The Bipolar Spectrum

RECOGNIZING AND TREATING

THE BIPOLAR SPECTRUM: the great pretender

Jeffry Klugman M.D. and Douglas A. Berv M.D.

Copyright 2002-2006

A note about pronouns: Doug Berv and I, Jeff Klugman, are psychiatrists who run a psychiatric practice which also includes nurses, psychologists, and social workers. This book reflects the work, the experience and the thinking of both of us, but I translated our conversations into the words of this book. Thus the “I” and the “we” in the text.

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CONTENTS

1. The great pretender Part I- the diagnosis and the illness 2. bipolar illness: making the diagnosis 3. clinical depression-not! 4. bipolar and adhd 5. unstable mood and personality disorder and sometimes ptsd 6. cutters- adult division 7. adolescent cutters and the risks of antidepressants 8. sequential diagnostics and prioritizing treatment 9. schizophrenia and bipolar disorder 10. bipolar and obsessive compulsive disorder 11. stress and genetics 12 mild versus severe 13 resistance to the diagnosis Part II- treatment 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

the role of psychotherapy working with your doctor: self-monitoring self-care medication strategy: treat activation first! anti-activation medication group 1-lithium multiple medications anti-activation medications group 2 – anticonvulsants anti-activation medications group 3 – atypical antipsychotics anti-activation intervention – ect bipolar depression – depression or mixed? Bipolar depression – step 1 Antidepressant atypicals Antidepressant antidepressants Treating multiple diagnoses Pregnancy FAQ’s Residual symptoms and side effects Family matters

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1. The Great Pretender Suppose the thermostat at home is set for 70 degrees. When the temperature drops to 68 the furnace goes on. When the temperature reaches 72 degrees the furnace shuts off. If your thermostat is defective, though, the temperature might have to drop to 40 before it turns on the furnace, and the temperature might have to rise to 90 before it shuts off. You’ll be putting on sweaters at one moment, and changing to shorts and a t-shirt the next. Now suppose that you have a full climate control system. Along with a furnace you have central air conditioning with its own thermostat and controls. And let’s say we don’t know if the air conditioner thermostat is working properly or not. At times the furnace and the air conditioner will both be on at the same time, working against each other. You house might be cooling off or heating up, depending on which system is stronger, but either way your utility bills will skyrocket. If the temperature is 80, and both the furnace and the air conditioner are on, fighting each other, you know the furnace control is messed up because it should have shut off the heat. But you can’t know about the air conditioning control in that scenario. It might be working fine, and switched on only in response to the high temperature produced by your heating system. At other times neither system will be working, while the temperature in your home drifts down to 50 or up to 85 depending on the weather outside. If the temperature

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goes down to 55 without the heat turning on you know your furnace control is messed up, but, again, you can’t tell about the air conditioner. Sometimes just one of the systems will be on. The house will be warming or cooling, but you can’t predict how extreme the temperature is going to get. Your furnace works fine, and so does your air conditioner. The problem is in the controls. You have a problem regulating the temperature in your home. Bipolar disorder is also a problem with regulation, not too different from the disordered climate control system I’ve just described. Before discussing in more detail what bipolar disorder is, however, I want to clear up some misconceptions. First, bipolar disorder is not “manic-depressive

illness.” This is like saying “fruit is not apples.” Fruit may be apples, but it may be guava, or blueberries, or even tomatoes. Manic-depressive illness is the most famous type of bipolar disorder. But classical manic-depressive illness is rare, and it’s terribly misleading to focus on it. This book is about the bipolar spectrum, a term we use to emphasize that bipolar disease is a much broader illness than most people realize, an illness with many, many different ways of expressing itself. When I say “bipolar” or “bipolar illness” or “bipolar disorder,” I mean to include the whole bipolar spectrum. Second, although the term “mood swings” is commonly associated with bipolar disease, it means different things to different people. Some people use that term to mean periods of elevated mood alternating with depressed mood, but other people use it to mean a quick temper, or irritability. Some people mean switching between a normal mood and depression, or a depressed mood and anger, and still other people mean an easily changeable, or labile, mood. Any or all of these might be produced by a bipolar disorder, but none of them necessarily means that someone has bipolar disorder. In 2

general, psychiatrists use the term “mood swing” to describe the classic manicdepressive-style swing between euphoria and depression, so I’ll use the term only in that sense. Everyone with bipolar illness does have an unstable mood. Sometimes we’ll tell patients with milder forms of the illness that their diagnosis is “unstable mood disorder” – not an officially recognized diagnosis -- in order to offer a label they can accept more readily than “bipolar.” But bipolar illness isn’t the only cause of unstable mood, just a likely cause.

Third, most people with bipolar disorder have never, ever been

euphoric. People think bipolar illness means having classical mood swings: elevated moods – euphoria – alternating with depression. Wrong. I think of bipolar illness as a disturbance in the regulation of two

processes: an activating process and a depressive process. Think about your furnace and your air conditioner and a problem in one or both of their control systems. In the dramatic, classical, form -- “manic-depressive illness” -- the activating process includes euphoria, but in most bipolar disorders activation rarely if ever manifests itself as euphoria. Instead activation usually shows up as racing or multiple thoughts (I’ll explain these terms later), agitation, hyper feelings and irritability, and most often comes with a depressed, not an elevated, mood. Technically the diagnosis of “mania” requires either elevated mood or irritability. In fact it’s almost always irritability, but for historical reasons the term “mania” commonly makes people think “euphoria.” That’s why I prefer the term “activation.” It’s mood neutral. It doesn’t imply anything about euphoria or depression.

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The depressive process usually shows up as a depressed mood, but occasionally it shows up as just “de-activation”: extreme lethargy and increased sleep, but without a depressed mood. Let me repeat: there are people who are in a state of “depression” without being “depressed” in the ordinary sense. They tend to have very low energy and motivation, and sleep 14 to 16 hours a day, but they don’t feel down, blue, sad or whatever other synonym you care to use for the everyday sense of “depressed.” This form of non-depressed depression is almost always part of a bigger bipolar picture – it’s a passing, depressed state of someone with bipolar disorder. The two processes behind bipolar illness vary over time. And the two processes can vary independently. If they take turns, and are extreme enough, and last long enough, we call it classic manic-depressive illness. But I’ve seen people in whom the two processes go through every combination you can think of. Sometimes they’re euphoric; sometimes they’re depressed with racing thoughts; sometime their mood is normal but they’re irritable and hyper; sometimes they’re depressed without raciness; and sometimes their mood isn’t bad but they can’t make the effort to do anything and they’re sleeping 16 hours a day. The same person can experience all those states over time, but most sufferers have an individual pattern which only includes a few of the possibilities. So bipolar illness is a different disease than most people think, even most professionals. It’s more variable and more common than almost anyone realizes, and it can be extremely hard to diagnose.

One study done in 1992 showed that 73% of

patients with bipolar disorder received the wrong diagnosis when first evaluated.

Think

about that: three out of four patients with a serious, potentially life-threatening illness went to an expert and received the wrong diagnosis! In 2000 another study demonstrated that diagnostic accuracy had improved: only 69% got the wrong diagnosis.! [see http://www.dbsalliance.org/PDF/BPHowFar1.pdf] At this rate of progress we’ll get it right 3 out of 4 times by the year 2088. The average bipolar patient today was in treatment over 8 years and was seen by 3.3 psychiatrists before getting the right diagnosis. Forty-eight percent of people

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currently diagnosed with bipolar disorder were treated by five or more mental health professionals before getting the right diagnosis. To make matters worse, delaying diagnosis, and thus being sick longer before proper treatment, makes the future long term course of the illness worse, even once it’s properly treated. This book is being written to help people who are being misdiagnosed and getting the wrong treatment. And this book is being written to help people understand their treatment once they have been properly diagnosed. So what is this illness anyway? And why is it so easily overlooked or misdiagnosed? First, I want to emphasize that bipolar disorder IS an illness, a biologically based disease. Psychiatric illnesses are disturbances in the functioning of the brain. Since the brain is the organ of thinking, feeling and behaving, these illnesses manifest themselves in disturbed thoughts, feelings and behaviors. Whoever coined the phrase “chemical imbalance” should get an award for cleverly capturing a notion of biology that people can easily grasp, although we know these illness are far more complex than that simple phrase conveys. Psychiatric illnesses have a basis in both genetics and experience. If one identical twin has schizophrenia, for example, the odds that the other twin will also have it are 50-50. Since identical twins have identical genes, you might guess that if one twin had schizophrenia, the other one would also. But, although there’s a strong genetic basis for schizophrenia, genes aren’t everything. If one identical twin has bipolar disorder, the odds for the other twin having it are three out of four. Pretty high odds, but not 100%, because experience, usually in the form of stress, also plays a role in bringing on the illness. The fact that stress is a factor doesn’t make the illness any less real or any less biological. If someone with diabetes eats Twinkies all the time, the physiological stress

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of the sugar may make their diabetes harder to manage. Similarly, psychological stress causes physiological changes: an acute stress, BOO!, will cause a release of adrenaline, elevate the pulse and blood pressure, change the distribution of blood flow, and so on. Chronic stresses lead to physiological changes. Whatever the triggers, however much stress versus however much genetic predisposition, if you’ve got bipolar illness you’ve got to treat it. Sometimes people will come in with symptoms, an illness, and when I make a diagnosis and recommend treatment they’ll say “But I’m only depressed [and not sleeping, not eating, unable to enjoy things] because I got fired” or “got divorced” or “got cancer” or whatever. And I’ll reply that’s like someone saying, “My leg’s only broken because I fell down the stairs.” It doesn’t matter if it’s because you fell down the stairs or you got hit by a car; you’ve got a broken leg that needs treatment. In the same way, you’ve got to treat psychiatric illness. But what is bipolar illness? What does it look like? Let’s describe a few of its forms: The most famous form is actually quite rare. It’s what used to be called manicdepressive illness, now one subtype of bipolar disorder type I. Psychiatrists used to think this was the only kind of bipolar disorder, and so we thought bipolar illness was rare. In manic-depressive illness someone might look perfectly normal for a while, until there’s a mood swing. Usually the high comes first, although it can go the other way around. The high is characterized by an elevated mood -- euphoria -- although there may also be some irritability -- a great mood ‘til something happens, then POW an ugly anger. The person is speeded up, pressured, talking too fast for others to understand comfortably. Racing thoughts – not just a busy mind but yourmindisgoingsofastthatifyouhadtosayitoutloudyourtonguecouldhard lykeepupwithit. Increased sex drive, spending a lot of money, making a lot of phone calls, infectious humor or anger. When I was in training, working in the Emergency Room, if I walked in to see a patient and within 30 seconds I was either laughing or

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angry, I learned to think: “bipolar.” People who are high don’t sleep much; they aren’t tired. They don’t eat much; they’re not hungry. And they go like that for anywhere from minutes to months, depending on the individual, until they burn out and crash. Fly now, pay later. Everything goes into reverse. Instead of being up, they’re down. They may be depressed in the sense of sad or gloomy, but maybe not. They can just have extremely low energy, be lethargic and apathetic. Not depressed, just listless. Instead of being speeded up they’re slooowwwed dooowwwnn. Instead of not needing to sleep, they want to sleep 14 or 16 hours a day. Instead of not being hungry they want to eat a horse. So they’re up, then they’re down, then they work their way back to normal, and then they do it all over again. That’s manic-depressive illness, and it’s now called bipolar type I as long as there has been at least one manic episode severe enough to be disruptive to that person’s life, and that episode lasted at least one week. If it was less than a week, the illness goes into a wastebasket category: bipolar disorder n.o.s. [“not otherwise specified” This duration criterion is just one of the many problems with the official DSM diagnostic categories.] Bipolar type II is characterized by hypomanic episodes -- less disruptive, briefer, often entirely overlooked highs that last at least four days but less than one week – and significant lows. This form of bipolar illness is frequently misdiagnosed as clinical depression. Often missed as well are “mixed states,” up and down at the same time. People in this condition have the worst of both worlds: all the energy of the activated state but none of the fun -- an uncomfortable energy. There’s an agitated mixed state – restless, jumping out of your skin, irritable, agitated, angry, miserable, hard to sleep, impossible to relax, yuck. It’s like being in a car with its motor racing, the pedal to the metal, but the brakes are locked and you’re going nowhere and you begin to smell something burning. This is a very uncomfortable set of feelings, and sometimes leads to suicide. There’s

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another type of mixed state I call “wired and tired” – someone looking entirely listless but having the feeling of a motor racing inside, draining all their energy. Here the motor is racing but the car is in neutral and so there’s no observable action and no smoke, just a waste of gas. These states are often misdiagnosed as clinical depression, sometimes as anxiety disorders. Also people often try drugs or alcohol to deal with these feelings, or sometimes they cut themselves or engage in other self-destructive behaviors. Remember, bipolar disorder is apparently a combination of two processes. There’s an activating process that rarely produces euphoria, but more often just shows up as raciness with irritability or agitation. Most bipolar patients have never, ever been euphoric. “Mania” means activation, not necessarily euphoria. The second process is de-activating and/or depressive. This almost always has elements of depressed mood, but it doesn’t have to. It may just show up as a lack of energy. Remember, these two processes can each vary independently. If they take turns and are each fairly extreme then we say it’s bipolar type I, or manic-depressive illness. If they take turns and the activating process is mild and brief but the depressions severe, we call it bipolar II. But far more often they don’t take turns, they can mix and mingle in constantly changing ratios, looking at one time like a low-energy depression, another time like an irritable depression, another moment like a high-energy productive state, another like hostile, angry agitation. Or perhaps the elevated phase was decades ago and relatively mild, when the person felt good and was energetic and s/he only ever slept 4 hours a night until s/he started getting miserable and s/he hasn’t felt good since. The fact that an activated period may have only occurred years in the past is part of what makes the diagnosis hard. And the fact that a DSM diagnosis may require a patient to be very specific about the duration of episodes that may have occurred years earlier is another reason why the official DSM categories are not worth much in clinical practice. When people talk about their problems they don’t mention the good parts of their lives, by the way. How can a high energy period, a productive and active period, be part

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of the problem? They emphasize the miserable, the unproductive, and the parts that get their husbands or wives or parents or bosses pissed off at them. They’ll only talk about the apparently good parts if they’re asked very specific questions that most mental health treaters don’t know or don’t bother to ask. And this is part of why the diagnosis is missed. Let’s start with some examples of bipolar disorder that was disguised as other problems. The two people described below came to my offices over 10 years ago, looking for help for a problem that surprisingly turned out to be a bipolar disorder in disguise. They were among the first patients in whom I started seeing the breadth of the bipolar spectrum. Brad Brad was in his early 30’s, looking for help with his drug and alcohol problem. The drugs were stimulants mostly – speed and cocaine -- but also marijuana sometimes and of course some alcohol, but the way he combined them was unusual. A lot of people who use cocaine or speed hate coming down from the high, not so much because of missing the high, though that’s true enough, but because coming down they feel awful--jangled, restless, crummy. Alcohol and marijuana are depressants, drugs that usually have a sedating, calming effect. So after using stimulants like cocaine many people use a depressant like alcohol to smooth the way down. This guy, though, did it differently. He used cocaine or speed for weeks on end, then alcohol and marijuana for weeks, then went back on stimulants again. This pattern had felt fine for years, but lately he was having trouble: he couldn’t feel right. And besides it was starting to cost too much money, and was beginning to get him in trouble with his girlfriend. So he figured it was time to clean up. He told me how for weeks or even months at a time he would feel sluggish and depressed. That was when he wanted cocaine or speed. And then for weeks he would feel hyper, jittery, anxious and racy, and sleep only a few hours a night. That’s when he would use alcohol and marijuana to calm himself down. When I told him that his main problem wasn’t drugs or alcohol, but bipolar disorder, he wasn’t all that surprised: he suddenly recalled that his aunt was manic-depressive.

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Charlie Then there was a Charlie, in his forties, with a long, long history of heavy alcohol use, up to a quart of vodka a day. He’d been sober at times but never for long; he’d had a few detoxes but relapsed quickly each time. When he came to see me after his most recent detox, his mood seemed ok and he agreed to join our practice’s relapse prevention therapy group. He’d never really tried outpatient treatment before, yet he managed to connect with the group leader and stick around for several months with only minor slips – a drink here or there but no out-and-out relapse. It was during one of those group meetings when he said he really wished he could relax, if only he could stop his thoughts from racing. He told us that he’d had periods of racing thoughts ever since he was a teenager, and he couldn’t sleep at all during those times. He said that he was irritable most of the time, angry but not depressed. He never slept very well and went through his days feeling that he hadn’t gotten enough sleep. He felt agitated, stirred up, and unable to relax. Only alcohol made him feel calmer. There were drinkers on both sides of his family, and an aunt had tried to commit suicide. He relapsed again and needed another detox before I began treating him with mood stabilizing drugs for bipolar illness. After seeing a few cases like that I began looking more closely for bipolar illness. My practice partner, Doug Berv, had some similar experiences and soon he and I were running a two-person seminar on bipolar illness, discussing our cases. (Our practice has several locations, so our seminar was conducted via voice mail exchanges.)

Doug has a

buddy from his residency years who conducts research on bipolar illness, so when we got stuck, Doug would call his friend and then relay his friend’s answer on my voice mail. And so it went for about a year. That was roughly 1995. As a result of our discussions about cases in which bipolar illness had been masked by other problems, we began to take a harder look at our patients, especially at our drug and alcohol patients. We knew that substance use could obscure or even

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partially treat mood swings (as was the case with Brad). In fact it was probably the mood problems that got these people into substance abuse in the first place. But most of these patients didn’t have mood swings as clear-cut as Brad’s: they had just bits and pieces of the classic manic-depressive pattern. All we’d been taught about in training was something called “manic-depressive illness,” characterized by clearcut mood swings. But some of the people we were treating had symptoms of mania and symptoms of depression all mixed up, mish-mashed and fluctuating in seemingly random ways. They didn’t have that classic episodic high-low, high-low we had been taught to look for. If there were enough bits and pieces, however, we decided to call the patient bipolar anyway, and then tried to figure out which of the official bipolar diagnoses fit the best. There’s an official list of diagnoses in a book called the DSM, diagnostic and statistical manual, which has to be used in order for a patient to receive medical insurance benefits (a nightmare for a different book). Sometimes we’d use the code 296.6, referring to a mixture of mania and depression simultaneously. Most often none of the official categories fit very well, and so we wrote the diagnosis as 296.80, the code for “bipolar disorder not otherwise specified,” a wastebasket category for people who wouldn’t fit in the usual pigeonholes. As we got into the habit of looking for the bits and pieces of bipolar symptoms with our substance abuse patients, we started to recognize clues for the illness in other patients as well. Lacking specific definitions for the various manifestations of bipolar illness that we began to diagnose, we had a growing population of patients diagnosed with bipolar n.o.s. (“not otherwise specified”). While bipolar hid behind the drugs and alcohol in our substance abuse patients, it was frequently masked as depression in other patients.

In smaller numbers, it lay

underneath anxiety or presented as anger problems, or as self-destructive behavior. Almost no one came in to our office and said they wanted to be treated for bipolar disorder.

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Occasional patients diagnosed themselves as having bipolar disorder because they were having mood swings, but most of these patients were in fact experiencing periods of depression or anger, not the mood swings referred to by mental health professionals that might indeed suggest a diagnosis of bipolar disease. Certainly nobody ever came in and said they needed help because they were feeling too good. I actually believe that the statistics I quoted earlier about what a poor job the psychiatric profession does in diagnosing bipolar illness, as bad as they are, are overly optimistic. These statistics were gathered from patients who finally did get diagnosed, whose symptoms were finally clear enough to meet what are probably overly narrow diagnostic criteria. If we could get statistics that included all the people with illnesses in the bipolar spectrum who are still undiagnosed, who have never been treated properly and perhaps never will be, the rate of successful diagnosis of bipolar illness would be even worse.

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The fact is, too many people don’t get better: drug and alcohol users especially, and people with treatment resistant depression to name a few. The druggies and the drinkers relapse all the time, dropping out of treatment if they ever got into it in the first place. They might get some clean time, but somehow, sometime, they go back to using their substance of choice. The people with difficult to treat depression are always being given the next antidepressant on the list. Maybe they get better for a while, and then they get depressed all over again. So they take more, or go on to the next drug, or the next combination of drugs, only to see the same pattern of response and deterioration all over again. Ultimately the person gets discouraged and drops out of treatment for a while, or goes on to another psychiatrist with another bright idea, then another psychiatrist, and so on. We, like our colleagues, always found explanations, excuses more accurately, for our treatment failures. We could blame the patient. For example, like most mental health professionals who are not substance abuse specialists, we used to look at the drug users with some disdain, thinking of them as defective, manipulative people. Somehow it was their own fault that they were abusers. Of course we were the victims of our own preconceptions – both in our view of our patients and in our diagnoses. We were falling for the obvious. The alcoholics and addicts we diagnosed as having a substance abuse problem. Duh! Everyone knows how hard that is to change! And the refractory depressives’ problem was tough illness. These patients met all the criteria for a diagnosis of clinical depression. The problem was that the available treatments, through no fault of our own, weren’t good enough -- you can’t win ‘em all.

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Turns out that often our approach was wrong from the get-go. We were making the wrong diagnosis. So of course we were offering the wrong treatment. Unfortunately, many of our colleagues are still making the wrong diagnoses, and that’s part of why we are writing this book.

10 brief stories of misdiagnosis First, we learned from alcohol and drug abusers. Let’s look at the two cases we began with: Brad, mentioned earlier, had an obvious problem with addiction. He abused amphetamines and would drink about a pint and a half of hard liquor over the course of a day, but his main drug was cocaine. He binge snorted about an eighth ounce of coke once a week or so. He started with alcohol at about 14, marijuana at 16, occasionally used mescaline for a while, but then started with stimulants, his favorite type of drug. He used alcohol and cocaine or amphetamines for about 14 years after that. His two marriages had been destroyed by his drug use. He went to an addiction treatment program and to Cocaine Anonymous, but it didn’t help. Charlie, also mentioned earlier, was a 43-year-old guy with a wife and 2 kids. He had used both drugs and alcohol for about 10 years from the age of 15 to 25. Then he settled on alcohol alone for the next 13 years, drinking about a quart a day. Finally his wife asked him to leave and he became depressed, thinking about suicide. He clearly had an alcohol problem, and needed detox. Perhaps he had a clinical depression as well. Wrong.

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Next, the “treatment resistant depression”. It turns out that a treatment history of “5 psychiatrists and 20 medications” most likely means it’s not a clinical depression in the first place. Wrong diagnosis leads to wrong treatment. Rebecca was in her late 50’s and had seen several psychiatrists since she first began treatment 6 years before. She was "probably like this all [her] life" - depressed, anxious, jittery, sad, but not teary. Nothing was pleasurable or fun: in the past she could enjoy some things at least some of the time, but she often felt like she was “just going through the motions.” For the last year she hadn’t enjoyed anything at all. She sometimes thought that it would be easier to be dead, but she never truly contemplated suicide. She’d been given at least 4 different antidepressants, but they made her sleepy or jittery or, oddly, sometimes sleepy and jittery at the same time. After learning about unstable mood from our substance abusing patients and from the “refractory depressives”, we began to see it among patients with apparently ordinary depressions. Of course you don’t see it if you don’t look for it. Linda had problems with depression as long as she could remember. She was first treated in 10th grade with psychotherapy, and first given meds after an overdose attempt at age 17. She took Prozac 20mg with some benefit for a while, then stayed at that dose without much benefit, and then switched to Zoloft 50-100mg. That really helped but she developed side effects, feeling shaky, so she stopped the Zoloft. She got depressed all over again. But the shakiness, it turned out, wasn’t really a side effect – it was agitation, and depression wasn’t exactly what she was experiencing – it was a mixed state. Sally was 40. Her primary care doctor had given her tranquilizers on and off to help with her anxiety attacks, which came and went. After 6 years of this, she began to feel depressed. She talked to a therapist, while her doctor prescribed an antidepressant. It seemed to help some, at least for a while. She was on the antidepressant for over a year, not feeling quite right.

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Teri was 32. She had some panic attacks in her mid 20’s, and used Valium briefly. The panics went away after 2 years. In her late 20’s her mother died, then an aunt, then her grandmother. She went to a therapist who recommended Prozac, but she didn’t really want medications. She used some Xanax (a tranquilizer also called alprazolam) which helped some. She felt more depressed and then took an antidepressant, Paxil, for about 2 months. That helped her mood only a little. She had trouble with her sleep and was losing weight, typical of a clinical depression. Wrong diagnosis. Mary was sent by her obstetrician. She had had her second child a few months earlier, and now she was depressed and irritable. She cried every day, felt constant anxiety, had thoughts of hitting people in her frustration, and couldn’t enjoy a thing. She and everyone she had talked with thought she had a post partum depression. Wrong again. Then the anxiety disorders: Abby was a 48 year old woman who had begun having anxiety attacks at the age of 9, although she didn’t know to call them that until much later. The panics seemed to subside through her teens, but after she had her first child the panics worsened, and she got depressed as well. A psychiatrist gave her a tranquilizer, a standard treatment for anxiety attacks. The tranquilizer helped some with the anxiety, but she remained depressed. Another doctor suggested she try an antidepressant, Elavil, which didn’t help but caused a lot of side effects. Later she was given Prozac, which made her more nervous. She wasn’t getting better and the reason was that she didn’t in fact have a panic disorder and it wasn’t clinical depression either.

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Carole had debilitating anxiety which dated back to age 16. After marrying she didn’t leave her house for two and a half years. Only when she got pregnant and had to see an obstetrician did she go out her door, shaking, accompanied by her husband. She started doing a bit better, but got worse again after having her second child. Even now, in her late 20’s, she could hardly leave her house unless accompanied by a family member. She had repetitive fears of vomiting. She couldn’t shop for food, she couldn’t go to a restaurant, she couldn’t drive. Her mood was ok; she wasn’t depressed, just terribly anxious. She was tried on various antidepressants with antianxiety and/or antiobsessional actions (Prozac, Zoloft, imipramine, Serzone, Luvox, and nortriptyline), and on anti-anxiety medication as well (Klonopin/clonazepam and Xanax/alprazolam). She needed something different. David had obsessive thoughts and some depression as well. He had had violent thoughts running through his mind as long as he could remember. He felt guilty and at that the same time knew it was irrational: he thought that he had somehow made an old girlfriend pregnant even though they had never had sexual relations. If he did something with his right hand, he had to do the same thing with his left. He was sad all the time, crying and thinking of suicide. He was hospitalized because of his suicidality, but the hospital didn’t do much good. He was given the antidepressant and anti-obsessional drug Anafranil together with a tranquilizer without much success. Prozac seemed to help a bit at first, but he needed more. But high doses of Prozac made him agitated, so he was given antipsychotic drugs to calm his agitation. He still didn’t feel right. These ten people all had some sort of bipolar disorder. Sometimes the diagnosis was subtle, sometimes it had taken time for the important symptoms to emerge or become clear, but for the most part all ten had been misdiagnosed because no one had asked the right questions.

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In fact it took us quite a while to see what was hidden. We knew that substance abusers had about a 70% rate of dual diagnosis: a combination of a drug or alcohol problem and an underlying psychiatric illness – usually, we thought, depression, an anxiety disorder or attention deficit disorder. There was the occasional bipolar substance abuser, usually with an unclear, mixed up pattern of symptoms that didn’t fit into any of the usual bipolar categories, but “smelled” bipolar once our “noses” had become more educated. Once we started seeing it in our alcoholics and druggies, we started noticing it in people with difficult depressive illnesses, and then we started seeing it occasionally lurking behind what were “obvious” anxiety disorders and depressions. So we came to define an atypical form of bipolar illness, atypical in the sense that the classic bipolar symptoms were not as obvious or pronounced or well organized as we had been taught to define them. However, these symptoms were sufficient to destroy lives. And for all that we’ve focused on this illness, we STILL miss the diagnosis. I say that because there are still patients for whom we make another diagnosis, and later realize that their problem is really bipolar illness. Only by about the summer of 2001 could I say that I was changing as many diagnoses from my mistaken label of bipolar illness to something else, as I was changing diagnoses from my mistaken label of something else to bipolar illness. Finally, after about 5 or 6 years of studying bipolar illness, I was equally likely to make errors in either direction. (Nobody’s perfect, so by looking at this kind of correction-of-error rate I can finally say that I am not systematically, consistently underdiagnosing bipolar disorder.)

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Why did we miss the truth for so long? You’d think we would have known better. We had each been in practice for 13 to 15 years before we got together to form a group practice at the start of 1991. We were experienced and knowledgeable Ivy League grads, trained in psychiatry at Yale and on the Yale clinical faculty. But our roles changed as the new group practice geared up. We were now doing just biological psychiatry, medication treatment, full time. We saw many more patients than when, in the old days, we were also doing psychotherapy. Seeing many more patients, we were in a much better position to learn from them. We had also been hobbled by our traditional thinking about bipolar illness. We thought bipolar illness meant manic depression, and that was a rare problem. Very few patients came in with classic highs and lows. In medical school we had learned two important medical maxims. One was “when you hear hoof-beats, don’t think of zebras,” which was a way of saying that rare illnesses really are rare, and that common diagnoses should be thought of first. And we also learned “Sutton’s law.” Willie Sutton was a bank robber in the 1930’s. When he was finally caught someone asked him why he robbed banks. His answer: “Because that’s where the money is.” If an illness looked like a depression, walked like a depression, and quacked like a depression, it was, we thought, a depression. We thought wrong.

It is especially for all the still misdiagnosed people and their families that we are writing this book, and also for the people who are finally getting the right diagnosis and treatment after all these years, and for health professionals who struggle to sort out the symptoms of this disease. We offer this book as a field guide for patients and. professionals alike, as the field of psychiatry wakes up to the many and varied forms of bipolar illness, the great pretender.

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Part I – the diagnosis and the illness

2. Bipolar illness: making the diagnosis

history

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In the last chapter I described bipolar illness as two processes -- an activating process and a depressing or de-activating process. They can vary independently, mixing and mingling in any possible combination. One key word here is “vary.” Symptoms change over time, so the diagnosis requires looking carefully at a person’s history, not just looking at the current symptoms. The only clear-cut activated state might have been five years ago or twenty years ago, for example, but it’s important to find out about it. In fact it might be the key to understanding what’s going on currently. It’s important to keep in mind that bipolar illness usually starts young. Thirty years ago the most common age of onset was in the 20’s. Now the most common age of onset is in the teens. We don’t know why, but it’s getting earlier and earlier. Part of this may be better diagnoses, but another part is that ALL the common psychiatric illnesses are becoming more common, and ALL of them are getting earlier in onset. There’s an epidemic of psychiatric illness. My own theory is that, having evolved in simpler times, we were not made to cope with this complicated, fast-paced, and stressful world we’ve created. When I was a child I went out and played after school. When my oldest daughter gave up the piano at age ten, I remarked that she had already given up more activities than I had had in my entire life. Anyway, whatever the reason, bipolar is in general an illness that starts early. Depression, on the other hand, is in general an illness that starts later, an illness of 40 year olds, not 14 year olds. But a 14-year-old CAN have a plain vanilla depression. The question though is whether it stays a plain vanilla depression later in life. Researchers have compiled what they call “life charts” of people with bipolar illness: graphs representing the history of someone’s mood extending over a lifetime. These sometimes show a depression early in life, perhaps in adolescence. Then another depression in the early twenties. Then another depression. Then a manic episode followed by a depression. And so on. You get the picture: a simple depression early in life can be the forerunner of bipolar illness later.

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An antidepressant drug study was done at Washington University in St. Louis, trying a new drug on pre-adolescent children with depression. In order to make the study as “clean” as possible, any child with any hint of bipolar symptoms or any family history of bipolar illness was eliminated from the study. The antidepressant didn’t work, by the way, but that’s not the point of this story. Two years later one of the researchers decided to see what had become of the children in the study: one third of them had since been diagnosed with bipolar illness. This is one third of a group in which every effort had been made to ELIMINATE any hint of bipolar illness. And this was only two years later. The number diagnosed with bipolar disorder could only rise given more time. Other studies have come up with similar numbers, saying that roughly 30-50% of children with depression later go on to develop bipolar disorder. These numbers use diagnostic standards that I think are overly strict, so I would guess that at least 50% of youngsters with depression later develop bipolar spectrum illness. Or perhaps it would be more accurate to say that depression is for many youngsters merely an early manifestation of bipolar illness. This may sound like pure semantics but it has implications for treatment. Antidepressant medicines can make bipolar worse, or bring it out earlier, or even bring it out when perhaps it would not have appeared at all. Given the odds of later being diagnosed bipolar, should a youngster who looks depressed, just depressed, be given an antidepressant, or would it be wiser to start a trial of mood stabilizers? No one has a good answer to this question yet. Antidepressants have been in the news in recent years, accused of causing suicidal thinking and suicidal behavior in youngsters. My interpretation of this is that all of those kids were bipolar but misdiagnosed as depressed, or they were in fact just depressed but destined to become bipolar. The antidepressant then caused agitation and activation combined with depressed mood, a mixed state, and so the kids got suicidal. The typical story of these cases is instructive. The kids are taken to primary care doctors who prescribe antidepressants. Perhaps there is some initial brightening of mood,

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but then the youngsters become increasingly irritable, argumentative and rambunctious, impulsive and prone to get into trouble, and have increasing problems sleeping. Then they kill themselves. This is a pretty clear description of a developing mixed state. I was taught in residency training to watch out for suicidality in patients who had recently started taking antidepressants. Some patients “get their energy back” before their moods improve, I was told, and then they kill themselves. In retrospect, I think those were bipolar patients, misdiagnosed, who were given antidepressants and thrown into a mixed state. How early can bipolar start? Some psychiatrists are diagnosing bipolar illness in 5 year olds. I don’t treat children that young, so I can’t speak from personal experience, but my impression is that these are kids who in the past would have been diagnosed with severe attention deficit hyperactivity disorder combined with the world’s worst behavior problems -- a lot of wild and often violent behavior. In some ways the change in label hasn’t meant a lot – these kids used to be treated with antipsychotics, but now, with the new label, they still tend to be treated with antipsychotics. Still, I don’t want to appear cynical about this: I think the change in label does make an important difference. The other mood stabilizing agents are used as well now, whereas they wouldn’t have been thought of before. Also the development and evolution of the illness will be followed more closely with the bipolar label, and treaters will be on the lookout for different kinds of symptoms. Some people wonder if early onset, really early onset, pre-adolescent onset, implies a somewhat different disease, one with a worse prognosis. Maybe. I don’t think we know. The story of pediatric bipolar illness is instructive in another important way. The leaders in understanding and popularizing the diagnosis of pediatric bipolar disorder are the child psychiatrists at Massachusetts General Hospital. Among other services, they run an outpatient clinic, and about 85% of the referrals used to come to this clinic for

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what the parents or referring clinicians thought was attention deficit disorder. Every new patient was given a “kiddy SCID.” The SCID is the Structured Diagnositic Interview for Diagnosis, and the “kiddy SCID” is a SCID that’s been adapted for children. Someone suggested going back over all the kiddy SCID’s they had accumulated, to see what was there. They were surprised to discover that 16% of the children met criteria for a diagnosis of bipolar. Part of the surprise was that they knew that other academic centers also used the kiddy SCID. Why hadn’t anyone seen this before? It turned out that the other centers left out the bipolar section of the kiddy SCID because everyone knew that children couldn’t have bipolar disorder. I can’t think of a better example of how easily we mislead ourselves when we don’t bother to ask all the questions. So what are the bipolar questions? DIGFAST.

“DIG FAST” In order to diagnose mania – remember, think “activation” not euphoria – there are a set of criteria that need to be met. There are seven symptoms and you need 3 plus euphoria, or 4 plus irritability, to make a diagnosis of mania. Remember that someone who is bipolar is not necessarily manic NOW, so these are standards to apply to any episode of activation at any time past or present. The seven symptoms can be remembered with the mnemonic “dig fast.”

D = Distractibility Distractibility is not exactly the same thing as poor concentration: it’s just one form of poor concentration. People who are depressed often have trouble concentrating because their thinking is fuzzy and vague. They can’t get started thinking about something. Their minds are empty. People who are activated have too much flying around in their heads, so their attention flits from subject to subject. Attention deficit

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disorder is also characterized by distractibility, and someone can have both bipolar disorder and attention deficit disorder, so distractibility alone is certainly not enough to make a diagnosis. Later in this book I’ll return to the topic of attention deficit and bipolar disorder. Patients experiencing bipolar depression (not a mixed state) often report that their minds feel empty or slowed.

I = Insomnia Insomnia in this diagnosis does not necessarily mean an inability to sleep. People who are activated sometimes don’t NEED to sleep; they don’t DESIRE sleep. In the extreme case, they stay up around the clock, possibly for days at a time. I had a patient who drank a fifth of scotch every night so that he could sleep for five hours. More common is just a diminished need for sleep: “four hours are plenty!” This sounds too jaunty to convey the possibilities. In clinical depression, people also usually have sleep problems – trouble going to sleep, frequent awakenings during the night, waking up early and not being able to get back to sleep. But a bipolar patient who is mixed, both activated and depressed, may be sleeping only 5 hours and feeling tired all the time, complaining that s/he wants to sleep but can’t. If the person has other symptoms of activation, the diagnosis of bipolar may be clear, but at times it may be hard to figure out which kind of insomnia this is.

G = Grandiosity In the extreme, someone with bipolar illness may be psychotic and think they have special powers and can fly, for example. More common is a pattern in which you just feel you can do SO MUCH! You can take on that project at work, and volunteer at church, and arrange to take your uncle to the hospital, and plan that big dinner for friends, and pick up the kids after school, and so on and so forth. I had one teenage girl tell me she just had this feeling that she could do anything she wanted to do – that she was 25

capable of anything and was permitted to do anything. So what she did was punch her mother. I had a 14 year old boy who nonchalantly asked his mother for the car keys because he wanted to go the mall.

F = “Flight of ideas” Another phrase for this is “racing thoughts.” Sometimes people think they have racing thoughts when really they just have a lot on their minds. There’s this, there’s that, oh my god what about the other thing, and so on. Racing thoughts are not merely busy, they’re FAST: yourmindisgoingsofastthatifyouhadtosayitoutloudyourtonguecouldhard lykeepupwithit. Or-maybe-it-isn’t-that-fast-it’s-only-this-fast-but-it’sstill-pretty-fast-and-you-don’t-have-to-be-talking-this-fast-but-onlythinking-this-fast. Sometimes people say they don’t have racing thoughts but they have multiple thoughts: several thoughts SIMULTANEOUSLY. This is something I learned about from one of my patients. I was treating a teenage boy who I thought was bipolar, but I couldn’t nail down the diagnosis. I asked repeatedly, over a period of weeks and months, about racing thoughts. I asked again and the boy said, with exasperation: “I told you I don’t have racing thoughts. I do have six of them though.” I said “Really? Tell me about that.” The usual stream of thought is like traffic on a one-lane road with traffic moving at 60 miles an hour. If there’s a lot on your mind, there’s a lot of traffic. If there are several things on your mind, the traffic will be mixed: there’s a truck, a car, a car, a van, another truck. If your thoughts are racing then the traffic is moving 100 miles an hour. If you have multiple thoughts then you’ve got a 5-lane highway. Having multiple thoughts

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is like having three different televisions tuned to different stations, as opposed to channel surfing on one set. Anyway you look at it, there’s a whole lot of thinkin’ goin’ on. Sometimes it’s hard to distinguish racing thoughts from anxiety. People who are acutely anxious, especially those with panic attacks, may feel flooded by their thoughts, mostly their fears and worries, and may confuse this with racing thoughts. If a patient only experiences “raciness” during anxiety attacks I tend to discount the symptom. But since people with a bipolar disorder can experience anxiety as part of their activation or as a separate symptom, it is sometimes hard to tell the difference.

A = increased Activity level Activation implies a high level of energy, and often this energy gets a lot done. “Do you ever feel like you can do the work of two or three people?” Usually this means a high level of “goal directed” activity: there is an intention to accomplish something, and sometimes something actually does get accomplished. The activity can be disorganized by distractibility, however, so sometimes little is actually achieved. Sometimes the increased energy starts feeling uncomfortable, like “I’m tired but I can’t stop dancing.” Sometimes it shows up as restlessness and agitation, a feeling of wanting to jump out of your skin. And at a certain point activity can get too fast and become disorganized: “running around like a chicken with its head cut off.”

S = pressured Speech This just means talking fast. Do people ever say, “Hey, slow down, you’re talking too fast”?

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T = “Thoughtlessness” This is the “reach.” You know how a lot of mnemonics have a reach? A word that’s twisted to make the mnemonic work? “T” is a reminder that people who are activated are “thoughtless”: not in the sense of inconsiderate, but more “heedless” or impulsive. They don’t stop and think. They spend too much money, often in splurges or “spending sprees;” they are promiscuous. This is another criterion in which I think the DSM is too limiting. The DSM requires impulsive pleasure seeking activities -classically spending and promiscuity, or poorly thought-out and grandiose impulsive business decisions. In my experience the most common impulsive behavior in bipolar disorder is violence – hitting people, throwing things, breaking things, punching holes in the wall, kicking the cat.

duration, number of symptoms, and “N.O.S.” To be called a manic episode the symptoms need to persist for at least 7 days, and they must be severe enough to be disruptive. To be called hypomanic, an episode needs to last at least 4 days and not be severe enough to be disruptive. If symptoms last only 2 days but are severe, they technically do not constitute either a manic or hypomanic episode. If symptoms last twenty minutes out of every waking hour, as I had one patient tell me, they don’t fit either pigeonhole. If the symptoms occur about two days a week, they don’t fit. And so on. This is one reason many patients are bipolar “NOS” – not otherwise specified. If someone is depressed and irritable, has never been euphoric, but is also distractible, has clear-cut racing thoughts and feels like s/he can’t sleep enough but has no other symptoms of activation, s/he doesn’t qualify for the official diagnosis: this adds up to irritability and only 2 or 3 symptoms depending on how you count the insomnia. Frequently these patients have been diagnosed with clinical depression in the past, but

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have not responded to prior treatments. I think this is a bipolar spectrum illness and mood stabilizers, not antidepressants, are the way to go. This is another patient I diagnose bipolar nos. For me, racing thoughts is the most important symptom in making a diagnosis of bipolar. If there are clear-cut racing thoughts I feel pretty confidant making the diagnosis, even if other symptoms are missing. If there are no racing thoughts, I might still make the diagnosis but I don’t feel entirely comfortable about it. I’m just not completely convinced when there are no racing thoughts. Some people think a bipolar patient with the label “nos” must have a milder illness than someone labeled bipolar bipolar I or II. This is simply not true. For example, the depressed and irritable patient with clear raciness but not enough symptoms to make a diagnosis of mania may be severely suicidal or even psychotic. The person who is activated for only 3 days at a time every week may be unable to function in work or school, and has his life totally disrupted. These people are quite ill but just don’t fit the pigeonholes of the DSM.

beyond DIGFAST Remember that all this needs to be looked at over time, longitudinally. These symptoms come and go, in episodes that can last from minutes to months. Appetite often varies along with sleep: diminished appetite with diminished need for sleep. But it doesn’t have to be this way. High energy can be goal directed, but it can also come out as agitation, “wired” feelings, and restlessness. This agitation may lead to violence. Irritability is not specific for bipolar disorder, though. It can be a part of depression or of attention deficit hyperactivity disorder. The irritability of bipolar illness can get driven by the high energy and so may be expressed in more extreme forms, for example

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road rage with true violence. I had someone come in who had been riding around with a gun in case someone pissed him off, and another person who impulsively but deliberately rammed another car when the driver annoyed him. More often, though, irritability will just show up as “mouthiness,” temper, and displays of anger. Mania can increase sexual energy and sex drive. People who are manic and euphoric are charismatic, full of energy and life and charm and jokes. Combine this with some grandiosity and impulsivity and you get promiscuous behavior. Sometimes I wonder about some politicians who are charming and highly energetic and promiscuous. Chronic hypomania? Of course someone may be promiscuous without being manic: it could be psychologically, not biologically, driven. Agitation and irritability can sometimes be “treated” with alcohol, or perhaps heroin. Gambling and risk taking may sometimes be driven by grandiosity and poor judgement, but this is more clearly a reflection of bipolar illness if it occurs in an episodic pattern. Bipolar disorder can cause psychotic symptoms, most likely paranoia but possibly other delusions or even hallucinations. Again, these behaviors can have other causes. The diagnosis is based on a pattern of symptoms and behaviors, not on any one thing.

family history Even if the pattern of symptoms is unclear, a family history of bipolar disorder is certainly suggestive. So is a family history of suicide and to a lesser degree depression or drug and alcohol abuse. There is strong evidence of a genetic component for bipolar disorder but many patients are unable to name a single blood relative with any psychiatric problems whatsoever. The genetics of bipolar disorder is complex, presumably involving many genes in combination. If you think of someone’s genes as a “hand” made up of

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cards dealt from each of their parent’s “hands,” you can imagine a situation in which neither parent has a bipolar combination of cards, but the cards selected from each parent come together in a combination that’s just wrong, producing the illness.

trials of treatment Worse comes to worse, and the diagnosis is still unclear, it may be worth having a trial of treatment with some of the medications we’ll be discussing. Sometimes I’m left diagnosing “mood disorder” but not being clear what kind. The drugs used to treat bipolar illness will not make depression worse, but the drugs used to treat depression may worsen bipolar illness. So if in doubt, try stabilizers first.

3. Clinical Depression – not! Sometimes it’s quite difficult to see bipolar illness underneath what looks like an obvious clinical depression. I had one patient, for example, whom I treated for many years for what I thought was a chronic refractory (difficult to treat) depression. She would get depressed and I would adjust her antidepressants, increasing something she was on or adding something new. She’d feel better but soon have medication side effects. I’d lower the dose of something and she’d do well for a while, ‘til her mood deteriorated once more. Eventually I added the mood stabilizer lithium, but not as a mood stabilizer. I added it as a booster, or “augmentation” agent, for the antidepressants. That helped for a while, but soon we were back on the same merry go round. Finally I remembered my own rule of thumb, that a patient who’s seen 5 psychiatrists and been on 20 antidepressants is bipolar until proven otherwise. There was

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little evidence for a bipolar diagnosis except for the fact that when she felt bad her sleep, never more than five and a half hours, would diminish even further. It was impossible for me to tell, however, whether her insomnia was inability to sleep or diminished need for sleep. Finally we decided on a trial of treatment with Depakote, a mood stabilizer, in addition to lithium as well as the multiple antidepressants she was taking. She got better, and since that time has been significantly more stable than before, requiring less frequent and less extreme med adjustments. She’s still on a slew of medications and the question arises: does she truly have bipolar disorder? Beats me. I’m just glad that she’s doing better. I still hold my breath when she comes into my office and I ask how she’s doing: I can never take her stability for granted. Someday I suspect that we’ll have genetic tests and functional MRI scans that will help make the diagnosis, but in the meantime we do our best coping with the limits of our knowledge. One thing is sure, however, and that is that whatever she has, it’s no run of the mill, routine depression. Depressed mood in the setting of a bipolar mixed state is far more dangerous than depression alone. One older study showed a suicide rate of 15% for bipolar disorder. This number is probably too high, because the data was collected when the only people getting the diagnosis were severely ill, usually hospitalized, patients. With a broader definition of the illness, and with better treatments available, the mortality won’t be as bad, but it’s bad enough. The data showed that people with untreated bipolar had 30 times the general population’s rate of committing suicide. With treatment that rate was still 6 times the general rate. The agitation and depression can be tremendously uncomfortable; people feel like they want to jump out of their skins. They may, instead, kill themselves. The other problem is the T in digfast: thoughtlessness or impulsivity. Feel awful, want to be dead, grab a gun, bang, as quick as that. When I hear of a family history of suicide I think it’s likely that the relative in question did not have clinical depression, but had bipolar illness.

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One reason that many people who have bipolar disorder are misdiagnosed as clinically depressed is that they answer “yes” to all the depression questions: are you depressed in the sense of sad or gloomy most of the time? Yes. Have you lost the ability to enjoy yourself? Yes. How is your energy? Low, I’m exhausted. How’s your concentration? Terrible. Do you have thoughts of death? Yes. How’s your sleep? Lousy. Maybe you’re tearful and/or irritable. DONE! You’ve met criteria for the diagnosis of clinical depression! The problem is that most clinicians don’t bother to go on and ask the “mania” or activation questions. They don’t distinguish between distractibility and inability to think as different forms of poor concentration, they don’t ask about racing thoughts, they don’t ask about bursts of high energy, or insomnia as diminished need for sleep instead of inability to sleep, and so on. Also, they are misled because most patients have never been euphoric. Most clinicians incorrectly believe that clinical depression is very much more common than bipolar disorder, and they get lazy, they don’t ask the bipolar questions, they just ask the depression questions. And the answers are all “yes,” and they make the wrong diagnosis. Some psychiatrists just don’t get it: they’re stuck in the “bipolar disorder IS manic depression” mode. One of us had a patient who had seen a psychiatrist for many years, trying to treat her “depression.” She then came to our practice, was diagnosed with bipolar disorder and got WELL with mood stabilizers. She decided to go back and see her former psychiatrist to tell him what had happened. He told her “no, you don’t have bipolar disorder,” in spite of her sitting there in front of him, better than he had ever seen her, courtesy of her mood stabilizers. There are none so blind as those who will not see.

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Bipolar and ADHD Occasionally someone will come in saying that they have attention problems. Perhaps they were diagnosed in childhood with attention deficit disorder (ADD) or attention deficit hyperactivity disorder (ADHD). Perhaps they had been given Ritalin, and perhaps it had helped. But perhaps they have bipolar disorder instead. The diagnosis of attention deficit disorder is made by looking at a checklist of symptoms. Attention deficit disorder, with or without hyperactivity, is not something that is developed later in life; it’s something you’re born with. There must be evidence of attention problems by the age of 6 or 7, the age that school begins. The most common symptoms are distractibility, carelessness, difficulty sticking with complex or demanding tasks, avoiding demanding tasks, losing things, restlessness, boredom, irritability, changeable moods, appearing as if “driven by a motor” (a quote from the DSM diagnostic guide), impulsivity. Sound familiar? One study showed that people with bipolar disorder had more symptoms of attention deficit disorder than people with attention deficit disorder did. Does this mean that every person with bipolar disorder has attention deficit disorder? No, not really. It just means that sometimes it’s hard to know if someone with bipolar disorder also has ADD or ADHD. What needs to be done is to make the bipolar diagnosis if appropriate and defer any conclusions about ADHD. Then treat the bipolar disorder. Then go back and re-evaluate the attention issues. I’ve had bipolar patients who thought they had ADHD discover they could concentrate just fine once their racing thoughts were controlled. On the other hand, I’ve had people who were no longer activated but still had the attention issues that lead to an ADHD diagnosis, and who did much better with, for example, Ritalin along with their mood stabilizers.

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4. Unstable mood and personality disorders and sometimes PTSD “Borderline personality disorder” is a diagnosis that’s sometimes used as an epithet by mental health professionals. That’s because people with this disorder are often so difficult to treat, so frustrating, so manipulative. They somehow know how to get to their treaters, emotionally. They’re unstable and their relationships are unstable. They’re inappropriately extreme in their emotions, impulsive and often self-destructive, quick to anger or even violent. They have an unstable sense of themselves. Often, you won’t be surprised to hear, they really have bipolar spectrum disorder. I don’t know what percentage of people diagnosed with borderline personalities actually have bipolar disorder. But I think it’s a big enough group that clinicians need to do a better job looking for the diagnosis. After all, someone with bipolar disorder can be unstable, impulsive, so uncomfortable that they can become self-destructive, irritable and even violent. There’s a complicated wrinkle in making this diagnosis: you can have both. It happens that many people with borderline personality have been victims of abuse, physical and/or sexual abuse, in childhood. It’s believed that these experiences can interfere with the normal development of personality, so that a young child’s primitive and extreme notions of self, relationships and the world never get to become more complicated, nuanced and mature. So who’s doing this abuse? Often it’s an unstable, drug or alcohol abusing, violent parent. This raises an interesting question: was this parent perhaps bipolar? If so, that helps us understand (not excuse) the parent’s behavior. And did this person with borderline personality disorder therefore inherit a bipolar tendency along with being exposed to extreme stress interfering with normal psychological development? And so does this person perhaps have both disorders, intertwined? Also of course the trauma can cause post-traumatic stress disorder (PTSD), with intense anxiety, flashbacks, and dissociation or spaciness. In fact, in our practice we

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have several patients with bipolar disorder, PTSD, borderline personality and, usually, substance abuse problems all at the same time. Treating this combination isn’t easy, but it’s a whole lot easier if the bipolar piece has been properly diagnosed and treated. Of course it’s also possible to have both bipolar disorder and a personality disorder without a history of abuse. Examples: Barbara was in her late 40’s when she first came to see me. She recalled problems with depression back to early childhood, and she had started her first course of psychotherapy, the first of many, when she was 13. She was given medications, antidepressants, for the first time in her early 20’s, and had been on antidepressants most of the 25 years since that time. She drank regularly, sometimes heavily. She had been hospitalized once, after cutting her wrists. She tended to get spacey, or dissociated, when she was depressed, tearful, and suicidal. She had lifelong sleep problems. She rarely enjoyed much of anything. Every few weeks she felt restless for periods of a day or two, with increased energy and an increased ability to do things, but accompanied by an even worse mood than usual, a combination of depression and irritability. It was unclear to both of us whether she ever had racing thoughts, whether her sleep was just crummy or reflected a diminished need for rest, or whether she any other symptoms of bipolar activation. After her periods of increased energy, though, for the next few days she would feel more depressed but less irritable, and would spend more time in bed and sleep 10 hours a night. In sum she did not have good evidence of a bipolar disorder, but her mild “cycling,” if indeed that’s what it was, was suggestive. She was adopted and so we had no family history to help with the diagnosis. Chronically depressed, she had given up on medications being of very much use and didn’t want to “experiment.’ It took a long period of knowing each other before she would agree to try new meds, and years of fiddling with various medications for her to end up on the six (that’s right, six) medications she is currently taking. Between these meds and the excellent psychotherapy she’s been getting from someone in our practice,

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she is somewhat better: dissociating less, not drinking, no longer cutting herself, somewhat less self-destructive in her thinking, sleeping more consistently. But still pretty miserable a lot of the time. Sorry about that, but I wanted to include an example that reflects the unfortunate reality of some of these cases. They can be HARD: difficult, complicated. In this case we’re still trying to get it right after four years of treatment together. Making the right diagnosis is key, but it’s not the whole story. There’s also figuring out the right treatment. Don’t get me wrong, THE OVERWHELMING MAJORITY OF PEOPLE WITH BIPOLAR DISORDER CAN BE VERY MUCH BETTER WITH TREATMENT. Those ten cases of misdiagnosis described earlier, for example, also happen to be ten cases of people feeling really good when properly diagnosed and treated. But sometimes it’s very hard. We will return to these issues when we discuss treatment in more depth, later in this book. One diagnostic issue that may at times be difficult is distinguishing PTSD (posttraumatic stress disorder) from bipolar disorder. One characteristic of PTSD is heightened states of arousal and severe anxiety. This can produce a picture of pressured, sleepless misery than can be mistaken for a bipolar disorder. Sometimes it is only after years of treatment that this can be sorted out. Another common confusion is sorting out what’s going on with adolescents who have irritability and behavior problems. Studies have shown that 80% of these kids respond to Depakote, a mood-stabilizer. So do they have bipolar disorder? Unclear.

6. Cutters – adults

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One typical form of self-destructive behavior is cutting – wrist cutting, leg cutting (to keep the cuts hidden), arm cutting (wear long sleeves). This kind of cutting is not an attempt at suicide. Instead, self-inflicting wounds serves as a distraction from other sorts of pain, or perhaps as a way for someone who is emotionally numbed to feel something, anything at all. This behavior is most frequent in women who have been diagnosed as having borderline personality disorder, and in adolescents of both sexes, for whom no diagnoses may have yet been made. Examples of adult cutters: Nancy was in her early 40’s and had first sought help in early 20’s. She had been in and out of therapy ever since, for twenty years. She had gotten medications from her family doctor at times, as well as from various psychiatrists over the years. She had been on at least five different antidepressants and three different tranquilizers. She abused pain medications, had been detoxed once, but became re-addicted almost immediately afterwards. We could make a good guess at the diagnosis with this information alone, based on the five-psychiatrists-and-twenty-medications rule, but let’s go on. She cut her arms whenever she was upset, which was often. She was depressed and cried frequently. She felt tired all the time, but hyper as well. She talked very fast and when questioned said she had racing thoughts most of the time. She had spending sprees, and periodic highs, which ended in her mood crashing. For 15 years she hadn’t slept without the help of a tranquilizer or pain pills. During her most depressed periods she slept 10 or 11 hours a day and felt even more exhausted than usual. Nancy was adopted and didn’t know anything about her family history. Having read this far, you’re wondering why it took 20 years for someone to make the diagnosis. Answer: no one had ever asked the bipolar questions, they only asked the depression questions.

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Ellen came to see me to treat her eating disorder, her depression and her anxiety. She had been hospitalized four times because of her eating disorder – anorexia alternating with bulimia (binge eating and purging by vomiting and/or using laxatives). Her problems went back to early adolescence when, at age 12, she first became anorexic. For the next few years she was either anorexic or bulimic, seeing therapists but not getting better. Finally she was given Prozac, which helped a lot, so much so that after a while she stopped it and found she could go without it. A year later, however, she became depressed again, but the Prozac didn’t work as well the second time around. She dropped out of treatment until, in her early 20’s, her weight became dangerously low and she had her first hospitalization. About two hospitalizations later she started cutting, having picked up the idea from some fellow psychiatric inpatients. She was depressed, with suicidal thoughts but no immediate plans to kill herself. Her concentration was poor. She had no racing thoughts but had multiple thoughts most of the time. She was irritable most of the time but occasionally had wonderful moods lasting up to a day, followed by her terrible periods of depression. She could sleep as little as 3 hours a night for 3 days running, during which time she felt restless, anxious and depressed. She spent a lot of money at these times but didn’t like the feeling: “I feel tired and a lot of energy at the same time. I can’t slow down.” She was “multitasking and doing ten things at once.” At the end of these periods she would sleep 12 hours a night for the next two days. Diagnosis: bipolar disorder. Again: why did it take so many years to get the diagnosis? No one asked the right questions. This is not to say that every adult cutter has bipolar disorder. But enough do so that it’s an important possibility to consider. Consider, too, Ellen’s early history of eating disorder and depression, which responded well, at least the first time around, to antidepressant treatment. Certainly no one diagnosed her as bipolar at that time, and it must have all looked very straightforward. But there is no record that anyone asked the bipolar questions at that time. And either way there’s a problem. Perhaps she had bipolar symptoms at that early

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time, too, in which case missing the diagnosis and giving her antidepressants was really poor treatment, since although the antidepressant may help in the short run, it might have made things worse long-term (more on the effects of antidepressants later). On the other hand, maybe she didn’t have any bipolar symptoms at that time and we have another instance of an adolescent depression being a precursor to bipolar illness later in life, raising still broader questions about whether it’s ever a good idea to give adolescents antidepressants.

7. Adolescent cutters and the risks of antidepressants This brings us to the problem of adolescent cutters. These kids are far more diverse than the adults, and can have behavior problems, anxiety disorders, depression or bipolar disorder. Mary Ann was a 9th grader having some problems with her schoolwork. Her teachers wondered if she had a learning problem. Or was she depressed? She saw a therapist and revealed that she had been cutting herself regularly for over a year, cutting only on her legs so she could conceal it. She had started cutting more frequently in the last few months, almost every day. She described very mild mood swings, with periods of one or two hours of feeling really, really good, followed by down periods lasting several days. It wasn’t clear whether the ups were anything beyond normal excitement or pleasure over happy events. She had some irritability, but only with her parents. (What adolescent doesn’t?) Although she could still enjoy things, her mood had been deteriorating further over the prior few months, and she was starting to cry regularly. She had started having thoughts wishing she were dead and a few days before seeing the therapist had her first thoughts of suicide. She had never had racing or multiple thoughts, and never 40

experienced periods of excess energy. Her concentration had deteriorated along with her mood, but was not distractibility so much as an inability to think. She had a longstanding sleep problem, difficulty falling asleep and only five or six hours of sleep, but slept nine or ten hours on weekends. Perhaps her sleep problem was just anxiety. Her appetite had always been normal. She was adopted and so we had no family history to help. So what did we have for a bipolar diagnosis? Think DIG FAST. D, distractibility – not quite. I, insomnia in the form of diminished need for sleep – not clear. G, grandiosity – no. F, flight of ideas – no. A, increased activity or energy level – no. S, pressured speech – no. T, thoughtless, impulsive acts – yes, her cutting. There was no way we had enough evidence for a bipolar diagnosis, but her mild mood swings were suggestive. I made the diagnosis of depression with anxiety, with a “rule out”, i.e. possible alternative, of bipolar disorder, along with another “rule out” of a personality disorder. I prescribed an antidepressant after having a long talk with her and her mother about the possibility of bipolar disorder emerging. She started the antidepressant and began to feel at least somewhat better. But about six weeks into treatment she took an overdose of her antidepressants. She said she didn’t really want to die, but just to get sick and avoid school. The fact that she told her parents about the overdose immediately after taking the pills lent her story some credibility. She told me the she was having “mood swings,” by which she meant very rapid mood shifts. When her mood was up she was truly euphoric and, to some degree, grandiose. Then her mood would plunge for no reason and she would want to die. She was having racing thoughts on and off irrespective of her mood. She now was having periods of pressured speech. These swings were getting worse, more rapid and more extreme, but she had been having them, she said, for weeks or months. It wasn’t clear whether these swings were just more extreme versions of the mild swings she had been having for a long time, or were something qualitatively different. What was clear was that she had bipolar disorder. I stopped her antidepressant and started a stabilizer, Depakote. Within a few months she was feeling fine, on a combination of two mood stabilizers, Depakote and lithium.

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Some psychiatrists think that if bipolar symptoms only emerge when someone is given antidepressants, then that person doesn’t really have bipolar disorder. In my opinion those psychiatrists are wrong. Right or wrong, though, however you label those patients, they have to be given stabilizers before antidepressants can even be considered. Was it a mistake to start an antidepressant? Antidepressants can make bipolar disorder worse, but there was little evidence for a bipolar diagnosis. My experience is that even with really good evidence it is hard to convince adolescents and parents that a youngster has a bipolar disorder. They don’t want to hear it. And I thought bipolar was only a possibility, a “rule out.” It’s always easy to know what to do in retrospect, but given the evidence at the time I had little reason to do anything other than what I did. I do think it’s important to alert teenagers and their families to the possibility of bipolar symptoms being triggered by the antidepressant. At least you’ve got a chance to catch the problem before it spins entirely out of control. Still, we have those life charts showing early depressions with bipolar illness emerging later in life. And depression is a disease of forty year-olds, not fourteen-yearolds. Should adolescents with depression and no good evidence of bipolar disorder be given stabilizers as their “first line” treatment? How about depressed adolescents with just one or two bipolar symptoms? A family history? This position has little or no support among practitioners. I don’t do it myself, but I wonder if someday, when the proper research is finally done, this will be standard practice. As I’m writing this, I just spent some time reviewing all the adolescent cutters I’ve seen in the last two years. It’s impressive how many question marks there are in my notes. The typical case has some depression, some anxiety and some situational problems, difficulties with the parents, some deterioration of schoolwork. There is rarely clear evidence of bipolar disorder. But there is rarely a clear picture of anything. There are a lot of “rule outs” in my diagnoses. Early trials of antidepressants and later trials of stabilizers. Patients stopping their medications and returning months later to start over.

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Or just disappearing from my practice. This may be a commentary on adolescents who cut themselves, or perhaps it’s a commentary on me and my ability to help them. I’d like to think it’s the former, and I think it is, as there are a reasonable number patients like Mary Ann who, even if things are confusing at the start, end up doing really well. More cases: Kelly, a 15 year old, had problems with irritability and anger which had started about six months before she came to see me. The irritability lasted a few hours to a day or two, and then went away, but then she felt “blah,” low energy and mediocre mood. That would last one or two days, and she’d just sit around during those periods. When she was angry she punched holes in the wall. She had started cutting herself a few months prior to seeing me. Her moods were labile, varying widely and quickly. During the periods of irritability she had pressured speech, broken concentration, high energy, and slept only three or four hours. During the “blah” periods she slept ten or eleven hours a night, felt mildly depressed and had some passive wishes for death but no true suicidal thoughts. She still couldn’t concentrate well but she didn’t feel at all racy. She’s now fine on a low dose of lithium. This sounds so straightforward, and indeed it was because I asked the bipolar questions. Someone who did not ask the bipolar questions would have diagnosed her with depression and given her an antidepressant. Jennifer had been cutting her wrists and forearms for a few months before her father happened to notice the cuts. Her parents took her to a therapist who suggested evaluation by a psychiatrist. As a young child Jennifer had always been very sensitive, easily upset by criticisms or disappointments. For years, though, she said she had been feeling more and more numb, and she started cutting herself in order to feel something. She had felt depressed for as long as she could remember. And she looked depressed, one of the most depressed-looking kids I had seen in 25 years of practice. She said she had used to think about dying, but that those thoughts had gone away a few months ago as she got still more numb. She had racing thoughts all the time, and sometimes multiple thoughts, but she said her concentration was ok. Her parents were surprised to learn that

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she only slept two or three hours a night. She went to bed at a normal hour and they had assumed she was sleeping, but she wasn’t. She said she was “not really tired.” Her energy was always low. She had no impulsive behavior other than her cutting, no irritability and no periods of elevated mood. Now, remember the official DSM criteria for the diagnosis of mania: 3 dig fast symptoms plus euphoria or 4 dig fast symptoms plus irritability. So Jennifer, had 3 digfast symptoms -- insomnia, flight of ideas, thoughtlessness. But she had never been either euphoric or irritable, so she never met criteria for mania and so she never met criteria for bipolar disorder. The official criteria are in fact of only marginal use out here in the real world. Most bipolar patients end up with a diagnosis of “bipolar disorder n.o.s.” (n.o.s. = not otherwise specified): the wastebasket category for people you want to diagnose with bipolar but who don’t fit in the usual pigeonholes. The DSM sucks.

8. Sequential diagnostics and prioritizing treatment Dawn was in her late 30’s when she came to see me. Her first course of treatment had been in her teens, after she had gotten into alcohol and drugs – binge drinking and heroin. Earlier in her life she had been physically and sexually abused. She described feeling pressured all the time, doing everything fast but getting nothing done. Her energy varied from high to higher. She had periods of racing thoughts lasting up to a week at a time, accompanied by increased irritability. She slept four or five hours a night. She had never been either euphoric or depressed – she was just irritable in varying degrees. She had been given Prozac and felt high for a few weeks, then had a few weeks of being tired with increased sleep, then had no effect. So this looks like bipolar disorder along with substance abuse, perhaps post traumatic stress disorder (PTSD) since she also had flashbacks to her abuse as well as dissociative episodes. She also reported longstanding

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problems with concentration, distractibility, and various other symptoms of a possible attention deficit disorder. Did she have PTSD? Maybe. Or maybe those symptoms were somehow part of the bipolar disorder. Dissociation and flashbacks are key symptoms for the diagnosis of PTSD, along with anxiety or “arousal,” but the high arousal of bipolar disorder might be somehow promoting the other symptoms. That is, if the bipolar disorder were controlled and Dawn was less agitated and racy, perhaps she wouldn’t experience the other symptoms at all. Who could tell? Did she have attention deficit disorder? Maybe. But we know that bipolar disorder can cause all the symptoms of ADHD. So where do you start treatment? You start with the “deepest,” most important diagnosis. And when it’s there, the deepest, most important diagnosis is bipolar disorder. So first treat the bipolar disorder, then re-evaluate. Emily had been in therapy 35 years and hospitalized seven times because of the voices in her head. She said she had three personalities that would try to take control of her. She had been anorexic at times, weighing as little as 90 pounds, but she also had periods of binge eating alternating with purging – self-induced vomiting. Because of her panic attacks, she had trouble leaving the house. She used drugs heavily for a few years, tranquilizers and sedatives, but had given them up. She hadn’t really felt depressed for some time, just scared. She had trouble going to sleep, especially because her thoughts were racing all the time. But she was rarely tired, anyway. She had been both sexually and physically abused as a child, and had flashbacks frequently. She was being treated with an antidepressant and a tranquilizer, but wasn’t any better. Enough to work on here? Where do you start? You could diagnose an eating disorder, ptsd, multiple personality disorder, substance abuse, panic disorder and agoraphobia, psychosis and of course bipolar disorder. But bipolar disorder can cause psychotic symptoms: paranoia, hallucinations and delusions. It also predisposes to drug abuse. It can cause panic attacks, which in turn cause agoraphobia. The ptsd and multiple personality disorder and eating disorders might have a life of their own, but were

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certainly made worse by the bipolar activation and anxiety. And by the way, the antidepressant was probably making things worse instead of better. So you start with the bipolar disorder and chip away. And you arrange for some good psychotherapy with someone who understands bipolar disorder as well as psychology. Emily is now doing really well. Her mood is good, although rarely she still purges. She isn’t very anxious and can function normally. No more voices. No more multiple personalities. No more drug abuse. No more flashbacks. We will discuss medications and treatment later, but you might be interested in knowing that Emily is taking two anti-seizure-type mood stabilizers, one of which has antidepressant properties. She is also on an atypical antipsychotic which has mood stabilizing properties. And she’s on a high dose of a tranquilizer. And she’s taking a stimulant for the attention deficit disorder that was revealed years into treatment. Five medicines. Treatment can be about as complicated as the illness itself.

9. Schizophrenia and bipolar disorder Bipolar disorder sometimes produces psychotic symptoms – grandiose delusions most obviously, but also paranoid feelings and even hallucinations. In the past I’m sure there were many individuals given the diagnosis of schizophrenia who were really bipolar, so when I hear “grandpa was schizophrenic” I always take that with a grain of salt. If the psychotic symptoms are relatively mild or minor, my tendency is to think of the problem as just bipolar disorder. If the psychotic symptoms are more prominent but there is also evidence of bipolar illness, then the problem is labeled “schizo-affective.” Although this sounds like just a mixture of schizophrenia and a mood disorder, my guess is that this kind of problem has a different course and a different prognosis than either bipolar or schizophrenia. But that’s just a guess. In the absence of research data, which has not been gathered, worrying about these labels is like debating the number of angels 46

on the head of a pin – these theoretical issues make no difference whatsoever in the treatment. Maybe someday that will be different, maybe someday we’ll have biochemical or genetic markers that differentiate between clinical conditions and lead to meaningful differences in treatment approach. But it’s not someday right now, it’s today. And today there is no practical meaning to worrying about what schizoaffective disorder really is. Just treat it.

10. Bipolar and obsessive compulsive disorder Sometimes a patient will come in with what looks like the world’s worst case of obsessive compulsive disorder (OCD). Their intrusive thoughts are overwhelming, persistent, insistent, and intense. They’re upset, tremendously upset and disturbed and need something done as soon as possible because they can’t stand it; the thoughts are too much. Anti-obsession drugs, which are the antidepressant drugs in the Prozac family, or the tricyclic antidepressant Anafranil, don’t seem to help much, if they help at all. That’s because these patients have bipolar illness hiding underneath their obsessional symptoms. Harry was in his twenties and had suffered with violent thoughts and images as long as he could remember. He checked locks multiple times; if he did something with his left hand he had to do it with his right as well; he was afraid of contamination. He was depressed, tearful, and unable to enjoy anything. He was anxious, even terrified, about his condition. He had been given high dose Prozac, a standard treatment for obsessive compulsive disorder, felt a bit better for a while but then had stopped it because it made him feel agitated. He had then been switched to Anafranil. He had been hospitalized twice in the three months prior to seeing me. My diagnosis: obsessivecompulsive disorder. On our second visit, howver, he came in very pressured and agitated, and I discovered he had racing thoughts. New diagnosis: bipolar disorder. This patient came to see me in 1994 or perhaps I would have made the proper diagnosis on the first visit. No one had made it during his prior outpatient treatment or hospitalizations. 47

Since that time I’ve had several patients with bipolar illness and obsessivecompulsive disorder. Often the bipolar illness has been missed by prior treaters, because the obsessional problems are so in your face. But it’s the pressure behind the obsessional symptoms that’s the tip-off that something else is going on. Obsessive-compulsive patients are often depressed or have other anxiety symptoms, but they are not usually pressured. Treating the combination of bipolar and obsessive compulsive disorders is really tricky. As I mentioned a moment ago, the standard treatment for OCD is an antidepressant drug like Prozac or Anafranil. As I mentioned earlier, however, antidepressants can make bipolar illness worse, so the treatment is like walking a tightrope. We will return to this issue in the treatment section of this book.

11. Stress and genetics So how does anyone get this illness? Round up the usual suspects: nature and nurture. There appears to be a strong genetic component to bipolar disorder. One way we know this is from data on identical twins. Identical twins result when a single fertilized egg develops into a group of cells which happens to split in two and then produces two fetuses. So identical twins have identical DNA, identical genes. If one twin has schizophrenia, for example, the odds the other has schizophrenia are 50-50. This says that genes are important but not the whole shooting match. If one twin has bipolar disorder the odds are 75%

Still not 100% but high.

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Usually there’s something in the family history of people with bipolar: depression, alcoholism, something. But sometimes there’s no family history of psychiatric illness: nothing. How can this be if genetics are so important? The genetics of bipolar disorder is complex – it’s not as simple as eye color or height. You need a complex combination of many genes, just the wrong combination. So, again, if you think of your genes as a hand in a game of cards, with half your hand coming from each parent, you could get cards from each side that combine in just the wrong way to give you the illness. Even this is an oversimplification. We don’t know if bipolar disorder is just one illness or several related ones. We don’t know if people with identical looking illnesses have even similar looking, let alone identical, genes underlying their problems. We do know something about the genetics of these illnesses. Most importantly we know that there is a genetics. They run in biologic families, even when the kids are adopted by other families without the illness – showing that, in terms of getting the illness, the family you’re born into is more important than the one in which you grow up. We even have candidate genes that we think are involved: one on the short arm of chromosome 18, one on the long arm of chromosome 21, one on the long arm of 18 that shows up only in bipolar type ii, and so on. Let’s suppose that one day we show that there are 11 genes involved. But what if you only have 8 of the 11 genes? What does that produce? And what if it’s these 8 versus what if it’s those, overlapping but different 8? Maybe that kind of thing explains the different forms of the illness. We also know, though, that stress usually plays some role in the illness. Remember that an identical twin has a 75% chance of having bipolar if the other twin has it. What about that other 25%? We know that stress is important. Illnesses ofter first appear in the context of stress. Someone whose illness has been well controlled often becomes symptomatic when stressed. And stress may take different forms. There is psychological stress- marital problems, financial problems, family worries, and so on.

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And there is physiological stress – sleep loss, drug or alcohol use, pregnancy, exposure to steroid drugs, etc. One patient of mine flew to Europe for a vacation, got jet lagged and lost sleep, destabilized and had to fly right back home. A common time for the onset of mood problems is early adolescence, presumably a result of hormonal changes. Of course adolescents are notoriously “moody,” but those who do become ill will often date their symptoms to the age of 12 or 13, and many newly diagnosed adults will recall feeling depressed or severe irritability or various forms of misbehavior back to early adolescence. But some will say they recall feeling depressed in their earliest memories, back to 6 or 7, so hormonal stress is not a universal precipitant. Many adults will say they don’t know why they started feeling bad, but some will associate the onset of symptoms to events in their life, not necessarily bad events either. One patient recalled feeling high, euphoric, not needing to sleep, at one with the world, when he traveled abroad as a college student. These were the earliest symptoms we were able to identify.

12. Mild versus severe It may seem obvious, but my experience tells me it’s not, so I’ll say it: bipolar illness, like any illness, can be mild or it can be severe. Duh! People react to the term “bipolar illness” like they do to the word “cancer.” It’s scary, life threatening, catastrophic. I’m not up on cancer treatment, but I gather that reaction is overgeneralized for cancer. It’s certainly over-generalized for bipolar disorder. Bipolar can be subtle or obvious. It can be totally incapacitating or merely troublesome. It may be easily controlled or very difficult to treat. There is no research to prove it, but it is my strong belief that good treatment of the illness in its mild forms will prevent it turning into a more severe form.

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13. Resistance to the diagnosis and to treatment Having an illness sucks. Having to take medicine sucks. These are the unpleasant realities you are faced with when you’re given the bipolar diagnosis. No normal person wants an illness, and no normal person wants to take pills. And that is how I view my patients: normal people who happen to have an illness. People are beginning to become familiar with the bipolar diagnosis – I’ve been told that soap opera characters are getting the diagnosis. It’s in the movies, books and magazines. So it’s not quite as exotic a notion as it used to be, but it sounds serious, and it is serious. It’s a serious illness that requires lifelong treatment. It’s like diabetes: if you have diabetes you can take your insulin, but when you wake up the next morning you’re still diabetic. And like diabetes, remember, it can be severe or mild, easy to treat or brittle. Whatever it’s particular characteristics, however, it is serious and deserves to be taken seriously. That’s the bad news. The good news is that treatment is pretty good, and we have more treatments all the time. Many mental health practitioners have the idea that people with bipolar tend to stop taking their medications because “they miss the highs.” This was the lore I was taught in training. It’s baloney because, as you know, most people with bipolar have never been high. People tend to stop the medications for two reasons: they don’t like the side effects, and/or they don’t want to need medication. My feeling is that if I’m going to ask you to take medications for the rest of your life, I’d better be willing to knock myself out to find medications you can live with. Occasionally I’m in the position of saying: “We’ve tried many, many things. You’re 51

pretty good right now but have some side effects. I’m not sure we can do better, or that it’s worth the risk of making you worse while trying to find a better combination of medications.” I want my patients to know I’m not going to say that lightly. Still more common, however, is the desire to be well, not merely in the sense of having your illness well-controlled, but in the sense of not having any illness at all. At a certain point, when feeling good, you’re tempted to say “why am I taking these stupid pills if I feel good?” This leads to two kinds of complicated questions. Sometimes a patient who has been doing well will come to an appointment and announce that they’ve stopped their meds and are feeling fine. What can we conclude? Not much. The illness, remember, is often episodic, and episodes tend to be sparser earlier in its course. Did we have the diagnosis wrong? Will stress or time lead to another episode down the line? How soon? We don’t have good answers to any of these questions. I may or may not try to convince my patient to restart meds, depending on how severe past episodes have been and how sudden in onset. But I believe that there will inevitably be problems down the road, and I try to educate so that future symptoms will be recognized and treated as early as possible. The other questions arise come from the following scenario, presented by someone at a conference I attended: a patient had been doing well for 15 years, taking just lithium. She decided that, after all that time being stable, she wanted to try going off the medication. She became very ill and was given lithium again and it didn’t work. And neither did anything else. I’ve had similar experiences, and so has every psychiatrist I’ve ever asked about this. It’s not common; most of the time if you add back the medication it works just fine. But sometimes it doesn’t. The only theory I’ve heard that might explain this phenomenon has to do with stress. As background, understand that all the cells in your body have the same DNA, the same genes, but that different genes are turned on or off at different times in different cells. Different genes have to be expressed to make a liver cell a liver cell,

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and a nerve cell a nerve cell. It’s been shown that putting animals under stress can change which genes are expressed in parts of their brains. Being ill is itself a stress. Thus, perhaps the stress of becoming ill is changing gene expression in parts of the brain and thus changing the nature of the illness itself, making it a worse illness. This is speculation, but the phenomenon of people becoming harder to treat as they have repeated episodes of illness is an unfortunate reality. So there are two worries when people go off meds. The first is that down the road they might become very sick very fast, with immediate bad consequences. The second is that they might become sick with the consequence of worsening the course of their illness for the rest of their lives.

Part II – treatment 14. The role of psychotherapy Everybody’s different. (Duh!) There is no one approach, no one medicine, no one correct mixture of medications and psychotherapy. Every patient needs to be educated about the illness, but while some do fine with just medications, many benefit immensely from psychotherapy. Psychotherapy plays several roles: it provides a more in-depth and individualized setting for learning about the illness and its manifestations in that particular individual, it offers support in accepting the diagnosis and its implications, and it helps in avoiding or coping with stress.

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Let’s talk more about stress. Older women tend to develop osteoporosis, a loss of minerals from the bones that leaves the bones weakened. So if an older woman falls down, does she break her hip? Well, that depends. How hard did she fall? At what angle did she hit? How thinned were her bones? In fact, what happens to her is a result of the interaction of the physical stress of that particular fall and her particular biological vulnerability. In these psychiatric illnesses stress counts. But what makes a stress a stress? The same event can happen to two people, and one will collapse while the other is hardly fazed. What are your support systems and how well do you utilize them? Could you handle situations differently to make them less stressful? Could you avoid them? Are you doing things that create unnecessary stress in the first place? These are useful issues for people to deal with in psychotherapy. Stress is real, and managing it better can have a dramatic impact on the course of the illness. As we said earlier, we teach diabetic patients about nutrition, and if they eat properly their treatment goes better. If they eat a case of Twinkies, though, things may not go so well. Twinkies are a physiological stress. If you put someone under an acute emotional stress – BOO! – their blood pressure and pulse rate will go up, their adrenals will secrete adrenalin, and there are various changes in brain chemistry. Having an illness sucks. Knowing you have an illness is a stress in itself. The process of digesting bad news is called mourning, and every patient has some mourning to do in accepting the reality of the illness. Some people do this alone or with their families, others benefit from a therapist’s help in this process. If available, a bipolar support group may be terrifically helpful. It’s preferable for such groups to be run by a professional who is knowledgeable about bipolar spectrum disorder. Self-help groups are a mixed bag, and so is information you get on the internet.

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In general there are only two kinds of people who’ll spend time in psychiatric disorder themed internet chat rooms: those who are newly diagnosed and those who aren’t doing well. The people who are doing well have better things to do with their time; they’re out living their lives. People are often reluctant to go to a group, but those who go to one that’s well run are almost unanimous about its value. Just as a diabetic monitors blood sugar to know how well treatment is going, so must the bipolar patient learn to monitor his or her own mental and emotional state, energy level, hours and quality of sleep, mood and level of irritability. Some people benefit from the help of a therapist in learning to pay closer attention to these things, so monitoring and the teaching of self-monitoring is another role for psychotherapy.

15. Working with your doctor: self-monitoring The patient is a partner in treatment, not the passive recipient of treatment. We have no objective measures of bipolar activation. The only objective symptom we might track is hours of sleep, and sometimes an observer can’t be sure of that, and even so usually can’t monitor the quality of the sleep. The patient’s self observations and self reports are key to understanding the illness’s current state, and measuring whether any progress has been made, and if so in what way. I ask all bipolar patients about most of the DIGFAST symptoms at every appointment. That’s how I know how they’re doing. I always ask about sleep, about racing or multiple thoughts, and about concentration: these are key for assessing activation. I ask about a patient’s impulsive behavior if that’s been significant – temper tantrums, shoplifting, spending, violence, and so on. I rely on their answers to these questions in figuring out the next step in treatment. I tell patients that they need to observe these things, and that such observing will help them in two ways. First, it will help me know what’s going on. Second, it will give 55

them some perspective. By learning to assess themselves with at least some objectivity, they get a little distance from their own emotions. They may feel depressed and anxious and hyper, and at the same time they can know they’re in a mixed state. Knowing doesn’t change feeling, but it can help. Knowing you’re in a mixed state doesn’t get you out of that mixed state – you still feel depressed and anxious and hyper. But a part of you has a little distance. Your heart or your gut is ringing an emergency buzzer, but your head knows what’s going on: you’re in a mixed state. You’ve been in this state before, perhaps, and know that certain medications were helpful at those times. The emergency buzzer in your gut is still buzzing, but you don’t feel quite as alarmed if you have perspective on what’s happening. Such perspective can help get you through rough times. As a bipolar patient you have to learn to trust your (well-educated) head instead of your (poor, sick) gut. DON’T TRUST YOUR GUT! TRUST YOUR HEAD! The more accurately you report your symptoms the more precisely your doctor can adjust your medications, or at least reassure you or educate you about what’s happening. A 15 year old girl was answering my questions about her symptoms when I asked her if there was anything else to tell me or ask me before we brought her mother into the room. She hesitated, and then told me, blushing, that lately she was wanting to be with boys a lot more. I explained to her about hypersexuality and mania. Explaining didn’t make the symptom disappear immediately; it did help her understand what she was experiencing, and it contributed to her long-term education about her illness. I was impressed by her being able to raise that subject, however euphemistically. She risked embarrassment, no small thing for a 15 year old girl, to tell me what she was feeling. As it happened I already knew she was activated and I was planning to increase her antiactivation med, so it didn’t change our immediate plan. But it was another step in cementing our partnership in learning about and treating her illness. What a great patient! Sometimes I’ll ask a patient to keep a mood chart. Every day they mark 2 numbers between –10 and +10, one mark representing the best mood of the day and one mark representing the worst. We define –4 to +4 as the normal mood range: anything

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more extreme is, well, extreme. Along the bottom of the chart we track hours of sleep, along with any other dimensions that are important for that patient – irritability, exercise, tasks completed. I usually ask for charting if the going gets complicated. Some psychiatrists use charting from the first visit, and perhaps that’s a better idea. By the time I ask for it, though, it’s clear to both me and my patient that we really need better and more detailed information. I had one patient who had a clearcut cycle every day: depressed and sluggish every morning, giddy and hyper in the evening. The treatment was very difficult: she’d improve some, then worsen, we’d think a med was working, then it wasn’t. It finally occurred to me that perhaps there was also a longer cycle that was misleading us. When she started charting we saw a two week cycle superimposed on her daily cycle – her broad mood range would shift over a period of weeks while every day her mood cycled within that range. Another part of self-monitoring is keeping track of how you take your medication. It’s really frustrating to have a patient say they’re not doing so well and then to find out that they’ve been missing doses of medication and furthermore they’re unable to say how frequently they’ve skipped doses. What do you learn from this? Nothing. If you knew they took all their medications at least you’d know that particular combination of meds didn’t work. But you don’t even know that. Maybe they’d work if they were taken properly. You lost a turn. Another few days or weeks lost, another few days or weeks of being ill.

16. Self-care The more variables you control, the faster you learn about your illness, the sooner you feel better. Don’t use any alcohol until you feel better. That’s what I tell my patients except for those with clear alcohol problems, who should plain stay away from it for good. Look, you may not be drinking much at all, or not much compared to your friends. If we lived in Europe a couple of glasses of wine would be the norm. But you’re 57

drinking enough to mess up your mood. I’ve had patients I’ve been treating for depression have two drinks, just two, and get depressed for four to seven days. You can drink and feel happy for an hour or two, and then worse for almost a week. Of course some people must be more sensitive than others, and the people I described are probably at the sensitive end of the spectrum, but why do anything that’s going to make it harder to get better? Cut it out until you get better. Then, when you’re feeling well, you can reintroduce alcohol into your life if you want, carefully and observantly, and see how it goes. Marijuana will tend to bring out anxiety and paranoia. Plus it creates a smoke screen (hah) that obscures whatever your meds might be doing. You see where I’m going here? Protect your sleep. This is the single biggest factor under your control. Sleep disruption is the single most common cause of destabilization. I had a patient fly to Europe, get jet lagged, miss sleep, and have to fly right back home. (I repeat myself but it’s an important point.) Some people blame the increased incidence of bipolar disorder on the invention of the light bulb. If we had to go to sleep earlier we might be better off. I saw a case presented, a patient at the National Institute of Mental Health who had severe bipolar disorder but for some reason couldn’t or wouldn’t take any medications. This patient wore a device on his wrist that looked like a wristwatch, but in fact recorded his level of physical activity, moment by moment. Looking at the output of the device showed that his physical activity was at a high level, disorganized, and scattered throughout the 24 hour day. This guy was not sleeping, or at least not in any normal way. The treatment consisted of telling him he had to lie in bed in a dark room for 12 hours every day, the same 12 hours every day. He could sleep or not, but he had to lie in the dark room for that time period. The movement recorder showed that, over a period of months, his physical activity got organized, and more and more concentrated during the daylight hours. He started sleeping more normally, and his symptoms improved.

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Staying up to work late is as dangerous as staying up to party -- not counting any alcohol or drugs consumed at the party. Shift workers can be very hard to stabilize, especially if they try to change their sleep cycle twice a week to take advantage of their days off. They never sleep properly. If you gain weight (!!- we’ll return to this), you may develop sleep apnea, and this will destabilize your mood. So protect your sleep. There’s some evidence that omega-3 fatty acids helps stabilize mood, so take some. They’re good for your heart, reducing the risk of heart attack. They reduce the risk and intensity of inflammatory bowel disease. They’re good for you. They’re available at drug stores, health food stores, Walmart, Costco, on the internet. There are two important subtypes of omega-3, DHA and EPA. You want the total of EPA and DHA to be at least 50% of the total fat in the gelcap or liquid that you buy. Thus, if you get a gelcap that says it contains 1 gram of fat, that’s 1000 milligrams. Then, in that case, you want the total of EPA and DHA to be at least 500 milligrams. This ensures that the oils are prepared by microdistillation, and thus that there is no mercury or other heavy metal contamination. The ratio of EPA to DHA is usually 3:2. You want that ratio, or perhaps more EPA. Some people think that EPA is antidepressant and DHA is antimanic. The cheapest source that I’ve found is Twin Labs Mega TwinEPA, purchased on the internet. The purest preparation and the one with the highest ratio of EPA is Omegabrite, available only on the internet. If the fishy taste of some of these supplements is too much for you, try Omega Brite. It’s more expensive but more palatable. It appears you need at least 1000 to 4000 mg of EPA + DHA to make a difference. Start at about 1000 to 1500 and work up. If you develop diarrhea, lower the dose and increase more slowly. Watch out for bruising; omega3’s can inhibit clotting and thus promote bleeding. If you’re bruising easily, you’re taking too much. It’s especially important for pregnant women to take omega-3’s. The level of omega-3’s drops in the last trimester of pregnancy because omega-3’s are being sucked out of the mother to help make the baby’s brain. These substances are a major component of nerve cell membranes, and thus a big part of our brains. This, as well as

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the usual-suspect hormonal changes, may have something to do with post-partum psychiatric illnesses.

17. Medication strategy: Treat activation first! People don’t come to treatment because of racing thoughts. They don’t usually come to a psychiatrist for help with irritability or even sleep problems. And I’ve never had a patient complain that they needed help because they were feeling too good. Most commonly, they want help because they’re depressed. But if they’re depressed with bipolar disorder, antidepressants are likely to make things worse. In fact bipolar patients have often been put on antidepressants by their primary care doctors or other psychiatrists before they arrive at my office, and the first thing to do to help them is to taper off the antidepressants. It is not safe to give an antidepressant or any medicine with anti-depressant effects until the activation is controlled. Activation is the first target for treatment: the first goal is no racing thoughts and at least a moderate amount of sleep. Irritability and concentration are ambiguous, since they can accompany depression and thus not indicate activation. But racing or multiple thoughts should be completely gone, or almost completely gone, and sleep should be at least in the 5 or 6 hour range in order to conclude that activation is under control. Sleep may remain somewhat disturbed if there is residual depression. And at that juncture, you should do…. nothing. Nothing. Let the dust settle for 2-3 weeks before starting down the next road. This is a complicated illness and you need to know that the activation is really under control, not just randomly diminished for the moment. Also many people will have their depression improve significantly or even disappear once the activation is controlled. They no longer feel agitated and

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uncomfortable, and their mood improves. For others, though, some depression remains and has to be dealt with. In general, at this point I still avoid antidepressants. Why? No one knows what is really safe. No one knows whether any antidepressants are any safer than any others. One set of statistics I heard said that about 20% of people with bipolar disorder who are given antidepressants will “switch” immediately (change to an activated manic or mixed state), and another 20% will have their mood problems worsened not immediately but down the road. If they are cyclers, they will start to cycle more frequently and more extremely. They will experience “roughening,” not a clear cycling but increased symptoms of instability. Their mood, though perhaps intially improved, will worsen. So if activation is controlled but depression persists, I prescribe drugs which are not classified as antidepressants, but which have both antidepressant and anti-activation effects, in the hope (hope) that they will be less likely to cause switching or roughening. In overview, then, treatment consists of two phases: the anti-activation phase first, and the anti-depressant phase second if needed at all. This is, of course, a vast oversimplification since activation may intrude at any time, and especially may be triggered by the medications used in the anti-depressant phase. But treating activation always comes first and always has priority whenever activation is present. There’s another way to describe these two phases: “hurry up” and “wait.” The treatment of activation can be aggressive and go quickly, doses can be changed as frequently as every day or even titrated over the course of a day, and symptoms respond quickly if they’re going to respond at all. The treatment of activation is the “hurry up” phase. That’s a good thing because the activation phase is more dangerous than the depressed phase. Someone is more likely to commit suicide in a mixed state than a

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purely depressed state; or may make bad business judgements, have impulsive affairs or become violent when activated. Depressed people are less likely to get into trouble. The treatment of the depressed phase tends to be much slower. Some medications take weeks to work or build-up, and meds are likely to be introduced in a gingerly fashion because of concern about switching. It also takes time to evaluate things that may be episodic. For a cyclic mood problem, for example, it takes at least 3 cycle times to have some confidence that something’s changed. If someone gets depressed about every 2 months, I’m going to have to wait 6 months to know for sure that they’ve stopped. It’s not that you’re doing nothing, but the “wait” phase goes slowly. But being depressed is the opposite of “time flies when you’re having a good time.” The treatment is slow and it feels even slower. That is the overview of the medication strategy. We will discuss the nuances when we look at the various drugs available at this time. The most important point, though, is that treating activation always takes priority. In real estate the most important factors are location, location, and location. In bipolar treatment the most important rules are treat activation first, treat activation first, and treat activation first. And delay and avoid antidepressants if you can. Between roughly 20 and 30% of bipolar patients will eventually need antidepressants, by the way, so they’re not poison. They’re just dangerous. After reviewing the medical treatments, we’ll return to an overview, this time of treating bipolar when it presents in combination with some other psychiatric symptoms. I referred earlier to the treatment of combined bipolar disorder and obsessive compulsive disorder as walking a tightrope. Treating bipolar and substance abuse, bipolar and personality disorders, bipolar and anxiety disorders also present special issues.

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18. Anti-activation medication group 1 – lithium For some reason people often wince when I suggest they take lithium. They don’t know anything about the drug, but it sounds bad to them. I don’t know why, but I have my theories. There are three groups of medicines used to treat activation: lithium is unique and is a whole group by itself; some anticonvulsants (anti-seizure drugs) are used to treat activation; and the so-called atypical antipsychotics are used as well. Lithium has been used for over 50 years to treat bipolar disorder. It is the best researched, one of the most effective and probably the single most useful drug we have. For a long time it was all we had, and I think that’s part of how it got its undeserved bad reputation. It is only in the last 10 years or so that we have gotten a broader view of bipolar illness. Before that, the only people who were diagnosed were people with classical manic-depressive disorder, with big mood swings and extreme symptoms. Athough lithium is a very useful drug, by itsef it is usually not good enough to do the job. Starting in the mid-1950’s these patients also got Thorazine to help calm them down, and for many years lithium and Thorazine were the only drugs officially licensed in this country for the treatment of mania. Thorazine is a powerful antipsychotic medication with lots of side effects, and even with the combination of lithium and thorazine many patients did not do well. So who was getting lithium? People with extreme illness who were only partially treated by the lithium and Thorazine, and who had thorazine side effects. My theory is that this association is the source of lithium’s bad name.

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Anyway, lithium is just another drug, with important benefits and with side effects to watch out for, just like any other drug. It’s important, however, because of some special features that make it unique. One feature is that it helps antidepressants work better in treating depression: it’s what’s called an antidepressant augmentation agent. Sometimes, when the diagnosis is really unclear, maybe it’s bipolar and maybe it’s just depression, lithium will help cover both bases. Starting with lithium will help treat bipolar it that’s what it is, but otherwise you can add an antidepressant to it, have the lithium possibly help protect against bipolar switching and at the same time have the lithium help the antidepressant work better at a lower dose. When you think about bipolar spectrum disorder, atypical or “soft” bipolar, the fact that lithium works as an augmentation agent for depression makes you wonder about who exactly it works for. It doesn’t work for everyone. Who is that subpopulation of depressed patients for whom lithium augments antidepressants? Is their illness somehow related to bipolar disorder? When we have better methods of looking at people’s genetic makeup, maybe we’ll be able to answer that question. An important feature of lithium is that it’s not sedating. There are individuals who find lithium makes them lethargic, but mostly it’s neither sedating nor stimuating. Given the tendency of anti-activation drugs to make you tired or sleepy, this comes in handy when it’s time to add another drug for activation and you’re close to groggy from the meds you’re taking. You can lower the sedating meds you’re on and add nonsedating lithium. Side effects tend to be dose related. At higher doses especially, people experience tremor, stomach upset or diarrhea and increased urination (increased urine volume, not just frequency). Lithium sometimes has dose related cognitive side effects, interfering with concentration and memory. Longer term, lithium can have suppressing effects on the thyroid – not a big deal, something checked once a year and easily treated. More seriously, but more rarely, lithium can have effects on the kidneys. This is checked with periodic blood tests.

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How often does lithium cause kidney damage? No one knows. When I was in training in the 1970’s, I was taught that lithium caused kidney damage. In the 1980’s we believed that lithium did not cause kidney damage: some people on lithium had kidney problems, but no more so than people who did not take lithium. In the 1990’s, maybe lithium caused kidney damage. In this new century, lithium definitely can cause kidney damage. I figure that if it took us 40 years to sort it out, it can’t happen too often. It appears that the risk of kidney injury is related to lithium levels, and becomes especially likely if you become lithium toxic or run high levels. Thus it may be worth trying to keep levels at the lower end of what is for you the effective range, especially as we can expect lithium levels to bounce around a bit depending on fluid intake, spacing of doses and so on. There is no evidence that spreading out the lithium doses helps, and there is some evidence that it is the trough, or lowest, level of lithium that is important in determining risk to the kidneys. If it doesn’t upset your stomach, take all your lithium at bedtime. If you’re going to have a tremor, it will be worst while you’re asleep. Your trough level will be as low as possible immediately before your next dose. It will be lower than if you spread out the pills, and thus you will lower your kidney risk. Also since lithium levels are standardized at a 12 hour interval from when your last pills are taken to when the blood is drawn, you can do your labs in the mornings and the timing will be about right. Why take a medicine that might ever hurt your kidneys, even if that risk is low? Treatment is always balancing risk and benefit. If you’re on lithium it’s because you have an illness that needs treating. Your choice isn’t feeling good on lithium or whatever medications, versus feeling good without any medications. It’s between taking medications and living with their risks versus being sick, depressed, irritable, angry, impulsive, upsetting your family and ruining your career. Or whatever your symptoms happen to be. You can live with a small risk of bad effects or you can be guaranteed to be miserable every day of your life. Seems like an easy choice to me.

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What is the right lithium level? For outpatients the broad range is between 0.5 and 1.0 or maybe 1.2, with a tighter and usually preferable range of 0.6 to 0.8. There’s no right blood level, just whatever works. Blood levels tell us whether we have room to maneuver before we’re likely to hit side effect problems, they help check on whether someone has actually been taking lithium as prescribed, and they may help clarify whether physical symptoms are probably side effects or not. For example, are you nauseous and vomiting because you have the flu or because you’re taking too much lithium? In general, because of kidney concerns I lean toward lower blood levels if they work. I won’t increase a dose just to get to a higher level. I don’t treat blood levels, I treat people. Who benefits the most from lithium? Early research showed that the best benefits for lithium are in people who haven’t been sick very often, haven’t used drugs or alcohol, and don’t have mixed states. These are people with relatively early onset slow-cycling classical manic-depressive style bipolar disorder. And perhaps this is true in terms of treating with lithium alone. But lithium is of great benefit in most bipolar patients, it just can’t do the job alone. I tend to start with lithium as the first drug in the classic cycling patients, but lithium is often the second or third drug in everyone else.

19. Multiple medications You may have noticed that I’ve mentioned “the first drug” and “the second drug.” And in the cases discussed earlier, some people were on six medications. Most people with bipolar disorder are on several medications. 70% are on three or more medicines. How come?

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There are three reasons that people end up on multiple medications, two practical and one theoretical. One practical reason has to do with the management of side effects, the theoretical one relates to maintaining stability. . Suppose you’re started on an anti-activation medicine and it really helps. But it makes you sleepy. And let’s say you need more medicine, because it’s helped but not enough. Increasing the dose of what you’re already on will make you unacceptably groggy, so what I suggest is adding lithium. I don’t want you to stop something that’s helping in order to try something that may not help. But you can’t take more, so we add something else. And now you’re on two medicines. Suppose the lithium we added helps, too, but also not enough. When we increase it you develop an unacceptable tremor. So we reduce it, you continue on the first medication and you continue on lithium, and you’re definitely better than when you started but you’re not better, you’re not well yet. So we add something else, but now you’re too tired and we have to reduce medication 1 in order to make room for medication 3. And so on. Or maybe med 1 plus lithium controls your activation completely, but you’re left with some depression, and we have to add another medication to help with that. This is another practical reason that people are on several medications: medications that control activation will often leave you with depressive symptoms that require additional treatment. The theoretical justification for multiple medications has to do with the maintenance of stability. It makes sense that several medications with different mechanisms of action may provide more stability than relying on just one medicine with one mechanism of action. It makes sense, but we haven’t proven it. This theoretical justification is a psychological comfort, though, letting us think that perhaps there’s some extra benefit in the complicated medication cocktails we brew.

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Someone may be on some odd combination of meds but still not be well. If they’re not having unacceptable side effects, you are then faced with a choice: you can take time to reduce some of the current meds to see if they’re really needed, or you can add something new in the hope of improving their condition. Usually people prefer the second option: make them better a.s.a.p. But suppose your strategy works? They are now on the odd combination plus something else, and they feel fine. Do you now try to remove or reduce something? This is really a dilemma. You don’t want people staying on more medicine than they really need. On the other hand, the only way to find out if you need a medicine is to reduce it in steps and then stop taking it altogether. Ultimately, the only way to know you’re taking the minimum medication is to keep reducing until you’re taking too little and get sick again. Then what? Obviously you add back what you last reduced or took away. There’s a problem, though. Adding back what was working before doesn’t guarantee you’ll get better again. Every psychiatrist has stories of patients who were well, stopped a medicine, got sick, restarted the medicine, but stayed sick. (This scenario was discussed earlier.) The medication won’t necessarily work the same way when you add it back. Furthermore, there is reason to think that in this scenario you may not only suffer with symptoms right now, you may permanently change the course of your illness. You may alter the trajectory of your illness, and have less stability and more symptoms for the rest of your life. So there’s a lot to be said for the maxim “If it ain’t broke, don’t fix it.” If you’re doing well and not having side effect problems on some odd combination of medications, you’re probably better off just continuing on that odd combination, never knowing whether all the meds you’re taking are really necessary.

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One of the best researched and most effective anti-mania drugs we have is Depakote. Originally an anti-seizure medication, Depakote has a number of side effect issues. The most common problem is that it often causes significant weight gain. The newer, extended release form is somewhat less likely to do this, but I wouldn’t want to bet on it. [There’s a generic form, depakene, which is therapeutically equivalent but more likely to cause upset stomach – depakene is worth knowing about if you’re the one paying for the prescription.] Depakote can cause upset stomach, nausea, dizziness, tiredness, clumsiness – all typical anti-convulsant side effects. It can cause hair breakage that looks like hair loss – the difference is that the follicle is till healthy and your hair can grow back. Taking a multivitamin with minerals, especially selenium and zinc, may prevent the hair problem. Depakote can cause liver damage, which is detected by blood tests done early and repeated in the first few months on the drug, as well as occasionally thereafter. Rarely it can cause pancreatitis, which shows up as severe abdominal pain. And we worry that it may contribute to polycystic ovary syndrome in young women. I know this list sounds horrible, but Depakote is a great drug, an effective drug, a useful drug. Unfortunately, there’s no free lunch. As you have seen and will see again and again, every drug has got a problem or a worry associated with it. You don’t have to gain weight on depakote, most people don’t. It doesn’t change the laws of physics – your metabolism still must obey the rule that matter is neither created nor destroyed except in high energy nuclear reactions. If you don’t put the food in your mouth, it can’t make you gain weight. But depakote can increase appetite, making it harder to resist putting the food in your mouth. And so on. Depakote is another drug that is monitored with blood levels. Most labs think that 50 to 100 is the therepeutic range, but very few people get significant benefit below about 80. Many people require levels of 100-125, and as long as they don’t have significant side effects, that’s fine. I’ve had patients tell me that other psychiatrists had prescribed

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Depakote for them without success, but if I hear their blood level only got to 60 my feeling is that they never really tried the drug. Tegretol is another anti-seizure medicine with a long history of being used to treat bipolar disorder. Only recently, however, were the proper studies performed for it to get official approval as an antimanic drug, in the form of an extended release preparation called Equetro. Besides the normal anti-seizure drug side effects of tiredness, nausea, and dizziness, it can cause a severe anemia, suppressing the production of blood cells in the bone marrow. It can also interact with other medicines, causing the body to break down various medicines more quickly than usual and thus requiring an adjustment of the dose. These risks made psychiatrists steer clear of this drug for some time. But again, although scary, the problems are for the most part manageable. The risk of aplastic anemia is real, but low, perhaps a hundreth of one percent. It shows up as severe bruising and/or sudden spiking fever. A milder variation just produces easy bruising. Sounds scary. But the risk is low, if it does happen you’re likely to become aware of the problem and fix it before it harms you, and the drug might make your life worth living. That’s the trade-off. Trileptal is closely related to Tegretol. There’s virtually no research on it for bipolar, and it has not been officially approved for use in psychiatry. Many psychiatrists, including us, have prescribed it, however, hoping to get the benefits of Tegretol without the problems. Trileptal is much more palatable than tegretol, it has many fewer and less serious problems. Unfortunately, it’s not as good as we’d like it to be. It is useful. It seems to be an effective antimanic for some patients, but it’s not as broadly effective as depakote. Although it’s not as effective in as many people, we have seen people who did not respond to Depakote or lithium, but got better on Trileptal. Tegretol, those who are experienced with it say, is in the same league as Depakote. Trileptal, I can tell you, is not quite as good. But it’s great for cases which are not so severe and in which you have the leisure to try meds that are in general less effective, in the hope that this will be one of the times it works.

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Another anti-convulsant in the same category is Zonegran. I’ve compiled 34 of my own cases in which I’ve prescribed this drug, of whom 14 had significant benefit. A colleague is writing this up, and when we get it published it will be the biggest Zonegran case series in the world! Isn’t that pathetic?! That’s how little is known. Zonegran, along with the usual antiseizure med side effects has one nice side effect, however: it reduces appetite and causes weight LOSS. This is desirable in many cases, and so may make Zonegran something worth trying if you’ve got the leisure, or if other drugs have failed or caused too much weight gain. Other anticonvulsants have been tried but are widely understood to have failed as mood stabilizers: Topamax and Neurontin most notably, Gabatril and Keppra as well. An occasional patient seems to benefit from one of the these, but they should be low on the list of meds to try. There is one other anticonvulsant which is widely used and very, very important: Lamictal. Lamictal is not an anti-activation drug, though, it’s a maintenance drug with antidepressant properties, so we will discuss it later.

21. Anti-activation medications group 3 – atypical antipsychotics These drugs were originally developed to treat schizophrenia, but also turned out to be useful for bipolar illness. They’ve gone through the process of being officially approved for various uses in bipolar illness and in fact, they’re very effective, useful drugs. Unfortunately, there’s no free lunch: they also have a big worry attached. They can cause tardive dyskinesia. This is a neuromuscular problem producing twitchy, ticlike movements, often starting around the mouth and tongue, that may not go away even

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after the medicine is stopped. The risk is low, perhaps a half of one percent, we’re not sure. And usually the movements will go away, eventually, if the medicine is stopped. But there it is – no free lunch. But although lunch isn’t free, it is lunch, and these are very valuable medications which alleviate enormous suffering in millions of people every day. I subdivide the five atypicals into 2 subgroups. The first group is strongly antimanic, and includes Zyprexa, Risperdal and Seroquel. The second group is more complicated, as each agent has a mixture of both antimanic and antidepressant effects, and these effects vary with the dose. The second group includes Geodon and Abilify. These are the atypicals that are most widely used. There is one other, the first atypical, Clozaril, which is in fact the most effective medicine we have. Clozaril has a lot of side effect problems, though, and requires weekly and then biweekly blood tests as long as you continue to take the med. I try to avoid it for those reasons. Of the stabilizers commonly prescribed, Zyprexa is probably the single most effective anti-activation drug. Push comes to shove, if I have a patient who is so sick as to be, so-to-speak, at the hospital door, I’ll prescribe Zyprexa in high doses. The standard dose of Zyprexa, according to the PDR and the FDA, is up to 20 milligrams per day. If I have a very sick, very activated patient I’ll tell them to take 10 mg of Zyprexa an hour before bedtime, and then take another 5 to 10 mg every hour til they’re asleep. This is usually a very sedating drug, but I’ve had a little 13 year old girl require 45 mg of Zyprexa, and then get only 5 hours of sleep! The next night she took 35mg and slept 6 hours. As she got better she required still less medicine. But 45 mg on the first night is what kept her out of the hospital. Let me take a moment here to talk about “off label” uses of medication. The government, the FDA, officially approves a medication for certain uses, and establishes the official prescribing information, dosing guidelines and so on. But then, once a drug is available, if may be prescribed for anything or everything, in any dose.

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Is this a good thing or a bad one? On the whole, I’d say good. The atypicals, for example, were on the market for years before they were approved for bipolar disorder. There were studies in the literature that showed the drugs were useful and I had patients who weren’t getting better on the other drugs. Should I have waited for official approval? Tegretol has been used for decades for bipolar disorder, but it is only recently that the Shire corporation spent the money to get official approval for their slow-release preparation, called Equetro. Should we not have prescribed the drug prior to that? I mentioned the scarcity of data about Zonegran, as well as my own opinion that it’s a useful drug for bipolar. The patent on Zonegran is running out, so the company that owns it will never spend the money to run the studies required for official approval. Once the drug is generic, no one will spend money to study it. This is our reality. Should we not prescribe the drug? And what about the drugs that are officially approved? Zyprexa is approved up to 20mg per day. Lilly, the company that makes it, didn’t do studies at higher dose, but I’ve seen many patients who get a partial response at that dose but a better response at a higher dose. There’s nothing magical about that 20mg. They could show an effect at 20mg, and studying higher doses meant bigger studies on many more patients, and many millions of dollars spent for no extra monetary return to Lilly. This is how the system works. Another limitation is that drugs are studied in isolation, as the sole drug treating the illness. But we said that 70% of bipolar patients are on three or more drugs. And anyone who has a physical illness or a drug or alcohol problem is excluded from the studies. But that’s a lot of people! So the studies are interesting and informative, but far from definitive. They help guide treatment, but “evidence based medicine,” as it’s called, runs out of evidence all too quickly. And when the evidence says to use medicines that cause weight gain and either your patient just refuses to consider such a drug or your patient is already obese and medically endangered by their weight, what good is that evidence?

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This is why the practice of medicine is not a science. The studies can only tell you that a certain percentage of people with specified characteristics will respond is suchand-such a way. But the person in front of you may or may not fall into that percentage. And they probably don’t have exactly those specified characteristics anyway. So the practice of medicine is not a science, but it is informed by science. The limitations of our evidence is not a license for random, chaotic treatment or ideological pet theories. The science, such as it is, limited as it is, should provide the background to every decision. Bipolar is a miserable, destructive illness and the only way to shorten the time of suffering is for treatment to proceed in a rational, organized way. So, anyway, back to Zyprexa. Weight gain – terrible problem. Diabetes, even in the absence of weight gain. Elevated cholesterol and triglycerides. Ugh. But a lifesaver for some, and not everyone gets these side effects anyway. Many will gain some weight, some will gain a lot of weight, and only a small number will have the metabolic problems. Risperdal is much less sedating than Zyprexa. It can cause weight gain, but usually more so in younger patients for some reason. It can have hormonal effects. It can cause other neuromuscular side effects – tremor, spasms. It’s a very useful antiactivation drug, especially at low or lowish doses, in the range of 0.25 to 3 or 4 mg per day, with a predictable linear response as you increase the dose. Seroquel is the third predictable anti-activation atypical. It’s more sedating than Risperdal, more like Zyprexa in that way. It’s less likely to cause weight gain or hormonal problems or movement disorders. It’s used in 2 ways, in 2 dose ranges. When it’s the mainstay of treatment, the foundational anti-activation drug, its average dose is 600mg. When it’s added on as the second or third drug the dose may be as low as 25 to 50mg. There is some evidence that Seroquel may have antidepressant properties, but I would say the jury is still out on that question.

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Sometimes when I tell someone to start Seroquel, I might have them experiment with the dose, increasing it until they are sleeping properly. When I tell them they can go as high as 600 or 800 or 1000 milligrams, they’re startled and remark on how high that dose is. They are impressed by the number, 600 or 1000. I tell them that they are being impressed by the wrong thing. A big dose just means it’s a relatively weak medicine, so you need a lot of it to do the job. I said that sometimes I give as little as 0.25mg, ¼ mg, of Risperdal. Now, there are 16 ounces in a pound, over 28 grams in an ounce, and 1000 milligrams in a gram. And I’m prescribing ¼ milligram and it’s actually doing something. That’s impressive. The other two atypicals, Geodon and Abilify are complicated drugs with complicated effects. They both have significant antidepressant properties. I have seen both cause switching into mixed states. With each the prominance of antidepressant effects is higher when the drug is given in lower doses. In general Geodon is more predictable than Abilify, which is a crapshoot. Geodon has some cardiac effects, lengthening the transmission time of the electical signal that coordinates the heart muscle. It’s not clear whether this problem is more than theoretical, and the effect is less than that of some antihistamines, but it’s worth knowing about if you have an arrhythmia. At higher doses, 120 or 160 mg, Geodon can function as the main anti-activation agent and contribute some antidepressant effects as well. At lower doses it may give an antidepressant boost. Abilify is very unpredictable, it can do wonders and it can do nothing. Also its dose effects are unpredictable. It can cause an annoying restlessness, which can be stubbornly resistant to any and all attempts to reduce it. I have a patient who is helped enormously by Abilify, but even after two years on the drug still feels like she must shift continuously from side to side whenever she is standing. But it saved her life.

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22. Anti-activation intervention – ECT One Flew Over the Cuckoo’s Nest was a great movie, but I wish it had never been made. The image of Jack Nicholson being given ECT, electo-convulsive therapy or shock treatment, seems to be the image of ECT in everyone’s mind. It’s a horrible, terrifying image, inaccurate but so intense that it overshadows reality. ECT is a safe, effective procedure for depression and bipolar disorder, and most importantly its effectiveness doesn’t correlate with the effectiveness of medications. This means that even if meds haven’t worked, ECT has just as good a chance to work as it ever does. We don’t perform ECT ourselves; we’ve no vested interest here. When it’s indicated we refer to other psychiatrists who perform the procedure. When meds don’t work, ECT often does. And afterwards meds might work better. The first bipolar patient I referred for ECT had an illness like a runaway freight train – nothing could slow him down. I prescribed enormous doses of strong medicines and they didn’t touch him, though they did cause side effects. Finally I arranged for him to get ECT. I’ve been seeing him for 8 years since then, and he’s doing fine on about one third to one half as much medicine as I was giving him before ECT. Not everyone has such a good result, of course, and there are occasional problems, most commonly memory problems which are usually transient and clear eventually. But it’s a safe and painless procedure, the patient is unconscious and has no memory of it. Just don’t close your mind to this option – it’s a potential lifesaver.

23.Bipolar depression – depression or mixed? 76

Once activation is controlled we leave the “hurry up” phase of treatment and enter the “wait” phase. The first thing we do is wait, a bit. Some people, once their activation is controlled will become depressed but sometimes this will clear without further intervention. The risk of intervening too soon is that the person might be coming out the depressed phase anyway, and adding an agent with antidepressant properties might accelerate them into an activated state again. For many patients the depressed mood is just the other, uncomfortable side of the coin from the activation. Once the activation resolves they relax and their mood improves. For others it’s like diving into a pool – they’re below water for a bit, but will surface without further effort. For too many, though, you slow their flight and they crash. The first problem, however, is to be sure that there isn’t any residual activation accompanying their depressed mood. There are studies showing that adding another antimanic agent helps the depression of lots of depressed bipolar patients, but I always wonder if I would view those patients as really mixed -- did they have any residual activation? If so, then a pure antimanic effect would explain why they feel better. Remember, treat activation first.

24.Bipolar depression -- step 1 Lithium is an antimanic mood stabilizer, but remember that it also augments the action of antidepressants. Lithium also has some mild antidepressant effects of its own, and it has been shown to reduce the risk of suicide, even in people who say they don’t feel any better. This last effect is kind of interesting: it reduces suicide even in people on low dose and in people who say they are just as depressed as ever. It might be reducing impulsiveness; that would explain the finding at least. Whatever the explanation, if I have a patient who is on antimanic agents and is no longer activated but is depressed, I always consider adding lithium if it’s not already in the mix. 77

The alternative first step is adding Lamictal. Lamictal is another anticonvulsant but it is unique: it is described as stabilizing from below. Studies showed that it did a good job of keeping stable patients from becoming depressed, and a fair job of keeping them from becoming activated. Studies in which it has been used to treat acute bipolar depression have been mixed, but I’ve been prescribing this drug since 1996 and I can tell you that it has antidepressant properties. The icing on the cake that proves it’s an antidepressant is that it can cause switching, triggering a switch from depression to activation. The very first patient I put on Lamictal, in 1996, was a classic bipolar who came in quite depressed. I’d heard of lamictal being used for bipolar depression, so I prescribed it. Twenty five milligrams had little effect, but at 50mg my patient was swinging from the chandeliers. I stopped the drug and the patient became depressed again. I thought that perhaps the mania was just a coincidence, so started lamictal again. At 50mg she was swinging from the chandeliers once more. Now it is a very rare situation in which I’ll prescribe lamictal without first prescribing an antimanic agent. There is reason to think that lamictal may cause less switching than a straight antidepressant, however, that reason being the lack of switching in the maintenance studies done with the drug. Still, Lamictal illustrates a maxim I have about treating bipolar depression: any drug that can help depression can cause switching, i.e. trigger activation. Even lithium – three times in my 29 years of practice I’ve seen lithium at non-toxic levels cause agitation and even psychosis! So, what’s the drawback with Lamictal? Lamictal may cause a fatal rash – two words we rarely see paired together. The risk is very low, perhaps one in ten thousand, lower than for some other medicines which cause the same thing but with which we don’t even bother to inform people of the risk, it’s so low. So why do we inform people of the risk with lamictal? What keeps the risk low is that we build the dose very slowly. Before we knew that, we went fast. Thus the rash became associated with the drug and we have to inform people. Other side effects aren’t very common because we build the dose slowly – the typical anticonvulsant effects of sedation, nausea and so forth.

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The odds are you won’t get a rash on lamictal. If you do get a rash, the odds are 9 out of 10 that it will be a benign, insignificant rash. There is only one kind of person who can make this judgement, though: a dermatologist. Not me, not you, not your primary care doctor. If you get a rash, see a dermatologist immediately. Otherwise, if you just stop the drug and the rash disappears, your treater will be afraid to prescribe lamictal to you in the future, and lamictal is a unique drug. You don’t want to lose unnecessarily the chance of using it. We don’t have anything else like it. Lamictal may help with bipolar depression as early as the third week.

25. Antidepressant atypicals You may recall that I said that Geodon and Abilify had antidepressant as well as antimanic properties. In lower doses, especially, the antidepressant effects tend to predominate. Thus, adding a lowish dose of these meds may help with bipolar depression, while we can at least hope that the combined antimanic effects reduce the likelihood of switching. We can only hope, however, because we don’t have any data. I’ve seen a lot of patients whose depressions were helped by adding these meds. Note that in these sections on depression, I keep talking about adding medications. The antimanic meds that brought the activation under control are to be maintained, and antidepressant meds added to them, not substituted in their place. Otherwise you are inviting switching, and just pushing the swing to more and more extreme positions.

26. Antidepressant antidepressants Finally, we consider adding, carefully, gingerly, antidepressants. We go slowly, we go with low doses and small steps, because we don’t want to make things worse.

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Remember, antidepressants can induce mixed states, agitation, cycle acceleration, worsened depression, suicidality. But about one fifth to one third of the time they are necessary. So we add antidepressants. There are many antidepressants available, over 20, and I suppose they’ve all been used in this situation. There’s some evidence that one of the older classes of antidepressant, the tricyclics, are more likely to cause switching, but I wonder if that’s just because they tend to be dual action drugs, working on more than one transmitter system. Anyway, I usually prefer to use a pure serotonin type drug, an ssri, or a pure non-serotonin type drug, bupropion or Wellbutrin, in order to know what I’m doing and, I hope, lessen the odds of switching. There’s really no evidence to guide the choice here. If the antidepressant works you then have the dilemma of how long to continue prescribing it. Some experts say try to get rid of it in about 6 weeks, others say if it hasn’t caused problems, leave it alone. The timing of any attempt to reduce or discontinue antidepressants should also be guided by what’s going on in the patient’s life, how stressful life is at that particular time. My own leaning is to wait for a relatively stable and low stress time, and then try to very slowly reduce the antidepressant. Sometimes this works, and sometimes not. And sometimes my patient doesn’t want to touch it, and I can respect that decision too. Sometimes the antidepressant works, but then the patient becomes activated, gets irritable, develops racing thoughts, starts sleeping worse. Then you reduce or stop the antidepressant and they get depressed. So maybe you try a different kind of antidepressant and it doesn’t work or the same thing happens. They need the antidepressant, but it activates them. In that case, we add more antimanic drug along with the antidepressant, and hope that we can “clamp” their mood. This strategy will often work, at least for a while. No one knows if antimanic drugs can really protect against antidepressant activation in the long run. We’ll probably never know, because the studies required would be enormously complicated and enormously expensive. And

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even if we knew, statistically, what would do differently, here and now? We’d do exactly what we’re doing, and hope for the best.

27. Treating multiple diagnoses Many people with a bipolar spectrum disorder also have other psychiatric symptoms – drug or alcohol abuse, anxiety disorders, psychological problems. Each of these situations raises special issues in treatment.

Bipolar and substance abuse In discussing self-care, earlier, I talked about how valuable it is to stop using alcohol ( as well as marijuana or any other recreational drugs) while in treatment. Those comments applied to people without substance abuse problems, just average social drinkers. I said that the destabilizing effects of alcohol would make it harder to get better, and that applies all the more to people who are heavy drug consumers. The dilemma is whether to treat in the hope they stop their substance abuse when and if they feel better, or to insist they stop in order to begin treatment. The “insist they stop” strategy is obviously preferable, but often unrealistic. I’m probably going to be the 100th person to tell them to stop, with just as much success as my 99 predecessors. So I’ll usually push them to stop but not make it a condition of treatment initially. If they stop, great, treatment will go better. Usually they’ll cut down somewhat, and I cross my fingers and start treatment with the hope that if I can help them feel better, they’ll be able to reduce or stop their drug use altogether. Sometimes it actually works out that way. Sometimes, however, after we’ve tried to make a go of things for a while, it becomes clear that they’re not getting better and that they’re still using a lot of drugs or alcohol. At that point we’ve reached an impasse, and I’ll suggest that that they stop abusing substances in order to continue in treatment, stop treatment in order to continue abusing

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substances, or consider going to a drug treatment program that also treats dual diagnosis, i.e. that can also address their bipolar disorder. [Many drug or alcohol programs refuse to deal with other psychiatric diagnoses and refuse to allow participants to take medications. Not the way to go if you’ve got bipolar.] When there’s a medication available to help a person stop abusing I will of course offer it. For people with alcohol problems there are a number of options. One I prefer is Neurontin, an anticonvulsant I mentioned earlier as an unsuccessful mood stabilizer. I think Neurontin doesn’t work for bipolar disorder, but it helps anxiety and it’s used, as other antiseizure medicines can be used, to help alcohol withdrawal. I don’t know why, but a lot of people with alcohol problems really like Neurontin. They tell me they feel more relaxed and don’t crave alcohol as much, or at all. I’ve tried using other anticonvulsants in this way and they don’t work, I don’t know why. Anyway, I’ve got many patients who had alcohol problems who are now taking Neurontin long-term. Other options to reduce alcohol cravings are naltrexone and acamprosate. I’ve not been very impressed with naltrexone in this use and I’ve not prescribed acamprosate because I prefer the anti-anxiety benefit of Neurontin [even though acamprosate is indicated for alcohol cravings and Neurontin is not]. Doug tells me he’s had good results with acamprosate in the handful of cases in which he’s prescribed it. Then there’s antabuse. If you drink alcohol while on antabuse you get violently ill, potentially fatally ill. When you drink alcohol your body breaks it down in a series of steps until it’s excreted as water and carbon dioxide. Antabuse destroys the enzyme needed for one of those steps, so that the alcohol is converted to formaldehyde, the liquid that the frogs were preserved in when you took high school biology. Formaldehyde is not good for you, and you get sick. Your blood pressure may drop and you can go into shock. We had a patient in our practice who nearly died a few years ago: he was on antabuse, drank some, felt ok, drank some more and then started vomiting so violently he tore his esophagus and bled enough to lose consciousness. Luckily someone found him before he bled to death. Alcohol in mouthwash, cough medicine, even aftershave [absorbed through the skin] can also trigger reactions. And since it takes time for your

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body to make more of that enzyme, you can’t drink for at least two weeks after stopping antabuse. It may sound drastic, and I suppose it is, but it’s helped a lot of people. For opiate abusers, we have naltrexone. Naltrexone is an opiate blocker. If you have naltrexone in you and you take percodin or vicodin or oxycontin or heroin, you don’t get high. If the opiate is already in you before you take naltrexone you go into immediate, severe withdrawal. So if an opiate abuser is taking naltrexone, it prevents pleasurable opiate use. I always have someone else, a family member usually, administer the naltrexone. It’s too easy to skip a pill and go get high. The family member should crush it [so it can’t be hidden under the tongue on in the cheek], mix it with some liquid and watch it being consumed [so it won’t be dumped down the drain]. It’s a crutch, but crutches have their uses. Ever have a broken leg? A large number of people with bipolar also have substance abuse problems, and you can debate the cause-and-effect relationships. My impression is that the majority were experiencing uncomfortable mood disorder symptoms first, and that led them to drugs and alcohol to try to feel better, or at least feel different. In some people, if may be that the physiological stress of substance use triggered the mood disorder to which they were prone but had not yet manifested itself. Someday these issues may make a difference, but for now they don’t. You just treat as best you can.

Bipolar and ocd Bipolar with obsessive-compulsive disorder can be a bear. First you must control the activation [“treat activation first!”]. With luck this will also reduce the intensity of obsessive-compulsive symptoms, on the theory that the activation is providing the “push” behind the obsessional thoughts. Then, if necessary, you slowly introduce antiobsessional drugs, an ssri. You might require more antimanic drug as the ssri is increased, since the ssri, like all antidepressants, tends to trigger switching. With luck,

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you can balance these effects. Sometimes you’re not so lucky though. I have one patient who couldn’t tolerate enough antimanic drug to counteract the activation produced by the anti-obsessional drugs he required. He’s now getting regular ECT [shock treatment] along with tolerable amounts of anti-manic drugs as well as the anti-obsessional drugs required to keep his ocd symptoms under control. Whew! Most of the time it’s not that hard to first stabilize the mood and then relieve most of the obsessive compulsive symptoms that remain.

Bipolar and anxiety Many bipolar patients seem to have residual anxiety symptoms when their activation is controlled – worry and rumination, panics and jitteriness. These anxiety problems, when they are the only problems and thus in the absence of bipolar disorder, are usually treated with antidepressants and perhaps some tranquillizers. In bipolar patients I tend to lean the other way, prescribing tranquillizers and perhaps some antidepressant. Again, I’m trying to avoid antidepressants if possible. Also, I’m likely to try increasing or adding more antimanic drugs before using tranquillizers. The atypicals, and especially the anticonvulsants, have some anti-anxiety effects. If a patient is going to be taking more pills, they might as well be something that will also help control the bipolar problem. Sometimes, however, a tranquillizer, something from the valium family of drugs, works best.

Bipolar and adhd In section 4 I discussed the occasional difficulty of diagnosing adhd along with bipolar disorder. Basically, because bipolar can cause all the symptoms of adhd, you have to treat the bipolar disorder first. Once you’re mood is stabilized, however, if you

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still can’t concentrate, can’t organize well, are distractible, misplace things, make careless errors and so on, and you’ve been doing these things since childhood, then you have adhd along with bipolar disorder. There are basically two kinds of medicines used to treat adhd: stimulants -- drugs which mimic and/or release dopamine in the brain, and antidepressants and antidepressant-like drugs -- drugs which interfere with the reuptake of norepinephrine and, indirectly or directly, the reuptake of dopamine in the brain. The stimulants are subdivided into two groups, dexedrine and related compounds like Adderall on the one hand, and ritalin and long acting ritalin preparations like Concerta on the other hand. The antidepressant-like drug which has official approval for adhd is Strattera. The antidepressants which are in fact also used for adhd are Wellbutrin, nortriptyline and desipramine. Antidepressants destabilize bipolar disorder, and when I’ve tried using these medications for patients with adhd and bipolar, I’ve had exactly that problem. Now I won’t use antidepressants or Strattera for adhd in people who also have bipolar. I’ll use stimulants. I’ve never seen stimulants destabilize bipolar disorder. Once I had a college student who decided to use his dexedrine to stay up 4 nights in a row to catch up on his schoolwork – he became destabilized, but I don’t think that should count. And we know sleep deprivation is destabilizing anyway. So stimulants are the way to go.

Bipolar, emotional problems and personality disorders Saying you’ve got bipolar disorder, a biological illness, doesn’t mean you can’t have emotional problems, too. I’ve discussed the role of psychotherapy in helping treat

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bipolar by helping with stress management and stress avoidance. The benefit can work the other way as well: it’s very hard to work on your emotional problems when your emotions are out of control on a biological, and not just a psychological basis. You may be irritable and defensive as a residue of your treatment as a child, but if you’re also irritable because of uncontrolled bipolar disorder, good luck! So treating the biological ilnesss may make it possible to deal more successfully with your emotional issues. Sometimes it’s hard to know what is emotional and what is biological. I’m not even sure what that sentence means, since our emotions are experiences accompanying certain patterns of activity in our brain, especially our limbic systems. But let’s, for the moment, say that what is psychological is in essence a learned pattern of behavior, while what is biological is determined more by genetics than experience. This would include physiological states triggered by stress but based on genetic vulnerability. Anyway, sorry for the digression, but my strong belief is that you can’t diagnose a personality disorder in a patient with bipolar illness until the bipolar illness is fully stabilized. The most common personality diagnosis thrown around in these situations is borderline personality. I’ve seen “borderline personality” disappear in patients with serious depression or bipolar disorder, once they were properly medicated. Labelling a patient prematurely is an expression of therepeutic nihilism, a way of giving up and distancing the treater from the patient. The patient deserves aggressive and effective biological treatment before being labelled with a personality disorder diagnosis.

28. Pregnancy Earlier I talked about treatment being for life, but what if you get pregnant? That’s the one situation in which I consider recommending going off medication. Certainly there are some medications that are potentially horrible for fetuses. Depakote, for example, can cause terrible birth defects and should be stopped for at least the first trimester. Remember, it’s during the first three months of gestation that the fetus is 86

developing its organs and structures, and this is the time it’s most vulnerable to nasty chemicals. Once the first trimester is past, many medications can be given without causing any known problems, at least until delivery approaches and you start to worry about medication that might be present in the newborn at birth. Lithium is known to increase the risk of cardiac abnormalities, but the increase, although statistically significant, is from tiny to low, maybe 1-2%. I’ve had patients choose to stay on lithium through their pregancies because of how badly they felt when they had stopped lithium in the past. Doug had a patient choose to stay on Depakote and Tegretol even in the first trimester. She took high doses of folate and prenatal vitamins and happily everything came out ok. There’s always a weighing of risks and benefits, an individual weighing of the risk to the fetus versus risk to the mother. Depakote has a 3 to 5 percent risk of causing neural tube defects – defects in the development of the spine and central nervous system. What does a 5% risk mean? If you had a five percent chance of getting hit by a car when crossing the street, you would have less than a fifty percent chance of successfully crossing 14 times in a row. But on one trial, one pregancy, everything will be ok 19 out of 20 times, plus the pregnancy can be monitored closely and, for those who will consider it, abortion is an option if necessary. Remember, the choice isn’t between feeling good on the medicine and feeling good without the medicine. A miserable, depressed pregnant woman may not eat properly, may not sleep properly and may even contemplate killing herself. The fetus is at risk either way, the risk of medication exposure versus the risk of poor nutrition, altered physiological states in the mother, or even death. There’s no free lunch. It’s risk weighed against risk, benefit against benefit. Pregnant women are at risk for destabilization, and they are at greater risk for postpartum psychiatric problems. Bottom line- you want close monitoring.

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The only treatments during the first trimester that seem to be supported by the experts are old style antipsychotics, the predecessors of the atypicals, and ECT. YES! ECT is one of the safest treatments around. Most people don’t like the idea, but it’s the safest way to go in this situation, if you’ve got to treat at all. Some women will struggle through at least the first trimester off all drugs, and good for them if they’re lucky enough to have illnesses mild enough to allow for this option. Getting proper sleep and avoiding stress are things anyone can do, and that helps. The other alternative is a typical [not atypical] antipsychotic. These are known to have antimanic effects, and they’ve been around a long time and thus have been given to pregnant women many times, without apparent ill effect. These older antipsychotics have been replaced by the atypicals because the new medicines have fewer side effects, as well as some extra chemical actions that help treat additional symptoms in schizophrenia and perhaps in bipolar disorder as well. Some people are using the newer, atypical antipsychotics during pregnancy, and this will likely emerge as the new standard of care. But it hasn’t yet.

29. FAQ’s How long will it take for me to get better? Figure it’s going to take about 6 to 12 months to straighten out your medications. If you’re lucky it will go faster, if you’re unlucky it will take longer. That doesn’t mean that you’re going to be terrible for 8 months and then suddenly get well. It means that most likely there will be a gradual process of improvement. But since people don’t get better in a straight line, there are probably going to be occasional setbacks along the way. In the hurry-up-and-wait model, the activation will come under control pretty fast in most cases. It’s depression and any medication side effects that will take more time and finesse.

After I’m better will I get sick again?

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Maybe. Bipolar illness is like any chronic illness, you can have a mild case or a severe case, and it can be easy to manage or hard to manage. There is some risk of experiencing a full recurrence of the illness , but more likely, especially if you’re well medicated, you may experience what is called “roughening.” Roughening means the reappearance of symptoms, but symptoms which are milder and/or fewer in number than what we would call a recurrence. Usually your medications can be tweaked, but it is important to be observant. After a few years you’ll have a sense of just how stable your illness is, and how likely you are to require repeated adjustments of your medications. In general I’m optimistic. Most people seem to be able to do pretty well, and lead normal lives.

How do you know I have bipolar disorder? Is there a test? There’s no test -- no scan, no blood test, no biopsy, no x-ray – to validate the diagnosis. The diagnosis is made first and foremost on the basis of the symptoms and the history of the symptoms. How well do your symptoms fit the DIGFAST criteria? That’s basically how certain you can be of the diagnosis. There are other factors that can help in the diagnosis, however. How old were you when the symptoms started? Depression, the illness depression, is an illness of 40 year olds. Bipolar is an illness of 14 year olds. There are exceptions, of course, but the age of onset is important. Is there a family history? You can’t make a diagnosis based only on family history, but it can help confirm suspicions. Finally, how do you respond to treatment? If, after evaluation, you’re still not sure, you can have a trial of treatment. If the symptoms are at least reminiscent of bipolar, and they improve with the use of antimanic agents, then call it what you will, you might as well call it bipolar disorder. 89

How long do I have to take medication? When can I stop? We get the wrong idea about illness and medicine when we’re children or have children. We think that medicine is about things like strep throats and middle ear infections: take the antibiotic for 10 days and you’re done. If you spend the day in the waiting room of a doctor who treats adults, an internist or family practictioner, you’ll see that most patients are there for chronic illness: diabetes, high blood pressure, coronary artery heart disease, low thyroid function, Crohn’s disease, migraine, and so on. These are problems that don’t go away. They are treated, not cured. This is why the medicine cabinet of a 70 year old looks different than the medicine cabinet of a 30 year old. Furthermore, we know that with bipolar illness, the more often you get sick, the more difficult you are to treat. That means that letting yourself get sick may in itself worsen the essential nature of your illness and make it harder for you to get better. Adding back the medicine you just stopped may not work! You may be sicker, and harder to treat, for the rest of your life! The stakes are high. There is even some evidence that there is a loss of brain tissue – brain nerve cells shrink or die – in people with chronic psychiatric illnesses, and that the loss of gray matter in bipolar disorder is specific to that disease, not just some nonspecific effect. There is also evidence that treatment has a neuroprotective effect, protecting nerve cells and even promoting the growth of new brain cells as well as helping injured cells regain healthy functioning. The data we have is for lithium and Depakote, but I would guess that this would be the case for any effective treatment. So, how long should you take medications? As long as you want a healthy brain.

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Are you sure I have to stay on meds? No, I’m not entirely sure. At least not always. Especially with some teenagers, I’m not as sure. Especially if I wasn’t sure of the diagnosis in the first place. I’ve had kids I’ve treated get better and then stop their medications and seem ok, at least for a while. Now the nature of the illness is that it can change, it can come and go. So that means that if you feel good off medication, you may still have the illness but be in a quiet period, a period of remission. It might be lurking out there, waiting to return, especially if you’re put under stress, and especially if you’re off the medications that might protect you. But here’s a kid who may be taking medications for 60 years! And maybe I’m not sure. The reality in these situations is that patients, and especially kids, will often try to make a go of it off medications. And I hope I’m wrong, and they’re right. But I suspect that most of the time they’ll run into trouble down the line and end up back in my office or the office of some other psychiatrist.

But I hate the idea of taking medicine! Nobody in their right mind likes the idea of taking medicine. Do you think people with diabetes wake up and say “oh, boy! Today I get to take insulin!”? People take medicine because it’s better than being sick, the lesser of two evils.

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Having the illness and taking medicine is a weakness Many people seem to think that psychiatric illness is weakness, not illness. I wish it were true, because then I could try to talk you out of it. Instead, it’s illness, biology. I hate the phrase “mental illness,” because “mental” means abstract, disembodied, emotional and psychological. I don’t prescribe medication to treat mental illness, I prescribe to treat psychiatric illness. I prefer the word “psychiatric” because psychiatry is a medical specialty, and psychiatric illness is biological illness. Some genius coined the phrase “chemical imbalance.” I’m not sure exactly what that means, as opposed to “neurophysiologic imbalance,” or “micro-neuroanatomical variant” or god-knows what other phrase, because basically we don’t understand these illnesses very well. But whoever coined the phrase “chemical imbalance” was a genius because people have latched onto that idea, the idea of physical, chemical, not mental problems being at the heart of psychiatric illness. And that’s correct. To repeat something we said earlier, we do know something about the genetics of these illnesses. Most importantly we know that there is a genetics. They run in biologic families, even when the kids are adopted by other families without the illness. To repeat something mentioned earlier, we even have candidate genes that we think are involved: one on the short arm of chromosome 18, one on the long arm of chromosome 21, one on the long arm of 18 that shows up only in bipolar type ii, and so on. Let’s suppose that one day we show that there are 11 genes involved. But what if you only have 8 of the 11 genes? What does that produce? And what if it’s these 8 versus what if it’s those, overlapping but different 8? Maybe that kind of thing explains the different forms of the illness.

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But even if we knew for sure that it was those 11 genes, we still don’t know how those genes make the illness, produce the symptoms that we see and diagnose. And how do the medications work? Beats me. I’ve got some scraps of information and a heap of speculation, but basically I don’t know. Lithium does something that affects neuronal intracellular second-messenger functioning, which probably changes gene expression. It also has a stabilizing effect on glutamate transmission. Got that? I understand some of what I just wrote, but I don’t know what that has to do with bipolar illness. How does changing that second-messenger functioning stabilize mood? Beats me. So we’ve got a long way to go to understand these illnesses, but at least we know what road we’re on: the biological, biochemical, physiological, anatomic road. Not the mental, moral-fiber road. What is moral fiber anyway? Something you take for moral constipation ? Whatever it is, it may be relevant to psychotherapy; in fact it may be shorthand for the capacity to handle stress. And I suppose in some cases if someone could handle stress better they might not develop the illness. But once they’ve developed the illness, they’ve got it and it needs to be treated. Someone might say “of course I got sick, I’m depressed, I just got divorced, I just got fired, I just got cancer.” But once the symptoms progress to the point of diagnosis, in an important sense it doesn’t matter what the stresser was. “Of course I’ve got a broken leg, I just got hit by a car!” So don’t bother with the cast? Whatever the precipitant, once the problem gets to the point of diagnosis it’s got a life of its own, and needs treatment. Sometimes people think it’s somehow their own fault they have the illness. “If I were stronger, better, smarter, richer, better-looking, taller, younger or blonder I wouldn’t have this problem.” You didn’t sign up for this, did you? Did you order it on the internet or call an 800 number? Don’t waste your energy on guilt or shame about an illness, or do see a therapist about those issues. It’s an illness. If you get adult type diabetes secondary

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to weight gain, it’s not going to help much to worry about the ice cream you ate last week. Focus on getting better, on refraining from the potential ice cream tomorrow, and put your psychological self-insights to work to handle stress better going forward. I think part of the problem in accepting these illnesses is that they affect our minds, how we think and feel. If your leg is infected, you’re still you. If you have diabetes, you’re still you unless you’ve gone into coma. With psychiatric illnesses, in some sense you’re not you anymore. You think differently, you feel differently, you act differently. So who are you? This is frightening, so much so that everyone wants to believe that it could only happen to someone else, not to them. It’s a deep question, really, that awaits a better understanding of how a brain thinks and feels.

Can I take less medicine? People seem to think that there’s some kind of medal for taking fewer milligrams of medication. They struggle to reduce the dose, thinking somehow this means that they’re better medically, or perhaps that they’re better people. There’s no medal. Taking fewer milligrams doesn’t necessarily mean you have a less severe illness. Some people may have very difficult to treat illness which requires many medicines and lots of them, but when they’re sick they’re not totally disabled – they can function, limp along. Other people get very sick and become totally unable to function, but require fewer medicines and not necessarily at high doses. Who is sicker? This is not a contest. You take the hand you’ve been dealt and you play it as best you can. But it’s a game of solitaire, there aren’t any other players. Naturally you don’t want to take more medicine than you need, but how much is that? The only way to know for sure is to reduce it enough so that you get sick again. Also, given that this illness bounces around, it’s a good a idea to take more than the absolute minimum. If you take just barely enough medicine, then at some point your illness is going to shift so that it’s not quite enough anymore, and you’ll get symptomatic 94

and have to increase the dose. Then if you’re taking just barely enough at the new level, this process can repeat. It’s probably better to take a bit more than the minimum, have a margin of safety, and not get sick. In the long run you will have a better course, and most likely take less medicine overall. If there’s a reason to reduce medication, a side effect problem, that’s a different story. Of course you try to reduce something. I’m asking you to take these medicines for the rest of your life, so we ‘d better work hard to make that as palatable as possible.

Does taking anti-seizure meds mean I have a seizure disorder? No one knows why some anti-seizure medications are helpful in bipolar disorder. A smart fellow named Robert Post at the National Institutes of Mental Health developed something called the “kindling model” of bipolar disorder, based on an analogy to epilepsy, and that’s been helpful in thinking about the progression of the illness. It’s a theory of how your brain develops patterns of activity that become more and more prevalent over time. But bipolar is not a seizure disorder. We take aspirin for headaches. And we take aspirin for heart attacks. And there actually may be a connection between those uses in terms of aspirin’s effects on prostaglandins and inflammation. But connection or not, those are pretty different uses. A medicine gets labelled by either its mechanism of action, e.g. beta-blockers, or by its first approved usage, e.g. antidepressants. But it may be used in many ways, and it may eventually get officially approved for other uses. Beta blockers can be used for high blood pressure, or heart rhythm problems or also for anxiety. Antidepressants are also the treatment of choice for most anxiety disorders, and low doses of tricyclic

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antidepressants have been prescribed in pain clinics for decades for patients with pain but without depression. So, no, taking an antiseizure medicine doesn’t mean that bipolar illness is a seizure disorder.

Where can I go to learn more about bipolar disorder? Is there a book? A website? Forums or chat rooms? A book? There are a bunch of books, but I don’t know most of them to recommend them. The usual dilemma is balancing the science against readability for non-psychiatrists. This book tilts heavily toward readability and clinical practice, and pretty much ignores the basic science. There are two famous autobiographies, one by the actress Patty Duke, called Brilliant Madness, the other by a bipolar expert who reveals she is also a bipolar sufferer, Kay Jamison, titled An Unquiet Mind. Jamison also wrote a book about famous people with the illness, Touched with Fire. A website? There’s a website, www.psycheducation.org, note it’s .org not .com, that looks pretty good. I’ve only read bits and pieces, but what I’ve seen looks reasonable. Remember, anybody can post anything on the net, so be careful about the provenance of anything you read there. And be especially careful about forums and chatrooms. There are only two kinds of people who spend time there- those who are newly diagnosed and those who aren’t doing well. The people who are doing well have better things to do. They’re out living their lives.

SOME MORE FAQ’S FROM DOUG 96

Can I stay in college? I have been the psychiatric consultant to a midsized university for more than 10 years. When a student comes to the attention of the university because of a behavior problem that is identified as a psychiatric in nature the school asks me to answer two questions: Is the student at risk to harm him/herself or anyone else? Can the student cope with the demands of the academic environment. Of those students who are ill and with Bipolar Spectrum disorder, there may be someone who is able to stay at school, get treated, and function well enough to successfully stay at school, but I haven’t seen one yet. Most of the time the student is so functionally impaired that it is a no brainer that they have to go home. They have such a deep depression that they are at risk for suicide, their impulse control is so poor that they are dangerously abusing drugs or alcohol, or their concentration is so impaired that they can’t read and remember their textbooks. Several times over the years I, the student, the parents, and the school have decided together to keep the student in school and begin treatment. So far, not one has been able to stay more than a few weeks.

Can my child get it? Children of one parent with a mood disorder have a 25% to 30% chance of developing a mood disorder. If both parents have a mood disorder, one of them having bipolar illness, the likelihood of a child having a mood disorder is 50 to 75%.

Will the medication change my personality?

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Yes and no.

30.Residual symptoms and side effects Concentration problems Some patients have lingering problems with concentration, even after their mood is well-stabilized, they’re sleeping well and they have no racing thoughts. What is this problem? It might be residual distractibility, some remnant of a DIGFAST symptom that hasn’t responded to treatment. It might be a residual symptom of depression – depressed people have problems with concentration. It might be a medication side effect. Many of the medications are sedating and beside that can produce problems with memory and concentration. Or maybe it’s a symptom of untreated attention deficit disorder, showing its true colors now that the mood disorder has been treated. If there is a problem with sedation anyway, then certainly try to reduce a sedating drug, and you can see if the attentional problem improves. If there is no sedation, you might try reducing something anyway, on the theory that the cognitive side-effect is more subtle and can be present even without frank sleepiness. If that doesn’t work, then consider increasing something, on the theory that this is a residual symptom. Is there a history of attentional problems back to age 6 or 7, prior to the onset of mood problems? If so, then you possibly have attention deficit disorder along with bipolar. But what if none of the above works, and there is no early history of attention problems. What then?

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In this situation I’ve been recommending symptomatic treatment, that is taking a medicine to relieve the symptom, ignoring whatever might be the underlying cause. I’ve prescribed stimulants, as if I were treating attention deficit disorder even though I know that I’m not, and I’ve prescribed a drug called Provigil, a non-stimulant used to treat narcolepsy, which promotes wakefulness. And symptomatic treatment often helps. Got a problem with the idea of symptomatic treatment? If you have a headache, you probably take ibuprofen or acetaminophen or naproxen or aspirin. Symptomatic treatment. If you have an infection you may take one of these pain relievers to feel better while waiting for your antibiotics to work. They help. And if there isn’t much in the way of side effects, why not? This isn’t recreational drug use, this is treating discomfort and disability. You need to concentrate normally if you’re going to live normally. Want to keep your job? Symptomatic treatment might be the way to do that.

Weight gain This is the big one, no pun intended. Weight gain is the most common problem caused by the medications I prescribe, and it’s the problem that most often leads to people discontinuing those medications. When I make the diagnosis, and at choice points after that, I’ll present my patient with a menu of options. I’ll describe each alternative, “increase this” or “add that,” along with the side effect issues associated with each. When I say “weight gain” I see people literally recoil in their chairs. I won’t go into a psycho-sociological spiel about why Americans have the attitudes they have, or the physiology of the weight problems per se, but it’s a real problem. And many of my patients, like many Americans in general, are overweight to start with. They don’t need weight gain. Now medications don’t change the laws of physics, although there is some question as to whether lithium may have an effect on carbohydrate metabolism. If you’re 99

careful in your eating you won’t gain weight. But some of these medicines can sometimes cause ravenous appetites, making it very hard to control eating. Note the emphasis on the word “sometimes” in the previous sentence. Don’t eliminate a choice from your menu, a choice that might make your life much more satisfying and liveable, because it sometimes causes weight gain. You may want to move it lower on the list, but don’t cross it off. It might be the drug that’s going to save your life. If you have the leisure, mild enough symptoms and time to experiment, you can try some of the drugs with more palatable side effect profiles. If they work, great. But don’t cross off those other drugs. What if the drugs you need to get better also make you gain weight? I’m not sure about the word “make” in that sentence, but let’s focus on weight control. I am not a weight control expert, but I’ve done a fair amount of reading and what makes sense to me is low carbohydrates [not no carbohydrates] and 5 or 6 small meals with protein a day, aimed at keeping your blood sugar levels constant and never getting really hungry. You won’t exercise your weight away. It takes an enormous amount of exercise to work off a piece of toast. But exercise maintains muscle mass, and muscle mass raises your metabolism. If you gain 3 pounds of muscle, that’s the equivalent of running 17 miles a week. I’ll recommend a website here, http://hussman.org/fitness/index.htm. This site was constructed as a hobby by a very smart guy, John Hussman, who is an economist and mutual fund manager. It has nothing to sell you. It was set up as a public service and a hobby, and it is written from the perspective of an intelligent non-physician.

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Another frequently asked question, which I did not address in the FAQ’s section, is a question asked by family members: What can I do to help? There are some things family members can do to help. They can collaborate with the patient in organizing their lives so that they’ll get enough sleep. And they can work together around issues of stress reduction. They can help the patient remember to take medications, and they can monitor observable symptoms and report them to the patient and the treater. But these tasks are two-edged swords. If a family member is overly controlling, a patient may lose sight of his true self-interest in treating his illness, and instead become engaged in struggling for a sense of independence, using treatment resistance as a tool in the struggle. Except for my youngest patients, who are early adolescents, I always try to make it clear that it’s up to the person with the disease to be ultimately responsible for its treatment. No one can force you to accept treatment. In a similar vein, it’s important for family members to refrain from using the patient’s illness as a weapon or excuse in their relationship. I’ve seen situations in which, for example, my patient would make some complaint in his marriage, and the response was “have you taken your medication?” Or a parent would deal with a kid’s behavioral issues by focussing on the medications, as if some pills were going to solve all the problems of being the parent of a teenager. On the other hand, it can be very hard to be the family member of someone suffering from bipolar illness. The patient may be nasty or irritable – how do you respond? They may be depressed and hopeless – how do you respond? They may be gambling away your savings, driving drunk, getting arrested, mistreating your children. HOW DO YOU RESPOND? I’m afraid I’ve got no easy answers here. There are too many variables, too many considerations for a book like this to give much in the way of advice.

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It helps to understand the illness, though. It gives you some perspective when you’re trying to figure out exactly how to respond. It helps but it doesn’t make it easy.

32. How to use this book We became interested in bipolar early, and so we saw lots and lots of misdiagnosis, lots of patients who hadn’t done well in treatment because our colleagues didn’t know enough about bipolar disorder. In the late 90’s we got some data that showed we were making the bipolar diagnosis five times more frequently than other treaters in Connecticut! We’ve done a lot of speaking, mostly sponsored by various drug companies, teaching about the bipolar diagnosis. Sometimes I joked that I felt like “Johnny Bipolar-seed,” spreading the word as best I could. Maybe we should have signed this book that way, “Johnny Bipolar-seed.” What I see happening now is that our colleagues are doing a better job of making the diagnosis. Not exactly great, though some are great, but significantly improved. What my colleagues, as a group, still don’t understand are the dangers of antidepressants and the benefits of avoiding them if possible. That will come over the next few years I expect, as the momentum moves from awareness of the bipolar diagnosis to the complexities of treating bipolar depression. This book is not a doctor. I’m not your doctor, unless you happen to be someone I’m treating in my office. This book is not a substitute for treatment, and it’s not even a guide to treatment. I hope I’ve made clear that there really aren’t any rules, there are only choices, probabilities and risks. I’ve tried to supply some background on the most common situations and treatments, but you can only make real treatment decisions in collaboration with your own knowledgeable treater. Take care of yourself.

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