Surviving Bipolar Disorder
What you need to know to effectively cope with bipolar disorder
(August 18, 2004) -- David J. Miklowitz, Ph.D., is a professor of
psychology at the University of Colorado and a nationally recognized
expert on bipolar disorder. The creator of a family focused
psychotherapy for the disorder, he is also the author of a highly
regarded book of practical advice for patients, The Bipolar Disorder
Survival Guide: What You and Your Family Need to Know (Guilford,
2002). In a recent conversation, he discussed how patients can lessen
the impact of the disorder on themselves and their lives.

Medication and psychotherapy
Medication has to be combined with psychotherapy wherever possible.
There is a need to learn self-management--illness-management skills.
People need to learn to recognize when they're starting to cycle. And
to get preventive intervention--sometimes medical, sometimes
behavioral--when starting to cycle into manic or depressive episodes.
You don't learn that from medication.

HealthyPlace.com Radio
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In addition, people need to learn about stress triggers. What events
or changes in one's life bring about these mood cycles or contribute
to them? In college, for example, students are in constantly shifting
sleep-wake cycles, but it is known that depriving someone of a
night's sleep can bring about manic symptoms. Experiences of loss or
rejection can be associated with depression; family conflict can be
associated with relapse. Patients need to be aware of and know how to
cope with all those situations.

Another issue psychotherapy addresses is acceptance of the illness.
Many people do not take the diagnosis of manic-depression seriously.
They may take prescribed medication for a while and then go off,
precipitating a relapse or worse. Psychotherapy helps a person accept
that they have an illness, that it's likely to be recurrent, and that
they need to learn to manage it both behaviorally and physiologically.

Psychotherapy options

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Interpersonal and Social Rhythm Therapy

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There are basically three new forms of therapy for bipolar disorder
that are validated by research.

* family-focused therapy, which involves patient and family, since
family dynamics affect the outcome of mood conditions, and educates
them about the disorder and trains them in communications and problem-
solving skills.

* interpersonal and social rhythm therapy, which helps patients learn
to manage their sleep-wake cycles and regulate their daily-living
routines.

* cognitive behavioral therapy specific to bipolar disorder, which
helps patients restructure not only the pessimistic thinking
associated with depression but the unduly optimistic cognitions of
mania; patients often say things to themselves like "I've got to have
it now or something terrible will happen if I don't get what I want
this moment," or they underestimate the risks of doing something and
overestimate the benefits.

Proper medical treatment

It's increasingly difficult in these days of managed care for
patients to get proper treatment. Plans may dictate certain doctors,
who may or may not be expert in mood disorders. Alternatively there
may be a doctor expert in managing bipolar patients but is booked for
several months when a patient is in need of finding outpatient care
quickly. The people who do best with bipolar disorder latch on to a
doctor that they trust and see over time, through the ups and downs,
who monitors them and experiments with new mediations where
necessary. Seeing a doctor for 15 minutes every couple of months is
not good enough for managing this disorder. That's why it is
increasingly necessary for patients to learn illness-management
skills.

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Getting a life back

Once mood cycles are under control, patients face the challenge of
getting their life back. They may no longer be symptomatic but they
may have trouble holding a job or having a relationship. Sometimes
that's because there are residual cognitive problems that don't
disappear right away--with memory, attention, vigilance,
concentration. Further, some medications can affect cognitive
functioning. In addition, following a manic episode some people have
a mild or moderate depression even though they are no longer
characterized as cycling, which makes it harder for them to regain
the level of functioning they had before the episode.

Self-management skills

There are many things patients can learn on their own to minimize the
chance of manic or depressive episodes. One crucial tool is mood
charting, keeping track of mood states on a regular basis. People who
observe themselves in an objective way every day--rate their mood,
record daily activities and amount of sleep (use the form above)--
will see patterns that identify the triggers for their ups and downs.

Is it alcohol or drugs? Sleep patterns or stressful arguments? Work
demands or changes in medications?

Workplace issues

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Many bipolar patients have trouble with a 9 to 5 routine. That is
ironic, because a predictable schedule keeps them on a regular sleep-
wake cycle. But sometimes they do better with jobs that provide some
flexibility of hours or allow them to do some work at home.

They also run into the puzzle of whether to tell co-workers about the
disorder. I recommend that they tell someone at work only if they
want that person to help them in some way and knowing that they're
bipolar is necessary for that help. For example, perhaps you've had
several episodes, are finally stabilized and get a job--but know that
you could cycle into mania and that one of first signs is that you
stay late at work or get physically intrusive with other people. You
could acquaint a co-worker that those are your early signs, and to
please point it out to you if you are doing any one of them.

But to tell someone you're bipolar just to get it off your chest can
backfire.

Alcohol and substance abuse

Bipolar patients are extra prone to alcohol and substance abuse
disorders by quite a margin; 60% of people with bipolar disorder have
a history of some sort of substance abuse, compared to the general
population rate of 10 or 15%. The cycling of the disorder involves
either the craving for drugs and alcohol or self-medicating.

Patients usually describe their substance use as self-medication. But
when you're manic you crave more of everything--more food, more sex,
more excitement, and more alcohol or drugs, including marijuana, to
accentuate the high. Sometimes substance abuse treatment is needed in
addition to medication aimed at mood stabilization.