A beautifully written article in the New York Times from 2013 from a woman with Bipolar II disorder...
http://www.nytimes.com/2013/04/28/magazine/the-problem-with-how-we-treat-bipolar-disorder.html?pagewanted=all&_r=0
Life In This Bipolar World
We are a team of clinicians in an NYC family clinic who specialize in treating the bipolar spectrum. We come here to jot down some of our thoughts and experiences in helping people navigate the ups and downs of the bipolar world.
Wednesday, February 18, 2015
Monday, November 10, 2014
A new study offers clues for diagnosing and treating bipolar disorder
Here's a link to a study that was published today by a research team from the Vanderbilt University Medical Center. For those who are interested in the neurological side of bipolar disorder, this is cutting edge research which will hopefully bring us a step closer to understanding the origins of this illness and finding better ways of treating it.
Monday, November 25, 2013
The Essential Role of Family in Treating Bipolar Disorder
by Amy Mednick, MD and Alison Heru, MD
This article was originally published in Clinical Psychiatric News on October 18th, 2013 and can be found at this link.
Kevin was doing very well in law school, until he showed up at his professor’s house in the middle of the night. Normally a thoughtful, quiet, introverted young man, Kevin was hardly recognizable to his professor, who found him outside yelling loudly and demanding to speak about an underground conspiracy he believed he had uncovered. He had always been a good student, and his family was very proud of his accomplishments up until now. At the age of 24, Kevin’s first manic episode was triggered by late nights studying for his law school exams and marijuana use to cope with stress.
Police responded to noise complaints, and Kevin was hospitalized. The manic episode resolved surprisingly quickly in the absence of marijuana use and with the help of an atypical antipsychotic. The patient’s intelligence and articulate lawyer-in-training charm made his inpatient doctors hard pressed to justify an extended hospital stay, and he was discharged 3 days later with a prescription and instructions for follow-up. He promptly discarded both.
When his next manic episode arose, Kevin disappeared for 2 weeks, and after fearing the worst, Kevin’s family was relieved to receive a call from Kevin’s aunt, who lived across the country and had just found him at her doorstep. This time, without the involvement of law enforcement, there seemed to be no way for Kevin’s mother, father, older sister, and aunt to persuade Kevin to enter the hospital or to take medications. Kevin’s aunt accompanied him on a plane home, and in the face of Kevin’s unwillingness to enter treatment alone, they decided to enter treatment as a family.
Predictors of episodes
The strongest predictors of future episodes and poor outcome in patients with bipolar disorder are a greater number of previous episodes, shorter intervals between episodes, a history of psychosis, a history of anxiety, persistence of affective symptoms and episodes, and stressful life events. Some evidence has suggested that poor job functioning, lack of social support, increased expressed emotion in the family, and introverted or obsessional personality traits all might predict poor outcome in bipolar disorder (J. Psychiatr. Pract. 2006;12:269-82).
An overwhelmingly emotional home environment can make a large contribution to relapse. Multiple studies have shown that a high level of "expressed emotion" (characterized by overinvolvement and excessive criticism) predicts patient relapse independent of medication compliance, baseline symptoms, and demographics (Arch. Gen. Psychiatry 1988;45:225-31)
Because bipolar disorder is an unpredictable, potentially destructive illness, it is important to grab any factors that we and our patients might have control over and do our best to modify them positively. With this in mind, the Family Focused Treatment (FFT) model was developed, with the philosophy that by keeping patients well informed about the facts and realities of the disorder and working on the communication and coping mechanisms operating within the family, relapse prevention and emotional stability will be better maintained. In this way, the predictive factors of stressful life events, poor social support, and family-expressed emotion can be modified. FFT is a time limited (usually 12 sessions), highly effective treatment modality.
The principles of FFT were adapted into an ongoing-treatment model that can be implemented in a community setting, termed Family Inclusive Treatment (FIT) and used by the Family Center for Bipolar in New York City, for example. FIT consists of an engagement period at the initiation of treatment, focused on psychoeducation and relapse prevention planning. FIT is unique in that every patient is required to sign a release of information giving permission for full, open communication at all times between the patient’s clinician and a treatment partner of their choosing.
After the initial engagement period, there are quarterly family visits to supplement regular individual treatment. Other modalities such as individual therapy, pharmacotherapy, and group therapy are used according to the clinician’s judgment.
This form of treatment is innovative in that it treats bipolar illness just like any other chronic illness. It promotes open communication between families of patients with bipolar disorder and the patients themselves with regard to symptoms and medications. In this way patients are not isolated from their families; they can talk openly with one another and their clinician as they would do if somebody in the family had Alzheimer’s disease or diabetes.
It has been reported that up to 46% of the caregivers of patients with bipolar disorder report depression, and up to 32.4% report use of mental health services. These symptoms tend to be dependent on the nature of the caregiving relationship, suggesting that specialized interventions addressing the psychiatric needs of bipolar families might result in improved outcomes for both patients and their family members, in addition to decreases in health care costs (J. Affect. Disord. 2010;121:10-21).
Together with therapy and medication management, clinicians working in the FIT model strive to create an environment that minimizes, as much as possible, the impact of bipolar disorder on the affected individuals and their close loved ones.
Many studies have confirmed the efficacy of various psychosocial treatments for bipolar disorder (J. Consult. Clin. Psychol. 2003;7:482-92; J. Clin. Psychiatry 2006;67 [suppl. 11]:28-33; J. Affect. Disord. 2007;98:11-27), and there has been a push for the integration of psychosocial treatment with pharmacotherapy, as the latter is less often sufficient on its own in preventing relapse.
Patient, family begin journey
Kevin and his family entered into family treatment. They started off with the psychoeducation portion of the treatment, and many of the myths and misinformation that they had held about bipolar disorder were dispelled. Even Kevin was able to engage in the information exchange, which he initially approached from an academic, impersonal vantage point. The communication skills phase proved more problematic as it became more personal, but still, the focus was on the family’s communication and not on Kevin as a psychiatric patient, so he responded well.
It was uncovered that Kevin’s father has always been highly critical, and Kevin’s mother tends to overprotect her children to compensate. They were taught new skills to express their feelings toward one another, and especially toward Kevin, in more productive and positive ways. In addition, they got a chance to practice those skills in subsequent sessions.
The modules continued in this vein until the family portion of treatment had completed. By this time, Kevin had developed a good rapport with his clinician, and he continued treatment despite his persistent reservations about accepting his illness. The family environment improved, and though Kevin was only sporadically compliant with his medication, the reduced stress at home and improved coping skills drove him less often to use marijuana for "self-medication," which decreased his manic episodes.
Kevin’s family periodically rejoined him in treatment sessions at predefined intervals, to check in and assess his and their progress. They were comfortable speaking with Kevin’s doctor and would call when they noticed any of the warning signs that they had collaboratively determined as markers of upcoming mania. In this way, they were all effective at keeping Kevin’s moods stable and keeping him out of the hospital.
The psychiatrist in routine practice might neither follow a manualized algorithm for family treatment nor have the time or resources at her disposal to provide a full "curriculum." Still, she can have the same success in engaging a family in understanding their loved one’s illness and contributing to the family member’s stability.
Objectives for family-focused treatment
The following objectives are adapted from "Bipolar Disorder: A Family-Focused Treatment Approach," 2nd ed. (New York: The Guilford Press, 2010):
• Encourage the patient and the family to admit that there is a vulnerability to future episodes by educating them about the natural course, progression, and chronic nature of bipolar disorder.
• Enable the patient and the family to recognize that medications are important for controlling symptoms. Provide concrete evidence for the importance and efficacy of medications and the risks of discontinuation. Explore reasons for resisting medications, including fears about becoming dependent.
• Help the patient and the family see the differences between the patient’s personality and his/her illness. Make a list of the patient’s positive attributes and a separate list of warning signs of mania. Frequently reinforce the distinction between the two.
• Assist the patient and the family in dealing with stressors that might cause a recurrence and help them rebuild family relationship ruptures after an episode. Suggest methods for positive, constructive communication such as active listening (nodding, making eye contact, paraphrasing, asking relevant questions) and expressing positive feelings toward a family member related to a specific example of a behavior.
Wednesday, November 6, 2013
Film Review: The Last Interview of Thomas Szasz
The Last Interview of Thomas Szasz
Directed by Philip Singer, PhD • Documentary • 2013 • 50 minutes
A Traditional Healing Productions Film • Witness Films (www.witnessfilms.com)
Directed by Philip Singer, PhD • Documentary • 2013 • 50 minutes
A Traditional Healing Productions Film • Witness Films (www.witnessfilms.com)
Written by: Zimri S. Yaseen MD, Clinician at the Family Center for Bipolar
The Last Interview of Thomas Szasz would make
an excellent discussion piece for a psychiatry residency ethics seminar,
because it pushes the viewer to think more deeply about the issues and
principles that underlie capacity and informed consent. It would also serve
well in any introduction to a psychotherapy course, since it draws out
distinctly and compellingly the question, “What is the nature of the therapeutic
conversation?”
Thomas Szasz, a
psychiatrist and psychoanalyst, reportedly ended his own life
last year, at the age of 92, after a spinal compression fracture.1
His suicide might be a topic of debate, however, because some obituaries report
that Dr Szasz “died of a fall.”2
Director Philip Singer, PhD, a
medical anthropologist whose focus has been the cross-cultural study of healing
practices, interviewed Szasz 2 years before his death. The interview focuses on
the central argument in the 1961 book The Myth of Mental Illness:
Foundations of a Theory of Personal Conduct, for which Szasz is
best known. It forms the core of Szasz’s career-long sermon, a radical—which is
to say, epistemological—attack on the construct of mental illness. Namely, he
argues that illness belongs to bodies and not to minds; the brain can be sick,
but the mind cannot.3
An important and elusive corollary
of this observation is that mental illnesses must be defined
syndromically in terms of mental and behavioral symptoms. The lack of change in
the basic diagnostic system of DSM-5, which follows DSM-IV in this approach,
speaks to this logic. What is easy to lose sight of is that where symptoms of
an illness typically represent problems for the ill, those of mental illnesses,
while certainly presenting problems for their sufferers, may more often also represent
problems for somebody else; after all, many of the patients we see have been
brought to us by loved ones who are distressed by the patient’s behavior or by
the police for disturbing the peace.
This epistemological argument is
ultimately motivated, however, by Szasz’s unbending libertarian ethics; the
point of saying minds cannot be sick is revealed in this interview to be a
principled guarding against the intrusions of society on personal liberty and
liberty of thought. Permitting such an intrusion might also allow for society
to slip into totalitarianism. This might be paraphrased as “Don’t call your
distress at someone else’s behavior their sickness; if a person wants help with
a problem, it is their own responsibility to seek it. If they are bothering
you, that is your problem.” Although Szasz indicates that some societal
controls are acceptable, he resents the presentation of such controls as
medical matters, a tactic that quietly removes them from the realm of social
debate.
Although principled, in this
context, it is also a deeply emotional defense. That hidden emotionality makes
the discussion difficult, but it also highlights its importance. In fact, such
an argument highlights the importance of a questioning approach to the concepts
that make up “mental illness,” and this emotionality should perhaps also be
understood as a necessary “flaw” in the discussion. The questions themselves
are essentially emotional ones. Insofar as we are social animals, the complex
functions of a mind are necessarily to a great extent socially constructed,
even as they necessarily have biological underpinnings (a physical event in the
organism underlies the non-physical event of a thought). The controversial
elimination of the bereavement exclusion from
the major depressive episode criteria in DSM-5 is a prime example.
Dr Szasz places equal demands on
patient and doctor—of doctors, to act only in accord with the patient’s
immediate (free) will, and of the patients, to act in accord with their best
interests or (freely) suffer the consequences of their poor choices or bad
luck.
Singer, attempting to find a
situation Szasz might regard as a moral gray zone in his critique of common
psychiatric practice, is driven to call him “Jesuit” in his adherence to his
conclusions. Here, something emotional has come into play; how do we recognize
the imbalances in a doctor-patient relationship and how do we feel about them?
Szasz’s avoidance here is telling.
Indeed, the perplexing power of
Szasz’s epistemological problem with “mental illness” is obscured at times by
its complex, often tenuous, connection to the libertarianism that motivates it.
This is not to say that his libertarianism is not powerfully thought-provoking
in its own right and must give any psychiatrist pause when pursuing involuntary
commitment or treatment over objection. Even if one is ultimately to disagree
with Szasz (as, in practice at least, almost all psychiatrists do), such pause
is an invaluable burden.
Beyond these matters, which are
readily available in Szasz’s writings, Singer’s film allows us to meet Szasz near the end of
his life. I cannot help but feel that the hard edges of his arguments serve as
guards against survivor guilt that could otherwise cripple a man of evidently
deep, tender, and curious humanity. (Szasz emigrated to the US in 1938 to study
medicine, wittingly escaping the storm of fascism already overtaking central
Europe.)
Throughout the interview, we find
Szasz demands that the discussion be on his terms. “I never saw anyone before
talking to them myself,” he explains. “My secretary didn’t make any
appointments.” To explore this, Singer plays a prospective patient: “Help me to
want to live again,” to which Szasz replies, “That’s not the kind of thing I
can do. I would not make an appointment.” A pause ensues and, slightly
frustrated, Singer tries again: “Okay. I’ve heard, Dr Szasz, that you’re a very
good psychiatrist and I just don’t feel I can live this way anymore; can you
help me?” Szasz responds, “Perhaps. Okay. We can have a conversation; come and
see me.” The transcript reads perhaps as harsh, but in Szasz’s voice there is
something ameliorating. When he says, “Come and see me,” he does not sound
clinical. Rather, one hears a genuine and fully willed invitation.
What is the difference between
Singer’s first, rebuffed, approach and his second, accepted one, besides the
compliment to Szasz? In the first, Singer lacks agency. He positions himself as
seeking rescue. In the second, he seems similarly distressed but he takes
ownership of his choice to seek Szasz’s help. Szasz demands ownership of his
own choices; he decides whether he will see someone, but he demands that
ownership of choice of others as well. “The goal,” he says, “is to assume more
responsibility and therefore more liberty and more control over one’s own life.”
Szasz’s fierce independence and his
symmetric insistence on the responsibility of others for their own fate read to
me as a defense against the emotional burden of having escaped the Holocaust.
Indeed, that fierce independence seems to be one that he held to the death.
Singer asks, “If you were dependent on someone else, caretakers . . . would you
think . . . of killing yourself?” Szasz pauses and smiles before replying, “Off
the record.”
Should Szasz’s alleged suicide,
then, be seen as a courageous adherence to the principles by which he lived or
a symptom of a pathological avoidance of helplessness? Dr Szasz might reply
that either way, it was his choice.
- See more at:
http://www.psychiatrictimes.com/film-and-book-reviews/film-review-last-interview-thomas-szasz/page/0/2#sthash.mT3cwc2X.dpuf
New Therapy Groups!!
The Family Center is excited to announce that we are starting two new weekly psychotherapy groups:
“Quality of Life”
“Sane Eating”
Those of you who are
already in psychotherapy may think:”Why join a group? Will it add anything useful
to my treatment?” The answer to this question is that group therapy is a unique
resource that can nicely compliment individual treatment and deliver additional
therapeutic gains. Bonding with other group members, receiving and offering
emotional support, showing up for your peers are the things that facilitate learning
new skills, expand your social competence and boost the sense of well-being. Those
of you who are not in individual therapy in their turn may wonder if group
therapy alone would be as beneficial as individual therapy. I am happy to assure
you that group therapy can effectively stand on its own. Research shows that
there is no difference in effectiveness between group and individual therapy
although individual therapy appears to have a quicker effect.
So what do the two new groups have to offer? In the “Quality
of Life” group you will learn and put to practice the three essential skills;
mindfulness, emotion regulation, and interpersonal competence. Simply put, you
will learn to become mindful of your internal experiences and surf the emotional
waves without becoming crushed by them. In a supportive environment you will practice
negotiating solutions to conflicts, asking for what you need and listening with
open mind. This practice can help you to alter the course of your relationships
and improve the quality of your life.
The “Sane eating” group’s goal is to help you gain freedom
from unhealthy persistent eating habits. The group will not teach you
what to eat beyond some basic nutritional facts. Instead, using the wisdom of
psychotherapy, it will help you to develop a healthy relationship with food.
You will learn to understand and change the ways you think about and respond to
impulses to eat. Stress reduction and emotional balance are additional
anticipated benefits.
All we have to do is begin!
If you would like more information or are interested in signing up, please call Dr. Gaiane Kazariants at 212-844-1742.
Monday, November 4, 2013
What is a prodrome?
ˈprōˌdrōm/ noun: an early symptom indicating the onset of a disease or illness
In
psychiatry, the word prodrome is often used to describe a period of time during
which an individual begins to display symptoms of a mental illness, typically
accompanied by some type of disturbance in functioning, but before the disorder
fully presents itself. Classically it
has often been used to describe a period of time of social isolation, change in
mood or behavior, and change in functioning who go on to develop schizophrenia,
but often people who go on to receive a diagnosis of bipolar disorder have a
prodrome as well.
Unfortunately,
sometimes the prodrome is best identified in hindsight. After a teen or adolescent develops a major
depressive episode or a manic episode, parents and family look back and say “oh
yeah … he WAS moody and irritable, he DID stop hanging out with friends, he DID
seem a bit restless and agitated, he WAS very distractable, his grades DID drop
significantly”. Often in the moment,
symptoms seem like normal adolescent behavior or “just a phase”, or often can
be related to other issues going on, such as peer problems, academic problems,
or other life stressors. That is because the symptoms don’t tend to be severe,
may not happen all together, and are often non-specific - meaning that they
could be seen in a variety of disorders, such as depression, anxiety,
attentional disorders, drug and alcohol disorders, etc.
Bipolar
disorder often cannot be clearly diagnosed during this period, unless there are
symptoms that are specific to the disorder.
However, any changes in an adolescent’s mood or behavior that affects
their relationships and their function at school, with peers, and at home, is
worth evaluation by a child and adolescent mental health specialist. This person can help you monitor changes in
symptoms and response to treatment so that whatever may be brewing beneath the
surface can be caught early and treated appropriately.
-Dr. Buchanan-
Thursday, October 17, 2013
My mood episode is under control, when can I stop taking these pills??
The following question was posed by one of our blog
readers:
“If I start taking medications for bipolar, will I have to be on them my whole life?”
The answer, unfortunately, is often yes. There are some
great treatments for bipolar disorder that can keep the illness under control,
and maintaining that control is the best thing you can do for your health, your
relationships, and hopefully your life overall.
We can learn about the natural course of untreated
bipolar disorder by looking at how the illness progressed back in the days when
there were no medications to treat it at all. Observations showed that
some people would end up spending ten or more years in a depressive episode.
As the illness progressed over time there would be more and more episodes, with
shorter and shorter periods of healthy stable mood in between. Luckily,
this no longer has to be the case.
On the positive side, many studies have shown that the
earlier and more comprehensive the treatment for a mental illness, the better
the response. This isn’t too different from what we would expect from any
other chronic illness, like diabetes or heart disease. Studies have also
shown that mood stabilizers are actually good for the brain and can protect it.
For example, lithium increases the amount of gray matter in the brain (i.e.,
brain cells) of bipolar patients.
Here is an article that talks about this in a bit more detail.
However, if the side effects are just too intolerable for
you to imagine a life on your particular medication, that probably means it’s
not the right medication for you. I always hope that my patients will be honest
with me about how they really feel about the medication—I won’t take it
personally if you hate what I prescribed you! Your doctor should make you
feel comfortable to express your opinions about the medications, and you should
always discuss with him or her before making any changes or stopping any
medications-- to be on the safe side.
Dr. Mednick
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