Understanding Bipolar Disorder

Introduction

Bipolar disorder, also known as manic depression or manic-depressive illness, is a medical illness that affects more than three million Americans. Bipolar disorder is highly treatable, and new options are continually improving the outlook for consumers and their loved ones. (The term consumer is preferred over patient by most people with serious mental illnesses.) Despite impressive progress, two thirds of people with bipolar disorder are not properly diagnosed or treated. With accurate diagnosis, effective medication, and proper support, many people with bipolar disorder can lead normal, productive, and fulfilling lives.

When left untreated, however, bipolar illness can have destructive and costly effects, not just for the ill people, but also on the lives of their family members and society. Roughly 40 percent of people with untreated bipolar illness abuse alcohol or drugs, and 60 percent will have marriages that end in divorce. Job loss is not uncommon, and suicide is too often a consequence of the illness. Because of the wide range of potentially damaging symptoms and behaviors that accompany the disorder and because of misunderstanding by the public, people with bipolar illness are often unnecessarily stigmatized by society.

This paper will explain what scientists know about the cause and symptoms of bipolar disorder, discuss its treatment, and suggest ways to successfully manage it. Taking the time to read this information is an important first step toward understanding the illness and seeking proper medical care.

Recognizing Bipolar Disorder

What is bipolar disorder?

Bipolar disorder, or manic depression, is a disorder of the brain resulting in episodes of mania and depression. These episodes last days to months. Between episodes, most people with bipolar illness have periods of relatively normal moods and activity, and they may go years or decades without a major episode—indeed, with little or no sign of illness. For others, managing their illness poses a greater challenge, sometimes because their symptoms may respond only partially to treatment or may recur even with ongoing treatment. These consumers require very careful self-monitoring and frequent medication adjustments.

Bipolar disorder is common. It affects approximately one percent of the adult population. In contrast to depression alone, which is more common in women, bipolar illness is seen equally as often in men and women. This brain disorder often begins in adolescence or early adulthood and continues throughout life. A major life event may trigger the first episode. In its early stages, bipolar disorder may masquerade as a different problem, such as alcohol or drug abuse or poor functioning at work or school.

Bipolar disorder is a chronic condition with recurring episodes, much like diabetes, and it generally requires ongoing treatment. If it is left untreated, it tends to get worse, and the symptoms become more pronounced. With proper treatment, it can be controlled.

Recognition of the disorder at its various stages is important so that the ill person seeks and receives appropriate treatment and can avoid the harmful consequences of the disorder.

Although bipolar disorder is described as a mood disorder, episodes of illness produce significant changes in a wide range of areas, including activity, energy, sleep, appetite, speech, thinking, and judgment.

Mania is the word that describes the activated phase of bipolar disorder. When it is less severe, it is called hypomania. Symptoms of mania may include:

· either an elated, happy mood or an irritable, angry, unpleasant mood

· increased activity and energy

· more thoughts and faster thinking than normal

· increased talking, more rapid speech than normal

· ambitious, often grandiose, plans

· poor judgment

· increased sexual interest and activity

· decreased sleep and decreased need for sleep

Depression is the other phase of the illness.

Its symptoms may include:

· depressed or apathetic mood

· decreased activity and energy (sometimes, however, restlessness and irritability may be prominent, rather than inactivity)

· fewer thoughts than normal and slowed thinking

· less talking and slowed speech

· less interest in, less participation in, and less enjoyment of activities that are normally enjoyable

· decreased sexual interest and activity

· hopeless or helpless feelings

· feelings of guilt, worthlessness, pessimistic outlook

· suicidal thoughts

· changed appetite, either significantly increased or decreased

· changed sleep, either increased (with an increased need for sleep) or decreased (with tiredness and an inability to fall asleep or stay asleep)

The patterns of untreated episodes vary markedly both among individuals and at different times in a given individual’s life. Some people with untreated bipolar disorder have only an occasional episode of mania and repeated episodes of depression. Others may experience mania or hypomania as their main symptom and have few episodes of depression. Symptoms of mania and depression can also occur together in what is known as a mixed state of bipolar disorder, or mixed mania. Often a period of depression will follow a manic episode, and sometimes people go directly from depression into mania.

Rarely, individuals may develop rapid cycling, which is regularly alternating periods of mania and depression. Rapid cycling is more common in women, and it may be triggered by antidepressant treatment. What is called ultradian cycling—in which significant mood changes occur several times during the day—is less well studied, and both its relationship with classic bipolar disorder and its response to classical treatments are less clear.

You may also hear the terms bipolar I and bipolar II. If someone has experienced at least one manic episode, the illness is called bipolar I; if the individual has experienced only hypomania, the illness is called bipolar II. Some people who initially have only hypomania (bipolar II) will later have a manic episode (thus developing bipolar I), while others have only recurring hypomania.

It is extremely important to recognize mania and depression early in the course of bipolar illness because early diagnosis and treatment can help prevent the harmful consequences of untreated episodes such as school failure, loss of employment, damage to important relationships, divorce, and suicide.

However, particularly in its early stages, bipolar illness may be hard to recognize. And even if others see signs of trouble, it may be very difficult to get the person with symptoms to seek help. During hypomania or mania, mood is often elated and judgment impaired. People often deny that their changed mood and behavior is an illness. During depression, a sense of hopelessness or guilt or a lack of energy may be so profound that seeking help seems useless or impossible. Friends and family members may have to intervene actively and assertively.

“It became tough to live my life with the depression and with the manic side. The highs got too high and the lows got too low and there was very little middle.”

The experience of mania and hypomania

People on the “high” side of bipolar disorder may feel on top of things, productive, sociable, and self-confident—but the feeling are exaggerated. Many people have described the “highs” of hypomania as feeling better than at any other time in their lives. They cannot understand why anyone would call their experience abnormal or part of a disorder. They feel excited, have surges of energy, and describe feeling more creative, active, intelligent, and sexual. They can often accomplish tremendous amounts of work. Hypomania is particularly appealing to individuals who have recently come out of a period of depression.

Unfortunately, the “high” frequently does not stop with hypomania. The mood becomes more elevated or irritable, behavior more unpredictable, and judgment more impaired as mania develops. People often make reckless decisions during periods of mania. Spending sprees, alcohol and drug abuse, and hypersexuality are common. These periods of perceived self-importance and unencumbered empowerment can cause confusion and loss of contact with reality for the person with the disorder; and more often than not, he or she is oblivious to the negative consequences of extreme actions. People with bipolar disorder rarely seek treatment during a manic episode because they do not recognize that anything is wrong.

“It does come to a point of accepting the fact that you have a medical illness, very similar to high blood pressure or diabetes and one in which you have to monitor over time shifts in mood, changes in behavior and just be really observant of it.”

The experience of depression

Clinical or medical depression goes far beyond a normal sense of sadness. When they are depressed, people with bipolar disorder are often in a profoundly sad, irritable or “flat” mood. The inner pain may be intense and result in feelings that life is totally without pleasure and not worth living. When depressed, people with bipolar disorder lose interest in their usual activities. Even eating and sex are no longer enjoyable. Former interests seem boring or unrewarding, and the ability to feel and offer love may be diminished or lost.

The “lows” of depression are often so physically debilitating that people in this phase of the illness may even be unable to get out of bed. Sleep is disrupted. Typically, depressed individuals have difficulty falling asleep, waken throughout the night, and waken an hour to several hours earlier than they’d like to. However, about 20 percent of depressed people sleep more than usual. In either case, they awaken without feeling rested.

Most depressed people lose their appetites, and their weight loss can be significant. About 15 percent will have an increased desire to eat and gain weight, but most of these people will still report that the food they eat does not actually appeal to them.

The most frightening part of bipolar disorder to people who are depressed is often their inability to concentrate, remember, and make decisions. In the midst of a severe depression, people may not be able to follow a newspaper story or a television comedy. Major decision-making is impossible. Even minor decisions such as what to have for dinner can seem overwhelming.

Self-esteem is very low in a depressed person, who often dwells on memories of losses or failures and feels guilty and helpless. “I am not worth much” and “the world is a terrible place” are common negative thoughts.

Symptoms of depression often come together in a strong feeling of hopelessness, a belief that nothing will ever improve, and exaggerated pessimism. Periods of depression can lead to the wish to die or thoughts of suicide—or actual suicide. Suicide is always a danger, sometimes because ill people may become overwhelmed by what they have done while in a manic state and sometimes because of the depth of the depression.

It is important to realize that not everyone with bipolar disorder experiences periods of mania and depression with the same intensity. People will more often seek treatment during a depressive episode because they can better recognize these symptoms as disruptive to their daily life.

“If I’m an artist and I’m bipolar and I take the medication, what happens, where’s my creativity fall into that spectrum of who I am on or off medication?”

Difficulties diagnosing bipolar disorder

Even for a trained professional, bipolar disorder can be difficult to diagnose. If someone with biplar disorder seeks treatment during a depressed period, he or she may be misdiagnosed as having clinical depression, especially if the physician is unfamiliar with the person’s previous life events and moods. On the other hand, people rarely seek treatment during a manic episode because they do not realize that they have a problem. A correct diagnosis is more likely when the physician knows the patient’s history and observes mood-swing patterns. Information from family members and friends is often crucial to a correct diagnosis because people in the midst of an episode may not recognize, remember, or report important symptoms and behaviors.

“Everybody struggles with this illness and denies that they’re sick or denies that they have it and denies that their life has to change. But it’s like any other chronic illness, if you have rheumatoid arthritis, you know, you’re not going to be opening jars for a living, okay?”

What causes bipolar disorder?

While no one knows the exact cause of bipolar disorder, researchers believe it is the result of a chemical imbalance that affects certain parts of the brain. Researchers exploring the origin of the disorder have uncovered a genetic link to the illness. Because bipolar disorder tends to run in families, close relatives of someone with the disorder are more likely to be affected by the disease. Heredity, however, is not always apparent in people with bipolar disorder, and certainly not everybody with genetic predisposition becomes ill.

Sometimes a serious life event is said to “cause” bipolar illness. A better way to think about this disorder is to realize that a serious loss, chronic illness, very difficult relationship or financial problem, or any major change in life can trigger an episode in some individuals with a predisposition to develop the illness. But episodes can also occur without an obvious trigger because of the cyclical nature of bipolar disorder.

There are two other “triggers” of bipolar episodes worthy of special mention. Treatment of a depression with antidepressant medication can sometimes trigger a switch into hypomania or mania. This can often be avoided by starting treatment with a mood stabilizer before the antidepressant. And hypothyroidism (perhaps as an effect of lithium treatment) can contribute to a depression or mood instability. Hypothyroidism can be treated with small replacement doses of thyroid hormone.

“Well the question that nagged me the most was why did I end up like this? What caused it? Could it have been prevented?”

Can bipolar disorder be cured?

Currently, bipolar disorder cannot be cured, but it can be controlled. It is a chronic disorder that requires ongoing treatment, but almost all ill people can get substantial relief from their symptoms with proper therapy. Medication is often prescribed indefinitely to maintain a normal pattern of mood. While no cure exists, most who seek and continue treatment can lead reasonably stable and satisfying lives. Without proper treatment, however, many people have repeated episodes of illness that may become progressively more severe and lead to unproductive lives.

“It doesn’t bother me much to take medication everyday because then I get to function, you know, that’s the gift it gives.”

Getting treatment

How is bipolar disorder treated?

Medication is an essential part of successful treatment for people with bipolar disorder. In addition, psychotherapy and support groups are important to help people understand the impact the illness has on their lives and their families’ lives and to learn how to cope with the stresses that can trigger episodes. A person with bipolar disorder—and his or her family—should learn as much as possible about the illness and become involved in the treatment plan from the time it is started and through all its stages or adjustments. Changes in medications or doses may be necessary, and treatment plans may change during different stages of the illness.

In this section, we will pay the most attention to mood stabilizers and mention just briefly the role of antidepressant and antipsychotic medications. This paper cannot discuss everything you should know about specific medications, so be sure to get detailed information about all medications you consider taking, either from NAMI fact sheets, from your doctor, from the pharmacy, or from guides to psychiatric medications you can find in bookstores.

Two medications commonly used to treat bipolar disorder are called mood stabilizers, and they include lithium (with brand names such as Eskalith or Lithobid) and divalproex sodium (Depakote).

Lithium has been the primary medication used to treat mania because of its ability to stabilize mood. This drug is effective for preventing episodes from occurring and for treating an episode after it has begun. Manic and depressive episodes occur less frequently and are less severe when people take lithium regularly. It can take about seven to 14 days to respond to lithium.

The therapeutic dose of lithium varies a great deal among individuals and even as phases of the illness change. Blood levels of lithium must be monitored because many factors—such as kidney function, fluid intake, and salt intake—can influence an individual’s blood level of this drug even when he or she regularly takes a specific oral dose. During severe episodes, doctors try to keep doses and blood levels higher than during a stable, maintenance phase of the illness.

Lithium has side effects—including hand tremors, excessive thirst, excessive urination, and memory problems—but they often become less troublesome as the body adjusts to it. Particularly bothersome tremors can be treated with an additional medication. In a very few people, long-term lithium use can interfere with kidney function. Decreased thyroid function should be treated with thyroid hormone. Consumers should not dramatically change salt and fluid intake while on lithium, and athletes may need to use salt tablets to replace salt loss.

Divalproex sodium (Depakote) is the first medication in 25 years to be approved by the FDA as a treatment for bipolar disorder. Depakote is an anticonvulsant that has been used to treat epilepsy since 1983, but it was approved as a treatment for the manic episodes of bipolar disorder in 1995. Depakote appears to be as effective as lithium for treating mania, and it has fewer side effects. It typically takes five to ten days after starting treatment for people to respond to Depakote. In addition to its having fewer side-effects and its taking effect quickly, Depakote appears to be useful for treating various types of bipolar disorder, including rapid cycling (at least four episodes of mania or depression within a year) and mixed mania.

Liver problems and problems with white blood cell count and blood platelets, which can be severe, may develop while taking Depakote, especially during the first six months of treatment. Therefore, blood tests to monitor liver function and blood cells are an important part of treatment with Depakote. And Depakote is not given to those with liver disease. Other common side effects of Depakote are nausea, drowsiness, dizziness, and tremors. For many taking this medication, however, these problems lessen or go away over time.

Another anticonvulsant, carbamazepine (Tegretol), is also a helpful treatment, and it is used by some doctors for consumers with rapidly changing cycles of mania and depression or for those who cannot take lithium. (Tegretol has not, however, been officially approved by the FDA for the treatment of bipolar diisorder.) Apart from relatively minor side effects, the major concern with carbamazepine is a decrease in white blood cells, which may in very rare cases be fatal. Because of this risk, doctors monitor consumers’ white blood cell count. Frequent dose adjustment and monitoring of drug levels in the blood may also be needed early in treatment.

Doctors have found other anticonvulsant medications helpful in treating bipolar disorder, too, even though these drugs are not specifically approved by the FDA for the treatment of this illness. The other anticonvulsants include lamotrigine (Lamictal), gabapentin (Neurontin), can be used to treat mania, either those called conventional and topiramate (Topamax). You can learn more about these medications by talking with your doctor or pharmacist or reading a copy of NAMI’s “New treatment options for bipolar disorder” fact sheet, available by calling the NAMI HelpLine (1-800/950-NAMI [6264]) or visiting the NAMI Web site (www.nami.org).

Mania may also be treated with antipsychotic medications, usually in addition to a mood stabilizer. A variety of antipsychotic medications antipsychotics (older, well-established, widely used antipsychotics) or newer atypical antipsychotics (antipsychotics with similar, rapid effectiveness but with different side effects that are probably safer for long-term use).

Consumers with bipolar disorder may need antidepressant medication during periods of depression. Because of the risk of triggering mania, doctors often prescribe antidepressants with a mood stabilizer. A variety of antidepressant drugs are used for depression. Some are tricyclic antidepressants (TCAs), monoamine oxidase inhibitors (MAOIs), or selective serotonin reuptake inhibitors (SSRIs). Newer antidepressants, which function in different ways, are also available. Electroconvulsive therapy (ECT) may be used if a consumer is intensely suicidal or cannot take antidepressant medication.

Antidepressant medications relieve depression, elevate mood, and activate behavior, but it often takes three to four weeks for a consumer to respond to them. Doctors will sometimes try a variety of antidepressants and doses before finding the drug or drug combination that works best for a particular individual. Consumers and their families must be quite cautious during the early stages of treatment when the ability to make decisions and to take action returns before mood improves. At this time—when decisions are easier to make, but depression is still severe—the risk of suicide may temporarily (and paradoxically) increase because a consumer may decide on suicide before the depression lifts.

Pregnancy is a special concern with all medications, and women should discuss the risks and benefits of various treatment with their doctors if they are, or plan to become, pregnant.

Medications—and often specific combinations of medication—are often quite effective in treating the symptoms of serious mental illnesses, but consumers must learn to recognize their own patterns of illness and ways to cope. Taking the medication prescribed by a doctor is an essential way to control the illness, but psychotherapy, education, and supportive counseling are also often critical to effective treatment.

Psychosocial therapies—the “talking” therapies that concentrate on behaviors, current conflicts, or relationships with others—come in many varieties and are offered for groups, families, couples, or individuals. Psychotherapy can help consumers and families, but its effectiveness in the treatment of bipolar disorder has not been well researched. For serious mental illnesses, the most useful psychosocial therapies generally focus on understanding the illness, learning how to cope with it, and changing self-defeating patterns of thinking or interacting. It is best to clearly understand how a particular therapist or group approaches psychotherapy or counseling before making a commitment to it, just as it is important to understand the effects and side effects of specific medications.

“I don’t have a problem, I didn’t have a problem. I didn’t think I needed medical help. I thought I could deal with it on my own. I thought I was tough enough to be able to take care of this myself....”

How successful are treatments for a person with bipolar disorder?

After an accurate diagnosis, most people with bipolar disorder can be successfully treated with medication. Early treatment may help keep the illness from becoming more severe, and for many patients continued treatment is critical for maintaining stability. Good treatment includes educating the consumer, family, and friends about the disorder and its treatment. This education should also teach how to identify specific warning signals of recurrence and the best response if they occur.

How well treatment works depends on the severity of the bipolar disorder, how long the consumer has had symptoms, how he or she responds to medical and psychological treatments, and how much responsibility he or she takes for maintaining a balanced lifestyle. In combined treatment, medications treat the symptoms of bipolar disorder while talk therapy may help with the problems the disorder causes in daily living.

Consumers may need more intensive treatment when their symptoms of bipolar disorder are extreme or when the symptoms continue for long periods. Although most people with bipolar disorder can be treated successfully as outpatients, severe episodes may require brief hospitalization for careful evaluation, protection, and medication adjustment.

For some people whose illness does not respond fully to medication and therapy, managing bipolar disorder can be a continuing challenge that requires excellent ongoing treatment, adjustments of medications, careful attention to maintaining a stable lifestyle, refraining from alcohol and drug abuse, and continuing support from family, friends, and peer support groups.

“As hard as it sometimes is, I try to get out of bed. It’s as simple as getting out of bed at a regular time every morning. For me that’s very beneficial.”

What professionals are qualified to treat bipolar disorder?

Family physicians, clinics, and health maintenance organizations (HMOs) all may refer to mental health specialists who treat bipolar disorder.

A psychiatrist is a medical doctor who specializes in mental disorders and is the only mental health professional who may legally prescribe medications. It is important to find a psychiatrist who knows about all medications, including new treatments for bipolar disorder. It may be helpful, too, if the physician is familiar with the American Psychiatric Association’s treatment guidelines for bipolar disorder.

A clinical psychologist conducts psychological evaluations and psychotherapy and works with individuals, groups, and families to resolve problems associated with bipolar disorder.

Psychiatric or clinical social workers have advanced degrees in social work and are trained in counseling and psychotherapy. They are also trained in client-centered advocacy, so they can offer information, referrals, and help when consumers and families must deal with government and local agencies.

Mental health counselors provide professional counseling services that involve psychotherapy, human development, learning theory, and group dynamics. Their goal is to promote and enhance healthy, satisfying lifestyles. These counselors can be found in mental health centers, private practice, or community agencies.

Pastoral counselors are trained members of the clergy who work with their parishioners and family members to help them understand their illness, solve problems, and manage situations that could result in another episode of mania or depression.

Many people with bipolar disorder or those trying to help an ill friend or family member start by seeking help from a family physician. Because the symptoms of brain disorders can be caused by other illnesses, a complete physical examination is essential for an accurate diagnosis. When other medical conditions are ruled out, the family practitioners can either treat the consumer for bipolar disorder or refer him or her to a mental health specialist for further evaluation and treatment. The treating physician should have experience with bipolar disorder, its diagnosis, and the full range of appropriate medications.

Community mental health centers provide help at a cost based on a person’s ability to pay, and some hospitals and universities have special research centers that study and treat bipolar disorder in exchange for participation.

“But I try to structure my life so I know where I’m going and I don’t have free time. And that’s not saying that everybody should do that, but for me, free time is dangerous.”

What supports are helpful?

As mentioned, psychotherapy—or talk therapy—can help consumers (and families) learn to deal with the disruption bipolar disorder can cause in everyday living, but emotional support from others with the disorder and from family members and friends is also an important part of treatment. Too often people with this disorder are unaware that there are others who have the illness and have had similar experience. It is helpful for consumers to share their thoughts, fears, and questions with others with the same illness.

Family, friends, the community, and healthcare professionals are important sources of support, especially when consumers with bipolar disorder are too ill to carry out their normal activities.

Family and friends can encourage consumers to seek and continue treatment. They can be very supportive and helpful, especially if they are educated about the disorder. Family and friends can also try to create a low-stress, comfortable environment for the ill person by reducing stimulation, keeping life predictable, talking calmly and clearly, and boosting self-esteem and confidence. People close to someone with bipolar disorder can show caring and respect by maintaining as normal a relationship as possible, pointing out distorted thinking in a noncritical way, and offering help, kindness, and affection.

Sometimes friends and family members must deal with dangerous situations by taking vigorous and assertive action. During a depression, suicide may be a significant danger. Asking someone who is depressed whether he or she has thoughts of suicide does NOT increase the chance it will happen. Actually, the ill person is often relieved to learn that these thoughts are part of the illness and that sharing them can offer protection until treatment relieves the depression. When someone is suicidal, guns and extra medications should be removed from the house. If the depression and suicidal thoughts are more severe, a friend or family member may have to insist on contacting a professional and explain to the consumer that hospitalization may offer safety. Remember that severely depressed people may not be able to make decisions and get treatment without help. Friends or family members may have to be persistently involved.

Mania causes its own problems for friends and family members. It may be difficult or impossible to get someone with bipolar disorder to seek treatment—especially during early episodes of illness, before the ill person has learned about the consequences of untreated mania. To avoid damage to relationships and employment, families and friends might suggest a leave of absence from a job. Because both overspending and poor judgement are common symptoms of this phase of bipolar illness, relatives and friends may have to protect a consumer’s financial assets.

It’s a good idea to discuss issues such as treatment and money when the consumer is stable. It may be possible to agree on a set of protections if another episode occurs. Write these plans down, either formally, as in what is called an advance directive, or in an informal letter.

Family members and friends also need support. The daily problems of living with someone with bipolar disorder can be enormous and extremely stressful. Groups like NAMI provide support for both consumers and their family members. For both, sharing experiences is an excellent way to learn new coping skills and to stay up to date about current treatments and services.

Services, like medications, must be selected on their ability to meet the individual needs of the consumer. Programs and resources are available in each community that may improve the quality of life and daily functioning of a person with bipolar disorder. Local resources may include consumer/peer self-help support groups, family support and education, vocational rehabilitation, social-skills training/feedback, and/or housing or living arrangements designed to support an individual’s special needs. People with bipolar disorder have different life activities they may need support or assistance with.

Consumer support groups allow people with chronic mental illnesses to share their thoughts and experiences with others who know what they are going through. People in such self-help groups provide emotional support for each other; share their feelings of grief, frustration, and hope; and exchange current information about resources, research, and treatment options. Peer support groups offer the unique understanding and insight that can make life easier and hope more real.

Although the ultimate opportunity for managing an illness and working toward recovery lies with the consumer, a supportive and informed group of family members and friends can make both easier and more likely. Family and friends should read as much as they can about the illness. Especially helpful is reading personal accounts of both family members of people with bipolar disorder as well as of those who have the illness themselves. Another good source of information is family support groups. In addition to providing valuable insight, they offer empathetic support to families and friends that can make their own coping easier—and that can therefore make them more effective supports for their ill loved one.

“Wraparound” services, which provide comprehensive assistance in managing life’s various activities, should be related to those specific areas in which a consumer needs help. Consumers should ask their case managers, therapists, or doctors about the resources in their own community.

People interested in a general overview of community resources can also call the NAMI HelpLine at 1-800/950-6264 and request a copy of the NAMI brochure You Are Not Alone.

“You feel expansive. You’re laughing at things whether they’re funny or not. You’re talking. You’re ready to go spend money, but for me that quickly degenerates into anxiety and irritability and then finally depression...this can all happen in one day.”

Managing and coping with bipolar disorder

What can a person with bipolar disorder do to cope?

Everyone learns to cope with bipolar disorder differently, and accepting the diagnosis of bipolar disorder is the critical first step. Proper diagnosis and treatment will help consumers, but so will knowledge about the disorder. Accurate information from doctors, books, inserts in medication packages, libraries, support-group programs, and community lectures will make the illness less mysterious. As people become more familiar with their disorder, they learn to recognize abnormal patterns of behavior. If consumers recognize these signs and seek appropriate and timely care, they can often prevent relapses.

The provider/consumer relationship is also fundamental to successful management of bipolar disorder. Consumers and their providers should view each other as partners in treatment. The provider should play an active role in the consumer’s recovery and offer advice and information to help the consumer manage side effects and cope, in general, with the disorder.

Consumers also benefit tremendously from taking responsibility for their own treatment regimen. Once the illness is under control, they must report side effects, changes in mood, and changes in lifestyle. The provider and consumer should be able to discuss—with respect for each other—changes in medication, dose, or any other aspect of fine-tuning treatment for successful “maintenance.”

“If something bad happens, I catch my breath after getting knocked down and I say to myself, the first thing is I got to be able to eat and I got to be able to keep myself safe.”

Acceptance

Recovery is an on-going, daily process. No one can manage an illness as well as the person who is experiencing it. However, no one would truthfully say it is easy.

Every day give yourself credit for having the courage to make the necessary changes in your life. Acknowledge that this process is hard, that even taking medication every day can be hard. The changes you may have to make, and the changes to your external life you may have to accept, are major ones. Family and friends should appreciate the difficulties you face. However, like life adjustments made by people with diabetes or hypertension, these changes are the necessary price for a reclaimed life. Celebrate the life you reclaim; learn from any setbacks, but don’t let guilt or frustration about mistakes impair your ability to continue the process.

Bipolar disorder presents a special challenge because its manic or hypomanic stages can be seductive. Consumers may be afraid that they will feel flat, be less capable, or be less creative if they seek treatment; however, these fears must be judged against the benefits of getting well. Consumers may feel “good” while manic, but may make choices that could seriously damage their relationships, financial situation, health, home life, or job prospects. And they may later discover that the product of their “creative energy” is really nonsensical, unfocused, or even harmful to them. Often people who are manic feel irritated or out of control or they have delusions. And a mixed or depressive state may closely follow the feeling of energy or confidence. Such volatile emotions can lead to despair, pain, and even suicide.

Many people who accept treatment for bipolar disorder are leaders of industry, entertainers, artists and craftsmen, successful men and women in any line of work. Treatment is not the end of the possibility for achievement; it is the beginning.

It is very common for people with bipolar disorder to want to discontinue their medication, a thought that may be appealing because side effects of drugs may be uncomfortable or life-affecting or because it has been a long time since the last episode of illness. Consumers should remember, however, that the current medications cannot cure bipolar disorder. Discontinuing medication carries the very real risk of a devastating relapse. A discussion of all options with a doctor is essential before any treatment changes should be made.

“Read everything you can on the subject. Be as smart as your doctor. Ask your doctor all kinds of questions and take your medication.”

Coping Strategies

Developing a balanced lifestyle will help make living with bipolar disorder easier. Incorporating strategies that promote wellness will help consumers take control of their illness. Other people with bipolar disorder have said the following strategies are helpful.

· Be an expert on the disorder.

There are many excellent sources of information, including books and other publications suggested in this paper. Being well informed includes knowing about medications by reading medication inserts in packaging and fact sheets or by consulting a doctor or pharmacist. Keep up with current research and treatment options by reading newsletters such as the NAMI Advocate or those published by other reputable groups, attending conferences, enrolling in credible listservs, and networking with other consumers at support groups.

· Become a partner in treatment.

To be a partner, you must develop a give-and-take relationship with your doctor or other mental health provider. Provide the information he or she needs to treat you effectively, including complete and honest reports about reactions to medications, symptoms that are improving or worsening, and new stresses. Ask questions; write them down before appointments. You must work as a team to fine-tune doses, adjust appointments, or make any other helpful changes.

· Develop a plan for emergencies with your therapist or doctor.

Know what to do in a crisis no matter where or when it occurs. Almost all communities have crisis hot lines or emergency walk-in centers, even if they’re housed in the local hospital’s emergency room.

· Avoid alcohol and illicit mood- or mind- altering substances.

These drugs destroy the emotional balance that can be so hard to maintain. They may also interact dangerously with medications. Both depression and mania make these drugs dangerously attractive as ways to “slow down,” “perk up,” or “forget it all,” but the damage thay can do can seriously block your road to recovery.

· Beware of interactions.

Make sure that any food, additional prescription drugs, over-the-counter medications, or herbal supplements you consider or take will not interact adversely with either your disorder itself or the medications used to treat it. Discuss adding anything to your daily regimen with a doctor or pharmacist.

· Eat for health.

Many consumers find that eating a well balanced diet, avoiding caffeine, and limiting sugar daily improves how they feel.

· Stay on a regular sleep schedule.

Lack of sleep can bring on symptoms, and sleeping much more than normal or being unable or unwilling to sleep can indicate the beginning of an episode of illness.

· Know what may be signaling a relapse.

What have been the first symptoms before? Common ones include irritability or agitation, changes in sleep, feeling overwhelmed or “stressed out,” loss of interest in activities or people that were enjoyed before, or feeling uncharacteristically impulsive. Problems with mood, concentration, sex drive, appetite, or self-esteem may also be signs of relapse. Every person’s early indicators are unique. Ask a few caring, trustworthy people to note changes in your behavior or mood, to be honest about them, and to speak up if signs of reoccurring illness appear.

· Attend support groups.

You will find reassurance, information, friendship, empathy, and encouragement when you talk and listen to people who face similar issues, problems, and feelings.

· Develop a personal support system.

Find people among your friends, family, and acquaintances who are willing to learn about bipolar disorder, accept that treatment is necessary, and support your recovery. Choose those who can be trusted to tell the truth, even if it’s unpleasant.

· Try regular exercise.

Scheduled exercise has great emotional and physiological as well as physical benefits.

· Follow a regular schedule.

A schedule adds much-needed structure to your life. Be sure you include personal time to spend alone.

· Consider volunteer work or hobbies.

If paid employment is not an option now, both these activities will enrich your life, teach useful skills, and give you a sense of purpose and—again—structure.

· Set and respect your limits.

When you must tell others about those limits, be friendly but firm.

· Identify and reduce sources of stress.

· Balance periods of activity with time for quiet and relaxation.

· Continue with life.

Don’t let your illness take control, but recognize that—as with any chronic illness—some plans may have to be changed, canceled, or postponed. Perhaps vacation or other leave time can be reserved for a “tune-up” hospitalization or time off, if needed.

· Be patient, but persistent.

Accept that it takes time for medications to take effect, and it takes time to find the right combination of treatments for each individual. Don’t give up after one or two attempts don’t live up to your expectations.

“I was scared [that when taking medication] I was going to be like a zombie, you know, that I was going to be walking around like you see in One Flew Over the Cuckoo’s Nest or something.”

Monitoring for relapse: a shared task

Learn to recognize warning signs that symptoms are developing. This vital coping strategy needs further comment. Since the best intervention occurs early, before symptoms become severe, recognizing early signs of an episode is a major key to living successfully with bipolar disorder. On one hand, early recognition is vital; on the other, you can’t constantly ask yourself how you are feeling or become totally focused on your behavior or emotions.

Consumers and their families must work together and discuss past episodes so they can clearly recognize the early signs of a developing episode. While people’s symptoms vary, sleep is one of the best indicators of illness because it is usually disturbed very early in an episode, easy to observe, and an objective activity to evaluate (in contrast to feelings). Sleep is also important to monitor because episodes can be triggered by sleep deprivation, even if caused simply by travel or work or social events.

Whatever the indicators of possible relapse, consumers and families or friends should agree on what the objective signs of a possible episode are. When they appear, they should prompt a call to the therapist, who may adjust medications.

“Sometimes it’s very sudden. And sometimes I try and stop it before it even becomes hypomania because I know the course it takes. It always takes this degenerative course.”

What can a family member or friend do to cope?

Family members and close friends should be supportive and willing to listen to their ill loved one talk about his or her feelings, but they need support and the opportunity to talk to people who care and can help, too. Both the person with the illness and family members will likely experience grief because of the drastic changes in their lives and the trauma that previous episodes may have caused. Family and friends find it easier to handle this sometimes frustrating illness if they learn what is possible with good treatment, stay positive about the future, become partners in the process of recovery, and accept and respect whatever independence their loved one attains. It’s worth repeating that the more families and friends know about the illness, symptoms, and treatment, the better they, too, will be able to cope with it.

Try some of these additional coping strategies:

· Be honest about feelings and fears.

Talk about your own emotions and anxieties—as well as your hope—with others who are trying to understand.

· Develop specific and realistic plans.

Know exactly what you will do for the person with bipolar disorder in an emergency or during a relapse, but keep clearly in mind that everyone has good and bad

days, that a change in mood is not necessarily the start of a new episode.

· Heed talk of suicide.

Take any warning signs of suicide seriously and seek help.

· Accept reality and reach out to others.

Learning to accept the illness (and how to adjust to the differences it makes in your life) and developing your own support system will help with both everyday problems and major crises.

· Find resources.

Seek out help finding and taking advantage of everything you now need, from a good doctor or therapist to assistance programs to decent and safe housing for people with mental illnesses. Your local NAMI affiliate is a good place to find suggestions and direction. In many areas, family support groups or free family education classes like the NAMI Family-to-Family Education Program offer both support and education. The NAMI HelpLine (1-800/950-6264) also has fact sheets for family members, including “Coping Tips for Siblings and Adult Children” and one for spouses and partners.

Research is yielding important information about bipolar disorder, and physicians understand more about the disorder’s social, physiological, and psychological effects than ever before. In most cases, bipolar disorder can be successfully treated with medication.

For more information about Mental Illnesses -

Contact:

The Alliance for the Mentally Ill

NAMI of Greater Chicago

1536 West Chicago Ave, Chicago, IL 60622

Phone: 312-563-0445