Book

The Bipolar Disorder Survival Guide

David J. Miklowitz

Last highlighted September 30, 2020 ← All highlights

Bipolar disorder can be a great teacher. It’s a challenge, but it can set you up to be able to do almost anything else in your life. —CARRIE FISHER (Location 125)
I firmly believe that people with bipolar disorder lead happier lives when they do not carry the expectation that recovery means being free of all symptoms. A better definition of recovery is to lead a satisfying and fulfilling life despite symptoms of the illness and being able to work toward your life goals without sacrificing your mental or physical health. (Location 278)
Moreover, people with bipolar disorder cannot always tell when their cognitive functioning is off-kilter. As a result, family members may get frustrated and blame you for not trying hard enough. (Location 326)
Many people who have bipolar disorder burden themselves with guilt and self-blame because they believe their mood disorder is caused solely by psychological factors or even sheer weakness of character. Martha could have avoided such self-blame if she had known that her dramatic mood shifts were associated with changes in the function of nerve cell receptors or activity in the limbic system of the brain. (Location 517)
People who are close to you might feel sympathetic at first but then get irritated and annoyed. They may think you’re not trying hard enough or could make this all go away if you had “the right mental attitude.” (Location 818)
people in manic episodes are driven toward rewards and often cannot stop themselves from getting entangled in schemes to achieve these rewards. When depressed, these drives are replaced by a withdrawn, amotivational, or apathetic state, with little pleasure from anything. (Location 834)
Changes in drive states, of course, can have a tremendous impact on one’s daily life and productivity. (Location 836)
People in hypomania believe they are more intelligent, better looking, more clever, more creative, and less likely to make poor decisions than anyone else, but it does not reach the level of delusional thinking (for example, having special powers). They may believe that their actions will always lead to rewards and never other consequences. (Location 867)
In depression, it can seem nearly impossible to initiate those tasks even if you desperately want to. In other words, depression is quite different from being lazy. (Location 875)
To observers, your activated behavior while initially hypomanic may look attractive or encouraging at first, especially if you are coming out of a depression. But it loses its charm as you become more and more manic and your behavior begins to look frenetic and purposeless. Observers (notably family members) are usually unaware of the feeling of purposefulness that you may be experiencing. (Location 887)
In parallel, they may become frustrated with your inactivity during depressed phases and give you “pep talks” that can contribute to your feelings of guilt or inadequacy. (Location 891)
A key point to remember here is that, to you, the increases in energy and activity that accompany manic or even hypomanic episodes may feel productive, creative, and purposeful. To others, including your doctor, they may seem pointless, unrealistic, or to signal a developing illness. (Location 901)
Grandiose delusions are especially common, such as thinking you are exceptionally talented in an arena in which you have had no formal training, that you have extraordinarily high intelligence, or that you have mental telepathy (the ability to receive information from others without speaking). (Location 921)
The client above was still delusional. His thinking frequently got him into trouble with others, especially his parents, who were mostly concerned about his inability to hold a job. They were angered by his unrealistic beliefs in himself and his elaborate schemes for fighting the educational system. (Location 937)
Ruminations, in which a person thinks about a certain event again and again, are a frequent accompaniment to depression. Ruminations during the depressive phase are often self-recriminating. (Location 942)
Depressive ruminations frequently include guilt or shame over past misdeeds, or feeling worthless, hopeless, or helpless. They can become all-encompassing and affect one’s day-to-day functioning. (Location 946)
When you are depressed, you may become hypersomnic, sleeping much more than usual (for example, 16 hours a day) and become unproductive and unable to function outside of the home. (Location 967)
Some use cocaine, amphetamine, or marijuana to heighten and intensify the euphoric experiences of mania. (Location 994)
More than any other associated condition, drug and alcohol abuse makes the course of your bipolar disorder much worse (Yen et al., 2016). (Location 996)
Your doctor will probably be skeptical of the bipolar diagnosis unless there is concrete evidence that your mood swings occur when you do not use drugs or alcohol. (Location 1006)
Family members or significant others are not likely to understand these widely fluctuating moods (unless they have bipolar disorder themselves) and are likely to focus on how your behavior affects them and others in your life. (Location 1013)
You’re not alone in feeling that mania and depression are very personal and intense experiences. Nor are you alone if you are wary of any stranger’s ability to understand what you’re going through, no matter how highly qualified as a medical professional. (Location 1041)
Hypomanic episodes can be quite enjoyable to the person experiencing them. In general, others will be baffled and put off by your energetic, hypersexual, intrusive, and driven quality when hypomanic (for example, they may tell you to “chill out”). Your family members or friends may also be relieved by what they perceive to be the disappearance of the depressive states that often precede the energized one. (Location 1144)
You can also obtain information about who in your area treats persons with mood disorders from the American Psychiatric Association (888-35-PSYCH; apa@psych.org) or the Castle-Connolly “America’s Top Doctors” website (www.castleconnolly.com/doctors/results2.cfm). If you are seeking a therapist who knows something about mood disorders, the provider referral list of the Association for Behavioral and Cognitive Therapies (www.abct.org) is a good place to start. (Location 1290)
People with both bipolar disorder and ADHD are at an increased risk for suicide, possibly due to the increased impulsiveness associated with the two conditions (Lan et al., 2015). (Location 1436)
Cyclothymia is listed in DSM-5 as a mild form of bipolar disorder. About one in every four children and adults with cyclothymia progresses to bipolar I or II disorder (that is, they develop full-blown manic episodes, longer hypomanias, or major depressive episodes) over periods of 2 to 4 years (Kochman et al., 2005; Axelson, Birmaher, Strober, et al., 2011). (Location 1500)
In the most common situation, a person has had repeated episodes of major depression and then undergoes a brief period (a few days) of feeling “wired,” “up,” and “ready to take on the world.” Is this bipolar II disorder? Or simply the high most of us would feel after coming out of a long depression? (Location 1545)
A hypomanic person sleeps less, feels mildly or moderately elated or irritable, and has racing thoughts or becomes talkative. If this state lasts for days at a time, and others have commented on it, a hypomanic episode (and bipolar disorder) is suspected. In contrast, a person who simply feels good and more energetic after being depressed, but who has few or none of the other symptoms in the hypomanic cluster, probably has major depressive disorder. (Location 1548)
Anxiety disorders may co-occur in as many as 75% of patients with bipolar I or II disorder, with lifetime histories of panic attacks being the most common (Merikangas et al., 2011). (Location 1559)
Amphetamine, in particular, has been known to produce irritable, hyperactivated, paranoid, and delusional states. (Location 1585)
“Where does my identity stop and the disorder begin?” (Location 1686)
Denial or thought suppression refers to the process of avoiding emotionally painful problems by pushing them out of conscious awareness. (Location 1738)
Ellen Frank, a professor of psychiatry at the University of Pittsburgh, has termed the emotional issues underlying the denial of bipolar disorder “grieving the lost healthy self” (Frank, 2007). Many people with bipolar disorder were very energetic, popular, bright, and creative before they became ill. Then, once their illness is diagnosed and family members or friends start treating them like a “mental patient,” they become resentful and start yearning for who they used to be. They may think that if they go on acting as if nothing has changed, their old self will come back, like a long-lost friend— (Location 1744)
In my experience, people with bipolar disorder have strong feelings about the importance of personal achievement and independence. The disorder has a way of derailing achievements, making the person feel like a failure, and bringing negative self-appraisals to the surface. (Location 1751)
people with the disorder tend to find mates who themselves have mood disorders (also called assortative mating; Smoller & Finn, 2003). (Location 1785)
you are habitually an introverted person, a sudden increase in your socializing may be quite useful as a sign of a developing episode. (Location 1809)
Akiskal’s Four Temperamental Disturbances Hyperthymic: chronically cheerful, overly optimistic, exuberant, extraverted, stimulus seeking, overconfident, meddlesome Cyclothymic: frequent mood shifts from unexplained tearfulness to giddiness, with variable sleeping patterns and changing levels of self-esteem Dysthymic: chronically sad, tearful, joyless, lacking in energy Depressive mixed: simultaneously anxious, speedy, irritable, restless, and sad, with fatigue and insomnia (Location 1831)
You may start to think that you can accomplish little in your life, believing “All I am is bipolar, and I can’t change. It’s all a brain disease, and I can’t expect much from myself.” This way of thinking may make you avoid going back to work, withdraw from social relationships, and rely more and more on the caregiving of your family members. (Location 1934)
In case it isn’t obvious, I disagree with this way of characterizing bipolar disorder. Many—in fact, most—of my patients are productive people who have successful interpersonal relationships. They have adjusted to the necessity of taking medications, but they don’t feel controlled by their illness or its treatments. They have developed strategies for managing their stress levels but don’t completely avoid challenging situations either. (Location 1937)
This is, in part, because depression dampens your motivation to initiate certain activities, like work, socializing, or sexual intimacy. You may have subtle problems with memory or concentration as well, rendering the world a confusing, blurry place that demands too much. The illness can seem like an incredible burden that erases any hopes for the future. When you feel this way, you may, understandably, begin to merge the illness with your sense of who you are and who you will become. (Location 1943)
But remember also that your depression is likely to go away, with the proper combination of medications, psychotherapy, family and friendship support, physical exercise, and time. So, it’s a good idea to set some limited goals for what you can accomplish even while you’re depressed, to help you become more energized. Maintaining a certain level of behavioral activation can protect you against a worsening mood state (Location 1948)
The central goal of this chapter is to give you psychological self-management techniques that you can use during the early phases of depression, before it becomes incapacitating. (Location 5400)
Mostly, this chapter is about hope. Depression is a painful aspect of the human condition, and people with bipolar disorder experience it more intensely than virtually anyone else. (Location 5409)
Try to think of bipolar depression in the same way you would think of a flu, chronic pain, or perhaps a long-term medical illness such as diabetes. No one would think of blaming a person with diabetes for not being able to control the way his or her body processed sugar. No one would blame a person with epilepsy for having seizures, or a person with atherosclerosis for having a stroke. Likewise, you should not blame yourself for having depression. (Location 5434)
In other words, low self-esteem is not a trait. Rather, it may just be a symptom of your depression. (Location 5441)
One of the leaders in our field, Dr. Martin Seligman of the University of Pennsylvania, has compared self-esteem to a fuel gauge: It is a measure of how we’re doing at any one time—how much fuel is in the tank—which can change depending on what we are able to accomplish (Seligman, Reivich, Jaycox, & Gillham, 1996). (Location 5442)
Depression is not due to an unwillingness to accept responsibility, fears of coping with reality, laziness, cowardice, or weakness. It is an illness. To be sure, there are things you can do to make yourself feel better or at least stop your depression from worsening. (Location 5445)
Distraction means seeking out and engaging in activities that keep you busy, give you pleasure, draw your attention, and keep your mind off your pain and anguish. A related strategy is behavioral activation, in which you become more engaged with your environment, whether through outdoor exercise (for example, hiking, riding a bike), spending time with others whose company you enjoy, listening to music, reading, or visiting places that you haven’t been before, even if that is just a local coffee shop. The rewards that come from increased activation can improve your mood such that you want to do these things more often. (Location 5452)
Some of the coping strategies involve emotion-focusing. That is, you learn to recognize that you’re depressed and experiencing pain and teach yourself to look at these emotions, label them, and accept them without becoming overwhelmed, as Alexis learned to do. This is what we refer to as mindfulness. (Location 5456)
A fourth strategy, cognitive coping, involves learning to combat and challenge negative thinking patterns about specific situations or events (for example, self-blaming thoughts) and considering alternative ways to view these situations or events. As you’ll see, these strategies are not mutually exclusive. (Location 5460)
Four Strategies for Combating Depression Distraction Behavioral activation Emotion-focusing/mindfulness Cognitive coping (Location 5471)
is “Am I bipolar I or II?” Many people with bipolar II wonder if the severity of their depression means that they actually have bipolar I. In fact, it doesn’t seem to matter: depressive episodes in bipolar II are just as severe as those in bipolar I, and you can’t really tell them apart on the basis of symptoms or duration of episodes. As explained in Chapters 2 and 3, the real difference between bipolar I and II lies in the severity of the manic pole of the illness—people with bipolar II only experience hypomanic episodes, which are shorter and less impairing than bipolar I manic episodes. (Location 5572)
Nonetheless, knowing how to cope or ask for help when these changes appear can be central to your recovery and well-being. You may be able to implement the self-care strategies in this chapter to keep the depression from worsening or to make your “rebound” depression more tolerable. Keep these goals in mind—the fact that your depression doesn’t disappear entirely is not a sign that you have failed in your attempts to cope with it (Location 5590)
There are two assumptions behind behavioral activation. First, depression results in a loss of pleasurable activities or positive reinforcements. That is, being depressed makes you less likely to do the sorts of things that will help you get something positive from your environment. Second, the lack of these reinforcements worsens your depression and makes you want to withdraw even more. It is certainly true that being depressed makes it very difficult to get yourself to do anything. But it’s equally true that, in combination with your biological predispositions, not engaging with your environment keeps you depressed and eventually makes you feel worse. (Location 5659)
As noted psychologist Peter Lewinsohn put it, “The more we do, the less depressed we feel; and the less depressed we feel, the more we will feel encouraged to do things” (Lewinsohn, Muñoz, Youngren, & Zeiss, 1992, p. 74). (Location 5668)
A 3-Minute Mindfulness Breathing Exercise Behavioral activation strategies can be supplemented by exercises that get you in touch with your body, your breathing, and your surroundings within the present moment, or what we call “mindful awareness.” Try the following the next time you feel mildly anxious or down: Find a comfortable chair to sit in: sit with your back upright and your hands on your thighs, not touching the back of the chair. You can also lie on your back. Close your eyes or stare at an object in the room. Spend 60 seconds being aware of the noises in your room—the sound of the air conditioner or heating, sounds from the street, music, people’s voices. Ask yourself, “What am I experiencing in my thoughts, my emotions, and my body?” Acknowledge to yourself each sensation, thought, or feeling, whether pleasant or unpleasant. Now, for the next 60 seconds, focus on your breathing. Keep focusing on your in-breath and out-breath, like you were riding a wave. It’s inevitable that your mind will wander. If your attention shifts to thinking of other things, notice what took you away but gently escort your mind back to your breathing. Now, for the next 60 seconds, shift your attention to your entire body—your belly, feet, legs, thighs, buttocks, stomach, chest, neck, and facial expression. Notice your posture and the sensation in different parts of your body as you breathe in and out. If your mind wanders, gently escort your awareness back to your body and breathing. Slowly open your eyes and come back in contact with the room. (Location 5714)
Scheduling Pleasurable Activities Next choose one or two activities from this list to do each day of the next week (see the “Scheduling Pleasurable Activities” form). Pick the day you will do each activity and set a target time in the “Day of the Week” column. If you feel that one activity per day is too much, choose one to do every other day or even one every week and build up from there. If you’re feeling very depressed or low in energy, pick easier activities such as putting on a favorite piece of clothing, taking a bath, or spending 5 minutes outside in the sun. It will feel therapeutic to be able to do something small for yourself each day, or every few days, when it feels impossible to do more. (Location 5735)
You may feel, “Of course I should be doing those things—the problem is that I can’t!” When your depression is gradually worsening, it becomes especially important to reengage with your environment and do the things that give you a different experience of your emotions. (Location 5933)
“I can tell that my mood and energy are off kilter today; this is one of those days I can’t expect as much from myself … This is not about my flawed character; it’s about my biology … My depression is causing me to view things more pessimistically than I have to—it doesn’t follow that I’m not a good person because I can’t control my moods.” (Location 6122)