NYT: The problem with how we treat bipolar disorder.

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

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.

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.

 

But it can be a scary and daunting thought to imagine taking a medication for your whole life, especially when there are side effects that you are having difficulty with. 

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

What’s Love Got to Do with It? (Couple Therapy and Bipolar Disorder)

What's love got to do with it?

By "it" I mean you and your partner’s struggle with Bipolar Disorder - a struggle that can result from a clinician breaking the news of the diagnosis, the storm and aftermath of a bad manic episode, or the dread of a never ending depression. Can working on your relationship as a couple help to deal with any of these challenges? As a psychologist who is excited about the power of couple work I’d like to say yes, there is definitely a good place for couple therapy in your effort to tame Bipolar illness. 

The opportunity of introducing couple's therapy into the treatment of Bipolar Disorder is often overlooked because of the broadly acknowledged notion that Bipolar illness is at its core a biological illness. We've all heard the many variations of this notion. Bipolar disorder is cyclical, it has a genetic component, it has little to do with the patient’s personality, it is effectively treated by medication. The truth is, there is a lot about Bipolar Disorder that we do not know, and this hefty biology tends to push the considerations of what may be going on beyond the psychiatric symptoms to the margins. For the purposes of this blog, I would like to put the biological component aside for a bit and focus on something different. 

From a relational perspective, Bipolar Disorder is a trauma to the couple’s relationship that requires healing. 

The stories that the couples typically tell often reflect the relief of being able to identify and label the irrational behaviors as well as the hope that their subjective emotional experiences of the disorder will be controlled as long as the patient’s symptoms are well managed. Here is what a clinician would often hear: 

“He was not acting like himself… she was angry at everyone all the time… he went crazy with the credit card behind my back… she was blaming me for everything… we were constantly fighting… I was thinking about divorcing him… we almost broke up…”  

And then the story continues:

 “She got diagnosed and it all made sense… I know what symptoms to watch out for… as long as he gets enough sleep and takes the medication we should be fine… as long as I can get in touch with the psychiatrist when I need to I feel safe.”  

Figuring out the diagnosis and getting the right treatment for the person with the Bipolar illness is an absolutely necessary piece for success, but is it always sufficient to get the couple to a place where they feel secure with each other and confident in their future together? Sometimes it is. Maybe the stress produced by Bipolar disorder made you even stronger on the other side, or maybe it made you see each other in a new light and have deeper respect for each other. If you are involved with the Family Center, maybe you learned about the symptoms in depth, developed an alliance with the clinician, learned some new communication skills and feel supported and hopeful. 

But what if you still feel disrupted, if not traumatized by what the Bipolar illness brought into you relationship? What if you are resentful for what your loved one’s mania put you through or for your new “sick role?” What if you feel so powerless against your moods and doubtful of your capacity to have a clear judgment that you withdraw from the relationship instead of participating in it? And, finally, what if like many couples you had had preexisting problems and the Bipolar issue only added another layer to them? 

You can let time do all the healing but you can also turn to couple therapy and use it for what it is designed to do; bring the two partners closer together and help them develop an intimate relationship that can serve as a buffer against many troubles in life, including the ones caused by the illness. We all know, and I don’t think there is a need to look for research references here, that a good relationship, in which both partners feel understood and cared for make it easier to weather almost anything; problems at work, uncertainty of the future, cultural transitions, serious losses. Moreover, there maybe a bonus to the couple’s success; some experts believe that  changing a person’s way with his or her significant other can on it’s own change his or her behaviors and emotional responses outside this relationship...in other words, produce a higher level of overall mental health.

If you have any questions about couple's therapy and bipolar disorder, please leave them in the comments section below - I'd love to hear them! 

-Dr. Kazariants

Mania/Hypomania and the Creative Process

Mania and hypomania are often referred to as the "up" side of bipolar disorder. Though either a manic or a hypomanic episode can be quite destructive, we as clinicians often hear concerns from patients about treating these kinds of mood episodes. The reality is that after a long struggle with depressive episodes, a manic or hypomanic episode can sometimes feel like a welcome break for our patients. It is during these episodes that patients oftentimes become non-compliant with their medicine and other on-going treatment modes (e.g. therapy) - perhaps because a part of them does not want to let go of the euphoria that mania and hypomania induce.

As clinicians it is our responsibility to negotiate this difficult and delicate dilemma in our patients' mood functioning. On one hand we want our patients to feel good, and on the other we know how precipitous the guise of euphoria can prove to be for the patient, his/her loved ones, and for the course of treatment.

In my own experience working with patients with bipolar illness I often hear people express fear that treating mood symptoms, especially hypomania, will negatively impact their creative process. On one hand I can easily empathize with their concerns, yet as a clinician I worry about the impact that these concerns will have on their treatment and progress. There are no easy answers to this dilemma.

In contemplating about all this I recently came across a very interesting article that poignantly discusses this very real and fairly common predicament.

You can read the article here:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3181877/pdf/DialoguesClinNeurosci-10-251.pdf

If you have any thoughts or input on this topic - whether from a clinician's or patient's point of view - kindly share it with us. We would love to hear your thoughts.

Be prepared!

Getting sick is bad, but getting sick and not having a safety plan can be even worse! Take a moment to build a plan with your loved ones that indicates what to do should you get sick and make sure everyone has a copy of the plan!

Here are some ideas for what to include in your plan:

1. List the names and contact information for all your doctors, case workers, or any other professional involved in your care
2. Make a list of all your medications you take and the reason you take each medication! Be sure to include any over-the-counter medications or supplements you take, as well as the doses of each medication and when you take them. You may want to note some possible side effects of the medications. This way you and your support network can be mindful of any side effects you could experience.
3. Write out any allergies that you have! Note any adverse reactions to medications or medications that you do not want to take and why!
4. Write down a list of people you trust who know about your disease and are willing to help you. Be sure to include their names and phone numbers! This can help you when you aren't feeling well. You may want to include a list of signs that you experience when you are starting to feel manic or depressive. Knowing these early signs that you might be getting sick can allow people to help you get care early.
5. Write down the names and numbers of any family members or employers that may need to be contacted if you experience an emergency or need to stay in the hospital for a period of time for treatment.
6. Write out your insurance plan information
7. Include in your safety plan any other directions that you have for your care. Be sure to include what kinds of medical interventions you do and do not want. You can include any "Advanced Directive" or "Living Will" documents with the plan!
8. Finally, you may want to indicate any instructions regarding the care of any pets or plants you have or regarding bills or other household matters should you need to be in the hospital.

Maybe some items above aren't for you. That's okay. This list is just to get you started on putting your plan together. You don't have to build your plan alone either. Talk with your doctor, your case manager, your family, or the other people you trust to help you build a plan that works for you. Make sure your doctor and the people on your support list have a copy of the plan so they can know how to best help you!

CLEAN UP YOUR SLEEP!!!

I am often shocked by the poor sleep habits of some of my patients with bipolar disorder. Sleep is one of the most important regulators of mood, but surprisingly, many of my patients don't give it much thought. They go to sleep only when they feel tired, they wake up only when they feel like getting out of bed, and they take naps if they feel sleepy during the day. As doctors, we call that bad sleep hygiene.

Good sleep hygiene, on the other hand, is one of the most effective ways to regulate your mood. Did you know that not getting enough sleep can actually trigger a manic episode? And once, triggered, continuing to not get enough sleep can perpetuate it, and make the manic phase more intense, and longer lasting. Conversely, getting too much sleep can cause depressive episodes. More than 80% of people who suffer from unipolar depression complain of insomnia--they don't feel like they're getting enough sleep at night, or the quality of their sleep isn't good.
But interestingly, people with bipolar depression tend to have the opposite problem. They have hypersomnia, or excessive sleeping during their depressive episodes. Getting too much sleep may cause a depressive episode to last longer!
 Also, bad sleep habits can literally be a pain. People who have poor sleep habits, whether too much, or too little, or complain of poor quality of sleep, sometimes develop a condition called fibromyalgia which is a painful, nondegenerative, muscle disorder.
Good sleep hygiene means talking with your doctor about how much sleep you need each night. For patients who are in a manic phase, a doctor may recommend getting more sleep. For patients in a depressive phase, a doctor may recommend getting a bit less sleep. So speak with your doctor about what the optimal amount of sleep would be each night, given your current mood. Then try to go to bed every night at the same time, and set an alarm so that you can get out of bed every day at the same time. And avoid taking naps.  
Stabilizing your sleep is one of the easiest ways of stabilizing your mood.  
So practice good sleep hygiene!
Sweet dreams !

From Jazz to Hip Hop - Routing the Manic Episode

Last week somebody reminded me how individual early signs of mania can be.

Insomnia is a universal late sign of the beginning manic episode. 

Almost all bipolar patients have insomnia during their manic episodes. In other words, when somebody stops sleeping, the manic episode has already begun. In this case prevention and therapy alone are no longer an option. Only aggressive medication treatment can stop a manic episode once insomnia has kicked in.

However, the very early signs of mania are very individual and could be very subtle. 

Changes in voice are common – higher pitch in particular is something to pat attention to. Also common are changes in the way people dress and in the make-up they use. A more revealing style of dress or change of lipstick to a brighter color could be very early signs of oncoming mania. Another sign of an upcoming episode is becoming critical or quarrelsome with people you usually gets along with. Some people actually change the music they listen to such as classical to pop, or jazz to hip-hop. Changes in exercise routine – the list goes on and on...

The take home message is this -- try to remember the very first subtle changes (or patterns) you or your loved ones notice in you before the episode becomes severe and share them with your doctor. In this way both you (and your family) as well as your psychiatrist will be in the position to be early detectors of upcoming mania.

Similar thinking applies to depressive episodes, but I will address this next time.

Stay Healthy!

Dr. G.

KEEP A MOOD DIARY

Keeping a Mood Diary is a very helpful tool for managing your bipolar disorder. It not only helps you track your symptoms on a daily basis, but over time it will help you to see how your mood patterns emerge. 

• It may help you identify the onset of a new mood cycle, and guide you in taking preventative actions.
• Further, a mood diary will make speaking with your doctors easier, because when they ask you how you’ve been doing, your can pull out your mood diary and show them the actual record of how you’ve been doing mentally and physically, over the last few weeks or months.  
• Lastly, a mood diary will help you stay focused on day-to-day coping strategies, as well as long-term life goals. Keeping a mood diary helps you maintain control over your bipolar symptoms, while reminding you that you have life to live outside of your bipolar disorder.

Here are some things you might include in your Mood Diary.

Mood Chart: Create a scale of your daily mood from 1 to 10 with 5-6 being normal, 1 being very severely depressed, and 10 being severely elevated. Next to the numerical value for that day, write some words that describe how you’re feeling that day. Examples include: energized, annoyed, important, full of ideas, talkative, impulsive, spending, sleepy, sleepless, guilty, drained, apathetic, indecisive, inadequate, hopeless, suicidal.

Anxiety Chart: Chart you level of anxiety and/or irritability. Use a scale of 1 to 4 with 1 being not very anxious/irritable, and 4 being severely anxious and irritable.

Events Chart: Make notes of important events in your life. Include joyful events like a birthday celebration, and stressful events like getting reprimanded at work. Also make a note of how your mood that day had a positive or negative impact on that event.

Coping Chart: If you’re experiencing mood symptoms, either depression or elevation, chart something that has helped you cope with these symptoms in the past. Examples include: contacting your doctor or family/friends, identifying the triggers, avoiding drugs and alcohol, maintaining your normal activities, maintaining good sleep habits, identifying any changes in medications that may be impacting your mood.

Sleep Chart: Chart the time you went to sleep, the time you woke, and rate the quality of your sleep on a scale from 1 to 10, with 1 being very poor sleep with frequent awakening, and 10 being very deep sleep with difficulty awakening.

Medication Chart: Keep a record of your current meds and their dosages and whether you took them, forgot to take them, or chose not to take them.

Body Chart: Rate how you feel physically on a scale of 1 to 3, with 1 being feeling bad, 2 being feeling ok, and 3 being feeling good physically. Also write a word that describes how you feel that day. Examples include: sick, sleepy, sore, strung-out, stable, strong, sexy. Record your weight every day, and for women, chart your period.

Goals Chart: Every month set a goal, or continue to pursue an existing goal. Each day write down anything you did that moved your closer, or further away from achieving that goal.

Notes: Be sure to leave a little space at the bottom just for notes that you’d like to remember about that day.