the begin-
ning
ning of
of a manic period.
a manic period. Identifying
Identifying warning
warning signs
signs may
m a y also involve identifying
also involve identifying
the
the circumstances
circumstances that
that elicit
elicit these
these symptoms
symptoms (for
(for example,
example, drinking heavily,
drinking heavily,
 Whot
What (on
Can1I110DoIf IIfThink I'm Getting
I Think I'm GettMonic?
ing Manic? 187 187

missing medication
missing medication dosages,
dosages, missing
missing your
your therapy
therapy or physician
or physician appointments,
appointments,
encoumering
encountering snessful stressful work w o r k situations)
situations)..
In
In the
the second
s e c o n d step,
step, listing
listing prevemative
preventative measures,m e a s u r e s , you
y o u brainstorm
brainstorm with with
your relatives
your relatives abouta b o u t what
w h a t actions
actions to to take
take if if one
o n e or
or more
m o r e prodromal signs ap­
p r o d r o m a l signs ap-
pear (for
pear (for example,
e x a m p l e , call
call your
y o u r psychiatrist,
psychiatrist, go g o in
in for
for ana n emergency
e m e r g e n c y medical
medical ap­ ap-
pointment,
pointment, arrangearrange for for others
others to to take
take care
care of of your
y o u r children).
children). These T h e s e actions
actions in- in­
volve you,
volve y o u , your
y o u r doctor,
doctor, and a n d members
m e m b e r s of of your
y o u r core
core circle
circle (see (see alsoalso the
the
examples in
examples in the
the sections
sections that that follow)
follow)..
In
In the
the third
third phase
p h a s e you,
y o u , your
y o u r significant
significant olhers,
others, and a n d your
y o u r doctors
doctors put p u t the
the
first and
first a n d second
s e c o n d steps
steps together
together and a n d develop
develop a a written
written plan,plan, which
w h i c h isis aa kind
kind of of
contract,
contract, for for what
w h a t toto dod o when
w h e n you
y o u feel
feel a a manic
m a n i c episode
episode comingcoming o on.
n . It's
It's impor­
impor-
tant that
tant that all
all key
k e y players
players have h a v e ready
ready access
access to to the
the comract
contract so so that
that they
they cancan help
help
you
y o u put
put it it imo
into action
action when w h e n youy o u are
are beginning
beginning to to cycle-since
cycle—since that that isis when
when
you're
you're least
least likely
likely to to seek
seek help.
help.
This
This chapter
chapter focuses
focuses only only on o n the
the prevention
prevention of of manic
m a n i c episodes.
episodes. This This mate­
mate-
rial
rial is
is also
also relevam
relevant to to preventing
preventing hypomanich y p o m a n i c episodes,
episodes, which w h i c h often
often havehave a a
similar
similar set set of
of warning
w a r n i n g signs
signs and a n d can
c a n be
b e derailed
derailed with with somes o m e ofof the
the same
s a m e preven­
preven-
tative
tative strategies.
strategies. The T h e next
next two t w o chapters
chapters discuss
discuss ways w a y s toto prevent
prevent or or minimize
minimize
the
the downward
d o w n w a r d spiral
spiral of of depression.
depression. But B u t before
before 11 get get imo
into the the actual
actual mechanics
mechanics
of
of developing a contract, let m e say s o m e t h i n g about a sensitive issue that
developing a comract, let me say something about a sensitive issue that may
may
have
have already
already occurred
occurred to to you:
y o u : the
the discomfort
discomfort of of relying
relying on o n others
others when w h e n you
you
are
are becoming ill.
b e c o m i n g ill.

A
A Little
Little Help
H e l p from
f r o m Your
Y o u r Friends
Friends

"I"Istart
startyelling
yelling and
andthen
thenI'mI'm suddenly
suddenly happy
happy again,again, my gets
my sleep sleepall
gets all dis­
dis-
turbed,
turbed, my m y thoughts
thoughts go g o so
so fast
fast II can't
can't grasp t h e m . II get
grasp them. get high-spirited
high-spirited and and
strong-willed.
strong-willed. But B u t the
the weirdest
weirdest thing
thing toto me
m e is
is that
that II don't
don't even
e v e n know
k n o w I'mI'm
ill
iH,, and
a n d why
w h y would
w o u l d II take
take my
m y medications
medications if if I'm
I'm not
not ill?
ill? My
My h husband al­
u s b a n d al-
ways
w a y s knows first, mmy
k n o w sfirst, sister next,
y sister next, aand then mmy
n d then best friends.
y best friends. I'm
I'm always
always the the
last
last one
o n e to
to know
k n o w when
w h e n I'm
I'm getting
getting manic.
manic." "
-A
— A 33-year-old
33-year-old woman
w o m a n with
with bipolar
bipolar II disorder
disorder

The loss
The loss of insight
of insight into into yourself
yourself is a neurological
is a neurological sign
sign of of mania-people
mania—people
don't
don't see
see anything
anything a abnormal
b n o r m a l about
about their
their behavior
behavior when
w h e n inin the
the height
height of of an
a n ep­
ep-
isode,
isode, and
a n d sometimes
s o m e t i m e s even
e v e n when
w h e n they're
they're cycling
cycling upward
u p w a r d or
or coming
c o m i n g out
out of
of an
an
episode
episode (Ghaemi et al.,
( G h a e m i et al., 1995). It's much
1 9 9 5 ) . It's m u c h like
like when
w h e n someone
s o m e o n e has
has a stroke but
a stroke is
b u t is
unaware
u n a w a r e of
of the
the memory
m e m o r y deficits
deficits that
that follow,
follow, or
or when
w h e n someone
s o m e o n e is
is hypnotized
hypnotized
or
or in
in aa dream
d r e a m state
state but
b u t doesn't
doesn't realize
realize he
h e or
or she
she is
is acting
acting differently. Because of
differently. Because of
this
this lack
lack ofof insight,
insight, close
close relatives
relatives (your
(your parents,
parents, Siblings,
siblings, oror spouseJromamic
spouse/romantic
188
188 SElF-MANAGEMENI
SELF-MANAGEMENT

partner)
partner) and and friends
friendsare areoften
oftenthethe firstfirst
to recognize your developing
to recognize your developing mania, mania,
seeing things in your behavior that you cannot (see the quotations
seeing things in your behavior that you cannot (see the quotations from
from rela­
rela-
tives
tives on
on page
page 190).
190). ForFor that
that reason,
reason, it's it's essential
essential to to involve
involve them them in in the three
the three
steps
steps ofof the
the relapse
relapse drilldriH process.
process. ReferRefer backback to to the
the exercise
exercise in in Chapter
Chapter 8, 8, inin
which
which youyou were
were asked
asked to to lisl
list lhose
thosefamily
familymembers
m e m b e r s and
and friends
friendswhomw h o m you
you feel
feel
you could
you could trust
trust in in an
an emergency.
emergency.
Close
Close relatives
relatives should
should be be involved
involved in in the
the care
care ofof any
any person
person withwith a a chronic
chronic
illness,
illness, whether
whether it it is
is aa psychiatric disorder or
psychiatric disorder or aa traditional medical disorder
traditional medical disorder
like
like heart
heart disease.
disease. We W e knowk n o w from
from research
research in in health
health psychology
psychology that that people
people
who
w h o have
have the the best
best health-care practices tend
health-care practices tend lO to engage
engage family
family members
members in in
changing
changing theirtheir unwanted
unwanted habits. habits. ForFor example,
example, their their family
family members
members encour­encour-
age
age them
them to to eat healthy foods,
eat healthy foods, avoid
avoid smoking,
smoking, or or get
get exercise. However, in-
exercise. However, in­
volving others
volving others is is aadouble-edged
double-edged sword: sword:Accepting
Accepting the the help
help ororoversight
oversightof ofan­
an-
other
other person
person will will probably
probably generate
generate a a certain
certain amount
amount of of psychological
psychological distressdistress
in you
in (Lewis &
you (Lewis & Rook,
Rook, 1999).
1999).
What
W h a t is
is this
thisdistress
distressabout?
about?Most Mostpeoplepeopleresentresentthe theidea
ideaof ofhaving
havingothers­
others—
particularly
particularly theirtheir close
close relatives-in
relatives—in a a position
position of of aUlhority
authority whenw h e n they
they start
start toto
become
become ill. ill.InInthetheextreme,
extreme,ititcan canfeelfeel like
likeagreeing
agreeingtotohave havesomeone
someoneelse elsetake
take
away your
away your independence.
independence. These These are are understandable
understandable reactions reactions shared
shared by by people
people
with
with many
m a n y other
other medical
medical illnesses.
illnesses. For Forexample,
example,people peoplewith withinsulin-dependent
insulin-dependent
diabetes
diabetes dislike
dislike thethe idea
idea that
that someone
someone else else might
might havehave to to inject them, if
inject them, ifthey
theygo go
into
into shock.
shock. People
People with with high
high blood
blood pressure
pressure or or cardiovascular
cardiovascular diseases dislike
diseases dislike
the idea that
the idea that aa spouse
spouse mightmight monitor
monitor their their food
food or or salt
salt intake.
intake.
People with
People with bipolar
bipolar disorder
disorder seemseem espeCially
especially prone prone to to feeling
feeling this way. 1I
this way.
have
have heard
heard the the statement
statement "I "I hate
hatethetheideaideaof ofgiving
giving up up control
controlto toanyone"
anyone"from from
many
m a n y clients,
clients,whether
whetherthe thecontrol
controlis isbeing
beinggiven givenup uptotoa alover,
lover, a spouse,
a spouse, a doc­
a doc-
tor,
tor, oror(especially)
(especially)aaparent. parent.IIthink think there
thereare areseveral
severalreasons
reasonswhy w h y the
theissue
issueof of
control is
control is so
so salient
salient to to people
people with with bipolar
bipolar disorder.
disorder. First,
First, when
w h e n you
you experi­
experi-
ence
ence the
the internal
internal feelings
feelings of of chaos
chaos thatthat m mood fluctuations cause,
o o dfluctuations cause, it itcan
canbecome
become
especially
especially important
important to to feel
feel like
like you're
you're at at least
least in in control
control of of your
your outside
outside
world.
world. Second,
Second, the the feelings
feelings of of confidence
confidence and power associated
and power associated with with thethe early
early
and
and later
later stages
stages of mania m
of mania make
a k e youyou especially
especially prone prone to to rejecting
rejecting the the ad­ad-
vice,
vice,opinions,
opinions,or ordirect
directhelphelpof ofothers.
others.Third,Third, many
m a n people
y people with
with bipolar
bipolar disor­
disor-
der
der have
have had had bad bad experiences
experiences in in the the past
past whenw h e n others-however
others—however well- well­
intentioned-tried
intentioned—tried to to exert
exert control
control over over them during emergenCies.
them during emergencies.
If
If your
your reaction
reaction to to involving
involving others
others is isnegative,
negative,thinkthink about
about why w h y you
you feel
feel
this
this way.
way. What
W h a t bothers
bothers you you most
most about
about leaning
leaning on on others?
others? Is Is the
the issue really
issue really
about
about control
control or or personal
personal autonomy?
autonomy? Is Is ititabom
aboutcompetition?
competition?Do D oyou
youfearfearthat
that
there will
there will bebe "strings
"strings attached"
attached" to the help?
to the help? Alternatively,
Alternatively, do do you
you feel thatyou
feelthat you
already
already ask ask tootoo much
m u c h of that person?
of that person? In In addreSSing
addressing the the issue
issue of of whom
w h o m to to
choose
choose to to help
help inin emergencies,
emergencies, clients clients have have said:
said: "The
"The only
only person
person who w h o would
would
probably
probably do this for
do this for me
m e is is exactly
exactly the the person
person II don'tdon't want
want to to have
have anyany more
more
 Whot
What (on
Can IIDoDoIfIfI Think I'm IGetting
I Think 'm GettiMonic?
ng Manic? 189189

control over
control over mymylife—my
life-my mother";
mother"; "My relationship
"My relationship with my withwifemy iswife
suchisthat such that
there's always
there's always a a price
price to to pay.
pay. If If II lean
lean ono n her,
her, she'll
she'll slam
slam me m e in in some
s o m e other
other
way";
w a y " ; and
a n d "My
" M y brother
brother and a n d 1I have
h a v e always
always been
b e e n competitive.
competitive. If If he
he w were to step
e r e to step
in
in when
w h e n I
I got
got manic,
m a n i c , it
it would
w o u l d be
b e kind
k i n d of
of like
like saying,
saying, 'You
'You won.'
w o n . ' ''
" It's
It's impor­
i m p or-
tant to
tant to try
try to
to understand
understand what w h a t issues
issues areare at
atstake
stake for
foryouy o uwhen
w h e n you
y o useek
seek helphelp
from
from others.
others.
With
W i t h these
these issues
issues in in mind,
m i n d , there
there areare various
various waysw a y s that
that you
you c can
a n make the
m a k e the
involvement
involvement of of others
others feelfeel more acceptable. First,
m o r e acceptable. First, remember
r e m e m b e r that
that you're
you're asking
asking
them to
them to step
step inin when
w h e n you
y o u get
get sick,
sick, not
not when
w h e n you
y o u are
are healthy
healthy and
a n d competently
competently
running
running your
y o u r day-to-day
day-to-day life.
life. You
Y o u may
m a y fear
fear that
that ifif you
y o u let
let others
others control
control oone
ne
difficult interval
difficult interval in in your
y o u r life,
life, giving
giving up u pcontrol
controlin inother
other areas
areaswillwillsoon
s o o n follow.
follow.
You
Y o u may
m a y fear
fear that
that your
y o u r wife,
wife, husband,
h u s b a n d , or
or family
family member
m e m b e r will
will always
always be b e hover�
hover-
ing
ing over
over you
y o u and
a n d making
m a k i n g sure
sure youy o u eat,
eat, sleep,
sleep,work,
w o r k , and
a n dsocialize
socialize according
according to to
his
his or
or her
her rules.
rules. But B u t the
the truth
truth is is that
that youy o u are
are giving
giving up u p control
control over over onlyonly a a
fragment
fragment of of your
y o u r life,
life, and
a n d for
for only
only thethe brief
brief period
period during
during which
w h i c h you
y o u are
are esca­
esca-
lating
lating into
into mania.
m a n i a . In
In fact,
fact, you
y o u may
m a y want
w a n t to
to make
m a k e this
this point
point clear
clear toto them:
t h e m : that
that
you
y o u are
are asking
asking for for help
help onlyonly when
w h e n you
y o u become
b e c o m e ill, not
ill, n o t when you're well.
w h e n you're well.
Second, try
Second, try toto involve
involve peoplepeople withwith whomw h o m youy o u dod o not
n o t have
have a a long
long history
history
of
of control
control battles.
battles. If If you
y o u have
h a v e aa history
history of of severe
severe confliclS
conflicts withwith your
y o u r mother
m o t h e r or
or
father
father over
over independence,
i n d e p e n d e n c e , involve
involve youry o u r Siblings
siblings or or close
close friends
friends instead.
instead. There There
may
m a y be
be members
m e m b e r s of of your
your core core circle
circle whom
w h o m you you see see frequently,
frequently, who w h o would
would
know
k n o w if
if something
something was was going
going wrong,
wrong, and and whom
w h o m youyou would
would trusttrust withwith a de­
a de-
gree
gree ofof deCision-making
decision-making capacity capacity during
during a a time
time of of crisis.
crisis.
A
A practical
practical problem
problem that that can
can come
c o m e up u p when
w h e n relying
relying on on social
social supporlS
supports is is
that
that no
no one
one in in your
your core core circle
circle m may
a y see
see you
you often
often enough
enough to to know,
k n o w , within
within a a
brief
brief time,
time, whether
whether you you are are showing
showing the the early
early warning
warning signs. signs. IfIf your relatives
your relatives
live
live far
far away
away or or speak
speak to to you
you onlyonly by phone, they
by phone, they maym a y not
not observe
observe the the subtle
subtle
changes that constitute your cycling, or they may not have the practical re-
changes that constitute your cycling, or they m a y not have the practical re­
sources
sources (for(for example,
example, access access to to your
your physician)
physician) to to be
be able
able toto help. Clients
help. Clients
have
have handled
handled this this byby relying
relying more more heavily
heavily on on local
local friends
friends or or roommates
roommates to to
perfonn
perform the the same
same functions
functions or or by
by giving
giving long-distance
long-distance relativesrelatives the the phone
phone
numbers
numbers of of their
their phYSicians,
physicians, with with instructions
instructions to to call
call if
if the
the relative
relative has has con­
con-
cerns.
cerns.
If
If you
you do do notnot have
have local
local connections
connections with with significant
significant others,
others, then then i itt be­
be-
comes
comes all all the
the more
m o r e important
important to to observe
observe your your own o w n mood
m o o d andand behavior
behavior and and
seek
seek help from your
help from your doctor
doctor when w h e n you
you need
need it. it. Some
S o m e people
people use use the fluctua­
the fluctua-
tions
tionson ontheir
theirmoodm o o dcharlS
charts(Chapter
(Chapter8) 8)to todetermine
determinewhen w h e nto toincrease
increasecontactcontact
with
with their
their therapist
therapist or or physician.
physician. You Y o u maym a y observe
observe very very minor
minor increases
increases in in
your
your mood
m o o d asas the
the episode
episode is is building,
building, even even overover intervals
intervals as as short
short as as a a few
few
days.
days. Although
Although subjective,
subjective, these these observations
observations can can still
stiH inform
inform youryour treatments
treatments
and
and areare far
far preferable
preferable to to ignoring
ignoring your your illness
illness and and letting
letting it it take
take ilS its ownown
course.
course.
190
190 SEU-MkiAGLMEHI
SELF-MANAGEMENT

Step 1:
Step I : Identifying
Identifyingthe
theEarly Warning
Early Signs
Warning of of
Signs Mania
Mania

"He
"He getsdisconnected
gets disconnectedand
andwithdrawn,
withdrawn,kind
kindofofoverwhelming,
overwhelming,irritable
irritable
..in
inyour
your face,
face,loud,
loud,insensitive.
insensitive.He
H ealmost sounds
almost like
sounds someone
like someoneelse inin
else
his
his body.
body. But
But at
at this point LI know
this poim k n o w what
what it
it looks like."
looks like."
-The
— T h e wife
wife of
of a
a 50-year-old
50-year-old bipolar
bipolar II patient
patient

"I"Istart
start Lhinking
thinkingthat
thatI made
I mademistakes
mistakesat at
mymy
jobjob
las[as
a refrigeralOT repair­repair-
a refrigerator
man!. . . IIstart
m a n ] ..... startwondering
wonderingifif
I wired things
I wired incorrectly
things and
incorrectly then
and that
then the
that the
refrigerator
refrigerator in
in someone's house wlll
someone's house will blow
blow up
up and
and burn
burn them . . II start
them.. .... start
wondering whether
wondering I've just
whether I've just thought
thought things
things or
or said
said them
them out
out loud. It
loud. It
makes
makes me
m e pull
pull away
away from
from everybody.
everybody. II gel tight-lipped."
get tight-lipped."
— A 60-year-old
-A 60-year-old man
m a n with bipolar II disorder
with bipolar disorder with
with psychotic
psychotic features
features

"She'susually
"She's usually shy,
shy,but
butwhen
when she's
she'sgeuing high
getting she she
high gelSgets
in people's faces; faces;
in people's
she
she gets imposing, overly
gets imposing, overly emotional
emotional and effusive, like
and effusive, like telling her whole
telling her whole
life story
life story to
to a
a bank
bank teller.
teller. . ...
. . IIcan
cansee
seeother
otherpeople
peoplebacking
backing off
offand
and sort
sort
of looking
of looking at
at me,
m e , but
but she
she doesn't
doesn't know
k n o w that's
that'show
h o w she's
she'scoming
comingacross.
across." n

-The
— T h e husband
husband of a 37-yea,.-0Id
of a woman
3 7-year-old w with bipolar
o m a n with I disorder
bipola,. I diso,.der

Defining Your
Defining YourProdromal
ProdromalPha,e
Phase

Recall that
Recall thatinin
Chapter 2, I2,1
Chapter described the manic
described syndrome
the manic as involving
syndrome changeschanges
as involving
mood,
in m
in energy or
o o d , energy or activity
activity levels,
levels, thinking
thinking and
and perception,
perception,sleep,
sleep,and
andimpulse
impulse
control. Think
control. Think about
about the
the beginning
beginning phases
phases of
of mania
mania as
as involving
involving any
any or
or all
all of
of
these. The
these. The prodromal
pmdmmal phase, usually defined
phase. usually defined as
as the
the period
period from
from the first onset
the first onset
symptoms to
of symptoms
of to the
the point
point at
at which
which symptoms
symptoms reach
reach the
the height
height of
of their
their sever-
sever­
can last
ity, can
ity, last a
a day
day or
or two
two to
to even
even a
a week
week or
or several
several weeks.
weeks. During
During this
this
prodromal phase,
prodromal phase, your
your symptoms
symptoms will
will probably
probably be
be mild
mild and
and not
nOl necessarily
necessarily
troublesome-and therefore
troublesome—and therefore difficult
difficult to
to detect.
detect. They
They are
are usually
usually muted ver­
muted ver-
sions of
sions of the
the symptoms
symptoms of
of a
a full
full manic
manic episode.
episode. It
It is
is during
during this
this prodromal
prodromal
phase that
phase that the
the train
train has
has only
only just
just begun
begun to
to leave
leave the
the station,
statioll, and
and you
you have the
have the
most control
most control over
over your
your fate. encourage m
fate. II encourage my clients to
y clients err on
to err on the
the side
side of
of cau-
cau­
tion: The
tion: Theappearance
appearanceof ofeven
evenoneonemild
mildprodromal
prodromalsymptom
s y m p t o misisoften
often Signal
aa toto
signal
seek help.
seek help.
In a
In a study
study of
of the
the prodromal
prodromal phases
phases of
of manic
manic episodes,
episodes, Emily
Emily Altman and
Altman and
our group
our group at
at UCLA (1992), observed
U C L A (1992), observed people
people with
with bipolar
bipolar disorder
disorder over a nine­
over a nine-
mmonth period following
o n t h period following a
a hospitalization
hospitalization and
and rated
rated their
their symptoms
symptoms every
every
month. S
month. Some had manic
o m e had manic episodes
episodes during
during the
the observation
observation period.
period. The
The patients
patients
wwho developed mania
h o developed mania showed
showed very
very mild
mild increases
increases in
in "unusual
"unusual thought
thought con-
can-
 Whot Con II00DoIfIIfThink
What (on I'm IGelting
I Think Monic?
'm Getting Manic? 191191

tent" in
tent" in the
the month beforetheir
month before theirfull
fullepisodes.
episodes.TheseThese unusual
unusual thoughts
thoughts were re­
were re-
flected in
flected in statements
statements the the patients
patients madem a d e during
during clinical
clinical interviews
interviews regarding
regarding
their beliefs
their beliefs inin the
the influences
influences of of spirits,
spirits, psychic
psychic powers,
p o w e r s , or
or the
the occult;
occult; their
their
overly
overly optimistic
optimistic schemes
s c h e m e s for
for making
m a k i n g money
m o n e y qUickly;
quickly; their
their feeling
feeling that
that others
others
w e r e staring
were staring oror laughing
laughing at at them;
t h e m ; or
or believing
believing that
that their
their mind
m i n d was
w a s sharper
sharper
than everyone else's (in other w o r d s , m i l d psychotic s y m p t o m s ) . These
than everyone else's (in other words, mild psychotic symptoms). These
changes
changes in in thinking
thinking were w e r e mild,
mild, anda n d in
in some
s o m e cases,
cases, even
e v e n the
the person
person expressing
expressing
t h e m could
them could admit
a d m i t the
the ideas
ideas sounded
s o u n d e d odd
o d d or
or unrealistic.
unrealistic. So, S o , observable
observable
changes in
changes in the
the content
content of
of your
y o u r thinking
thinking and
a n d speech
speech in
in the
the month
m o n t h before
before aa mallie
manic
episode may
episode m a y be
be a
a due
clue that
that you
y o u are
a r e beginning
beginning toto cycle.
cycle.
A
A survey
survey by
by Grace
Grace Wong
W o n g and
and Dominic
Dominic Lam (1999) asked
L a m (1999) asked people
people with bi­
with bi-
polar disorder
polar disorder toto describe
describe their
their early
early warning
warning Signals
signals prior
prior to previous manic
to previous manic
episodes.
episodes. TheT h e most
most frequent
frequent Signals
signals reported
reported werewere reduced
reduced sleep
sleep and
and an in­
an in-
crease
crease inin activity,
activity, both
both repofted
reported byby over 4 0 % of
over 40% of the
the respondents.
respondents. Less fre­
Less fre-
quently,
quently, people
peoplereported
reported feeling
feelingeuphoric
euphoric or orirritable,
irritable,having
havingracing
racingthoughts,
thoughts,
or
or being
being energetic
energetic and and productive
productive (goal-driven)
(goal-driven) in in the
the interval just before
interval just before
their
their episode.
episode.
It
It appears
appears that
that many
m a n y people
people with
with bipolar
bipolar disorder
disorder areare able to describe
able to describe
how
h o w they
they behave
behave when
w h e n they're
they're getting
getting manic,
manic, at at least
least when
w h e n they're
they're asked af­
asked af-
ter
ter the
the fact.
fact. The
The harder
harder question
question is,
is, how
h o w do
do you
you know
k n o w ahead
ahead of of time
time what
what
symptoms
symptoms you you should
should be be looking for? One
looking for? O n e way
w a y to
to increase
increase the probability
the probability
that
that you
you or
or others
others will
will recognize
recognize a
a developing
developing episode
episode is
is to
to mahe a list,
make a list, when
when
you're well, of
you're well, of early
early wanting
warning signs
signs recalled
recalled from
from your
your last few episodes.
last few episodes. In
In
other
other words,
words, take
take advantage
advantage of of the
the greater
greater insight
insight youyou have
have into
into your illness
your illness
when
w h e n you
you are
are well.
well. This
This kind
kind ofof objectivity
objectivity will
will bebe harder
harder toto summon
s u m m o n when
when
you
you areare heading
heading into
into an
an episode,
episode, butbut having
having thethe list
list available
available m may
a y help
help youyou
view
view youryour escalating
escalating mood,
m o o d , thoughts,
thoughts, andand behaviors
behaviors in in aa different light.
different light.
Soon
Soon I'llI'll talk
talk about
about what
what youyou cancan actually
actually dodo when
w h e n these
these prodromal
prodromal signssigns
appear.
appear.
The
The follOwing
foUowing exercise
exercise will
will help
help get
get you
you stafted
started recording
recording your
your prodromal
prodromal
symptoms.
symptoms. Your Your early
early warning
warning signs,
signs,however,
however,may m a y be
bedifferent
differentfrom
from thetheones
ones
listed
Hsted in in the
the exercise.
exercise. Nancy
Nancy experienced
experienced the the onset
onset of of her
her hypomaniC
hypomanic episodes
episodes
as
as an
an increase
increase inin anxiety
anxiety and
and worry.
worry. Pete
Pete reported
reported that,
that, despite
despitefeeling
feehngspeedy
speedy
and
and internally
internally stimulated,
stimulated, he he withdrew
withdrew more more when
w h e n he
he was
was escalating
escalating because
because
he
he knew
k n e w that
that he
he would
would alienate
alienate other
other people
people once
once he he became manic. Heather
became manic. Heather
became
became obsessed
obsessed with
with aa certain
certain movie
movie star
star and
and began
began "seeing
"seeing things
things out
out of
of the
the
corner
corner of of my eye."
m y eye."
It
It is
is important
important to to distinguish
distinguish the the early
early warning
warning signssigns of
of mania from those
mania from those
of
of depression,
depression, which which usually
usually involve
involve feeling
feeling slowed
slowed down, fatigued, self-
d o w n , fatigued, self­
critical,
critical, hopeless,
hopeless, oror uninterested
uninterested in in things
things (see
(see the
the next
next chapter). Holly re-
chapter). Holly re­
ported periods of increased irritability and anxiety prior to manic episodes but
ported periods of increased irritabflity and anxiety prior to manic episodes but
 LISTING
LISTING YOUR
YOUR PRODROMAL
PRODROMAL SYMPTOMS
SYMPTOMS OF
OF MANIA
MANIA OR
OR HYPOMANIA
HYPOMANIA

With the help

With the help of
ofyour
yourclose friends
close or relatives,
friends list a couple
or relatives, list aofcouple
adjectives describing what
of adjectives your mood
describing what you
islike
is likewhen
w h e n your
your manic
manic or
orhypomanic
hypomanic episodes
episodesfirst begin(examples:
firstbegin (examples:up.
up,happy,
happy,more
moreaware,
aware,willIu
l,
willful,
more
more reactive,
reactive, cranky,
cranky, irritable,
irritable, euphoric,
euphoric,anxious,
anxious,wired,
wired,cheery,
cheery,like
likeaayo-yo,
yo-yo,pumped
p u m p e dup).
up).

Describe
Describe changes
changes in your activity
in your and mergy
activity and energy levels
levels as
as your
your manic episode is
manic episode is developing ("goal­
developing ("goal-
directed
directed behavior").
behavior"). Include
Include changes
changes in
in how
h o w you
you relate
relate to others (examples:
to others (examples: call
call 1olS
lots of people, make
of people, make
loIS
lots of
of new
n e w friends,
friends, take
takeon
onmore
moreprojects
projectsor
orstart
start"multitasking,"
"multitasking,"talk
talkmore
more and
and faster,
faster,get
getininpeople's
people's
faces,
faces, tell
tell people
people off,
off, feel
feel"horny"
" h o m y " or
orvery
very sexually
sexually driven).
driven).

Describe
Describe changes
changes in
in your
your thinking and perception
thinking and perception (examples:
(examples: thoughts
thoughts race
race or
or at
at least
least go faster,sounds
go fasler, sounds
gel
get louder,
louder, colors
colorsget
getbrighter,
brighter,I Ithink
thinkI can dodo
I can anything, I think
anything, others
I think areare
others looking at at
looking memor laughing
e or laughing
at m e , II get
at me, getmore
more interested
interestedin
inreligion
religionor
or the
theoccult,
occult,I Ifeel really
feel smart
really and
smart andconfident, I start
confident, thinking
I start thinking
about
about many
m a n y new
n e w ideas
ideas involving
involving money,
money, other
other people
people seem
seem boring
boring and
and closed-minded,
closed-minded, II get
get
extrasensory perception, II have
extrasensory perception, have psychic
psychic abilities,
abilities, IIthink about
think abouthurting
hurtingor
orkilling
killingmyself,
myself,IIruminate
ruminate
about
about things,
things, II get
get easily
easily distracted).
distracted).

Describe
Describe changes
changes in
in your sleep
your patterns (examples:
sleep patterns (examples: sleeping
sleepingtwo
two hours
hoursless
lessthan
thanusual
usualbut
butnot
notfeeli
ng
feeling
tired.
tired the
the next
next day,
day, waking
waking up
u p aalot
lotduring
during the
thenight,
night,staying
stayingup
u plate
lateand
andrelying
relyingon
o ncatnaps duringtht
catnapsduring the
day,
day, not
not needing
needing sleep).
sleep).

Describe
Describe anything
anything you've
you've done
done in
in the
the last
last week
week that
thatyou
you wouldn't
wouldn't ordinarily do (examples:
ordinarily do (examples:spent
spentaalot
lot
of
of money
m o n e y or
or invested
invested money
m o n e y on
o n impulse,
impulse, got
got one
one or
or more
more speeding
speeding tickets
tickets or
or drove recklessly,had
drove recklessly, had
more
more sexual
sexual encounters
encounters with
with partner
partner or
or other
other partners,
partners, gambled
gambled money).
money).

Describe the context (any

Describe the (any changes,
changes, events,
events, or circumstances) associated
or circumstances) associated with
with these
these symptoms
symptoms
(examples:
(examples: an
an increase
increase in
in your
your work
work stress,
stress, stopping
stoppingor
orbecoming
becoming inconsistent
inconsistentwith
withyour
yourmedication,
medication,
missing
missing your
your doctor's
doctor's appointments,
appointments, starting
startingto
todrink
drink or
oruse
use drugs,
drugs,starting
startingaanew
n e w project, changesinin
project,changes
your
your work
work hours,
hours, travel
travel across
across time zones,
time zones, more
more family
family or
or re1.ationship
relationship conflicts,
conflicts, starting a nnew
starting a ew
relationship
relationship or
or ending
ending another
another one, changes iin
one, changes n your
your fmancial circumstances).
financial circumstances).

192
192
 Can IIDoDoIfIIfThink
What(on
Whol I'm IGelling
I Think Monic?
'm Getting Manic? 193193

misidentified
misidentified these theseasassigns signs of of depression.
depression. Prior Prior to learning
to learning more more
about herabout her
disorder, she
disorder, u s e d to
s h e used self-medicate her
to self-medicate her irritability over-the-counter reme­
w i t h over-the-counter
irritabdity with reme-
dies as St.
s u c h as
dies such John's wort.
St. John's wort. During period of
o n e period
D u r i n g one escalation she
of escalation e v e n con­
s h e even con-
vinced an
vinced a n internist
internist to prescribe an
to prescribe antidepressant, which
a n antidepressant, w h i c h made her manic
m a d e her manic
symptoms w o r s e . With
m u c h worse.
s y m p t o m s much time, she
W i t h time, observed that
she observed that irritability a n d anxiety
irritability and anxiety
usually portended
usually rather than
m a n i a rather
p o r t e n d e d mania depression, and
than depression, a n d she learned to
s h e learned rely on
to rely on
more prevention methods,
traditional prevention
m o r e traditional s u c h as
m e t h o d s , such increasing the
as increasing dosage of
the dosage of her
her
m o o d stabilizer.
mood stabilizer.
If you've had
If you've only one
h a d only o n e or episodes, you
t w o episodes,
or two m a y have
y o u may difficulty listing
h a v e difficulty listing
your prodromal
your symptoms. Your
prodromal symptoms. family or
Your family friends may
or friends be able
m a y be able to help you
to help you
here,as
here, doctor.In
yourdoctor.
m a y your
asmay Chapter 2,
InChapter I talk
2,1 abouthow
talkabout mania can
h o w mania lookquire
can look quite
different to
different people who
to people have the
w h o have versus how
disorder versus
the disorder looks to
it looks
h o w it their family
to their family
members or
members doctors. You
or doctors. m a y not
Y o u may agree with
not agree relatives that
your relatives
with your that a a certain
certain
behavior (for example. your aggreSSiveness) or thinking
behavior (for example, your aggressiveness) or thinking pattern (for example, pattern (for example.
characterizes you
distractibihty) characterizes
distractibility) you when you're getting
w h e n you're manic, but
getting manic, it's better
but it's better toto
list these
list behaviors or
these behaviors or thinking patterns if
thinking patterns might in
they might
if they some way
in some help your
w a y help your
relatives recognize your
relatives recognize episodes early.
your episodes Likewise, record
early. Likewise, record youryour own views of
o w n views of
your early warning
your early signs or
warning signs or eliciting circumstances even
eliciting circumstances even if views don't
these views
if these don't
coincide with
coincide what your
with what relatives think.
your relatives think.
Robert, the
Robert, discussed at
m a n discussed
the man at the beginning of
the beginning chapter, reponed
the chapter,
of the feel­
reported feel-
ing sexual and
very sexual
ing very having racing
and having thoughts before
racing thoughts before he he had changes in
had changes his
in his
mood. His
mood. girlfriend Jessie
His girlfriend saw it
Jessie saw differently: She
it differently: thought he
She thought he became irritable
became irritable
then loud
first, then
first, and phYSically
loud and Another person
intrusive.Another
physicallyintrusive. personwith bipolardisor­
with bipolar disor-
T o m , said
der, Tom,
der, that his
said that almost always
manias almost
his manias always involved religious preoccupa­
involved religious preoccupa-
tions
tions and paranoia. His
and paranoia. His parents described him
parents described him as "getting a
as "getting a certain look in
certain look his
in his
eyes" "muttering stuff
and "muttering
eyes" and underneath his
stuff underneath breath." The
his breath." physician who
The physician w h o treated
treated
Alan,
Alan, the 60-year-old refrigerator
the 60-year-old repairman who
refrigerator repainnan believed that
w h o believed that others could
others could
hear what he
hear what he was thinking, felt
was thinking, felt that
that Alan's "bouncy, upbeat
Alan's "bouncy, upbeat quality"
quality" was his
was his
first prodromal sign.
first prodromal Characterizations like
sign.Characterizations these are
Hke these helpful in
are helpful rounding out
in rounding out
what
what your prodromal phases
your prodromal phases look like from
look like your own
from your vantage point
o w n vantage point and the
and the
vantage point of
vantage point others.
of others.
If you
If bipolar II
have bipolar
you have disorder, you
II disorder, you may wonder whether
m a y wonder whether your hypo­
your hypo-
manias really
manias have a
really have a definable beginning and
definable beginning and end. Hypomanic episodes
end. HypomaniC episodes can can be
be
very and, because
subtle, and,
very subtle, because they they dodo not interfere with
significantly interfere
not Significantly with your day-to­
your day-to-
day functioning, they
day functioning, they cancan be hard to
be hard to distinguish
distinguish from baseline state.
your baseline
from your state.
However, even
However, hypomania involves
even hypomania physical, cognitive,
observable physical,
involves observable cognitive, and and emo­
emo-
tional changes
tional changes relative
relative to ordinary state.
your ordinary
to your prodromal symptoms
Typicalprodromal
state. Typical symptoms of of
hypomania are
hypomania are sleep (sometimes a
loss (sometimes
sleep loss change of
a change an hour
only an
of only hour oror two), in­
two) , in-
creases
creases in energy levels,
in energy increasesin
levels, increases thespeed
inthe ofyour
speed of thoughts or
your thoughts speech,and
orspeech, and
or impatience.
irritability or
irritability impatience. Perhaps you can
Perhaps you when
recall w
can recall h e n these changes last
these changes oc­
last oc-
curred and
curred you k
and you knew
n e w something different.
was different.
something was
194
194 SHf·MANAGfMfNT
SELF-MANAGEMENT

Identifying thethe
Identifying Context in Which
Context Your Your
in Which Early Early
Warning Signs Occur
Warning Signs Occur

You may
You mayhave
have an
an easier
easier time
timedescribing
describingyour prodromal
your signs
prodromal if you
signs also also
if you re­ re-
cord information
cord information ahoUl about thethe context
context in which they
in which they occur.
occur. ForFor example,
example, RobenRobert
felt
felt that
that his irritability during
his irritability during hishis last
last episode
episode was was closely
closely tied
tied toto increases
increases in in
his work demands
his work demands and annoyances expressed
and annoyances expressed by by coworkers,
coworkers, w who
h o had
had begun
begun
pressuring
pressuring him him about
about the
the company's
company's financial
financial outlook.
outlook. For For Ruth
Ruth (see
(see Chapter
Chapter
8), manic
8), manic cycles were nearly
cycles were always precipitated
nearly always precipitated by by alcohol
alcohol usage,
usage, sometimes
sometimes
even
even in in small
small quantities.
quantities. In In the
the exercise
exercise above,
above, there
there isis a space to
a space to record
record
any
any eliciting
eliciting circumstances
circumstances (usual (usual oror unusual)
unusual) that that y you-or any of
o u — o r any your
of your
relatives-think
relatives—think may be associated
m a y be associated withwith your
your early warning signs.
early warning signs.
Ident ifying circumstances
Identifying circumstances associated
associated with your prior
with your prior manic
manic episodes
episodes can can
help
help youyou minimize
minimize the the impact
impact of of the
the next
next one.
one. If you know
If you that aa particular
k n o w that particular
circumstance
circumstance (for (for example,
example, an an increased
increased workload
workload due due toto the
the Christmas
Christmas holi- holi­
days)
days) waswas associated
associated withwith your
your last
last episode
episode (even
(even if you don't
if you don't think
think it it caused
caused
your illness),
your illness), youyou may
m a y want
wantto tobecome
become more
more vigilant
vigilantabout
about your
yourfeeling
feelingstates
states
or
or behavior
behavior during
during thethe next
next interval
interval in which this
in which this or
or aa similar
similar source
source of of stress
stress
occurs
occurs (for(for example,
example, the next lime
the next you know
time you your wwork
k n o w your o r k demands
demands will will in-
in­
crease).
crease) .This Thiskindkindofof vigilance
vigilancecan canhelp
helpyou
youdetermine
determinewhen w h e nyou
youshould
shouldask ask
for
for medical
medical or or other
other kinds
kinds of help.
of help.
Teresa worked as
Teresa worked as an
an accountant.
accountant. She She carne
came to to realize
realize that
that tax
tax season,
season, with with
irs
its much longer work
m u c h longer work hours,
hours, waswas aa trigger
triggerfor
forher
her manic
manic episodes.
episodes.Prior Priorto totax
tax
season,
season, sheshe obtained
obtained a a prescription
prescription from her doctor
from her doctor for for aa tranquilizing
tranquilizing medi­ medi-
cation
cation (in(in her
her case,
case, Seroquel)
Seroquel) to to be
be started
started ifif she was unable
she was unable to to sleep,
sleep, experi­
experi-
enced
enced racing
racing thoughts,
thoughts, or or felt
felt overly
overly goal-driven.
goal-driven. She was also
She was also able
able to to arrange
arrange
aa few
few days
days offoff in
in the
the middle
middle of of tax
tax season
season when
w h e n she
she felt
felt her
her mood
m o o d escalating.
escalating.
As
As a a result,
result, she she was
was able
ableto toget
getthrough
through taxtaxseason
seasonwithout
without aafull episode,al­
fullepisode, al-
though
though she she remained
remained aware aware of of an
an underlying
underlying energized
energized statestate that
that waswas only
only
partially
partially masked
masked by the medication.
by the medication.

Step 2,
Step 2, Part
Part A:
A: Preventative
Preventative Steps
Steps You
You Can
Can Take
Take Yourself
Yourself
or
or with
with Others'
Others' Help
Help

The focus of
The focus ofthis section
this sectionis on
is preventative maneuvers
on preventative you and
maneuvers you your signifi­
and your signifi-
cant
cant others can take
others can at the
take at the appearance
appearance ofof one
one or
or more
more early
early warning signs. I've
warning Signs. I've
separated this section
separated this section from
from the
the next
next (Part
(Part B), which concerns
B), which negotiating help
concerns negotiating help
from
from your
your doctor
doctor and
and the
the mental
mental health
health system.
system. Later,
Later, we'll
we'H put
put Steps
Steps 11and
and 22
together
together into
into aa written
written contract
contract (Step
(Step 3).
3).
Not
Not all
all of
of the
the following
following preventative
preventative steps will apply
steps will apply to For example,
you. For
to you. example.
 Whot
What(on
ConII00DoIf IIfThink I'm Gen
I Think I'ming
GettMonic?
ing Manic? 195195

you may
you may behe a person
a person whowho has trouble
has trouble with with
money money
but not but
withnot with
sexual sexual indis­
indis-
cretions. You
cretions. Y o u may
m a y have
have a
a history
history of
of making
m a k i n g impulsive
impulsive life
life decisions but
decisions b u t have
have
never driven
never driven recklessly.
recklessly. Your
Y o u r individual
individual pattern
pattern of
of prodromal
p r o d r o m a l symptoms may
symptoms m ay
dictate which
dictate w h i c h of
of the
the following
following preventative
preventative measures
m e a s u r e s are
are most
m o s t urgent
urgent aand
nd
which
w h i c h can wail. So,
c a n wait. S o , for
for example,
e x a m p l e , if
if your
y o u r prodromal
p r o d r o m a l symptoms
s y m p t o m s are
are irritability
irritability
and a decreased
and a decreased need
n e e d for
for sleep,
sleep, your
y o u r may
m a y want
w a n t to
to see
see your
y o u r physician
physician immedi­
immedi-
ately, but
ately, b u t asking
asking someone
s o m e o n e else to hold
else lO hold on
o n to
to your
y o u r credit
credit cards may
cards m not
ayn o t be as
b e as
essential (unless irritability
essential (unless irritability and
a n d sleep
sleep disturbances
disturbances have,
have, in
in the past, heralded
the past, heralded
a
a drive
drive toward
t o w a r d haphazard
h a p h a z a r d investments).
investments).

Monog;ng Money
Managing Money

"Onetime
"One time II took
took aacab way
cab waydowntown,
downtown, tipped
tippedthe driver 50%, and
the driver 50%,then
and then
bought
bought two
two very
very expensive
expensive dresses
dresses at
at aa department
department store
store that
that II thought
thought
was
was having
having aa big
big sale.
sale. It
It turned
turned out
out they
they weren't.
weren't. II bought
bought the dresses
the dresses
without
without knowing
knowing anything
anything about
about the materials II was
the materials was buying
buying or whether
or whether
the
the prices
prices were
were good,
good, without
without taking
taking anyone
anyone with
with me, which II would
me, which would
have
have done
done normally.
normally. II spent
spent over
over aa thousand
thousand dollars,
dollars, which
which we we didn't
didn't
have.
have. I1 eventually
eventually took
took one
one ofof them
them back,
back, butbut (when
[when IIwas
was manic]
manic]IIde­ de-
stroyed
stroyed the
the other
other one
one by
by leaving
leaving anan iron
iron onon top
top ofof it."
it."
-A
— A 55-year-old
55-year-old woman
w o m a n with
with bipolar
bipolar II disorder
disorder
describing
describing a a manic
m a n i c episode
episode

Bipolar
Bipolar disorder makes
disorder makes managing
managing money moneymuch much harder
harder than it would
than ordi­ ordi-
it would
narily be. When people are becoming manic, and especially when they are
narily be. W h e n people are becoming manic, and especially when they are
fully
fully manic,
manic,theytheyoften
oftengo goononspending
spendingspreesspreesandandinvest
investwildly.
wildly.InInmany
many ways
ways
this
this is
is one
one ofof the more humorous
the more humorous symptoms
symptoms of of bipolar
bipolar disorder.
disorder. Jamison's
Jamison's
1995 autobiography. An
1995 autobiography, An Unquiet
UnquietMind,
Mind,has hasgood
goodexamples
examplesofofthe thethinking
thinkingbe­be-
hind
hind spending
spending sprees.
sprees. ButBut as
as Jamison
Jamison recounts,
recounts, spending
spending sprees
sprees and foolish
and foolish
business
business investments
investments can can damage
damage youryour life
life and
andcontribute
contributeto toyour
yourfeelings
feelingsof of
hopelessness
hopelessness after
after the
the manic
manic episode
episode has cleared.
has cleared.
Mania
Mania tends
tends to to generate
generate "hyperpositive
"hyperpositive thinking,"
thinking," in in which
which you overesti­
you overesti-
mate
mate your
your abilities
abilities to toachieve
achieve(for(forexample,
example,make makea alot
lotofofmoney)
money)and andunder­
under-
estimate
estimate the
the risks
risks (for
(for example,
example, going
going intointo debt)
debt) of
of your
your behavior (Leahy,
behavior (Leahy,
1999; Quo
1999; Otto et
et al., 1999; Newman
al., 1999; N e w m a n etetal.,
al.,2001).
2001). When
W h e nyou
youhavehavehyperpositive
hyperpositive
thoughts,
thoughts, itit can
canbebehard
hard to tostep
stepback
back and and evaluate
evaluate them
them objectively.
objectively.In In fact,
fact,
some
some people equate imagining
people equate imagining being
being able
able toto do
do something
something with with actually being
actually being
able to do
able to do il.
it. If you can
If you can imagine
imagine making
making aa lot lot of
of money
money very very qUickly,
quickly, how
how
much
much harder
harder could
could itit be
be toto actually
actually do it?
do it?
196
196 SHF-MANAGEMENI
SELF-MANAGEMENT

You You and yOUT

and your signific3m
significant others
others cancan become
become attuned
attuned to to noticing
noticing when
when
your
your thinking
thinking takes
takes on
on anan overly
overly optimistic
optimistic or hyperpositive turn.
or hyperpositive turn. Do
D o you
you
suddenly
suddenly believe
believe you you have
have found
found qUick
quick answers
answers to to financial
financial problems
problems that
that
have
have been
been plagUing
plaguing you you for
for some
some time?
time? Are
Are you
you becoming
becoming moremore and
and more
more en­
en-
thralled
thralled with
with "get
"get rich
rich quick"
quick" schemes?
schemes? Do D o you
you find
find yourself
yourself unusually
unusually preoc­
preoc-
cupied
cupied with m o n e y or merchandise, driven to purchase expensive things (see
with money or merchandise, driven to purchase expensive things (see
the
the example
example of of Robert
Robert and
and his
his electric
electric guitars)?
guitars) ?Do D o you
you think
thinkthat
thatyou
youmust
must
have
have those
those things,
things,sooner
sooner rather
rather than
than later,
later, oror else
else you
you will
will be
be "ripped
"ripped off"?
off?
Have
Have you
you come
c o m e to
to believe
believe that
that your
your finances
finances aTe are virtually
virtually unlimited?
unlimited? DoD o you
you
feel
feel impatiem
impatient with
with your
your spouse
spouse when
w h e n he
he oror she
she tells
tellsyou
you that
thatyou
you can't
can'tafford
afford
something?
something?
You
You may
m a y not
not be
be able
able to
to prevent
prevent these
these thoughts
thoughts fromfrom occurring,
occurring, but
but here
here
are
are some
some concrete
concrete things
things you
you can
can dodo when
w h e n they
they first
first appear:
appear:

• Have
• Have someone
someone else else
holdhold on your
on to to your creditcards
credit cards
•
• Avoid
Avoid trips
trips to
to the
the bank
bank unless
unless you
you are
are going
going to
to take
take aa trusted
trusted person
person
with
with you
you
•
• Stay
Stay away
away from
from your
your favorite
favorite stores
stores
•
• Avoid
Avoid watching
watching television
televisionstations
stationswhose
whose primary
primary purpose
purpose is
isto
tosell
sellyou
you
goods
goods
•
• Don't
Don't give
give your
your credit
credit card
card numbers
numbers or
or bank
bank account
account information
information to
to
"telemarketers"
"telemarketers'' or investmem counselors
or investment counselors who
w h o call
call you
you with
with their
their spe­
spe-
cial
cial deals (an advisable
deals (an advisable practice, even when
practice, even w h e n you're feeling well,
you're feeling well, of
of
course!)
course!)
•
• Avoid
Avoid investing
investing in
in the
the stock
stock market
market altogether
altogether or or making
making sudden
sudden
changes in, or
changes in, or withdrawals
withdrawals from, your retirement
from, your retirement accounts
accounts
•
• Stay
Stay away
away from
from on-line
on-line trading
trading

In other
In other words,
words, decreasing
decreasingyour
youraccess to to
access thethe
meaflS of of
means implementing your
implementing your
plans makes
plans makes iitt less
less likely
likely you
you will
will actually
actually carry
carry them out.
them out.
Some
S o m e people recommend aa 48-hour
people recommend 48-hour rule: Wait 24
rule: Wait 24 hours two good
after two
hours after good
nights of
nights of sleep
sleep before
before making
making a a purchase
purchase that
that exceeds
exceeds aa certain limit (for
certain Hmit ex­
(for ex-
ample, Leahy,
ample, Leahy, 1999;
1999; Newman et al.,
N e w m a n et aI., 2001).
2001).During
During these
these48
48 hours,
hours,discuss
discussthe
the
imended purchase
intended purchase with
with as
as mmany
a n y as three trusted
as three trusted people
people (a
(a family
family member,
member, aa
friend, and
friend, and a a doctor
doctor or
or therapist).
therapist). During the waiting
During the waiting period,
period, ask yourself:
ask yourself:

• If• someone
If someone
elseelse wanted
wanted to to
do do what
what I am
I am intending
intending totodo,
do, what
whatadvice
advice
would II give
would give that
that person?
person?
• What
• W h a t is
is the
the worst
worst thing
thing that
that could
could happen if II wasn't
happen if wasn't able
able to
to follow
foHow
through with
through with mmy plans?
y plans?
• What
• W h a t is
is the
the worst
worst thing
thing that
that could
could happen
happen if
if II did
did carry
carry them
them out?
out?
 What
What (an
Can IIDoDoIfIf
I lhink I'm Getting
I Think I'm GettMank?
ing Manic? 197197

The passageofoftime,
The passage time,youryour ownown critique
critique of the
of the situation,
situation, andand
the the inpU[
input of oth­
of oth-
ers may
ers m a y help
help you y o u evaluate
evaluate the the likely
likely success
success of of your
y o u r financial
financial decisions.
decisions.
Another
A n o t h e r practical
practical maneuver
m a n e u v e r isis to
to arrange,
arrange, when w h e n you're
you're well,
well, toto make it
m a k e it
logistically difficult
logistically difficult for for you
y o u toto get
get a a hold
hold of of large
large sums
s u m s ofof money
m o n e y in
in a
a short
short
period of
period of time.
time. There
T h e r e are
are several
several waysw a y s to
to do
d o this,
this, including
including keeping
keeping youryour
money
m o n e y inin small
small amounts
a m o u n t s spread
spread across
across several
several accounts
accounts in in different
different banks,
banks,
or keeping
or keeping the the majority
majority of of your
y o u r money
m o n e y inin a
a joint
joint account
account that that requires
requires a a co­
co-
signer
signer for for a a withdrawal.
withdrawal. Karla, Karla, a a 35-year-old
35-year-old woman w o m a n with bipolar II disorder,
with bipolar disorder,
made
m a d e the
the following
following agreement
a g r e e m e n t with
with her her boyfriend,
boyfriend, Taki: Taki: Karla
Karla obtained
obtained
three
three bank
b a n k debit
debit cards
cards from f r o m their
their three
three shared
shared accounts.
accounts. Each E a c h of
of her
her cards
cards
was
w a s labeled
labeled with w i t h an
a n expense
expense category
category (for (for example,
e x a m p l e , ""clothing")
clothing") and and h had
ad aa
posted
posted spending
spending limit. limit. The T h e two
t w o agreed
agreed to to determine
determine which w h i c h purchases
purchases she she
h a d already
had already made m a d e and
a n d how
h o w close
close she
she was
w a s to
to the
the spending
spending limitlimit inin each cate­
each cate-
gory
gory on on a a weekly basis.
w e e k l y basis.
If you
If y o u work
w o r k closely
closely with
w i t h an
a n investment
investment counselor,
counselor, it it may
m a y be
b e possible
possible toto
entrust
entrust him h i m or
or her
her with
w i t h information
information about about your
y o u r illness
illness soso that
that heh e or
or she
she can
can
stop
stop you
y o u from
f r o m investing
investing too too wildly
wildly oror irrationally.
irrationally. Consider
Consider asking
asking h him
i m or
or her
her
to
to set
set an
an upper
upper limitlimit onon howh o w much
m u c h money
m o n e y you
you cancan exchange
exchange within
within a single
a single
transaction.
transaction.
Of
Of course,
course, maintaining
maintaining these these kinds
kinds of of controls
controls overover your
your finances
finances implies
implies
that
that your
your thinking
thinking is isstill
stillfairly
fairlyrational
rationaland andthat
thatyouyoucan
canmake
m a k egood
gooddecisions.
decisions.
Rational
Rational thought
thought is is often
often possible
possible during
during the the prodromal
prodromal phasesphases of mania (an-
of mania (an­
other
other reason
reason to to catch
catch youryour episodes
episodes early).
early). ButBut asas you
you may
m a y know,
k n o w , once
once your
your
symptoms
symptoms have have accelerated,
accelerated, it it becomes
becomes difficult
difficult to to make
m a k e logical
logical decisions
decisions ofof
any
any type
type andand you
you maym a y become
b e c o m e highly
highly resentful
resentful of of anyone
anyone else's
else's intervention.
intervention.IfIf
you
you getget your
your Significant
significant others
others involved
involved earlyearly in in the
the escalation process, and
escalation process, and
trust
trust them
them enough
enough to to take
take your
your credit
credit cards,
cards, provide
provide final
final signamres
signatures on in­
on in-
vestments,
vestments, or or offer
offer input
input intointo your
your spending
spending decisions,
decisions, you you may
m a y be able to
be able to
avoid
avoid a a major
major financial
financial collapse.
collapse. Remember
R e m e m b e r that
that most
most major
major financial deci­
financial deci-
sions
sions require
require a a second
second opinion
opinion eveneven in in the
the best
best ofof circumstances!
circumstances!

Giving Up
Giving Up the
theCar
CarKeys
Keys

Are
Art your
your manic
manic episodes
episodes usually
usually characterized
characterized byby reckless
reckless driving?
driving? This is the
This is the
case
case for
for some
s o m e people
people and
and not
not for
for others.
others. One
O n e male
male client put it
cHent put it SUCCinctly:
succinctly: "My
"My
highs
highs almost
almost always
always go
go along
along with
with some
some problem
problem involving
involving my
m y car."
car." If
If you
you do
do
have
have a a poor
poor driving
driving record,
record, your
your early
early warning
warning signs
signs may
m a y Signal
signal the need to
the need to
stop
stop driving
driving for
for now.
n o w . Mania-much
M a n i a — m u c h like
like drinking
drinking alcohol-makes your driv-
alcohol—makes your driv­
ing
ing unsafe
unsafe for
for yourself
yourself andand others.
others. You
Y o u are
are at
at espeCially
especially high
high risk for an
risk for an auto
auto
accident
accident if
if you
you are
are in
in a
a manic
manic state
state and
and are
are also
also drinking
drinking and
and driving,
driving, as
assome
some
people
people do.
do.
198
198 SElf-MANAGEMENI
SELF-MANAGEMENT

ThisThis is yet
is yet anotherarena
another arena in
in which
which it
ithelps
helpstoto
have others'
have input.
others' Your sig­
input. Your sig-
nificant
nificant others
others can
can collaborate
collaborate in
in helping
helping you
you make good judgments
m a k e good judgments about
about
whether
whether you
you can
can drive
drive safely.
safely. While
While you
you will
will resent that your
resent that your spouse
spouse or sib­
or sib-
lings
lings have
have access
access to
to the
the car and you
car and you don't,
don't, remember
remember that itisisonly
thatit onlyfor
forthe
thelim­
lim-
ited
ited time until your
time until manic or
your manic or hypomanic
hypomanic symptoms
symptoms have
have cleared.
cleared. Your doc­
Your doc-
tor's
tor's input
input will
will also
also be valuable if
be valuable if he
he or
or she
she knows
k n o w s your
your driving
driving history.
history.

Avoitling
Avoiding Maior
MajorLife Decisions
Life Decisions

When youhave
when you haveone
oneor
or more early warning
more early warningsigns,
signs,avoid making
avoid decisions
making that that
decisions
could
could affect
affect your
your or
or olhers'
others' futures,
futures, particularly
particularly if
if these
these decisions involve
decisions involve
meetings with people
meetings with people who
w h o have
have a
a degree
degree of
of "fate
"fate controL"
control." Now
N o w is
is not
not the
the time
time
to
to ask
ask your
your boss
boss for
for a
a raise
raise or
or a
a change
change in
in job
job duties-you
duties—you are
are likely
likely to
to come
come
across to
across him or
to him or her
her as
as demanding
demanding and
and entitled
entitled (see
(see also Chapter 12
also Chapter 12 on strate­
on strate-
gies
gies for
for coping
coping in
in the
the work
work setting)
setting).. If
If you
you are
are an
an employer,
employer, delay
delay your deci­
your deci-
sion
sion to
to assemble
assemble your employees to
your employees to inform
inform them
them of
of major structural changes
major structural changes
in
in the
the company.
company. Likewise,
Likewise, avoid
avoid making
making decisions about your
decisions about your family
family life
life that
that
could
could lead
lead to
to long-term
long-term consequences,
consequences, such
such as
as getting
getting married,
married, divorced,
divorced, de­
de-
ciding
ciding to
to have
have children,
children, deciding
deciding to
tobuy
buy aanew
n e w house,
house,moving
moving to
toanother
anothercity,
city,
or
or Switching
switching your
your children
children to
to a
a new school.
n e w school.
It's
It's hard
hard to
tomake
m a k e these
theseagreements
agreements with
withyourself,
yourself,and
and even
even harder
harder to
toim­
im-
plement
plement them
them when
w h e n you
you feel
feel so
so good,
good, so
so optimistic,
optimistic, and
and so
so elated.
elated. The deci­
The deci-
sions
sions you
you feel
feel pressed
pressed to
to make
m a k e when
w h e n you
you are
are getting
getting manic
manic seem
seem like great
like great
ideas
ideas at
at the
the time,
time, even
even though to others--or
though to others—or even
even to
to yourself
yourself when
w h e n you're
you're
well-the ideas
well—the ideas seem
seem unrealistic
unrealistic and
and extremely
extremely risky.
risky. Try
Try to think of
to think of the pres­
the pres-
sure
sure to make
to m these decisions,
a k e these decisions, along
alongwith
withyour
your feeling
feelingof
ofgreater mentalclarity,
greatermental clarity,
as
as a
a pan
part of
of your
your illness
illness (especially
(especially if
if you
you also
also notice
notice other
othersymptoms,
symptoms,such
such as
as
distractibility,
distractibility, racing
racingthoughts,
thoughts,or
oran
an increase
increase in
inyour
your sex
sexdrive).
drive).People
Peoplewith
with
bipolar
bipolar disorder
disorder almost
almost invariably
invariably make
m a k e their
their best
best life
life decisions
decisions when they're
w h e n they're
in the remitted,
in the remitted, euthymic
euthymicstate,
state,and
andthey
theyusually
usuallyend
endup
upregretting
regrettingthose
thosedeci­
deci-
sions
sions they
they made
m a d e while
while manic.
manic.

Avoitling
Avoiding Risley
RiskySexua' Situations
Sexual Situations

"I" Iwas
wasgetting
getting real
real manic
manic and
and got
got tired
tiredofofbeing
beingaround
aroundCarol
Caroland
andthe
the
kids, so II went
kids, so went out
out to
to a bar. II ran
a bar. ran into
into this
this old girlfriend and
old girlfriend got drunk
and got drunk
with her. We
with her. W e wound
w o u n d up
up in
in bed
bed that night. II can't
that night. believe II did
can't believe did that-I'm
that—I'm
not
not that
that kind
kind of
of person
person!! IItt seemed
seemed like
like such
such a
a great
great thing
thing at
at the time. Of
the time. Of
course,
course, II felt
felt terrible
terrible about it later
about it later and
and it
it really
really hun
hurt my
m y relationship
relationship with
with
 What
What(an
Can IIDoDoIf IIfThink I'm Getting
I Think I'm GettManic?
ing Manic? 199 199

Carol.
Carol. EvenEven though
though she about
she knows knows about
mania andmania and its
its biology andbiology and all that,
all that,
she
she still
still blames
b l a m e s me
m e for
for geuing
getting myself
myself in
in that
that situation
situation in
in the first place.
the first place.
S h e thought
She thought it
it was
w a s what
w h a t II really
really wanted
w a n t e d to
to do,
d o , and
a n d the
the mania
m a n i a just
just gave
gave
me
m e the
the excuse
excuse to
to do it."
d o it."
-A
— A 46·year·old
46-year-old man
m a n with
with bipolar
bipolar II disorder
disorder

Like Like
many many rewarding
rewarding endeavors,
endeavors, sex has asex has a particular
particular pull whenpull when
you're you're get·
get-
ting manic.
ling m a n i c . This
This can
c a n be
b e lrue
true even
e v e n if
ifyou're
you're aaperson
person who
w h o is
issexually
sexually conserva­
conserva-
tive in
tive in your
y o u r stable
stable times.
times. People
People get
get themselves
themselves into
into very
very risky
risky sexual
sexual situa­
situa-
tions
tions when
w h e n they
they are
are escalating,
escalating, and
a n d sometimes
s o m e t i m e s the
the emotional
emotional results-which
results—which
can
can include
include feelings
feelings of
of shame,
s h a m e , humiliation,
h u m d i a t i o n , and
a n d anger-worsen
a n g e r — ^ w o r s e n their
their cycling
cycHng
mood
m o o d state.
state. And,
A n d , as
as you
y o u know,
k n o w , impulsive
impulsive encounters
encounters carry
carry a
a high risk of
high risk of con­
con-
tracting sexually
tracting sexually transmitted
transmitted diseases.
diseases.
As
A s 1I discuss
discuss in
in Chapter 2, mania
C h a p t e r 2, m a n i a is
is more
more a
a goal-driven
goal-driven state
state than a happy
than a happy
one. When
one. W h e n you
y o u feel
feel strongly
strongly pulled
pulled toward
toward rewards,
rewards, it's
it's hard
hard to
to step
step back
b a c k and
and
ask
ask whether
w h e t h e r you're
you're making
m a k i n g healthy
healthy decisions
decisions for
for yourself.
yourself. Some people benefit
S o m e people benefit
from knowing
from k n o w i n g that
that they're
they're prone
p r o n e to
to sexual
sexual �acting
"acting out"
out" when
w h e n they're in the
they're in the
prodromal
p r o d r o m a l and
a n d active
active phases
phases of
of mania.
m a n i a . Knowing
K n o w i n g this
this about yourself is
about yourself is the
the first
first
step toward controlling
step toward it.
controlling it.
The
T h e best
best way
w a y to
to avoid
avoid dangerous sexual situations
d a n g e r o u s sexual situations is
is to
to sspend
p e n d as
as much
much
time as possible
time as possible with
with people
people yyou
o u kknow
n o w aand trust, wwho
n d trust, can talk
h o can talk yyou out of
o u out of
impulsive
impulsive sexual
sexual encounters.
encounters. That
T h a t is,
is, when
w h e n you
y o u go out at
g o out at night,
night, ggo with a
o with a
friend
friend who
w h o knows
k n o w s about
about your illness and
y o u r illness who
and w h o can
can "run interference" when
"run interference'' when
you start to
y o u start to show
s h o w ppoor
o o r jjudgment.
u d g m e n t . MMake special efforts
a k e special to stay
efforts to stay away
a w a y from alco­
f r o m alco-
hol and
hol street drugs:
a n d street drugs: There is nothing
T h e r e is nothing worse
w o r s e than "self-medicating" a
than "self-medicating" an escalat·
n escalat-
ing
ing mmood
o o d wwith caffeine, drugs,
i t h caffeine, drugs, or
or alcohol,
alcohol, which
w h i c h will
will almost
almost certainly
certainly contrib­
contrib-
ute to
ute to y
your
o u r mmood escalation aand
o o d escalation lower yyour
n d lower o u r threshold for acting
threshold for acting oon
n aa sexual
sexual
impulse.
impulse. EEncourage your
ncourage y friends to
o u r friends to take
take y
you home
ou h if they
o m e if they think
think you're
you're making
making
foolish decisions.
foolish decisions. Ultimately
Ultimately the
the decision
decision to
to have,
have, or
or not
not have,
have, sex
sex with
with s
some­
ome-
one
o is yours
n e is yours alone,
alone, b
but limit-setting from
u t limit-setting others (even
f r o m others (even if
if quite
quite irritating
irritating to
to you
you
at the
at the time)
lime) ccan help k
a n help keep
e e p yyou
o u ffrom getting into
r o m getting into encounters
encounters that
that you'll
you'll regret
regret
later.
later.
SSome people report
o m e people report that
that their
their primary
primary romantic
romantic relationships
relationships improve
improve
wwhen they get
h e n they get mmanic or hhypomanic
a n i c or because they
y p o m a n i c because they bbecome
e c o m e mmore sexually en-
o r e sexually en­
gaged with
gaged with their
their partners.
partners. Others
Others report
report that
that aan increase in
n increase in their
their sexual
sexual en-
en­
counters wwith
counters their partner
i t h their partner contributes
contributes to
to their
their uupward escalation into
p w a r d escalation into mmania.
ania.
But, for
But, for mmost people, being
o s t people, being mmanic doesn't mmean
a n i c doesn't having to
e a n having to avoid
avoid sex
sex with
with their
their
regular partner.
regular partner. In
In fact,
fact, sex
sex ccan
a n bbe
e aa ggood outlet for
o o d outlet for yyour energy if
o u r energy if it
it is
is with
with
the right
the right pperson at the
e r s o n at the right
right time.
time. TThe
h e kkey is not
e y is not to
to allow
allow yyour
o u r mmania to drive
a n i a to drive
yyou
o u ttoward irresponsible or
o w a r d irresponsible or risky
risky sex.
sex.
200
200 S£lF-/MNAGEMENT
SELF-MANAGEMENT

A
A Reminder
Reminder to
to Use
Use YOUI
YourIIMaintaining
"MaintainingWeI/ness"
Wellness"Straleg;es
Strategies

Whenyou
When youare
arein
inthe
the early
early stages
stagesofofmania,
mania,it it
is essential to implement
is essential the the
to implement
strategies
strategies for
for maintaining
maintaining wellness
wellness outlined
outlined in in Chapter
Chapter 8.8. [I won't reiterate
won't reiterate
them
them all
all here;
here; suffice
suffice itit lO
to say
say that
that now
n o w is
is an
an especially
especially important
important time to
time to
maintain
maintain a a regular
regular daily
daily routine. Try as
routine. Try as well
well as
as you
you can
can to
to get
get aa full night's
full night's
sleep
sleep (your
(your doctor
doctor may
m a y be
be able
able to
to recommend
recommend sleeping
sleeping medications)
medications) and to
and to
keep
keep your
your hours
hours consistent
consistent from
from the week to
the week to the
the weekend. Avoid stressful
weekend. Avoid stressful in­
in-
teractions with
teractions with other
other people, particularly family
people, particularly family members,
members, lO to the
the extent
extent possi­
possi-
ble.
ble. Stick
Stick closely
closely to
to your
your medication
medication regimen.
regimen. Continue
Continue lOto chart
chart your
your mood
mood
on
on aa daily
daily basis
basis to
to identify
identify changes
changes inin your
your status
status as
as early
early as possible.
as possible.

Step
Step 2,
2, Pari
PartB:B:Preventative
PreventativeManeuvers
ManeuversInvolving
InvolvingYour Doctor
Your Doctor

Collaborating with
Collaborating withyour psychiatrist
your to prevent
psychiatrist or diminish
to prevent the impact
or diminish theofimpact
your of your
manic
manic episodes
episodes is is more
more complicated
complicated than than itit sounds.
sounds. Most Most psychiatrists
psychiatrists will will tell
tell
you that you
you that you should
should call
call them
them for for an
an emergency
emergency medicalmedical appoimment
appointment when when
you
you think
think your
your illness
illness is
is getting
getting worse.
worse. This
This sounds
sounds like like aa "no
"no brainer."
brainer." ButBut
the
the reality
reality is is that
that you
you may not believe
m a y not believe youyou are
are really
really ill
ill or
or that
that your
your illness
illness isis
bad
bad enough
enough to to warrant
warrant a a phone
phone call.call. Alternatively,
Alternatively,you you maym a y not
notfeel
feelcomfort�
comfort-
able calling
able calling youryour doctor,
doctor, especially
especially if if he
he or
or she
she isis nnew
e w to
to you
you or if you
or if you have
have
had bad
had bad experiences
experiences with with calling
calling himhim or her in
or her in the past.
the past.
Even
Even if if you
you see
see the
the need
need forfor emergency
emergency care, care, youyou rr..ay have
m_ay have doub[S
doubtsaboUl
about
how
h o w much
m u c h your
your dOClor
doctor will
wiH really
really help
help you.
you. YouY o u may
m a y fear that he
fear that he oror she
she will
wiU
introduce medication
introduce medication changes
changes that that have
have worse
worse side side effects
effects than
than thethe ones
ones you
you
already
already experience.
experience. You You m may fear that
a y fear that hehe or
or she
she will
will immediately hospitalize
immediately hospitalize
you,
you, which
which wouldwould cause
cause youyou social
social embarrassment
embarrassment at at work
work or or atat home.
home. Of Of
course,
course, youyou arearemore
more likely
likelyto toavoid
avoid hospitalization
hospitalization if ifyou
you call
callyour
your physician
physician
early than
early than if if you
you wait until the
wait until the point
point ofof "no
"no return.
return." But
� But calling during an
calling during an
emergency
emergency requires
requires aa certain
certain amount
amount of of trust
trust thal
that the
the physician
physician will wiH approach
approach
you
you compaSSionately
compassionately and and take
take steps
steps that
that will
wiH alleviate,
aHeviate, not notworsen,
worsen,your yoursymp­
symp-
toms.
toms. This
This section
section deals with strategies
deals with strategies forfor collaborating
collaborating with with your physician
your physician
during times of
during times of emergency.
emergency.

"When Should II Cott,

"When Should Call, ond Wha'
and Should
What I Say?"
Should I Say?"

A good rule
A good rule of
ofthumb
thumb isistoto
call
caHas as
soon as you
soon as youfeel feel
like your
like mood or energy
your mood or energy
level has changed upward or downward, or if you believe (or if a significanl
level has changed upward or downward, or if you believe (or if a significant
other
other believes)
believes) that
that you've
you've developed
developed one
one or
or more
more prodromal
prodromal symptoms.
symptoms. In In
 Whot
What Con
Can II Do
Do IfIf IIThink
ThinkI'm
I'mGetting
GettingMonic?
Manic? 2201
01

other words,
other words,err err
on the
onside
theofside
gettingofhelp when you
getting or others
help when youthinkoryou might think y
others
it, rather
need it,
need rather than
than assuming
assuming you you don't
don't and
and being
being wrong.
wrong.
Make sure
Make your doctor's
sure your phone numbers
doctor's phone numbers (or the numbers
(or the numbers of of the
the clinic
clinic
where he
where he or
or she
she works)
works) are
are easily accessible, including
easily accessible, includinghis
hisororher
heremergency
emergency
contact
contact information.
information. There
There are places on
are places on your mania prevention
your mania prevention contract
contract (at
(at
the end
the end ofof this chapter) to
this chapter) to record
record this
this information.
information. Most
Most physicians
physicianshave
have an­
an-
other doctor available
other doctor available for
for emergencies
emergencies during
during vacations
vacations or on weekends.
or on weekends.
Usually
Usually the phone numbers
the phone numbers of of this
this backup
backup physician
physicianare
areincluded
included ininthe
themes­
mes-
sage on
sage on your
your doctor's
doctor's or
or the
the clinic's
clinic's emergency
emergency phone
phone line.
line. When
W h e n you
you do
do
reach
reach your
your phYSician
physician oror his
his oror her
her backup,
backup, be beready
readyto
torecount
recountanyanyprodromal
prodromal
symptoms you
symptoms think you
you think you have
have developed.
developed.
Below
Below isis a
a telephone interchange between
telephone interchange between a a person
person with bipolar I
with bipolar I disor­
disor-
der, Chad, and
der, Chad, and his
his psychiatrist,
psychiatrist, Dr. Dr.Eastwood.
Eastwood.

CHAD: Yeah,
Chad: Yeah,1 I
think I'm I'm
think going off again.
going off again.
Dr. EASTWOOD:
DR. Eastwood: What's
What's going
going on?
on?
CHAD:
Chad: I'm
I'mtaking
takingmy
m y medication,
medication,but
butI'm
I'mhaving
havingall
allsorts
sortsofofthoughts and
thoughts andstuff.
stuff.
Dr. EAsTWOOD:
DR. Eastwood: ThoughlS
Thoughts about
about what?
what?
CHAD:
Chad: Like
Like about
about the
the past.
past. About
Aboutmy
m y dad
dad and
and his
hisdeath
deathand
and stuff.
stuff.
Dr. EASTWOOD:
DR. Eastwood: How's
How's your
your mood,
mood, Chad?
Chad? Any
Any changes?
changes?
CHAD:
Chad: Yeah,
Yeah, just
justmore
more pissed
pissedoff,
off, getting
gettinggrouchy,
grouchy,yelling
yellingat
atthe
thekids.
kids.IIjust
just
don't
don't know
know ifif I1 wanna
wanna do
do the
the whole
whole family
family thing
thing anymore.
anymore.
DR.
Dr. EASTWOOD:
Eastwood: How's
How's your
your sleep
sleep been
been the
the last
last few
few nighlS?
nights?
CHAD: O K , but
Chad: OK, but not
not great;
great; can't
can'tstay
stayasleep
asleepvery
verylong.
long.I've been
I've beenpacing
pacingatatnight
night
and
and stuff.
stuff.ThoughlS
Thoughtsgoing
goingaamile
mfleaaminute.
minute.Bed's
Bed'snot
notcomfortable.
comfortable.
Dr. EASTWOOD:
DR. Eastwood: Sounds
Sounds like
Hke aa lot's
lot'sgoing
goingon
onright
rightnow.
now. Anything
Anythingelse
elseI need
I needtoto
know?
know? Are
Are you
you thinking
thinking about
about hurting
hurting yourself?
yourself? Do
D o you
you feel
feel like
Hke you
you
need
need to
to be
be in
in the
the hospital?
hospital?
CHAD:
Chad: No,
No, not
not there
there yet.
yet. Just
Just upset
upset and
and stuff.
stuff.Mad,
Mad,can't
can'tsleep.
sleep.
Dr. EAsTWOOD:
DR. Eastwood: How
H o w have
have things
things gone
gone with
with your
your medications?
medications?
CHAD:
Chad: II missed
missed my
m y lithium
Hthium this
this morning,
morning, took
took it
it this
this evening.
evening.

In this
In this interchange, Dr.
interchange. Dr.Eastwood
Eastwood has done
has a quick
done assessment
a quick and con­
assessment and con-
cluded
cluded that
that Chad
Chad may
may bebe in
in the
the prodromal
prodromal phases
phases of
ofaa manic
manic or
or aa mixed
mixed epi­
epi-
sode.
sode. At
At this
this stage,
stage, Chad's
Chad's escalation
escalation can
can be
be treated
treated onon an
an outpatient
outpatient basis,
basis,
which
which Dr.
Dr. Eastwood
Eastwood diddid by
by setting
setting up
up an
an emergency
emergency medical
medical appointment,
appointment,in­ in-
creasing
creasing the
the dosage
dosage of
of Chad's
Chad's lithium,
lithium,and
andadding
addingaasmall
smalldose
doseof
ofananantipsy-
an tipsy-
202
202 SElf-MANAGEMENT
SELF-MANAGEMENT

chotic
chotic medication.
medication.AAblood bloodtest testrevealed
revealed thatthat
Chad's lithium
Chad's levellevel
lithium was low,was low,
even
even though
though ChadChad said
said that
that hehe had
had been
been taking
taking the
the medication relatively regu�
medication relatively regu-
larly.
larly. These
Thesechanges
changesto tohis
hismedication
medicationregimen
regimendid didthe
thetrick
trickwithout
withoutaahosthostofof
new
n e w side
side effects.
effects. Within
Within aaweek,
week,Chad's
Chad'smania
mania hadhad stopped
stopped escalating
escalatingand and hehe
began
began 1O to return
return toto his
his baseline state.
baseline state.
Chad
Chad diddid aa good
good job
job ofof describing
describing his his prodromal
prodromal symptoms.
symptoms. Dr. Dr. Eastwood
Eastwood
guided
guided himhim toward
toward describing
describing these
these symptoms
symptoms and and his
his medication
medication usage.
usage. SheShe
was
was fairly
fairly task-oriented
task-oriented and and kept
kept Chad
Chad from
from going off the
going off the track.
track. Notice that
Notice that
Dr.
Dr. Eastwood
Eastwood did did not
not pursue
pursue any any psychotherapeutic
psychotherapeutic issuesissues over
over the phone,
the phone,
such
such as as Chad's
Chad's feelings
feelings about
about hishis father
father oror his
his current
current family.
family. Expect that
Expect that
when
w h e n you
you call your physician
call your physician under
under emergency
emergency circumstances,
circumstances, in in most cases
most cases
he
he or she will
or she will not
not conduct
conduct a a psychotherapy
psychotherapy sessionsession with
with you.
you. This
This may
m a y be
be
frustrating
frustrating because you m
because you may
a y feel
feel that
that certain
certain personal
personal issues
issues areare important
important in in
explaining
explaining youryour symptoms.
symptoms. Many M a n y people
people believe
believe that
that their
their manic
manic symptoms
symptoms
are triggered by
are triggered feelings of
by feelings loss. as
of loss, as was
was Chad's
Chad's belief.
belief. But
But the
the emergency
emergency
phone
phone call
call to your physician
to your physician is is mainly
mainly forfor the
the purpose
purpose of of evaluating
evaluating whether
whether
aa change
change in in medication
medication is is necessary
necessary or, or, in
in more
more extreme
extreme circumstances.
circumstances,
whether
whether youyou need
need to
to be
be hospitalized.
hospitalized. In In aa session
session with your therapist,
with your therapist, once
once
your
your symptoms
symptoms have have settled
settled down,
d o w n , he or she
he or she m may
a y be
be able
able toto help you make
help you make
sense
sense ofof how
h o w current
current or past stressors
or past stressors areare contributing
contributing to to your
your escalating
escalating
mood.
mood.

If I'm
"WhatIf
"What I'm Uncomfortable
Uncomfortablewith MyMy
with Physician?"
Physician?"

Robert,
Robert, described
described at at the
the beginning
beginning of of this
this chapter,
chapter, did did not
notparticularly
particularlylikelikehis
his
physician and
physician and saw
saw herher infrequently.
infrequently. Perhaps
Perhaps as as a
a result,
result, this doctorwas
thisdoctor was not
notasas
helpful as
helpful as she could have
she could have been
been inin preventing
preventing his his manic
manic episode.
episode. Had H a d he
he been
been
in
in contact
contact with
with aa doctor
doctor with
with whom
w h o m he
he had
had a a good relationship, aaface-to-face
good relationship, face-to-face
session might have
session might have been
been arranged
arranged qUickly,
quickly, with more positive
with more results.
positive results.
Not everyone
Not everyone feels
feels comfortable
comfortable calling
calling hishis or
or her
her doctor
doctor during
during an emer­
an emer-
gency,
gency, and
and during
during a manic escalation
a manic escalation your
your discomfort
discomfort may be exaggerated
m a y be exaggerated
(most emotions
(most emotions become
become moremore dramatic
dramatic during
during mania).
mania). One O n e ofof my psychother­
m y psychother-
apy
apy clients,
clients. Holly,
Holly, had longstanding frustrations
had longstanding frustrations withwith herher doctor.
doctor. She called
She called
Dr. Nelson
Dr. Nelson on on aa number
number of of occasions
occasions whenw h e n she felt she
she felt she was
was rapidly cycling.
rapidly cycling.
Typically,
Typically, Dr.
Dr. Nelson
Nelson did not call
did not call her
her back.
back. SheShe considered
considered Switching physi­
switching physi-
cians but wasn't
cians but wasn't convinced
convinced she she had
had given
given Dr.Dr. Nelson
Nelson a a fair try.
fair try.
II encouraged
encouraged HollyHolly toto talk
talk over
over this
this dilemma
dilemma with with Dr. Nelson, aa man
Dr. Nelson, man
w h o m II had
whom had experienced
experienced as as very
very approachable.
approachable. But But Holly
Holly feltfelt uncomfortable
uncomfortable
broaching
broaching the the topic,
topic, fearing
fearing that
that he
he was
was going
going to "fire me
to "fire m e asas a patient." II fi­
a patienl." fi-
nally
nally interceded
interceded andand called
called Dr.
Dr. Nelson
Nelson whenw h e n Holly
Holly developed
developed mixed affective
mixed affective
symptoms
symptoms and and suicidal
suicidal thoughts.
thoughts. Dr.Dr. Nelson
Nelson laidtold me
m e that
that hehe had
had tried
tried to talk
to talk
 Whol
What (on
Can IIDoDaIfIIfThink I'm IGelling
I Think 'm GettiMani{?
ng Manic? 203203

to Holly
to Holly on
ona anumber
number of occasions
of occasions bUl that
but that she hadn't
she hadn't returned
returned his calls.
his calls. He He
also
also found
f o u n d that
that when
w h e n giving
giving Holly
Holly advice
advice on
o n how
h o w to
to control her symptoms,
control her symptoms,
she would
she w o u l d become
b e c o m e angry
angry and
a n d uncooperative.
uncooperative. So
S o there
there were frustrations on
w e r e frustrations on
both
both sides.
sides.
Eventually,
Eventually, we w e scheduled
scheduled a a meeting
m e e t i n g involving
involving Holly,Holly, Dr.
Dr. Nelson,
Nelson, and
a n d my­
my-
self
self and
a n d hammered
h a m m e r e d out
out a
a series
series of
of agreements
agreements regarding
regarding what
w h a t steps
steps would
w o u l d be
be
taken if
raken if she
she developed
developed mixed
m i x e d or
or manic
m a n i c symptoms
s y m p t o m s in
in the
the future. Dr. Nelson
future. Dr. Nelson
gave
gave an a n additional
additional phone
p h o n e number
n u m b e r toto Holly,
Holly, and a n d explained,
explained, again,again, hishis emer­
emer-
gency
gency and a n d backup/vacation
backup/vacation policies.policies. There
T h e r e isis still
still tension
tension in in their
their relationship
relationship
about
about handling
handling emergencies
emergencies b but
u t to
to a a lesser
lesser degree.
degree. Ultimately,
Ultimately, Holly's treat­
Holly's treat-
m e n t was
ment w a s made
m a d e more
m o r e successful
successful by b y the
the direct
direct contact
contact between
b e t w e e n her
her psychiatrist
psychiatrist
and
a n d psychotherapist
psychotherapist (see (see also
also Chapter
Chapter 66). ).
Your
Y o u r best
best option
option isis to
to talk
talkover
over your
y o u r concerns
concerns with with your
y o u r physician
physician untiluntil you
you
feel
feel reasonably
reasonably comfortable
comfortable aboUl about contacting
contacting him h i m or
or herher in in an
a n emergency.
emergency.
Explain
Explain your y o u r fears
fears about
a b o u t new
n e w medications,
medications, side side effects,
effects, oror the
theneed
n e e d for
forhospital­
hospital-
ization
ization (discussed
(discussed more m o r e on
o n pages
pages 206-208).
2 0 6 - 2 0 8 ) . If
If your
your " "bottom
b o t t o m line"
line" is is that
that you
you
would
w o u l d never
never callcall this
this person
person whenw h e n you're
you're feeling
feeling bad,
bad, find
find another
another physician.
physician.

"ShouldSomebody
"Should SomebodyElseElse
CallC.II
for'0' Me?"
Me?"

When
When youyou feel
feel exhilarated,
exhilarated, excited,
excited, andand goal-driven,
goal-driven, youyou
may may seereason
see no no reason
to to
destroy
destroy it it by
b y taking
taking whatw h a t the
the physician
physician has has to to offer-which
o f f e r — w h i c h isis usually
usually more more
medication.
medication. For F o r this
this reason,
reason, it it may
m a y make
m a k e sense
sense forfor someone
s o m e o n e dose
close to to you to
y o u to
make
m a k e thethe call
call toto your
y o u r physician.
physician. Give G i v e members
m e m b e r s ofof your
y o u r core
core circle
circle s some lee­
o m e lee-
way
w a y inin deciding
deciding when w h e n 10 to make
m a k e this
this call,
call, recognizing
recognizing that that you
you m may not agree
a y not agree
that
that your
y o u r physician's
physician's help help is is needed.
needed. It It is
is my
m y strong
strong impression-both
i m p r e s s i o n — b o t h in
in mymy
clinical
clinical practice
practice and a n d inin our
o u r research
research studies-that
studies—that people people who w h o have
h a v e allowed
allowed
members
m e m b e r s of of their
their core
core circle
circle to to call
call their
their doctors
doctors in in emergencies
emergencies have h a v e had
had
better
better outcomes
o u t c o m e s (for
(for example,
e x a m p l e , Miklowitz
Miklowitz et et aI.,
al., 2000).
2 0 0 0 ) . For
F o r example, Paul, the
e x a m p l e , Paul, the
husband
h u s b a n d of
of Lorraine,
Lorraine, a a 64-year-old
64-year-old woman w o m a n with bipolar II disorder,
with bipolar disorder, routinely
routinely
called
called his his wife's
wife's doctor
doctor whenever
w h e n e v e r she
she became
b e c a m e giddy,
giddy, delusional,
delusional, or or agirated.
agitated.
Lorraine's
Lorraine's doctor doctor was w a s usually
usually able able to to deal
deal with
w i t h the
the escalation,
escalation, over over the the
phone,
p h o n e , by
b y making
m a k i n g adjustments
adjustments to to her
her prescriptions,
prescriptions, instead instead of of hospitalizing
hospitalizing
her.
her.
Contact
Contact between
b e t w e e n your
y o u r relatives
relatives anda n d your
y o u r doctor
doctor may m a y require
require mmutual
u t u a l un­
un-
derstanding
derstanding about a b o u t treatment
treatment policies.
policies. YourY o u r doctor
doctor should
should make
m a k e clear
clear to to you
you
and
a n d your
y o u r relatives
relatives the the circumstances
circumstances under u n d e r which
w h i c h they
they should
should callcall (for
(for exam­
exam-
ple,
ple, when
w h e n youy o u are
are clearly
clearly escalating,
escalating, whenw h e n you
y o u are
are refusing
refusing all all yyour treat­
o u r treat-
ments).
m e n t s ) . Your
Y o u r relatives
relatives may m a y have
have a a set
set of
of expectations
expectations that that may
m a y bbe unrealistic,
e unrealistic,
such
such as: as: Your
Y o u r doctor
doctor will will call
call them
t h e m as
as soon
s o o n as
as you've
you've missed
missed an a n appointment
appointment
or
or asas soon
s o o n as
as you've reported any
you've reported any symptoms;
s y m p t o m s ; your
y o u r doctor
doctor willwill discuss
discuss any any
204
204 SSElF�MANAGEMENI
ELF-MANAGEMENT

planned
plannedmedication
medicationadjustments with them
adjustments withbefore
them making
before them; they
making can call
them; they can c
whenever
whenever there
there has
has been
been aa family
family argument
argument or
or whenever
whenever they
they want
want to
to know
know
something
something about
about bipolar
bipolar disorder.
disorder. These
Theseare
areassumptions
assumptionsyour
yourphysician
physicianmay
may
not
not share.
share. Remember
Remember to
tosign
signaarelease-of-information
release-of-informationform
formfor your
for doctor,
your al­ al-
doctor,
lowing
lowing your
your chosen
chosen relative
relative to
to exchange
exchange infonnation
information with
with him
him or
or her.
her.
Consult
Consult your
your physician
physician as
as to
towhether
whetheraafriend
friendor
orclose
closerelative
relativecan accom­
can accom-
pany
pany you
you to
to your
your emergency
emergency medical
medical visits.
visits. IfIfyou
youhave
havebecome
becomeconfused
confusedoror
distractible
distractibledue
dueto
toyour
yoursymptoms,
symptoms,your
yourSignificant other
significant may
other bebe
may better able
better to to
able
recall
recall the
the physician's
physician's recommendations
recommendations when
when you
you need
need to
to implement
implement them
them
later
later (see also Chapter
(see also 12).
Chapter 12).

"What Will
"Who' WillMy
M y Doc'or
Doctor001"
Do?"

During
Duringan
anemergency
emergencysession, your physician
session, will probably
your physician willtake the stepstake
probably out­ the step
lined
lined in
in the
the sidebar.
sidebar. He
He or
orshe
shewill
vidllstart byby
start assessing your
assessing symptoms
your and
symptoms re­re-
and
evaluating
evaluating your
your medication
medication regimen.
regimen.Your
Yourdoctor
doctormay
maydecide
decideto
tomake
makechanges
changes
to
to your
your regimen
regimen over
over the
thephone
phone if
ifan
anappointment
appointmentcan't
can'tbebearranged. AA
arranged. major
major
intent
intent of
of catching
catching and
and treating
treatingyour
your symptoms
symptoms early
earlyis
isto
tohelp
helpyou
youavoid
avoidhos­
hos-
pitalization,
pitalization,but
butififthis is is
this notnot
possible, your
possible, doctor
your can can
doctor helphelp
youyou
arrange one.one.
arrange
He
He or
or she
shewill
willusually
usuallybegin
beginby
byasking
askingyou
youthe
thekinds
kindsofof
questions Dr.
questions East­
Dr. East-
wood
wood asked
asked Chad. PhYSicians vary
Chad. Physicians vary on
on which
which symptoms
symptoms they
they emphaSize
emphasize (some
(some
focus
focus on
on mood
mood and
and others
others on
on activity
activity levels
levels or
orsleep),
sleep),but
butgenerally,
generally,the more
the more
you
you can
can speak
speak to him or
to him or her
her in
in the
the language
language of
of prodromal
prodromal symptoms
symptoms (for
(forex­
ex-
ample,
ample, racing
racing thoughts,
thoughts, goal-driven
goal-drivenbehavior,
behavior,decreased
decreased need
need for
forsleep),
sleep),the
the
more
more he
he or
or she
she will
will know
know what
what to
torecommend.
recommend.Your
Your physician
physician will
willprobably
probably
want to
want to know
know if
if you
you have
havemissed
missed any
any dosages
dosages of
ofyour
your medication,
medication,and
and you
you
should
should be
be as
as honest
honestas
aspossible
possibleabout
aboutthis!
this!It's
Itnot at all
's not at uncommon for people
all uncommon for people

Steps Your Physician

Steps Your Physician Will
Will Take
Take
to
to Prevent
Prevent the
the Escalation
Escalation of
of Mania
Mania

•
• Perfonn
Performananassessment
assessment of the
of severity of your symptoms
the severity of your symptoms
•
• Evaluate
Evaluate blood
blood levels
levelsof
ofyour
your mood
mood stabilizing
stabiHzing medications
medications
•
• Make
Make changes
changes totoyour
your medication
medication regimen,
regimen,including
includingadding
addingor
or
subtracting
subtracting certain
certain medications
medications or
or increasing
increasing the
the dosage of
dosage of
current
current medications
medications
•
• Arrange
Arrange aahospitalization,
hospitalization,ifif
necessary
necessary
 What
What Con
Con IIDoDoIfIIfThink I'm Getting
I Think Mani<?
I'm Getting Manic? 205205

to miss
to miss dosages (especiallyif
dosages (especially if they
they are
are expected to take
expected to take aa lot
lot of
of pills)
piHs) when they
when they
are
are becoming manic or
becoming manic or hypomanic.
hypomanic.
If
If you
you are
are on
on lithium,
lithium, Depakote,
Depakote,or
or(less
(lessfrequently)
frequently)Tegretol,
Tegretol,your
yourdoctor
doctor
may
m a y ask
ask you
you to
to get
get your
your blood
blood level
level tested.
tested. He
H e or
or she
she will
will most
most likely be inter-
likely be inter­
ested in
ested in your
your "trough"
"trough" level,
level,which
whichis
isusually
usuallycollected
collected10-- 1 4 hours
10-14 hoursafter
afteryour
your
last
last dose
dose (people
(people who
w h o get
get their
their blood
blood level
level checked
checked just
just a
a few
few hours
hours after tak­
after tak-
ing their
ing their last
last dose
dose may
m a y appear
appear to
to be
be getting
getting enough
enough medication when,
medication w h e n , in fact,
in fact,
they
they are not). For
are not). For example,
example, if
if you
you have
have been
been taking
taking lithium
lithium and your trough
and your trough
level
level is 0.6 mEqll
is 0.6 m E q / L or
or less
less (see
(see Chapter 6), he
Chapter 6), he or
or she
she may
m a y conclude
conclude that
that you've
you've
missed
missed dosages
dosages or
or that
that your dosage is
your dosage is too
too low
low to
to be
be therapeutic
therapeutic and
and recom­
recom-
mend
m e n d that
that you
you increase
increase your
your lithium
Hthium dosage
dosage as
as a
a way
w a y of
of preventing
preventing further
further es­
es-
calation. Because
calation. Because it
it may
m a y take
take a
a few
few days
days before
before your
your blood level is
blood level is processed,
processed,
your doctor
your doctor may
m a y decide
decide not
not to
to wait
wait for
for that
that information
information before
before changing
changing your
your
dosage,
dosage, especially
especially if
if he
he or
or she
she has
has been
been collecting
collecting blood
blood level
level information all
information all
along.
along. If
If possible,
possible, he
he or shewill
orshe willincrease
increasethe
thefrequency
frequency of your treatment
ofYOUT treatment ses­
ses-
sions
sions during
during the
the interval
interval in
in which
which your
your symptoms
symptoms are
are worsening.
worsening.
If
If your
your physician
physician increases
increases the
the dosage
dosage of
of your
your primary
primary mood stabilizer,
m o o d stabilizer,
you
you and
and your
your significant
significant others
others will
will want
want to
to become
become familiar
familiar with
with the
the signs of
signs of
"neurotoxicity"
"neurotoxicity" (see
(see also
also Chapter 6), which
Chapter 6), which are
are the
the medical
medical complications as­
complications as-
sociated
sociated with
with getting
getting too
too much
m u c h of
of a
a medication.
medication. For
For lithium,
lithium, these
these symptoms
symptoms
include
include drowsiness,
drowsiness, severe
severe nausea,
nausea, abdominal
abdominal discomfort,
discomfort, severe diarrhea,
severe diarrhea,
blurry
blurry vision,
vision, slurred
slurredspeech,
speech,muscle
muscletwitching,
twitching,or
orbeing
beingconfused
confusedas
astotowhere
where
or
or who
w h o you
you are.
are. For
For Depakote,
Depakote, they
they include
include severe
severe dizziness,
dizziness, drowsiness,
drowsiness, ir­
ir-
regular
regular breathing,
breathing, severe
severe trembling,
trembling, or
or coma.
coma. For
For Tegretol,
Tegretol, they
they include
include dou­
dou-
ble
ble vision,
vision, unsteadiness
unsteadiness when
w h e n walking,
walking, or
or feeling
feeling dizzy.
dizzy. If
If you
you show
s h o w any of
any of
these
these symptoms,
symptoms, your
your doctor
doctor should
should be
be notified
notified immediately-by
immediately—by you
you or a
or a
member
m e m b e r of
of your
your core
core circle--so
circle—so that
that he
he or
or she
she can
can adjust,
adjust,or
oreven
even take
takeyou
you off,
off,
these medications.
these medications.
Your
Your doctor
doctor may
m a y add
add some
s o m e of
of the
the medications
medications discussed
discussed in
in Chapter 6, in­
Chapter 6, in-
cluding
cluding atypical
atypical antipsychotiCS with
antipsychotics with mood
m o o d stabilizing
stabiHzing properties
properties such
such as
as
Zyprexa,
Zyprexa, or
or benzodiazepines
benzodiazepines such
such as
as Klonopin
Klonopin or
or Ativan.
Ativan. These
These medications
medications
may
m a y help
help bring
bring you
you down
d o w n from
from an
an activated,
activated, agitated
agitated state,
state, improve
improve your
your
sleep,
sleep,and
and treat
treatdelusional
delusionalthinking
thinking(for
(forexample,
example,paranoia).
paranoia).If
Ifyou
you are
areon
on only
only
one
one mood
m o o d stabilizer,
stabilizer, your
yourdoctor
doctormay
m a y add
addaasecond
second one
one (for
(forexample,
example,adding
adding
Depakote
Depakote to
to lithium).
lithium). These
These decisions
decisions are
are often
often based
based on
on physician
physician choice
choice
rather
rather than
than research
research data.
data. For
For example,
example, we
w e do
do not
not know
k n o w whether
whether simply in­
simply in-
creasing
creasing the
the dosage
dosage of
of lithium
lithium or
or valproate
valproate is
is more
more or
or less
less effective
effective in prevent­
in prevent-
ing
ing relapses
relapses of
of mania
mania than
than taking
taking the
the two
two mood
m o o d stabilizers
stabilizers together (Sachs,
together (Sachs,
1998).
1998).
Don't
Don't be
be surprised
surprised if
if your
your physician
physician believes
believes that
that the
the best treatment for
best treatment for
your escalating
your escalating mania
mania is
is to
to stop
stop taking
taking one
one of
of your
your current
current medications rather
medications rather
206
206 SElF�MANAGEMENT
SELF-MANAGEMENT

than to
than to start
startyou onon
you a new
a newone. If you
one. are are
If you getting manicmanic
getting andbelieved
and are to
are believed to
have rapid
have rapid cycling
cycling (four
(four or
or morE':
more episodes
episodes per
per year)
year),, the
the most
most effective inter­
effective inter-
vention may
vention m a y be
be to
to discontinue
discontinue your
your antidepressant,
antidepressant, if
if you
you are
are on
on onE':
one
(Kukopulos
(Kukopulos et
et al., 1980; Wehr
al., 1980; W e h r et
et al., 1988; Sachs,
al, 1988; 1996). Your
Sachs, 1996). Your physician is
physician is
unlikely
unlikely to
to start
start you
you on
on an
an antidepressant
antidepressant when
w h e n you
you are
are escalating
escalating (see
(see Chap­
Chap-
ter 6). Your
ter 6). Your physician may
physician m a y also
also recommend
recommend that
that you
you discontinue
discontinue your anti­
your anti-
psychotic medications
psychotic medications or
or your periodic use
your periodic use of
of caffeine
caffeine or
or bronchodilators
bronchodilators
such
such as
as Proventil (Sachs, 1996).
Proventil (Sachs, 1996).

�'WhenIs
"When Is Hospitalization
Hospitalization Required?"
Required?"

M a n y people
Many people with
with bipolar
bipolar disorder
disorder never
never need
need to
to be
be hospitalized. In addition,
hospitalized. In addition,
alternatives
alternatives to
to inpatient
inpatient hospitalization-such
hospitalization—such as
as partial hospital or
partial hospital or day hospi­
day hospi-
tal
tal programs-have
programs—have emerged
emerged in
in recent
recent years
years as
as shan-term
short-term strategies
strategies for
for emer­
emer-
gencies.
gencies. These programs prOvide
These programs provide close
close monitoring
monitoring of
of your
your symptoms
symptoms and
and
treatment response without
treatment response the need
without the need to
to enter
enter an
an inpatient
inpatient facility.
facility. But
Butififyour
your
manic
manic symptoms
symptoms escalate
escalate to
to a
a cenain
certain point
point of
of disruptiveness,
disruptiveness, or
or if
ifyou
you are
areac­
ac-
tively
tively suicidal
suicidal or
or dangerous
dangerous to
to others, there is
others, there is a
a good
good chance
chance that
that your doctor
your doctor
will recommend
will recommend thal
that you
you be
be hospitalized
hospitalized for
for a
a period
period of
of time.
time. You
Y o u are
are more
more
likely
likely to
to be
be hospitalized
hospitalized if
if you
you are
are manic (or mixed)
manic (or mixed) than
than if
if you are
you are
hypomanic
hypomanic or
or depressed.
depressed.
h is
It is very
very common
c o m m o n for
for people
people in
in manic
manic episodes
episodes to
to believe
believe that
that being in
being in
the
the hospital
hospital is
is not
not necessary.
necessary. Often
Often they
they insist
insist on
on leaving
leaving very
very soon
soon after they
after they
are
are admitted,
admitted, thinking they are
thinking they are closer
closer to
to recovery than their
recovery than their doctors
doctors or
or others
others
may think. Perhaps
m a y think. Perhaps you
you have
have had
had some of these
some of these experiences. But if
experiences. But if your doc­
your doc-
tor believes
tor believes that
that you
you are at imminent
are at imminent risk
risk of
of hurting
hurting yourself
yourself or
or someone else,
someone else,
or
or are
are otherwise
otherwise not
not able
able to
to take
take care
care of
of yourself, it is
yourself, it is his
his or
or her profeSSional,
her professional,
ethical,
ethical, and
and legal
legal responsibility
responsibility to
to seek permission from
seek permission from a
a judge
judge to
to continue
continue
inpatient
inpatient treatment, under a
treatment, under coun order
a court order if
if necessary.
necessary. You
Y o u won't
won't feel
feel good
good
about this course
about this course of
of action,
action, but
butititmay
m a ybe
benecessary
necessarytotopreserve
preservesafety
safetyfor
foryour­
your-
self
self and others.
and others.
If your
If your doctor
doctor does
does recommend
recommend hospitalization, it is
hospitalization, it is usually
usually easiest
easiest if
if he
he
or
or she
she calls
calls the
the hospital to arrange
hospital to for an
arrange for an inpatient
inpatient bed. In some
bed. In some cases,
cases, you
you oror
your
your family members m
family members may have to
a y have to make
m a k e the
the arrangements
arrangements (for example, ifif
(for example,
your doctor
your doctor hasn't
hasn't seen
seen you
you in
in some
some time
time or
or doesn't
doesn't have
have hospital
hospital admitting
admitting
privileges).
privileges). As
As a
a relapse
relapse prevention maneuver, keep
prevention maneuver, keep the
the phone of the
number of
phone number the
recommended hospital's
recommended hospital's emergency
emergency room
room and
and your
your insurance
insurance cards
cards in easily
in easily
accessible
accessible places
places (see the Contract
(see the Contract for
for Preventing
Preventing Mania
Mania exercise
exercise on
on pages
pages
109-110).
209-210).
Nowadays,
Nowadays, many
m a n y people
people have
have "managed
"managed care'·
care" health
health insurance
insurance plans that
plans that
stipulate
stipulate which
which hospitals
hospitals can
can or
or cannot
cannot admit
admit them,
them, and
and for
for how
h o w long. Before
long. Before
 Whol
What (on
CanIIDoDoIf IIfThink I'm Getting
I Think I'm GettMonic?
ing Manic? 207207

signing up
signing upfor
for aa new
newinsurance
insurance policy,
policy, ititisis important
important tolOfind
findout
outififthe
thepsychi-
psychi­
atrist whom
atrist w h o m you
y o u see
see is
is "in
"in network"
n e t w o r k " and
a n d if
if the
the hospitals
hospitals at
at which
w h i c h he
h e or
or she
she hhas
as
admission
admission privileges
privileges are
are providers
providers within
within the
the plan.
plan. Otherv.rise,
Otherwise, y your
o u r health in­
health in-
surance
surance policy
policy could
could require
require you
y o u to
to be
b e admitted
admitted 1O
to a
a different hospilal from
different hospital from
the
the one
one your
your doclOr
doctor might
might recommend.
recommend.

"WhatWill
"What Happen
WillHappen to to
Me Me in the
in the Hospit.I?"
Hospital?"

If you
If do have
you do haveananinpatient
inpatient hospitalization,you
hospitalization, you will
will probably
probably meet
meet on aon a daily
daily
basis
basis with
with an inpatient psychiatrist
a n inpatient psychiatrist (who
( w h o may
m a y or
or may
m a y not
not be
b e your
y o u r regular
regular doc­
doc-
lOr)
tor).. You
Y o u should
should expect
expect some
s o m e individual
individual or
or group
g r o u p counseling
counseling sessions
sessions con­
con-
cerning
cerning life
life issues,
issues, relapse
relapse prevention,
prevention, and
a n d posthospital
posthospital adjustment. In
adjustment. the
In the
best case
best case scenario,
scenario, family
family or
or spousal
spousal visits
visits are
are encouraged
encouraged and
a n d become
b e c o m e an
a n inte­
inte-
gral
gral part
part of
of the
the treatment
treatment plan.
plan.
Hospitalization
Hospitalization can
c a n be
be a
a scary
scary proposition.
proposition. Many
M a n y people
people fear
fear that psychi­
that psychi-
atric
atric hospitals
hospitals are
are like
like snake
s n a k e pits-a
p i t s — a place
place where
w h e r e things
things are
are dirty, people are
dirty, people are
violent,
violent, the
the nurses
nurses are
are cruel,
cruel, and
a n d little
little help
help is
is delivered.
delivered. Although this is
A l t h o u g h this is
largely
largely a
a distortion
distortion based
based on
o n the
the past,
past,hospitals
hospitals do
d ovary
vary considerably
considerably in
inqual­
qual-
ity,
ity,just
just as
asdo
d o the
thedoclOrs
doctors and
a n dnurses
nurses who
w h owork
w o r k within
within them.
t h e m . Many
M a n y hospitals
hospitals
are excellent
are excellent and
a n d proVide
provide slate-of-the-an
state-of-the-art mental
m e n t a l health
health care.
care. Others are
Others are
under-funded,
under-funded, employ
e m p l o y out-of-date
out-of-date models
m o d e l s of
of intervention,
intervention, and
a n d are
are not
not ori­
ori-
emed
ented toward
toward treatment
treatment as
as much
m u c h as
as the
the protection
protection of
of others.
others. If you
If y o u have
h a v e been
been
in
in a
a hospital
hospital more
m o r e than
than once,
o n c e , you
y o u probably
probably have
h a v e had
h a d diverse
diverse experiences,
experiences, de­
de-
pending
pending on
o n which
w h i c h hospilal
hospital you
y o u went
w e n t 1O
to and
a n d the
the condition
condition in
in which
w h i c h you
y o u were
were
admitted.
admitted.
Consider
Consider the
the following
following if
if you
y o u need
n e e d 1O
to be
b e hospitalized.
hospitalized. First,
First, many
m a n y people
people
confuse
confuse being
being hospitalized
hospitalized with
w i t h being
being institutionalized.
institutionalized. The
T h e latter
latter usually
usually
means
m e a n s that
that a
a person
person is
is kept
kept in
in a
a hospital
hospital for
for months
m o n t h s or
or years
years at
at a time. Nowa­
a time. Nowa-
days,
days, psychiatric
psychiatric hospitalizations
hospitalizations are
are very
very short,
short, averaging
averaging about
about a
a week
w e e k long.
long.
Second,
Second, the
the treatment
treatment you
y o u receive
receive in
in the
the hospital
hospital is
is usually
usually geared
geared toward
toward
controlling
controlling your
y o u r acute
acute symptoms
s y m p t o m s (including
(including suicidal
suicidal thoughts
thoughts or
or intentions)
intentions)
and
a n d keeping
keeping them
t h e m from
f r o m worsening
w o r s e n i n g in
in order
order to
to reduce
reduce the
the immediate
i m m e d i a t e risk to
risk to
you
y o u and
a n d those
those around
a r o u n d you.
y o u . Hospitalization
Hospitalization also
also allows
allows you
y o u to
to "dry out" if
"dry out" if you
you
have
have been
b e e n drinking
drinking or
or using
using drugs
drugs during
during your
y o u r manic
m a n i c escalation.
escalation. Your
Y o u r inpa­
inpa-
tient
tient stay
stay will
will enable
enable you
y o u to
to start
start a
a new
n e w regimen
r e g i m e n of
of medications
medications or
or newly ad­
n e w l y ad-
justed
justed dosages,
dosages, or
or try
try other
other treatments
treatments (for
(for example,
e x a m p l e , electroconvulsive
electroconvulsive ther­
ther-
apy
apy if
ifyou
y o u are
are acutely
acutely manic,
m a n i c , mixed,
m i x e d , or
ordepressed
depressed and
a n dnot
not responding
responding to
to mood
mood
stabilizers,
stabilizers, antipsychotics,
antipsychotics, or
or other
other agents).
agents). However.
H o w e v e r , your
y o u r stay
stay will
will probably
probably
not
not be
b e long
long enough to know
e n o u g h 1O k n o w if
ifyour
y o u rnew
n e wregimen
r e g i m e nisiseffective
effectivein
inthe
thelong
long term.
term.
Third,
Third, hospitalization
hospitalization is
is not
not a
a personal
personal failure.
failure. You
Y o u have a biological
have a biological iim­
m-
balance
balance that
that is
is not
not fully
fully under
u n d e r your
y o u r control,
control, and
a n d it
it is
is not
not your
y o u r fault if you
fault if y o u need
need
208
208 IHF-MANAGEMENT
SELF-MANAGEMENT

hospitalization.
hospitalization. Being hospitalized
Being hospitalizeddoes not
does mean
not that
meanothers
that have
othersto run
haveyour
to run your
life
life from
from now
n o w on. Instead, it
on. Instead, it signifies
signifiesthe
thetemporary
temporary giving u p of
giving up ofcontrol
controlfor foraa
short
short period
period ofof lime. Y o u will
time. You will have
have your
your life
life back
back soon enough, especially
soon enough, especially iif f
you
you areare successful
successful in in collaborating
collaborating withwith your
your daclOT
doctor in in developing
developing an effective
an effective
posthospital plan.
posthospital plan.
Finally,
Finally, hospitalization
hospitalizationcan canprovide
provideyouyouwith
withaamuch-needed
much-needed rest restor orbreak
break
from
from the stresSOTS of
the stressors of your
your day-ta-day
day-to-day life.
life.Ahhollgh
Althoughyou'dyou'dno nodoubt
doubtrather
ratherspend
spend
aa week
week inin the
the Bahamas,
Bahamas,aashort shortor oreven
evenaalonger
longerhospital
hospitalstay
staycan
cangive
giveyou
youtime
timetoto
think
think through
through what
what isis and
and isn't
isn'tworking
workingahoUl
aboutyour
yourtreatment
treatmentplan.
plan.ItItcan
canalso
also
give
give you
you distance
distancefrom
from your
your relatives,
relatives,which
whichyou you(and
(andthey)
they)may
m a yneed
needfromfromtime
time
to
to time.
time.Robert's
Robert'shospitalization
hospitalizationhelpedhelpedhimhimrethink
rethinkhishisfeelings
feelingsaboutJessie
about Jessie andand
his
his children,
children, andand upon
u p o n being
beingdischarged,
discharged,he he felt
feltmore
moreresolved
resolvedtotomake
m a k ethings
things
work.
work. ItIt will
willbe behard
hardto totake
takethis
thisview
viewwhen
w h e nyou
youarearefirst admitted
first admitted toto
a hospital,
a hospital,
but
but later
later you
you may
m a y have
have quite
quite a a different
different view
view ofof the experience.
the experience.

Step
Step 3:
3: Developing
Developing a
a Mania
Mania Prevention
Prevention Contrad
Contract

Now Iel's put

Now let's puttogether
together everything
everything discussed
discussedso farsoinfar
thisinchapter into a writ­
this chapter into a writ-
ten contract for
ten contract for relapse
relapse prevention.
prevention. The The following
following exercise
exercise asks
asks you
you toto sum­
sum-
marize
marize what
what you you have
have concluded
concluded about
about your
your prodromal
prodromal phase,
phase, the steps you
the steps you
and
and your
your Significant
significant others
others can
can take
take toto prevent
prevent relapse,
relapse, and and emergency
emergency proce­
proce-
dures
dures involving
involving youryour doctors.
doctors. Consult
Consult with with your
your family
family members, spouse,
members, spouse,
doclOr,
doctor, and and other trusted persons
other trusted persons 1O to make
m a k e sure
sure that
that everyone
everyone understands
understands
what
what he he oror she
she is
is being
being asked
asked to do.
to do.
W h e n fill
When ing out
filling out this
this contract,
contract, try
try to
to include
include as as many
m a n y options
options asas possible.
possible.
Some
S o m e of
of the
the options
options will
will probably
probably seem
seem more
more comfortable
comfortable to to you
you than others,
than others,
but
but it's
it's better
betterto towrite
write them
them down
d o w n even
even ififyou
youdon't
don'tendendup upusing
usingthem.
them.En­
En-
courage
courage youryour Significant
significant others
others to
to be
be open
open about
about what
what theythey do
do and
and don't feel
don't feel
comfortable
comfortable doing doing w when
h e n you're
you're cycling
cycling into
into mania. Write into
mania. Write into the
the COnlract
contract
only
only those
those responsibilities
responsibilities you you and
and they
they are
are willing
willing to to accept.
accept. Alternatively,
Alternatively,
list
list all
all of
of your
your possible
possible options
options and
and rank
rank each
each one
one from
from toptop to
to bottom
bottom as to
as to
how
h o w preferable
preferable it it is.
is. Ask
Ask everyone
everyone to to sign
sign the contract.
the contract.

Tlouhleshooling
Troubleshooting YOUI
Your Con'lo,'
Contract

Things
Things improved
improved for for Robert
Robert afterhis
after his hospital
hospital discharge.
discharge. founda new
HeHefound a new
psychiatrist,
psychiatrist. Dr.
Dr. Barnard,
Barnard, who
w h o met
met with him several
with him several times
times after
after his dis­
his dis-
charge
charge to help him
to help him optimize
optimize his
his medication
medication regime.
regime. Roben
Robert and
and Jessie
Jessie also
also
mel with
met with aa psychologist,
psychologist, who
w h o helped
helped them
them develop
develop aa relapse
relapse prevention
prevention
 CONTRACT
C O N T R A C T FOR
F O R PREVENTING
P R E V E N T I N G MANIA
MANIA

Your
Your physician's
physician'sname: ________ Phone number, office:
name: Phone number, office: _______

Phone
Phone number,
number, emergency:
emergency: _______

Your therapist's
Your therapist's name: ________ phone number, office:
name: Phone number, office: _______

phone
Phone number,
number, emergency:
emergency: _______

Name
N a m e of
of local
local hospital:
hospital: ________ Emergency
Emergency room
room number:
number: _____

Your
Your insurance
insurance carrier:
carrier: ________ Policy
Policy number:
number: _________

Group
Group number
number (if
(if applicable):
applicable): _____

List your
1 . List
1. yourtypical early
typical warning
early (prodromal)
warning signssigns
(prodromal) of a manic episode
of a manic (from the
episode (from the
exercise
exercise on
on page 192 above).
page 192 above).

2. List
2. List the
the circumstances
circumstances in
in which
which these
these prodromal
prodromal symptoms
symptoms are
are most
most likely to
likely to
occur.
occur.

3.
3. Ask
Ask one
one or
or more
more members
members of
of your
your core
core circle
circle to
to add
add any
any other
other early
early warning signs
warning signs
they've
they've observed,
observed, and,
and, if
if relevant,
relevant,the circumstances in
the circumstances in which
which these
these signs
signs first
first
appeared.
appeared.

4.
4. List
List what
what behaviors
behaviors you
you can
can perfonn
perform when
w h e n these
these symptoms start to
symptoms start to appear
appear
(examples:
(examples: calling
calling your
your doctor,
doctor, getting
getting your
your blood
blood level
level tested,
tested, sticking
sticking closely to
closely to
your
your medication
medication regimen,
regimen, trying
trying to
to get
get regular
regular sleep,
sleep, getting
getting back
back on
on aa structured
structured
daily
daily and
and nightly
nightly romine,
routine, avoiding
avoiding alcohol,
alcohol, drugs,
drugs, ororcaffeine,
caffeine,giving
givingupupyour
yourcredit
credit
cards
cards and
and car
car keys,
keys, avoiding
avoiding major
major financial
financial oror other
other life
life decisions,
decisions, aVOiding risky
avoiding risky
sexual
sexual situations).
situations).

(conI.)
(cant.)

209
209
210
210 sm-MANAGEMENI
SELF-MANAGEMENT

CONTIIACT
CONTRACT FOR
FOR PRMNTlNG
PREVENTING MANIA
MANIA (ron,nuea)
(contlnuedj

5. List
5. List what behaviors
what your relatives,
behaviors significant significant
your relatives, others, or friends can perform
others, or friends can perfo
(t'Xtlmples:
(examples: call
call your
yourphysician,
physician,talk
talktotoyou
youinina asupportive
supportiveway,
way,tell
telyou
l youwhat
whatyou
you
are
are doing
doing that
that worries
worries them,
them, tell
tell you
you howhow much
much theytheycare
careabout
aboutyOll,
you,keep
keepyou
yourself, call
you
from
from overscheduling
overscheduling yourself, callthe
thehospital
hospitalemergency
emergencyroom,
room,remind
remindyou
youtototake
take
your medication, accompany you to doctor's appointments, take
your medication, accompany you to doctor's appointments, take care of your care of your
children,
children, accompany
accompanyyou youwhen
whenyouyougo goout
outat
atnight,
night,help
helpmanage
manageyouryourmoney,
money, help
help
you
you stay
stay on
on aa regular
regular sleep-wake
sleep-wake cycle,
cycle,help
helpyou
youstaystayaway
away from
fromalcohol
alcoholorordrugs).
drugs).

6. List
List what
whatyou
you would
would like
likeyour
yourpsychiatrist
psychiatristto do (examples:
todo meetwith
(examples:meet withyou
youon
onan
an
emergency
emergency basis,
basis, take
takeyour
yourblood
bloodlevel,
level,revise your
revise yourmedication
medicationregimen
regimenasas
appropriate.
appropriate, call
callthe
thehospital
hospitaland
andarrange
arrangefor
foradmittance,
admittance,ifinecessary).
f necessary).

Signatures
Signatures Date
Date

contract.
contract. Together
Together they
they developed
developed a a list
list of
of his
his prodromal
prodromal symptoms,
symptoms,
which
which included
included mild irritability, mistrustfulness,
mild irritabihty, mistrustfulness, standing
standing too
too close
close toto
people and talking
people and talking too
too loud,
loud, aasudden
sudden disinterest
disinterestin inhis
hisjob,
job,an
anincrease
increasein in
his sex
his sex drive,
drive, and
and aa subjective
subjective feeling
feeling of
of mental
mental clarity.
clarity. They
They made
m a d e aadis­
dis-
tinction
tinction between
between these
these early warning signs
early warning signs and
and signs
signs of full-blown ma­
his full-blown
of his ma-
nias, such as
nias, such feeling elated
as feeling elated or
or expansive,
expansive, SOCially
socially inappropriate
inappropriate outbursts
outbursts
of
of anger,
anger, spending
spending excessively
excessively and
and impulSively,
impulsively, grandiose
grandiose beliefs
beliefs about
about
his musical
his talents, severe
musical talents, severeloss
lossofofsleep,
sleep,andand aafirm
firm denial
denialthat
thatanything
anything
was wrong. They
was wrong. They also
also agreed
agreed onon the
the environmental
environmental circumstances associ­
circumstances associ-
ated
ated with
with his
his escalations:
escalations: ananexcessive
excessiveworkload,
workload,family
familyarguments,
arguments,and andfi­fi-
nancial problems.
nancial problems.
Robert
Robert and]essie
and Jessie negotiated
negotiated a a series
series of
of prevention
prevention steps.
steps. One of these
O n e of these
 Whot Can IIDoDoIfIIfThink
What (on I'm Genin
I Ihink g Monic?
I'm Getting Manic? 211 211

involved giving
involved giving jessiethe
Jessie the freedom
freedom to call
to call his psychiatrist
his psychiatrist if Robert
if Robert ap- ap­
peared
peared to
to be
b e escalating.
escalating. They
T h e y also
also agreed
agreed that
that when
w h e n his
his symptoms
s y m p t o m s were
were
still
still mild,
mild, Jessie
Jessie would
w o u l d help
help get
get him
h i m away
a w a y from
f r o m his
his immediate
i m m e d i a t e stressors
stressors
(for
(for example.
example, encourage
encourage him
h i m to
to take
take a
a few
few days
days off
off work
w o r k with her). They
with her). They
agreed,
agreed, as
as a
a couple,
couple, to
to try
try to
to maintain
maintain regular
regular sleep-wake
sleep-wake routines,
routines, espe­
espe-
cially
cially when
w h e n one
one or
or more
more of
of his
his prodromal
prodromal signs
signs were
were observable. Finally,
observable. Finally,
Robert
Robert consented
consented to
to have
have jessie
Jessie accompany
accompany him
h i m to
to the
the hospital
hospital emer­
emer-
gency
gency room,
room, if
if it
it became
became necessary.
necessary.
Robert
Robert did
did not
not stay
stay episode-free,
episode-free,however.
however.His
Hisnext
nextmanic
manic episode
episodebe­
be-
gan
gan about
about two
two months
months later,
later, but
butthis
thistime
timehe
he and
andjessie
Jessiecaught
caught ititearlier.
earlier.
Once
Once again,
again, he
he refused
refused to
to make
m a k e an
an appOintment
appointment with
with his
his doctor:
doctor: He ad­
H e ad-
mitted
mitted that
that he
he was
was probably
probably escalating
escalating but
but didn't
didn't want
want to
to take
take any
any more
more
medication.
medication. He
H e and
and jessie
Jessie began
began to
to argue.
argue. As
A s Robert
Robert later
later described it,
described it,
Jessie became
jessie became "rigid
"rigid ... .. .
finger-pointing, serious,
finger-pointing, notnot
serious, lOving. " jessie
loving." gotgot
Jessie in­ in-
creaSingly
creasingly more
more desperate
desperate when
w h e n she
she found
found that
that Dr.
Dr. Barnard
Barnard was
was out of
out of
town.
town. She
She called
called Dr.
Dr. Barnard's
Barnard's backup,
backup, who
w h o preSCribed
prescribed an
an increase
increase in the
in the
dosage
dosage of
of Robert's
Robert's antipsychotic
antipsychotic medicine.
medicine. Robert
Robert agreed
agreed to
to the medica­
the medica-
tion
tion adjustment,
adjustment, which
which kept
kepthim
him from
from going
goingback
back into
intothe
thehospital.
hospital.None­
None-
theless,
theless, more
more damage
damage was
was done
done to
to their
their relationship,
relationship, and
and jessie
Jessie consid­
consid-
ered leaving.
ered leaving. Robert
Robert also
also had
had more
more conflicts
conflicts with
with his
his coworkers and other
coworkers and other
family
family members
m e m b e r s during
during this interval.
this interval.
A
A meeting
meeting with
with his
his psychologist,
psychologist, arranged
arranged about
about a
a week
w e e k after
after Roben
Robert
changed
changed his
his medication,
medication, focused
focused on
on troubleshooting
troubleshooting the
the relapse
relapse preven­
preven-
tion
tion plan.
plan. Roben,
Robert, who
w h o was
was still
still slightly
slightly hypomaniC,
hypomanic, complained
complained that the
that the
plan
plan hadn't
hadn't worked
worked because
because of
ofjessie's
Jessie's emotional
emotional stance.
stance. He
H e said that he
said that he
needed
needed her
her to
to be
be "kinder
"kinder and
and gentler"
gentler" in
in her
her approach.
approach. The
The psychologist
psychologist
asked
asked him
h i m to
to be
be more
m o r e specific,
specific,and
andhe
hesaid,
said,"I"Iwant
wanther
hertototell me
tell m eshe loves
she loves
me,
m e , and
and inin a
a more
more tender
tender way
w a y tell
tellme
m e that
thatshe
shethinks
thinksIIneed
need help
helpand
and why,
why,
even
even ifif I'm
I'm not
not receptive.
receptive."" He
H e added
added that
that he
he wished
wished she
she wouldn't
wouldn't take his
take his
irritability
irritability so
so personally
personally and
and instead
instead see
see it
it as
as part
part of
of his
his disorder.
disorder.jessie,
Jessie,in
in
tum,
turn, expressed
expressed frustration
frustration that
that he
he hadn't
hadn't gone
gone to
to his
his medication appOint­
medication appoint-
ments
ments when
w h e n Dr.
Dr. Barnard
Barnard had
had been
been in town. "1
in towo. "I want
want him to go
him to go for
for me or
m e or
for
for our
our relationship,
relationship, if
ifhe
hewon't
won'tdo
do ititfor
forhimself,
himself,knOwing
knowingthat
thatI'm
I'mspeak­
speak-
ing
ing out
out of
of caring
caring for
for him.
him." She
She wasn't
nwasn't sure
sure if
if she
she could
could take a gentler
take a gentler emo­
emo-
tional
tional stance
stance when
w h e n dealing
dealing with
with his
his escalating
escalating mood.
mood.
The
T h e psychologist
psychologist encouraged
encouraged Robert
Robert and
and jessie
Jessie to
to practice
practice communi­
communi-
cating
cating inin the
the way
w a y the
the other
other wished:
wished: jessie,
Jessie, to
to be
be more
more tender
tender in
in her ap­
her ap-
proach
proach and
and Robert,
Robert, to
to cede
cede a
a degree
degree of
of control
control to
to her.
her. They
They also
also discussed
discussed
the
the potential
potential involvement
involvement of
of other
other family members, such
family members, such as Robert's son,
as Robert's son,
at
at times
times of
of emergenCies.
emergencies. Robert
Robert decided,
decided, however,
however, that
that he
he wanted to
wanted to
shield
shield Brian
Brian as
as much
m u c h as
as possible
possible from
from his
his illness
illness and
and didn't
didn't want
want his
his son
son
interacting
interacting with
with his
his doctors.
doctors. jessie
Jessieagreed.
agreed.
W h e n she
When she returned
returned from
from her
her trip,
trip. Dr.
Dr. Barnard
Barnard met
met with
with Roben
Robert and
and
Jessie and
jessie and told
told them
them of
of a
a medication
medication plan
plan to
to undenake
undertake if
if Roben had one
Robert had one
212
212 SElf-MANAGEMENT
SELF-MANAGEMENT

or more:
or more prodromal
prodromal signssigns
andand could
could notnot immediately
immediately getin
get to see
in to see her:
her:in­in-
crease
crease hishis dosage
dosage ofof Zyprexa
Zyprexa and and add
add a benzodiazepine (K!onopin)
a benzodiazepine (Klonopin) for for
sleep. She
sleep. She wrote
wrote aaprescription
prescription withwith aaplan
planforforincreasing
increasing the
thedosage,
dosage,with
with
the
the understanding
understanding thatthat Robert would come
Robert would in to
c o m e in see her
to see her as
as soon
soon asas possi­
possi-
ble after initiating
ble after initiating the
the new
n e w dosing
dosing schedule.
schedule. TheseThese modifications
modifications werewere all
aU
written
written intointo their
their modified
modified COnlract
contract (for(for example,
example, "Robert
"Robert to increase
to increase
Zyprexa dosage;
Zyprexa dosage; Robert
Robert toto call his doctor
call his doctor and and be
be willing
willing to let jessie
to let Jessiemake
make
the call if
the call if he
he will
willnot;
not;Jessie
Jessietototry
trytotorecognize
recognizeRobert's
Robert'sirritability
irritabilityas
aspart
part
of
of the
the manic
manic syndrome").
syndrome"). Roben
Robert and Jessie agreed
and Jessie agreed to
to reexamine
reexamine the con­
the con-
tract
tract every
every three
three months
months andand revise
revise itit as necessary.
as necessary.
Robert
Robert has continued to
has continued to have
have m mood cycles, but
o o d cycles, his episodes
but his increas­
episodes increas-
ingly resemble
ingly resemble hypomanias rather than
hypomanias rather manias. H
than manias. Hee feels
feels he
he has
has aa good re­
good re-
lationship with
lationship with Dr. Barnard and
Dr. Barnard and his
his psychologist,
psychologist, and and hehe and
and Jessie are
Jessie are
still
still together
togetherandand working
working on on their
theirproblems.
problems.He H e has
hasexplained
explained hishisbipolar
bipolar
disorder
disorder to his son,
to his son, wwho, with time,
h o , with time, isis becoming
becoming moremore understanding.
understanding.

Think
Think of your
of your mania
mania prevention
prevention comractasasaa work-in-progress.
contract work-in-progress. The
Thepre­
pre-
vention steps
vention steps can
can be
be defined,
defined, agreed-upon,
agreed-upon,and
andpracticed
practicedwhen
w h e nyou're
you'rehealthy,
healthy,
bUl no one
but no one can
can be
be certain how
certain h o w well
well they will work
they will work until you put
until you put them
them into
into ac­
ac-
tion. Knowing
tion. your prodromal
Knowing your signs, being
prodromal signs, being responsive
responsive to
tothe
thefeedback
feedback of
ofoth­
oth-
ers, and knowing
ers, and when
knowing w h e n to ask for
to ask help are
for help are all
all cemral
central to
to making the contract
making the contract
effective
effective in
in real
real life.
life.
If
If you
you do
do have
have aa manic
manic episode
episode despite
despite your
your prevention
prevention contract,
contract,sit
sitdown
down
with your
with doctor, family,
your doctor, family, or
or therapist
therapist after
after the dust has
the dust has settled
settled and
and try
try to de­
to de-
cide what did
cide what did and
and did
did not
not work. Were
work. W you unable
e r e you unable to
to reach your physician
reach your physician or a
or a
backup
backup physician?
physician? If
If so,
so, ask your doctor
ask your doctor to
to recommend
recommend medication adjust­
medication adjust-
ments
ments that you can
that you can make
m a k e on your own
on your o w n the
the next
next time you start
time you stan to
to escalate.
escalate. Ask
Ask
him or
him or her
her to
to write down
write d your emergency
o w n your emergency medicine
medicine plan in prescription
plan in prescription form,
form,
with the
with the understanding
understanding that you will
that you will fill
fill the
the prescription
prescription wwhen early
your early
h e n your
warning signs
warning signs appear
appear and
and arrange
arrange an
an in-person
in-person meeting
meeting as soon as
as soon possible
as possible
thereafter.
thereafter.
Were
W e r e there
there other
other problems
problems that
that prevented
prevented the
the contract
contract from
from working?
working? For
For
example, were you
example, were you hostile
hostile to Significant others,
to significant others, wwho
h o then
then threw
threw up their
up their
and refused
hands and
hands refused to
to help
help any
any further?
further? Were your relatives
W e r e your relatives unnecessarily con­
unnecessarily con-
trolling?
trolling? Alternatively,
Alternatively, did you ask
did you ask for help but
for help but no
no one
one was
was available? If so,
avaUable? If so,
perhaps you
perhaps you can
can think
think of
of other
other relatives
relatives or
or friends
friends to whom
to w you are
h o m you less likely
are less likely
to react
to negatively in
react negatively emergencies, or
in emergencies, or who might be
w h o might be available with Htde
available with no­
little no-
tice.
tice.
Was
W a s the
the contract
contract ineffective because you
ineffective because you found
found the
the recommendations
recommendations
m a d e by
made by Significant
significant others
others unacceptable?
unacceptable? If
If so, how
so, h o w could
could the
the contract
contract be
be
modified
modified to
to make
m a k e these
these recommendations
recommendations more
more palatable?
palatable? For
For example,
example, Ga­
Ga-
briel
briel refused
refused to see a
to see a certain
certain doctor
doctor whom his parents
w h o m his parents insisted he see.
insisted he He
see. H e was,
was.
 What Con IIDoDoIfIfI Think
What (an I'm IGetting
I Think 'm GettiManic?
ng Manic? 213213

however, willingtolOsee
however, willing seeaa doctor
doctorhehehad
had found
found by by himself.
himself. Being
Being ableable to see
to see his his
preferred
preferred doctor
doctor was
w a s entered
entered as
as a modification to
a modification to their
their mania
m a n i a prevention
prevention con­
con-
tracl.
tract. You
Y o u will
will find that the
find that the contract
contract has
has a a much
m u c h greater
greater chance
chance ofof succeeding
succeeding
if you
if y o u have
h a v e had
h a d input
input into
into each
each step,
step, have
h a v e listed
listed choices
choices ofof strategies
strategies rather
rather
than only
than only oneo n e singular
singular strategy,
strategy, and
a n d can
c a n troubleshoot
troubleshoot anda n d revise
revise the
the contract
contract
as
as you
y o u go
g o along.
along.

* * *

Because
Because of of the
the influences
influences of of your
y o u r individual
individual neurophysiology,
neurophysiology, you y o u should
should
not
not expect
expect lO to be
b e able
able lO to fully
fully prevent
prevent manic m a n i c episodes.
episodes. But B u t you
y o u have
have a a window
window
of opportunity
of opportunity in in the
the early
early stages
stages of of manic
m a n i c escalation
escalation in in which
w h i c h you
y o u may
m a y be
be
able
able to to decrease
decrease the the severity
severity of of your
y o u r oncoming
o n c o m i n g episode.
episode. Being Being ableable toto identify
identify
your
your episodes
episodes earlyearly anda n d receive
receive emergency
e m e r g e n c y treatment
treatment will will give
give y you
ou a a greater
greater
feeling
feeling of of autonomy
a u t o n o m y in
in the
the long
long run,run, even
e v e n if
if it
itmeans
m e a n s having
having to togive
giveup u p control
control
to
to others
others in in the
the short
short run.
run. A A written
written contract,
contract, especially
especially if if it
it is
is developed
developed and and
filled out
filled out when
w h e n you
y o u are
are feeling
feeling well,
well, willwill enhance
e n h a n c e the likelihood that
the likelihood that your
y o u r and
and
others'
others' prevention
prevention effortsefforts will
will be b e successful.
successful.
Depressive
Depressive episodes
episodes have have a a differem
different quality.
quality. For F o r most
m o s t people,
people, they they ddo o not
not
c o m e on
come o n suddenly
suddenly and a n d often
often lastlast longer
longer than than manic
m a n i c episodes.
episodes. But B u t as
as is
is true for
true for
mania,
m a n i a , identifying
identifying and a n d combating
c o m b a t i n g the
the early
early warning
w a r n i n g signs
signs of of depression
depression will will
help
help you
y o u feel
feel more
m o r e in
in control
control of of your
y o u r disorder.
disorder. In
In Chapter 10, you'll
Chapter 10, see how
you'll see how
you
y o u can
can use
use the
the support
support of of your
y o u r core
core circle,
circle, along
along with
with certain personal strate-
certain personal strate­
gies
gies such
s u c h as
as behavioral
behavioral activation
activation and a n d cognitive
cognitive restructuring,
restructuring, toto try
try lO
to keep
keep
your
your depressions
depressions from f r o m becoming
b e c o m i n g more
m o r e serious
serious or
or debilitating.
debilitating.
 1 0
1 0

What
W h a t Can
C a n I I Do Iff II Think
D o I Think

I'm
I ' m Getting
G e t t i n g Depressed?
Depressed?

"One
"One day
day you
you realize that your
realize that your ent ire life
entire life is
isjust
justawful,
awful,not notworth
worthliving,
living,aa
horror
horror andand a a black
black blot
blot on the white
on the white terrain
terrain of
of human
h u m a n existence.
existence. One One
morning you
morning you wake
wake up up afraid
afraid you
you are
are going
going toto live
live.. ... .. That's
. That'sthethething I I
thing
want to
want to make
m a k e clear
clear ahoUl
about depression:
depression: It'sIt's got
got nothing
nothing at at all
all to
to do
do with
with
life.
life. In
In the
the course
course of of life,
life, there
there is
is sadness
sadness andand pain
pain and and sorrow,
sorrow, all of
all of
which,
which, in in their
their right
right lime
time andand season,
season, areare normal-unpleasant,
normal—unpleasant, bUl nor­
but nor-
mal.
mal. Depression
Depression is is in
in an
an altogether
altogether differem
different zonE':
zone because
because it it involves
involves a a
complete absence:
complete absence: absence
absence of of affect,
affect, absence
absence of of feeling,
feeling, absence
absence of re­
of re-
sponse, absence
sponse, absence of of interest.
interest. The pain you
The pain you feel
feel in
in the
the course
course of of a
a major
major
clinical
clinical depresSion
depression is is an
an attempt
attempton on nature's
nature'spart
part(nature,
(nature,after afterall,
all,abhors
abhors
a
a vacuum)
vacuum) to to fill
fillup
up the
theempty
empty space."
space."
-Wurtzel
— W u r t z e l (1994,
(1994, p. p. 22)
22)

In bipolar
In bipolar disorder, depression
disorder, depressioncan canoccur
occurin "pure"
in "pure" form-in which
form—in feel feel
you you
which
extremely
extremely sad,
sad,slowed
sloweddown,
d o w n ,lethargic,
lethargic,fatigued,
fatigued, oror
numb-or
n u m b — o as part
r as of a
part ofmixed
a mixed
episode-which
episode—which means you feel
means you feel both
both the
thesympLOms
symptoms of ofdepression
depression andand those
thoseofof
mania.
mania. Many
M a n y writers have described
writers have described the
the despair of depreSSion,
despair of depression,both bipolarand
bothbipolar and
unipolar
unipolar (major
(major depressive)
depressive) formsforms (for
(for example.
example, Jamison,
Jamison, 1995. 2000a;
1995, 2000a;
Manning,
Manning, 1996;
1996; Solomon,
Solomon, 2001;
2001; Styron,
Styron, 1992;
1992; Thompson,
T h o m p s o n , 1996).
1996). WWhat is im­
h a t is im-
portant
portant for
for you,
you, however,
however,isisthat you
that learnLOtorecognize
youlearn recognizethe theearly
early warningsigns
warning signs
that your
that your depresSion
depression isisrecurring.
recurring.The Thecentral
centralgoal
goalof ofthis
thischapter
chapterisis
totogive
giveyou
you

214
214
 Whol
What (on
Can 1I110DoIfIfI Think I'm I6eHing
I Think Depresse
'm Getting d?
Depressed? 215
215

psychological self-managemem
psychological self-management techniques
techniques that
that you you
can usecan
to use to greatest
greatest benefitbenefit
during
during the
the early
early phases
p h a s e s of
of depression, before it
depression, before it becomes
b e c o m e s incapacitating.
incapacitating. When
When
self-management
s e l f - m a n a g e m e n t techniques
techniques effectively
effectively improve
i m p r o v e your
y o u r mood
m o o d during
during these
these early
early
stages, you
stages, y o u may
m a y be able to
b e able avoid the
to avoid the medical
m e d i c a l imerventions
interventions that are usually
that are re­
usually re-
quired wwhen
quired h e n depression
depression reaches
reaches its
its most
m o s t severe
severe poim.
point.
Medical
M e d i c a l imervemions
interventions usually
usually include
include amidepressam
antidepressant agents,
agents, higher
higher dos­
dos-
ages of
ages of mood
m o o d stabilizers,
stabilizers, ECT,
E C T , and
a n d hospitalization.
hospitalization. For
F o r reasons
reasons that
that are
are dis­
dis-
cussed in
cussed in Chapter 6, it's
C h a p t e r 6, it's best
best to
to avoid
avoid some
s o m e of
ofthese
these alternatives
alternatives if
ifyou
y o u possibly
possibly
can
can (for
(for example,
e x a m p l e , antidepressants,
antidepressants, wwhich
h i c h can
c a n inadvertently
inadvertently lead
lead to
to rapid cy­
rapid cy-
cling).
cling). Nonetheless,
Nonetheless, it's
it's essential
essential to
to consult
consult your
y o u r physician
physician about these medi­
a b o u t these medi-
cal alternatives
cal alternatives if
if self-management
s e l f - m a n a g e m e n t or
or your
y o u r personal
personal psychotherapy is not
psychotherapy is not
keeping
keeping your
y o u r depression
depression from getting worse.
f r o m getting worse.
In
In the
the next
next chapter,
chapter, II talk
talk about
a b o u t suicidal
suicidal episodes
episodes and
a n d how
h o w to
to combat
combat
them. Suicidal
them. Suicidal thoughts
thoughts and
and impulses
impulses are
are a very common
a very c o m m o n component
component of
of the
the
bipolar
bipolar syndrome.
syndrome. They
They are nothing to
are nothing to be
be ashamed
ashamed of-virtually
of—^virtually everyone
everyone
with
with this
this disorder
disorder has
has thought
thought about
about suicide
suicide at
at some
s o m e point.
point. Fortunately, there
Fortunately, there
are ways to
are ways to protect yourself from
protect yourself from sinking
sinking further
further when you begin
w h e n you begin to
to feel sui­
feel sui-
cidal.
cidal.
Mostly,
Mostly, this
this chapter
chapter is about hope.
is about hope. Depression
Depression is
is a
a painful
painful aspect
aspect of
of the
the
human
h u m a n condition, and people
condition, and people with bipolar disorder
with bipolar disorder experience it more
experience it more in-
in­
tensely
tensely than virtually anyone
than virtually anyone else.
else. To
T o make
m a k e matters
matters worse,
worse, the pain may
the pain m a y not
not
be obvious
be obvious to
to those
those around
around you,
you, and
and they
they may want you
m a y want you to
to just
just snap
snap out
out of it.
of it.
You
You can't
can't do
do that,
that, but
but there
thereare
aresome
s o m e things you can
thingsyou can do-often
do—often with
with the
thesup­
sup-
port
port of
of others-to
others—to help
help combat it.
combat it.

Bipolar
Bipolar Depression:
Depression: An
A n Illness,
Illness, Nol
Not aa Character
Character Flaw
Flaw

Alexis,
Alexis, a 37-year-oldwoman
a 37-year-old woman with with bipolar
bipolar II IIdisorder,
disorder, had
had been
been dealing
dealing
with
with an
an ongoing
ongoing depressive
depressive state
state for years-a state
for years—a state that
that occasionally
occasionally be-be­
came worse and
came worse and incapacitated
incapacitated her.her. She
She had
had tried
tried to
to alleviate
alleviate her depres­
her depres-
sion
sion through various antidepressants,
through various antidepressants, medicinal
medicinalherbs,
herbs,cognitive
cognitive therapy,
therapy,
group
group treatment,
treatment, and,
and, at
at times,
times, "exercising
"exercising to to aa fault
fault .. driving
driving myself
myself
constandy
constantly until
until my body gave
m y body gave out"
out." Her
Her depressions
depressions were
were usually
usually accom­
accom-
panied
panied byby self-accusations
self-accusations about being weak,
about being weak, notnot haVing
having the the courage to
courage to
face
face up
u p to her problems,
to her problems, andand notnot being
being able
able to accomplish her
to accomplish her goals.
goals. She
She
had
had heard
heard that
that depression
depression hadhad a a strong
strong biological
biological basis,
basis, especially
especiallyin inbipo­
bipo-
lar
lar disorder, but had
disorder, but had never
never really
really connected
connected thisthis fact
fact to
to her situation.
her situation.
A breakthrough occurred
A breakthrough occurred in in her
her therapy
therapy when
w h e n her
her clinician
clinician said to
said to
her,
her, "If
"If you
you had
had diabetes, would you
diabetes, would you bebe blaming
blaming yourself
yourself for not being
for not being
able
able to
to control
control your
your blood
blood sugar
sugar levels?"
levels?" She began to
She began to entertain
entertain the idea
the idea
that
that she
she needed
needed to
to "make
"make an
an end
end run
run around
around my
m y depression"
depression" rather
rather than
than
216
216 SElF·MANAGEMfNI
SELF-MANAGEMENT

trying to to
trying get gelridridof
of it
itandandfeeling
feelinglikelike
a failure for notfor
a failure notable
being to do
being ableso. to do so.
When
W h e n she
she started
started thinking
thinking ofof her
her depression
depression as a physical
as a illness that
physical illness that was
was
caused
caused by by factors
factors notnot entirely
entirely within
within her her control-and
control—and something
something she she
needed
needed to to learn
learn to to live
live with-her
with—her moodm o o d began
began toto improve,
improve, albeit gradu­
albeit gradu-
ally. She
ally. She learned
learned thatthat accepting
accepting thethe reality
reality of depression was
her depression
of her was not
not the
the
same
same as as giving
giving into
into itit or
or becoming
becoming immersed
immersed in in it.
it.
She eventually
She eventually recognized
recognized that,
that, when
w h e n depressed,
depressed, she she needed
needed to to slow
slow
down,
d o w n , lake
take care
care ofof herself
herself (sleep
(sleep regularly
regularly and balance her
and balance her pleasurable
pleasurable
versus
versus workwork activities),
activities), "give
"give myself
myself a a break,"
break," andand not
not try
try too
too hard
hard toto
drive
drive herher depression
depression away with frenetic
away with frenetic activity. She has
activity. She has never
never been en­
been en-
tirely
tirely free
free ofof depression,
depression, bm but nnow
o w she
she has
has a a different
different perspective:
perspective: "I"I can
can
now ignore those old tapes in my mind telling me I'm a bad
n o w ignore those old tapes in m y mind telling m e I'm a bad person. I now person. I now
see
see that
that this
this isis the
the depression talking."
depression talking."

If
If you
you hadhad a a bad
bad case
case ofof the flu, what
theflu, what would
would you you do?do? Most
Most of of us
us would
would
take
take time
time to to convalesce
convalesce and and not
not expect
expect too too m much
u c h ofof ourselves
ourselves while recover+
while recover-
ing.
ing. Likewise,
Likewise, if you were
if you were suffering
suffering fromfrom chronic
chronic pain,pain, such
such as as severe
severe back
back
problems,
problems, you you would
would probably
probably givegive yourself
yourself a a break
break in terms of
in terms your physical
of your physical
expectations
expectations of of yourself
yourself byby declining
declining to to lift heavy objects,
lift heavy objects, notnot siuing
sitting in the
in the
same
same position
position for for hours,
hours, andand carefully
carefully selecting
selecting a a "back-friendly"
"back-friendly" form form ofof ex­
ex-
ercise.
ercise. In all likelihood
In all likelihood you you would
would pay pay close
close anemion
attention to to those
those things that
things that
helped
helped alleviate your pain
alleviate your pain and
and avoid
avoid those that made
those that m a d e it
it worse.
worse.
Try
Try toto think
think of of bipolar
bipolar depression
depression in in the
the same
same wayw a y you
you would
would think
think ofof aa
flu,
flu,chronic
chronicpain,pain,ororperhaps
perhapsa along-term
long-termmedicalmedicalillness
illnesssuch
suchasasdiabetes.
diabetes.No No
one would
one would think
think of of blaming
blaming aa diabetic
diabetic forfor not
not being
being able
able to
to control
control thethe way
way hishis
or
or her
her body
body processed
processed sugar.
sugar. No N o one
one would
would blame
blame a a person
person withwith epilepsy
epilepsy for for
having
having seizures.
seizures. likewise,
Likewise, youyou should
should nOl not blame
blame yourself
yourself for for haVing depres­
having depres-
sion.
sion. AsAs IItalk
talkabout
aboutin inChapter
Chapter 5, 5,bipolar
bipolardepression
depressionisisstrongly
strongly influenced
influenced byby
biochemical,
biochemical, genetic,
genetic, andand neurological
neurologicalfactors.
factors.It Itisisnot
notthetheproduct
productof ofaachar­
char-
acter flaw, personality
acter flaw, defect, or
personality defect, or lack
lack ofof moral fiber.
moral fiber.
Even
Even the the well-known explanatory concept
well-known explanatory concept for for depression
depression of of low self­
low self-
esteem
esteem is is suspect
suspectwithwith regard
regard to tobipolar
bipolar depression.
depression.Many M a n y people
people think
think that
thatifif
you're
you're depressed,
depressed, you you must
must notnot think
think much
m u c h ofof yourself.
yourself. ThisThis low
low estimation
estimation
might
might characterize
characterize the the way
w a y you
you feel
feel when
w h e n you're
you're depressed,
depressed, but but you
you may feel
m a y feel
quite
quite differently
differently about
about yourself
yourself when
w h e n you're
you're well.
well. InIn other
other words,
words, low self­
low self-
esteem
esteem is is not
not a a traiL
trait. Rather,
Rather,ititmay m a yjust
justbe bea asymptom
s y m p t o mofofyour
yourdepression.
depression.InIn
fact,
fact, one
one of the leaders
of the leaders in in our
our field,
field, Martin
Martin Seligman,
Seligman, of the University
of the University of of
Pennsylvania, has
Pennsylvania, hascompared
compared self-esteem
self-esteem to toaafuel
fuelgauge:
gauge:It Itisisa a
measure
measureofof how how
we're
we're doing
doing atat anyone
any one time-how
t i m e — h o w much
m u c h fuel
fuel isis in
inthe
thetank-but
tank—but it itcan
canchange
change
depending
depending on on what
what wew e are
are able
able toto accomplish
accomplish (Seligman
(Seligman el et al.,
al., 1996).
1996).
 What Con tI Do
What (on ThinkI'm
Do IfIf tIThink I'mGetting
Getting Depressed?
Depressed? 217
217

Depression
Depression is not
is not due
due totoan
anunwillingness
unwillingness to
to accept
acceptresponsibility, fearsfears
responsibility, of of
coping with
coping with reality,
reality, laziness,
laziness, cowardice,
cowardice, or
or weakness.
weakness. It
It is
is atl illness. To
an illness. T o be
be
sure,
sure, there
there are
are things
things you
you can
can do
do toto make
m a k e yourself
yourself feel
feel better or at
better or at least
least SlOp
stop
your depreSSion
your depression from
from worsening.
worsening. But But the
the fact
fact that
that you
you have
have depreSSion
depression in the
in the
first
first place,
place, or
or that
that you're
you're having
having a a di££icult
difficult time making it
time making it go away, probably
go away, probably
says
says more
more about
about your
your biology
biology than
than it
it does
does about
about your
your effort, willpower, or
effort, willpower, or
self-esteem.
self-esteem. Knowing
Knowing this this basic
basic fact
fact about
about depression
depression will
will not
not make
make i itt disap­
disap-
pear,
pear, but
but may
m a y make
m a k e it
it easier
easier to
to cope
cope with.
with.

DiHerent Styles 01
Different Styles Coping with
of Coping with Depression
Depression

As
As you
you read
read this
thischapter
chapter and
andthethenext,
next,you'll see Ithat
see that
you'll recommend
I recommend a diverse
a diverse
set
set of techniques for
of techniques for coping
coping with
with depression.
depression. These These involve
involve changes
changes in in your
your
behavior
behavior and and thinking
thinking as as well
well asas in
in your relationships with
your relationships with others. You'll see
others. You'll see
that
that some
some of of the
the techniques
techniques involve
involve distraction.
distraction. Distracting
Distracting yourself
yourself in a posi-
in a posi­
tive
tive manner
manner means
means seeking
seeking OUl,
out, and
and engaging
engaging in in activities
activities that
that keep
keep you
you busy,
busy,
give
give you
you pleasure,
pleasure, and and help
help keep
keep your
your mindm i n d off
off your
your pain
pain and
and angUish.
anguish. Exam­
Exam-
ples
ples include
include spending
spending time time with
with others
others withwith whom
w h o m you
you feel
feel close,
close, exercising,
exercising,
listening
listening 1O music, reading,
to music, reading, and
and relaxing.
relaxing.
Some
S o m e of
of the
the coping
coping strategies
strategies involve
involve emotion-focusing.
emotion-focusing. That That is,
is, you
you learn
learn
to
to recognize
recognize thatthat you're
you're depressed
depressed andand experiencing
experiencing pain pain and
and you
you teach
teach your­
your-
self
self to
to look
look at
at it,
it, label
label it,
it, and
and accept
accept it it without
without becoming
becoming overwhelmed
overwhelmed by it,
by it,
as
as Alexis
Alexis learned
learned 1O to do. Emotion-focused coping
do. Emotion-focused coping usually
usually involves talking
involves talking
about
about your
your feelings
feelings withwith people
people whow h o are
are supportive
supportive and and empathic.
empathic.
A
A third
third strategy,
strategy, cognitive
cognitive coping,
coping, involves
involves learning
learning toto combat
combat and chal­
and chal-
lenge
lenge negative
negative thinking
thinking patterns
patterns about
about specific
specific situations
situations oror events
events (for
(for exam­
exam-
ple,
ple, self-blaming
self-blaming thoughts)
thoughts) andand considering
considering alternative
alternative ways
ways to to view
view these
these sit­
sit-
uations
uations or or events.
events. As A s you'll
you'll see,
see, these
these strategies
strategies are are not
not mutually
mutually exclusive.
exclusive. In In
fact,
fact, the
the people
people who w h o do
do best
best with
with bipolar
bipolar depressions
depressions seemseem ableable toto sample
sample
from
from allall three,
three, using
using different
different strategies
strategies at at different times.
different times.

Are
Are You
You Depressed
Depressed Right
Right Now?
Now?

DepreSSion is
Depression isnOl
notjust
justsadness. As As
sadness. youyou
knowknowif if
you've hadhad
you've a serious depres­
a serious depres-
sion,
sion, it
it can
can be
be aa blunted,
blunted, empty,
empty, inhibited
inhibited state
state marked
marked byby loss
loss of interest in
of interest in
most
most things,
things, an
an inability
inability to
to experience
experience pleasure,
pleasure, and
and withdrawal
withdrawal from every­
from every-
body and everything (see the quote by Elizabeth Wurtzel that opened this
body and everything (see the quote by Elizabeth Wurtzel that opened this
chapter).
chapter). Some people don't
S o m e people don't even
even feel
feel sad
sad when
w h e n they're
they're depressed.
depressed. Instead,
Instead,
218
218 Sm-MANAGEMENT
SELF-MANAGEMENT

they just
they justfeelfeelnumb.
numb.IfIf
you've
you'vehadhad
mixed
mixedepisodes,
episodes,you're probably
you're familiar
probably familiar
with the feeling
with the feeling ofof being
being fatigued
fatigued and
and drained
drained but
but also
also charged up, irritable,
charged up, irritable,
and
and anxious
anxious ("tired
("tired but
but wired"),
wired"). InIn the
the same
same way that mania
w a y that mania is
is not
not always
always a a
happy state, depression is not always a sad state. But unlike
happy state, depression is not always a sad state. But unlikemania,
mania, depression
depression
is almost
is almost never
never enjoyable
enjoyable or or intoxicating.
intoxicating.
Try
Try taking
taking thethe lung (1965) Self-Rating
Zung (1965) Self-Rating Depression
Depression Scale
Scale that follows.
that follows.
This
This scale
scale is
is intended
intended toto measure
measure thethe severity
severity of
of your
your depression
depression as
as you've ex­
you've ex-
perienced
perienced ititininthe
thepast
pastseveral
severaldays.
days.Fill
Fillout
outthe
thescale
scaleaccording
according to
tohow
h o w you've
you've
felt
felt most
most of of the time and
the time and tally your total
tally your total score,
score, which
which can range from
can range from 2020 (not
(not
at
at all
all depressed)
depressed) to to 8080 (very
(very depressed),
depressed). In In adding
adding up up your
your score,
score, you'll
you'llnotice
notice
that
that some
some of of the
the items
items are pOSitive and
are positive and some
some areare negative.
negative. The
The negative scale
negative scale
items (for
items example, "I
(for example, "I have
have trouble
trouble sleeping
sleeping at at night")
night") are scoredaa11ififyou
arescored youan�
an-
swered
swered "a "a little
little of
of the
the time" and 4
time" and 4 if
if you
you answered
answered "most"most ofof the
the time."
time." The
The
positive
positive items
items areare reverse·scored.
reverse-scored. That That is, "Ifeel
is, "I feelhopeful
hopefulabout
aboutthethefuture"
future"andand
"1
"I still
still enjoy
enjoy thethethings
things]Iused
used to"
to"are scored aa 11 if
arescored ifyou
youanswered
answered"most "mostof ofthe
the
time" and 4
time" and if you
4 if you answered
answered "a "alittle
littleofofthe
thetime."
time."TheThereverse-scored
reverse-scoreditems itemsare
are
starred.
starred.
Generally,
Generally, people
people whow h o have
have scores
scores of of less
less than
than 5050 are
are considered
considered not de·
not de-
pressed
pressed andand those
those inin the 50-59 range,
the 50-59 range, mildly
mildly depressed.
depressed. People
People with
vnth scores
scores inin
the 60-69 range
the 60-69 range have
have a a moderate
moderate to to marked
marked levellevel of
of depression
depression thatthat warrants
warrants
the attention
the attention of of aa doctor
doctor oror therapist;
therapist; and and over
over 7070 indicates
indicates a serious and
a serious and
probably
probably incapacitating
incapacitating depression
depression that that urgently
urgently requires
requires treatment (Nezu et
treatment (Nezu et
aI., 2000; Zung,
al., 2000; 1965). Your
Zung, 1965). Your score
score maym a y change
change from
from oneone week
w e e k to
to the next.
the next.
This
This isis the
the nature
nature of of depression, particularly of
depression, particularly of the
the bipolar type.
bipolar type.
If
If you
you scored
scored between
between 50 50 and
and 70,70, the
the self-management
self-management techniques
techniques de- de·
scribed
scribed inin this
this chapter
chapter andand the
the next
next are
are particularly
particularly relevant
relevant toto you
you right
right now.
now.
But they
But they maym a y also
also be
be helpful
helpful ifif you
you areare not feeling depressed
not feeling depressed (below
(below 50) 50) but
but
want to
want to develop
develop skills
skills for
for preventing
preventing or or alleViating
alleviating episodes
episodes of depression in
of depression in
the future.
the future.

How
H o w Does
Does Your
Your Depression
Depression Wax and Wane?
W a x and Wane?

Depression
Depression comescomes andand goes
goes in indifferent ways
different for for
ways different people.
different talk I talk
Here I Here
people.
about two
about two types
types of of depressive
depressive onset
onset as
as experienced
experienced byby people
people with
with bipolar dis­
bipolar dis-
order.
order. It
It is
is helpful
helpful to to know that for
k n o w that for some
some people,
people, depressive
depressive onsets
onsets are dra·
are dra-
matic,
matic, whereas
whereas for for others,
others, the
the onsets
onsets are
are subtle.
subde. If your onsets
If your onsets are
are subtle,
subtle, itit
may
m a y not
not always
always be be clear
clear to
to you
you (or
(or your
your Significant
significant others)
others) whether
whether your de­
your de-
pression
pression isis a
a new
n e w episode
episode or or the
the continuation
continuation of
of an
an existing
existing one. With experi-
one. With experi.
ence,
ence, you
you may
m a y be able to
be able to distinguish minor differences
distinguish minor differences over time in
over time in the sever·
the sever-
ity
ity of
of your
your depressed mood
depressed m o o d or
or your
your energy and activity
energy and levels.
activity levels.
 What Con
Whol Do IfIfI Think
Can II 00 I ThinkI'mI'mGetti
ng Depl"essed?
Getting Depressed? 219
219

ZUNG
Z U N G SElF·RATING
S E L F - R A T I N G DEPRESSION
D E P R E S S I O N SCALE
SCALE

Date
Date ____

Read
Read each
each statement
statement and
and decide
decide how
h o w much
m u c h of
of the
the time
time the
the statement
statement describes how
describes h o w you
you
have
have been
been feeling
feeling during
during the
the past
past several
several days.
days.

A
A Good
Good
little
little of
of Some
S o m e of
of part
part of
of Most of
Most of
Make
M a k e check mark (..J)
check mark (V) inin appropr iate column.
appropriate column. the
the time
time the
the time
time the
the time
time the
the time
time
I.
1. II feel
feel down-hearted
down-hearted and
and blue
blue
2.
2. Morning
Morning is w h e n II feel
is when feel the
the best""
best*
3. have crying
3. II have crying sspells
pells or
or feel
feel like
like it
it
4.
4. II have trouble slee
have trouble ping at
sleeping at night
night
5. II eat
5. eat as
as much
m u c h as
as II used
used to""
to*
6. still en
6. II still joy sex""
enjoy sex*
7.
7. II notice
notice that a m losing
that II am losing weight
weight
8.
8. II have
have trouble
trouble with
with consti
pation
constipation
9.
9. Mv
M y heart
heart beats
beats faster
faster than
than usual
usual
10.
10. IIget tired
get tired for
for no
no reason
reason
11. M y mind
11. Mv is as
mind is as dear
clear as
as it
it used
used to
tobe""
be*
12.
12. II find
find it
it easy
easy to
to do the things
do the things II used to""
used to*
13.
13. II am
a m restless
restless and
and can't
can't keep still
keep still
14.
14. II feel
feel hopeful about
hopeful about the future"
the future*
15.
15. II am
a m more
more irritable
irritable man
than usual
usual
16.
16. II find it easy
find it easy to
to make
m a k e decisions'"
decisions*
17. II feel
17. feel that
that II am
a m useful
useful and
and needed"
needed*
18.
18. M
My
y life isp
life is retty full*
pretty full·
19.
19. 1I feel
feel that
that others
others would
would be
be better off if
better off I
if I
were
were dead
dead
20.
20. II still
still eenjoy
njoy the things II used
the things used to
to do""
do*

Now,
N o w , total
total up
u p your
your score,
score, which
which should
should range from 20
rangefrom to80.
20 to 80. The
The starred items (2,
starreditems (2, 5,
5,6,
6,
II,
11, 12,
12, 14,14,16,
16,17,
17,18, and 20)
18, and 20)are
arereverse-scored
reverse-scored (a
(alittle
littleof
ofthe time::=44and
thetime and most
most of
ofthe
the
time = 1 )1).
time ", . The
The remaining
remaining items
items are
are scored from 11 (a
scored from (a little
little of
of the
the time) to ..
time) to (most of
4 (most of the
the
time).
time).

Adapted
Adapted by
by permission from
permission from Zung (1965).Copyright
Zung (1965). Copyrightby
bythe
the American
AmericanPsychiaaic
PsychiatricAssociation.
Association.I also wish
I also wish
to
to acknowledge GlaxoSmithKline
GlaxoSmithKline for
for reprinting thisscale
reprinting this scaleon
ontheiT
theirwebsite,
website,www .wdlbulrin-sr.comlhcpl
www.wellbutrin-sr.com/hcp/
depressionlzung.html, July,
depression/zung.html, July,2001.
2001.
220
220 SHF-MANAGEMENT
SELF-MANAGEMENT

In the
In the first
first type,which
type, whichI Icall the classic
call the classicrecurrent type,
recurrent a full-bore
type, de­ de-
a full-bore
pression or
pression or mixed
mixed disorder
disorder develops
develops eithereither following
following a a period
period of of lime
time in in
which you've been
which you've been functioning
functioning at at your
your baseline
baseline (or (or what,
what, for for you,
you, is is your
your
typical
typical mood slale) or
m o o d state) or just
just after
after a a manic
manic episode,
episode, withwith little
little oror no
no break
break in in
between.
between. The The onset
onset of of this
this depressive
depressive episode
episode is is usually
usually not not as as sudden
sudden as as
the onset
the onset of of a a new
n e w episode
episode of of mania
mania or or hypomania.
hypomania. Instead,Instead, it it usually
usually in-in­
volves
volves a a gradual
gradual winding
winding down d o w n ofof your
your moodm o o d state
state over
over a a period
period of of days,
days,
weeks,
weeks, or or even
even months,
months, until until you reach aa stale
you reach state ofof full
full clinical
clinical depression
depression or or
mixed disorder.
mixed disorder. For For some
some people
people the the onset
onset cancan be tied to
be tied to specific
specific lifelife events
events
(see
(see ChapLer
Chapter 5). 5).
In
In the
the other
other type, called double
type, called double depression,
depression, you you have
have an an ongOing
ongoing Slate state of
of
sadness
sadness (dysthymia)
(dysthymia) that that m may
a y have
have been
been present
present for for years
years and and is is quite un­
quite un-
pleasant but still allows you to function. Then, a major depressive episodede­
pleasaOl but still allows you to function. Then, a major depressive episode de-
velops
velops on on top
top of of this
this slate
state ofof dysthymia.
dysthymia. This This new
n e w episode
episode of of bipolar depres­
bipolar depres-
sion
sion isis kind
kind of of aa "slow
"slow burn"
burn":: ItIt develops
develops gradually
gradually and and perniciously,
perniciously, almost almost
imperceptibly
imperceptibly from from day day to to day.
day. When
W h e n thisthis severe
severe depression
depression remits,remits, you you
may return to a milder state of depression or dysthymia rather than to a
m a y return to a milder state of depression or dysthymia rather than to a
depression-free
depression-free slate. state. This
This cycle
cycle cancan bebe quite
quite frustrating
frustrating and and demoralizing.
demoralizing.
Norice
Notice thatthat in in describing
describing thesethese course
course patterns,
patterns, II don't
don't refer
refer to depres­
to depres-
sion
sion asas aa change
change from from normal
normal m mood.
o o d . In
In mym y experience,
experience, people people withwith bipolar
bipolar
disorder
disorder do do not
not ever
ever feel
feel like
like they
they get
get to to a a stale
state of of nonnal
normal mood. mood. In fact,
In fact,
they
they feel
feel that
that their
their moods
m o o d s are
are always fluctuating. Many
alwaysfluctuating. M a n y say
say that
that they
they are
are al­
al-
ways
ways somewhat
somewhat depressed.
depressed. Of Of course,
course, it's it's not
not entirely
entirely clear
clear what
what normal
normal
mood
m o o d means
means for for the
the typical
typical person-some
person—some people people seemseem to to feel
feel fine
fine most
most of of
the
the time,
time, whereas
whereas othersothers areare always
always somewhat
somewhat anxious,
anxious, angry,
angry, bored, disap­
bored, disap-
pOinted,
pointed, or or sad.
sad.
Whether
Whether you you have
have classic
classic recurrent
recurrent or or double
double depression,
depression, it it is
isimportant
important
to
to learn
learn toto recognize
recognize your your prodromal
prodromal signs signs of of a
a new
n e w episode.
episode. As A s IItalk
talkabout
aboutin in
Chapter 9, prodromal signs are those early indicators that your mood state is
Chapter 9, prodromal signs are those early indicators that your m o o d state is
changing.
changing. If Ifyou
you live
liveinin an
an ongOing
ongoing statestateof ofdysthymia,
dysthymia,the theprodromal
prodromal signs signsof of
aa new
n e w depressive
depressive episode
episode will
will probably
probably be be more
more subtle
subtle than
than those
those experienced
experienced
by people with
by people with classic
classic recurrent
recurrent depressions,
depressions, and and will
will mainly reflect changes
mainly reflect changes
in the degree
in the degree to to which
which you you experience
experience depressive
depressive symptoms
symptoms (for example, the
(for example, the
seriousness
seriousness of of your
your suicidal
suicidal thoughts).
thoughts). Nonetheless,
Nonetheless, knowingknowing how h o w to inter­
to inter-
vene
vene when
w h e n these
these signs
signs appear
appear can can bebe central
central to to your
your mood
m o o d stability
stabiHty and well­
and well-
being.
being. YouYou maym a y be
be able
able toto implement
implement the the self-care
self-care strategies
strategies in in this
this chapter
chapter to to
keep
keep the
the depression
depression from from becoming
becoming as as bad
bad asas it
itotherwise
otherwisemight mightbecome,
become,or orto to
make
m a k e your
your "rebound"
"rebound" dysthymia
dysthymia more more tolerable.
tolerable. It It is
isimportant
important to to keep
keep these
these
targets
targets in m i n d — tthe
in mind - h e fact
fact that
that your
your depression
depression doesn't
doesn't disappear
disappear entirely
entirely is isnot
not
a
a sign
sign dial
that you
you have
have failed
failed in in your
your attempts
attempts to to cope
cope with
with itit (see
(see the
the earlier
earlier ex­
ex-
ample
ample of of Alexis).
Alexis).
 What Can
What Can IIDoDoIfIfI Think I'mI'mGeni
I Think ng Depressed?
Getting Depressed? 221
221

How D o You
H o w Do If You're
Know "
You Know M o r e Depressed?:
Getting More
You're GeHing Depressed?:
M o o d Spiral
The Mood
The Spiral

One s y m p t o m of
O n e symptom depression seems
of depression seems to to feed on others:
feed on negative moods
others: negative like sad­
m o o d s like sad-
ness and anxiety,
ness and along with
anxiety, along with the the physical symptoms of
physical symptoms depression like
of depression leth­
Hke leth-
argy or
argy produce negative
insomnia, produce
or insomnia, thinking (for
negative thinking example, negative
(for example, "self­
negative "self-
statements," the
statements," voice in
critical voice
harshly critical
the harshly head), and
your head),
in your and vice T h e com­
versa. The
vice versa. com-
bination of
bination negative mood,
of negative negative thought
m o o d , negative patterns, and
thought patterns, physical changes
and physical changes
can m a k e you
can make feel less
you feel motivated to
less motivated which can
hard, which
try hard,
to try you withdraw
m a k e you
can make withdraw
and, in
and, in turn, worsen your
turn, worsen your negative thinking and
negative thinking m o o d . This
and mood. undesirable pat­
This undesirable pat-
tern is
tern called the
is called the mood Consider the
spiral. Consider
m o o d spira1. experiences of
following experiences
the follOwing two peo­
of two peo-
ple with
ple bipolar depressions.
with bipolar depressions.
Denise, a
Denise, 27-year-old with
a 27-year-old with bipolar
bipolar II disorder, was
II disorder, typically mildly
was typically mildly de- de­
pressed and
pressed pessimistic in
and pessimistic in her day-to-day life,
her day-to-day life, despite loyal to
being loyal
despite being to her re­
her re-
gime of
gime Tegretol and
of Tegretol Paxil. Her
and Paxil. Her more depressions had
serious depresSiOns
more serious had a gradual but
a gradual but
predictable course. Her
predictable course. Her first sign of
first sign of a recurrence was
depressive recurrence
a depresSive was ruminating
ruminating
about things
about realistic but
were realistic
that were
things that blown out
but blown out of proportion. For
of proportion. For example,
example,
prior to her most recent episode, she felt slighted by a colleague at work and
prior to her most recent episode, she felt slighted by a colleague at work and
angry at
angry herself for
at herself not having
for not adequately to
responded adequately
having responded to the slight. She
the slight. ex­
She ex-
panded the
panded significance of
the Significance of this minor event
this minor thinking that
into thinking
event into that no one at
no one at work
work
liked her. She
liked her. became very
then became
She then very self-critical, claimingitit was
self-critical, claiming washer lackof
her lack ofinter­
inter-
personal skills that
personal skills led others
that led others to dislike her.
to dislike depressed mood
Her depressed
her. Her m o o d worsened,
worsened,
and she had
and she more and
had more going to
difficulty going
more difficulty
and more work. Her
to work. Her performance
performance startedstarted
to deteriorate, and
to deteriorate, she developed
and she insomnia. "Sick
developed insomnia. followed. Eventually
days" followed.
"Sick days" Eventually
she took a
she took a leave from her
leave from her jobjob and
and became inactive and
became inactive and withdrawn
withdrawn in in her
her
home.
home. At point she
this point
At this she became tearful and
became tearful suicidal.
and suicidal.
Denise eventually came
Denise eventually came out out of her depressions
of her through a
depressions through a combination
combination of of
medication changes (for
medication changes example, an
(for example, an increased dosage of
increased dosage her mood
of her stabilizer),
m o o d stabilizer),
regular psychotherapy, and
regular psychotherapy, exercises assigned
activation exercises
behavioral activation
and behavioral assigned to her by
to her by
her therapist. These
her therapist. These exercises usuallyincluded
exercisesusually spendingtime
includedspending timewith friendsand
with friends and
neighbors,
neighbors, various forms of
variousforms lightphysical
oflight exercise,and
physicalexercise, thatinvolved
activitiesthat
andactivities involved
her young niece.
her young niece.
Carlos, age
Carlos, 35, had
age 35, had bipolar disorder with
bipolar II disorder classic recurrent
with classic depressions.
recurrent depressions.
He'd had
He'd had numerous episodes and
numerous episodes learned to
and learned recognize the
to recognize symptoms that
the symptoms that sig­
sig-
naled
naled the onset of
the onset of a depressive episode
a depressive episode with mixed features.
with mixed features. His His prodromal
prodromal
signs took
signs took thethe form
form of mild fatigue,
of mild sleepiness,and
fatigue, sleepiness, andpoor concentration.These
poorconcentration. These
signs were usually
signs were intermixed with
usually intermixed feelings of
with feelings anxiety, dread,
of anxiety, dread, and and a restless
a restless
"jumping out
"jumping out ofof mmyy skin" feeling.
skin" feeling.
Fortunately, when
Fortunately, w h e n he had been
he had well, Carlos
been well, and his
Carlos and therapist had
his therapist had putput into
into
place a prevention plan for staving off his worst symptoms. His plan included
place a prevention plan for staving off his worst symptoms. His plan included
222
222 SElF-MANAGEMENT
SELF-MANAGEMENT

getting
gettingon
ona aregular bedtime/wake-up
regular routine,
bedtime/wake-up eating
routine, moremore
eating protein and fewer
protein and fewer
carbohydrates,
carbohydrates,avoiding
avoidingalcohol
alcoholand
andstreet
streetdrugs,
drugs,scheduling
schedulingat
atleast
leastone
onecon­
con-
tact
tact each
each day
day with
with a
a person
person who
w h o could
could give
give him
him pOSitive
positive input,
input, and
and taking
taking
breaks
breaks from
from work
work when
w h e n he
he needed
needed to.
to. He
H e also
also kept
kept a
a "thought
"thought record"
record" (see
(see
page 232)
page 232) in
in which
which he
he recorded
recorded examples
examples of
of self-blaming
self-blaming statements
statements or
or
overgeneralizations
overgeneralizations about
about his
his situation
situation (for
(for example,
example, "My
" M y life
life has
has never
never had
had
any
any joy
joy or
or fulfillmentn).
fulfillment"). He
H e also
also learned
learned to
to counter
counter these
these thoughts
thoughts with
with more
more
adaptive
adaptive ones
ones ("I'm
("I'm going
going through
through a
a tough
tough time
time.. ... .. I've dealt
. I've with
dealt this
with before
this before
and
and come
c o m e out
out of
of it.
it. . . Depression
Depression isisgoing
going to
tocolor
color the
the way
w a y I Ifeel
feelabout
about
things").
things").
The
The following
following exercise
exercise will
will help
help you
you list
list the
the prodromal
prodromal signs
signs of
of your de­
your de-
pression
pression (your
(your mood
m o o d spiral).
spiral). The
The list
list is
isnot
notexhaustive,
exhaustive,and
andspaces
spacesare
areleft
leftfor
for
symptoms
symptoms that
that are
are not
not included
included here.
here. In
In completing
completing the
the exercise,
exercise, try to think
try to think
back
back on
on the
the last
last time
time you
you became
became depressed.
depressed. If
If you
you are
are currently
currently depressed,
depressed,
you
you may
m a y be
be able
able to
to recall
recall ilS
its earliest
earliest phases.
phases. What
W h a t were
were ilS first signs?
its first signs? If
If you
you
were
were already
already depressed
depressed when
w h e n the
the new
n e w episode
episode developed, how
developed, h o w did
did you
you know
know
it
it was
was getting
gettingworse?
worse? As
As you
you did
didwhen
w h e n listing
listingyour
your prodromal
prodromal signs
signsof
ofmania,
mania,
include
include the
the input
input of
of your
your spouse
spouse or
or another
another family
family member
m e m b e r or
or friend
friend who
w h o has
has
observed
observed you
you during
during the
the early
early phases
phases of
of depression.
depression.
Notice
Notice how
h o w the
the prodromal
prodromal signs
signs of
of depression
depression differ
differ from
from the
the signs
signs of
of ma­
ma-
nia (Chapter 9).
nia (Chapter The depressive
9). The depressive warning
warning Signals
signals usually
usually involve
involve feeling
feeling slowed
slowed
down,
down, negative,
negative, unmotivated,
unmotivated, uninterested,
uninterested, mentally
mentally sluggish, and hopeless.
sluggish, and hopeless.
The mania Signals
The mania involve feeling
signals involve feeling sped
sped up,
up, goal-driven,
goal-driven, energi
zed, mentally
energized, mentally
swift, and, often,
swift, and, often, overly
overly optimistic
optimistic or
or even grandiose.
even grandiose.
Keep
Keep your
your list
list of
ofdepression
depressionwarning
warning signs
signsin
inaaplace
placewhere
where you
you can
can find
finditit
later.
later. If
Ifyou
youfeel
feelyour
yourmood
m o o doror
energy level
energy start
level to to
start shift, refer
shift, back
refer to the
back listHst
to the to to
see if you
see if you are
areexperiencing
experiencing aanew
n e w onset
onset of
ofdepression.
depression.You
Y o ucan
canthen
thenmove
m o v eon
onto
to
introdUcing
introducing self-care
self-care strategies
strategieswhen
w h e none
oneor
ormore
moreof
ofthese
thesesigns
signsappears.
appears.As
Asyou
you
did with
did with your
your mania
mania list,
list,share
sharethis
thislist
listwith
withyour
yourclose
closerelatives
relatives(your
(yourspouse,
spouse,
trusted
trusted friends,
friends,parents)
parents)sosothat
thatthey
theycan
canlearn
learntotorecognize
recognizewhen you'regetting
w h e nyou're getting
depressed
depressed and
and are in a
are in position to
a position to offer
offer help
help (for
(for example,
example, listen supportive1y,
Hsten supportively,
look
look after your kids,
after your kids, provide
provide aa distraction,
distraction,help
helpyou
youcontact
contactyour
yourdoctor).
doctor).

Self·Care Strategy
Self-Care Strategy No.
No. 1:
I : The
The Behavioral Activation Method
Behavioral Activation Method

"When
"When I getdepressed,
I get depressed, it's
it's hard
hardfor memetoto
for even be be
even outout
in public. I with­
in pubHc. I with-
draw, I
draw, I get tired, II think
gettired, think in
in very
very black
black and
and white
white terms, disqualify any­
terms, II disqualify any-
thing good
thing good that
that happens.
happens. But
But I've
I've learned
learned not
not to
to give
give up.
up. I
I k
know that 12
n o w that 12
in the afternoon
in the afternoon is
is my
m y worst
worst time,
time,so so IIforce
forcemyself
myselfto
togo
goto
tothe
thegym
g y m then.
then.
I1 just
just pray
pray no
no one
one will
wiH talk
talk to
to me.
m e . On
O n other
other days
days I'll
I'Hjust
justhave
havecoffee
coffeewith
with
 Whol
What Coil
Can IIDo I ThinkI'mI'm6ening
Do IfIfI Thillk GettingDepressed?
Depressed? 223
223

LISTING
LISTING YOUR
Y O U R PRODROMAL
P R O D R O M A L SIGNS
S I G N S OF
O F DEPRESSION
DEPRESSION

Listaa couple
list couple of
ofadjectives
adjectivesdescribing what
describing whatyour
yourmood
moodisislike when
like whenyour
yourdepressive
depressive
episodes
episodes first
first begin (examples: sad,
begin (examples: sad, anxious,
anxious, fearful,
fearful, irritable,
irritable, grouchy,
grouchy, down
d o w n hearted,
hearted,
blue,
blue, "blah,"
"blah," flat,
flat, numb,
n u m b ,bored).
bored).

Describe
Describe changes
changes inin your activity and
your activity and energy levels as
energy levels as your
your depressive
depressive episodes
episodes develop
develop
(examples: feeling
(examples: feeling slowed
slowed down,
d o w n , withdrawing
withdrawing from
from people,
people, moving
moving more
more slowly,
slowly,talking
talking
more
more slowly,
slowly, doing
doing fewer
fewer things,
things, having
having little
little or
or no
no sex
sex drive,
drive, feeling fatigued, feeling
feeling fatigued, feeling
"tired
"tired but
but wired").
wired").

Describe
Describe changes
changes in
in your thinking and
your thinking and perception (examples: thoughts
perception (examples: thoughts gogo more
more slowly,
slowly,
can't
can't get
get interested
interested in
in things,
things, colors
colors seem
seem drab,
drab, people
people look
look like
like they're
they're moving
moving tootoo fast,
fast,
feel
feelself-doubting,
self-doubting,self-critical,
self-critical, oror
self-blaming,
self-blaming, feel guilty,
feel regret
guilty, pastpast
regret deeds, feel feel
deeds, hopeless,
hopeless,
concentrate
concentrate poorly,
poorly, feel
feel dumb,
d u m b , can't
can't make
m a k e decisions,
decisions, think
think about
about hurting
hurting or killing
or killing
myself,
myself, ruminate
ruminate and
and worry
worry about
about things).
things).

Describe
Describe changes
changes in your sleep patterns
in your (examples: want
patterns (examples: ing to
wanting to sleep
sleep more,
more, waking
waking up in
up in
the
the middle
middle ofof the
the night
night or
or not
not being
being able
able to
to fall
fall asleep
asleep easily,
easily,waking
wakingupup an
an hour
hour or
ortwo
two
earlier
earlier than
than usual).
usual).

Describe anything
Describe anything else
else that
that seems different when
seems different w h e n you're
you're getting
getting depressed.
depressed.
224
224 SEU-IMNAGlMEf(f
SELF-MANAGEMENT

a friend. It's
a friend. It's lough, I dread
tough, it, Iit,
I dread feel Ilike I'mlike
feel so down
I'm and I can't
so down anddoIthis, I do this,
can't
just
just can't.
can't. But,
But, without
without aa doubt,
doubt, it
it helps
helps me."
me."
-A
— A 41-year-old woman
41-year-old w o m a n with
with bipolar II disorder
bipolar II disorder

Behavioral
Behavioral activation
activation is is
oneone of the
of the mostmost important
important components
components of of
cognitive-behavioral
cognitive-behavioral therapy therapy (Beck(Beck el et aI., 1979; Jacobson
al., 1979; Jacobson el etaI., 1996). There
al.,1996). There
are
are two
two assumptions
assumptions behind behind behavioral
behavioral activation.
activation. First.
First, depression
depressionresultsresultsinin
aa loss
loss of
of pleasurable
pleasurable activ ities or
activities or "positive
"positive reinforcements."
reinforcements." That That is,is,being
beingde­ de-
pressed
pressed makes
makes you you less
less likely
likely to to do
do the
the sons
sorts ofof things
things that
that will
will help
help youyou get
get
something
something positive
positive from from youryour env ironment. Second,
environment. Second, the the lack
lack of of these rein­
these rein-
forcements
forcements worsens
worsens your your depression
depression and and makes
makes you want to
you want withdraw even
to withdraw even
more.
more. ItIt is
is cerlainly
certainly truetrue that
that being
being depressed
depressed makesmakes it it very
very difficult
difficult to get
to get
yourself
yourself toto do
do anything.
anything. But But it's
it'sequally
equallytrue truethat,
that,inincombination
combination wilh
withyouryourbi­
bi-
ological predispositions, not
ological predispositions, not engaging
engaging with your environmem
with your environment keeps keeps youyou de-de­
pressed and evenlUaUy
pressed and eventually makesmakes you feel worse.
you feel worse.
Depression
Depression has has aa way
w a y of
of spoiling
spoiling youryour experience
experience of ofthings
thingsyou youused
usedto tolove
love
to
to do.
do. They
They just
just don't
don't seem
seem fun fun anymore.
anymore. Sometimes
Sometimes the the events
events thatthat make
m a k e you
you
depressed
depressed (for(for example.
example,the theending
endingof ofaarelationship)
relationship) result
result inin
limiting
limiting yourcen­
your con-
laCt with
tact with people
people whosewhose company
company you you used
used totoenjoy
enjoy andand decreasing
decreasing your your access
access
to
to activities that used
activities that used toto give
give youyou pleasure.
pleasure. All All ofof this
this will
will mmake you feel
a k e you feel like
like
withdrawing. But
withdrawing. But wwhen you're depressed,
h e n you're depressed, the the worst
worst thing
thing you
you cancan dodo is
is stay
stayinin
bed, sit
bed, sitatathome,
h o m e ,and
andavoid
avoidpeople.
people. It's
It'certainly
s certainlyunderstandable
understandable that you'll
that want
you'll want
to do
to do these
these things,
things, and and you
you maym a y have
have to tofrom
from time
time tototime.
time.But Butififlhis
thisSlate
stateofof
in­in-
activity dominates
activity dominates your your life,
life, your
your depression
depression will willonly
only get
getmore
more severe.
severe."The"The
more wwe
more do, the
e do, the less
less depressed
depressed we w e feel;
feel;and andthe
theless
lessdepressed
depressedwe w efeel, the
feel, more
the more
we
w will feel
e wiH feel encouraged
encouraged to to dodo things"
things" (Lewinsohn
(Lewinsohn et el al,
aI., 1992,
1992, p. p. 74).
74).
goal behind
The goal
The behind behavioral
behavioral activation
activation is is to
to try
try toto increase
increase your COnlact
your contact
your physical
with your
with physical and and social
social environment,
environmem, to to the
the point
point where
where you you start
Slart feel­
feel-
ing better
ing better about
about yourself.
yourself. Of Of course,
course, you you need
need aa regular
regular slate
slate ofof routines
routines and and
pleasurable activities
pleasurable activities even
even wwhen you're wwell
h e n you're (Chapter 8),
e H (Chapter but iit's
8), but t's especially
especiallyim­ im-
poTtam to
portant to introduce
introduce activating
activating exercises
exercises wwhen you recognize
h e n you recognize aa worsening
worsening
state of
state of depression.
depression. In this section,
In this section, IIgive giveyouyouaabrief
briefsetsetofofinstructions
instructionsfor forim­
im-
p1ememing the
plementing the behavioral
behavioral activation
activation method.
method. For For more
more thorough
thorough directions,
directions,
consult the
consult the self-help
self-help book
book Control
Control YourYour Depression
Depression by by Peter
Peter Lewinsohn
Lewinsohn and andhishis
associates (1992).
associates (1992).

M.kea• List
Make Li,t ./ofPle.,ur.ble Activitie,
Pleasurable Activities

Start by
Start byexamining
examiningthe
theprevious week
previous or,or,
week if you
if prefer, take notes
you prefer, takeon yourself
notes on yourself
for the
for the forthcoming
forthcoming week.
week. Your
Your mmood chart should
o o d chart should help
help you
you track
track informa-
infonna­
tion about
tion about your
your daily
daily habits.
habits. Ask
Ask yourself
yourself the
the follOWing:
foHowing:
 What
What (on
Con IIDoDoIfIfI Think I'm IGetting
I Think Depressed?
'm Getting Depressed? 225
225

• Are• your
Are days
yourcharacterized
days characterized byofa structure?
by a lack lack of structure?
•
• Are
A r e there
there long
long periods
periods of
of time
time when
w h e n you
y o u have
h a v e nothing
nothing to
to do?
do?
•
• Are
A r e there
there particular
particular points
points during
during the
theday
d a ywhen
w h e n you
y o u feel
feel down?
down?
•
• Are
A r e the
themornings
m o r n i n g s long
long expanses,
expanses, with
with nothing
nothing to
tolook
look forward to?
forward to?
•
• Do
D o you
y o u dread
dread [he
theweekend
w e e k e n d because
because there
there is
isnothing
nothing to
to do?
do?
•
• Is
Isthe
the beginning
beginning of
ofthe
the workday
w o r k d a y inviting
inviting just
just because
because it
it gets
gets you o u tof
y o u out of
the
the house?
house?

Alternatively:
Alternatively:

• Have
• Have yourbeen
your days daysdominated
been dominated by too
by too many many activities,
activities, most are
most of which of which are
required
required by
b y your
y o u r work
w o r k or
or family
family life
life but
b u t which
w h i c h you
y o u don't
don't find
find rewarding?
rewarding?
•
• If
Ifyou're
you're not
n o tworking,
w o r k i n g , has
h a sthere
there been
b e e n aa good
g o o d balance
balance between
b e t w e e n pleasant
pleasant
activities and
activities a n d "must
" m u s t do"
d o " activities?
activities?
•
• Are
A r eyou
y o uengaged
e n g a g e d in
in enough
e n o u g h positive,
positive, rewarding
rewarding activities
activities to
to keep
k e e p your
your
mood
m o o d from
from spiraling
spiraling downward?
downward?

Next,
Next, try try
to to listas
list as many
manypleasurable
pleasurable or
or engaging
engaging activities
activitiesas you can.can.
as you II It
can
can bebe hard
hard to
to think
think of
of pleasurable
pleasurable things
things to
to do
do when
w h e n you're depressed, but
you're depressed, but
filling
filling out
out the
the exercise
exercise on
on page 226 will
page 226 will get
get you
you started.
started. At
At the boltom you'll
the bottom you'H
find a list of examples of activities many people find pleasurable when they're
find a list of examples of activities m a n y people find pleasurable w h e n they're
feeling
feeling down.
down. List
List all
all of
of the
the activities
activities that
that could
could bebe pleasurable
pleasurable for you, even
for you, if
even if
they
they don't
don't seem
seem feasible
feasible (for
(for example,
example, you you may
m a y really
really enjoy
enjoy fishing,
fishing, but
but there
there
is
is nowhere
nowhere to to fish
fish nearby).
nearby).
Just
Just because
because you
you list
listaanumber
n u m b e r of
ofactivities
activitiesdoesn't
doesn'tmean
m e a n you
you should
should try
tryto
to
do
do all
all of
of them.
them. In
In fact,
fact, the
the objective
objective here
here isis first
first to
to make
make a a list
list of
of pleasurable
pleasurable
events
events and
and then
then to
to introduce
introduce oneone each
each day,
day, or
or perhaps
perhaps more
more thanthan one
one if
if you
you
feel
feel up
up totoit.
it.Make
M a k e aa panicular
particular effort
efforttotolist
listactivities
activitiesthat
thathave
havethe
thepotential
potentialto
to
(1) keep
(1) keep youyou engaged
engaged withwith other
other people
people andand make
m a k e you
you feel
feel valued
valued or re·
or re-
spected
spected (for
(for example,
example, hiking
hiking with
with a friend), (2)
a friend), (2) give
give you
you aa sense of compe·
sense of compe-
tence
tence and
and purpose
purpose (for(for example,
example, taking
taking aa piano
piano lesson
lesson oror a
a foreign
foreign language
language
class), and 0)
class), and (3) make
m a k e you
you likely
likely to
to experience
experience emotions
emotions other
other than
than depression
depression
(for
(for example.
example, watching
watching a a humorous
humorous movie,
movie, being
being outout in
in nature). Keep in
nature). Keep in
mind that what
mind that what is
is pleasurable to other
pleasurable to other people
people may
m a y not
not be
be pleasurable
pleasurable to you,
to you,
and
and vice
vice versa
versa (see
(see the
the extended
extended list
list prOVided
provided by
by Lewinsohn
Lewinsohn et al., 1992).
etaI., 1992). Try
Try
to
to list
list only
only activities
activities that
that you
you want
want to to do
do and
and know
k n o w you
you would enjoy.
would enjoy.

Scheduling PI.asurableActivities
Scheduling Pleasurable Activities
Next,
Next, choose
c h o o s e one
o n e or
or two
t w o activities
activities from
f r o m this
this list
list to
to do
d o each
each day of the
d a y of the next
next
week
w e e k (see
(see thethe first
first exercise,
exercise, "Scheduling
"Scheduling Pleasurable
Pleasurable Activities,"
Activities," on p a g e 2227).
o n page 27).
226
226 SElHMNAGEMENT
SELF-MANAGEMENT

LISTING
LISTING PLEASURABLE
P L E A S U R A B L E ACTIVITIES
ACTIVITIES

Listasas
Ust many
manyactivities as youas
activities can think
you canofthink
that you
of would findwould
that you rewarding
findand pleasurable.
rewarding and pleasurab
Include
Include activities that keep
activities that keep you
you engaged with other
engaged with other people,
people, activities that increase
activities that increase your
your
sense of
sense of competence,
competence, and
and activities that might
activities that might allow you to
allow you to experience
experience emotions other
emotions other
than depression.
than depression.

(Examples: taking a
(Examples: taking a walk,
walk, going
going to
to a
a church
church or
or synagogue
synagogue group,
group, playing
playing a
a musical
musical
instrument,
instrument, walking
walkingthe
thedog, watchingaaTV
dog,watching T Vprogram,
program,going
goingtotothe
thelibrary,
library,talking onon
talking the
the
phone
phone to
to a
a friend,
friend,talking
talkingto
toaatherapist,
therapist,playing
playinga aspan, watching
sport, a comedy
watching movie,
a comedy having
movie, having
sex, riding
sex, ridingaabicycle,
bicycle,visiting
visitingthe
theHumane
H u m a n eSociety,
Society,listening toto
listening music, practicing
music, practicinga hobby.
a hobby,
siuing in
sitting in aa cafe,
cafe, cooking,
cooking,driving,
driving, sewing,
sewing, dancing,
dancing,working at aathomeless
working shelter,
a homeless writing
shelter, writing
in a
in a journal,
journal, taking
taking phomgraphs. taking aa class
photographs, taking , painting
class, painting oror d rawing, so
drawing, aking in
soaking the
in the
bathtub,
bathtub, eating
eatingatataarestaurant,
restaurant,listening
listening totoa relaxation
a relaxationtape, shopping,
tape, shopping,hiking, gardening,
hiking, gardening,
praying,
praying, meditating,
meditating,going foraaswim,
goingfor swim,eating
eatinglunch
lunchoutside,
outside,attending
attendinga lecture, washing
a lecture, washing
your
your face
face or
or hair,
hair, lying
lyingout
outinin the
thesun,
sun,playing
playingwith
with aapet)
pet)

Sourct:
Source: Lewinsohn
Lewinsohn (1992)
et al.et al. (1992)

Pick the
Pick the day
day youy o u will
will do
d o each
each activity
activity and
a n d set
set aa target
target time
time inin the
the "Day
"Day of of the
the
Week"
W e e k " column.
c o l u m n . If
Ifyou
y o u feel
feel that
that one
o n e activity
activity per day is
per day istoo
too much, choose one
m u c h , choose one toto
do
d o every
every other
other day day oror even
even oneo n e every
every three
three days,
days, and
a n d build
build up u p from
from there.
there. If If
you're
you're feeling
feeling very very depressed
depressed or or low
l o w in
in energy,
energy, pick
pick easy
easy activities
activities such
such as as
putting
putting on on a a favorite
favorite piece
piece ofof clothing,
clothing, taking
taking a a bath,
bath, oror spending
spending five five minutes
minutes
outside
outside in in the
the sun.
sun. ItIt will
will feel
feel therapeutic
therapeutic to to be
b e able
able to
to do
d o something
something small s m a H for
for
yourself
yourself eacheach day,day, oror every
every fewfew days,
days, when it feels
w h e n it feels impossible
impossible to d o more.
to do more.
Some
S o m e activities
activities anda n d events require coordination
events require coordination of of other
other people's
people's sched­
sched-
ules,
ules, extensive
extensive travel,
travel, m money,
o n e y , and
a n d reservations
reservations m made
a d e well
w e U in
in advance
advance (for(for ex­
ex-
ample,
ample, concert tickets, ski
concerttickets, ski lessons).
lessons). You Y o u may find it
m a y find it easier
easier toto choose
choose activities
activities
that
that do
d o not
not reqUire
require suchsuch planning.
planning. Perhaps
Perhaps activities that require
activities that require planning
planning can can
be
be introduced
introduced later. later.
 Con II Do
Whol Can
What Do IfIfI IThink
ThinkI'm
I'mGell
ing Depressed?
Getting Depressed? 277
227

SCHEDUUNG
S PLEASURABLE ACTIVITIES
C H E D U L I N G PLEASURABLE ACTIVITIES

Actual time
Actual time of
of day
day Mood before
Mood before and
and
Day of
Day of the
the week
week Pleasurable
Pleasurable each activity
each activity was
was activity
after each activity
and target
and time
target time activities
activities done
done ( 3/+3)
(-3/+3)
Monday
Mondav -- I.
1. I.
1.
2.
2 2.
2
Tuesday
Tuesday -- I.
1 I.
1
2.
2 2.
2
Wednesday
Wednesday I.
1 I.
1
2.
2 2.
2
Thursday
Thursdav -- I.
1 I.
1
2.
2 2.
2
Friday
Fridav -- I1. I1.
2.
2 2.
2
Saturday
Saturday -- I.
1 I1.
2.
2 2.
2
Sunday
Sundav I.
1 I.
1
2.
2 2.
2

Try to
Try to pick
pick activities
activities that
that win
will not
not disrupt
disrupt your
your work
w o r k routine
routine or
or your
your
sleep-wake
sleep-wake cycle.
cycle. For
For example,
example, if
if you
you like
like to
to exercise,
exercise, avoid
avoid doing
doing it
it in
in the
the
evening,
evening,especially
especiallyright
rightbefore
beforeyou
yougo
go to
tobed.
bed.If
If you
you enjoy
enjoyconversations
conversationswith
with
a
a specific
specific person
person but
but feel
feelwired
wired or
or energized
energized by
by these
these talks,
talks,avoid
avoidthem
themafter
afteraa
certain
certain time
time of
ofnight. Try not
night. Try not to
to be
be too
too ambitious
ambitious (at
(atleast,
least,atatfirst)
first)inin
schedul­
schedul-
ing
ing activities
activities early
early in
in the
the morning.
morning.
Next,
Next, record
record the
the actual
actual time
time of
of day
day that
that you
you completed
completed each
each activity.
activity. Re­
Re-
cord
cord your
your mood
m o o d on
o n the -3 (severely
the -3 (severely depressed)
depressed) to +3 (severely
to +3 (severely manic)
manic) scale
scale
that you
that you used
used for
for your
your mood
m o o d chart
chart in
in Chapter 8. Rate
Chapter 8. Rate your
your mood
m o o d before
before you
you
begin
begin the
the activity
activity and
and again
again as
as soon
soon as
as you
you are
are finished.
finished. For example, if
For example, if your
your
activity was
activity was gardening,
gardening,record
record how
h o w you
you felt
feltjust
justprior
priorto
togoing
goingout
outto
tothe
thegar­
gar-
den
den and
and then
then give
give yourseU
yourself another
another rating
rating for
for the
the hour
hour or
or so
so after
after finishing.
finishing.
Make
M a k e copies
copies of
of this
this form
form before filling it
beforefilling itout
out so
so that
thatyou
you can
can use
use it
it in
in subse­
subse-
quent
quent weeks.
weeks.
Notice
Notice that
that I've
I've asked
asked you
you to
to keep
keep track
track of
of your
your high
high as
as well
w e H as
as your
your low
low
moods. As
moods. A s you
you know
k n o w from
from previous
previous chapters,
chapters,certain
certain activities
activities can
can contribute
contribute
to
to manic
manic symptoms.
symptoms. For
For example,
example, exercise
exercise generally
generally improves
improves aa person's
person's
228
228 Im·MANAGEMENT
SELF-MANAGEMENT

moods, but
moods, but some
some people
people exercise
exercise to
to excess
excess and
and become hypomanic. It's
become hypomanic. It's im-
im�
to keep
portant to
portant keep data
data on
on yourself so that
yourself so that you
you can
can determine
determine whether
whether certain
certain ac­
ac-
tivities improve
tivities improve your
your m
mood or "overcorrect."
o o d or "overcorrect. "

rroubleshooti.g Your
Troubleshooting YourPI••
Plan

After scheduling
After scheduHng pleasurable
pleasurableevents forfor
events a week or more,
a week evaluate
or more, whether
evaluate the the
whether
plan is
plan is working.
working. Are
Are your
your m
mood ratings more
o o d ratings more positive
positive on
on the
the days
days in
in which
which
you did
you did one or more
one or more pleasurable activities? T
pleasurable activities? To determine this,
o determine this, complete
complete the
the
"Impact of Your
"Impact of Behavior Activation
Your Behavior Activation Plan" exercise (on
Plan" exercise this page),
(on this in which
page), in which
you
you rate
rate each day in
each day in the
the last
last week on the
week on the -3 +3 scale
to +3
-3 to and make
scale and a check
make a check
mark next
mark next to
to the
the days you completed
days you completed at least one
at least of your
one of your planned
planned activities.
activities. If
If
your
your mood varied considerably
m o o d varied conSiderably during
during any
any given day, use
given day, use the rating that
the rating that you
you
think
think best
best characterizes the whole
characterizes the whole day,
day, rather
rather than how
than h o w you
you felt at a
felt at particu­
a particu-
larly
larly tough
tough moment.
m o m e n t . Then,
Then, calculate
calculate an
an average
average mood
m o o d rating
rating for
for the days that
the days that
you
you did,
did, and
and did
didnot,
not,complete
complete your
your activities.
activities.You
Y o ushould
shouldbe
beable
abletototell
tellfrom
from
this
this overview
overview whether
whether your
your activity
activity plan has had
plan has had a
a beneficial
beneficial impact on your
impact on your
mood
m o o d in
in the
the last
last week.
week.
If
If your
your plan
plan is
is not
not working
working yet,
yet, consider
consider the
the possibility
possibility that
that you are
you are
choosing
choosing events
events that are too
that are too hard,
hard, that
that require
require too
too much
m u c h planning,
planning, or
orthat
thatyou
you
don't
don't really
really enjoy. For
enjoy. Forexample,
example,if
ifyou
youhave
haveincluded
includedtaking
takingaaforeign
foreignlanguage
language
class
classbut
butdon't
don'treally
reallylike
likethe
theprocess
process of
oflearning
learningaalanguage,
language,you
youmay
m a ynot
notwant
want
to
to include
include this
this activity.
activity.Also,
Also,consider
considerthe
thebalance
balancebetween
betweenactivities
activitiesyou
youmust
must

IMPACT
IMPACT OF
O F YOUR
Y O U R BEHAVIOR
BEHAVIOR ACTIVATION
ACTIVATION PLAN
PUN

Check ((V)
Check ..;) ififyou
youfollowed
followed
Day
Day of
of the
the week
week Mood
Mood that day (-3
that dav to +3)
(-3 to +3) our activity
your activityplan
plan
Monday
Monday
Tu",",
y
Tuesday
Wednesda
y
Wednesday
Thursdav
Thursday
Friday
Friday
Saturday
Saturday
Sunday
Sunday

Average
Average mood
mood rating
rating for
for the
the days
days you
you followed
followed your
your plan
plan
Average
Average mood
mood rating
rating for
for the
the days
days you
you did
did not
not follow
follow your
your plan
plan
 What
What Can
Can II00DoIfIfI Think I'm Getting
I Think Depressed?
I'm Getting Depressed? 229229

do and those
do and thoseyou
youreally
reallywant
wanttoto do.
do. IfIfyour
your depression
depression is is related
related toto the
the absence
absence
of pleasurable
of pleasurable events
events as
as well
well as
as the
the avoidance
avoidance of
of unpleasant activities that
unpleasant activities that
have to
have to be
b e done
d o n e (for
(for example,
e x a m p l e , sweeping
s w e e p i n g the
the garage,
garage, preparing
preparing yyour taxes), in­
o u r taxes), in-
troduce
troduce a
a combination
c o m b i n a t i o n of
of pleasurable
pleasurable and
a n d required
required activities
activities into
into yyour
o u r sched­
sched-
ule.
ule. Start
Start slowly: Don't ny
slowly: Don't try to
to schedule
schedule a
a "must
" m u s t do"
d o " activity
activity every
every day.
day. Work
Work
your
your way
w a y up
u p to
to a
a reasonable
reasonable balance,
balance, such
s u c h as
as two
t w o pleasurable
pleasurable activities
activities aand
nd
o n e required
one required activity
activity per
per day.
day.
If things
If things have
h a v e gone
g o n e well
well for
for you
y o u so
sofar,
far,and
a n d you've
you've noticed
noticed that
that your
y o u r mood
mood
has improved
has improved (or,
(or, at
at minimum,
m i n i m u m , your
your prodromal
prodromal depressive
depressive symptoms
symptoms haven't
haven't
worsened),
worsened), start
start introducing
introducing more
more pleasurable
pleasurable activities
activities into
into various
various parts
parts of
of
your
your day.
day. You
Y o u may
m a y find,
find, for
for example,
example, that
that you
you feel
feel beller
better if
if you
you have
have some­
some-
thing
thing pleasurable
pleasurable to
to do
do during
during the
the lunch
lunch hour
hour (for
(for example,
example, silling at an
sitting at out­
an out-
door
door picnic
picnic table)
table) as
aswell
wellas
assomething
somethingto
tolook
lookforward
forwardto
towhen
w h e n you
you get
gethome
home
from
from work,
work, school,
school, or
or other
other activities.
activities. If
If you
you are
are not
not working or going
working or to
going to
school,
school, it's
it's espeCially
especially important
important to
to have
have rewarding
rewarding activities
activities at the beginning
at the beginning
and
and end
end of
of the
the day
day so
so that
that some
s o m e structure
structure is
is introduced
introduced into your routines.
into your routines.
The
The behavioral
behavioral activation
activation method
method may
m a y seem
seem somewhat
somewhat superficial
superficial or too
or too
obvious.
obvious. You
Y o u may
m a y feel,
feel, "Of course II should
"Of course should be
be doing
doing those
those things-the prob­
things—the prob-
lem
lem is
is that can'tV When
that II can't!" W h e n your
your depression
depression is
is gradually
gradually worsening, it becomes
worsening, it becomes
especially
especially important
important to
to reengage
reengage with
with your
your environment
environment and
and do
do the
the things
things
that
that give
give you
you a
a different
different experience
experience of
of your
your emotions.
emotions. The
T h e key
key is not to
is not to push
push
yourself
yourself too
too hard
hard with
with these
these activities.
activities. Don't
Don'ttry
tryto
todo
do too
toomany
m a n y all
allat
atonce.
once.At
At
first,
first,pick
pickaafew
fewyou
you can
cando
doeasily
easily(for
(forexample,
example,taking
takingaashort
shortwalk,
walk,listening
listening
to
to music,
music, taking
taking a
a bath,
bath, birdwatching,
birdwatching, playing
playing cards)
cards).. Then
Then work
work on
on building
building
up
up to
to a
a reasonable
reasonable number
n u m b e r each
each day,
day, until
until you
you find
find yourself
yourself looking
looking forward
forward
to
to the
the next
next day
day because
because of
of the
the pleasant
pleasant activities
activities you've
you've scheduled. Trouble­
scheduled. Trouble-
shoot
shoot the
the plan
plan at
at the
the end
end of
of each
each week
w e e k to
to determine
determine why
w h y it
it didn't
didn't work.
work. On
On
your
your first
first few
few tries,
tries, you
you probably
probablywon't
won'tbe
beable
ableto
tocomplete
completecertain
certainaspects
aspectsof
of
the
the plan.
plan. Try
Try not
not to
to get
get discouraged;
discouraged; it
it may
m a y take
take a
a few
few weeks
weeks to
to formulate a
formulate a
plan
plan that
that really
really works
works for
for you.
you.
Even
Even if
if it
it sounds
sounds simple,
simple, you
you may
m a y be
be surprised
surprised at
at how well your
h o w well your plan
plan
helps
helps to
to prevent
prevent your
your depression
depression from
from spiraling.
spiraling. In
In all
all likelihood,
likelihood, you'll
you'llget
getaa
feeling
feeling of
of mastery
mastery from
from making
making your
your plan
plan work,
work, which
which will
will make you want
m a k e you want to
to
extend
extend it
it further.
further.

Self·Care
Self-Care Strategy
Strategy No.
N o . 2:
2: The
The Cognitive
Cognitive Restruduring
Restructuring Method
Method

You are probably

You are probably aware
aware that
thatmood states are
mood states areaffected by by
affected thethe
things you you
things tell tell
yourself-by
yourself—^by what
what we
w e call
call "cognitionsn
"cognitions" or
or "self-statements."
"self-statements." Many studies
M a n y studies
have
have shown
s h o w n that
that negative
negative thinking
thinking is
is associated
associated with
with depressed
depressed and
and anxious
anxious
moods
m o o d s (for
(for example,
example, Clark
Clark et aI., 1999;
et al, 1999; DeRubeis
DeRubeis et
et al., 1998). People
al., 1998). People with
with
230
230 SELf·MANAGEMENT
SELF-MANAGEMENT

depression often
depression oftenhave
havenegative
negative"core beliefs"
"core themselves
aboutabout
beliefs" (for example,
themselves (for example,
"I'm
"I'm not
not a a likable
likable person"),
person"), about
about people
people in in general
general (for example, "people
(for example, "people are are
generally motivated
generally motivated by by selfish
selfish concerns")
concerns"),, and and ahoUl
about their
their future
future ("I'm
("I'm never
never
going
going to to accomplish
accomplish my m y goalslbe
goals/be lovedlbe
loved/be healthy").
healthy"). The The assumption
assumption of of cogni­
cogni-
tive-behavioral
tive-behavioral therapy
therapy (Beck
(Beck etet a1., 1979) is
al., 1979) is that
that certain events provoke
certain events provoke dis- dis­
lOrted
torted "automatic
"automatic negative
negative thoughts"
thoughts" that that reflect
reflect core
core beliefs
beliefs about
about one's un­
one's un-
worthiness
worthiness or or unlovability.
unlovability. TheseThese automatic
automatic thoughts
thoughts and and core
core beliefs
beliefs areare
important
important in in causing
causing andand maintaining
maintaining depressed
depressed mood m o o d and
and behaviors
behaviors (for (for ex­
ex-
ample,
ample, withdrawing
withdrawing from from others)
others).. InIn cognitive
cognitive restructuring,
restructuring, you you hold
hold youryour
assumptions
assumptions up up toto the
the light
light to
to see
see ifif they
they are
are logical
logical andand accurate
accurate or or ifif there
there
are other
are other ways
ways to to make
m a k e sense
sense ofof your
your experiences.
experiences. You Y o u may
m a y recall
recall my discus­
m y discus-
sion
sion ofof cognitive therapy in
cognitive therapy in Chapter
Chapter 6; 6; it
it is one of
is one of [he
the most
most effective treat­
effective treat-
ments for
ments for depressive
depressive and and anxiety
anxiety disorders
disorders (Clark
(Clark el et al.,
al., 1999).
1999).
The
The relationship
relationship between
between thoughts
thoughts and and mood
m o o d states
states isis probably
probably not not one­
one-
way:
way: Depressed
Depressed m moods
o o d s also
also generate
generate distorted
distorted thoughts
thoughts and and increase
increase a per­
a per-
son's access
son's access La negative memories
to negative memories or or images (Gotlib &
images (Gollib & Krasnoperova,
Krasnoperova, 1998). 1998).
But learning La
But learning to modify
modify negative
negative thoughts
thoughts and and replace
replace themthem with
with more adap­
more adap-
tive
tive or
or balanced
balanced cognitions
cognitions can can go
go a a long
long way
w a y toward
toward alleviating
alleviating your depres­
your depres-
sion.
sion.
Cognitive
Cognitive restructuring
restructuring involves
involves a a sequence
sequence of of techniques.
techniques. First,First, youyou
identify
identify thethe automatic
automatic thoughts
thoughts or or self-statements
self-statements associated
associated with with certain dis­
certain dis-
turbing
turbing situations
situations or or life
life events
events andand link
link these
these thoughts
thoughts with with your
your moodmood
states.
states. You
You will
willprobably
probablyfind findthat
thatcertain
certainthoughts
thoughtsor orimages
imagesare aremore
morepower­
power-
ful
ful than
than others
others inin provoking
provoking your your emotional
emotional reactions
reactions ("hot
("hot cognitions").
cognitions"). Sec­ Sec-
ond,
ond, youyou evaluate
evaluate thethe evidence
evidence for for and
and against
against these
these automatic thoughts.
automatic thoughts.
Next, based on
Next, based on this
this for/against
for/against evaluation,
evaluation, you you learn
learn to to replace
replace your original
your original
thoughts
thoughts withwith self-statemems
self-statements that that prOvide
provide a more balanced
a more balanced interpretation
interpretation of of
your experiences.
your experiences. Last, Last,you youobserve
observethe theeffects
effectsof ofthese
thesenew n e wself-statements
self-statementson on
your mood.
your mood.
This
This method
method is is nor
not a
a matter
matter of
of blithely
blithely replacing
replacing bad
bad thoughts
thoughts with
with good
good
ones,
ones, which
which many
m a n y people
people find
find superficial
superficial and
and unrealistic.
unrealistic. Instead, it involves
Instead, it involves
thinking up alternative
thinking up or more
alternative or more balanced
balanced ways of understanding
ways of understanding the
the things
things that
that
have
have happened
happened toto you
you and
and looking
looking at
atyour
your situation
situationfrom
fromaanumber
numberof ofdifferent
different
vantage points. A
vantage points. A simple
simple example:
example: Some
S o m e people
people automatically
automatically blame
blame them­
them-
selves
selves when
w h e n someone
someone elseelse treats
treats them
them badly,
badly, without
without conSidering
considering the
thepossibil­
possibil-
ity that
ity that this
this other
other person
person is is having
having a a bad
bad day
day or often behaves
or often behaves inin a similar
a similar
manner with other people.
manner with other people.
In
In this section, II describe
this section, describe thethe method
method of of cognitive
cognitive restructuring
restructuring and out­
and out-
line
line exercises
exercises to help you
to help learn it.
you learn it. Like
Like the
the pleasurable
pleasurable activity
activity scheduling,
scheduling,
cognitive
cognitive restructuring
restructuring will
will probably
probably have
have its greatest power
its greatest power once
once you
you have
have
noticed
noticed the
the ·appearance
appearance of of one
one or more depressive
or more depressive prodromal symptoms, be-
prodromal symptoms, be-
 Who)
What (on
Can IIDoDoIfIfI Think I'm IGening
I Think Depressed?
'm Getting Depressed? 231231

fore your
fore your depression
depression gets getsreally
reallysevere.
severe. If If you wanttotoexplore
you want explorethisthismethod
method fur-fur�
ther,
ther, II suggest
suggest consulting
consulting the b o o k Mind
the book O v e r Mood
M i n d Over M o o d by
b y Dennis
D e n n i s Greenberger
Greenberger
a n d Christine
and Christine Padesky
P a d e s k y (1995)
( 1 9 9 5 ) or
or books
b o o k s on
o n the
the use
u s e of
of cognitive�behavioral
cognitive-behavioral
therapy
therapy with
w i t h people
people who w h o have
h a v e bipolar
bipolar disorder (Basco &
disorder (Basco & Rush,
R u s h , 11996;
996;
Newman
N e w m a n et
et al.,
al., 2001).
2001).

Sfep 1: Ide.lilyi.g
Step I: Identifying Neg.five
Negative Thoughls
Thoughts

Jacob,
Jacob, ageage
49,49, struggled
struggled withsevere
with severebipolar
bipolar depressions
depressions thatthat alternated
alternated
with
with mixed
mixed episodes.
episodes. When
W h e n he
hewas
was feeling
feelingwell,
well,he
fiewas
wasa a
popular
popularcoach
coachofof
aa children's
children's soccer
soccer team.
team. BmBut when
w h e n he
he felt
felt he'd
he'd had
had aa bad
bad day
day of
of coaching
coaching
(for
(for example,
example, his
his concentration
concentration had had been
been poor
poor or
or the
the kids
kids had
had not re�
not re-
sponded
sponded toto his
his suggestions),
suggestions), hishis m mood
o o d would
would sink.
sink. He
H e became
became aware
aware of a
of a
self�statement
self-statement that
that went
went like
like this:
this: "I'm
"I'm just
just no
no good
good with
with kids.
kids. II have
have ma�
ma-
JOT
jor character flaws that
character flaws that they
they can
can seesee in
in me."
me." Sometimes,
Sometimes, just just the
the word
word
character
character would
would pop
pop into
into his
his mind,
mind, and and hehe would
would feel
feel his
his mmood drop.
o o d drop.
Character
Character became
became a a hot
hot cognition
cognition closely
closely tied
tied to
to his
his mood state of
m o o d state of depres­
depres-
sion.
sion.
Jacob
Jacob was
was actually
actually quite
quite good
good with
with children,
children, andand the
thekids
kidsand
and parents
parents
on
on his
his team
team frequently
frequently expressed
expressed their
their appreciation
appreciation of of him. Nonetheless,
him. Nonetheless,
his
his thinking
thinking andand resulting
resulting mood
m o o d contributed
contributed to to his
his increasing
increasing desire to
desire to
quit
quit coaching
coaching altogether.
altogether. When
W h e n asked
asked to
torecount
recountwhy w h y he
he thought
thoughthe
he had
had aa
bad
bad character,
character, he he tended
tended to
to focus
focus onon one
one or
or more
more mistakes
mistakes he he had
had made
made
and
and magnify
magnify or or overgeneralize
overgeneralize these
these mistakes
mistakes ("1("I was
was impatient with one
impatient with one
of
of my
m y kids.
kids. II was
was too
too hard
hard on him. 1I can't
on him. can't work
w o r k well
well with
with people because I1
people because
can't
can't be
be patient
patient with
Mdth myself').
myself).

The The
firstfirst
stepstep in cognitive
in cognitive restructuringisistotobecome
restructuring become aware
aware of the
of the
though15, images, or
thoughts, images, or memories
memories that that crop
crop up
up when
w h e n you
you have
have experiences
experiences thatthat
negatively
negatively affect
affect your
your mood.
m o o d . Be
Be particularly
particularly attuned
attuned to to experiences
experiences involVing
involving
your
your work,
work, family,
family, oror close
close relationships.
relationships. Take
Take a a look
look atat the thought record
the thought record
exercise
exercise on page 232,
on page 232, which
which we'll
we'll be
be completing
completing throughout
throughout this this section. Pick
section. Pick
out three
out three negative
negative experiences
experiences you've
you've had
had in
in the
the past
past week
w e e k and record them
and record them inin
the
the table
table (column
(column 1). 1). Rate
Rate the
the intensity
intensity ofof your
your mood
m o o d (column
(column 2) 2) in reaction
in reaction
to
to these
these events
events on on aa scale
scale ofof 0%
0 % (not
(not depressed)
depressed) to to 100%
1 0 0 % (very
(very depressed).
depressed).
(Alternatively,
(Alternatively, use the -3
use the -3 - +3 scale
- +3 scale we
w e talked
talked about
about inin Chapter
Chapter 8 8 if
if you're
you're
more
more comfortable
comfortable with that rating
with that rating format).
format). List
List other
other moods
m o o d s you
you may
m a y also
also be
be
feeling
feeling (for
(for example,
example, anxiety)
anxiety) andand also
also rate
rate their
their intensity.
intensity. TryTry to distinguish
to distinguish
how
h o w you
you felt
felt during
during oror immediately
immediately afterafter the
the event,
event, not
not how
h o w you
you felt
felt that en­
that en-
tire
tire day.
day.
Now
N o w see
see ifif you
you can
can recall
recall any
any negative
negative self-statemen15
self-statements that that came
came into
into your
your
 THOUGHT
THOUGHT RECORD
RECORD

5.
5. Evidence
Evidence that dCM"S
does

�;
4. Evidence
Evidence thai
that supports not s
upport the hot
not support hot 6. Altemativdbalanccd
6. Altemative^alanced 7. Rate
Rate
1. Situation
1. Situation 2.
2. Moods
Moods 3.
3. AUiomatic
Automatic thOUi-hlS
thoughts(ima.2es)
(images) the
the hot
hot thouSlht
thought thou
thought thoughts moods now
moods now

Ask
Ask yourself:
yourself:
What
What was
was going
going through
through my
my Ask yourself:
Ask yourself:
mind
mind just before II slana!
just before started to
to feci
feel is there an alternative or
Is
this
this way? Ask yourself:
Ask yourself:
way? mon:
more balanced way way of
does this
What docs this mean about
about me?
me? W h e n I1 am
When nOI ffecling
a m not feeling thinking about this
m y Iifd
my life? my fUlurd
m y future? this
this way,
way, do
do IIthink
think situation? If someone else Copy
Copy the
Whom
W h o m were
were What
What is
is the
the worst
worst thing
thing that Circk
Circle hot
hot thought
thought in previous
previous about this type of was in this situation,
was situation, how
how mo"'"
moods
you
you with?
with? Describe
Describe ach
each could happen if
could happen if Ihis
this isislnle?
true? column for
for which
which you
you are Situation
situation any
any would I
would I suggest thai
that he
he or
or from
from
What were
were mood
m o o d in
in ont:
one What
What does
does this
this mean
mean aboUi
about how
how looking
looking for
for evidence.
evidence. Have I1 had
differently? Have had she understand
understand it? Write Column
Column 2.
you doing?
you doing? word.
word. Rate
Rate th�
the othu
other person(s)
person(s) fecl(s)!
feel(s)/ Write factual
factual evidence to support any
any experiences
experiences that down balanced Rerate me
down alternative or bl.lanc�d the
When
W h e n was
was it? intensity
intensity of
of think(s)
think(s) about
aboutme?
me? this
this conclusion.
conclusion. show !:hat this
show that !:his thought thoughts. Rate h
thoughts. how
o w much
much intensity
intensity or
of
Wlu:re
Where were
were mood
m o o d (()...
(0- What
What images
images or
or memories do I1
memories do (Try
(Try to
to avoid
avoid mind-reading
mind-reading and
and is
is not
not completely
completely true you believe in each one each
each mood
mood
you?
you?_ 100%).
100%). have
have of
of !:his
this situation?
situation? reinterpretation of
reinterpretation of facts.)
facts.) all
all the time?
time? (()...100%).
(0-100%). (0-100%).
(0-100%).

Adapted
Adapted by
by permission
permission from Greenberger and
from Greenberger Padesky (l99S).
and Padesky (1993). Copyright
Copyright by
by The
The GUilford Press.
Guilford Press.
 Whot Can 1I110DoIfIfI Think
Whaf Con I'm IGetting
I Think Depressed?
'm Getting Depressed? 233
233

rightbefore
headright
head beforeyou
you started
started feeling
feeling bad,
bad, or or notice
notice and and record
record any come
any that that come
into
into your
y o u r mind
m i n d now
n o w as
as you
y o u review
review the
the events.
events. Write
W r i t e these
these in the "Auto­
in the "Auto-
matic
matic Thoughts"
T h o u g h t s " column.
c o l u m n . To
T o help
help you
y o u "snag"
"snag" these
these statements
statements or
or automatic
automatic
thoughts,
thoughts, try
try to
to be
b e attuned
attuned to
to questions
questions like
like these (Greenberger &:
these (Greenberger & Padesky,
Padesky,
1995):
1995):

• Why
• Why did did
this this eventhappen?
event happen?
•• What
What was
wasgoing
goingthrough
throughmym y mind
mindjust
justbefore
before] Istarted totofeel
started this
feel way?
this way?
•• What
What does
does this
thisevent
event say
say about
about me
m e or
or what
what others
others think
think ofof me?
me?
•• What
What does
does this
thismean
mean will
willhappen
happen in
in my
m y future?
future?
•• What
What is
is the
the worst
worst possible
possiblereason
reason this
this could
could have
have happened?
happened?

Don't Don'tbe be surprised if

surprised ifyou're
you're not not
immediately
immediatelyaware of any thoughts
aware of any or im­
thoughts or i
ages.
ages. YouYou may
may find
findthat
thatyouyou can't
can'tquite
quiteremember
remember how how you
you felt
feltororwhat
whatyou you
thought
thought after
after aaparticular
particularevent.
event.IfIfyou youarearehaving
havingtrouble
troubleremembering,
remembering,prac­ prac-
tice
ticebybyfocusing
focusingon onrecent
recentevents
eventsthat thatcaused
causedyou youtotohave
havestrong
strongemotional
emotionalre­ re-
actions
actions (for
(for example,
example, rejections
rejectionsfrom from aaromantic
romanticpartner,
partner,run-ins
run-inswith withpeople,
people,
problems
problems with your boss at work). These events are probably most closely as­
with your boss at work) . These events are probably most closely as-
sociated
sociated with
with certain
certain identifiable
identifiable hot hot thoughts.
thoughts. Try Try talking
talking or or writing about
writing about
this
this experience
experience to to see
see ifif you
you can identify thoughts
can identify thoughts as as opposed
opposed to to feelings.
feelings.
You
You maymay find
find it
it helpful
helpful to to carry
carry aa note
note padpad or
or hand-held
hand-held tape tape recorder
recorder to to
record
record your
your thoughts
thoughts whenwhen you you experience
experience emotion-provoking
emotion-provoking events. events. This
This
kind
kind of of on-line
on-line recording
recording will will increase
increase the the probability
probability of of tracking your
tracking your
thoughts
thoughts accurately,
accurately,rather
ratherthanthantrying
tryingto toreconstruct
reconstructthemthemafter
afterthethefact.
fact.With
With
time,
time, asas you
you become
become more more familiar
familiar withwith this
this thought
thought tracking method, you
tracking method, you
may
may nono longer
longer need
need recording devices.
recording devices.
Some
Some people
people are
are more
more visual,
visual,and andtheir
theirhot
hotthoughts
thoughtscomecomein inthe
theform
form of of
disturbing
disturbing images
images (for(for example,
example, aa picturepicture of of themselves
themselves as as a a child being
child being
picked
picked on on by
by other
other kids
kids on on the
the playground).
playground). For For others,
others,specific
specificwordswordsare arehot
hot
thoughts.
thoughts. For For Jacob,
Jacob, ititwas
wasthe word character.
theword character.For ForSuzanna,
Suzanna, itit
was
wasthe theword
word
crazy.
crazy. IfIf single
single words
words or or images
images are are associated
associated with
with your mood changes,
your mood changes, re­ re-
cord
cord them
them in the Automatic
in the Automatic Thoughts Thoughts column,
column, and and see
see if
if you
you cancan expand
expand
them
them into
into aa full
full sentence
sentence(for (forexample,
example,-as "aslong
longasasIIact
actthis
thisway,way,people
peoplewillwill
always
always think
think ofof me
m e asas being
being crazy").
crazy").
Let's
Let's imagine
imagine youyou hadhad an an unpleasant
unpleasant conversation
conversation withwith your
your father
father last
last
week,
week, and and that
thatyou
youhave
havebeenbeenruminating
ruminatingabout aboutit,it,ononand
andoff, since
off, sincethen.
then.Re­ Re-
cord
cord thethe event
event asas "Conversation
"Conversation with with DadDad thatthat didn't
didn't gogo well"
well" in in the "Situa­
the "Situa-
tion"
tion" column.
column. Let's
Let's also
also assume
assume your your resulting
resulting depressed
depressed mood mood was was 7 70%
0%
(quite
(quite depressed)
depressed) out out of possible 100%
of aa possible 100% (extremely
(extremely depressed)
depressed).. For For the col­
the col-
umn
u m n labeled
labeled "Automatic
"Automatic Thoughts,"
Thoughts," you you would
would record
record the
the self-statements
self-statements or or
images
images thatthat came
came up up during
during the the conversation
conversation or or immediately
immediately after it. Exam-
after it. Exam-
234
234 SElF·MANAGEMENT
SELF-MANAGEMENT

pies
piesmight
mightinclude
include"I "I
never will will
never be able
be to live to
able up live
to hisup
expectations" or "I let
to his expectations" or "I
him
him down
d o w n again,"
again," both
both of
of which
which might
might fuel
fuel your
your low
low mood.
mood.

Step 2:Challenging
Step 2: ChallengingNegative Thoughts
Negative Thoughts

Now
N o w let's
let's work
work on on modifying
modifying your your automatic
automatic thoughts.
thoughts.Your Your thoughts
thoughts can canbe be
considered
considered hypotheses,
hypotheses, rather rather than
than hard
hard facts,
facts, ahom
aboutcenaill events.Complete
certainevents. Complete
the
the next
next twotwo columns,
columns, "Evidence
"Evidence That That Supports"
Supports" and and "Evidence
"Evidence That That Does
Does
Not
Not Support"
Support" your your hot hot thoughts.
thoughts. Be Be aa scientist
scientist observing
observing your your owno w n thought
thought
process: Is
process: Is there
there anyany evidence
evidence for for or
or against
against your
your conclusion
conclusion that that you
you let
let your
your
dad
dad down
d o w n or
or can't live up
can't live up toto his
his expectations?
expectations? Did Did your
your father
father saysay anything
anything
that
that indicated
indicated differently?
differently? Have Have youyou had
had anyany experiences
experiences with with your
your dad re­
dad re-
cently
cently that
that would
would show show thatthat these
these conclusions
conclusions are are not
not always
always true?
true? Are
Are youyou
discounting
discounting anything
anything positive
positive thatthat he
he said?
said? Could
Could your
your sadsad mood have made
m o o d have made
you view
you view thethe conversation
conversation differently
differently fromfrom what
what i itt really
really was?
was? Would
W o u l d you
you
have viewed
have viewed i itt differently
differently in in a
a different
different mood
m o o d state?
state? Was the outcome
W a s the outcome of of the
the
conversation
conversation reallyreally within
within your
your control? (Greenberger &.
control? (Greenberger & Padesky,
Padesky, 1995).
1995).
The
The nextnext stepstep is is to
to complete
complete the the column
column titled
titled "AltemativelBalanced
"Alternative/Balanced
Thoughts."
Thoughts." This This is the chance
is the chance to to consider
consider alternative
alternative viewpoints
viewpoints that that are
are more
more
balanced
balanced (as (as opposed
opposed to to distorted)
distorted),, even
even if you don't
if you don't believe
believe them
them fully.
fully. Try
Try
writing
writing down
d o w n all
all of
of the
the other
other causes,
causes, explanations,
explanations, or or conclusions
conclusions you you could
could
have
have drawn
drawn from from thisthis event,
event, and
and rate
rate each
each of them on
of them on a 0 - 1 0 0 % scale
a 0-100% scale as to
as to
how
h o w credible
credible you you find
find them ( 1 0 0 % means
them (100% means youyou believe
believe this
this alternative explana­
alternative explana-
tion fully,
tion fully, 0% means not
0 % means not atat all).
all). Examples
Examples might include: "I
might include: "I think
think Dad
Dad was was
just
just in
in aa bad
bad mood
m o o d that
that day
day and
and II got
got defensive" (40%); �We
defensive" (40%); " W e got on the
got on the touchy
touchy
subject
subject of of money,
money, which which always makes us
always makes us both uncomfortable" (70%);
both uncomfortable" (70%); and and
"Dad
"Dad expressed
expressed disappointment
disappointment in in me,
m e , but
but some
some important
important thingsthings came
came to to
light that
light that wew e needed
needed to to talk
talk about" (50%). Once
about" (50%). Once youyou have
have generated
generated and re­
and re-
nected
flectedon onthese
thesealternative
alternativethoughts,
thoughts,make m a k enew
n e wratings
ratingsofofyour m o o d s(de­
yourmoods (de-
pression,
pression, anxiety,
anxiety, or or any
any other
other emotions
emotions you listed in
you listed in column
column 2) 2) using the
using the
same 0-100% (or -3 - +3) scale.
same 0 - 1 0 0 % (or -3 - +3) scale.
In
In developing
developing alternative
alternative thoughts,
thoughts, consider
consider the the follOWing strategies
following strategies
(Greenberger &.
(Greenberger & Padesky,
Padesky, 1995). Write a
1995). Write a sentence that summarizes
sentence that summarizes all aH of the
of the
"for" and
"for" and ""against"
against" evidence
evidence for for your
your cognition
cognition about
about this
this event
event (perhaps link
(perhaps link
the evidence
the evidence with with the word and
the word or but,
and or hut, as
as in
in the
the examples
examples in the preceding
in the preceding
paragraph). Consider
paragraph). Consider what
what advice
advice you
you would
would give
give another
another person
person who
w h o was in
was in
the
the same
same situation,
situation, had had the
thesame
same thoughts
thoughtsandand moods,
moods,and and had
had given
givenyou
you the
the
same
same for/against
for/against evidence.
evidence. Consider
Consider the
the best,
best, worst,
worst,andand most
mostlikely
likely(realistic)
(realistic)
outcomes
outcomes if if your hot cognition
your hot cognition turns
turns out
out toto be
be true.
true. For
For example,
example, if the hot
if the hot
cognition ""I
cognition I ler
let Dad
Dad down
d o w n again"
again" turns
turns out
out to
to be true, a
be true, worst-case outcome
a worst-case outcome
might
might bebe that
that he
he reminds
reminds you you ofof your
your failings
faihngs the
the next
next lime
time you
you talk to him
talk to him
 What (an
What Can IIDoDoIfIfI Think I'm IGetting
I Ihink Depressed?
'm Getting Depressed? 235
235

and youend
and you endupup feeling
feeling even
even worse;
worse; a best�case
a best-case outcome
outcome mightmight behe
be that that he apol�
apol-
ogizes
ogizes and admits he
a n d admits h e was
w a s wrong,
w r o n g , and
a n dyou
y o u feel
feel great;
great;aa realistic
realistic outcome
o u t c o m e might
might
bbe that you
e that y o u feel
feel tension the next
tension the next time
time you
y o u talk
talk to
to him
himbbUl that y
u t that you
o u effectively
effectively
steer
steer the
the conversation
conversation ttoward
o w a r d more comfortable topics.
m o r e comfortable topics.
Jacob, the
Jacob, soccer coach,
the soccer coach, learned to evaluate
learned to evaluate the
the evidence for a
evidence for and
n d against
against
his automatic, self�blaming
his automatic, self-blaming thought that '''I'm
t h o u g h t that "I'm non o good
g o o d with kids." T
with kids." There
h e r e wwas
as
plenty of
plenty of evidence to the
evidence to the contrary,
contrary, given the many
given the m a n y positive
positive comments he
comments h re�
e re-
ceived,
ceived, on
o n an
a n ongoing
o n g o i n g basis,
basis, from
f r o m his
his wife,
wife, the
the soccer
soccer players, and
players, a n d their par�
their par-
ents.
ents. He
H e was
w a s able
able to
to generate
generate more
m o r e balanced
balanced thoughts:
thoughts: "Sometimes
" S o m e t i m e s the
the kids
kids
get uncooperative
get uncooperative when
w h e n I'm
I'm nnot
o t feeling
feeling my
m y best";
best"; "Coaching
" C o a c h i n g can be
can b a difficult
ea difficult
task no
task n o matter
matter how
h o w good
g o o d you
y o u are";
are"; "Today
" T o d a y the
the kids
kids were
w e r e getting
getting overstimu�
overstimu-
lated and
lated and weren't
weren't in
in the
the mood
m o o d to
to learn."
learn." His
His mood
m o o d tended
tended to
to improve upon
improve u in�
p o n in-
troducing
troducing and repeatedly restating
and repeatedly restating to himself these
to himself these countelVaihng thoughts.
countervailing thoughts.
Another
Another person
person with
with bipolar
bipolar disorder,
disorder, Katrina, age 41,
Katrina, age 41, had
had emigrated to
emigrated to
the
the United
United States
States from
from Hungary.
Hungary. A
A year
year after
after arriving
arriving she
she obtained
obtained a job at
a job at an
an
inner
inner city
city school teaching teenagers
school teaching teenagers who
w h o were
were developmentally disabled. Dur-
developmentally disabled. Dur�
ing
ing a
a particularly
particularly difficult
difficult day,
day, three
three of
of the
the boys
boys in
in the
the class
class cursed
cursed at
at her
her and
and
told
told her
her she
she was
was the
the worst
worst teacher
teacher they'd
they'd ever
ever had.
had. By
By day's
day's end,
end, she
she felt
felt quite
quite
depressed
depressed and
and anxious,
anxious, and
and didn't
didn't want
want to
to go
go back
back to
to work.
work. She
She took
took two
two days
days
off,
off, Citing
citing "mental
"mental exhaustion."
exhaustion." She
She recounted
recounted thoughts
thoughts in
in reaction
reaction to this
to this
event,
event, such as, "Maybe
such as, "Maybe II shouldn't
shouldn't be
be a
a teacher
teacher .. II don't
don't know if I1 have
k n o w if the
have the
strength
strength and
and willpower
willpower ... .
. I'm notnot
. I'm effective; I can't
effective; dealdeal
I can't with it by
with it myself . . I. 1
by myself.
don't
don't belong;
belong; II can't
can't make
m a k e it."
it." She
She identified
identified "I'm
"I'm not
not effective"
effective" as the most
as the most
powerful,
powerful, emotion-provoking
emotion-provoking hot
hot thought.
thought.
In
In examining
examining the
the evidence
evidence for
for and
and against
against this
this thought,
thought, Katrina
Katrina cited
cited the
the
fact
fact that
that she'd
she'd had
had to
to call
call in
in the
the school
school counselor
counselor to
to help
help mediate
mediate the conflict,
the conflict,
that
that the
the kids
kids liked
liked her
her only
only when
w h e n she
she was
was being
being friendly
friendly and
and casual
casual but
but not
not
when
w h e n she
she was
was actually
actually teaching,
teaching,and
and that
thatshe
sheseemed
seemedmore
more powerfully
powerfullyaffected
affected
by
by this
this incideOl
incident than
than the
the other
other teachers
teachers thought
thought she
she should
should be.
be. She
She was
was also
also
able
able to
to generate
generate evidence
evidence against
against her
her hot
hot cognition,
cognition, including
includingthe
thefact
factthat
thatshe
she
had
had received
received positive
positive evaluations
evaluations of
of her
her teaching
teaching from
from the
the school
school administra�
administra-
tion
tion and
and that
that her
her earlier
earlier teaching
teaching experiences
experiences in
in Hungary
Hungary had
had been
been quite posi�
quite posi-
tive.
tive. She
She admitted
admitted that
that "the
"the kids
kids are
are troubled
troubled and
and angry
angry at
at everybody"
everybody" and
and
"I've
"I've seen
seen them
them curse
curse out
out other
other teachers."
teachers." She
She also
also recalled
recalled that
that the
the incident
incident
began
began after
after one
one of
of the
the boys
boys had
had verbally
verbally taunted
taunted another
another boy
boy in
in the class.
the class.
She
She eventually
eventually settled
setded on
on more
more balanced
balanced views
views that
that did
did not
not rule
rule out
out her
her
own
o w n role
role in
in causing
causing the
the incident
incident but
but that
that included
included the
the contrary
contrary evidence: "I'm
evidence: "I'm
aa good
good teacher,
teacher,but
butI Ihave
haveaadifficult
difficultset
setof
ofstudents
studentsthat
thatanyone
anyonewould
would have
haveaa
problem with
problem with.. ....
. . II sometimes
sometimes struggle
struggle with
with my
m y own
o w n boundaries
boundaries and
and how
h o w to
to
set
set limits
limits with people. ... .
with people. I'm new
I'm at at
new this, and
this, it'sit's
and hard notnot
hard getget
to to mym buttons
y buttons
pushed
pushed.. ... .. .
I'm still
I'm making
still a difference
making in in
a difference their lives,
their andand
lives, they're teaching
they're me m e
teaching
236
236 SElF-MANAG£MENT
SELF-MANAGEMENT

a
a lot
lotabout
aboutmyself
myself even though
even thoughthey hurt
they my my
hurt feelings sometimes."
feelings Her mood
sometimes." Her mood
in
in reaction
reaction to
to the
the confrontation
confrontation improved
improved significantly
significantly upon
u p o n reviewing these
reviewing these
balanced
balanced thoughts.
thoughts. Over
Over time,
time, as
as her
her depression
depression lifted,
lifted, she
she focused
focused on
on the
the
larger
larger question
question of
of whether
whether she
she wallled
wanted toto teach, which had
teach, which had become
become confused
confused
in
in her
her mind
mind with
with whether
whether she
she was
was good
good at
at it.
it.

What'sDifferent
Whafs Differe.t about
aboutThinking
ThinkingPatter.s i. Bipolar
Patterns Depressio.?
in Bipolar Depression?

So far,
So far, the cognitive
the restructuring
cognitive methodmethod
restructuring I've described could apply
I've described to almost
could apply to almost
any form
any form of depression or
of depression or anxiety.
anxiety. TheThe method
method applies well to
applies well to bipolar disor­
bipolar disor-
der,
der, but
but bipolar
bipolar depressions
depressions tendtend toto be
be much
m u c h more severe than
more severe those experi-
than those experi­
enced by
enced people going
by people going through
through lifelife transitions.
transitions. So, So, in
in constructing
constructing your alter­
your alter-
native
native or or balanced
balanced thoughts,
thoughts, consider
consider thethe role
role ofof your disorder-particularly,
your disorder—particularly,
its biological and
its biological and genetic
genetic underpinnings-in
underpinnings—in modulating modulating your your view
view of of the
the
causes
causes of of negative
negative events.
events. DoD o chemical imbalances of
chemical imbalances of [he
the nervous
nervous system
system ex-ex­
plain your
plain your behavior
behavior in in certain
certain situations
situations better
better thanthan character flaws? Could
character flaws? Could
your
your emotional
emotional reactions
reactions inin the heat of
the heat of the
the moment
m o m e n t have been due
have been due to
to your dis­
your dis-
order rather than
order rather than your
your inability
inability toto deal
deal with
with people?
people?
Jacob,
Jacob, forfor example,
example, recognized
recognized that that soccer
soccer coaching
coaching did did not
not go
go asas well
well
when
w h e n he experienced the
he experienced the physical
physical signs
signs ofof depression
depression or or anxiety
anxiety (for
(for example,
example,
poor concentration,
poor headaches, low
concentration, headaches, low energy)
energy).. On O n days
days in
in which
which his
his coaching
coaching
and
and athletic performance were
athletic performance were impaired,
impaired, he he introduced
introduced balanced thoughts,
balanced thoughts,
such
such as,as, "1
"I can tell that
can tell thatmy
m y mood
m o o d and
and energy
energy are areoff offkilter
kiltertoday;
today;this
thisisisone
oneofof
those
those days
days II can't
can'texpect
expectas asmuch
m u c h from
from myself
myself. . . .. ..This is not
. This about
is not my flawed
about m y flawed
character;
character; i it's
t's about
about mym y biology.
biology. .. . . MyM y depression
depression isiscausing
causing mem e totoview
view
things more
things more peSSimistically
pessimistically thanthan II have to-it doesn't
have to—it doesn't follow that I'm
follow that I'm not
not aa
good
good person
person because
because II can't
can't control
control my
m y moods."
moods." These
These thoughts
thoughts gave
gave him
him a a
sense
sense of
of self-acceptance
self-acceptance when
w h e n his
his moods
m o o d s interfered
interfered with
with his
his high
high standards
standards of
of
performance.
performance.
Katrina worried
Katrina worried that
that "I'm
"I'm too
too emotionally
emotionally unstable
unstable to to be
be a
a consistent
consistent fig­
fig-
ure
ure in
in their
their (her
(her studems')
students') eyes."
eyes." Indeed,
Indeed, negative
negative interactions
interactions with
with her stu­
her stu-
dents
dents probably
probably had
had aa more
more powerful
powerful effect
effect on
on her
her mood states than
m o o d states might be
than might be
the
the case
case for
for a
a person
person without bipolar disorder,
without bipolar disorder, bUl
but not
notOUl
outof
ofher
herown
o w n choice
choice. .
She
She learned
learned to
to internally
internally rehearse
rehearse the
the self-statements
self-statements "I'm
"I'm going
going to have more
to have more
severe ups
severe ups and
and downs than the
downs than the ordinary
ordinary teacher,"
teacher," "Not
"Not all
aH of
of my
m y emotional
emotional re­
re-
actions will be under my comrol, but that doesn't mean I can't teach," and
actions wHl be under m y control, but that doesn't m e a n I can't teach," and
Ul'm
"I'm good
good at
at what
what IIdo,
do,and
andthere
thereisisa agreat
greatdeal
dealofof
meaning
meaningininit." She
it." alsorec­
Shealso rec-
ognized
ognized the
the need
need to
to give herself more
give herself more time
time to relax and
to relax and decompress
decompress after
after work
work
than might
than might be
be required
required by
by some
some of her coworkers.
of her coworkers.
Consider
Consider another
another example.
example. Say
Say you've
you've had
had a a string
string of
of negative interac­
negative interac-
tions
tions with
with your
your employer
employer over
over the
the last
last week
week but
but generally
generally have
have had
had good
good rela-
rela-
 What Can IIDoDoIIIIfThink
What (on I'm IGelling
I Think Depressed?
'm Getting Depressed? 231237

tions
tions withwith himhimor orher.
her. Is
Is it
it possible
possible that that your
your irritability
irritabilitywith withyour your boss
boss derives
derives
from
f r o m depressive
depressive or or m mixed
i x e d symptoms
s y m p t o m s rather
rather than than your
y o u r "short
"short fuse,"
fuse," "angry
"angry
nature,"
nature," "problems
" p r o b l e m s getting
getting along
along with with people,"
people," or or "problems with authority
" p r o b l e m s with authority
figures"? II am
figures"? a m notn o t saying,
saying, "Blame
" B l a m e everything
everything on o n your
y o u r bipolar
bipolar disorder."
disorder." I'm I'm
r e c o m m e n d i n g that
recommending that you
y o u take
take a a more
m o r e balanced
balanced perspective
perspective on o n the
the factors influ­
factors influ-
encing events
encing events in in your
y o u r life, including your
life, including y o u r disorder.
disorder.
To
T o sum
s u m up,u p , cognitive
cognitive restructuring
restructuring has has thethe potential
potential to to help
help you
y o u alleviate
alleviate
y o u r depressed
your depressed mood m o o d byb y identifying
identifying and a n d revising
revising the the automatic
automatic thoughts
thoughts that that
trigger
trigger low l o w mood
m o o d states.
states. The
T h e role
role your
y o u r bipolar
bipolar disorder
disorder may play in
m a y play in stimulat­
stimulat-
ing your
ing y o u r emotional
emotional reactionsreactions to to persons,
persons, situations,
situations, and a n d challenging
challenging events events
should
should not n o t beb e underestimated.
underestimated. In In combination
c o m b i n a t i o n with
with behavioral
behavioral activation
activation
m e t h o d s , cognitive
methods, cognitive restructuring
restructuring has h a s the
the potential
potential to to help
help alleviate
alleviate your
y o u r de­
de-
pression
pression or, or, at at minimum,
m i n i m u m , keep
k e e p itit in
in check.
check.

* * *

This
This chapter
chapter has h a s introduced
introduced you y o u to
to important
important self-management
self-management tools for
tools for
coping
coping with with youry o u r depresSion.
depression. Implementing
I m p l e m e n t i n g these
these toolS-identifying
tools—identifying your your
early
early warning
w a r n i n g signs,
signs, scheduling
scheduling pleasurable
pleasurable and/or and/or activating events, and
activating events, re­
a n d re-
considering
considering the the way
w a y you
y o u think
think about,
about, and a n d respond
r e s p o n d to,
to, the
the events
events in in yyour
o u r life­
life—
can
can go go a a long
long wayw a y toward
t o w a r d comrolling
controlling the the negative
negative spiral
spiral of of depression.
depression.
Don't
Don't be b e too
too concerned
c o n c e r n e d ifif you
y o u don't
don't taketake to to these
these m methods
e t h o d s right
right away.
away.
They
T h e y require
require guided
guided practice
practice and a n d skill
skill before
before they they feel
feel natural.
natural. If If you
y o u hhave
a v e ac­
ac-
cess
cess to to a a cognitive-behavioral
cognitive-behavioral therapist, therapist, consider
consider doing doing these
these exercises
exercises with with
his
his oror her
her guidance
guidance at first.
at first.
The next chapter
T h e next chapter deals deals withw i t h ana n issue
issue thatthat many-in
m a n y — i n fact,
fact, most-people
most—people
with
with bipolar
bipolar disorder
disorder deal deal with
w i t h at
at one
o n e time
time or or another:
another: suicidal
suicidal thoughts
thoughts or ac­
or ac-
tions.
tions. This
This topic
topic is,is, for
for many,
m a n y , ana n uncomfortable
uncomfortable one. one. But
B u t like
like many
m a n y other
other at-at­
tributes
tributes of of bipolar
bipolar disorder,
disorder, you y o u will
will putp u t yourself
yourself in in the
the driver's
driver's seatseat once
o n c e you
you
are
are able
able to to understand
understand suicidal suicidal impulses
impulses as as symptoms
s y m p t o m s of
of your
y o u r illness
Hlness that re­
that re-
quire management.
quire m a n a g e m e n t . You
Y o u will
will seesee thethe special
special rolerole of of psychotherapy,
psychotherapy, medication,
medication,
social
social supports,
supports, and a n d self-management
s e l f - m a n a g e m e n t tools
tools in in alleviating
alleviating suicidal
suicidal despair.
despair.
 1 1
1 1

Dealing
D e a l i n g with
w i t h Suicidal
S u i c i d a l Thoughts
Thoughts

and
a n d Feelings
Feelings

"{
"I had
had been
been getting
getting mort':
more and
and more
more depressed
depressed and
and had
had thought
thought about kill­
about kUl-
ing
ing myself,
myself, butbut somewhere
somewhere in thereIIdecided
inthere decided lO tofinally
finallydo do it.
it.One nightI I
O n enight
came
came home
h o m e from
from work
work to to my
m y apartmem
apartment and went through
and went through a a whole rituaL
whole ritual.
II had
had decided
decided II was
was going
going to
to do
do itit by
by overdosing
overdosing on on mym y lithium,
lithium, since
since
that's
that's the
the drug
drug II had
had the
themost
most of.of.IItook
tookit,it,little
littleby bylillie,
little,throughout
throughout the
the
evening, pill after
evening, pill after pill,
pill, and then II got
and then got inin the
the shower,
shower, but but by
by then
then I1 was
was
starting
starting to puke and
to puke gOl the
and got runs really
the runs really badly
badly.. .... think1I1051
. . II think lostconscious­
conscious-
ness at
ness at some
some point,
point, and
and somewhere
somewhere in in there
there II had
had the the presence
presence of of mind
mind
to call
to call Dylan
Dylan {boyfriend]
[boyfriend], , who
w h o called
called the
the paramedics,
paramedics, and and they took me
they took me
to
to the
the hospital.
hospital. II ended
ended upup there
there with
with a a catheter
catheter and and thethe whole thing. II
whole thing.
looked
looked awful
awful and
and felt
felt awful.
awful. Everybody
Everybody was was telling
telling me m e how
h o w fortunate
fortunate I 1
was
was to
to be
be alive,
alive,but
butthat
thatmade
m a d e me
m e feel worse.1 Isure
feelworse. sure didn't
didn'tfeel
feel fortunate."
fortunate."
-A
— A 28¥year-old
28-year-old womanw o m a n with
with bipolar
bipolar II disorder,
disorder,
recounting
recounting her
her first
first suicide
suicide attempt
attempt

If you
If you are are cycling
cycling into
into a period
a period ofof depression, it
depression, it is
is common
common totohave
have
thoughts
thoughts of of ending your life.
ending your Hfe. You
Y o u may
m a y have
have been
been having these thoughts
having these all
thoughts all
along,
along, but
but they
they can
can become
become moremore severe
severe ifif your depression is
your depression getting worse.
isgetting worse.
You
Y o u may
m a y also
also find
find that
that your
your suicidal
suicidal thoughts
thoughts go go along
along with
with an
an increase in
increase in
your
your anxiety
anxiety andand worry.
worry. Some
S o m e people
people feel
feel suicidal
suicidal chronically,
chronically, not just when
not just when
they
they are
are depressed.
depressed. One
O n e patient said, "I
patient said, "I know
k n o w I'll
I'll kill
kill myself
myself someday.
someday. IIt's
t's
gonna
gonna happen.
happen. TheThe only
only question
question is is when."
when."

238 238
 Dealing
Dealing with
with Suicidal
SuicidalThoughts
ThoughtsandandFeelings
Feelings 239
239

Suicide
Suicide can becan be accomplished
accomplished in impulsive
in a sudden a suddenactimpulsive act or a carefully
or a carefully
planned
planned event.event. It It usually
usually occursoccurs during
during a a depressive
depressive or or a a mixed episode, but
m i x e d episode, but
s o m e people
some people with with bipolar
bipolar disorder
disorder kill kill themselves
themselves accidentally
accidentally or or ono n impulse
impulse
w h e n they
when they are are psychotic
psychotic and a n d in
in the
the manic
m a n i c phase.
phase.
By
B y some
s o m e estimates,
estimates, people people with w i t h bipolar
bipolar disorder
disorder are are at at 151 5 times
times the the
risk for
risk for committing
c o m m i t t i n g suicide
suicide of of people
people in in thethe general
general population
population (Harris (Harris & &
Barraclough,
Barraclough, 1997). 1 9 9 7 ) . Up
U p to 1 5 % of
to 15% of people
people with w i t h bipolar
bipolar disorder
disorder die die by b y suicide;
suicide;
as many
as m a n y as 5 0 % attempt
as 50% attempt suicidesuicide at at least
least once
o n c e in
in their
their lives
lives Oamison,
Q a m i s o n , 2000b;
2000b;
Simpson &
Simpson & Jamison, 1 9 9 9 ) . Tragically,
J a m i s o n , 1999). Tragically, suicidal
suicidal thoughrs
thoughts and a n d feelings
feelings are are aa
part
part ofof bipolar
bipolar illness,
illness, connected
connected with with irs its biological
biological and a n d genetic
genetic mechanisms.
mechanisms.
We
W e know
k n o w thatthat levels
levels of of serotonin
serotonin aTe are lower
lower in in thethe brains
brains of of people
people w who
ho
attempt
attempt or or complete
c o m p l e t e suicide
suicide (Mann ( M a n n etet al., 1 9 9 9 ; Asberg
al., 1999; A s b e r g et
et al., 1 9 8 6 ; Arango
al., 1986; et
A r a n g o et
a1., 1 9 9 5 ) . In
al., 1995). In other
other words,
w o r d s , suicidal
suicidal impulses
impulses are are related
related to to thethe neuro­
neuro-
physiology
physiology of of your
y o u r disorder;
disorder; they they areare notn o t caused
caused by by a a mmoral
o r a l failing
failing or or weak­
weak-
ness
ness on o n your
y o u r part.
part.
Therefore,
Therefore, you y o u should
should not notfeel
feel alone
alone with,
with, or o rashamed
a s h a m e d oof,
f, suiddal
suicidal thoughts.
thoughts.
Virtually
Virtually every every person
person with with bipolar
bipolar disorder
disorder has has entertained
entertained the the idea
idea o f suicide
of suicide
at
at one
o n e point
point or another. In
o r another. In fact,
fact, many
m a n y people
people without
without the the disorder
disorder have have
thought
thought about about it, it, even
e v e n if
ifjust
just in inpassing.
passing. But B u t among
a m o n g people
people with with bipolar
bipolar disor­
disor-
der,
der, the
the thoughts
thoughts often often become
b e c o m e frequent
frequent and a n d intense
intense and a n d are
are more likely to
m o r e likely to be
be
aniculated
articulated into into a a plan
plan of of action
action (for(for example,
e x a m p l e , to
to kill yourself with
kill yourself with pills
pills at at a
a
specific
specific time).time). For F o r first-person
first-person accounrsaccounts of of suicidal
suicidal feelings
feelings and a n d actions
actions
among
a m o n g people
people with with bipolar
bipolar disorder,
disorder, read read KayK a y Jamison's
Jamison's 1995 1 9 9 5 autobiography,
autobiography.
An
A n Unquiet
Unquiet Mind, M i n d , oror her
her recent
recent bookb o o k ono n suicide,
suicide, NightNight Falls Fast Oamison,
Falls Fast Qamison,
2000.).
2000a).

The Desire 10
The Desire to Escape
Escape

People with
People with bipolar
bipolarand
andother
otherdepressive
depressivedisorders often
disorders feel feel
often hopeless, as if as if
hopeless,
nothing will
nothing will ever
ever change
change for for the
the better.
better. They
They feel
feel a
a strong
strong need for relief
need for relief from
from
'-psychiC pain colored by the fear and anticipation of increasing, uncontrolla­
"psychic pain colored by the fear and anticipation of increasing, uncontrolla-
ble,
ble, interminable
interminable pain"
pain" (Fawcett
(Fawcett et et al.,
al., 2000,
2000, p. 147). Some
p. 147). S o m e people
people honestly
honestly
want
want toto die.
die. But
But inin my
m y experience,
experience, mostmost people
people with
with bipolar
bipolar disorder want re-
disorder want re­
lief
lief from
from thethe intolerable
intolerable lifelife circumstances
circumstances and and the
the emotional, mental, and
emotional, mental, and
physical
physical pain
pain that
that goes
goes along
along with
with depression
depression and and anxiety.
anxiety. When
W h e n your
your depres­
depres-
sion
sion is
is spiraling
spiraling downward
d o w n w a r d and
and you
you feel
feel aa sense
sense of
of dread
dread and
and apprehension,
apprehension,
you
you may
m a y desperately
desperately wantwant to to live,
live, but
but suicide
suicide can
can feel
feel like
Hke thethe only
only escape
escape
from
from your
your intolerable feelings.
intolerable feelings.
Even when
Even w h e n severe,
severe, however,
however, suicidal
suicidal thoughrs
thoughts cancan be
be managed
managed and con­
and con-
trolled
trolled medically.
medically. There
There is is strong
strong evidence
evidence that
that long-term
long-term treatment
treatment with lith-
with lith-
240
240 SElF·MANAG£MENT
SELF-MANAGEMENT

decreases suicide
ium decreases
ium suicideauempts andand
attempts completions by people
completions withwith
by people bipolar disor­disor-
bipolar
der
der (Baldessarini
(Baldessarini et al., 1999;
et a1., T o n d o &:
1999; Tondo & Baldessarini, 2000; Simpson &:
Baldessarini, 2000; Simpson &
Jamison, 1999). The
Jamison, 1999). The antidepressant,
antidepressant, anticonvulsant,
anticonvulsant, and
and antipsychotic
antipsychotic drugs
drugs
decrease
decrease the
the agitation
agitation and
and aggressiveness
aggressiveness that
that can
can bring
bring about
about suicidal actions
suicidal actions
Oamison,
Qamison, 2000b).
2000b).
The
The challenge
challenge in
in dealing
dealing with
with suicidal
suicidal despair
despair is
is to
to find
find other
other ways
ways of
of es­
es-
caping
caping from
from your
your intolerable
intolerable feelings. As IItalk
feelings. As talkabout
aboutin
inthis
thischapter,
chapter,your
yourop­
op-
tions
tions can
can include
include drug treatment, psychotherapy,
drug treatment, psychotherapy, the
the help
help of
of supportive
supportive
friends
friends or
or family
family members,
members, and
and self-management techniques. Your
self-management techniques. hopeless­
Your hopeless-
ness, pain, and
ness, pain, and emptiness
emptiness are
are temporary,
temporary, not
not permanent
permanent states,
states, even
even though
though
they
they may
m a y nOl
not seem that way
seem that w a y at
at the time.
the time.

Risk
Risl( Factors
Factors for
for Suicide
Suicide

You should know

You should about the
know about the factors
factorsthat increase
that your
increase probability
your of actually
probability of actually
hurting
hurting or killing yourself,
or killing yourself, so
so that
that you
you and
and your
your doctor
doctor can
can determine
determine how
how
imminent
imminent the
the danger
danger to
to you
you has
has become.
become. If
Ifyou
you plan
planon
on switching
switching doctors,
doctors,tell
tell
your
your new
n e w doctor
doctor about
about your
your risk
risk factors
factors so
so that
that he
he or
or she
she can
can determine the
determine the
seriousness
seriousness of
of your
your iOlent
intent and
and hopefully
hopefully be
be of
ofgreater
greater help
help to
to you
you in
in aa crisis.
crisis.
You
You are
are at
at particularly
particularly high
high risk
risk for committing suicide
for committing suicide if
if you
you . .. .

• have
• have a bipolar
a bipolar disorder and
disorder and are
are also
alsodrinking alcohol
drinking or using
alcohol drugsdrugs
or using reg­ reg-
ularly
ularly (in
(in addition
addition to
to making
making your
your illness
illness worse,
worse, using
using these
these substances
substances
makes
makes it
it unlikely
unlikely that
that you
you will
will take
take your
your mood
m o o d stabilizers
stabilizers regularly
regularly or
or
seek
seek help
help from
from others
others when
wheri suicidal)
suicidal)
•
• are
are male
male
•
• have been ill
have been illfor
foraashort
shortlime
timeand
andhave
havehad
hadonly
onlyaafew
fewbipolar
bipolarepisodes
episodes
•
• have
have panic
panic attacks,
attacks,agitation,
agitation,restlessness,
restiessness,or
or other
other indicators
indicators of
of severe
severe
anxiety
anxiety
•
• are
are prone
prone to
to impulsive
impulsive acts,
acts, such
such as
as driving
driving recklessly
recklessly or violent out-
or violent out-
bursts
bursts
•
• have
have recently
recently been
been hospitalized
hospitalized
•
• have
have preViously
previously tried
tried to
to kill
killyourself
yourself
•
• have
have one
one or
or more
more relatives
relatives in
in your
your family
family tree
tree who
w h o committed
committed suicide
suicide
or
or commiued
committed a violent act
a violent act
•
• have
have experienced
experienced aa receOl
recent stressful
stressful life
lifeevent
event involving
involving loss (for exam­
loss (for exam-
ple,
ple, a
a divorce
divorce or
or the
the death
death of
of a
a family
family member)
member)
•
• are
are isolated
isolated from
from friends
friends and
and family
family members
members
•
• do
do not
not have
have ready
ready access
access to
to aa psychiatrist
psychiatrist or
or psychotherapist
psychotherapist
 Dooling
Dealing with
withSuicidal
SuicidalThoughts andand
Thoughts Feelings
Feelings 241
241

• have
• have feelings
feelings of hopelessness
of hopelessness about
about your your
future future
and/or do andlor
not feeldo
younot feel you
have
h a v e strong
strong reasons
reasons to to keep
k e e p living
living (for
(for example,
example, a a commitmeOl
c o m m i t m e n t to rais­
to rais-
ing
ing children)
children)
• have
• h a v e thought
t h o u g h t about
a b o u t aa specific
specific plan
plan (for
(forexample,
e x a m p l e ,tototake
takepills,
pills,shoot
shoot
yourself,
yourself, jump j u m p from
f r o m aa high
h i g h place)
place)and
a n d have
h a v e the
themeans
m e a n s to
todod o it
it(access
(access to
to
pills
pills oror a a gun)
gun) (Fawcett
(Fawcett et et aL,
al., 2000;
2000; Jamison,
Jamison, 2000b) 2000b)

If you
If you feelsuicidal,
feel suiddal, you
you should
should always
alwaysinfonn
informyour
yourpsychiatrist, therapist,
psychiatrist, therapist,
family
family members,
members, and
and other
other Signi ficant people
significant people in
in your
your core circle. This
core circle. This is
is espe­
espe-
cially
cially true
true ifif you
you have
have one
one oror more
more ofof the
the preceding
preceding risk
risk factors.
factors. Don't
Don't stop
stop
yourself
yourself from
from disclosing
disclosing your
your suicidal
suicidal thoughts
thoughts because
because you
you are
are afraid
afraid of
of wor­
wor-
rying people
rying people or or hurting
hurting their
their feelings.
feelings. Many
M a n y people
people feel
feel this way
this w a y and
and then
then
don't
don't get
get the
the help
help they need. Err
they need. Err on
on the
the side
side of
of informing
informing your
your doctors
doctors and
and
significaOl
significant others,
others, even
even if
if you're
you're not
not sure
sure how
h o w serious
serious you
you are
are about suicide.
about suicide.
Later
Later in
in this
this chapter
chapter II talk
talk about
about what
what your
your doctor,
doctor, therapist,
therapist, friends
friends and/or
and/or
family
family members
m e m b e r s can
can do
do to
to help
help you
you at
at these times.
these times.

How
H o w Can
Can You
You Prated
Protect Yourself
Yourself from
from Suicidal
Suicidal Adions?
Actions?

"Anyone
"Anyone whowho suggests
suggests thatthat coming
coming back back
from from suicidal
suicidal is a is a
despair
despair
straightforward
straightforward journey
journey has
has never
never taken it."
taken it."
-
— JJamison
a m i s o n (2000b, p. 49)
(2000b, p. 49)

If you
If you have
have been
been spiralinginto
spiraling iOlOaa depressive
depreSSive or
or mixed
mixed episode
episodefrom
fromyour
your
baseline
baseline state,
state, ororififyour
yourongoing
ongoingdepression
depressionhashasbeen
beengetting
gettingworse,
worse,you you may
may
have
have noticed
noticed an an increase
increase inin your
your suicidal
suicidal thoughts.
thoughts. These
These can can be
be vague
vague atat first
first
(for
(for example,
example, "I "I wonder
wonder what
what it it would
would bebe like
like to
to be
be dead?"),
dead?"), then
then more seri­
more seri-
ous ("I know
ous ("I k n o w that
that II want
want toto kill
kiH myself,
myself, II just
just don't
don't know
k n o w how"), then even
h o w " ) , then even
more
more serious
serious ("I've
("I've thought
thought ofof various
various suicide
suicide plans
plans andand have
have settled
settled onon one,
one,
as
as well
well asas a
a time
time and
and a a place").
place").
The
The feelings,
feeHngs, thoughts,
thoughts, andand behaviors
behaviors that
that make
m a k e up
up suicidal
suicidal despair are
despair are
quite
quite complex
complex and and not
not well
well understOod
understood by by behavioral
behavioral scientists.
scientists. Nonetheless,
Nonetheless,
we
w e know
k n o w that there are
that there are some
s o m e things
things you
you can
can dodo to
to protect
protect yourself
yourself from
from acting
acting
on
on these
these impulses.
impulses. In In this
this chapter,
chapter, you'll
you'll leam
learn how
h o w toto put
put tOgether
together a suicide
a suicide
prevention
prevention plan.
plan.
Suicide prevention involves
Suicide prevention decreasing your
involves decreasing your access
access to
to the
the means
means to
to commit
commit
suicide and increasing
suicide and increasing your
your access
access to
to support
support systems
systems (doctors,
(doctors, therapists,fam­
therapists, fam-
ily
ily members,
members, and friends). You
and friends). Y o u might
might wonder,
wonder, atat what
what point
point do these plans
do these plans
work,
work, and
and at
at what
what point
point is
is it
it already
already too
too late?
late? Keep
Keep a
a general
general caveat
caveat in
in mind
mind
242
242 SELF-MANAGEMENT
SELF-MANAGEMENT

when you develop

when you develop your
your plan:
plan:You Youhave
havemore
moreleverage
leveragein in
suicide prevention
suicide preventionif if
you
you have
have a a plan
plan in
in place
place when
w h e n you're
you're feeling
feeling well
well and begin implementing
and begin implementing i ittat
at
the
the first
first emergence
emergence of of suicidal
suicidal thoughts
thoughts oror other
other prodromal
prodromal signs
signs of clepres·
of depres-
sian.
sion. Don't
Don'twait
waitumil
untilyou
you are
arereally
reallyfeeling
feelingdesperate-don't
desperate—don'tlet letyourself
yourselfget
gettoto
that
that point.
point. When
W h e n suicidal
suicidal thoughts
thoughts andand plans
plans accompany
accompany thethe lowest
lowest point
point ofof
the
the depressive
depressive or or mixed
mixed episode,
episode, suicide
suicide attemplS
attempts can
can occur
occur by impulse.
by impulse.

Stlotegy No.
Strategy No.,:1:
Get RidRid
Get of the Means
of the to HUlt
Means YouISelf
to Hurt Yourself

One
O n e practical
practical step you can
step you can take
take right
right away
away isis to
toput
put those
those items
itemsyou
you might
might use
use
to kill
to kiH yourself
yourself out
out ofof your
your reach.
reach. These
These include
include guns,
guns, sleeping
sleeping pills,
pills, poisons,
poisons,
ropes,
ropes, and
and sharp
sharp knives
knives oror other
other weapons.
weapons. Give them [Q
Give them to a
a trusted
trusted friend
friend who
who
lives
lives apart
apart from
from yOll,
you, oror even
even your
your psychiatrist
psychiatrist oror therapist
therapist. To
T o avoid overdos­
avoid overdos-
ing
ing on
on your
your psychiatric
psychiatric medications,
medications, keepkeep only
only a a couple
couple ofof days'
days' dosages
dosages in in
your
your house
house and
and have
have your
your friend
friend oror relative
relative (or
(or perhaps
perhaps your
your doctor)
doctor) hold
hold on
on
to the
to the rest
rest of
of the
the pills,
pills,dispensing
dispensingthem them asasyou
youneed
need them.
them.Though
Though thisthispracti­
practi-
cal
cal maneuver
maneuver may m a y seem
seem like
like iitt only
only scratches
scratches thethe surface
surface (you
(you are,
are, after all,
after aH,
only
only getting
getting rid
rid of
of the means, not
the means, notyour
your intentions),
intentions),ititwill greatly
will greatlydecrease
decrease thethe
chances that
chances that you
you will actually kill
will actually kill yourself.
yourself.InIn the
the same
same manner,
manner,limiting
limitingyour
your
access
access toto such
such items
items as as a
a gun
gun decreases
decreases the
the chances
chances that
that you
you will
will use
use it
it on
on
yourself
yourself oror someone
someone else.else.

Stlategy No.
Strategy No.2:2:
See YOUI
See Psychiatlist
Your and Thelapist
Psychiatrist Immediately
and Therapist Immediately

If your
If your next
next appointments
appointments with with your
your psychiatrist
psychiatrist and and therapist
therapistareare not
not sched­
sched-
uled for
uled for several
several weeks,
weeks, call
call them
them and
and let
let them
them know
k n o w you
you are
are at
at risk,
risk, oror ask
ask aa
m e m b e r of
member of your
your core
core circle
circle toto make
m a k e lhe
the contact.
contact. If If at
at all
all possible,
possible, see
see your
your
doctor and
doctor and therapist
therapist together
together (assuming
(assuming they they are
are not
not the
the same
same person)
person) so that
so that
they can
they can help
help you
you develop
develop an an integrated
integrated planplan for
for managing
managing your your suicidal
suicidal im­im-
pulses, depression
pulses, depression or anxiety, stress,
or anxiety, stress, and
and medication.
medication.
What
W h a t will
will your
your doctors
doctors do do to
to help
help you
you when
w h e n you
you first
first start
start feeling sui­
feeling sui-
cidal?
cidal? InIn all
all likelihood,
likelihood,they theywill
willstart
startbybyasking
askingyou youquestions
questionsabout
aboutyouryoursui­
sui-
cidal
cidal intentions,
intentions, suchsuch asas any plans you've
any plans you've been
been thinking about and
thinking about your his-
and your his­
tory
tory ofof suicide
suicide attempts
attempts (if (if they
they don't
don't already
already know about those).
k n o w about those). Expect
Expect to to
spend
spend some
some time
time on these issues
on these issues before
before they
they get
get to
to the reasons you
the reasons want to
you want to kill
kill
yourself,
yourself, which
which maym a y be
be foremost
foremost in inyour
your mind.
mind.Be Be honest
honest about
aboutyour
yoursuicidal
suicidal
intentions,
intentions, eveneven if these feelings
if these feelings are
are new
n e w toto you,
you, foreign,
foreign, or,or, in your view,
in your view,
shameful.
shameful. TellTell them
them howh o w serious
serious you
you are,
are, that
that you
you maym a y not feel safe
not feel safe atat home,
home,
and that you
and that you have
have access
access to to weapons
weapons or or other
other means
means of of hUrling yourself.
hurting yourself.
Some people don't
S o m e people don't feel
feel comfortable
comfortable disclOSing information to
disclosing information to their
their doc­
doc-
tors about
tors their suicidal
about their suicidal impulses.
impulses. In In my
m y experience
experience they they fear that their
fear that their doctor
doctor
 Dealing with
Dealing withSuiddal
SuicidalThoughts andand
Thoughts Feeli�gs
Feelings 243
243

will (1)
will (1) immediately hospitalizethem,
immediately hospitalize them, (2)(2) be be deeply
deeply disappointed
disappointed in them in and
them and
feel that
feel that thethe treatmeD[
treatment plan plan has h a s failed,
failed, or or (3)(3) be b e uncomfortable
u n c o m f o r t a b l e wwith
i t h the
the topic
topic
of
of suicide.
suicide. None N o n e of of these
these predictions
predictions is is entirely
entirely a a distortion
distortion on o n your
y o u r part.
part. InIn
fact, your
fact, y o u r doctor
doctor may m a yindeed
indeed hospitalize
hospitalize you y o uif ifheh eororsheshe feels
feels thethe risk
risk totoyour
your
Hfe is
life is imminent.
i m m i n e n t . Keep
K e e p in
in mind
m i n d that
that this
this maym a y be b e the
the best
best thing
thing for for you.
y o u . Hospi­
Hospi-
talization gives
talization gives you you a a chance
c h a n c e toto get
get emergency
e m e r g e n c y treatment,
treatment, "regroup,"regroup," talk
n to
talk to
others
others who w h o feelfeel the
the same
s a m e as as you,
y o u , and
a n d get
get your
y o u r medication
medication reevaluated
reevaluated and a n d ad­
ad-
justed
justed (see (see also C h a p t e r 9).
also Chapter 9 ) . It
It will
will also
also getget youy o u away
a w a y from
f r o m the
the stimuli
stimuli that that m may
ay
be
b e provoking
p r o v o k i n g your
y o u r suicidal
suicidal thoughts
thoughts (for (for example,
e x a m p l e , certain
certain familyfamily members,
members,
noises, pictures in
noises, pictures in your
y o u r hhome,
o m e , your
y o u r bbedroom,
e d r o o m , certain
certain kindskinds of of mmusic,
u s i c , the tele­
the tele-
phone
p h o n e ringing).
ringing). If If you
y o u dod o gog o into
into thethe hospital,
hospital, at at least
least somes o m e ofof yyour
o u r inpatient
inpatient
treatment
treatment should s h o u l d involve
involve suicidesuicide prevention
prevention planning planning for for the
the interval
interval follow­
follow-
ing
ing your
y o u r discharge.
discharge.
Some
S o m e doctors
doctors are are indeed
indeed more m o r e comfortable
comfortable and a n d effective
effective in in dealing
dealing with with
suicide
suicide risk risk than
t h a n others.
others. If If you
y o u fear
fear that
that youry o u r doctors
doctors (that (that is, is,your
y o u r psychiatrist
psychiatrist
andlor
and/or psychotherapist)
psychotherapist) will will be b e uncomfortable
u n c o m f o r t a b l e with
w i t h your
y o u r disclosure
disclosure of of sui­
sui-
cidal
cidal thoughts,
thoughts, tell tell them
t h e m so.
so. YouY o u may
m a y be b e surprised
surprised at at how
h o w forthcoming
forthcoming they they
are
are inin expressing
expressing their their concern
c o n c e r n for
for you.
y o u . Your
Y o u r therapist
therapist or or medical
medical doctor doctor hhas as
probably
probably had h a d experience
experience with w i t h many
m a n y other
other suicidal
suicidal peoplepeople and a n d wworks
o r k s best
best
when
w h e n heh e oror sheshe knows
k n o w s the
the truth,
truth, even e v e n ifif it
it does
d o e s mean
m e a n reviewing
reviewing a andn d revising
revising
his
his oror her
her treatment
treatment plan. plan. YourY o u r doctors
doctors may m a y indeed
indeed feel feel like
like they haven't done
they haven't done
their
their jobjob right,
right, but b u t itit isn't
isn't your
y o u r responsibility
responsibility to to take
take carecare of of their feelings.
their feelings.
Rather,
Rather, it's it's essential
essential that that youy o u can
c a n beb e open
o p e n with
w i t h them
t h e m about
a b o u t your
y o u r feelings
feelings of of de­
de-
spair.
spair.
Your
Y o u r psychiatrist
psychiatrist is is likely
likely to to reevaluate
reevaluate your y o u r medication
medication regime. regime. Among Among
the
the options
options he
h e or
or she
s h e will
will probably
probably consider
consider is
is adding
a d d i n g an
a n antidepressant
antidepressant to
to
your
y o u r regimen,
r e g i m e n , switching
svdtching to to a a different
different antidepressant
antidepressant if if you
y o u are already o
are already onn
one,
one, increasing
increasing the the dosage
d o s a g e of
of your
y o u r mood
m o o d stabilizer,
stabilizer, or or adding
adding a a second
s e c o n d mood
mood
stabilizer.
stabilizer. In In extreme
e x t r e m e cases
cases he h e or
or she
she maym a y recommend
r e c o m m e n d electroconvulsive
electroconvulsive ther- ther­
apy.
apy. If If you
y o u have
h a v e prominent
p r o m i n e n t anxiety
anxiety symptoms,
s y m p t o m s , agitation,
agitation, or or psychOSiS,
psychosis, your your
doctor
doctor may m a y introduce
introduce an a n antipsychotic
antipsychotic medication medication or or a a benzodiazepine
benzodiazepine (see (see
Chapter 6).
Chapter 6 ) . When
W h e n anxiety
anxiety or or agitation
agitation are are controlled
controlled with w i t h drug
d r u g treatment,
treatment, sui­ sui-
cidal
cidal thoughts
thoughts sometimess o m e t i m e s diminish
diminish (Fawcett (Fawcett et al., 2000).
et aI., 2000).
Try
T r y to
to beb e realistic
realistic abouta b o u t the
the speed
s p e e d with
w i t h which
w h i c h your
y o u r medical treatments are
medical treatments are
likely
likely to to take
take effect.
effect. It It can
c a n be
b e quite
quite frustrating
frustrating to to have
h a v e toto go
g o through
through a a lrial
trial and
and
error
error period
period of of adjusting
adjusting medications
medications and a n d substituting
substituting others others wwhen h e n you're
you're al- al­
ready
ready feeling
feeling hopeless
hopeless and a n d pessimistic.
pessimistic. You Y o u maym a y have
h a v e the
the impulse to give
i m p u l s e to give upup
when
w h e n thethe first
first modification
modification to to your
y o u r medication
medication regime r e g i m e does
d o e s not
n o t immediately
immediately
achieve
achieve the the intended
intended result.result. Your Y o u r state
state of of suicidal
suicidal despair
despair will will almost
almost certainly
certainly
improve
i m p r o v e with
w i t h thethe proper
proper medication
medication adjustments,
adjustments, but b u t itit may
m a y take
take several
several
weeks before before the worst symptoms
the worst symptoms go go away
away (Fawceu
(Fawcett et al., 2000).
et al., Nonethe-
2000). Nonethe-
244
244 SElF-MANAGEMENT
SELF-MANAGEMENT

less, I have
less, been
I have continually
been amazed
continually at the
amazed atdegree to which
the degree whichminor
to even even medi­
minor medi-
cation
cation adjustments
adjustments can can positively
positively affect
affect even
even the most suicidal
the most suicidal person.
person. One One
client
client with
with bipolar
bipolar (mixed)
(mixed) disorder,
disorder,Gerard
Gerard(age 48),tried
(age48), triedLO toasphyxiate
asphyxiatehim­ him-
self
self by
by locking
locking himself
himself in in the
the garage
garage andand turning
turning on on his
his car.
car.After
Afteraabrief
briefhos­ hos-
pitalization,
pitalization, his hisdoctor
doctor added
added Paxil
Paxil(an(anantidepressant)
antidepressant)to tohis
hismood
m o o d stabilizer
stabilizer
regime.
regime. HisHis suicidal
suicidal thoughts
thoughts and and intentions
intentions rapidly
rapidly diminished,
diminished, and and his de­
his de-
pression
pression lifted,
lifted, though
though somewhat
somewhat less lessrapidly.
rapidly.
What
W h a t will
will your
your psychotherapist
psychotherapist do? do? The
The answer
answer depends
depends on on his
his or or her
her
theoretical
theoretical orientation
orientation and and howh o w long
long hehe oror she
she hashas been
been working
working with with you.you.
Most
Most will
will try
try lOto provide
provide emotional
emotional support
support and and teach
teach you
you ways
ways to to handle
handle your your
suicidal impulses (for
suicidal impulses (for example,
example, using using distraction,
distraction, relaxation
relaxation techniques,
techniques, or or
cognitive
cognitive restructuring)
restructuring) to to help
help alleviate
alleviate your
your immediate
immediate pain. pain. Your
Your therapist
therapist
and
and you
you may
m a y examine
examine the the antecedents,
antecedents, behaviors,
behaviors, and and consequences
consequences of of your
your
suicidal
suicidal thoughts
thoughts and and actions
actions (perhaps
(perhaps usingusing different
different tenns).
terms). Many thera­
M a n y thera-
pists,
pists, particularly
particularly those those with
with a a cognitive-behavioral
cognitive-behavioral or or interpersonal
interpersonal orienta-orienta­
tion (see
tion (see Chapter
Chapter 6), 6), view
view suicidal
suicidal thoughts
thoughts or or actions
actions as as occurring
occurring in in aa
context-as
context—as one one response
response in in aa series
series of responses.
of responses.
Certain
Certain events,
events, situations,
situations, images,
images, or or memories
memories may m a y stimulate
stimulate suicidal
suicidal
thoughts
thoughts or or actions.
actions. In turn, these
In turn, these thoughts
thoughts or or actions
actions areare sometimes
sometimes inadver-inadver­
tently
tently rewarded by other people. For Maria, age 39, suicidal thoughts often
rewarded by other people. For Maria, age 39, suicidal thoughts often
came
came up up in
in response
response to food. When
to food. W h e n depressed,
depressed, she she would
would eat eat voraciously
voraciously and and
then look in the mirror, thinking she had grown fat and ugly. It was usually
then look in the mirror, thinking she had grown fat and ugly. It was usually
then
then that
that she
she felt
feltsuicidal.
suicidal.She Shesought
soughtreassurances
reassurancesabout abouther herappearance
appearancefrom from
others at these times, but these reassurances did little to alleviate her suicidal
others at these times, but these reassurances did little to alleviate her suicidal
thoughts.
thoughts. Instead,
Instead, she shewould
would become
become more more suicidal
suicidaland and then
thencallcallmore
morepeoplepeople
for
for reassurance.
reassurance. Maria's Maria's therapist
therapist assisted
assisted her her in in disrupting
disrupting this this chain
chain of of
events by
events by working
working directly
directly with
with her her onon binge
binge eating
eating as as a a means
means of self­
of self-
medicating her
medicating her depression,
depression, developing
developing alternative
alternative thinking
thinking patterns
patterns when w h e n she
she
felt
felt unallractive,
unattractive, and and aVOiding
avoiding the pull to
the pull to seek
seek reassurance
reassurance regarding
regarding her ap­
her ap-
pearance.
pearance. Successfully
Successfully obtaining reassurance from
obtaining reassurance from others,
others, he hebelieved,
believed,was wasin­in-
advertently
advertently reinforcing
reinforcing her her suicidal
suicidal thoughts
thoughts ratherrather than
than alleviating
alleviating her dis­
her dis-
tress.
tress.
Your therapist
Your therapist may m a y also
also bebe able
able toto help
help you
you frame
frame your
your suicidal
suicidal feelings
feelings in in
terms
terms ofof broader
broader life life issues,
issues,suchsuchasasregrets
regretsabout
aboutevents
eventsininthe thepast
pastor orfeelings
feelings
of
of discouragement
discouragement about about your
your future.
future. He H e or
or she
she maym a y help
help youyou understand
understand
your
your suicidal
suicidal impulses
impulses in in terms
terms of of how
h o w they
they relate
relate to to the
the cycling
cycHng of of the bipolar
the bipolar
syndrome.
syndrome. Finally,
Finally, youryourtherapist
therapistcan can help
helpyouyou develop
developaa"safety
"safetyplan,"
plan,"which which
can include
can include calling
calling himhim oror her
her and/or
and/or going
going to the hospital
to the hospital whenw h e n you experi­
you experi-
ence
ence your
your next
next suicidal
suicidal impulse.
impulse. Possibly,
Possibly, he he oror she
she will
wiH invite
invite your family
your family
members
members or or close
close friends
friends to to come to aa session
c o m e to session withwith youyou to to make
m a k e sure they're
sure they're
aware
aware ofof your
your suicidal
suicidal thoughts,
thoughts, and and soso that
that they
they cancan help
help youyou design
design and and PUlput
 Dealing
Dealing with
with Suicidol
SuicidalThoughts
Thoughtsond
andFeelings
Feelings 245
245

into place aamore

into place more detailed
detailed suicide
suicide prevention
prevention plan (discussed
plan (discussed later in later
this in this
chapter,
chapter, pagespages 252-253).
252-253).
M a n y of
Many of these
these interventions
interventions will w H l be
b emost
m o s t powerful
p o w e r f u l in
inthe
the time
time period
period pre­
pre-
ceding
ceding when w h e n you
y o u become
b e c o m e actively
actively and
a n d dangerously
dangerously suicidal. suicidal. Be B e sure to use
sure to use
your first suicidal
y o u rfirst suicidal thoughts
thoughts as as a signal that
a signal that you
y o u nneed to see
e e d to see your physicianaand
y o u r physician nd
therapist on an emergency
therapist o n a n e m e r g e n c y basis.
basis.

S".'egy
Strategy No.
N o . 3:
3 : Use
U s e Your
Your Core
Core Circle
Circle

"When
"When I stan
I start thinking
thinking about abom the future,
the future, I go intoI agopanic,
into and
a panic,
that's and that's
when
w h e n II think
think about
about suicide.
suicide. But
Butsomehow
s o m e h o w when
w h e n IIget
getwith
withother
otherpeople,
people,I I
can
can fantasize
fantasize about about how
h o w things
things could
could be, be, and
and that
that injects
injects some
some energy
energy
into
into mem e .. ....
. . It
It gives
gives me
m e the
the feeling
feeling of
of purpose,
purpose, likelike II have
have some effective­
some effective-
ness
ness oror competence,
competence, like like II can
can channel
channel my m y energy
energy in in aa good
good way.
way. It's
It's not
not
just
just about
about geuing
getting rid
rid of
of loneliness,
loneliness, or or being
being needy.
needy. It's
It's a
a feeling
feeling of
of being
being
able
able toto make
m a k e other
other people
people laugh,
laugh, or
or affecting
affecting other
other people
people inin some
some way,
way,
that
that makes
makes me m e feel
feel alive again."
alive again."
-A
— A 43-year-old
43-year-old man m a n with
with bipolar
bipolar II disorder
disorder

Asknow,
As you you know, one
one theme of theme of is
this book thisthe
book
valueisof
the value
your coreof your of
circle core circle of
family
family members
m e m b e r s anda n d friends
friends in in helping
helping keep k e e p you
y o u well.
well. In In Chapter
Chapter 9 9 II talk
talk
about
about how
h o w members
m e m b e r s ofof your
y o u r core
core circle
circle canc a n help
help keep
k e e p you
y o u from
f r o m escalating
escalating into into
aa full-blown
full-blown manic m a n i c episode.
episode. They T h e y can
c a n also
also be b ehelpful
helpful when w h e n you
y o u are
are feeling
feeling sui­ sui-
cidal.
cidal. For
F o r the
the man
m a n quoted
q u o t e d above,
a b o v e , contact
contact withw i t h other
other people
people was w a s like
like a an antide­
n antide-
pressant,
pressant, giving
giving him h i m temporary
t e m p o r a r y feelings
feelings of of relief
relief from
f r o m painful
painful emotions.
emotions. When When
you
y o u are
are becoming
b e c o m i n g suicidal,
suicidal, contact
contact and a n d support
support from f r o m others
others is is absolutely
absolutely criti- criti­
cal
cal to
to keep
k e e p you
y o u from
f r o m sinking
sinking further.
further.
Be
B e aware
a w a r e that
that you're
you're more m o r e likely
likely to to reject
reject helphelp when w h e n you're
you're mmost o s t dde­
e-
pressed and suicidal (Fawcett et aI., 2000). You will
pressed a n d suicidal (Fawcett et al., 2 0 0 0 ) . Y o u will feel vulnerable at those feel vulnerable at those
times
times anda n d expect
expect others
others to to reject
reject you.
y o u . The
T h e tthought
h o u g h t that
that "I "I can't
can't be b e helped,
helped, I'll I'll
be
b e disappointed,
disappointed, II might m i g h t even
e v e n get
get worse"
w o r s e " will
will go g o through
t h r o u g h your
y o u r mmind,
i n d , contrib­
contrib-
uting
uting to to your
y o u r sense
sense of of hopelessness.
hopelessness. You Y o u may
m a y start
start to to believe
believe that that "I'm
"I'm all all
alone
alone with
w i t h this-no
t h i s — n o one
o n e can
c a n really
really helphelp me."
m e . " It's
It's important
important to to challenge
challenge these these
cognitions
cognitions by b y making
m a k i n g yourself
yourself seek seek support
support from f r o m others,
others, even e v e n if
if doing
d o i n g so
so feels
feels
useless
useless at at first.
first. Evaluate
Evaluate the the evidence
evidence that that being
being with w i t h others
others mmakesakes y youo u feel
feel
worse.
worse. In In all
all likelihood,
likelihood, your y o u r attempts
attempts to to seek
seek assistance
assistance will will generate
generate compas­
compas-
sion
sion ffrom
r o m others,
others, which
w h i c h in
in turn
turn will
will help
help ease
ease your
y o u r pain.
pain.
Start
Start by
by reviewing
reviewing the
the exercise
exercise for
for "Identifying
"Identifying Your
Your Core
Core Circle" in
Circle" in
Chapter
Chapter 8 8 (page 181). Who
(page 181). W h o on
on your
your list
listcan
canhelp
helpyou
you when
w h e n you
you first
firststart
startfeel­
feel-
ing
ing suicidal?
suicidal? If you have
If you have been
been depressed
depressed or
or anxious
anxious for
for some
some time,
time, whom
w h o m have
have
246
246 SElf-MANAGEMfNT
SELF-MANAGEMENT

you relied
you relied on when you
onwhen to "vent"?
needed to
you needed Hasthis
"vent"?Has person
this person these
(or(or people)
these people)
able to
been able
been help you
to help you clarify important issues
clarify important issues and and potential solutions without
potential solutions without
bringing you
bringing you down further? Have
d o w n further? Have you able to
been able
you been feelcloser
to feel closer to to this personas
thisperson as
result of
aa result confiding in
of confiding him or
in him her? One
or her? O n e of the few
of the positive things
few pOSitive about de­
things about de-
pression is
pression that it
is that result in
can resulL
it can making connections
your making
in your connections with others in
with others in ways
ways
you would not
you would not typically initiate.
typically initiate.
In evaluating your
In evaluating list,try
your list, try to think of
to think w h o is
of who likely to
is likely supportive in
be supportive
to be in
ways that
ways would find
you would
thatyou genuinely helpful.
find genuinely helpful. Is there someone
Is there someone on listwho
the list
on the who
can listen to
can listen you talk
to you wanting to
about wanting
talk about without "freaking
die without
to die out"? Some
"freaking out"? S o m e peo­
peo-
ple with
ple disorder find
bipolar disorder
with bipolar find theythey can't discuss these
can't discuss matters with
these matters with their par­
their par-
ents bUl
ents can do
but can do so with a
so with sibling,aafriend,
a sibling, spouse,or
friend,aaspouse, rabbior
oraarabbi priest.The
orpriest. The
relationship you
exact relationship
exact have to
you have person (be
the person
to the (be it m e m b e r or
family member
it family friend) isis
or friend)
probably
probably less important than
less important whether you
than whether trust that
you trust that person
person 10 to listen
listen 10 to you
you
calmly
calmly and attentively and
and attentively acknowledge your
and acknowledge your despair, judgment.ItItisis
withoutjudgment.
despair, without
helpful to
also helpful
also someone whose
choose someone
to choose whose stylestyle is optimistic and
is optimistic hopeful but
and hopeful but also
also
realistic (that is,
realistic (that aware of
is, aware ofthethelimitations imposed by
limitationsimposed by your disorderand
yourdisorder and your
your
environment). Don't
environment). choose a
Don't choose Finally,if
"Pollyanna." Finally,
a "Pollyanna." youare
ifyou closetotoa aperson
areclose person
w h o has
who some understanding
has some understanding of bipolar disorder
of bipolar disorder (see sidebar in
the sidebar
(see the in Chapter
Chapter
12,
12, "A Sheet on
Fact Sheet
Quick Fact
"A Quick on Bipolar Disorder for
Bipolar Disorder for Family Members," on
Family Members, n on pages
pages
260-261), or
260-261), someone who
or someone w h o has gone through
has gone periods of
through periods depression him-
of depression him- or or
herself, personmay
thatperson
herself, that m a y be ableto
beable offeraaunique
tooffer perspectiveon
uniqueperspective ways 10
on ways tocope
cope
with your
with despair.
your despair.
If no
If one on
no one your list
on your reallyfits
listreally fitsthese
these descriptors,
descriptors, trytry choose
[0 to choose thetheperson
person
or persons who
or persons comes the
w h o comes closest. It's
the closest. best to
It's best include on
to include on your as many
list as
your list many
people as
people possible and
as possible and not rely too
not rely heavily on
too heavily on anyany oneone person. Record their
person. Record their
names on
names the Suicide
on the Prevention Plan
Suicide Prevention Plan onon pages 252-253.
pages 252-253.
N o w think
Now about how
think about h o w youyou can can get members of
get members your core
of your core circle
circle to assist
to assist
you. Recall
you. Recall the
the three coping styles
three coping mentioned at
styles II mentioned atthe beginning of
the beginning Chapter 10
ofChapter 10
(emotion-focused,
(emotion-focused, cognitive, cognitive, and coping). First,
distraction coping).
and distraction encourage your
First, encourage your
significam others
significant others to listen to
10 listen you talk
to you talk about thoughts and
your thoughts
about your feelings. Tell
and feelings. TeH
them you
them don't need
you don't need for them to
for them solve all
to solve all of problems or
your problems
of your or ccome
o m e up with
up with
the "bromide"
the "bromide" that will make
that will m a k e allall the pain go
the pain away,but
go away, butyouyoudo needhelp
doneed helpto tofo­fo-
cus on
cus causing you
what's causing
on what's pain and
you pain and why. TherapiSts are
why. Therapists probably best
are probably best atat doing
doing
this, but
this, youhave
ifyou
but if friendor
haveaafriend familymember
orfamily who'saagood
m e m b e rwho's listener,give
goodlistener, givehimhim
or her a chance.
or her a chance.
Second, ask
Second, friend or
your friend
ask your family mmember
or family e m b e r toto help find a
you find
help you way to
a way to prevent
prevent
the immediate
the danger to
immediate danger £0 yourself.
yourself The objective is
The objective keep you
to keep
isto you safe.
safe.IfIfyouyouhave­
have-
n't been able
n't been able toto get yourself to
get yourself call your
to caH doctor or
your doctor therapist, ask
or therapist, your friend
ask your friend 10 to
do so.
do him or
Ask him
so. Ask her to
or her take the
to take weapons or
the weapons or pHls off your
pills off hands. If
your hands. you need
Ifyou need
to go to
to go to the hospital, ask
the hospital, ask himhim or her to
or her accompany you.
to accompany you. If If you won't or
you won't or can't
can't
go to
go hospital, is
the hospital,
to the heor
ishe orshe willingto
shewilling staywith
tostay withyou,you,even overnightififnec-
evenovernight nee-
 Deoling
Dealing with
with Suicidal
SuicidalThoughts
Thoughts andFeelings
and Feelings 247
247

essary, until
essary, until you feel you're
you feel you're out
outof
ofdanger?
danger?If If you
you feel
feel unable
unable to take
to take carecare
of of
your
your kids,
kids, can
c a n that
that person
p e r s o n do
d o it
it temporarily
temporarily or
or help
help you
y o u make
m a k e other
other arrange­
arrange-
ments
ments with
with someone
someone who
w h o can?
can?
Third,
Third, use
use distraction
distraction.. Many
M a n y people
people with
with bipolar
bipolar disorder
disorder are
are concerned
concerned
that talking
that talking about
about their
their painful
painful emotions
emotions will
will be
be a
a burden to others.
burden lO others. If
If you
you are
are
concerned
concerned about
about this,
this, consider
consider increasing
increasing the
the amount
amount of
of low-stress,
low-stress, low­
low-
demand
demand social
social time
time you
you spend
spend with
with your
your Significant
significant others
others or
or friends.
friends. These
These
activities don't
activities don't have
have to
to involve
involve talking
talking about
about your
your struggles.
struggles. Invite them to
Invite them see
to see
a movie
a movie with
with you,
you, go
go for
for aa walk,
walk, take
take aa drive,
drive, have
have dinner,
dinner, or
or read
read together.
together.
Physical
Physical or
or social
social activities
activities that
that have
have a
a degree
degree of
of structure to them
structure lO them and
and involve
involve
other people, such
other people, such as
asthose
thoseon
on your
yourpleasurable
pleasurableactivities
activitieslist
list(Chapter 10),are
(Chapter 10), are
especially
especially important
important to
to do
do right
right now
n o w to
to take
take your
your mind
mind away from your
away from sui­
your sui-
cidal
cidal thoughts.
thoughts.

Be Awa,e
Be Aware of
of Otbers'
Others'Limitations
Limitations

You may
You may feel
feel skeptical
skepticalabout thethe
about ability of members
ability of your
of members of core
yourcircle
core to help to help
circle
you.
you. You
Y o u are
are probably
probably correct
correct that
that if
if the
the people
people you're
you're confiding
confiding in
in do
do not
not
have
have bipolar
bipolar disorder
disorder themselves, they will
themselves, they will not
not be
be able
able to
to fully
fully understand the
understand the
depth
depth of
of your
your depression
depression or
or why
w h y your
your suicidal
suicidal thoughts
thoughts are
are increasing
increasing in fre­
in fre-
quency.
quency. You
Y o u may
m a y become
become distressed
distressed by friends or
by friends or relatives
relatives who seem irritated
w h o seem irritated
with
with you
you and
and insist
insist that
that you
you pull
pull yourself
yourself out
out of
of it.
it.Be
Bepatient
patientwith
withthem.
them.Their
Their
irritation
irritation probably
probably derives
derives from
from anxieties
anxieties about
about your
your fate
fate or
or their frustration
their frustration
at
at not
not being
being able
able to
to help
help more.
more. Likewise,
Likewise, try
try not
not to
to be
be frustrated
frustrated when they
w h e n they
give
give you
you platitudes,
platitudes, which
which people
people often
oftenissue
issuewhen
w h e n they
theycan't
can't think
think of
ofwhat
what
else
else to
to say
say (for
(for example,
example, "We've
"We've got
got only
only one
one life
life to
to live
live and
and we
w e have live it
to live
have to it
[ully").
fully").
Karen, age 35,
Karen, age 35, complained
complained that
that no
no one
one wanted
wanted to
to hear
hear about her depres-
about her depres­
sive
sive or
or suicidal
suicidal feelings.
feelings. Her
Her typical
typical pattern
pattern was
was to
to spend
spend hours
hours with
with others
others
talking
talking about
about her
her sadness
sadness and
and then
then to
to tell
tell them,
them, "Now
" N o w II feel a whole
feel a lot
whole lot
worse."
worse." It
It is
is not
not surprising
surprising that
that her
her friends
friends became
became burned OUl and
burned out didn't
and didn't
want
want to
to help
help her
her anymore.
anymore. It's
It's important
important to
to reward
reward or
or reinforce
reinforce members
m e m b e r s of
of
your
your core
core circle
circle for
for their
their efforts
efforts from
from time
time to
to time.
time. Remember, they are
Remember, they trying
are trying
to
to help,
help, even
even if what they
if what they do
do is
is not
not always
always helpfuL
helpful. They
They need
need to hear from
to hear from you
you
that
that talking
talking to
to them
them or
or simply
simply spending
spending time
time with
with them
them is
is helping
helping you. It
you. It
probably
probably is,
is, even
even if
if only
only minimally,
minimally, and
and it's
it's important
important to
to tell
tell them so.
them so.

Strategy
StrategyNo.
No.4:4:
Reviewing You,
Reviewing Reasons
Your fa, for
Reasons Living
Living

There
There will
will be
be times
times when,
w h e n , alone
alone with
with your
your suicidal
suicidal thoughts
thoughts and
and feelings,
feelings, they
they
begin to ovetwhelm
begin to you. This
overwhelm you. This is
is because
because suicide
suicide is,
is, in
in part, a cognitive
part, a pro-
cognitive pro-
248
248 SElF·MANAGEMENT
SELF-MANAGEMENT

cess. When
cess. people feel
When people feelmost
most desperate,
desperate,they begin
they to to
begin evaluate the pros
evaluate and and
the pros
cons
cons of of suicide
suicide as as a
a means
means of of solving
solving their
their problems.
problems. Suicide
Suicide begins
begins to to feel
feel like
like
a
a more
more viable
viable alternative
alternative whenw h e n you
you believe
believe thatthat nothing
nothing you you do do will
will yield
yield a a
positive
positive outcome,
outcome, or or that
that your
your depression
depression or or other
other life problems will
life problems will always
always
haunt
haunt you. The flip
you. The flip side
side isis that
that you
you will
will bebe most
most protected
protected against
against suicide
suicide if if
you
you believe
believe that you will
that you will be
be able
able toto cope
cope effectively
effectively with
with life's
life's problems,
problems,view view
life
life as
as having
having intrinsic value, or
intrinsic value, or feel that Olhers
feel that others areare dependent
dependent on on your exis­
your exis-
tence (Linehan, 1985;
tence (Linehan, 1985; Strosahl
Strosahl et al., 1992).
et a1., 1992). In In short, people are
short, people are protected
protected
from
from suicide
suicide whenw h e n they
they can
can access
access good
good reasons
reasons to live.
to live.
Marsha
Marsha Linehan
Linehan and and herher associates
associates have have developed
developed an an inventory
inventory of of
"Reasons
"Reasons for for Living"
Living" (see(see the sidebar on
the sidebar page 249).
on page 249). TheThe inventory
inventory was gen­
was gen-
erated
erated by by nonsuicidal
nonsuicidal people people whow h o were
were asked
asked to to write
write down
d o w n the
the reasons
reasons
they
they diddid nOl
not kill
kill themselves
themselves at at aa point
point when
w h e n they
they had previously considered
had previously considered
it, the
it, the reasons
reasons they they would
would not not dodo so so n now,
o w , and
and thethe reasons
reasons they believed
they believed
other
other people
people did did not (Linehan et
not (Linehan al., 1983).
et al., 1983). Linehan
Linehan and and colleagues
colleagues have have
found
found thatthat nonsuicidal
nonsuicidal individuals
individuals endorse
endorse mOTe more items
items on the Reasons
on the Reasons for for
Living
Living Invemory
Inventory than than those
those who
w h o have
have attempted
attempted or or thought
thought seriously
seriously about
about
suicide (Linehan
suicide (Linehan et al., 1983;
et aI., 1983; Osman
O s m a n el al, 1996).
et al., 1996). When people believe
W h e n people believe
they
they cancan overcome
overcome life'slife's problems,
problems, and and when
w h e n they
they feel
feel a a strong
strong sense
sense of of re­
re-
sponsibility
sponsibility to to family
family and and children,
children, they they areare less
less likely
likely to to make
make a a serious
serious
suicide attempt.
suicide attempt.
While
While thisthis logic
logic may
m a y seem
seem obvious,
obvious, it it has
has an implication for
an implication for the
the things
things
you can do on your own when you start to have suicidal thoughts. When peo­
you can do on your o w n w h e n you start to have suicidal thoughts. W h e n peo-
ple
ple are
are suicidal,
suicidal, theytheyusually
usuallyhavehaveaagreat
greatdealdealof oftrouble
troubleaccessing
accessingany anypositive
positive
reasons for being alive (Linehan, 1985). So, when you're feeling well, generate
reasons for being alive (Linehan, 1985). So, w h e n you're feeling well, generate
a llist
a s
i t of
ofyOUT
yourreasons
reasonsfor forliving
livingor orreasons
reasonswhy w h y you
you would
would not notcommit
commit suicide
suicide
if you were staning to think about it. You can then review these reasons when
if you were starting to think about it. Y o u can then review these reasons when
suicide
suicide begins
begins to to feel
feel like
like a a viable
viable option.
option.
Stan
Start by
by checking
checking the the items
items inin the
the inventory
inventory (on page 249)
(on page 249) that
that you be­
you be-
lieve
heve to to be
be true.
true. Then,
Then, in in the
the blank
blank spaces,
spaces, add add your
your own o w n reasons
reasons if if they are
they are
not covered in the other items. Try to do this while you're feeling reasonably
not covered in the other items. Try to do this while you're feeling reasonably
stable
stable and not seriously
and not depressed. When
seriously depressed. W h e n you're
you're depressed,
depressed, your your reasons
reasons forfor
living
living m may
a y be
be harder
harder toto endorse,
endorse, even though you
even though you might
might ordinarily
ordinarily believe in
believe in
them.
them.
You'll
You'll see that the
see that items cover
the items cover aa broad
broad spectrum
spectrum of of reasons,
reasons, including the
including the
belief
behef that you can
that you can cope
cope with,
with, and
and overcome,
overcome, youryour troubles, the value
troubles, the value you
you put
put
on
on life
life itself,
itself,the
thedegree
degreetotowhich
whichyouyoufeel optimistic,
feel optimistic, concerns
concernsrelated
relatedtotoyour
your
family and
family and children,
children, fears
fearsofofdisapproval
disapprovalby by society,
society,moral
moralbeliefs,
beliefs,and
andfears ofof
fears
the suicidal
the suicidal actact itself
itself (Linehan
(Linehan et al, 1983).
et al., 1983). Some
S o m e of
of these
these reasons
reasons may
m a y be
be
mOTe relevant to
more relevant to you
you than
than others.
others. Reviewing
Reviewing the the reasons
reasons you do not
you do not want
want to to
kill
kiH yourself
yourself when
w h e n the
the thought
thought crosses
crosses your
your mind
mind maym a y help
help protect
protect you
you from
from
acting
acting on on aa self-destructive
self-destructive impulse.
impulse.
 THE
T H E REASONS
R E A S O N S FOR
F O R UVING
LIVING INVENTORY
INVENTORY

Check the
check the statements
statements below
below that
that indicate
indicatewhy
why you
you would nor commit
would not commitsuicide
suicide if
if the
the
thought were
thought were to
to occur
occur to
to you or if
you or if someone
someone were
were to
to suggest
suggest it
itto
toyou.
you.

___ II have
have aa responsibility
responsibihty and
and commiunent
commitment to
to my
m y family.
family.
___ II believe
believe II can
can learn
learn to
to adjust to,
adjust to,or
or cope
cope with,
with, my
m y problems.
problems.
___ II believe
believe IIhave
have control
control over
over my
m y life
life and
and destiny.
destiny.
___ II believe
believe only G o d has
only God has the
the right
right to end aa life.
to end life.
II am
a m afraid
afraid of
of death.
death.
___ II want
want to
to watch
watch my
m y children as they
children as they grow.
grow.
___ Life is all
Life is all we
w e have
have and isbener
and is betterthan
than nothing.
nothing.
___ I1 have
have future
future plans
plans IIam
a m looking
looking forward
forward to
to carrying
carrying out.
out.
___ No
N o matter
matter how bad II feel,
h o w bad feel, IIknow thatititwill
k n o w that willnot
notlast.
last.
___ II love
love and
and enjoy
enjoy my
m y family
family too
too much
m u c h and
and could
could not
not leave
leave them.
them.
___ II am
a m afraid
afraid that
that my
m y method
method of
of killing
killing myself
myself would fail.
would fail.
___ II want
want to experience all
to experience all that
that life
lifehas
has to
to offer,
offer,and
andthere
thereare
aremany
m a n y experiences
experiencesII
have
have not
not had
had yet that II want
yet that want to
to have.
have.
___ It
It would
would not
not be
be fair
fairto
toleave
leave the
the children
children for
forothers
others to
to take
take care
care of.
of
II have
have aa love of life.
love of life.
___ II am
a m too
too stable to kill
stable to kill myself.
myself
___ My
M y religious
religious beliefs
beliefs forbid
forbid il.
it.
___ The
The effect
effect on
on my
m y children
children could
could be
be harmful.
harmful.
___ It
It would
would hurt
hurt my
m y family
family too
too much
m u c h and
and II would
would not
notwant
want them tosuffer.
them (0 suffer.
___ II am
a m concerned
concerned about
about what
what others
others would
would think
think of
of me.
me.
___ II consider
consider it
itmorally
morallywrong.
wrong.
___ II still
stillhave
have many
m a n y th ings left
things left to
to do.
do.
___ II have
have the
the courage
courage to
to face
face life.
life.
___ II am
a m afraid
afraid of
of the
the actual
actual "act"
"act" of
of killing
killing myself
myself (the
(the pain,
pain,blood,
blood, violence).
violence).
___ II believe
believe killing
killing myself
myself would
would not
not really
really accomplish
accomplish or
or solve
solve anything.
anything.
___ Other
Other people
people would
would think
think II am
a m weak
weak and selfish.
and selfish.
___ II would
would not
not want
want people
people to think II did
to think did not
not have
have control
control over
over my
m y life.
life.
� II would
would not
not want
want my
m y family
family to
to feel
feelguilty
guilty afterward.
afterward.

List
List other
other reasons
reasons for living.
for living.

Adapted
Adapted by
by pennission rrom
permission from Lint-han
Linehan et
etal.
al.(1983).
(1983).Copyright
Copyright1983 byby
1983 the American
the Psychological
American Asso­
Psychological Asso-
ci
ation.
ciation.
250
250 SElF-MANAGfMfNT
SELF-MANAGEMENT

StrategyNo.
SIralegy "Improv
No.S:5: "Improving Mom.nr'
ing Ihethe Tools
Moment" Tools

Some people
Some people feelfeel thatthattheir
theirsuicidal
suicidaldespair is always
despair in the background
is always in the background even even
when they distract
w h e n they themselves from
distract themselves from it.it. Suicide prevention can
Suicide prevention can include learn­
include learn-
ing to
ing feelings of
tolerate feelings
to tolerate despair when
of despair you can't
w h e n you them go
m a k e them
can't make away. What
go away. What
follows are
follows "improving the
some "improving
are some strategies for
m o m e n t " strategies
the moment" tolerating your
for tolerating your dis­
dis-
tress Linehan, 1993).
(after Linehan,
tress (after 1993).
Many people turn
M a n y people turn to they are
w h e n they
religion when
to religion alone and
are alone depressed and
feel depressed
and feel and
suicidal. For
suicidal. religion is
some, religion
For some, practiced in
best practiced
is best group settings
in group like aa church,
settings like church,
synagogue,
synagogue, or temple, but
or temple, but others prefer solitary
others prefer prayer. For
solitary prayer. some, praying
For some, praying for for
strength gives
strength them a
gives them sense of
a sense purpose and
of purpose Likewise, some
belonging. Likewise,
and belonging. some people
people
find spiritual readings
find spiritual because they
helpful because
readings helpful they put suffering into
put suffering into a larger perspec­
a larger perspec-
tive.
tive. For readingsby
example,readings
Forexample, bythe DalaiLama
theDalai L a m a seem inspirationalto
quiteinspirational
seem quite topeo­
peo-
ple in pain
ple in pain (The
(The Art Art o j Happiness
of Happiness by Lama &
by Lama Cutler, 1998,
& Cutler, 1998, or Ethics for
or Ethics for the
the
N e w Millenium
New Millenium by Lama, 1999).
by Lama, 1999).
If
If your depressed and
your depressed feelings are
suicidal feelings
and suicidal accompanied by
are accompanied Significant
by significant
anxiety, you
anxiety, you may fromself-relaxation
benefitfrom
m a y benefit exercises.Usually,
self-relaxationexercises. Usually, relaxation
relaxation in­in-
sitting in
volves sitting
volves in aa comfortable tensingand
chair; tensing
comfortable chair; relaxingeach
and relaxing each of yourmuscle
of yOUT muscle
groups, starting with
groups, starting with your feet and
your feet moving up
and moving up to your face;
to your imagining re­
and imagining
face; and re-
laxing, pleasant
laxing, scenes (for
pleasant scenes example, lying
(for example, lying on on a a beach). Relaxation exercises
beach). Relaxation exercises
often decrease the
often decrease anxiety and
the anxiety agitation that
and agitation accompany suicidal
that accompany thoughts.
suicidal thoughts.
Consult
Consult books books that you step-by-step
give you
that give instructions on
step-by-step instructions h o w to
on how relax and
to relax and
breathe more
breathe easily as
more eaSily well as
as well as h o w to
how your own
create your
to create relaxation tapes
o w n relaxation (for ex­
tapes (for ex-
Craske, 2001;
ample, Craske,
ample, Davis et
2001; Davis al., 2000;
et aI., Wilson &
2000; Wilson Wilson, 1996).
& Wilson, 1996).
For others,
For exercise is
others, exercise helpful. Many
is helpful. M a n y people report that
people report m o o d im­
their mood
that their im-
proves significantly and
proves Significantly and suicidal
suicidal thoughts diminish after
thoughts diminish they have
after they exercised.
have exercised.
course, it's
Of course,
Of hard to
it's hard togo work out
and work
go and outwhen you feel
w h e n you low in
feellow energy,apathetic,
inenergy, apathetic,
or hopeless. Try
or hopeless. Try some light exercise
some light exercise if if you feel especially
you feel lethargic, such
especially lethargic, such as as
walking, stretching, or
walking, stretching, ridingaastationary
orriding bicyclefor
stationarybicycle minutes.When
fewminutes.
foraafew W h e n ex­
ex-
ercising, focus
ercising, focus your attention on
your attention your body
on your body andand thethe physical sensations that
physical sensations that
accompany the
accompany the movement.
movement.
experience of
your experience
IIff your any of
of any these "improving
of these "improving the the moment" tasks is
m o m e n t " tasks is posi­
posi-
tive, consideradding
tive, consider adding themthem to toyour activationlist
behavioralactivation
yourbehavioral (Chapter 10).
list(Chapter 10). It's
It's
important
important to to try more than
these more
try these once and
than once m a k e them
and make them a a part
part of regular
your regular
of your
routine to maximize
routine maximize their impact.
their impact.

Developing a Sui,ide
Developing a Prevention Plan
Suicide Prevention Plan

Nowtry
Now putall
to pul
try to allof this information
of this together
information together into a prevention
imo a suicide plan.
suicide prevention plan.
The sidebar
The on pages
sidebar on pages 252-253 can be
252-253 can used as
be used a template.
as a the beginning
At the
template. At of
beginning of
the exercise, list
the exercise, prodromal signs
your prodromal
list your signs of depresSion (see
of depression exercises in
the exercises
(see the in
 withSuicidal
Dealingwith
Dealing SuicidalThoughts andand
Thoughts Feelings
Feelings 2S1
251

Chapter 10).Be
Chapter 10). list any
suretotolist
Besure suicidal thoughts
any suicidal thoughtsoror impulses,
impulses, including
including those
those
that seem
that s e e m fleeting or insignificant
fleeting or e x a m p l e , "1
(for example,
insignificant (for "1 start a b o u t dying,
thinking about
start thinking dying,
but
but [I would anything about
d o anything
never do
w o u l d never T h e n , examine
it"). Then,
a b o u t it"). e x a m i n e the of self­
list of
the list self-
all of
strategies, all
m a n a g e m e n t strategies,
management of which h a v e been
w h i c h have described in
b e e n described the prior
a n d the
this and
in this prior
chapter. Circle
chapter. Circle those items that
those items like reasonable
s e e m like
that seem for you
things for
reasonable things a n d others
y o u and others
to d o when
to do experience suicidal
y o u experience
w h e n you or other
thoughts or
suicidal thoughlS other signs of depression.
signs of depression.
share this
N e x t , share
Next, exercise with
this exercise doctor/therapist and
y o u r doctor/therapist
w i t h your the members
a n d the of
m e m b e r s of
your core circle,
your core a n d see
circle, and ifthey'd
see if b e willing
they'd be to perform
willing to these tasks,
p e r f o r m these s h o u l d you
tasks, should you
go into aa cr
g o into isis. If
crisis. friend or
If aa friend family member
or family is not
m e m b e r is w i H i n g to
n o t willing accept responSi­
to accept responsi-
bility for a
bihty for given item
a given (for example,
item (for of your
care of
taking care
e x a m p l e , taking calling your
kids, calling
y o u r kids, y o u r ther­
ther-
apist) consider assigning
apist) consider task to
that task
assigning that person. List
another person.
to another each member
List each of
m e m b e r of
your core circle
your core the end
at the
circle at of the
e n d of exercise and
the exercise w h i c h items
indicate which
a n d indicate the list
o n the
items on list
can be
can to him
assigned to
b e assigned or her.
h i m or her.
Keep suicide prevention
y o u r suicide
K e e p your plan in
prevention plan place that
in aa place readily accessible
is readily
that is to
accessible to
members y o u r core
of your
m e m b e r s of circle. It
core circle. m a y make
It may sense to
m a k e sense attach ititto
to attach m a n i a pre­
y o u r mania
toyour pre-
contract (Chapter
vention contract
vention (Chapter 99).
).

* * *

Suicide is
Suicide p e r m a n e n t solution
"a permanent
is "a to a
solution to t e m p o r a r y problem"
a temporary et aI.,
(Fawcett et
p r o b l e m " (Fawcett al.,
:WOO,
2 0 0 0 , p. 1 4 7 ) . But
p. 147). B u t the intolerable feelings
the intolerable that go
feelings that along with
g o along suicidal preoccu­
w i t h suicidal preoccu-
pations c a n be
pations can so painful
b e so feel permanent.
they feel
that they
painful that to combat
important to
It's important
p e r m a n e n t . It's combat
these states
these with a
states with of self-management
variety of
a variety tools to
s e l f - m a n a g e m e n t tools help activate
to help yourself,
activate yourself,
view circumstances from
y o u r circumstances
view your alternate perspectives,
f r o m alternate a n d reengage
perspectives, and w i t h iim­
reengage with m-
portant sources
portant of emotional
sources of a n d practical
e m o t i o n a l and T r y to
support. Try
practical support. be
to b up
eu front with
p front with
your doctor and
your doctor therapist about
a n d therapist a b o u t yyour
o u r suicidal impulses and
suicidal impulses a n d take into consid­
take into consid-
eration
eration their for emergency
r e c o m m e n d a t i o n s for
their recommendations treatment. MMost
e d i c a l treatment.
e m e r g e n c y mmedical o s t of all,
of all,
remain
r e m a i n hopeful y o u r most
that your
hopeful that depressive symptoms
severe depreSSive
m o s t severe will eventually
s y m p t o m s will eventually
disappear
disappear and y o u will
that you
a n d that return to
will return a more
to a tolerable emotional
m o r e tolerable state. It's
emotional state. It's
hardest to
hardest o u r way
see yyour
to see out when
w a y out y o u have
w h e n you hit bbottom,
h a v e hit so try
o t t o m , so to iimplement
try to as
m p l e m e n t as
m a n y of
many strategies as
these strategies
of these possible wwhen
as possible y o u experience
h e n you the first
experience the signs of
first signs de­
of de-
pression
pression or suicidal despair.
or suicidal despair.
The final chapter
T h e final offers a
chapter offers different wwindow
a different the question
o n the
i n d o w on question of self-man­
of self-man-
aagement:
g e m e n t : how o p e effectively
to ccope
h o w to effectively in your
in y family a
o u r family and o r k eenvironments
n d wwork after
n v i r o n m e n t s after
bipolar illness
aa bipolar episode. People
illness episode. w i t h bipolar
People with disorder often
bipolar disorder experience trou­
often experience trou-
ble in bboth
ble in settings—trouble nnot
o t h settings-trouble entirely ddue
o t entirely to their
u e to own
their o behavior. MMany
w n behavior. of
a n y of
problems
their p
their derive ffrom
r o b l e m s derive r o m others' having an
others' having inadequate understanding
a n inadequate of the
understanding of the
disorder the eexample
(see the
disorder (see Martha
of M
x a m p l e of a r t h a in Chapter
in C 1). I1 discuss
h a p t e r 1). discuss several strategies
several strategies
that will
that help yyou
will help feel eempowered
o u feel m p o w e r e d in negotiating yyour
in negotiating o u r family, n d work
social, aand
family, social, work
relationships. As
relationships. A s you've seen tthroughout
you've seen this bbook,
h r o u g h o u t this a n a g i n g yyour
o o k , mmanaging disorder
o u r disorder
involves acquainting
involves others wwith
acquainting others i t h the facts aabout
the faclS b o u t it and
it a n d being yourself oon
clear yourself
being clear n
what will,
what and will
will, and helpful1O
be helpful
not, be
willnot, your recovery.
toyour recovery.
 SUICIDE
SUICIDE PREVENTION
P R E V E N T I O N PLAN
PLAN

list
Listyour
yourtypical early
typical warning
early signs
warning of a depressive
signs episode.
of a depressive episode.

Circle
Circle the
the things you can
thingsyou can do
do if
ifone
oneor
ormort':
moreof ofthese
theseearly
earlywarning
warningsymptoms
symptomsappear, orifif
appear,or
you
you have
have suicidal
suicidal thoughts
thoughts or
or impulses.
impulses.

L Get
1. Get rid
rid ofofallall
dangerous
dangerousweapons
weapons
2. Call
2. Call your
your psychiatrist
psychiatrist and
and psychotherapist
psychotherapist toto ask
ask for
for an
an emergency
emergency appointment
appointment
3. Implement
3. Implement your your behavioral
behavioral activation
activation plan
plan by
by scheduling
scheduling rewarding
rewarding or
or distracti
ng
distracting
activities
activities
4. Challenge
4. Challenge negative
negative thoughts
thoughts through
through cognitive
cognitive restructuring
restructuring
5. Ask
5. Ask your
your core
core circle
circle of
of friends
friends and
and family
family members
members forfor support
support
6. Practice
6. Practice relaxation
relaxation techniques
techniques
7. Exercise
7. Exercise
8. Rely
8. on input
Rely on input from
from religious
religious and
and spiritual
spiritual sources
sources
9. Review
9. Review your
your reasons
reasons for
for living
living inventory
inventory

Circle the
Circle thethings your
things doctor
your and and
doctor t,herapist can do.
therapist can do.

L
1. See
See you
you on
on an
an emergency
emergency basis
basis
2.
2. Modify
Modify your
your medication
medication regimen
regimen
3.
3. Arrange
Arrange aa hospitalization
hospitalization (if
(if necessary)
necessary)
4.
4. Help
Help you
you understand
understand where
where your
your suicidal
suicidal thoughts
thoughts are
are coming
coming from
from and
and what
what
effects
effects they
they are
are having
having on
on you
you or
or others
others
5. Work
5. W o r k with
with you
you on
on behavioral
behavioral strategies
strategies for
for handling
handling your
your painful
painful thoughts
thoughts and
and
emotions
emotions

Circle those
Circle thosethings that
things members
that of of
members your corecore
your can do.
circlecircle can do.

1.
1. Listen
Listen to
toyou,
you,validate your
validate feelings,
your and offer
feelings, and suggestions
offer suggestions
2.
2. Avoid
Avoid being
being critical
critical or
or judgmental
judgmental
3.
3. Distract
Distract you
you through
through mutually
mutually enjoyable
enjoyable activities
activities
4.
4. Help
Help you
you take
take care
care of
of responsibilities
responsibilities that
that have
have become
become burdensome
burdensome or
or difficult to
difficult to
perfonn
perform (for
(for example,
example, child
child care)
care)
5.
5. Stay
Stay with
with you
you until
until you
you feel
feel safe
safe
6.
6. Call
Call your
your doctor
doctor to
to help
help you
you arrange
arrange an
an appointment
appointment
7.
7. Take
Take you
you to
to the
the hospital
hospital (if
(ifnecessary)
necessary)
8.
8. Agree
Agree to
to store
store your
your weapons
weapons or
or pills
pills away
away from
from you
you

252
252
list
List members
members of
ofyour
yourcore
corecircle
circleand
andput
putnumbers
numbersafter
aftereach
eachindicating
indicatingwhich
which of itemsI­
ofitems 1-
S
8 they
they are
are willing
willing to
to perfonn
perform (list
(listmore
more than
thanone item,ififappropri
oneitem, ate).
appropriate).

List
List your
your doctors'
doctors'names
names and
and phone
phone numbers.
numbers.

2S3
253
 11 2 2

Coping
C o p i n g Ef
E f fectively
f e c t i v e l y in
i n the
t h e Family
F a m i l y

and
a n d Work
W o r k Settings
Settings

h o m e and
home
B
and at
iPolar disorder
B .'ipolar
at work.
disorder poses
work. When
W h e n your
poses significant
your family
significant challenges
family members
challenges for
members firstfirst learned
for daily
daily life,
learned about
life,both
aboutyour
bothat
your disor­
disor-
at

der,
der, they
they may
m a y have
have been
been supportive,
supportive, intrusive,
intrusive, anxious,
anxious, or or angry.
angry. Some
S o m e may
may
have
have been
been eager
eager to to help,
help, while
while others
others subjected
subjected you you to to overt
overt rejection.
rejection. ButBut
even after
even after everyone
everyone has has seemed
seemed to to adjust
adjust to
to life
life with
with bipolar
bipolar disorder
disorder in in the
the
family,
family, difficulties
difficulties often
often reappear
reappear with with the next bipolar
the next episode.
bipolar episode.
Likewise,
Likewise,you you may
m a y experience
experiencefrustration
frustrationin inthe
thework
work setting.
setting.Perhaps
Perhapsyou you
want
want La to work
work and and be be productive,
productive, but but you
you don't
don't k know
n o w how
h o w to
to deal
deal with
with thethe
stigma
stigma of of the
the disorder,
disorder, the the lack
lack of
of understanding
understanding by by employers
employers or or coworkers,
coworkers,
or
or workplace
workplace demandsdemands that that are
are incompatible
incompatible with with your
your attempts
attempts to to manage
manage
your
your illness.
illness. FromF r o m many
m a n y research
researchstudies
studieswew e know
k n o w that
thatthethesymptoms
symptoms of ofbipo­
bipo-
lar
lar disorder
disorder affect
affect a a person's
person's ability
ability toto function
function in in the
the family
family oror work setting
work setting
(CoryeH el
(Coryell et aI., 1993; Dion
al., 1993; Dion et et aI., 1988; Goldberg
al., 1988; Goldberg et al., 1995;
et aI., Miklowitz &:
1995; Miklowitz &
Goldstein,
Goldstein, 1997).1997). TheThe good
good newsnews is is that
that you
you cancan learn
learn to to negotiate
negotiate thethe con­
con-
flicts
flicts andanddemands
demands of of
youryourfamily
family andandwork lifelife
work through
through a variety of communi­
a variety of communi-
cation
cation skills
skills andand self-care strategies.
self-care strategies.
Remember
R e m e m b e r Martha
Martha (Chapter
(Chapter 1)? 1)? After
After her
her manic
manic episode
episode and hospitaliza­
and hospitaliza-
tion, her children became suspicious, withdrawn, and fearful. Her husband
tion, her children became suspicious, withdrawn, and fearful. Her husband
acted rejecting
acted rejecting at at some
some points
points andand overprotective
overprotective at at others, before he
others, before he came
came to to
aa better
better understanding
understanding of
of the
the disorder
disorder through
through their
their couples'
couples' counseling.
counseling.Back
Back
at
at her
her computer
computer programming
programming job,
job, Martha
Martha had
had problems
problems concentrating.
concentrating. She
She
found
found the
the computer
computer screen
screen newly
newly confUSing
confusing and
and forgot how
forgot h o w to
to use
use the pro-
the pro-

254 254
 Coping
Coping Effectively
Effectivelyininthe
theFomily ondand
Family W()rk
WorkSettings
Settings 2SS
255

grams
grams she shehad had been
been so so expert
expert at using
at using before.
before. Her quickly
Her boss boss qUickly became became
impa- impa�
tient
tient withw i t h her
h e r lower
l o w e r performance.
p e r f o r m a n c e . Her
H e r coworkers
c o w o r k e r s avoided
avoided h her
e r and
a n d even
even
seemed
s e e m e d nervous
n e r v o u s in
in her
h e r presence
presence after after learning
learning of of her
her difficulties.
difficulties.
If
If you've
you've recently
recently recovered
recovered from from a a manic,
m a n i c , mixed,
m i x e d , or
or depressive
depressive episode,episode,
m a y feel
y o u may
you feel ready
ready to to reintegrate
reintegrate yourselfyourself into into the the family
family and a n dthethe workplace,
workplace,
only
only to to find
find that
that those
those you y o u live
live anda n d work
w o r k with
w i t h don't
don't treat
treat youy o u thethe w way
a y they
they
used to.
used to. Your
Y o u r loved
loved ones o n e s may
m a y become
b e c o m e angry
a n g r y and
a n d critical
critical or or overprotective.
overprotective.
Your
Y o u r partner
partner may
m a y seem
s e e m hesitant
hesitant to
to reestablish
reestablish intimacy
intimacy with
w i t h you.
y o u .A Att wwork
o r k yyou
ou
m a y feel
may feel like
like "It's
"It's thethe same
s a m e oldold menm e " butb u t get
get thethe impression
impression that that youry o u r col­
col-
leagues don't
leagues don't see see it it that
that way.
w a y . And
A n d if if you
y o u really
really do d o need
n e e d toto adjust
adjust your y o u r work
work
setting
setting and a n d work
w o r k routines
routines to to help
help you y o u maintain
maintain mood m o o d stability,
stability, h howo w much
m u c h ccan
an
you
y o u tell
tell them
t h e m about
a b o u t your
y o u r disorder
disorder and a n d still
still get
get them
t h e m toto treat
treat youy o u as the confi­
as the confi-
dent,
dent, competent
c o m p e t e n t person
p e r s o n you
y o u were
w e r e before?
before?
These
T h e s e issues
issues posep o s e undeniable
undeniable challenges,
challenges, but b u t II have
h a v e been
b e e n continually
continually iim­ m-
pressed
pressed with with how h o w effectively
effectively people people with w i t h bipolar
bipolar disorder
disorder can c a n learn
learn to to deal
deal
with
with them.
t h e m . Establishing
Establishing close close family
family or or couple
couple relationships
relationships is is pOSSible
possible even even
after
after the
the mmosto s t severe
severe of of mood
m o o d disorder
disorder episodes.
episodes. So S o is
is reclaiming
reclaiming successful
successful
w o r k lives
work lives anda n d reaching
reaching career career aspirations.
aspirations. As A s you'll
you'll soons o o n see,
see, maintaining
maintaining
successful
successful family family and a n d work
w o r k relationships
relationships has has a a 101
lot toto do
d o with
w i t h how
h o w youy o u educate,
educate,
communicate,
c o m m u n i c a t e , and
a n d solve
solve problems
p r o b l e m s with
w i t h others
others as as they
they go g o through
t h r o u g h their inevi­
their inevi-
table
table upsu p s and
a n d downs
d o w n s in in reacting
reacting to to your
y o u r disorder.
disorder.

"What
"What Family
Family Problems
Problems Might
Might II Encounter
Encounter
alter
after an
an Illness
Illness Episode?"
Episode?"

During
During your
your period
periodofofrecovery,
recovery,your close
your relatives
close are going
relatives are to have to
going confus­
have confus-
ing
ing feelings
feelings about
about your
your illness
illness and
and confuSing
confusing thoughts about how
thoughts about h o w to
to help you.
help you.
In
In the
the following
following sections
sections II explore
explore the
the most
most common
c o m m o n problems that may
problems that arise.
m a y arise.

Negalive Emolional
Negative Emotional Rea,'ions
Reactions 'rom
from YourYour Re/alives
Relatives

Randy,
Randy, a 45-year-old
a 45-year-old plumber, plumber,
had two had two of
episodes episodes
depression of depression
and several and several
hypomanic
h y p o m a n i c episodes.
episodes. His H i s most
m o s t recent
recent episode,
episode, a a depreSSion,
depression, led to the
led to the loss
loss
of
of his
his job.
job. HisH i s wife,
wife, Cindy,
C i n d y , had
hada a rrudimentary
u d i m e n t a r y understanding
understanding of of bipolar
bipolar
disorder
disorder but b u t was
w a s fairly
fairly intolerant
intolerant of of his
his apparent
apparent inability
inability to to function.
function. She She
frequently
frequently spoke s p o k e to
to him
h i m inin derogatory
derogatory psychiatric
psychiatric lingo: lingo: "That's
"That's your
y o u r mma­
a-
nia
nia talkingn;
talking"; "Last
"Last night
night whenw h e n wew e got
got into
into thatthat argument,
a r g u m e n t , you
y o u were
w e r e totally
totally
rapid
rapid cycling"
cycling";; "You're
"You're doing
d o i n g your
y o u r ADD
A D D [attention
[attention de£icit deficit disorder!
disorder] thing thing
again.n
again." In In marital
marital sessions,
sessions, however,
h o w e v e r , Cindy
C i n d y revealed
revealed that that she
she really
really didn't
didn't
believe
believe his his mood
m o o d problems
p r o b l e m s were
w e r e of
of a a biological
biological origin. origin. She S h e bblamed
l a m e d them
them
256
256 SElf·MANAGfMfNT
SELF-MANAGEMENT

on his
on his "crazy,
"crazy, dysfunctional
dysfunctional family,"his
family," his "temperamental
"temperamentalnature,"nature," and
and
"unconscious,
"unconscious, unresolved
unresolved stuff
stuff with
with mc."
me." She also wasn't
She also wasn't convinced
convinced by by
the
the genetic
genetic evidence
evidence that
that Randy's
Randy's father
father had
had hadhad bipolar
bipolar disorder.
disorder.
Their
Their debates
debates about
about the
the causes
causes ofof his
his behavior
behavior tended
tended toto degenerate
degenerate
into
into escalating
escalating interchanges
interchanges in in which
which Cindy
Cindy would
would berate
berate Randy
Randy andand he
he
would
would try try to
to defend
defend himself.
himself. He
H e typically
typically ended
ended up up agreeing
agreeing with
with hcr,
her,just
just
to
to stop
stop the
the argument,
argument, but but then
then would
would feel
feel resentful
resentful andand withdraw
withdraw to to pun­
pun-
ish
ish her.
her. Annoyed
Annoyed at at his
his withdrawal,
withdrawal, sheshe would
would continue
continue her
her atr.ack later
attack later
with
with thethe accusation
accusation that
that "You've
"You've never
never been
been able
able to
to deal
deal with
with things di­
things di-
rectly."
rectly." He
H e began
began toto consider
consider going
going off
off his
his medications
medications justjust to
to prove
prove "that
"that
II can
can deal
deal with
with all
all of
of this
this without
without anyone
anyone or or anything'S
anything's help."
help."

Why Why is Cindy

is Cindy so angry?
so angry? Most
Most of the
of the familymembers
family members I haveworked
I have worked with
with
are
are well-intentioned,
well-intentioned, caring
caring peopJe
people who honestly want
w h o honestly want to
to do
do what's
what's best for
best for
their
their bipolar
bipolar relative.
relative.But
Butthey
theydon't
don'talways
alwaysknow
k n o w what
what to
todo
dowhen
w h e n their
theirbipo­
bipo-
lar
lar relative
relative reacts
reacts negatively
negatively to
to their
their attempts
attempts to
to help.
help. They
They end
end up feeling
up feeling
frustrated and burdened
frustrated and burdened by
by the
the effort
effort reqUired
required of
of them
them to
to adapt
adapt to
to the disor­
the disor-
der,
der, and
and then
then often
often say
say and
and do
do things
things that
that are
are critical
critical or
or unhelpful.
unhelpful.
Your
Your relatives'
relatives' reactions
reactions to
to your
your disorder,
disorder, particularly
particularly during
during the
the period
period
when
w h e n you
you are
are recovering,
recovering, often
often reflect
reflect the
the same
same styles
styles of
of coping
coping or
or "causal
"causal at­
at-
tribution"
tribution" that
that you
you used
used at
at various
various stages
stages of
of adjusting
adjusting to your illness
to your (see
illness (see
Chapter 4): Underidentif
Chapter 4): ying with
Underidentifying with the
the disorder
disorder (attributing
(attributing your
your behavior
behavior
changes
changes to
to your
your personality
personality or
or habits)
habits) or overidentifyingwith
oroveridentifying withitit(attributing
(attributingall
all
or
or most
most of
of your
your behaviors,
behaviors, even normal ones,
even normal ones, to
to your
your illness).
illness). Highly critical
Highly critical
relatives
relatives are
are often
often underidentifying
underidentifying you
you with
with the
the disorder,
disorder, as
as Cindy
Cindy was do­
was do-
ing.
ing. They
They may
m a y believe
believe that
that your
your biologically
biologically based,
based, illness-related
illness-related changes in
changes in
behavior—including any
behavior-including any residual
residual mood
m o o d swings
swings from
from your
your last
last episode that
episode that
haven't cleared
haven't cleared up
up yet-are
yet—are really caused by
really caused by your
your character
character or
or morals,
morals, your
your
unconscious
unconscious motivations,
motivations, or
or your
your lack
lack of
of effort.
effort. If
If a
a family
family member
m e m b e r believes
believes
that
that these
these factors
factors play
play a
a causal
causal role,
role, he
he or
or she
she will
will also
also believe
believe that
that you
you have
have
more
more control
control over
over your
your mood
m o o d swings
swings than
than you
you really
really do.
do. Your relative may
Your relative may
then
then become
become angry
angry and
and critical
critical (Hooley,
(Hooley, 1987).
1987).

Overprolectiveness
Overprotectiveness

Alternatively,
Alternatively, you may
you mayfind that
find your
that relatives
your want want
relatives to watch you care­
you very
to watch very care-
fully
fuHy and
and manage
manage your
your disorder
disorder to
to the
the point
point where
where you
you feel
feel you're
you're being
being
treated
treated like
like aa child
child (overprotectiveness
(overprotectiveness or
or overinvolvement). Relatives who
overinvolvement). Relatives who
are
are overprotective
overprotective often
often tend
tend to
to overidentify
overidentify you
you with
with the
the disorder,
disorder, or label
or label
your
your everyday
everyday reactions
reactions as
as signs
signs of
of your
your illness. For example,
Hlness. For example, they
they say
say that
that
your
your illness
illness is
is reflected
reflectedin
ingetting
gettingangry
angryabout
aboutthings
thingsyou
you might
mightvery wellhave
verywell have
 (oping
Coping Effectively
Effectively in
in the
the Family
Family and
and Work
Work Settings
Settings 2 257
57

gotten
gotten angry
angryabout
aboutbefore
beforeyou
youbecame
became ilL Sometimes
ill. you
Sometimes and
you they
and areare
they both
both
right-your
right—^your anger
anger may
m a y be
be stimulated
stimulated by
by real
real things,
things, but
but your
your disorder
disorder makes
makes
you
you react
react with
with a
a level
level of
of emotional
emotional intensity
intensity that
that is
is out
out of
of proportion
proportion to
to the
the
circumstances. Nonetheless,
circumstances. Nonetheless, you
you may
m a y begin
begin to
to register
register that
that their
their labeling of
labeling of
your
your behavior
behavior makes
makes you
you feel worse. Relatives
feel worse. Relatives may
m a y remind
remind you
you repeatedly to
repeatedly to
take
take your
your medication,
medication, tell
tell you
you to
to communicate
communicate with
with your
your doctor
doctor or therapist
or therapist
about
about minor
minor problems
problems you
you have
have at
at home
h o m e or
or at
at work,
work, or
or even
even go
go behind
behind your
your
back to
back to talk
talk with
with your
your physician.
physician.
You may
You m a y even find, as
evenfind, as some
s o m e of
of my
m y clients
clients have
have found,
found, that
that when
w h e n you con­
you con-
frontyour
front your relatives
relativesabout
about their
theiroverprotectiveness,
overprotectiveness,they
theyuse
useyour
yourbipolar
bipolardiag­
diag-
nosis as
nosis as a
a weapon
w e a p o n against
against you.
you. For
For example,
example, you
you might
might express
expressannoyance
annoyance at
ataa
relative for
relative for asking
asking too
too many
m a n y questions
questions about
about your
your medication,
medication, only
only to
to have
have
him or
him or her
her tell
tell you
you that
thatyour
yourreaction
reactionis
is aasign
signof
of your
your illness.
illness.You
Y o ucan
cangel
getinto
into
a
a vicious
vicious cycle
cycle in
in which
which you
you complain
complain about
about their
their intrusiveness,
intrusiveness,your
yourrelatives
relatives
react
react as
as if
if you
you are
are cycling
cycling into
into an
an episode,
episode, you
you get
getmore
more annoyed
annoyed with
with their
theirla­
la-
beling
beling of
of you
you as
as mentally
mentally ill,
ill, their
their beliefs
beliefs about
about your
your cycling
cycling become
become more
more
confirmed,
confirmed, and
and then
then they
they become
become more protective.
more protective.

Prohlems with
Problems withIntimacy
Intimacy

Nowlet's
Now let's consider
considera different kindkind
a different of emotional reaction
of emotional that often
reaction thatarises
oftenbe­arises be-
tween
tween spouses
spouses or
or romantic
romantic partners
partners during
during the
the recovery
recovery period:
period: a
a discomfort
discomfort
with
with physical
physical intimacy
intimacy in
in your
your partner's
partner's relationship
relationship with you. Your
with you. Your spouse's
spouse's
discomfort
discomfort may
m a y not
not be
be associated
associated with
with criticism
criticism or
or overprotectiveness; in­
overprotectiveness; in-
s.tead, you may
stead,you m a y experience
experiencehim
h i m or
orher
heras
asemotionally
emotionallywithdrawn.
withdrawn.Physical
Physicalinti­
inti-
macy
macy may
m a y have
have stopped
stopped altogether
altogether during.
during, or
or shortly
shortly after,
after, your
your last
lastepisode
episode
(as
(as Martha
Martha experienced
experienced with
with her
her husband
husband after
after her
her hospitalization),
hospitalization), or
or it
it may
may
have
have gradually
gradually diminished
diminished over time after
over time after multiple
multiple episodes.
episodes.
It
It is
is quite
quite common
c o m m o n for
for relationships
relationships to
to be
be at
at a
a vulnerable
vulnerable point
point during
during the
the
recovery
recovery period,
period, even
even if
if the
the episode
episode was
was only
only a
a minor
minor one.
one. Many
M a n y spouses feel
spouses feel
angry
angry about
about events
events that
that occurred
occurred during
during the
the episode
episode and
and don't
don't feel
feel comfort­
comfort-
able
able being close.
being close.
If
If you
you are
are currently
currently hypomaniC,
hypomanic, you
you may
m a y have
have an
an increased
increased sex
sex drive.
drive, but
but
your
your spouse
spouse may
m a y have
have pulled
pulled away
away because
because of
of mistrust
mistrust related
related to your disor-
to your disor­
der
der (for
(for example,
example, an
an increase
increase in
in your
your irritability).
irritability). The
TheoppOSite
oppositecan
canalso
alsooccur:
occur:
You
You may
m a y be
be depressed,
depressed, and
and your
your spouse
spouse may
m a y want
want to
to reestablish
reestablish physical
physical con­
con-
tact,
tact,but
butyou
you may
m a y feel
feelunder
underpressure,
pressure,uncomfortable
uncomfortablewith
withyour
your body,
body,or
orbad
bad
about
about yourself
yourself as
as a
a sexual
sexual parmer.
partner.
If
If you've
you've been
been weU
well for
for some
some time,
time,you
you may
m a y have
havean
aneasier
easiertime
time negotiating
negotiating
intimacy
intimacy with
with your partner. But
your parmer. But even
even clients
clients who
w h o have
have remained
remained well
well com­
com-
plain
plain that
that basic
basic issues of trust
issues of trust between
between them
them and
and their
their parmers
partners were
were violated
violated
258
258 SElF�MANIGEMENr
SELF-MANAGEMENT

by
by their
their earlier
earlierillness states
illness and that
states and emotional and physical
that emotional intimacy
and physical has
intimacy has
been
been hard
hard to
to reestablish.
reestablish. If
If you
you are
are experiencing
experiencing one
one or
or more
more of
of these
these prob­
prob-
lems,
lems, you
you are
are certainly
certainly not
not alone.
alone. Fortunately, these couple
Fortunately, these couple problems
problems can
can be
be
addressed
addressed using
using a
a number
number of
of relationship-building
relationship-building skills,
skills, outlined
outlinedin thenext
inthe next
few sections.
few sections.

Tools
Tools for
for Improving
Improving Family
Family Relationships
Relationships alter
after on
an Episode
Episode

Educating
EducatingYour
YourFamily
Family

The
The first
first step
step in
in dealing
dealing effectively with
effectively family members
with family members a fter an
after an episode is to
episode is to
educate
educate them
them about
about your disorder.. This
your disorder This is
is generally
generally a
a good
good idea
idea even
even if
if your
your
family
family is
is functioning
functioning well,
well, but
but it
it is
isespeCially
especiallyimportant
important during
during your
your recovery
recovery
period,
period, when negative emotions
w h e n negative emotions aTC
are often
often at
at their
their peak.
peak.
Your
Your relatives
relatives may
m a y harbor
harbor many
m a n y misconceptions
misconceptions about
about the
the illness,
illness, its
its
treatments,
treatments, or
or what
what the
the future
future holds
holds for
for all
all of
of you.
you. This
This can
can happen
happen even if
even if
they
they have
have interacted
interacted with
with your
your doctors,
doctors, read
read any
any of
of the
the excellent
excellent popular
popular
books
books on
on the
the subject
subject Oamison, 1995; Copeland,
Qamison, 1995; Copeland,1998; Court&
1998;Court & Nelson,
Nelson,1996;
1996;
Fawcett
Fawcett et
et aI., 2000; Mondimore,
al., 2000; Mondimore, 1999; Papolos &
1999; Papolos & Papolos, 1999), and
Papolos, 1999), and have
have
listened
listened to
to your explanations.
your explanations.
Flawed
Flawed or
or incomplete
incomplete information
information about
about bipolar
bipolar disorder
disorder can
can cause
cause your
your
loved
loved ones
ones to
to be
be critical
critical or
or overprotective
overprotective of
of you.
you. Make
M a k e copies
copies of the sidebar
of the sidebar
on
on pages 260-261, which
pages 260-261, which summarizes
summarizes the
the basic
basic facts
facts about
about bipolar disorder,
bipolar disorder,
so
so that
that you
you have
have it
itavailable
availablefor
forall
allfamily
familymembers
members(whether
(whetheror
ornot
notthey
theyhave
have
directly
directly shared
shared in
in your
your experience),
experience), including
including your
your adult
adult or
or teenage children,
teenage children,
parents, Siblings,
parents, siblings, and
and other
otherextended
extended relatives.
relatives.
It is
It is imponant
important to
to have
have a
a common
c o m m o n language
language when
w h e n communicating
communicating with
with
close relatives
close relatives about
about your
your symptoms
symptoms or
or changes
changes in
in functioning.
functioning. Hidden
Hidden within
within
the different
the different terms
terms your
your family
family members
members use
use in
in discussing
discussing your
your behavior
behavior are
are
often
often subrle
subtle differences
differences in
in beliefs
beliefs about
about what
what causes
causes you
you to
to behave
behave in
in these
these
ways. Acquainring
ways. Acquainting your
your relatives
relatives with
with the
the facts
facts about
about the
the disorder
disorder may
m a y make
make
them
them think
think twice
twice about
about what
what causes
causes your
your mood
m o o d Swings.
swings. For example, your
For example, your
family members will
family members will be
be more
more supportive
supportive of
of you
you if
if they
they understand
understand that in­
that in-
creases
creases in
in your
your irritability
irritability are
are a
a sign
sign of
of the
the disorder's cycling rather
disorder's cycling than evi-
rather than evi­
dence that
dence that "you've
"you've gonen
gotten mean"
mean" or
or "you're
"you're more
more hostile
hostile than
than you used to
you used to be"
be"
or
or "you've
"you've got
got a
a temper
temper problem."
problem." Likewise,
Likewise, they
they should
should come
c o m e to
to understand
understand
that
that you
you are
are suffering
suffering from
from "depressed
"depressed mood"
m o o d " or
or "fatigue"
"fatigue" or
or "concenrration
"concentration
problems"
problems" rather
rather than
than "mental
"mental laziness"
laziness" or
or "a
"a pessimistic
pessimistic outlook
outlook on life."
on life."
Family
Family members
members who
w h o know
k n o w the
the basic
basic facts
facts about
about bipolar
bipolar disorder
disorder w i ll also
will also
be
be more
more supportive
supportive of
of your
your efforts
efforts to
to maintain
maintain consistency
consistency in
in your treatment.
your treatment.
 (oping
Coping Effectively
Effectivelyininthe
theFomily ondand
Family Work Settings
Work Settings 2S9
259

Well-meaning
Well-meaning relatives
relatives whowho dounderstand
do not not understand the disorder
the disorder may view drug
may view drug
treatment or
treatment or psychotherapy
p s y c h o t h e r a p y asas crutches,
crutches, or or believe
believe that that you're being too
you're being too
watchful
watchful over over youry o u r health
health and a n d moods.
m o o d s . They
T h e y may
m a y give
give youy o u direct
direct or or indirect
indirect
messages
messages about a b o u t how
h o w they
they liked
liked youy o u better
better before
before you y o u began
b e g a n your
y o u r medicine or
m e d i c i n e or
therapy.
therapy. These
These messages
messages may may make make youyou feel
feel even
even moremore ambivalent
ambivalent than than you you
already feel
already feel about
about your your treatments.
treatments. Your Your family
family needsneeds to to know
know why why you you are are
taking
taking medication,
medication, attending attending psychotherapy,
psychotherapy, and and engaging
engaging in self-manage­
in self-manage-
ment
ment tasks
tasks likelike sleep-wake
sleep-wake regulation.regulation.
Spend
Spend some some time time answering
answering their their questions
questions after after they
they have
have read
read thethe factfact
sheet.
sheet. TheyTheymay may have havetrouble
troubleunderstanding
understandinghow how you youhavehaveexperienced
experienced cer­ cer-
tain symptoms,
tain symptoms, where where in in thethe family
family treetree the
the illness
illness maymay havehave originated,
originated, or or
why
why you you areare taking
taking aa certaincertain combination
combination of of medications
medications (for (for example,
example, a a
mood
mood stabilizer
stabilizer and and an an antidepressant).
antidepressant). If If you
you are are sharing
sharing information
information about about
your disorder
your disorder with with your your school-age
school-age children,
children, try tryto tosee
seeififyouyou cancansimplify
simplifyitit
to
to fit
fit their
their developmental
developmental level. level. One
One man m a n explained
explained to to his
his six-year-old
six-year-old son, son,
"You
"You know
know how h o w happy
happy you you get get during
during youryour birthday
birthday parties?
parties? II getget that
that way way
sometimes
sometimes for for a a whole
whole week, week, and and then
then it it gets
gets hard
hard for for mem e to
to dodo my work."
m y work."
One
One woman
w o m a n explained
explained to to her
her seven-year-old,
seven-year-old, "You "You know
know how how when
when you you get get
excited,
excited,you youcan canusually
usuallycalm calmyourself
yourselfdown? down?When W h e n Daddy
Daddygets getsexcited,
excited,hehe
gets
gets going
going really
really fastfast andand he he can't
can't calm
calm down
down right right away."
away." Another
Another woman woman
explained
explained to to her
her daughters
daughters that that when
when she she became
became sad, sad, sheshe couldn't
couldn't turn tum it it
off
off like
like they
they could.
could. "You "You know know how how whenwhen you're
you're upsetupset and and someone
someone ttells ells
you
you aa joke,
joke, you you feel feel better?
better? Mommy M o m m y gets
gets upset,
upset, but but things
thingslike likejokes
jokeswon't won't
get
get her
her over
over it it right
rightaway-she
away—she needs needsmore more time."
time."She She alsoalsomade
made ititclear
clearto to
them
them thatthat they
they should
should not not blame themselves when
blame themselves when she she became
became depressed
depressed or or
withdrawn.
withdrawn.
Use
Use age-appropriate
age-appropriate terms terms whenwhen describing
describing your your disorder.
disorder. Kids relate
Kids relate
better
better to to tenns
terms such such as, as, "happy,"
"happy," "excited,"
"excited," "amped,"
"amped," "wired," "sad," or
"wired," "sad," or
"bummed"
"bummed" than than to to "manic"
"manic" or or "depressed."
"depressed." You You may may have
have to to explain
explain the the dis­dis-
order
order to to them
them in in several
several different
different waysways and and at at different
different times,
times, however.
however.Fol­ Fol-
lOwing
lowing aa lengthy
lengthy discussion
discussion of of the
the disorder,
disorder, one oneparent
parentreported
reportedhearing
hearingher her
nine-year-old
nine-year-old son son say say to to one
one of of his
his friends,
friends, "My"My mother
mother has has aa bipolar
bipolar in in her
her
head!"
head!"

Helping YourRelatives
Helping Your RelativesUnderstand
Understandthe the Medical
Medical BasesBases of Your
of Your Disorder
Disorder

It's important
It's thatyour
important that your close
close relatives
relatives understand
understand that that at least
at least a portion
a portion of of
your
your behavior
behavior isis biologically
biologically and
a n d chemically
chemically determined.
determined. WhenW h e n they
they finally
finally
come
c o m e to
to accept
accept this,
this, they
they will
will probably
probably bbecome
e c o m e less
less angry
angry or or hostile,
hostHe, asas
Rebecca did:
Rebecca did:
A Quick
A Quick Fact on Bipolar
Sheet on
Fact Sheet for Fami
Disorder for
Bipolar Disorder ly Members
Family Members

W h a t Is
What Bipolar Disorder?
Is Bipolar Disorder?

Havingbipolar
Having bipolardisorder means
disorder that I that
means may have
I may havemood
severe swings,
severe mood swings,
inwhich
in fromvery
gofrom
which IIgo andenergized
highand
veryhigh energized(manic) tovery
(manic)to low,un­
verylow, un-
motivated, lethargic(depressed).
andlethargic
motivated,and highperiods
M yhigh
(depressed).My maylast
periodsmay from
last from
aa few
fewdays toaamonth
daysto ormore.
monthor M ylow
more.My periods may last much longer,
p
low periods may last much longer,
from several weeks
from several severalmonths.
to several
weeks to in every
About 11 in
months. About every 70 eople in
70 people in
the United
the United States disorder.It
bipolar disorder.
has bipolar
States has mostoften
Itmost affectsaaperson
oftenaffects person
for the first
for the inadolescence
timein
firsttime youngadulthood.
oryoung
adolescenceor adulthood.

W h a t Are
What the Symptoms?
Are the Symptoms?

My main symptoms
My main duringa high
symptoms during period
a high may include
period feelingfeeling
may include overly overly
happy and
happy or overly
excited or
and excited irritable and
overly irritable and angry. alsofeel
may also
angry. II may likeI I
feellike
can do
can do things no one
that no
things that else can
one else (grandiosity). 1Imay
do (grandiosity).
can do sleepless
maysleep less
usual or
than usual
than not at
or not all,do
at all, once,have
thingsatatonce,
manythings
domany moreenergy,
havemore energy,
talk and express
faster and
talk faster many ideas
expressmany realisticand
(some realistic
ideas(some some unrealis­
and some unrealis-
tic),and
tic), easilydistracted.
beeasily
andbe distracted. 1 may
I maydodo things that
things that impulsive
areare impulsivewhenwhen
manic,like
manic, greatdeal
spendaagreat
likespend deal money
ofof money unwiSely
unwisely drive
oror recklessly.
drive recklessly.
experience the
may experience
II may symptoms of
the symptoms depression at
of depression other times,
at other times,
which can
which feeling very
include feeling
can include down,irritable,
sad,down,
verysad, irritable, anxious,
or or anxious,lOSing
losing
interest in
interest people or
in people sleeping too
things, sleeping
or things, much or
too much or being unable to
being unable to
sleep, having little
sleep, having no appetite,
or no
Htde or trouble concentrating
having trouble
appetite, having concentrating or or
decisions,feeling
making deCisiOns,
making fatiguedor
feelingfatigued lowininenergy,
orlow energy,moving
movingorortalking
talking
slowly, feelingvery
slowly,feeling bador
verybad orguilty aboutmyself,
guHtyabout contemplatingsui­
myself,ororcontemplating sui-
cide or
cide actually carrying
or actually carrying out suicide attempts.
out suicide attempts.

How
H Does Bipolar
o w Does Disorder Affect
Bipolar Disorder Family?
the Family?
Affect the

My bipolar disorder
My bipolar disorder affect
maymay my ability
affect my abihty others in
to relatetotorelate toour
others in our
family or
family in the
or in setting,especially
work setting,
the work especially whenI become
when I become Our
ill.iU. family
Our family
or relationship
or relationship problems may be
problems may most apparent
be most during or
apparent during just after
or just after
my
m episode of
y episode mania or
of mania depression,but
or depresSion, wUlprobably
thenwill
butthen improveas
probablyimprove as
I get
I better. We
get better. resolveour
canresolve
W e can familyconflicts
ourfamily throughgood
conflictsthrough good com­
com-
munication and
munication problem solving,
and problem support for
emotional support
solving, emotional other,
each other.
for each

260
and encouragement.
and encouragement. We
W e may
maywant
wantto
toget
getthe
theadditional
additionalhelp
helpof
ofa afam­
fam-
ily or
ily or couples
couples counselor
counselor or
or a
a family
family support
support group.
group.

W h a t Causes
What Causes Bipolar
Bipolar Disorder?
Disorder?

Having
Having bipolar
bipolardisorder means
disorder that 1that
means haveIimbalances in the brain's
have imbalances in the brain's
neurochemistry
neurochemistry involving
involving the
the ways
ways that
that cells
cells communicate
communicate with
witheach
each
other.
other. Nobody
Nobody chooses
chooses to
to become
become bipolar.
bipolar. It's
It'spossible
possiblethat
thatIIinher­
inher-
ited these
ited these imbalances
imbalances from
from my
m y blood
blood relatives,
relatives,although
althoughnot
notnecessar­
necessar-
ily
ily from
from my
m y parents.
parents. My
M y mood
mood swings
swings may
may also
also be
be affected
affected by
by llife
ife
stress
stress or
or sudden
sudden changes
changes in
in my
m y sleep-wake habits.
sleep-wake habits.

H o w Is
How Is Bipolar
Bipolar Disorder
Disorder Treated?
Treated?

II am
am probably
probablybeing treated
being with mood
treated with stabilizing medications
mood stabilizing such
medications such
as lithium,
as lithium, Depakote,
Depakote,Tegretol,
Tegretol,or
orLamictal.
Lamictal.IImay
may also
alsotake
takeantide­
antide-
pressant
pressantmedications
medicationsor
ordrugs
drugsto
tocontrol
controlmy
m yanxiety
anxietyor
orproblems
problemswith
with
thinking.
thinking. These
Thesemedications
medicationsrequire
requirethat
thatI 1see aa
see psychiatrist
psychiatristregularly
regularly
to
tomake
makesure
suremy
m y side
sideeffects
effectsdon't
don'tget out
get ofof
out hand and
hand to get
and mymblood
to get y blood
levels
levels checked.
checked. II may
may also
also benefit
benefit from
from individual
individual Lherapy, family
therapy, family
counseling
counseling sessions,
sessions,or
orsupport
supportgroups.
groups.Therapy
Therapymay
mayhelp
helpme
m etotolearn
learn
more
more about
about my
m y disorder,
disorder, learn
learn to
to prevent
prevent relapses,
relapses, monitor
monitor moods
moods
and
and sleep-wake
sleep-wake cycles,
cycles, and
and function
functionbetter
betterin
inthe
thefamily
familyand
andwork­
work-
place.
place. IfIfI I
ama mone
oneofof
the many
the people
many with
people bipolar
with disorder
bipolar who
disorder w h ohave
have
problems
problems with
with drugs
drugs or
or alcohol,
alcohol, mutual
mutualsupport
supportprograms
programslike
likeAlco­
Alco-
holics
holics Anonymous
Anonymous may
may also
also help
help me
m e and
and our family.
our family.

W h a t Does
What Does the Future Hold?
the Future Hold?

It isis
It likely that Ithat
likely will have highhave
I will and low mood
high andepisodes
low moodin the future. in the futu
episodes
But
But there
thereis
isevery
everyreason
reasontotobebehopeful.
hopeful.With
Withthe help
the of of
help a regular pro­
a regular pro-
gram
gram of
of medication,
medication,therapy,
therapy,and
andsupport from
support fromothers, my
others, m mood dis­
y mood dis-
order
order episodes
episodes can
can become
become less
less frequent
frequentand
andless
lessextreme.
extreme.With
Withhelp
help
and
and support,
support, II can
can accomplish
accomplish many
many of
of my
m y goals
goals for
for my
m y family
family and
and
work
work llife.
ife.

761
261
262
262 SElF-MANAGEMENT
SELF-MANAGEMENT

"I"I had
hadbought
boughtconcert
concert tickets
tickelS and
and was
was looking
looking fOlWard
forward to
tothe
theevent
eventforfor
weeks.
weeks. The
The night
night we
w e were
were supposed
supposed to
to go,
go, my
m y husband
husband said he wasn't
said he wasn't go�
go-
ing
ing to
to go,
go, that
that he
he was
was too
too tired
tired and depressed. II was
and depressed. was enraged-it
enraged—it just
just
seemed
seemed like
like something
something he
he should've
should've known
k n o w n before.
before. IIt
t felt
felt like
like he
he was
was do­
do-
ing it
ing it to
to hun
hurt me
m e and
and disappoint
disappoint me.
m e . I1 had
had really
really wanted
wanted us
us to
to do
do this
this to­
to-
gether. 1I called
gether. called to
to cancel
cancel the
the babysitter
babysitter and
and the
the next
next day
day went
went to
to the
the
ticket
ticket office
office for
for aa refund,
refund, feeling
feeling like
like II was
was arguing
arguing from
from a
a position
position of
of
weakness.
weakness. To
T o my
m y surprise,
surprise, II told
told them,
them, 'My
'My husband
husband has
has a
a medical ill­
medical ill-
ness.'
ness.' Somehow,
S o m e h o w , that
that cut
cut through
through my
m y anger.
anger. It
It helped
helped me
m e do
do away
away with
with
what II felt
what felt he
he was
was doing
doing to
tohun
hurtme.
m e .That
Thatwas
was how
h o w IIdecided
decidedtotoexplain
explainitit
to
to myself
myself and
and to
to the
the outside
outside world."
world."

Rebecca's
Rebecca's realizationthat
realization that her
herhusband
husband skipped
skippedthe
theconcert notnot
concert necessarily
necessarily
because
because he
he didn't
didn't want
want to
to go
go but
but because
because he
he could
could not
not go,
go, made
m a d e her
her feel
feel less
less
resentful
resentful of
of the
the limitations
limitations his
his illness
illness placed
placed on
on their
their lives.
lives. Understand,
Understand,how­
how-
ever, that the
ever, that the frustration
frustration and
and dissatisfaction
dissatisfaction that
that such
such limitations
limitations cause will
cause will
not
not evaporate
evaporate overnight.
overnight. Family
Family members
members need time and
need time and practice
practice to
to come to
come to
grips
grips with
with the
the changes
changes in
in their
their lives.
lives. Consider
Considerthe
theway
w a ythat
thatEvan's
Evan'srelationship
relationship
with
with his
his father
father evolved:
evolved:

"Foryears,
"For years, he
he didn't
didn'tunderstand,
understand,and wewecould
and barely
could talktalk
barely to each Olher.other.
to each
I'd
I'd shout
shout and
and scream
scream and
and spread
spread my
m y self-loathing
self-loathing all
all over
over him,
him, and
and of
of
course
course he'd
he'd get
get pissed
pissed off.
off. Then
Then I'd
I'd get
get depressed
depressed and
and even
even less
less able to
able to
deal with
deal with him.
him. But
But after
after my
m y second
second wife
wife and
and II split
splitand
and then
then IIlost
lostmy
m yjob,
job,
II finally
finally told
told him
him II had
had bipolar
bipolar disorder,
disorder,and
and we
w e were
were really
really open
open about
about
it.
it.I Ijust
justtold
toldhim,
him,'Dad, this
'Dad, is is
this one of of
one thethe
main reasons
main we've
reasons had
we've so so
had many
many
problems
problems between
between us.'
us.' II explained
explained how it's
how it's a
a chemical thing and
chemical thing and that
that it
it
wasn't
wasn't about
about how
h o w he
he raised
raised me,
m e , and
and he
he didn't
didn't believe
believe me
m e at
at first.
first.But
Butin
inan­
an-
other way
other w a y it
it made
m a d e sense
sense to
tohim�he's
him—he's got
gotaascientific
scientificmind
mind and
and ititput
putso
so
m a n y different
many different things
things ioro
into place
place .. my
m y temper,
temper, my job stuff,
m y job stuff, my
m y prob­
prob-
lems
lems when
w h e n II was
was aateenager.
teenager.When
W h e nhe
hecame
cametotoaccept
acceptitit
and
andwe
w ecould
couldtalk
talk
about it,
about it, he
hewas
was able topull
ableto pullback
backand
and think
thinkabout
abouthis
hisown
o w n responses
responsesto
to
m e . And
me. A n d I've
I've gotten
gotten a
a lot
lot calmer
calmer and
and less
less reactive
reactiveto
tohim.
him. ... we
. wget along
e get along
much
m u c h better
better now."
now."

It'sIt's unlikely
unhkely thatyour
that yourrelatives
relatives will
willimmediately
immediatelyadopt a medical
adopt view
a medical of of
view
your disorder�it
your disorder—it took
took Evan's
Evan's father
father quite
quite some
some lime.
time. But
But with
with repeated
repeated expo­
expo-
sure to educational
sure to educational information,
information, your
your relatives
relatives may
m a y begin
begin to
to reevaluate their
reevaluate their
belief that
belief you are
that you are behaving
behaving out
out of
of ill
iH will
will or
or negative
negative intentions.
intentions. This
This was
was the
the
case
case for
for Gray,
Gray, who,
w h o , with
with his
his wife,
wife, Arlene,
Arlene, was
was geuing
gettingmarital
maritaltherapy tohelp
therapy to help
adapt
adapt to
to Arlene's
Arlene's bipolar
bipolar disorder.
disorder.
 Coping
Coping Effedively
Effectivelyininthe
theFamily andand
Fomily Work Settings
Work Settings 263
263

ARLENE: When
Arlene: When 1 get
I get depressed,
depressed, it'sit's
Hkelike a veil
a veil just
just comes
comes overover
me. me.
It's It's
not not at all
at all
like when
like w h e n you
y o u get
get tired
tired after
after work.
w o r k . It's
It's like
like being
being numb,
n u m b , like
like a
atton of ce·
o n of ce-
m e n t siuing
ment sitting on
o n my
m y heart.
heart.
Gray: II know,
GRAY: k n o w , honey,
honey, but
but IIjust
justdon't
don'tthink
thinkthe
theanswer
answeris
isto
tomope.
m o p e .You've
You'vegona
gotta
get
get out
out there
there and
and deal
deal with things.
with things.
THERAPIST:
Therapist: Arlene,
Arlene, can
can you
you say
say more
more about
about what
what that
that depression
depression is like, and
is like, and
what
what you
you think
think causes it?
causes it?
ARLENE:
Arlene: It's
It's probably
probably something
something chemicaL
chemical. It
It feels
feels physical;
physical; it
it doesn't
doesn't feel
feel like
like
lack of
lack effort. 1Iknow
of effort. k n o w how
h o w frustrated
frustratedyou
youget,
get.Gray,
Gray,but
butyou
youhave
havetoto
realize
realize
it's
it's not
not something
something II want
want either. If 1Icould
either. If could pull
pull myself out, 1Iwould-in
myselfout, w o u l d — i n aa
minute.
minute.

CommunicDtion
Communication Skillsfor
Skills forReducing
Reducing Criticism
Criticism Dnd
and Conflict
Conflict

In the
In the interchange between
interchange between Arlene
Arlene and and
Gray,Gray, Arlene
Arlene made
made an an to
effort effort to validate
validate
her
her husband's
husband's pointpoint of view. Effective
of view. Effective communication
c o m m u n i c a t i o n is
is a
a very
very important
important com· com-
ponent
ponent ofof managing
m a n a g i n g your family or
y o u r family or marital
marital relationships
relationships and a n d can
c a n even
even help fa·
help fa-
dlitate
cilitate your
y o u r recovery
recovery ffrom r o m yyour
o u r illness
illness episode
episode (Falloon
(Falloon et al., 1984;
et aL, 1 9 8 4 ; Jacobson
Jacobson
&: Margolin, 1979;
& Margolin, 1979; Liberman
Liberman et al., 1981).
etal., 1981). In
In our
our study
study of
offamily-focused
family-focused ther­
ther-
apy,
apy, one
one of
of the
the most
most consistent
consistent changes,
changes, over
over time,
time, among
a m o n g patienlS
patients whose bi­
whose bi-
polar
polar disorder
disorder improved
improved was
was an
an enhanced
enhanced ability
ability to
to communicate
communicate with their
with their
spouse
spouse or
or parents
parents (Simoneau
(Simoneau et al., 1999).
et al., 1999). Following
Following is
is a
a selection of commu­
selection of commu-
nication
nication skills
skillsyou
you can
can try
tryout
outwhen
w h e n dealing
dealingwith
with criticism,
criticism,tension,
tension,oror
conflict
conflict
in
in your
your close relationships.
close relationships.
Although
Although the
the skills
skills look
look easy
easy on
on the
the surface,
surface, they
they can
can be
be difficult
difficult to
to apply
apply
and
and require
require regular
regular practice.
practice. Certainly,
Certainly, couples
couples and
and families
families without bipolar
without bipolar
disorder
disorder have
have to
to practice
practice regularly
regularly to
to make
m a k e these
these communication
communication skills
skills work
work
for
for them
them (Stanley
(Stanley et al., 1996).
et al., 1996). Yet
Yet the
the stress
stress of
of family
family life
Hfe after
after an
an episode re­
episode re-
quires
quires you to be
you to even more
be even m o r e skillful
skillful in
in your
your communication
communication than you would
than you would
ordinarily
ordinarily have
have to
to be.
be. And
A n d when
w h e n your
your mood
m o o d is
is swinging
swinging up
u p and
and down
d o w n and
and you
you
feel
feel that
that your
your relatives
relatives are
are unfairly
unfairly jumping
jumping on
on you,
you, using
using new
n e w communica­
communica-
tion
tion skills
skHlscan
can be
be doubly
doubly hard.
hard.These
These skills
skHlsrequire
requirethat
thatyou
you step
step back
back when
when
you
you feel
feel the
the heat
heat rising
rising and
and put
put yourself
yourself in
in another
another person's
person's place. As
place. A s with
with
many
m a n y self-management
self-management strategies,
strategies, familiarizing
famiharizing yourself
yourself with
with these skills
these skills
when
w h e n you
you are
are well
well makes
makes them
them easier
easier to
to use
use when
w h e n you
you are
are il1.
ill.

Skill No. 1: Active

No. L ActiveLiltening
Listening

After
After dealing
dealing with
with an
an episode
episode of
of bipolar
bipolar disorder
disorder or
or any
any other
other kind of signifi­
kind of signifi-
cant
cant stressor,
stressor, you
you will
wHl have
have trouble
trouble listening
listening to
to the
the feelings,
feelings, objections, or
objections, or
264
264 SW·MANAGEMENT
SELF-MANAGEMENT

troubles
troubles of of other
other family
family members.
members. This This difficultyis
difficulty quite understandable.
is qUite understandable. But But
if
ifyour
your family
family members
m e m b e r s don't
don't feel
feelthat
thatyou y o u or
or others
others in in the
the family
family care
care enough
enough
to
to listen,
listen, they
they will
will probably
probably be b e unwilling
unwilling to to perform
perform some s o m e ofof the
the other
other tasks
tasks
that are essential to your recovery (for example,
that are essential to your recovery (for example, keeping the h o m e environ- keeping the home environ­
m e n t low-key).
ment low-key). So, So, if ifyour
y o u r parents,
parents,spouse,
spouse,or or kids
kids areare responding
responding to to you
y o u neg­
neg-
atively
atively or or with
with criticism,
criticism, consider
consider helping
helping them t h e m modulate
modulate their their anger
anger by b y lis­
lis-
tening
tening anda n d expressing
expressing an a n understanding
understanding of of their
their pOSition,
position, even even if if you
y o u do
d o not
not
agree with
agree with it.
it. This
Thisis isaatechnique
technique called calledactive
activelistening,
listening,and a n d attempts
attempts to touse
useitit
will
will almost
almost cenainly
certainly changechange the the outcome
o u t c o m e of
of what
w h a t would
w o u l d otherwise
otherwise be b e unpro­
unpro-
ductive
ductive interchanges.
interchanges. The T h e sidebar
sidebar on o n this
this page
page listslists the
the steps.
steps.
In
In active
active listening,
listening, you y o u become
b e c o m e less
less active
active in in the
the speaking
speaking pan part ofof commu­
commu-
nication
nication thanthan you
y o u might
m i g h t be
b e used
used to,to, and
a n d you
y o u become
b e c o m e more
m o r e active
active on o n the
the listen­
listen-
ing
ing end.
end. You
Y o u don't
don't just
just sitsit there
there anda n d hear.
hear. YouY o u maintain
maintain eye eye contact
contact withwith thethe
person
person speaking
speaking to to you,
y o u , offer
offer nonverbal
nonverbal acknowledgments,
a c k n o w l e d g m e n t s , paraphrase
paraphrase or or oth­
oth-
erwise
erwise check
check out out whatw h a t you've
you've heardheard (otherwise
(otherwise known k n o w n as as "reflective listen­
"reflective listen-
ing"),
ing"), and
a n d ask
ask questions
questions designeddesigned to to get
get the
the speaker
speaker to clarify his
to clarify his oror her
her point
point
of
of view.
view. This
This is is a
a good
g o o d skill
skill toto use
use whenever
w h e n e v e r you
y o u talk
talk with
with youry o u r family
family mem­ mem-
bers,
bers, butbut ititwill
willbe b eespecially
especiallyhelpful
helpfulwhen w h e n arguments
argumentsstart startto toescalate.
escalate.There
Thereis is
nothing
nothing like like validating
validating someones o m e o n e else's
else's point
point of of view
v i e w in
in the
the middle
middle of of an
a n argu­
argu-
mment
e n t to
to reduce
reduce his his or or her
her anger-it's
anger—it's hard hard to to be
be m mad
a d atat someone
s o m e o n e who
w h o is
is mak­
mak-
ing a
ing a genuine
genuine attempt
attempt to to understand
understand you. you.
Active listening
Active listening requires
requires that
that you
y o u avoid
avoid any implication of
any implication of blaming
blaming the
the
other
other person.
person. That
That is,
is, stay
stay away
a w a y from
from anyany reflective
reflective statements
statements or
or questions
questions
that
that imply
imply the
the other
other person
person is
is at
at fault
fault for
for his
his oror her reactions or
her reactions or that
that involve
involve
name-calling.
name-calling. For For example, the statement
example, the statement "So "So yyouo u feel that if
feel that if you're
you're m mean to
e a n to
e , I'll
mme, change for
I'H change the better"
for the better" is
is not really a
not really a reflective
reflective statement
statement but but more of an
m o r e of an
accusation.
accusation. TThe h e question
question ""Why
W h y would
w o u l d you
you w want to bbe
a n t to e aa nnag if you
a g if y o u are
are trying
trying
to
to gel
get mmee to do
to d something oon
o something n my
m y own?"
o w n ? " mmay
a y feel like a
feel like reasonable question.
a reasonable question,

Ste
S tep of Active
p ss of Active Listening
Listening

•• Look
Lookatatthe
thespeaker
speaker
•• Attend
Attend to
to what
w h a t is
is said
said
•• Nod
N o d your
your head
head or
or say
say ·uh-huh"
"uh-huh"
•• Ask
A s k clarifying
clarifying questions
questions
•• Check
C h e c k out
out what
w h a t you
y o u heard
heard (paraphrase)
(paraphrase)

Adapted by permission from

Adapted from Miklowitz
Miklowitz. and Goldstein (1997). Copyright
and Goldstein Copyrightby
by The
The Guilford
Guilford Press.
Press.
 (Coping
Oiling Effectively
EffectivelyininthetheFamily andand
Family Wor� SeNings
Work Settings 265
265

but it will
but it nothelp
wiH not helpresolve
resolve thethe disagreement.
disagreement. It's hard
It's hard to avoid
to avoid saying saying
things things
like that
like that when
w h e n you're
you're angry
a n g r y or
or irritable.
irritable. But
B u t if
if you
y o u stay
stay at
at the
the level
level of
of asking
asking
simple,
simple, straightforward
straightforward questions
questions and a n d paraphrasing
paraphrasing exactlyexactly what
w h a t you
y o u have
have
heard from
heard f r o m your
y o u r relative
relative (even
(even word
w o r d for
for word,
w o r d , if
if necessary),
necessary), you
y o u will
will be
b e less
less
likely
hkely to
to say
say something
s o m e t h i n g to
to cause
cause him
h i m or
or her
h e r to
to take
take offense.
offense.
Consider
Consider the
the following
foHowing interchange
interchange between
between Randy
Randy and
and Cindy.
Cindy. Randy is
Randy is
practicing
practicing the
the skill
skill of
of active
active listening.
listening.

RANDY: You
Randy: were pretty
You were pretty mad at me
mad at this morning.
me this morning. What was up?
What was up? [clarifying
[clarifying
question)
question]

Cindy: II tried
CINDY: tried to
to get
get you
you to
to talk
talk about
about that
that tax-related
tax-related thing,
thing, and
and you
youjust
justblew
blew
me
m e off.
off. Why
W h y do
do II keep
keep trying?
trying?
RANDY: (pausing) So
Randy: (pausing) So you
you were
were frustrated
frustrated with
with me.
m e . You
Y o u wanted
wanted me
m e to
to get
get iit
t
done.
done, (paraphrasing]
[paraphrasing]
CINDY:
Cindy: (still irritated) Yes,
(still irritated) Yes, of course II didl
of course did! And
A n d II had
had asked
asked you
you a
a million
milHon
times.
times.
RANDY: (nods) Yes,
Randy: (nods) Yes, II understand
understand how
h o w that
that would
would be
be frustrating.
frustrating. But
But partly
partly it's
it's
because
because I'm
I'm having
having a a tough
tough time.
time. Were
W e r e you
you concerned
concerned that
that II wouldn't
wouldn't get
get
it
it done?
done? (clarifying
[clarifying question]
question]
CINDY:
Cindy: (so ftens) Maybe
(softens) M a y b e 1I came
came down
d o w n too
too hard
hard on
on you,
you, but
but the
the question is,
question is,
when
w h e n are
are we
w e gonna
gonna do do it?
it? The
The 15th
15th is
is coming
coming up
up pretty quick.
pretty quick.

Randy'S
Randy's reflectivelistening
reflective listening andand validation
validation of of
Cindy's point
Cindy's of view
point helped
of view helped
reduce
reduce herher irritation
irritation and
and the
the antagonism
antagonism thatthat had
had built
built up
up between
between them.
them.
Ideally, this
Ideally, thisdiscussion
discussionwould
would thenthenmerge
mergewith
withproblem
problemsolving,
solving,another
anotherskill
skill
that
that will
will help
help you
you negotiate
negotiate a a more
more productive
productive relationship
relationship with your spouse
with your spouse
or
or parent
parent (explained
(explained later
later in
in this
this section). But active
section). But active listening doesn't always
listening doesn't always
have
have its
its intended
intended effect,
effect, as
asis
isdiscussed
discussedininthe
thetroubleshooting
troubleshootingtips
tipslater
laterin
inthis
this
section.
section.

Skill
ill No.
No. 2:
2: Positive
Positive Requests
Requests for
for Chonge
Change

Another way
Another to reduce
way to reduce tension
tensionand
andavoid
avoidthe verbal
the auacks
verbal that can
attacks thattum
caninto
turn into
full-scale war is
full-scale war is to
to phrase
phrase your comments to
your comments family members
to family members as as positive
positive re-re­
quests
quests for change (Falloon
for change (FaHoon etet al.,
al., 1984).
1984). This
This involves
involves stating,
stating, specifically
specifically andand
diplomatically, what you'd
diplomatically, what you'd like to see
like to see happen differently in
happen differently in your interactions
your interactions
with
with your relative. Criticisms
your relative. Criticisms lell people what
tell people what theythey have
have done
done w wrong-"l re­
r o n g — " I re-
sent
sent that
that you
you always
always bring
bring up
u p my
m y illness
illness when
w h e n my friends are
m y friends are aaround"-
r o u n d " — and
and
naturally generate defensiveness.
naturally generate defensiveness. Stating
Stating the
the same thought in
same thought in a
a positive
positive way-way—
266
266 sm-WAGEMENT
SELF-MANAGEMENT

"It's very
"It's important
very to to
important meme
that when
that whenwe're
we'rewith our
with friends,
our we talk
friends, about
we talk about
things
things of
of importance
importance to
to us
us other
other than
than my illness"— is
m y illness" is almost
almost certain
certain to
- to reduce
reduce
any
any defenSiveness,
defensiveness, even
even though
though it's
it's not
not guaranteed to prevent
guaranteed to prevent it
it altogether.
altogether. If
If
you're
you're not
not entirely
entirely sure
sure of
of the
the difference
difference between
between the
the two, note that
two, note that positive
positive
requests
requests usually
usually ask
ask someone
someone to
to do
do something
something new
n e w and positive, whereas
and poSitive, whereascrit­
crit-
icisms
icisms usually
usually involve
involve telling
telling someone
someone to
to stop
stop doing
doing something.
something.
After
After being
being hospitalized
hospitalized for
for a
a mixed
mixed episode
episode of
of her
her bipolar
bipolar disorder,
disorder, Carol
Carol
returned
returned to
to her
her apartment,
apartment, only
only to
to discover
discover that
that her
her father,
father, Roy.
Roy, was
was con­
con-
stantly
stantly coming
coming over,
over, unannounced,
unannounced,and
and then
thencriticizing
criticizingher
herfor
forhow
h o w messy
messyshe
she
kept
kept her
her living
living room.
room. This
This surveillance
surveillance was
was a
a particularly sensitive issue
particularly sensitive for
issue for
Carol,
Carol, who
w h o felt
feltstrongly
stronglythat
thather
herautonomy
autonomyand
andindependence
independencewere
wereimportant
important
to
to her
her recovery.
recovery. Roy,
Roy,however,
however,had
hadbecome
become hypervigilant
hypervigilantand
and worried
worried that
thatshe
she
would
would deteriorate
deteriorate into
into another
another bipolar
bipolar episode.
episode. He
H e felt
felt that
that his
his concerns
concerns were
were
justified
justified by
by the
the fact
fact that
that she'd
she'd had
had several
several recent
recent mood episodes.
m o o d episodes.
Carol
Carol began
began saying
saying things
things like
like "Just
"Just don't
don't come
c o m e over
over here
here anymoren
anymore" or
or
"Why
" W h y don't
don't you
you leave
leave me
m e alone?
alone?" to which
" to which her
her father
father responded, "I do
responded, "1 do it be­
it be-
cause
cause 1I don't
don't think
think you
you can
can take
take care
care of
of yourself."
yourself." During
During family
family counseling
counseling
sessions,
sessions, her
her therapist
therapist encouraged
encouraged her
her to
to try
try transforming
transforming her
her criticisms into
criticisms into
positive
positive requests
requests for
for change.
change. At first she
Atfirst she had
had trouble
trouble with
with this
this communication
communication
tool,
tool,saying
sayingthings
thingslike
like"Dad,
"Dad,could
couldyou
you leave
leaveme
m e alone
alonemore?
more? That'd
That'dmake
m a k e my
my
life
life much
m u c h better."
better."With
With coaching,
coaching,she
shewas
was able
able to
toword
word her
her request
requestmore
more dip­
dip-
lomatically,
lomatically, and
and her
her father
father responded
responded more
more pOSitively
positively as
as a result:
a result:

CAROL: Dad,
Carol: Dad, will
willyou
youplease call
please me before
call you're
me before goinggoing
you're to come
to over? That'd That'd
come over?
give
give me
m e the
the chance
chance to
to clean
clean up first
up first.
THERAPIST:
Therapist: Good,
Good, CaroL
Carol. And
A n d how
h o w would
would that
that make
m a k e you feel?
you feel?

Making
Making a
a Positive
Positive Request
Request

• Look
• at your
Look at your family
familymember
member
• Say
• Say exactly
exactly what
what you
you would
would like
like him
him oror her
her to
to do
do
• Tell
• Tell him
him or
or her
her how
h o w it
itwould
would make
m a k e you
you feel
feel
• Use
• Use phrases
phrases such
such as:
as:

"I would
"1 would like
like you
you to
to "
"
"I
"I would
would really
really appreciate
appreciate it
it if
if you
you would
would _____ "
"!t's
"It's very
very important
important to
to me
m e that
that you
you help
help me
m e with
with the
the ____ "

Adapted by
by permission
permission n-om
from MikIowitz Goldstein (1997).
Miklowitz and Goldstein (1997). Copyright Press.
Copyright by The Guilford Press.
 Coping
Coping Effective�
Effectivelyininthe
thefamily WOlk
andand
Family Senings
Work Settings 267
267

CAROL:I'd
Carol: I'dlike
like it,
it, and I'd probably
and I'd probablyfeel
feelgrateful
gratefulthat
thatyou
you cared
cared about
about me and
me and
what
w h a t II need.
n e e d . It'd
It'd also
also be
b e nice
nice to
to see
see you.
you.
THERAPIST:
Therapist: That
That was
was excellent.
exceflent. Roy,
Roy, what
what did
did you
you think
think about
about what
what Carol just
Carol just
said?
said?

Roy: Much
ROY: M u c h better,
better, easier
easier to hear. And
to hear. A n d I1 might
might even
even do
do it
it (laughs)
(laughs)\l (From
[From
Miklowitz &
Miklowitz Goldstein, 1997,
6a: Goldstein, pp. 21�2111
1997, pp. 210-211]

YourYour family
family members
members are often
are often doing
doing their
their besttototry
best try to
to help
help you.
you. They
They
may
may benefit
benefit from
from knowing,
knowing, in
in a
a constructive
constructive way,
way, what
what they
they can
can do differ­
do differ-
ently. Making
ently. Makingpositive
positiverequests
requestsin
inthis
thisway
w a ymay
m a yfeel
feelartificial
artificiala tat
first, but
first, it will
but it will
help
help you
you make
m a k e your
your needs
needs known
k n o w n without
without alienating
ahenating your relatives.
your relatives.

Skill No.No.
Skill 3: Problem Solving
3: Problem to Defuse
Solving toFamily
Defuse(onflicts
Family Conflicts

Someof
Some of the
the arguments
arguments you
you have
have with
withyour
yourfamily members
family memberscan
canbebe
reduced to to
reduced
a
a specific
specific problem
problem that
that can
can be
be solved.
solved. As
A s you
you know,
k n o w , bipolar
bipolar disorder
disorder some­
some-
times
times generates
generates practical
practical problems
problems that
that need
need to
to be
be addressed
addressed as
as aa family
family or
or
couple,
couple, particularly
particularly in
in the
the aftermath
aftermath of
of an
an illness
illness episode.
episode. These
These can
can include
include
financial
financial problems,
problems, difficulties
difficulties related
related to
to resuming
resuming your
your work
w o r k or family roles
or family roles
(for
(for example,
example, child
child rearing),
rearing), problems
problems related
related to
to your
your treatments
treatments or
or medica­
medica-
tion,
tion,or
orrelationship
relationshipand
andliving
livingsituation
situationconflicts (Miklowitz&
conflicts(Miklowitz & Goldstein,
Goldstein,
1997).
1997). Often,
Often, these
these unresolved
unresolved but
but relatively
relatively specific
specific problems
problems fuel
fuel your rela­
your rela-
tives'
tives' expressions
expressions of
of criticism
criticism or
or resentment.
resentment. The
The more
more you
you can
can help direct
help direct
conversations
conversations with
with your
your family
family members
m e m b e r s toward
toward identifying
identifying and
and solving spe­
solving spe-
cific
cific problems,
problems, the
the less
less tension
tension there
there will
will be
be during
during your
your recovery
recovery period.
period.
The
The steps
steps in
in the
the Problem-Solving
Problem-Solving Worksheet
Worksheet on pages 268-269
on pages 268-269 prOvide a
provide a
structure
structure for
for resolving
resolving your
your disagreements
disagreements (Falloon
(Falloon et al., 1984;
et al., Libennan et
1984; Liberman et
aL,
al., 1981)
1981) .. Let's
Let's imagine,
imagine, for
for example,
example, that
that you
you gOl
got into
into an
an argument
argument with
with
your
your spouse
spouse about
about the
the lack
lack of
of intimacy
intimacy in
in your
your relationship
relationship since
since your last ep­
your last ep-
isode
isode of
of bipolar
bipolar disorder.
disorder. You
Y o u might
might find
find yourself
yourself getting
getting increaSingly irri­
increasingly irri-
tated,
tated, especially
especially if
if you
you were
were unclear
unclear about
about what
what your
your spouse wanted. First,
spouse wanted. First,
discuss
discuss the
the definition
definition of
of this
this problem (Step 1)
problem (Step 1) with
with your
your spouse:
spouse: Can
C a n the
the
broad
broad issue
issue of
of intimacy
intimacy be
be redefined
redefined as
as a
a more
more specific
specific problem
problem (for
(for example,
example,
lack of
lack of time
time spent
spent together
together away
away from
from the
the kids)?
kids)? Try
Try to
to get
get him
him or
or her to slow
her to slow
down
d o w n and
and help
help you
you define what the
define what the disagreement
disagreement is
is about
about. Use
Use your listening
your listening
skills
skills to
to help
help your spouse define
your spouse what is
define what is really
really bothering
bothering him
him or her.
or her.
Next,
Next, encourage
encourage your
your spouse
spouse or
or other
other family
family members
m e m b e r s to
to suggest
suggest as
as many
many
solutions
solutions as
as possible
possible to
to the
the problem
problem you've
you've defined (Step 2).
defined (Step Let's imagine
2). Let's imagine
you've
you've defined
defined it
it as
as lack
lack of
of time
time spent
spent together.
together. Potential
Potential solutions could in-
solutions could in­
clude
clude cordoning
cordoning off
off an
an hour
hour or
or more
more of
of your
your time
time during
during the
the evening
evening when
when
268
268 SElF-MANAGEMENT
SELF-MANAGEMENT

PROBLEM·SOLVING
P R O B L E M - S O L V I N G WORKSHEET
WORKSHEET

Step 1: Define
Step 1: Define"What
"Whatisisthe
theproblem?�
problem?"Talk
Talkand
andlisten, ask
listen, questions,
ask and
questions, gelget
and everybody's
everybody's
opinion.
opinion.

Step 2: List
Step 2: List all
allpossible
possiblesolutions,
solutions,even
evenones
onesthat
thatdon't
don'tseem
seemfeasible.
feasible.Do
D onot
notevaluate the
evaluate the
pros
pros or
or cons
cons of
of any
any solution yet.
solution yet.

1.
1. __
____
____
____
____
____
____
____
____
____
____
__

2
2.. __
____________
________________________
__

3.
3. __
____
____
____
____
____
____
____
____
____
____
__

4.
4. __
____
____
____
____
____
____
____
____
____
______

5.
5.

Step 3: Discuss
Step 3: Discussand
andlist the the
list advantages and disadvantages
advantages of eachofpossible
and disadvantages solution. solution.
each possible
Advantages
Advantages Disadvantages
Disadvantages
.
I1.
2.
2.
3.
3.
4.
4.
5.
5.

Step 4:
Step 4: Choose
Choose the
the best
best possible
possible solution
solution or
or solutions,
solutions, and
and list.
list.Include
Includecombinations
combinationsofof
possible solutions.
possible solutions.

Step 5: Plan
Step 5: Plan how
h o w to
to carry
carry out
out the
the chosen
chosen solutions,
solutions, and
and set
set aa date
date to
to implement
implement them.
them.

______
Oate
Date

List who will

Listwho willdodowhat.
what.
 (oping EEffedive/y
Coping ffectively in
inthe
theFamily
Familyand
andWork
WorkSettings
Settings 269
269

List what
List what resources
resources you'll
you'll need
need (for
(for example,
example, mmoney,
oney, aa babysitter,
babysitter, access
access to
to a
a car,
car,
reselVations).
reservations).

Step 6: Implement
Step 6: Implement the
the chosen
chosen solution
solution and
and praise
praise each
each other's
other's efforts.
efforts.

Step 7:
Step 7: After
Afteryou've
you'veimplemented the solution,
implemented the solution, go
go back
back to Step 11 and
to Step and decide
decide whether the
whether the
problem wwas
problem solved. If
a s solved. If not,
not, try
try to
to redefine
redefine the
the problem
problem and
and ccome
ome u up with solutions
p with solutions that
that
will
will wwork better.
o r k better.

Adapted by
bypennission
permissionfrom Miklowiu
from and and
Miklowitz Goldstein (1997).
Goldstein Copyright
(1997). by The Guilford
Copyright Press.
by The Guilford Press.

the kids
the kids are
are not
n o t allowed
a l l o w e d to
to disturb
disturb you,
y o u , arranging
arranging a
a weekly
w e e k l y night u t together,
night oout together,
exercising
exercising together
together once
once or
or twice
twice a week, or
a week, or having
having one
one meal
meal at home
at h o m e each
each
week
week without
without the
the kids present. When
kids present. W h e n generating
generating solutions,
solutions, be
be careful not to
careful not to
evaluate
evaluate whether
whether they
they are
are good
good or
or bad
bad ideas
ideas just
justyet.
yet. It's
It's importam
important to
to get
get all
all of
of
the
the ideas
ideas out
out on
on the
the table first.
table first.
In Step 3,
In Step 3, weigh
weigh the
the advantages
advantages and
and disadvantages
disadvantages of
of each
each proposed solu­
proposed solu-
tion.
tion.For
Forexample,
example,aa
weekly
weeklynight
nightout
outtogether
togetherhas
hasthe
theadvantage
advantageofof
being
beingfun
fun
and
and pleasurable;
pleasurable; its
its disadvantages
disadvantages might
might include
include its
its costs.
costs. Then
Then try
try to
to choose
choose
one
one solution
solution or
or a
a combination
combination of
of solutions
solutions based
based on
on your
your mutual
mutual discussion
discussion
of
of the
the pros
pros and
and cons
cons of
of each
each possibility (Step 4).
possibihty (Step 4). For
For example.
example, you
you may
m a y agree
agree
that
that going
going out
out once
once aa week
w e e k is
is too
too costly
costly but
but that
that aa meal
meal at
at home
h o m e together,
together,
w h H e the
while the kids
kids are
are at
at aa babysitter's
babysitter's house.
house, achieves
achieves the
the same
same objective
objective (bring­
(bring-
ing
ing the
the two
two of
of you
you closer)
closer) without
without the
the cost.
cost.
In Step S,
In Step 5,think
think about
about the
the tasks
tasks involved
involved in
in making
making the
the solution
solution work.
work. In
In
this
this example,
example,you'll
you'H need
need to
to choose
choose aa night
night to
to have
have dinner
dinner together,
together,buy
buy food
food
to
to cook,
cook, and
and arrange
arrange aa babysitter.
babysitter. You
Y o u will
vnH find
find it
it easier
easier to
to implement
implement the
the
solution-and
solution—and the
the result
result will
wiH probably
probably be
be more
more satisfying-if
satisfying—if you
you divide
divide up
up
the
the tasks
tasks such
such that
thatyou
you do
do some
s o m e of
ofthem
them and
and your
your spouse
spouse does
does some
s o m e of
of them.
them.
In Step 6,
In Step 6, try
tryimplementing
implementing your
your solutions
solutions and
and see
see if
if the
the original
original problem
problem
has
has been
been addressed.
addressed. Problem
Problem solving
solving does
does not
not guarantee
guarantee that
that you'll
you'H come
c o m e up
up
with
with aa solution
solution that
that will
v^dH work.
work. Nonetheless,
Nonetheless, give
give some
s o m e encouragement
encouragement or
or
praise
praise to
to your
your spouse
spouse for
for his
his or
or her
her willingness
wiHingness to
to work
w o r k with
with you,
you, even
even if
if you
you
don't
don't feel
feel the
the problem
problem is
issolved
solved yet.
yet. For
For example,
example,say,
say,"I'm
"I'm really
really glad
glad you're
you're
working
working with
with me
m e to
to solve
solve this.
this.ItItmakes
makesme
m efeel
feelgood
goodthat
thatyou
youcare." Your
care." Yourrela­
rela-
tives
tivesneed
need to
to know
k n o w when
w h e n they
they are
are doing
doing things
thingsright,
right,and
andit's
it'simportant
importantto
toteU
teH
them
them so
so as
as often
often as
as possible.
possible.
270
270 SElf-MANAGEMENT
SELF-MANAGEMENT

You You may

may go go through
through a problem-solving
a problem-solving exercise
exercise only
only totodiscover that the
discover that the
original problem was
original problem was not
not defined
defined adequately
adequately in in the
the first
first place.
place. For
For example,
example,
the problem
the problem might
might bebe the
the lack
lack of
of personal,
personal, intimate
intimate conversations
conversations between
between
you and
you and your
your spouse rather than
spouse rather than simply
simply notnot having
having enough
enough time
time away
away from
from
the kids.
the kids. IfIf so,
so,try
tryredefining
redefining the
the problem
problem andand going
going through
through the
the solution
solution steps
steps
again (Step 7).
again (Step You
7). Y ou mmay be more
a y be more successful
successful the second time
the second time around.
around.
Some
S families or
o m e famihes or couples
couples find itt useful
find i useful to
toselect
selectaa weekly
weekly time
time lO
tosit
sitdo'NIl
down
and
and solve problems that
solve problems that have cropped up
have cropped up during
during thethe week.
week. Often,
Often, they
they deal
deal
with problems
with problems such such as
as household
household chores,
chores, managing
managing finances,
finances, or
or planning
planning so-
so­
cial events.
cial events. TheThe structure
structure that
that a regular meeting
a regular meeting provides
proVides helps
helps assure
assure that
that
certain nagging
certain disagreements, however
nagging disagreements, trivial, get
however trivial, getresolved.
resolved.

Communicating and
Communicating and Problem
Problem Solving
Solvingwith
withRelatives WhoWho
Relatives AreAre
Overprotective
Overprotective

"Bipolar illness is
"BipolarHlness is so
sotaxing emotionally
taxing to to
emotionally the the
family, and most
family, families
and most famihes
don't
don't have the skills
have the skills for
for knOwing
knowing howh o w toto deal with it.
deal with We
it. W feel over-
e feel over­
whelmed and
whelmed and our
our skills
skiHs are
are exceeded,
exceeded, and
and wew e can't
can't get
get answers
answers from the
from the
mental
mental health
health system.
system. All
All the
the while
while we
w e see
see our
our loved
loved one
one in pain. Who
in pain. Who
wouldn't
wouldn't get
get overprotective
overprotective under
under these circumstances?"
these circumstances?"
-A
— A 34-year-old
34-year-old son
son who
w h o rakes
takes care
care o j his
of his bipolar
bipolar mother
mother
during
during her
her manic
manic and
and depressive
depressive episodes
episodes

Communication
Communication and problem
and problem solving
solving can also
can also helphelp
youyou negotiatethe
negotiate thedif-
dif­
ficulties
ficulties that
that arise
arise when
w h e n your
your relatives
relatives start
start to
to overmonitor
overmonitor youryour behavior.
behavior.
Your first
Your first task
task is
is to
to try
try to
to understand
understand the the source
source ofof their
their responses.
responses. If If you've
you've
been ill recently, your relative is probably very concerned that you'll become
been ill recently, your relative is probably very concerned that you'll become
illagain.
ill again.HeH e or
orshe
shemay
m a y fear
fearthat
thatyouyou will
willkill
killyourself,
yourself,hurt
hurtsomeone,
someone,impul­ impul-
Sively
sively leave
leave the
the family,
family, spend
spend aalotlotof
ofmoney,
money,or orotherwise
otherwisedamage
damageyourself
yourselfor or
others. This
others. This anxiety
anxiety cancan result
result in
in aa desire
desire toto control
control things,
things, which
which often
oftenleads
leads
to overprotective behavior.
to overprotective behavior.
Use
Use active
active listening
listening as as you
you gemly
gently encourage
encourage youryour relatives
relatives to to recognize
recognize
and
and verbalize
verbalize their
their fears
fears about
about your
your future,
future, ififthey
theyhaven't
haven'tmade
m a d ethese
theseclear
cleartoto
you already.
you already. Reassure
Reassure themthem that
that you'll
you'll work
work hard
hard to
to manage
manage your disorder on
your disorder on
your
your own.
own. For
For example,
example, you
you might
might say,
say, " }
"I know
k n o w you're
you're afraid
afraid I'm
I'm going
going to
to be­
be-
come
come illillagain
againandandthat
thatthings
thingswill
willbe
behard
hardforforour
ourfamily
family\validating
[validatingtheir
theirfeel­
feel-
ings]. .I am
ings) I am taking
taking care of of
care myself, though,
myself, though, andandthethe
best
bestway
w ayou
y youcan help
can mem is
help e is
to let
to let me
m e do
do asas much
m u c h as
as I1 can
can on
on my
m y own."
own." TheyThey may
m a y be
be relieved
relieved to hear you
to hear you
say this. You may also be able to use your positive request skills to set appro­
say this. Y o u m a y also be able to use your positive request skills to set appro-
priate
priate boundaries
boundaries with with them,
them, asas Carol
Carol did
did with
with her
her father.
father.
In addition, consider the role of problem solving when
In addition, consider the role of problem solving w h e n dealing
dealing with rela­
with rela-
tives
tiveswho
w h o overmonitor
overmonitor your your behavior.
behavior.CanC a n you
you develop
develop agreemenlS
agreementswith with them
them
 Coping EEKective�
Coping ffectively ininthe
theFDmi� ond
Family andWork
WorkSeltillQs
Settings 271
271

in which
in you
which you dodo something
something to allay
to allay theirtheir anxiety,
anxiety, and they,
and they, in agree
in turn, turn, not
agree not
to wwatch
to you
atch y o u so
so closely? Bart, 118,
closely? Bart, 8 , was
w a s being
being constantly
constantly rreminded by
eminded b his
y his
mmother, Greta, to
o t h e r , Greta, to take
take his
his medication
medication and get his
a n d get his bblood level checked.
l o o d level He
checked. H got
e got
his
his revenge in a
revenge in a rather
rather uunproductive
n p r o d u c t i v e wway:
a y : leaving
leaving lithium tablets aaround
lithium tablets the
r o u n d the
hhouse for h
o u s e for her to find
e r to find (for
(for example,
e x a m p l e , on the kitchen
o n the floor, b
kitchen floor, behind the toilet).
e h i n d the toilet).
Greta then
Greta became more
then became more annoyed and anxious
annoyed and and increased
anxious and increased her
her monitoring
monitoring
of his behavior.
of his behavior. Bart
Bart said that he
said that he was
was willing
willing to take his
to take his medication and even
medication and even
have his blood
have his blood level
level checked,
checked, but not if
but not if it
it meant that his
meant that his mother "follows me
mother "follows me
around with
around with pills
pills in
in her hand." Understandably,
her hand." he wanted
Understandably, he wanted to feel like
to feel like taking
taking
medication was his
medication was his own
o w n decision. Greta expressed
decision. Greta expressed doubt that he
doubt that he would
would take
take
medication without
medication her vigilance.
without her vigilance. She
She complained, "How
complained, " H o w can I k
can 1 know if he's
n o w if he's
taking it if
taking it if II don't
don't ask?"
ask?"
Through
Through problem
problem solving,
solving,Bart
Bartand
and his
hismother
mother generated
generated aalist
listof
ofpossible
possible
scenarios:
scenarios: Bart
Bart taking
taking full
full responsibility
responsibility for
for his
his medication; Greta taking
medication; Greta taking all
all
the responsibility;
the responsibility; Greta
Gretareminding
reminding him
h i m only
onlyonce
onceper
perday;
day; Greta
Greta having
having more
more
phone
phone contact
contact with
with his physician. Eventually
his physician. Eventually they
they agreed that Greta
agreed that Greta would
would
place
place Bart's
Bart's four
four daily
daily lithium tablets on
lithium tablets on a
a plate
plate for
for him
him in
in the morning. He
the morning. He
was
was to
to agree
agree to
to take
take them
them during
during the
the day,
day, and
and she
she was
was to
to agree not to
agree not to mention
mention
his
his medication
medication unless
unless she
she found pills on
found pills on the
the plate
plate or
or lying
lying around the house
around the house
by
by the
the day's
day's end.
end. They
They also
also agreed
agreed that
that she
she could
could see
see his
his lithium
lithium level
level repon at
report at
the
the end
end of
of each
each month.
month. This
This agreement
agreement worked
worked well
well for
for both
both of
of them.
them.
What
W h a t if
if it
it is
is your
your spouse
spouse who
w h o is
is behaving
behaving in
in an
an overprotective
overprotective way?
way? Some
Some
of
of my
m y clients
clients say
say that
that their
their spouses
spouses feel
feel less
less anxious
anxious if
if they
they are
are allowed
allowed to
to at­
at-
tend
tend the
the drug
drug monitoring
monitoring visits
visits with
with the
the psychiatrist.
psychiatrist. There
There are
are some
some advan­
advan-
tages
tages to
to doing
doing this:
this: Your
Your spouse
spouse will
will feel
feel more
more secure
secure if
if he
he or
or she
she has
has input
input
into
into your
your care
care and
and has
has a
a connection
connection with
with your
your physician
physician (which
(which can
can be help­
be help-
ful in emergencies).
ful in emergencies). Your
Your spouse
spouse may
m a y also
also remember
remember certain
certain of
of the
the physician's
physician's
recommendations
recommendations that
that have
have slipped
slipped your
your mind
mind (and
(and likewise,
likewise, you
you may
m a y recall
recaH
things
things that
that your
your spouse
spouse has
has forgotten).
forgotten).If
Ifyou
you decide
decide to
togo
go this
thisroute,
route,you
youmay
may
want to
want to establish
establish some
s o m e agreemenls
agreements ahead
ahead of
of time
time about
about what
what role
role you
you wanl
want
your
your spouse
spouse to
to play
play in
in these
these medication
medication visits.
visits.For
Forexample,
example,you
youmight say,"}"1
mightsay,
want
want to
to invite
invite you
you to
to my
m y next
next medication
medication session,
session,but
but1Ineed todo
needto do most
mostof
ofthe
the
talking
talking about
about my
m y stale
state and
and what
what the
the medication
medication is
is doing.
doing. You
Y o u can
can chime in,
chime in,
but
but it's
it's really
really me
m e who
w h o has
has to
to describe
describe my
m y own
o w n experiences.n
experiences." Your
Your spouse
spouse may
may
feel
feel less
less of
of aa need
need to
to closely
closely monitor
monitor your
your behavior
behavior if
if his
his or
or her
her opinions
opinions are
are
regularly
regularly incorporated
incorporated into
into your
your treatmenl
treatment plan.
plan.

TTroubleshooting
rouhleshoot;ngYour
Your Use
Use of of Commun;c.t;on
Communication .nd Prohlem-Solving
and Problem-Solving Skills Skills

Putting communication
Putting c o m m u n i c a t i o n and
a n dproblem-solving
problem-solving skills
skHls into
into practice
practice during
during your
your
recovery
recovery period
period presents
presents some
s o m e challenges.
c h a H e n g e s . As
A s II mentioned
m e n t i o n e d preViously,
previously, even
even
the
the healthiest
healthiest of
of families
families can
c a n have
h a v e trouble
trouble communicating
c o m m u n i c a t i n g clearly
clearly and
a n d effi-
effi-
272
272 SElF-MANAGEMENT
SELF-MANAGEMENT

ciendy. BUl
ciently. Butwhen
whenyou
youare also
are dealing
also withwith
dealing dysregulations inmood
in your
dysregulations your and
mood and
thought
thought processes,
processes, it it can
can be even harder
be even harder to to step
step back
back andand phrase
phrase your stale­
your state-
ments
ments to to relatives
relatives in in the
the ways
ways thatthat I've
I've outlined,
outlined, or or to
to take
take a a step-by-step
step-by-step ap- ap­
proach
proach to to problem
problem solving.
solving. You Y o u will
will probably
probably feel feel easily
easily provoked
provoked and and impa­
impa-
tient.
tient. AsAs a a result
result you you may m a y quickly
quickly abandon
abandon the the skills
skills when
w h e n inin conflict
conflict withwith
relatives, which
relatives, which will willthen then keep
keep the thenegative
negative cycles
cyclesgoing.
going.
There
There are are several
several things
things youyou can can dodo toto address
address problems
problems in in implementing
implementing
these
these skills.
skills. First,
First,try trytotoflag
flag those
those instances
instances when
w h e nyouyouare aregetting
getting tootooupset
upset toto
listen
listen effectively
effectively or or solve
solve problems,
problems, and and then
then diplomatically
diplomatically exit exit the situation.
the situation.
For
For example, consider the scenario in which your relative is being criticaland
example, consider the scenario in which your relative is being critical and
accusatory,
accusatory, and and thethe thought
thought "this "this isis so
so unfair"
unfair" keepskeeps goinggoing through
through your your
mind. IIf
mind. fyou feel tlu:
you feel the heal
heat rising
rising andand cancan tell
tellthat
that the
the conversation
conversation is isgoing
goingin inaa
negative
negative direction,
direction, ask ask for
for a a "time-out."
"time-out." For For example,
example, you you might
might say,say, "}"I don't
don't
think
think II can can discuss
discuss this this right now. Let's
right now. Let's talk
talk later
later when
w h e n we're both calmed
we're both calmed
down."
down." A A time-out
time-out gives gives youyou breathing
breathing room r o o m so
so that
that you
you cancan think
think abom
about what
what
you
you dodo andand don't
don't want
want to to say
say to to your
your parent,
parent, spouse,
spouse,or orSibling.
sibling.ItIt also
alsoenables
enables
you
you toto examine
examine what what is is happening
happening that thatisismaking
makingyou youso soupset.
upset.You Y o umay
m a ywant
want
to
to resolve
resolve the the disagreement
disagreement with with your
your relative
relative later
later oror perhaps
perhaps just just drop
drop it,it,ififitit
doesn't
doesn't seemseem worthworth the cost of
the cost of another
another argument.
argument. There There may m a y be
be aa period after
period after
the
the time-out
time-out w when
h e n things
things are are awkward
awkward and and icyicy inin your
your household,
household, but but this
this
probably
probably would would have have occurred
occurred anywayanyway if if you
you hadhad letlet the
the argument
argument continue
continue
along
along its its destructive
destructive path. path.
Here's
Here's another
another difficulty
difficulty you you might
might experience:
experience: You Y o u know
k n o w the
the steps
steps of of aa
skill
skill (for
(for example,
example, makingmaking a a positive
positive request)
request) but but then
then forget
forget them
them as as soon
soon as as
an
an argument
argument starts. starts. It It is hard to
is hard to remember
remember to to draw
draw on on communication
communication skills skills
when
w h e n you
you are are angry
angry and and in in the
the midst
midst of of aa conflict
conflict with
with someone
someone w h o is
who is angry
angry
at
at you.
you. When
W h e n youyou recall
recallthe the conversation
conversation later later on,
on,youyou maym a y think
think of ofaa number
number
of
of things
things you you could
could have have said
said to to help
help defuse
defuse the the argument.
argument.
If this
If thisdifficulty
difficultysoundssounds familiar,
familiar,practice
practiceusingusingthe theskills
skillsfirst
firstwith
withpeople
people
outside
outside the the family
family who w h o don't
don't provoke
provoke you you andand withwith whom you're generally
w h o m you're generally
comfortable.
comfortable. For For example.
example, make make a a positive
positive request
request of of a a coworker
coworker ("I'd really
("I'd really
appreciate
appreciate it it if
ifyou
you could
could cover
cover for formem e next
next weekend
weekend so so that
that I1can
can take
take some
some
time
time ofr).
off), or or try
try paraphrasing
paraphrasing the the statements
statements of of a a friend
friend whow h o has
has described
described to to
you
you a a problem
problem he he or or she
she is is haVing
having (for (for example,
example, "Sounds
"Sounds like like you're
you're going
going
through
through a a rough time"). You
rough time"). Y o u may
m a y find
find that
that by by applying
applying a skill in
a skiH in non­
non-
threatening
threatening circumstances,
circumstances, it it becomes
becomes easiereasier to to remember
remember to to apply
apply it it when
when
the
the stakes
stakes are higher.
are higher.
Now
N o w consider
consider the the scenario
scenario in in which
which you you are are doing
doing youryour best
best with
with the the
communication
communication tools tools but there seems
but there seems to to be
be little impact on
Htde impact on your relationship.
your relationship.
You
You maym a y feel
feel annoyed
annoyed that thatyouyou arearethetheonly
only oneone whow h o is
istrying
trying to tocommunicate
communicate
or
or solve
solve problems
problems effectively,
effectively, whereas
whereas othersothers seemseem to to keep
keep doing
doing whatever
whatever
 (oping
Coping EffectivelV
Effectivelyininthe
theFamily andand
Family Work Senings
Work Settings 273
273

they've been
they've beendoing.
doing.ForFor example,
example, youbemay
you may bediplomatic
quite quite diplomatic
in askinginyour
asking your
close
close relatives
relatives to
to change
c h a n g e their
their behavior,
behavior, yet
yet the
the way
w a y they
they ask
ask you
y o u continues to
continues to
sound
s o u n d challenging
challenging and
a n d demeaning.
d e m e a n i n g . Of
O f course,
course, if
if you
y o u were
w e r e to
to ask
ask your
y o u r family
family
members
m e m b e r s for
for their
their view
v i e w of
of this
this problem,
p r o b l e m , they
they might
m i g h t say
say that
that they
they try
try to
to be
b e dip­
dip-
lomatic but
lomatic b u t that
that you
y o u get
get very
very defensive
defensive in
in return.
return.
If you
If y o u find
find yourself
yourself in
in this
this stalemate,
stalemate, consider
consider the
the long-term
long-term benef ilS of
benefits of
"unilateral
"unHateral change."
change." In
In other
other words,
w o r d s , try
try to
to change
c h a n g e your
y o u r own
o w n behavior in rela­
behavior in rela-
tion to yyour
tion to relatives first,
o u r relatives first, wwith the expectation
i t h the expectation that,
that, wwith time, they
i t h time, they will
will
change their
change their behavior
behavior toward
t o w a r d you.
y o u . In
In other
other words,
w o r d s , keep
k e e p trying!
trying! Your
Y o u r repeated
repeated
attempts
attempts at
at problem
p r o b l e m solving
solving or
or diplomacy
d i p l o m a c y (for
(for example,
e x a m p l e , continuing
continuing to
to validate
validate
other people's
other people's emotions
e m o t i o n s even
e v e n when
w h e n they
they refuse
refuse to
to do
d o so
so for
for you)
y o u ) will
w H l eventu­
eventu-
ally
ally have
h a v e an
a n iimpact
m p a c t on
o n their
their responses,
responses, especially
especially if
if you
y o u are
are able
able to
to stick
stick with
with
the
the formalS outlined for
formats outlined for engaging
engaging in
in active
active listening
listening and
a n d making
m a k i n g positive re­
positive re-
quests
quests for
for change.
c h a n g e . Of
O f course,
course, this
this requires
requires a
a high
high tolerance
tolerance for
for frustration,
frustration, but
but
there
there is
is potentially
potentially a
a high
h i g h payoff
payoff over
over time.
time.
To
T o increase
increase the
the chances
c h a n c e s that
that your
y o u r relatives
relatives improve
i m p r o v e their
their way
w a y of
of commu­
commu-
nicating
nicating with
w i t h you,
y o u , be
b e sure
sure to
to praise
praise them
t h e m for
for even
e v e n minor
m i n o r attemplS
attempts on
o n their
their
part
part (for
(for example,
e x a m p l e , "Thanks
" T h a n k s for
for asking
asking me
m e if
if II was
w a s upset
upset after
after our
o u r conversation.
conversation.
I'm
I'm glad
glad you
y o u noticed
noticed that
that it
it bothered
bothered me").
m e " ) . The
T h echances
c h a n c e sare
arehigh
high that,
that,over
over re­
re-
peated
peated discussions
discussions with
w i t h your
y o u r relatives,
relatives, they
they will
will do
d o or
or say
say something
s o m e t h i n g helpful
helpful
or
or that
that shows
s h o w s an
a n awareness
a w a r e n e s s of
of yOUT
y o u r viewpoint.
viewpoint. Be
B e ready
ready to
to acknowledge
a c k n o w l e d g e their
their
auemplS
attempts to
to make
m a k e things
things better,
better, even
e v e n if
if these
these attemplS
attempts seem
s e e m overshadowed by
overshadowed b y
everything
everything else
else they
they have
h a v e said.
said. The
T h e cardinal
cardinal rule
rule of
of behavior modification is
behavior modification is
that
that people
people increase
increase the
the frequency
frequency of
of those
those behaviors
behaviors that
that get
get rewarded
rewarded by
by others.
others.
You
Y o u may
m a y feel
feel that
that the
the communication
communication or
or problem-solving
problem-solving strategies out­
strategies out-
lined
lined here
here are
are artificial
artificial or
or superficial.
superficial. If
If you
you are
are still
still hypomaniC
hypomanic or
or energized,
energized,
it
it may
m a y feel
feel stifling
stifling to
to talk
talk in
in this
this very
very measured,
measured, careful
careful way.
way. What
W h a t happened
happened
to
to the
the eXCiting,
exciting, spontaneous
spontaneous interchanges
interchangesyou
you used
used to
tohave
havewith
with your
your partner
partner
or
or yOUT
your Siblings?
siblings? Remember
R e m e m b e r that
that you
you are
are trying
trying to
to improve
improve life
life during
during a spe­
a spe-
cific
cific interval-your
interval—your recovery
recovery period.
period.This
This period
period requires
requiresthat
thatyou
you be
be extra
extra ef­
ef-
ficient
ficient in
in your
your communication
communication and
and problem-solVing
problem-solving styles,
styles, above
above and
and beyond
beyond
what
what is
is required
required of
of others
others who
w h o do
do not
not have
have to
to cope
cope with
with bipolar disorder.
bipolar disorder.
Think
Think of
of incorporating
incorporating these
these skills
skills as
as trying
trying on
on a
a new
n e w pair
pair of
of shoes. At first,
shoes. At first,
they
they won't fit or
won't fit or feel
feel comfortable.
comfortable. If
If they're
they're still
still uncomfortable
uncomfortable after
after you've
you've
worn
worn them
them for
for a
a while,
while, you
you may
m a y decide
decideyou
you don't
don'tlike
likethem
them and
and take
take them
them off.
off.
Bm
But they
they have
have the
the potential
potential to work well
to work well for
for you
you if
if you
you break
break them in. Prac-
them in. Prac­
ticing
ticingthe skillsrepeatedly
theskills repeatedlywill
wiHeventually
eventuallymake
m a k ethem
themfeel
feellike
likesecond
secondnature
nature
and
and will
will probably
probably lead
lead to
to changes
changes in
in the
the way
w a y that
that your
your famLly
family members re­
m e m b e r s re-
spond
spond to
to you.
you. As
A s you
you recover
recover and
and your
your family
family relationships
relationships improve,
improve, you
you may
may
be
be able
able to
to return
return to more spontaneous
to more spontaneous ways
ways of
of communicating
communicating or
or making
making
your
your needs
needs known.
known.
274
274 SElf-MANAGEM£NT
SELF-MANAGEMENT

Reestablishing
Reestablishing Physical Intimacy
Physical Intimacy with Partner
with Your Your Partner Episode
after anafter an Episode

In previoussection,
theprevious
In the section, an example
sawsaw
youyou of problem
an example solving
of problem as related
solving to
as related to
emotional intimacy
emotional in aa couple's
intimacy in relationship. As
couple's relationship. for physical
As for intimacy, you
physical intimacy, you
and your partner
and your probably need
will probably
partner will some time
need some to get
time to with each
reacquainted with
get reacquainted each
other. If you
other. If would like
both would
you both to reinitiate
like to relationship, consider
physical relationship,
a physical
reinitiate a consider
getting the help
getting the a couple
of a
help of counselor who
couple counselor in sex
specializes in
w h o specializes therapy. Tradi­
sex therapy. Tradi-
tional encourage couples
therapists encourage
sex therapists
tional sex couples to take pan
to take in "sensate
part in focus" exer­
"sensate focus" exer-
cises that
cises they do
that they h o m e (for
at home
together at
do together LoPiccolo &.
example, LoPiccolo
(for example, & LoPiccolo,
LoPiccolo,
1978).
1978).
After Mara's bipolar
After Mara's mixed episode,
bipolar mixed and her
she and
episode, she Kevin aban­
husband Kevin
her husband aban-
doned their
doned sex life,
their sex "ourprimary
that··our
decidingthat
life, deciding asaacouple
goalas
primarygoal Mara'sre­
coupleisisMara's re-
covery." their couple
In their
covery." In sessions, they
couple sessions, recognized that
both recognized
they both had become
sex had
that sex become
frightening to them
frightening to and that
them and the illness
that the had become
illness had excuse for
an excuse
become an not dealing
for not dealing
directly each other.
with each
directly with Once they
other. Once agreed that
they agreed they wanted
that they reestablish a
to reestablish
wanted to a
romantic counselorencouraged
theircounselor
life,their
romantic life, totake
themto
encouragedthem smallsteps,
takesmall between
steps,inin between
greater intimacy.
toward greater
sessions, toward
sessions, intimacy. They started by
They started going our
by going on an
together on
out together an
evening date
evening one week,
date one other back
each other
giving each
week, giving the follOwing
rubs the
back rubs week, hug­
following week, hug-
and kissing
ging and
ging kissing the taking a
next, taking
the next, bath together
a bath next, and
the next,
together the graduallywork­
and gradually work-
ing back up
ing back up to sexual relationship.
a sexual
to a This relaxed,
relationship. This approach was
step-by-step approach
relaxed, step-by-step was
very
very important for Mara
important for Kevin in
and Kevin
Mara and regaining the
in regaining trust and
the trust intimacy they
and intimacy they
had shared
had prior to
shared prior to her episode.
her episode.
You m a y feel
Y o u may that the
feel that of a
guidance of
the gUidance is not
therapist is
couple therapist
a couple necessary. But
not necessary. But
couples do
m a n y couples
many have significant
do have anxiety concerning
significant anxiety sex. If
concerning sex. so, a
If so, therapist can
a therapist can
teach you
teach relaxation and
you relaxation and desensitization techniques (like
desensitization techniques those above)
(like those to
above) to
practice with
practice spouse between
your spouse
with your sessions.
between sessions.
The most
The important point
most important remember is
to remember
point to that anxiety
is that or discomf
anxiety or ort about
discomfort about
being dose
being close is part o
natural part
a natural
is a coping as
off coping a couple
as a with bipolar
couple with disorder, partic­
bipolar disorder, partic-
ularly during
ularly the recovery
during the period. Many
recovery period. M a n y couples are able
couples are able to this dis­
overcome this
to overcome dis-
comfort by
comfort moving slowly,
by moving not expecting
slowly, not too m
expecting too u c h from
much from each at first,
other at
each other first,
and being
and being willing to try
willing to again if
try again if their first attemplS
their first at sexual
attempts at are not
intimacy are
sexual intimacy not
as satisfying
as as they
satisfying as had hoped.
they had hoped.

Bipolar and the

Disorder and
Bipolar Disorder Woric SeHing
tlie Work Setting

Louise,
Louise, a 35-year-old woman
a 35-year-oldwoman with
with disorder,had
bipolarII disorder,
bipolar hada manic
a manicepisode
episode
that led
that to a
led to short (five-day)
a short hospitalization. Prior
(five-day) hospitalization. Prior to the development
to the development of of
her episode, she
her episode, worked as
had worked
she had as a paralegal in
a paralegal a law
in a firm. The
law firm. for
trigger for
The trigger
her appeared to
hospitalization appeared
her hospitalization to have been a
have been legal case,
a legal for which
case, for which the firm
the firm
had insisted
had that she
insisted that late at
work late
she work for several
night for
at night weeks to
several weeks prepare
help prepare
to help
the auorneys' arguments.
the attorneys' arguments.
Her episode
Her kept her
episode kept out of
her out of work for almost
work for a month.
almost a When
month. W she had
h e n she had
 Coping EEff
Coping ffeect vely ininfile
ctiive� thefomi�
Familyond
andWork
WorkSenings
Settings 275
275

mostly
mostly recovered,
recovered, she returned
she returned to her job. to her Shejob.
decidedShenot decided
to tell not hertoem-tell her em­
ployers that
ployers that s she
he hhad
a d bbeen
e e n inin thethe hospital
hospital a and instead explained
n d instead explained that thatsshe he
hhadad h hadad a an n uunnamed physical illness,
n n a m e d physical illness, a and did n
n d did not elaborate further.
o t elaborate further. BBut ut
she became
she phYSically uuncomfortable,
b e c a m e physically easily fatigued,
n c o m f o r t a b l e , easily fatigued, a and irritable after
n d irritable after
her ssecond
her e c o n d wweek
eek o on the jjob
n the o b wwhen
hen h her
e r eemployers started to
m p l o y e r s started to increase
increase hher er
wwork load again.
o r k load again. TThey expected her
h e y expected her to to wwork late shifts
o r k late shifrs oone night aand
n e night early
n d early
mmorning shifts the
o r n i n g shifts the next.
next. S She
h e ffound that she
o u n d that she w was
a s uunable to function
n a b l e to function men­ men-
tally at
tally at wwork the m
o r k the morning after a
o r n i n g after a night
night shift.
shift. EEvenv e n wworse, they aSSigned
o r s e , they assigned
her a
her an new task uupon
e w task arriving at
p o n arriving at work
w o r k in in the
the mmorning:
o r n i n g : calling clients wwho
calling clients ho
were delinquent on
w e r e delinquent their bills
o n their bills or or w who hadn't rresponded
h o hadn't e s p o n d e d toto letters.
letters. SShe he
ssummarized
ummarized h here r experience
experience this this way:
way:
"It w
"It was
as a abbad idea for
a d idea for m me e toto dod o ssomething
o m e t h i n g like that first
like that first thing
thing in in thethe
morning.
morning. It It made
made it it hard
hard for for m me e toto even
even get get upup to to go
go to to this
this job.
job. MyM y body
body
was slow, my
was slow, m y mind
mind was was slow.
slow.ItIt took took me m e aalonglong timetimeto tocome
come out out of ofmy my
haze. IfIf1Igot
haze. workatat9,9,1
gottotowork 1 had had totobebe upup byby 6 just
6 just to to
getgetmy m mind
y mind rolling.
rolling.I I
felt
felt rushed,
rushed,irritable,
irritable, then
then depressed.
depressed. MyMboss y boss gotgot controlling
controlling and andstarted
started
criticizing
criticizing my m y work.
work. .... . . I1got
gotstressed
stressedout outand andanxious,
anxious,and andthenthenI Iwould
would
try
try to
to calm
calm downdown and couldn't. 1Itried
and couldn't. triedto tomake
makemyselfmyselfbusy, busy,but thenI I
butthen felt
felt
even
even more
more lethargic
lethargic and and couldn't
couldn't get get thethe jobjob done."
done."
louise
Louise was was on on the
the verge
verge of of quitting
quitting her her jobjob when
when she she decided
decided to to have
have
an
an open
open conversation
conversation about about her her bipolar
bipolar disorder
disorder with with one one of of the
the partners
partners
in
in the
the law
law firm,
firm,aawoman w o m a n who,
who, she shefelt,
felt,had had been
been onon herherside.
side. Louise
Louise apol­
apol-
ogized
ogized for for her
her irritability
irritability and and explained
explained that that sheshe needed
needed more consisteD[
more consistent
work
work hours,
hours,adding addingthat thatthe theunpleasant
unpleasanttasks tasks sheshehad had been
been aSSigned
assigned ininthe
the
morning
morning were were better
better off off assigned
assigned to to thethe afternoon.
afternoon. The The law law partner
partner was was
unwilling
unwilling to to compromise
compromise on on thethe amount
amount of of work
work aSSigned
assigned to to Louise
Louise or or the
the
quality she expected. But given that Louise was a valued employee, the
quaHty she expected. But given that Louise was a valued employee, the
partner
partner did did compromise
compromise on on some
some other other issues:
issues:limiting
Hmitingthe thenumber
numberof oflate
late
nights
nights she she would
would have have to to work,
work, allowing
allowing her her toto dodo some
some of of her
her work
work at at
home,
home, and and deferring
deferring the the unpleasant
unpleasant tasks tasksuntiluntH later
later in inthetheday.
day. These
Thesead­ ad-
justments
justments made made aa greatgreat dealdeal of of difference
difference to to Louise.
Louise. She She eventually
eventually de- de­
cided
cided to to cutcut toto aa half-time
half-time work work week, week, which which was was muchmuch better better for for her
her
from
from the the standpOint
standpoint of of mood
mood stability.
stabHity.

If youhave
If you haveaa bipolar
bipolar disorder,
disorder, you you
can still
can be successful
still in your chosen
be successful in your cho
career. A
career. A survey
survey done
done byby atat the
the Center
Center forfor Psychiatric
Psychiatric Rehabilitation
Rehabihtation at at
Boston University
Boston University discovered
discovered that
that 73%
7 3 % of
of 500
500 profesSionals
professionals and
and managers
managers
(including
(including nurses,
nurses, newspaper
newspaper reporters,
reporters, corporate
corporate executives,
executives, lawyers,
lawyers, and
and
professors), previously diagnosed with a serious psychiatric illness, were
professors), previously diagnosed with a serious psychiatric Hlness, were
able to maintain
able to fuH-time employment
maintain full-time employment in in their
their chosen
chosen occupatiOns
occupations (Ellison
(EHison
&. Russinova,2001).
& Russinova, 2001). Of Of the
the respondents
respondents to to the survey,62%
the survey, 6 2 % had
had worked
worked inin
their
their position
position for
for more
more than
than two
two years, and 69%
years,and 6 9 % had
had increased
increased their
their levels
levels
of
ofresponsibility
responsibility in
in their
theirjobs. Most (84%)
jobs.Most (84%)wereweretaking
takingsome
some kind
kind of
ofpsychi­
psychi-
atric medication,and
atricmedication, and two-thirds
two-thirds hadhad been
been hospitalized
hospitalized three
three or
or more
more times.
times.
276
276 Sm-MANAGEMENT
SELF-MANAGEMENT

Above
Above all,all, many
many respondents
respondents said saidthatthatgetting
gettingback to their
back jobs was
to their jobsirnpor�
was impor-
tant
tant toto their
their recovery.
recovery.
Nonetheless,
Nonetheless, as as the
the story
story ofof Louise
Louise illustrates,
illustrates,people
peoplewithwithbipolar
bipolardisor­
disor-
der
der face
face significant
significant challenges
challenges in in the
the workplace.
workplace. SomeS o m e of
of these
these challenges
challenges arise
arise
from
from thethe stigma
stigma of ofbipolar
bipolar disorder
disorder and and the
the reactions
reactions of ofothers.
others.ButButfor
formost
mostof of
my
m y clients,
clients,the thebigger
biggerchallenge
challengeisisfinding
findinga ajobjobthat
thatisis
satisfying
satisfyingbut
butalso helps
also helps
keep
keep them
them from
from mood
m o o d cycling.
cycling. It It is
is difficult
difficult to
to balance
balance severely fluctuating
severely fluctuating
moods
m o o d s with
with a a stable
stable work
work life,
life,as asLouise
Louisefound.
found.JobsJobsthat
thatpermit
permitthis
thisbalance
balance
are hard to find, but they do exist or can
are hard to find, but they do exist or can be created. be created.
Maintaining
Maintaining aa stable
stable mood
m o o d isis essential
essential toto functioning
functioning well well at
at your job.
your job.
This
This is,
is,ofofcourse,
course,another
anotherreason
reasontotostaystayconsistent
consistentwithwithyour
yourmedication
medicationregi­regi-
men.
m e n . But
But it
it is
is equally
equally true
true that
that working
working within
within a a supportive
supportive environment
environment is is
importam
important to to maintaining
maintaining your
your mood
m o o d stability.
stability. The
Thekey keyisisfinding
findingthe
theright
rightbal­
bal-
ance
ance of of stability
stability in
in work
work hours,
hours, levels
levels ofof stress,
stress,levels
levelsof ofstimulation,
stimulation,and andsatis­
satis-
faction
faction with
with thethe directions
directions your
your jobjob is
is taking
takingyou.
you.IIam a moptimistic
optimisticthat
thatyou
youcancan
find
find this
this balance.
balance.In Inthis
thissection,
section,I Idiscuss
discuss some
someself-care
self-care strategies
strategiestotohelp
helpyou
you
get
get back
back into
into the
the working
working world
world after
after anan episode.
episode.

"HowWill
"How Will Bipo'ar
BipolarDisorder
DisorderAHec, My Job
Affect Perlormance?"
My Job Performance?"

"I"Iwas
washypomanic
hypomaniCall
all last
last weekend,
weekend, really
reallypushing thethe
pushing envelope. Me Me
envelope. andand
the
the guys
guys were
were up up partying until 3
partying until 3 inin the
the morning
morning both both Friday
Friday and Satur­
and Satur-
day
day nights,
nights, andand then
then IIslept
sleptuntil
until111 1 the
thenext
nextday,day,even
even though
though IIknewk n e w it
it
was
was aa bad
bad idea because II had
idea because had totoget
getup at66 for
up at forwork
w o r k on
on Monday.
Monday. IIforgotforgot
to take my
to take m y medications
medications on on Sunday
Sunday morning,
morning, and and 1I didn't
didn't sleep that well
sleep that well
Sunday
Sunday night.
night. By By Monday
M o n d a y II was
was tired,
tired, cranky,
cranky, withdrawn,
withdrawn, snappysnappy with with
my
m y boss,
boss, and
and just
just really
really wasn't
wasn't allall that
that efficient.
efficient. MyM y boss
boss reacted,
reacted, men­men-
tioned
tioned that
that I1 seemed
seemed like
likeI1waswasin inaabad
badmood,
m o o d ,hinted
hintedthatthatmaybe
maybein inthose
those
circumstances II should
circumstances shouldjustjusttake
take thetheday
day off.
ofL He
H e didn't
didn'tknow
k n o w about
about mym y bi­
bi-
polar
polar disorder.
disorder. II could just feel
could just feel the
the old
old 'authOrity figure' stuff
'authorityfigure' stuff coming
coming up up
again,
again, but
butIIalso
alsorecognized
recognizedI I waswashaving
having aadepression
depression hangover
hangoverofof sorts.
sorts. I 1
took it
took it easy
easy after
afterwork
work Monday
M o n d a y aflernoon,
afternoon,did did some
some lowlow stress
stressstuff
stufflike
like
talking
talking onon the
the phone
phone and and going
going forfor aa run,
run, had
had dinner
dinner andand went
went to tobed
bed atat
the
the usual time. II slept
usual time. fine and
slept fine and was
was back
back in
in the
the swing
swing of of things
things byby Tues­
Tues-
day.
day. II apologized
apologized to tomym y boss
boss and
and everything
everything waswas OKO K after
afterthat,
that,butbutI Ireal­
real-
ized that,
ized that, at
at some point, 1I might
some point, might have have to
to tell him about
tell him about my problems."
m y problems."
— A 27-year-old
-A 27-year-old man m a n with
with bipolar
bipolar IIII disorder
disorder

Astrue
As is is true formost
for mostpeople,
people, your
your mood state will
mood state wiHinfluence your
influence day-to-day
your day-to-day
job performance. This
job performance. This man's
man's cycle of sleep
cycle of sleep deprivation
deprivation and
and overstimulation
overstimulation
 (oping
Coping Effectively
Effectivelyininthe
theFami� andond
Family Work Settings
Work Settings 277
277

followed
foUowed byby irritability, lethargy,
irritability, lethargy,and
anddepression
depression could
could havehave described
described almostalmost
anyone. The
anyone. T h e difference
difference is
is that
that this
this cycle
cycle is
is magnified
magnified in
in bipolar
bipolar disorder,
disorder, and
and
the intensi[)7
the intensity of
of your
y o u r resulting
resulting mood
m o o d can
c a n affect
affect your
y o u r work
w o r k performanc,e
p e r f o r m a n c e more
more
than
than would
w o u l d be
b e the
the case
case for
for the
the average
average person.
person.
How
H o w are
are bipolar
bipolar symptoms
s y m p t o m s expressed
expressed in
in the
the work
w o r k setting?
setting? Manic or
M a n i c or
h y p o m a n i c reactions
hypomanic reactions can
c a n take
take the
the form
f o r m of
of flying
flying off
off the
the handle at things
h a n d l e at things that
that
normally
normally wouldn't
wouldn't annoy
a n n o y you
y o u or
or being
being preoccupied
preoccupied by
b y so
so many
m a n y ideas that
ideas that
concentrating
concentrating on
o n your
y o u r job
j o b becomes
b e c o m e s difficult.
difficult. You
Y o u may
m a y start
start more
m o r e projects
projects than
than
y o u can
you c a n possibly
possibly complete,
c o m p l e t e , darting
darting from
f r o m task
task to
to task
task without
w i t h o u t accomplishing
accomplishing
w h a t you
what y o u originally
originally set
set out
o u t to
to do
d o ("multitasking").
("multitasking"). During
D u r i n g hypomanic inter­
h y p o m a n i c inter-
vals, you
vals, y o u may
m a y be particularly prone
b e particularly p r o n e to
to arguments
a r g u m e n t s with
w i t h irritating
irritating coworkers or
c o w o r k e r s or
confrontations
confrontations with
w i t h your
y o u r boss
boss (a
(a client said, "[
client said, "I usually just think
usually just my
think m y cowork­
cowork-
ers
ers are
are idiots.
idiots. When
W h e n I'm
I'm manic, also tell
m a n i c , II also tell them
t h e m sso").
o").
When
W h e n you're
you're in
in a
a depressed
depressed phase,
p h a s e , your
y o u r physical
physical state
state is
is much
m u c h like
like a
a severe
severe
flu.
flu. AtAthese times
t these you
times y o (and
u ( a nothers) will
d others) not
will n obe
t bable to to
e able expeclas much
expect as m u c from
h f r oyour­
m your-
self.
self. Your
Y o u r thinking
thinking and
a n d physical
physical responsiveness
responsiveness (for
(for example,
e x a m p l e , your
y o u r typing
typing
speed)
speed) may
m a y be
b e slower.
slower. You
Y o u may
m a y also
also suffer
suffer from
f r o m considerable
considerable anxiety,
anxiety, which
w h i c h can
can
interfere
interfere with
w i t h your
y o u r concentration.
concentration. As
A s always,
always, you
y o u can
c a n use
use your
y o u r mood chart to
m o o d chart to
anticipate
anticipate when
w h e n you
y o u are
are entering
entering one
o n e of
of these
these phases
phases of
of mood
m o o d disorder.
disorder.
On
O n the
the other
other side,
side, some
s o m e people
people report
report that
that their
their bipolar
bipolar disorder
disorder enhances
enhances
their
their job
job performance.
p e r f o r m a n c e . Many
M a n y persons
persons with
w i t h bipolar
bipolar disorder
disorder work in high-level
w o r k in high-level
business
business or
or government
g o v e r n m e n t positions
positions and
a n d are
are known
k n o w n for
for their
their high
h i g h work
w o r k output.
output.
They
T h e y report
report that
that when
w h e n they
they have
have a
a major
m a j o r writing
writing project
project to
to do,
d o , an
a n oral
oral presen­
presen-
tation,
tation, or
or an
a n impotlam
important sales
sales meeting,
meeting, they
they use
u s e the
the "adrenaline rush" of
"adrenaline rush" of
hypomania
h y p o m a n i a to
to their
their advantage.
advantage. You'll
You'll recall
recall from Chapter 7
f r o m Chapter 7 the link between
the link between
mania
m a n i a and
a n d creativity
creativity or
or productivity (Jamison, 1993).
productivity Oamison, 1993).
In
In my
m y experience,
experience, people
people with
vvdth bipolar
bipolar disorder
disorder are
are able
able to
to benefit
benefit from
from
hypomania
h y p o m a n i a in
in the
the work
w o r k setting
setting only
only if
if they
they are
are able
able to
to harness
harness it.
it. Harnessing
Harnessing
hypomania
h y p o m a n i a includes
includes learning
learning to
to recognize
recognize when
w h e n you
y o u are
are moving
m o v i n g or
orspeaking
speaking
too
too fast,
fast, setting
setting limits
limits on yourself when
o n yourself w h e n work starts to
w o r k starts to make
m a k e you
y o u overly
overly goal­
goal-
driven,
driven, trying
trying to
to accomplish
a c c o m p l i s h only
only one
o n e task
task at
at aa time,
time,accepting
accepting feedback
feedback from
from
others
others about
about how
how you
you are
are coming
coming across,
across, and
andbacking
backingoff
offwhen
when people
peopleseem
seem
to
to be
be reacting to your
reacting [0 your intensity.
intensity.ItItmay
mayindeed
indeedbe
bepossible
possibleto
totranslate
translateyour
yourin­
in-
creased
creased energy
energy into
into work
work productivity,
productivity,but
butalso
alsobe
beaware
awareofofwhen
whenyou
youneed
needto
to
slow
slow down
down and
and take
take aa break.
break.

Self-Disclosure
Self-Disclosure io
in 'he Workplace:"Should
the Workplace: "Should I Tell
I Tell People
People .bou'
about My lIIoess?"
My Illness?"

Can bipolardisorder
Can bipolar disorderbe be kept
kept a secret?
a secret? In experience
In my my experience and
and that of that
manyof
ofmany of
my
m y colleagues,
c o H e a g u e s , people
people with
w i t h bipolar
bipolar disorder
disorder usually
usually adopt
a d o p t one
o n e of
of four
four solu­
solu-
tions
tions regarding
regarding disclosure:
disclosure:
278
278 Sm-MANAGEMENT
SELF-MANAGEMENT

1. They
1. They tellteU everybody
everybody about
about it, including
it, including theiT
theirboss
bossand
andcoworkers
coworkers
2. They
2. They tell
tell OTIe
one or
ormore
more trusted
trusted coworkers
coworkers who
w h o do
do not
notcarry
carrypositions
positionsof
of
authority
authority over
over them
them
3.
3. They
They do
do not
not tell
teH anybody,
anybody, but
but do
do admit
admit to bipolar disorder
to bipolar disorder on their
on their
work-sponsored
work-sponsored health
health insurance
insurance claims
claims (leaving
(leaving open
open the possibility
the possibility
that
that their
their employer
employer could find out)
could find out)
4.
4. They
They do not tell
do not tell anyone
anyone atat work,
work, and
and they
they do not use
do not use their
their work­
work-
sponsored
sponsored insurance
insurance to
to cover
cover their
their psychiatric
psychiatric costs
costs

There is
There isno
noSingle
singlesolution thatthat
solution is right
is for everybody.
right Let me go
for everybody. Letthrough the
me go through the
pros and cons
pros and cons of
of telling
telling employers
employers or
or coworkers
coworkers about
about your
your disorder,
disorder, to
to help
help
you
you decide
decide which
which option
option seems best to
seems best to you in your
you in your current
current or
or future
future work en­
work en-
vironment.
vironment.

Whal
What Are
AreIhe Disadvanlages
the of Disclosing?,
Disadvantages The Risk of The
of Disclosing?: Job Discriminalion
Risk of Job Discrimination

If you
If you are
arecurrently
currentlyemployed, the
employed, most
the obvious
most disadvantage
obvious of disclosing
disadvantage of disclosing
your
your disorder
disorder is is that
thatyou
you may
m a y get
getfired
firedorordemoted
demoted or ordenied
denied aa promotion
promotion or oraa
raise.
raise. Likewise,
Likewise,telling
tellinga aprospective
prospectiveemployer
employerabout aboutyour
yourdisorder
disorderintroduces
introduces
the
the possibility
possibility that that he
he oror she
she will
will decide
decide against
against hiring
hiring you,
you, without telling
without telling
you
you why.
why.
Some
S o m e people
people withwith bipolar
bipolar disorder,
disorder, including
includingsomesome of ofmy
m y clients,
clients,have
havere­re-
poned
ported job job discrimination.
discrimination. It It is
is unclear
unclear howh o w often
often this
this occurs.
occurs. In In aa study
study byby
Nicholas Glozier (1998)
Nicholas Glazier (1998) of of the
the Institute
Institute of of Psychiatry
Psychiatry in London, 80
in London, 80 British
British
personnel
personnel directors
directors were
were asked
asked to to evaluate
evaluate oneone of
of two
two hypothetical
hypothetical job job candi-
candi­
dates
dates who,
w h o , based
based onon a a written
written profile.
profile, were
were described
described ininanan identical
identicalmanner
manner
(for
(for example,
example, as as having
having a a good
good prior
prior work
work record).
record). One
O n e was
was described
described as as hav­
hav-
ing
ing had
had a a diagnosis
diagnosis of of depression
depression and and the
the other
other as
as having
having diabetes.
diabetes. Personnel
Personnel
directors
directors werewere less
less likely
likely to
to hire
hire the
the applicant
applicant with
with depression
depression and and more
more likely
likely
to believe thaI he or she would have an impaired performance in an executive
to believe that he or she would have an impaired performance in an executive
job.
job. InIn other
other words,
words, we w e have
have a a long
long way
w a y to
to go
go in
in educating
educating employers
employers aboutabout
depression
depression and and bipolar
bipolar disorders,
disorders, their
their Similarity
similarity to to other
other medical disorders,
medical disorders,
and how
and h o w they
they will,
will, and
andwill
wiflnot,
not,affect
affectjob
jobperformance.
performance.ItItisis not clear
not clearwhether
whether
an
an unwillingness
unwillingness to
to hire
hire a
a hypothetical
hypothetical candidate
candidate translates
translates into
into discrimina­
discrimina-
Lion once
tion once a a real
real person
person with
with depreSSion
depression or or bipolar
bipolar disorder
disorder is hired.
is hired.
If you
If you areare fired
fired oror are
are not
not hired
hired because
because of ofyour
your bipolar
bipolar disorder,
disorder,thethe law
law
is
is on
on your side.Under
yourside. Under the theAmericans
Americanswith withDisabilities
DisabilitiesAct (U.S.Equal
Act(U.S. EqualEmploy­
Employ-
ment Opportunities Commission, 1990), it is u"'awful to discriminate against aa
ment Opportunities Commission, 1990), it is unlawful to discriminate against
"qualified
"qualified individual
individual with with a a disability,"
disability," meaning
meaning a a person
person who,
who, "with
"with oror with­
with-
out reasonable accommodation, can perfonn the essential functions of the em­
out reasonable accommodation, can perform the essential functions of the em-
ployment
ployment position
position thatthat such
such individual
individual holds
holds or or desires" (p. 4).
desires" (p. 4). Bipolar
Bipolar disorder
disorder
 Coping ffectively ininthe
(oping EEffectively theFomily ond
Family andWork
WorkSettings
Settings 279
279

does quahfy
does qualifyasasa adisability,
disability,which
whichis is defined
defined as physical
as "a "a physical or mental
or mental impair­
impair-
mment that substantially
e n t that substantially limits
limits o
one or mmore
n e or of the
o r e of the mmajor
a j o r life activities of
life activities of such
such
individual" (p.
individual" (p. 33).
) . Discrimination refers to
Discrimination refers to prejudicial
prejudicial behavior
behavior o
on the em­
n the em-
part in
ployer's part
ployer's in j
job
o b application
application procedures,
procedures, hiring
hiring practices,
practices, promotion
p r o m o t i o n or
or dis­
dis-
charge, pay, o
charge, pay, orr training.
training. YYou
o u ccannot legally b
a n n o t legally bee denied an
denied a equal jjob
n equal for equal
o b for equal
pay,
pay, be
b e segregated
segregated ffrom others, or
r o m others, or classified
classified such that y
s u c h that your
o u r opportunities for
opportunities for
advancement are
advancement limited (for
are limited (for example, demoted to
example, demoted to working
working in
in the
the mail
mail room)
room)
because of
because of your disorder.
your disorder.
If you
If you are
are qualified for a
qualified for job, "reasonable
a job, "reasonable accommodations" can be
accommodations" can be re-
re­
quired of
quired of the
the employer.
employer. For
For a
a person with bipolar
person with bipolar disorder
disorder these may
these m include
a y include
modified
modified work
w o r k schedules
schedules (for
(for example,
example, consistent
consistent work
work shifts),
shifts), job
job reaSSign­
reassign-
ments
ments to
to positions
positions more
more suitable to your
suitable to your stress tolerance level,
stress tolerance or restructur-
level, or restructur­
ing your
ing your work
w o r k environment
environment to
to avoid
avoid overstimulation
overstimulation (see
(see examples in the
examples in fol­
the fol-
lowing case
lowing case and
and in
in the
the sidebar
sidebar on pages 284-285).
on pages 284-285). Of
O f course, the employer
course, the employer
has
has to
to know about your
k n o w about your disorder
disorder to
to make
m a k e reasonable
reasonable accommodations.
accommodations. Your
Your
employer
employer cannot legally fire
cannot legally fire you
you or
or refuse
refuse to
to hire
hire you because you
you because you need
need a
a
reasonable
reasonable accommodation,
accommodation, unless
unless he
he or
or she
she can
can prove
prove that
that such an accom­
such an accom-
modation
modation would
would prove
prove an
an undue
undue hardship
hardship for
for the
the business
business (for
(for example,
example, place
place
the
the firm
firm deeply
deeply in
in debt)
debt)..
Consider
Consider the
the experience
experience of
of Janine,
Janine, a
a 37-year-old
37-year-old woman
w o m a n who worked at
w h o worked at
an
an advertising
advertising firm.
firm.

Janine
Janine waswas a valued
a valued employee
employee of ofherher firmbecause
firm becauseof of her
her high
high productiv­
productiv-
ity.
ity. She
She said
said that
that she
she had
had always
always been
been somewhat
somewhat hypomanic
hypomanic by nature,
by nature,
and
and that
that this
this hypomania
hypomania hadhad served
served herher well
well in
in her
her high-demand
high-demand work­ work-
place.
place. Her
Her first
first major
major bipolar
bipolar episode
episode was was aa depression
depression withwith symptoms
symptoms of of
paranoia
paranoia thatthat developed
developed gradually
gradually and and significantly
significantly interfered
interfered withwith her
her
work
work productivity.
productivity. SheShe took
took aa leave
leave of of absence
absence butbut didn't
didn't know
k n o w at
at the
the time
time
that
that she
she had
had bipolar
bipolar disorder.
disorder. Following
Following successful
successful medical
medical treatment
treatment
with
with mood
m o o d stabilizers
stabHizers and
and an
an antipsychotic
antipsychotic agent,agent,sheshewrote
wrote aaletter
lettertotoher
her
firm
firm explaining
explaining whatwhat had
had happened.
happened. Upon U p o n learning
learning ofof her
her disorder,
disorder, herher
employer
employer dismissed
dismissed her.
her. She
She consulted
consulted an an attorney
attorney and
and challenged
chaHenged this this
move
m o v e on
on legal
legal grounds.
grounds. After
After several
several legal
legal back-and-forth
back-and-forth communica­
communica-
tions,she
tions, shewaswasinvited
invitedback
backtotowork
w o r katat
the
thefirm,
firm, but was
but was told she
told shecould
could dodo
so
so only
only if
if she
she found
found aa job
job in
in aa different
different department.
department. She She diddid find
find aa job
job
within
within thethe same
same firm
firm but
but was
was unhappy
unhappy there there and
and eventually
eventually decided
decided to to
leave.
leave.SheShe is
is now
n o w working
working inin another
another firmfirm that
that is
is more
more sympathetiC
sympathetic to to her
her
needs.
needs.

Proving
Proving thatthat
jobjob discriminationoccurred
discrimination occurred can
can be
be difficult.
difficult.If you
If think you you
you think
are
are being
being discriminated
discriminated against
against because
because of
of the
the disclosure
disclosure of
of your
your disorder
disorder
(whether
(whether it
itwas
was you
you or
or someone
someone else
else who
w h o made
m a d e the disclosure), 1I would
the disclosure), would ad-
ad-
280
280 Sm·MANAGEMENT
SELF-MANAGEMENT

vise
vise you
you to
to consult
consultan an attorney
attorneyand andthe theEqual
EqualEmployment Opportunities
Employment Opportunities
Commission.
Commission. TheyThey cancan help
help you
you determine
determine if if aa legal
legal action should be
action should be laken
taken
against your current
against your current or or former
former employer.
employer.
Janine
Janine could
could have
have continued
continued LO to pursue
pursue her her legal
legal case but decided
case but decided that
that she
she
did
did not
not want
want to
to work
work in in aa firm
firm that
that held
held these
these attitudes
attitudes toward
toward her.
her. Deciding
Deciding
whether
whether or not to
or not to pursue
pursue a a legal
legal case
case is
is very
verymuch
m u c h aapersonal
personaland and often
oftenaafam­
fam-
ily decision.
ily decision. Consider
Consider its its potential
potential impact
impact on on your
your mood
m o o d stability
stability as
as well
well as
as
the likely outcome
the likely outcome of of the
the case
case (for
(for example,
example, being
being reinstated
reinstated in
in your
your old posi­
old posi-
tion, which
tion, which you
you may
m a y no
no longer
longerwantwant or orfeel
feelcomfortable
comfortablein). in).Be
Be prepared
preparedforforaa
long
long period
period of
of frustrations
frustrations (and (and high
high economic
economic costs)
costs) before
before your
your case
case is
is re­
re-
solved.
solved. Nonetheless,
Nonetheless, after
afterweighing
weighing all allofofthe
therelevant
relevantfactors
factorsyou
youmay
m a ywell
wellde­
de-
cide that pursuing
cide that pursuing your
your case
case is worth it.
is worth it.

"Can My
"Can My Employer
EmployerAskAsk
Whether I Have
Whether I Bipolar DisorderrDisorder?"
Have Bipolar

The Americans
The Americans with
v.ri.th Disabilities
Disabilities ActAct
makes it clear
makes that employers
it clear are not
that employers to not to
are
ask
ask direct
direct questions
questions about
about youryour disability
disability or require their
or require their own psychiatric ex-
o w n psychiatric ex­
amination
amination on on aa job
job application
application or or during
during the
the course
course of ofyour
your employment,
employment,"un­ "un-
less such
less such examination
examination or or inquiry
inquiry is is shown
shown to to bebe job-related
job-related and and consistent
consistent
with
with business
business neceSSity"
necessity" (p. (p. 7).
7). They
They can can require
require a a medical
medical examination
examination after after
a
a job
job offer
offer has
has been
been made,
made, if ifone
oneisisrequired
requiredof ofall
allnew
n e wemployees,
employees, oror asaspan
partofof
an
an employee
employee health
health program.
program. An A n example
example would
would be be a a physical
physical exam
e x a m reqUired
required
for all
for all new
n e w personnel
personnel at at aa nursing
nursing home.
home.
Your
Your employer
employer wouldwould have have to to prove
prove that
that inquiring
inquiring about
about your
your mental
mental
health
health status
status is
is essential
essentialto toknowing
knowing whether
whetheryou you can
can perform
perform your
yourjob job duties
duties
or whether you
or whether you would
would endanger
endanger the the safety
safety of
of others.
others. In In most
most cases,
cases, having
having bi­
bi-
polar
polar disorder
disorder does
does not
not mean
m e a n that
that others
others are
are atat risk,
risk, unless
unlessyouyou have
have aadocu­
docu-
mented
mented history
history ofof violence
violence or or also
also have
have anan alcohol
alcohol or or drug
drug abuse
abuse problem.
problem.
These
These associated
associated problems
problems couldcould jeopardize
jeopardize the the safety
safety of of others
others (for
(for example,
example,
if
if you
you work
work at
ataa child-care
child-care faCility,
facility,operate
operateheavy
heavymachinery,
machinery,or ordrive
drivea avehi­
vehi-
cle).
cle).
If
If the
the business
business to to which
which you're
you're applying
applying doesdoes require
require a a medical
medical exam,exam, it it
has
has toto collect
collect this
this information
information in in aa form
form that
that can
can bebe treated
treated asas aa confidential
confidential
medical
medical record,
record, meaning
meaning that thatyou
you would
would have
have to togive
giveaaSigned
signedrelease
releaseof ofinfor­
infor-
mation
mation before
before your
your records
records were were sent
sent toto anyone.
anyone. However,
However, the the doctor
doctor or or nurse
nurse
who
w h o examines
examines you you can
can inform
inform a a supervisor
supervisor or or manager
manager of of work
work accommoda­
accommoda-
tions
tions required
required by
by your
your disorder,
disorder, as
as revealed
revealed ininthe
the medical
medical exam.
exam. Likewise,
Likewise,ifif
your
your firm
firm has
has safety
safety or first aid
orfirst aid personnel,
personnel, they they may
m a y be
be informed
informed thatthat your bi­
your bi-
polar
polar disorder
disorder could
could require
require emergency
emergency treatment.
treatment. These These disclosures
disclosures may m a y or
or
may
m a y not
not occur
occur inin your
your work
work sening
setting and,
and, inin any
any case,
case, cannot
cannotlegally
legallybe beused
used toto
discriminate against you.
discriminate against you.
 Coping
Coping Effectively
Effectively in
in the
the Fomi�
Family ond
and Work
Work Senings
Settings 2 281
81

WhatWhat should
should you you doyour
do if if your current
current ororpotential
potential employer
employer asks
asksabout
aboutyour
your
psychiatric
psychiatric history,
history, either
either directly
directly or
or on
on a
a job
job application?
application? You
Y o u can
can say that
say that
you don't
you don't wish
wish to
to answer
answer the
the question
question (or
(or leave
leave the
the question
question blank)
blank) or point
or point
out that
out that the
the question
question is
is inappropriate (Court &.
inappropriate (Court Nelson, 1996).
& Nelson, 1996). If
If your
your em­
em-
ployer presses
ployer you, you
presses you, you don't
don't have
have to
to lie
lie about
about haVing
having the
the disorder.
disorder. Just
Just say
say
you'd
you'd rather not discuss
rather not discuss this
this matter
matter or that you
or that you want
want to
to get
get a
a consultation be­
consultation be-
fore
fore you
you discuss it.
discuss it.
A
A potential
potential employer
employer can
can refuse
refuse to
to hire
hire you
you upon
u p o n learning
learning of
of your disor­
your disor-
der,
der, but
but only
only if
if he
he or
or she
she can
can prove
prove that
that the
the disorder
disorder will
wiH interfere
interfere with
with your
your
job functions
job functions and
and that
that no
no reasonable
reasonable accommodations
accommodations can
can be made. In
be made. In most
most
cases,
cases, he
he or
orshe
she will
willhave
have aa tough
tough time
timeproving
proving these
thesepoints
pointsjust
justbecause
because you
you
have
have bipolar
bipolar disorder.
disorder. Of
O f course,
course, you
you would
would need to initiate
need to initiate legal
legal action
action
against
against your
your prospective
prospective employer
employer to
to make
m a k e your case.
your case.

Disodvontoges of Disdos.re,
Disadvantages DeolingDealing
of Disclosure: with Stigmo ot Work
with Stigma at Work

If your
If yourcoworkers
coworkerslearn that
learn youyou
that have a mood
have disorder,
a mood you may
disorder, experience
you may a
experience a
feeling
feeling of
of stigma-the
stigma—the sense
sense that
that your
your behavior
behavior is
is being
being viewed
viewed negatively in
negatively in
light
Hght of
of your
your illness.
illness. Usually
Usually this
thisstigma
stigmawill
willbe
bemost
mostsalient toyou
salientto you right
rightafter
after
a
a major
major bout
bout of
of mania
mania or
or depreSSion,
depression, in
in part
part because
because you
you will
will still
still be de­
be de-
pressed
pressed or
or hypomanic
hypomanic and
and possibly
possibly more
more attuned
attuned to
to the
the reactions
reactions of others.
of others.
But
But even
even people
people whose
whose bipolar
bipolar disorder
disorder has
has been
been stable
stable can
can feel
feel stigmatized at
stigmatized at
work.
work. For
For example,
example, imagine
imagine that
that your
your illness
illness is
is "leaked"
"leaked" by
by a
a fellow
fellow coworker
coworker
who
w h o tells
tells others
others in
in the office. Julie,
the office. aged 55,
Julie, aged 55, became
became quite
quite angry
angry with
with a
a
coworker
coworker one
one day,
day, and
and the
the coworker
coworker left
left the
the office
office crying.
crying. Julie
Julie had earlier
had earlier
disclosed
disclosed her
her illness
illness to
to a
a woman
w o m a n in
in the
the office
office whom
w h o m she
she considered
considered to
to be a
be a
close
close friend.
friend.After
Afterthe
theincident
incidentthis
thisfriend
friendtold
toldothers
othersin
inthe
theoffice
officeabout
aboutJulie's
Julie's
illness,
illness, as
asaaway
w a y of
ofexplaining
explainingwhy
w h yJulie
Juliehad
had responded
responded so
soseemingly
seemingly irratio­
irratio-
nally.
nally. After that, Julie
After that, Juliefell
feltthat
thatothers
othersviewed
viewed her
her with
with apprehension.
apprehension.
The
The stigma
stigma you
you experience
experience at
at work
w o r k may
m a y feel
feel similar to the
similar to the stigma
stigma you ex­
you ex-
perience
perience in
in your
your family.
family. For
For example,
example, coworkers
coworkers may
m a y interpret
interpret problems in
problems in
your
your work
w o r k as
as stemming
stemming from
from your
your illness,
illness, even
evenwhen
w h e n you
you can
can point
pointto
toother
other
employees
employees who
w h o have
have the
the same
same problems
problems (for
(for example,
example, being
being late
late with assign­
with assign-
ments,
ments, reacting
reacting irritably
irritably to
to a
a disorganized
disorganized or
or harsh
harsh boss)
boss).. You
Y o u may
m a y also find
also find
that
that your
your coworkers
coworkers become
become distant
distant or
or overly
overly cautious
cautious in
in their
their interactions
interactions
with
with you.
you. Coworkers
Coworkers may
m a y even
even react
react by
by doting
doting on
on you
you or
or becoming
becoming overly so­
overly so-
liciwus
licitous (for
(for example,
example, frequently
frequently asking
asking if
if you
you want
want to
to talk
talk about
about your
your prob­
prob-
lems,
lems, repeatedly
repeatedly reminding
reminding you
you that
that ''I'm
"I'm there
there for
for you").
you"). All
All of
of these re­
these re-
sponses
sponses can
can feel
feel unhelpful.
unhelpful. To
T o be
be fair,
fair, coworkers,
coworkers, like
like family
family members, are
members, are
often
often struggling
struggling to
to figure
figure out
out how
h o w best
best to respond to
to respond to your disorder.
your disorder.
On
On a
a more
m o r e hopeful
hopeful note,
note, mood
m o o d disorders
disorders carry
carry less
less of
of a
a stigma
stigma than they
than they
282
282 SElF�MANAGEMENT
SELF-MANAGEMENT

used
used to.
to.Because
Because ofofthethe
bravery of many
bravery public
of many figures
public who have
figures whotalked
have openly
talked openly
about
about their
their experiences
experiences of of bipolar
bipolar disorder
disorder or unipolar depression (for exam­
or unipolar depression (for exam-
ple,
ple, Kay
Kay Jamison,
Jamison, Elizabeth
Elizabeth Wurtzel,
Wurtzel, Carrie
Carrie Fisher,
Fisher, Patty
Patty Duke,
Duke, Robert
Robert
Boorstin,
Boorstin, Margot
Margot Kidder,
Kidder, Mike
Mike Wallace,
Wallace, William
William Styron),
Styron), and
and because
because ofof
events
events such
such asas the
the National
National Depression
Depression Screening
Screening Day,
Day, the
the public
public has
has an in­
an in-
creased
creased awareness
awareness andand aa greater
greater acceptance
acceptance of
of mood
m o o d disorders.
disorders. As
As a result,
a result,
you
you may
m a y get
get more
more understanding
understanding from
from olhers
others than
than you
you expected.
expected.

What
What Are
Arethe Advantages
the of Disclosing?
Advantages of Disclosing?

There
There are
are arguments
arguments in in favor
favor of
of being
being open
open about
about your
your disorder
disorder as
as well.
well. First,
First,
disclOSing
disclosing can
can bebe destigmatizing
destigmatizing and and increase
increase your
your own
o w n acceptance
acceptance ofof the
the ill­
ill-
ness.
ness. You
Y o u may
m a y feel
feel that
that bipolar
bipolar disorder
disorder is is not
not so
so shameful
shameful ifif you
you telltell a
a
coworker
coworker andand hehe or
or she
she does
does not
not have
have a a strong
strong negative
negative reaction.
reaction. Upon
U p o n learn­
learn-
ing
ing of
of your
your disorder,
disorder, aacoworker
coworker maym a y admit
admitto tohaving
havingexperienced
experienced depression
depression
or having
or having a a family
family member
m e m b e r or
or friend
friend who
w h o has
has bipolar
bipolar disorder.
disorder. But
But toto whom
whom
you
you disclose
disclose requires
requires careful
careful thought
thought. Kay Jamison (1995)
Kay Jamison (1995) describes
describes the reac­
the reac-
tions
tions of
of others
others upon
upon learning
learning of of her
her disorder,
disorder, which
which varied
variedfrom
from empathic
empathic ac­ ac-
ceptance
ceptance to to outright
outright rejection
rejection and
and insensitivity,
insensitivity, in in An
A n UnqUiet
Unquiet Mind.
Mind.
When
W h e n considering
considering whether
whether or or not
not toto disclose
disclose your
your disorder
disorder to
to a
a coworker
coworker
or
or employer,
employer, first
first ask yourself several
ask yourself several questions (Court &
questions (Court & Nelson,
Nelson, 1996).
1996).

Why Why
do youdowant
you want
him or him
herortoher to know?
know?
How
H o w will
will it
it make
m a k e your
your life
lifeat
atwork
work easier-will
easier—willititlead
leadtotoaaspecific
specificwork
work
accommodation?
accommodation?
Will
Will it
it be
behelpful
helpfulfor
forsomeone
someone to toknow
k n o w about
aboutyour
your disorder ifthere
disorderif isan
thereis an
emergency
emergency at at work?
work?
Will
Will you
you feel
feel closer
closer to
to this
this coworker-is
coworker—is he he or
or she
she a potential friend?
a potential friend?
Will
Will his
his or
or her
her knowledge
knowledge of of your
your disorder
disorder help
help you
you explain
explain absences
absences or
or
lapses
lapses in
in your
your work
work productivity
productivity to to your
your boss?
boss?
If
If there
thereis
isno
no reason
reason totoexpect
expect that
thatthe
the illness
illnesswill
willimpair
impair your
your work,
work,whywhy
does
does he
he or
or she
she need
need to
to know?
know?

SomeSome
of myofclients
my clients
havehave chosen
chosen oneone trustedperson
trusted personatatwork
workto teU about
to tell about
the
the disorder.
disorder. Sharing
Sharing this
this kind
kind of of personal
personal information
information helps
helps to
to increase
increase mu­
mu-
lOal
tual trust
trust and
and can
can create
create anan atmosphere
atmosphere of of support
support within
within the
the work
w o r k seuing.
setting. If
If
it seems appropriate, use the Quick Fact Sheet (on pages 260--2 61) intended
it seems appropriate, use the Quick Fact Sheet (on pages 260-261) intended
for
for family
family members
members to to help
help you
you explain
explain the
the illness
illness to
to this
this coworker.
coworker.
There
There are
are ways
ways to
to tell
tell people
people of
of your
your disorder
disorder without
without actually
actually using
using the
the
label "bipolar."
label "bipolar." For
For example,
example, youryour disorder
disorder can
can be
be described
described asas "a
"a chemical
chemical
imbalance that affects my mood" or "a medical problem related to my energy
imbalance that affects m y m o o d " or "a medical problem related to m y energy
 (oping Fami�
Effectivelyininthethe
Coping Effectively Family Work
andand SeMings
Work Settings 283
283

that can
level that
level can affect my
affect my work and and
work Simple Simple
concentration."
concentration." explanations
explanations like like
these may
these m a ybe all that
b e all e m p l o y e r s or
that employers c o w o r k e r s require
or coworkers w h y your
u n d e r s t a n d why
to understand
require to your
w o r k performance
work h a s shifted,
p e r f o r m a n c e has or why
shifted, or h a v e been
y o u have
w h y you irritable, withdrawn,
b e e n irritable, or
w i t h d r a w n , or
absent lately.
absent lately.
DisclOSing to your
Disclosing to o n may
early on
b o s s early
y o u r boss set the
m a y set stage for
the stage c h a n g e s in
later changes
for later in the
the
structure or demands
structure or of your
d e m a n d s of j o b (see
y o u r job thesidebar
(seethe o npages
sidebar on 2 8 4 -2285).
pages 284-- 8 5 ) . You
You
may m o r e legal
h a v e more
m a y have protection if
legal protection disclose your
y o u disclose
if you disorder when
bipolar disorder
y o u r bipolar when
you are well.
you are If your
weH. 1f employer knows
your employer ahead of
k n o w s ahead time, you
of time, problem solve
can problem
you can solve
with him
with him or her about
or her what accommodations
about what seem reasonable
accommodations seem during your
reasonable during pe­
your pe-
riod Hlness and
of illness
riod of and once have begun
you have
once you recover (as
to recover
begun to Louise did).
(as Louise did).
There be instances
m a y be
There may w h e n you
instances when feel you
you feel must disclose
you must disorder to
the disorder
disclose the to
your boss,
your such as
boss, such w h e n you've
as when had multiple
you've had absences or
multiple absences clear deterioration
or aa clear deterioration
in your work
in your people decide
S o m e people
productivity. Some
work productivity. to wait
decide to to see
wait to their perfor­
if their
see if perfor-
mance actually does
mance actually thendisclose
andthen
slip,and
does slip, disorderto
thedisorder
disclosethe tothe w h e n ask­
bosswhen
theboss ask-
ing for time
ing for off or
time off w o r k ad
other work
or other adjustments. This can
justments. This be a
can be plan, but
sensible plan,
a sensible but
timingisisimportant:
timing bossmay
Yourboss
important:Your annoyedby
feelannoyed
m a yfeel disclosureififititoccurs
thisdisclosure
bythis occurs
in the
in midst of
the midst trying to
of trying meet an
to meet important deadline.
an important Also,when
deadline. Also, youare
w h e nyou inan
arein an
active period
active you may
illness, you
of illness,
period of notbe
m a y not ableto
beable teHififyour
totell work performance
yourwork performance
has changed or
has changed that you
or that need accommodations.
you need accommodations.

Self-Care Strategies
Self-Care for (oping
Strategies for Effectively in
Coping Effectively W o r k Selling
the Work
in the Setting

Adiusling the Work

Adjusting Ihe Your Disorder
to Your
Setting 10
Work Selling Disorder

There is
There isvirtually
virtuallyno research literature
no research on what
literature what of
onkinds kinds of best
jobs are arepeo­
jobs for best for pe
ple with
ple W e suspect
disorder. We
bipolar disorder.
with bipolar people with
that people
suspect that with the disorder should
the disorder should
avoid jobs that
avoid jobs involve sudden
that involve bursts of
sudden bursts of social stimulation with
social stimulation little down
with little down
time in between
time in (for example,
between (for being a
example, being at a
waitress at
a waitress a bar with a
bar with a "happy hour"),
"happy hour"),
frequent travel across
frequent travel time zones,
across time or conSistently
zones, or consistently stressful with
interactions with
stressful interactions
others
others (for
(for example, in aa hospital
working in
example, working emergency room)
hospital emergency also suspect
W e also
room).. We suspect
that
that people with the
people with disorder do
the disorder with constant
better with
do better work
constant w o r k hours predict­
and predict-
hours and
able
able workdays than in
workdays than jobs requiring
in jobs shifting schedules
requiring shifting example, working
(for example,
schedules (for working
on
on weekdays week
one w
weekdays one and then
e e k and then weekends the next,
weekends the or working
next, or shifts
evening shifts
working evening
followed immediately
followed immediately by morning ones).
by morning Jobs in
ones). Jobs restaurants, manufacturing,
in restaurants, manufacturing,
nursing, and
nurSing, often require
salesoften
retailsales
and retail shifts,whereas
variable shifts,
require variable whereasjobs inaccount­
jobsin account-
ing, computer
ing, banking, and
programming, banking,
computer programming, schools are
and schools are usually more consis-
usually more consis­
tent. But
tent. But if thejobs
ifthe in the
jobs in former category
theformer you, you
to you,
appeal to
category appeal m a y not
you may have to
not have to
rule them
rule them out. Pursue them
out. Pursue try to
but try
them but whether you
determine whether
to determine obtain some
can obtain
you can some
of the accommodations
of the listed in
accommodations listed the sidebar
in the pages 284-285.
on pages
sidebar on 284-285.
What
W constitutes reasonable
h a t constitutes accommodations? These
reasonable accommodations! These are or
innovations or
are innovations
in your
modifications in
modifications requirements or
job requirements
your job work
or w o r k schedule that give
schedule that give you a more
you a more
284
284 Sm�MANAGEMEHT
SELF-MANAGEMENT

Reasonable
Reasonable Workplace
W o r k p l a c e Accommodations
Accommodations
for
for Persons
Persons with
with Bipolar
Bipolar Disorder
Disorder

Work
W o r k Hours
Hours

•
• Working regular daily
Working regular dailyorornightly hours
nightly rather
hours thanthan
rather variable night/day
variable night/day
work
w o r k shifts
shifts
•
• Being
Being assigned
assigned work
w o r k shifts
shifts that
that fit
fitbest
bestwith
withyour
yourcircadian
circadianrhythms
rhythms
(for
(for example, 0 A.M.-7
example, 110 a.m.-7 P.M.
p.m.instead of88 A.M.-S
insteadof a.m.-5P.M.;
p.m.;working
workingthree�hour
three-hour
shifts
shifts for five days
forfive days rather
rather than
than five�hour
five-hour shifts
shifts for
for three
three days)
days)
•
•Avoiding work
Avoiding work early
early in
in the morning if
the morning ifyou
you suffer
sufferfrom
from "medication
"medication
hangovers"
hangovers"
•
• RedUcing
Reducing work
work hours
hours or
or changing
changing from
from full�time
full-time to
to part-time
part-time
•
• Being
Being excused
excused from,
from, or
or getting
getting reductions
reductions in,
in,overtime
overtime work
work
•• Completing
Completing some
some of
ofyour
your tasks
tasks at
at home
h o m e versus
versus at
atwork
work

Stress
Stress Management
Management

•• Being
Being allowed
allowed to
toshare responsibilities
share for projects
responsibilities with others
for projects with others
•• Being
Being placed
placed in
in an
an office
office or
or cubicle
cubicle that
that has
has aa degree
degree of
of distance
distance from
from
noise
noise and
and stimulation
stimulation
•
• Working
Working in
in well-lit,
well-lit,uncrowded
uncrowdedrooms
rooms
•
• Being
Being excused
excused from
from certain
certain work
work assignments
assignments that
that histOrically
historically have
have
been
been triggers
triggers for
for your
your mood
m o o d swings
swings
•
• Obtaining
Obtaining support
support or
or counseling
counseling from
from an
an employee
employee assistance
assistance program
program
•
• Leaving
Leaving work
w o r k for
for breaks
breaks or
or lunch to decompress,
lunch to decompress,exercise,
exercise,walk,
walk,or
or
use
use self-relaxation
self-relaxation techniques
techniques
•
• Taking
Taking aa greater
greater number
number of
of short
short breaks
breaks rather
rather than
than two
two long
long breaks
breaks
during
during an
an eight-hour
eight-hour work shift
w o r k shift

Absences
Absences from
from Work
Work

•
• Being
Being granted
grantedbrief
briefabsences forfor
absences medical appointments,
medical withwith
appointments, chances
chances
to
to make
m a k e up
up the
the hours
hours
•
• Being
Being granted
granted extended
extended leaves
leaves of
of absence
absence with
with aa doctor's
doctor's note
note
•
• Being
Being allowed
allowed to
to leave
leave work
work early
early when
w h e n having
having difficult
difficult mood
m o o d swings
swings
or
or anxiety/stress
anxiety/stress reactions
reactions
 Coping Effecti
Coping vely inin the
Effectively the FamilV
Family and Work Settings
and Wask Settings 2 28S
85

Communication with
Communication with Your
Your Employer
Employer
about P�rformance
about Performance Evaluations
Evaluations

•
• Having
Havingregular
regularandand
open communication
open withwith
communication your your
employer
employer
about
about your
your job
job performance
performance
• Hearing
• Hearing what
what you're
you're doing
doing right
rightas
aswell
weH as
aswhat
what you're
you're doing
doing
wrong
wrong
•• Being
Being judged by overall
judged by overaH productivity
productivity and
and task
task completion
completion as as well
weH
as number
as number ofof hours
hours worked
worked
•
• Revisiting
Revisiting these
these accommodations
accommodations from
from time
time to
to time
time to
to determine
determine
if they
if they are
are enabling
enabling you
you to
to be productive and
be productive and remain stable
remain stable

equal
equalshot
shotat
at successful
successfulemployment.
employment.Reasonable
Reasonableaccommodations
accommodations are
are usually
usually
requested
requested by
by you
you as
as the
the employee,
employee, and
andare
aregenerally
generallynot
notoffered,
offered,up
upfront, byby
front,
the
the employer.
employer. Remember
Remember that
that your
your employer
employer cannot
cannot be
be expected
expected to provide
to provide
accommodations
accommodations without
without knowing
knowing about
about your
your disorder
disorder and
and why
why these
these accom­
accom-
modations
modations are required.
are required.
The
The sidebar
sidebar on pages 284-285
on pages 284-285 lists
lists examples
examples of
of accommodations that
accommodations that
might
might be
be reasonable
reasonable to
to request
request of
of an
an employer.
employer. These
These items
items are not meant
are not to
meant to
reflect
reflect the
the adjustments that
adjustments that aU
all people
people with
with bipolar
bipolar disorder
disorder should expect.
should expect.
Rather,
Rather,they
theyare
are meant
meantas
as examples
examplesof
of things
thingsyou
youcan
canask
askfor.
for. Try
Trytoto detennine
determine
which
which of
of these
these are
are negotiable
negotiable for
for you
you and
and which
which are
are not.
not. It
It is
is highly
highly unlikely
unlikely
that
thatany
anyemployer
employer would
would grant
grantall
all or
oreven
evenaamajority
majorityof
ofthem
them (and
(andsome
somemay
may
be
be against
against the
the nature
nature or
or policies
policies of
of the
the finn).
firm). Nonetheless, your employer
Nonetheless, your employer
might
might approve
approve enough
enough of
of these
these adjustments (0
adjustments to help
help you
you function better at
function better at
work.
work. Note
Notethat
thatsome
some accommodations
accommodations would
would also
alsobenefit
benefitemployees
employeeswho
w h o do
do
not
not have
have bipolar
bipolar disorder
disorder but
but who
w h o are
are seeking
seeking ways
ways to
to manage stress.
manage stress.
It
It is
is not
not always
always possible to know
possible (0 know in
in advance
advance which
which accommodations will
accommodations will
work
work for
for you,
you, but
but your
your employer
employer will
will probably
probablybe
bemost
mostopen
open to
tothese
theserequests
requests
· onCe
once you
you have
have been
been offered
offered the
the job
job and
and are
are in
in the
the negotiation phase. Some
negotiation phase. of
Some of
the
the items
items (for
(for example,
example, changing
changing from
from full-time
full-time to
to part-time
part-time work,
work, negotiat­
negotiat-
ing
ing leaves
leaves of
of absence,
absence, the
the style
style of
of employer/employee
employer/employee perfonnance evalua­
performance evalua-
tions,
tions,asking
askingthat
thatyour
youroffice
officebebe
moved) may
moved) mayneed
needtotobebe
negotiated later,
negotiated once
later, once
you
you have
have worked
worked at
at the
the job
job for
for aa period
period of
of time
time and
and have
have identified
identified problems
problems
with
with the
the existing
existing structure.
structure.
Ralph, 52,
Ralph, 52, worked
workedas
asthe
theprimary
primaryshort-order
short-ordercook
cookin
inaarestaurant,
restaurant,where
where
he
he supervised
supervised two
two other
other cooks.
cooks. He
He detennined
determined that
that he
he was
was prone
prone to
to hyperac­
hyperac-
tivity,
tivity, irritability,
irritability, and
and inefficiency
inefficiency on
on nights
nights when
when the
the restaurant activity
restaurant activity
reached
reached aa certain
certain volume.
volume. With
With the
thesupport
supportof
of his
his employer,
employer,he
helearned
learnedtotodel-
del-
286
286 SElF-MANAGEMENT
SELF-MANAGEMENT

egate the
egate the task
taskofof
supervising food
supervising preparation
food to onc
preparation of the
to one of other cookscooks
the other at at
those
those times.
times. He H e would
would then then continue
continue his his shift
shift as
as the
the secondary
secondary cook cook andand
would
would take
take over
over again
again as as primary
primary cook cook thethe next
next day.
day.
Tina,
Tina, age
age 59,
59, worked
worked for for a a research
research firm firm that
that aSSigned
assigned employees
employees to to
closely
closely interconnected
interconnected cubicles.
cubicles. OneO n e of
of her
her coworkers
coworkers insisted
insisted on on listening
listening to to
his
his radio
radio while
while working,
working, whichwhich was was not
not against
against company
company policy
policy but
but waswas very
very
disturbing to
disturbing to Tina.
Tina. She
She became
became unable
unable to to concentrate.
concentrate. She
She tried
tried to
to reason
reason withwith
the
the coworker,
coworker, who w h o expressed
expressed mock m o c k sympathy
sympathy and and then
then went
went back
back to to playing
playing
his radio.
his radio. She
She became
became mOTe more andand more
more irritated
irritated and
and noticed
noticed that
that her
her thoughts
thoughts
began
began to to race.
race. She
She eventually
eventually consulted
consulted her her boss
boss about
about thethe problem
problem without
without
explaining
explaining thatthat she
she had bipolar II
had bipolar II disorder.
disorder. Her Her boss
boss felt
felt that
that Tina
Tina was
was a a good
good
employee
employee and and decided
decided to to let
let her
her move
m o v e toto a
a smaller
smaller room
r o o m where
where she she would
would
have
have less
less contact
contact with
with others.
others. This
This ad justment helped
adjustment helped Tina
Tina restore
restore her previ­
her previ-
ous
ous level
level of
of productivity.
productivity.
Beth,
Beth, aa 44-year-old
44-year-old woman w o m a n with bipolar II disorder,
with bipolar disorder, discovered
discovered that that her
her
mood
m o o d swings
swings were
were at at their
their worst
worst at at the
the onset
onset of
of her
her menstrual
menstrual period.
period. She She
worked
worked at at aanews
newsoffice
officewith
withvariable
variableshifts;
shifts;sheshehad
hadbeen
been unable,
unable, for a variety
for a varietyof of
financial
financial and
and personal
personal reasons,
reasons, to toobtain
obtainregular
regularhours.
hours.Despite
Despitethe theloss
lossofofpay,
pay,
she
she decided
decided to to ask
askto tobebeexcused
excusedfrom fromeight-hour
eight-hourwork workshifts
shiftsin inthe
thetwo
twodaysdaysjust
just
prior
prior to
to the
the onset
onset of
of her
her menstrual
menstrual period.
period. She
Sheresumed
resumed work
w o r katather
hernormal
normal pace
pace
once the worst
once the worst mood wings associated
m o o d sswings associated with with her
her menstrual
menstrual c ycle were
cycle were over.
over.

Balan,ing
Balancing Work
Work Time
Timeagain" Down
against DownTime
Time

One work-related difficulty

One work-related difficulty I'veI've
heard expressed
heard by a number
expressed by a number of people with with
of people
bipolar disorder is the feeling of being wired and driven at work and then feel­
bipolar disorder is the feeling of being wired and driven at work and then feel-
ing
ing spent,
spent, exhausted,
exhausted, or or depressed
depressed onceonce home
h o m e for
for the
the night. Their problems
night. Their problems
are compounded on the weekend if there is little to do and they feel like
are compounded on the weekend if there is little to do and they feel liketheir
their
body
body andand brain
brain have
have shut
shut down.
down. As As a a result,
result, some
some people
people feelfeel hypomanic
hypomanic
when they're working and depressed when they're not.
w h e n they're working and depressed w h e n they're not.
This
This form
form of
of cycling
cycling is is most
most likely
likely toto happen
happen whenw h e n you
you start
start a a new job.
n e w job.
Like most other new employees, you probably want to perform at your peak
Like most other n e w employees, you probably want to perform at your peak
and
and begin
begin pushing
pushing yourself
yourself hard.
hard. But
But a a cycle
cycle can
can occur
occur in in which
which you you try to
try to
produce at your maximum and are quickly rewarded with praise, compensa­
produce at your m a x i m u m and are quickly rewarded with praise, compensa-
tion,
tion, oror advancement
advancement by by anan appreciative
appreciative boss.boss. This
This reward
reward may m a y make
m a k e you
you
drive
drive yourself
yourself even
even harder,
harder, leading
leading toto more
more reward
reward butbut also
also more
more hypomania
hypomania
or
or even
even mania.
mania. AsAs I1 mention
mention in inChapter
Chapter 5, 5,johnson
Johnsonand andher coHeagues(2000)
hercolleagues (2000)
found
found thatthat "goal
"goal attainment
attainment life life events"
events" (events
(events that
that involve
involve reward
reward or or ad­
ad-
vancement
vancement and and that increase your
that increase your drive
drive toward
toward other
other goals)
goals) are
are particularly
particularly
potent
potent in in preCipitating
precipitating manic
manic episodes.
episodes. Unfortunately,
Unfortunately, these these manic
manic states
states of­of-
ten
ten lead
lead into
into a
a depreSSive
depressive or or mixed
mixed episode,
episode, along
along with
with negative
negative thoughts
thoughts and and
 Coping
Coping Effectively
Effectively ininthe
theFami�
Familyondond
Work Settings
Work Settings 287
287

feelings about
feelings yourcapabiHties
about your capabilities
("1("I used
used to able
to be be able to accomplish
to accomplish so much").
so much").
In turn,
In turn, your
your boss,
boss, who
w h o may
m a y not
not know
k n o w about
about your
your disorder,
disorder, may
m a y compare
compare
your performance
your performance when
w h e n depressed
depressed toto the
the way
w a y you
you performed
performed when
w h e n you first
you first
started
started the
the job
job (rather
(rather than
than to
to the
the performance
performance of of other
other workers in his
workers in his or
or her
her
firm).
firm). He
H e or
or she
she may
m a y wonder
wonder what
what happened
happened toto you.
you.
W h e n you
When you first
first start
start a job, try
a job, try to
to take
take a
a more
more cautious, measured ap-
cautious, measured ap­
proach. Turn
proach. Turn in
in a
a consistent
consistent work
w o r k performance
performance and
and get
get your
your footing
footing in the
in the
new job,
new job, but
but don't
don't try
try to
to be
be a
a superstar
superstar at at the
the outset.
outset. Know
K n o w when
w h e n you
you are over­
are over-
stressing yourself.
stressing yourself. It's
It's better
better toto be
be a a consistem
consistent employee
employee than than a "start-stop"
a "start-stop"
employee,
employee, on on whom
w h o m others
others are
are unsure
unsure they they can
can depend.
depend.
When
W h e n you
you get
get home
h o m e from
from work,
work, allow
allow yourself
yourself toto relax
relax but
but also
also introduce
introduce
some structure
some structure (see Chapter 8)
(see Chapter 8) and
and a a degree
degree of of low-key
low-key stimulation.
stimulation. AvoidAvoid
scheduling
scheduling lotslots of
of demanding
demanding socialsocial activities
activities forfor the
the weekday evenings. Dur­
weekday evenings. Dur-
ing weekends, avoid "sleep bingeing" (for example, sleeping 12 or more hours
ing weekends, avoid "sleep bingeing" (for example, sleeping 12 or more hours
and getting
and getting up
u p late)
late) totocounteract
counteractyour yourfatigue
fatiguefrom
fromgetting
gettingup up at A.M.every
at66A.M. every
morning
morning during
during the
the week.
week. Instead,
Instead, keepkeep youryourbedtimes
bedtimesand andwakewake times
timesduring
during
the
the weekend
weekend to within one
to within one hour
hour of of your
your times
times during
during thethe week.
week. PlanPlan aa social
social
activity or
activity or exercise
exercise for
for the
the mornings
mornings duringduring the the weekend
weekend to to assure
assure that you'll
that you'll
be
be out
out ofof bed
bed by
by aa certain
certain time.
time. That
That way,
way, youryour internal
internal clock
clock will
will stay regu­
stay regu-
lated as
lated as you
you transition
transition from
from the
the work
w o r k week
week to to the
the weekend.
weekend.
These
These recommendations
recommendations may m a y sound
sound rigid,
rigid,but
butthey
theywill
willhelp
helpyouyou function
function
in
in the
the early
early stages
stages ofof your
your new job. Once
n e w job. O n c e you
you have
have worked
worked at at a job for
a job for aa while
while
and
and have
have settled
settled into
into aa routine,
routine, youyou maym a y bebe able
ableto
tointroduce
introduce more more flexibility
flexibility
into
into your
your daily
daily habits
habits without
without sacrificing
sacrificing your your mood
m o o d stability.
stability. This
This balance
balance
varies
varies considerably
considerably fromfrom person
person to to person,
person, so so take
take your
your time
time toto find the solu-
find the solu­
tion
tion that
that works
works best
best for
for you.
you.

Using Vocational
Using Vocationa'Rehabilitation
RehabilitationSupport
Support
If
If you
you have
have been
been having
having trouble finding a
trouble finding a job
job that
that is
is suitable
suitable for
for you,
you, or trou­
or trou-
ble
ble keeping
keeping jobs, you may
jobs, you m a y want
want to
toconsider
considervocational
vocationalcounseling.
counseling.Most
Most states
states
have
have aa Division
Division of
of Vocational
Vocational Rehabilitation
Rehabilitation devoted
devoted to
to helping
helping people
people with
with
disabilities. Generally,
disabilities. Generally, you wiH not
you will not have
have to
to pay
pay for
for these
these services.
services. To
T o locate
locate
these
these services
services in in your
your area,
area, call
call the
the local
local mental
mental health
health center
center or
or your
your city
city or
or
town's
town's Chamber
C h a m b e r of
of Commerce,
C o m m e r c e , or
or look
look in
in the
the phone
phone book
book under " State" in
under "State" in the
the
government listings.
government listings.
Vocational
Vocational rehabilitation
rehabHitation specialists
speciaHsts cancan help
help you
you develop
develop aa plan
plan for fmd­
for find-
ing and performing
ing and performing successfully
successfully in
in a
a job.
job. These
These plans
plans are
are focused
focused on
on what
what you
you
want
want toto achieve
achieve (for
(for example,
example, part-time
part-time versus
versus full-time
full-time employment; people­
employment; people-
oriemed
oriented versus
versus more
more solitary
solitary work
w o r k settings).
settings). Rehabilitation
RehabHitation can
can involve voca­
involve voca-
tional
tional testing
testing (for
(for example,
example, questionnaires
questionnaires regarding
regarding your
your interests, environ-
interests, environ-
288
288 S£lF-MANAGfMENT
SELF-MANAGEMENT

ments you
ments you enjoy,
enjoy, or
or job
job skills);
skills); training in job-seeking
training shills skills
in job-seeking (for example,
(for example,
writing
writing a a resume,
resume, making
making initial
initial telephone
telephone calls calls to
to an
an employer,
employer, and and effective
effective
interviewing strategies); and job development (locating jobs
interviewing strategies); and job development (locating jobs in the community in the community
or
or sometimes
sometimes even even designing
designing themthem to to fit
fit your
your aptitudes
aptitudes and skills).
and skills).
Job
]ob co aching is
coaching is often
often the
the most
most active
active component
component of of vocational rehabilita­
vocational rehabilita-
tion. A
tion. A job
jobcoach
coachgoes
goeswith
withyouyou totoaanew
n e wjob
jobsite,
site,helps
helpsyouyoulearn
learnthe therequired
required
tasks,
tasks, and
and encourages
encouragesyou you totostay
staymotivated.
motivated.He H e or
orshe
shecan
can facilitate
facilitatecommu­
commu-
nication
nication between
between you you and
and your
your boss.
boss. A A job
job coach
coach may
m a y help
help explain
explain your disor­
your disor-
der
der to
to yOUT
your supervisor
supervisor andand clarify
clarify any
any special
special considerations
considerations you you maym a y require
require
(for
(for example,
example, a a work
work environment
environment with with as as few
few distractions
distractions as as possible).
possible).
Employers
Employers may m a y listen
listen and
and respond
respond more more readily
readily toto a
a job
job coach
coach thanthan toto an
an
employee.
employee. jamal,
Jamal, a a 25-year-old
25-year-old man m a n with
with bipolar
bipolar II disorder,
disorder, became stressed
became stressed
by
by his
his job
job atatan
an auto
auto parts
parts store
store after
afterbeing
being switched
switched fromfrom one
one sales
salesarea
area to
toan­
an-
other.
other. HeH e didn't
didn'tlike
likehis
hisnew
n e w supervisor,
supervisor,whom w h o mhehefound
foundsarcastic
sarcasticand andunsym­
unsym-
pathetic
pathetic to to the
the limitations
limitations imposed
imposed by the disorder.
by the disorder.just
Justbefore
beforehe he qUit,jamal's
quit, Jamal's
job
job coach
coach interceded
interceded and and explained
explained the the disorder
disorder to to this
this supervisor.
supervisor. They They
agreed
agreed on on rules
rules for
for their
their working
working relationship
relationship and and strategies
strategies byby which
which Jamal
Jamal
could
could temporarily
temporarily leave
leave the
the setting
setting when
w h e n he
he felt
felt ovelWhelmed
overwhelmed by by il.
it. He
H e even­
even-
LUally
tually left
left this
thisjob
jobandandfound
foundaanew n e wone,
one,butbuthehefell
feltempowered
empoweredby bythe
thefact
factthat
that
when
w h e n he
he left,
left, his
hissupervisor
supervisorhad had changed
changed his hisstyle
styleof ofdealing
dealingwithwithhim.him.
Job coaches
job coaches can
can also
also be
be helpful
helpful if
ifyou need aaleave
you need leaveofofabsence
absence from
from work.
work.
IIf
f you
you need
need to
tobe
be hospitalized
hospitalized for
foraa manic
manic oror depressive
depressive episode,
episode,you
youmay
m a ynot
not
be
be in
in a
a condition
condition to
to ask
ask your
your employer
employer forfor a
a leave.
leave. AA job
job coach
coach can
canwrite
writeaalet­
let-
ter
ter or
or call
call your
your employer
employer to to advocate
advocate onon your
your behalf.
behalf.

Applying
Applying for
forDisability
Disability

If you
If youhave
havehad
hada series of illness
a series episodes
of illness or unremitting
episodes symptoms
or unremitting and haveand have
symptoms
been
been unable
unable toto function
function at
at work,
work, you
you maym a y wanl
want toto apply
apply for
for disability
disability pay­
pay-
ments.
ments. IfIfyou
you have
have preViously
previously paid
paid for
forshort-term
short-term or or long-term
long-term private
privatedisabil­
disabil-
ity
ity insurance
insurance through
through your
your employer,
employer, youyou maym a y be
be eligible
eligible for
for payments
payments with
with
an accompanying
an accompanying doctor's
doctor's order.
order. You
Y o u may
m a y also
also apply
apply for
for disability
disabflity payments
payments
through (he
through the Social
Social Security
Security Administration.
Administration. SocialSocial Security
Security payments
payments areare not
not
large
large (for
(for example, about $500
example, about $500 per
per month),
month), but but they
they can
can help
help support
support you
you
during
during a a period
period ofof work disability.
work disability.
Usually,
Usually, you
you apply
apply for
for disability
disabflity through
through a a liaison
Haison atat your
your local
local Social
Social Se­
Se-
curity
curity Office.
Office. The
The application
application process
process cancan bebe long
long (about
(about six
six months)
months) and of­
and of-
ten frustrating.
len frustrating. The
The procedure
procedure usually
usually requires
requires thatthat your
your doctor
doctor and
and psycho­
psycho-
therapist
therapist prOVide
provide medical
medical records
records and
and answer
answer questions
questions about
about your
your ability to
abihty to
work.
work. IIff you
you are
arein
in touch
touch with
with aavocational
vocational rehabilitation
rehabihtation counselor,
counselor,he
he or
or she
she
may
m a y be
be able
able to
to acquaint
acquaint you
you with
with the
the application
application procedures
procedures or
or recommend
recommend
 (oping
Coping Effedively in the
Effectively in the Fomilv
Family and
and Work
Work Senings
Settings 2 289
89

someone whocan.
someone who can. Because
Because of
of the
thelength of of
length thethe
process, you may
process, be more
you may sta­ sta-
be more
ble by
ble by the
the time
time your
your payments
payments arrive
arrive than
than you
you were
were when
w h e n you first applied!
youfirst applied!
Receiving
Receiving disability
disabflity does
does not
not mean
m e a n you
you have
have to
to abandon
abandon the
the idea
idea of
of work­
work-
ing
ing in
in the
the future.
future. You
Y o u can
can be
be on
on disability
disabihty for
for a
a period
period of
of time (for example,
time (for example,
during
during a
a long-term
long-term depression
depression that
that is
is not
not responding
responding well
w e H to
to medication)
medication) and
and
then
then reconsider
reconsider the
the working
working world
world once
once you
you have
have recovered.
recovered. Being on disabil-
Being on disabil­
ity should
ity should not
not have
have to
to be
be stigmatizing
stigmatizing or shameful. In
or shameful. In fact,
fact, many
m a n y people
peoplewith
with
bipolar disorder
bipolar disorder and
and other
other medical
medical disorders
disorders conclude
conclude that they need
that they this
need this
kind of
kind of support.
support. In
In the
the Boston
Boston University
University survey
survey of
of professionals
professionals and
and manag­
manag-
ers, one-third
ers, one-third had
had received
received disability
disability payments
payments at
at some
some point
point in
in their
their past
past
(Ellison &
(Ellison Russinova, 2001).
& Russinova, 2001).

* * *

Despite
Despite the
the toll
toll that
that bipolar
bipolar disorder
disorder can
can take
take on
on your
your family
family and
and work
work
life,
life,I Istrongly
stronglybelieve
believethat
thatyou
youcan
canlearn
learnto
tocope
copeeffectively
effectivelyin
inboth settings.As
bothsettings. As
you've
you've just
just seen,
seen, coping
coping involves
involves being
being comfortable
comfortable with
with your
your own under­
o w n under-
standing
standing of
of the
the disorder,
disorder, educating
educating others
others about
about it,
it, knowing
knowing your limitations,
your limitations,
setting
setting appropriate
appropriate expectations
expectations for
for yourself,
yourself, and
and trying
trying to
to adjust
adjust your envi­
your envi-
ronment to
ronment to maximize
maximize the
the chances
chances that
that you'll
you'll function
function at
at your
your best.
best.Remember
Remember
to
torely
relyon
on the
the help
help of
ofothers
others (friends,
(friends,family,
family,and
andcoworkers)
coworkers)for support
for when
support when
it
it seems
seems appropriate.
appropriate. Connie
Connie Hammen
H a m m e n and
and her colleagues (2000)
her colleagues found that
(2000) found that
the
the people
people who
w h o did
did best
best within
within the
the work
w o r k setting
setting were
were those
those who
w h o had
had strong
strong
social
social and
and relationship
relationship support
support outside
outside of
of work.
work.
Now
N o w that
that you
you have
have arrived
arrived at
at the
the end
end of
of this
this book,
book, II hope you have
hope you be­
have be-
come
come convinced
convinced that
that the
the strategies
strategies recommended
recommended here-learning
here—learning as
as much
m u c h as
as
you
you can
can about
about the
the disorder,
disorder, getting
getting consistent
consistent medical
medical treatment, taking
treatment, taking
advantage of
advantage of psychotherapy,
psychotherapy, relying
relying on
on social
social supports,
supports, and
and using self­
using self-
management tools-can help
management tools—can help you
you cope
cope with
with the
the disorder
disorder on
on a
a day-to-day
day-to-day
basis.
basis. Bipolar
Bipolardisorder
disorderposes
posesmany
m a n y challenges
challengesthat
thatare
arehard
hardfor
foranyone,
anyone,except
except
those
those suffering
suffering from
from it,
it, to
to understand.
understand. As
A s one
one client
client who
w h o has
has been stable for
been stable for
some
some time
time articulately expressed, "I
articulately expressed, "I have
have learned
learned to
to manage
manage my
m y disorder
disorder
rather
rather than
than being
being managed
managed by it."
by it."
Resources
R e s o u r c e s Jor
f o r People
People

with
w i t h Bipolar
B i p o l a r Disorder
Disorder

National
National Organizations
Organizations

Depression and
Depression andBipolar
Bipolar Support
SupportAlliance
Alliance (800-826-3632;
(800-826-3632; www.dbsalliance.org)
www.dbsalliance.org) is is de­
de-
voted
voted toto educating
educating consumers
consumers and and their
their family
family members
members about
about mood
m o o d disorders,
disorders,decreas­
decreas-
ing
ing the
the public
public stigma
stigma ofof these
these illnesses,
illnesses, foster ing self-help,
fostering self-help,advocating
advocatingfor forresearch
researchfund­
fund-
ing, and improving
ing, and improving access
access toto care. You
care. Y o u can fill out
can fill out aa confidential
confidential on-line
on-line mood
m o o d disorder
disorder
screening
screening questionnaire
questionnaire to help you
to help you identify
identify whether
whether you have the
you have the signs
signs of
of bipolar disor­
bipolar disor-
der.
der. Positive
Positive results
results from
from this
this questionnaire
questionnaire suggest
suggest that
that aa more
more comprehensive
comprehensive mental
mental
health
health evaluation
evaluation may
m a y be
be necessary.
necessary.

National
National Alliance
Allianceforforthe
theMentally
MentallyIII111
(80D-950-NAMI;
(800-950-NAMI;www.namLorg)
www.nami.org) isisa agrass roots,
grass roots,
self-help,
self-help, support
support and
and advocacy
advocacy organization
organization for
forpeople
peoplew ith severe
with severemental
mental illnesses
illnesses(in­
(in-
cluding bipolar disorder,
cluding bipolar disorder, recurrent
recurrentdepression,
depression,andandschizophrenia),
schizophrenia),their
theirfamily
familymembers,
members,
and friends.
and friends.

and Adolescent
Child and
Child Adolescent Bipolar
Bipolar Foundation
Foundation(847-256-8525;
(847-256-8525;www.bpkids.org),
www.bpkids.org)a, aparent-
parent­
led
led organization,
organization, provides
provides information
information and
and support
support to to family
family members,
members, health-care pro­pro-
fessionals,
fessionals, and
and the
thepublic
public concerning
concerning bipolar
bipolardisorders
disordersin inthe
theyoung.
young.CABF advocatesfor
C A B F advocates for
health
health serviCes
services and
and research
research on the nature,
o n the nature, causes,
causes, and
and treatmenl
treatment of
of early-onset
early-onset bipolar
bipolar
disorder. Particularly
disorder. Particularlyuseful
usefulis
isinformation
informationon onhow
h o wtotolocate
locatea amental
mentalhealth providerwho
healthprovider who
sees bipolar children in your area.
area.

Bipolar Significant
Bipolar SignificantOther
OtherMailing List(www
Mailinglist .bpso.org) s
(www.bpso.org) i is
anane-mail exchange
e-mail groupinin
group
exchange
which members-relatives
which members—relatives or friends of
or friends of persons
persons with
with bipolar
bipolar disorder-share
disorder—share information
information

290 290
 Resour{es
Resourceslor
forPeople
Peoplewith Bipo
with lar Disorder
Bipolar Disorder 291
291

about
about the
the illness,
illness,provide support
provide supporttoto
one another,
one and
another, problem
and problemsolve
solveabout
aboutissues related
issues related
to the
to the impact
impact of
of the
the illness
illness on
o n families
families and
and intimate
intimate relationships.
relationships.

MassachusettsGeneral
Massachusetts General Hospital
Hospital Bipolar
Bipolar Clinic
Clinic and
and Research
Research Program
Program (617-726-6188;
(617-726-6188;
617-724-6058; www
617-724-6058; w w w .. manicdepressive.org)
manicdepressive.org) provides
provides information,
information, referrals for evaluation,
referrals for evaluation,
treatment,
treatment, research,
research, and
and self-care
self-care LOols
tools (for
(for example,
example, a
a downloadable
downloadable mood
m o o d chan)
chart) to
to per­
per-
sons
sons with bipolar disorder and
and their families.
families.

National Alliance
National Alliance for
for Research
Research on
on Schizophrenia
Schizophrenia andandDepression
Depression (800-829-8289;
(800-829-8289; www.
www.
narsad.org)
narsad.org) isis the
the largest
largest donor-supported,
donor-supported, nongovernment
nongovernment organization
organization dedicated to
dedicated to
raising and
raising and distributing
distributing funds
funds for
for research into the
research into the nature,
nature, causes,
causes, treatments,
treatments, and
and pre­
pre-
vention of
vention of severe
severe mental
mental illnesses,
illnesses, including
including bipolar
bipolar disorder,
disorder, schizophrenia,
schizophrenia, depression,
depression,
and
and severe
severe anxiety
anxiety disorders.
disorders. Their
Their website
website includes
includes up-to-date
up-to-date information
information about
about the di­
the di-
agnosis
agnosis and
and treatment
treatment ofof severe
severe psychiatric
psychiatric disorders.
disorders.

National Institute
National Instituteof of Mental
Mental HealthHealth Publications
Publications (www.nimh.nih.gov/publicall
(www.nimh.nih.gov/publicat/
bipolar.cfm)
bipolar.cfm) provides
provides excellent
excellent up-to-date
up-to-date information
information ono n the
the symptoms,
symptoms, course, causes,
course, causes,
and
and treatment
treatment ofof bipolar
bipolar disorder.
disorder. Separate
Separate sections
sections are
are devoted
devoted to
to child
child and
and adolescent
adolescent
bipolar
bipolar illness,
illness, suicide,
suicide, medical
medical treatments
treatments and
and their
their side
side effects,
effects, co-occurring illnesses,
co-occurring illnesses,
psychosocial
psychosocial treatmems,
treatments, sources
sources of
of help
help for
for individuals
individuals and
and families,
families, and
and clinical
clinicalresearch
research
studies.
studies.

National Mental
National MentalHealth
Health Association
Association (crisisline:
(crisis line: 800-SUICIDE;
BOO-SUICIDE; www.nmha.org)
www.nmha.org) is the
is the
oldest
oldest and largest nonprofit
and largest nonprofit organization
organization in
in the
the United
United States
States that
that addresses
addresses all aspects of
all aspects of
mental
mental health
health and
and illness.
illness. Research
Research information,
information,legislaive
legislaiveupdates,
updates,and
and practitioner
practitioner refer­
refer-
rals
rals are
are available
available on
o n its
its web
w e b site.
site.

Pendulum
Pendulum Resources
Resources (www.pendulum.org)
(www.pendulum.org) offersoffers information
information about about the DSM-IV
the DSM-IV diag- diag­
nostic
nostic criteria,
criteria, current
current medical
medical treatments,
treatments, books
books favored
favored by
by mental
mental health
health consumers
consumers
and
and family
family members,
m e m b e r s , articles
articles on
o n how
h o w to
to cope
cope w ith depreSSion
with depression or
or bipolar disorder in
bipolar disorder in your­
your-
self
selfor
or aa loved
loved one,
one,writings
writings and
and poetry
poetry byby people
people with
with bipolar
bipolar disorder,
disorder,links
linksto
toother
otherrel­
rel-
evant
evant sites,
sites, and
and updates
updates on o n research studies.
research studies.

DepressionCentral
Depression CentralWeb Web SiteSite (www.psycom.nelldepression.cemral.bipolar.html)
(www.psycom.net/depression.central.bipolar.html) is anis an
informational web
informational sit that
w e b sit that offers
offers links
links to
to the
the MMayo
a y o Clinic's
Clinic's bipolar
bipolar homepage;
homepage; answers fre­
answers fre-
quently
quently asked
asked questions
questions about
about bipolar
bipolar disorder;
disorder; discusses
discusses treatment
treatment guidelines;
guidelines; gives
gives up­
up-
to-date
to-date information
information on o n topics
topics such
such asas novel
novel treatment
treatment approaches,
approaches, use
use of
of lithium
lithium during
during
pregnancy,
pregnancy, sleep
sleep deprivation,
deprivation, differential
differential diagnosis,
diagnosis, adjunctive
adjunctive therapy,
therapy, suicide,
suicide, and sea­
and sea-
sonal
sonal mood
m o o d disorders;
disorders; andand provides
provides aa self-screening
self-screening tool.
tool.

Bipolar
Bipolar World (www.bipolarworld.net)
World (www.bipolarworld.net) provides
provides information
information onon bipolar
bipolar diagnOSiS,treat-
diagnosis, treat­
ments, and
ments, and suicide,
suicide, an
an �ask
"ask the
the doctor·'
doctor" link,
link, personal
personal stories,
stories, information
information on
o n disabilities
disabihties
and
and stigma,
stigma, community
c o m m u n i t y and
and family
family suppon,
support, relevam
relevant books,
books, aa bipolar
bipolar message board, and
message board, and
chat
chat rooms.
rooms.

The Bipolar Child

The Bipolar {www.bipolarchild.com)
Child (www.bipolarchild.com) offersup-to-date
offers up-to-dale research findings
findings pertaining
pertaining
to
to bipolar
bipolar children,
children, aa newsletter
newsletter on
o n new
n e w treatment
treatment approaches,
approaches, samples
samples of
of individualized
individualized
292
292 Resou[[e')
l^esourcesfor Peoplewith
forPeople withBipolar
BipolarDisorder
Disorder

educational programs,
educational programs, information
informationon
onupcoming
upcoming conferences,
conferences, andand tips
tips howhow
on on to start
to start a a
support
support group.
group. For
For contact
contact information,
information, go
go to
to http://bipolarchild.comlcontact.html.
http://bipolarchild.com/contact.html.

Bipolar Disorder
Bipolar DisorderSanctuary (www.mhsanctuary.comJbipolar)
Sanctuary(www.mhsanctuary.com/bipolar) includes
includes educational
educational arti-arti�
cles
cles on
on bipolar
bipolar disorder,
disorder, an
an �ask
"ask the
the therapist"
therapist" discussion
discussion forum,
forum, first-person
first-person accounts,
accounts,
chat
chat rooms
rooms for
for patients
patients and
and family
family members,
m e m b e r s , aa clinician's
clinician's forum,
forum, links
links to
to new
n e w research
research
studies,
studies, and
and an
an on-line
on-line bookstore.
bookstore.

HarborofofRefuge
Harbor RefugeOrganization,
Organization,Inc. (www.harbor-of-refuge.org)
Inc.(www.harbor-of-refuge.org) provides
provides peer-to-peer
peer-to-peer
support
support for for individuals
individuals diagnosed
diagnosed with
with bipolar
bipolar di
sorder who
disorder w h o are
are undergoing
undergoing treatment.
treatment.
There
There is is aa discussion
discussion forumlchat room. Information
forum/chat room. Information is
is provided
provided ono n self-care
self-care and illness
and illness
management strategies.
m a n a g e m e n t strategies.

International Society
International Society for
for Bipolar Disorders (412-802-6940;
Bipolar Disorders www.isbd.org)
(412-802-6940; www.isbd.org) aims
aims totopro-
pro­
mOte
mote awareness
awareness of of bipolar
bipolar conditions
conditions in in society
society at
at large,
large, educate
educate mental
mental health profes­
health profes-
sionals,
sionals, foster
foster research
research on
on bipolar
bipolar disorder,
disorder, and
and promOte
promote international
international collaborations. Its
collaborations. Its
journal,
journal. Bipolar
Bipolar Disorders-An
Disorders—An InternationalJoumal
International JouiTial of Psychiatry
of Psychiatry and Neurosciences, is
and Neurosciences, is be­
be-
coming
coming a a primary
primary outlet
outlet for
for new
n e w research
research on
on the
the diagnosis,
diagnosis, etiology,
etiology, and
and treatment
treatment ofof bi­
bi-
polar
polar conditions.
conditions. ISBD
ISBD publishes
publishes aa newsletter
newsletter and
and has
has several on-line chat
several on-line chat rooms,
rooms, includ­
includ-
ing
ing an
an �ask
"ask the
the experts"
experts" exchange.
exchange.

Internet Mental
Internet Mental Health (www.mentalheahh.comldislp20-md02.html)
Health (www.mentalhealth.com/dis/p20-md02.html) is another
is another infonna­
informa-
website. A
tional website. A strength
strength of
of this site
site is
is the
the direct
direct linkages
linkages between
between speCific
specific topicS
topics and
and
published
published research
research abstracts
abstracts pertaining
pertaining to
to the
the topics. It is
topics. It is aa particularly
particularly good
good site
site for
for new
new
research on
research on medications.
medications. Downloadable
Downloadable self-rated
self-rated mood
m o o d questionnaires
questionnaires andand mmood
o o d charts
charts
are
are available.
available.

Juvenile Bipolar Research

Juvenile Bipolar Foundation
Research Foundation (www.bpchildresearch.org)
(www.bpchildresearch.org) is the
is the firstcharitable
first charitable
organization
organization solely
solely dedicated
dedicated toto the
the support
support ofof research on on the
the etiology,
etiology, treatment,
treatment, and
and
prevention of juvenile-onset
juvenile-onset bipolar
bipolar disorder.
disorder. JBRF
J B R F has
has organized
organized aa consortium
consortium of ofcollab­
collab-
orating
orating research
research groups
groups and and individual
individual investigators
investigators fromfrom aa number
n u m b e r of
of medical
medical schools
schools
and
and treatment centers aroundaround the country.
country. Through
Through its its website,
website, parents can learn about about
and volunteer
and volunteer for
for research
research studies
studies that
that are
are sponsored
sponsored by by the
the foundation.
foundation. lnfonnation
Information is
provided
provided concerning
concerning educational
educational forums
forums for
for parents
parents and and teachers,
teachers, how h o w to
to subscribe
subscribe to
profeSSional
professional e-mail
e-mail list-serves
list-serves for
for physicians
physicians and
and therapists,
therapists, and
and nnew e w research
research fmdings
findings
pertinent to childhood-onset disorder. A
childhood-onset bipolar disorder. A case conference
conference series is is planned
planned for the
fall of 2003.
2003. For
For more
m o r e informalion,
information, e-mail info®jbrf.org.
info@jbrf.org.

MedlinePlus
Medline PlusHealth
HealthInformation
Information (www.nlm.nih.gov/medlinepluslbipolardisorder.html)
(www.nlm.nih.gov/medlineplus/bipolardisorder.html)
offers links
links to National Institute of Mental Health publications andand clinical trials. It in­
trials. It in-
cludes overviews
cludes overviews of
of current
current bipolar
bipolar research and
and information
information regarding
regarding children,
children, leenag·
teenag-
ers,
ers, and disorder. A
and seniors with the disorder. A link to the Medline search engine for the most
most recent
research articles on
on bipolar disorder isis provided.
provided.

http://bipolar.abouLcom is
http://bipolar.about.com isan
aninformational
informationalsite that
site contains
that articles,
contains discussion
articles, forums,
discussion forums,
book
book reviews,
reviews, and
and chat rooms.
rooms.

McMan'sDepression
McMan's Depression
andand Bipolar
Bipolar WebWeb (www.mcmanweb.com)
(www.mcmanweb.com) is a comprehensive
is a comprehensive web web
 Resources
Resourcesfor
forPeople
Peoplewith Bipolor
with Disorder
Bipolar Disorder 293
293

sitewith
site withsubstantial
substantiallinks to current
links research,
to current essays
research, on first-person
essays experiences,
on first-person and an and
experiences, an
opinion
opinion page.
page.

Books on Ihe
Books on the Subjecl
Subject
Info/motional
Informational Guides
Guides

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Johanson, A. L. (2000). II am
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Birmaher,
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 Psychotic Symptoms
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Reprinted by
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permission of
of Monk
M o n k et al. (1991).
et al. (1991). Copyright by
by Elsevier Science.
Science.

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