Thursday, 28 July 2016

What is bipolar disorder?

How many times have you heard someone say in casual conversation something like: "I'll bet she's bipolar!"  Often the comment is used to describe people who have wide mood swings and erratic behavior.  They can be be very up one moment and very down the next.  While this may have become the casual layperson's version of bipolar, from a clinical, more formal perspective, it does not begin to describe what people with bipolar struggle with and how complex this diagnosis really is.

To begin, for all of us, our moods fluctuate, not just from one day to the next but within the course of a day.  While it is true that people with bipolar disorder demonstrate wide mood fluctuations ranging from very high to very low, these shifts are typically very severe and they are by no means momentary.  The highs and the lows can last for weeks and even months.  Also, in this context, the term "mood" has many more meanings than just feeling up or down. For instance, irritability is often a hallmark of bipolar disorder.  A state of agitation is invariably present which affects both mind and body and can be very uncomfortable and difficult to tolerate.  Bipolar disorder is a serious condition, not easy to diagnose.

Interestingly, 80% of people diagnosed with bipolar disorder are likely to have been diagnosed with depression first.  It is not uncommon to discover when looking at their history that many different kinds of anti-depressant medications were tried without success.  In fact, people with bipolar disorder react very poorly to anti-depressant medication often becoming even more distressed and agitated. Effective medication for bipolar disorder is quite different from the type of medication that is used for just straight depression or what is known as "uni-polar" depression.  This is one instance where diagnosis truly is critical if one is to know what the best course of action is from a medication stand point. Those with a bipolar diagnosis require a mood stabilizer, not anti-depressant medication, in order to feel better.  Our contemporary understanding of depression is changing.  In fact, the most progressive view of depression now sees all types of depression as lying on a single continuum with depression at one end and bipolar disorder on the other.

There have been many recent changes in terminology and in our understanding of bipolar disorder. Manic depression was the original term used to describe bipolar disorder prior to 1980.  An even more recent change in just the last few years was the recognition that bipolar disorder can present in a milder form, the more severe form being referred to now as "Bipolar I" and the less severe kind, referred to as "Bipolar II".  Traditionally, manic depression or what is now called Bipolar I, requires that the person in addition to bouts of depression, experience at least one manic episode in the course of their lifetime. A manic episode is a very serious altered state where the person loses touch with reality.  Symptoms of mania can include a decreased need for sleep for days on end, rapid fire thoughts, pressured speech, delusions of grandeur such as believing one has superhuman powers, excessive behaviors that have a high potential for destructive consequences such as unrestrained buying sprees, sexual indiscretions or foolish business investments,

The most recent version of the Diagnostic Statistical Manual (the DSM-5), published in 2013 and used by psychiatrists and psychologists to assist in determining diagnoses, now states that a milder form of bipolar disorder exists referred to as "Bipolar II".  In this less severe form of bipolar disorder, a more mild form of mania expresses itself called "hypomania".  Hypomania does not involve delusional thinking but it has similar components to mania such as decreased need for sleep, exuberant or elated mood, rapid speech, exaggerated confidence, hyper focus on projects or tasks, greater creativity and productivity, increased energy and sexual drive, reckless behaviors and risky pleasure seeking behaviors.  As was the case with Robin Williams, many people with bipolar disorder are extremely talented and bright and the hypomanic edge when not out of control, may even result in more crisp thinking and greater productivity.  But this should not lead to a romanticized view of the condition.  In both Bipolar I and Bipolar II, the manic and depressive cycles are very painful and difficult to deal with. The depressive cycle of the illness looks very much like the depressive symptoms seen in uni-polar depression although they are often more severe.  When people crash, they really can hit rock bottom. Some of the symptoms present in the depressive phase include: decreased appetite, lack of energy, decreased motivation, difficulty concentrating and remembering things, feelings of hopelessness and pessimism, loss of joy, irritability, feelings of guilt, worthlessness and helplessness. Some people with bipolar disorder experience more the lows than highs and for others, the reverse is true.

We are learning that certain elements are common in those diagnosed with a bipolar condition such as: sleep problems often dating back to childhood; the preservation of sexual drive even in the context of a depressed mood (which does not occur in uni-polar depression); and often a history of failed attempts using standard anti-depressant medications. However, one should not be self diagnosing.  The cluster of symptoms that present themselves can be different for different people and the illness itself is often constantly evolving and can be very unpredictable.  It takes a highly skilled clinician to make the judgement call and even then, it can take an average of 10 years for a correct diagnosis to be made.  This is because the symptoms may be subtle and as time passes, the symptoms change. In other words, not all symptoms happen at once and therefore the picture is not consistent.  Often, you need a skilled psychologist or psychiatrist who has worked a lot with bipolar disorder to be able to diagnose it. Also, you need a doctor or psychiatrist who is willing to hang in with you and who will persist in tracking the symptoms and in trying different medications.

When mood stabilizers work, this is often confirming of a bipolar diagnosis.  Usually, patience is a prerequisite because experimentation is needed to come up with the right type and dosage of mood stabilizer.  Not only the professional but the client has to be willing to stay the course.
Understandably, too many people get frustrated when anti-depressant medication after anti-depressant medication does not work and so they give up.  Persevering, however, is often worth it for the sense of well being that can emerge as a result of proper diagnosis, medication and psychological assistance.  People with this disorder differ in their symptoms, severity, coping strategies, life situations and which treatment plan works the best.  One thing is for certain.  Bipolar disorder is an illness.  It does not define the person and it is not an identity.  You don't want to be talking about someone as being bipolar.  Just as you are not arthritis or diabetes, so no person is bipolar.  Bipolar disorder is a complex condition that requires treatment and a large dose of understanding. Most often, when it is understood and managed properly, the individual can be fully functioning and can experience good quality of life.  We need to be able to be more open in sharing information about this mental health issue.  Shame and having to keep it hidden add incredibly to the stress and difficulty of being able to manage the symptoms with strength and courage.

* For those interested in an excellent resource on Bipolar II, check out the book: "Why Am I Still Depressed" by Jim Phelps.

Thursday, 14 July 2016

Affairs: To tell or not to tell?

It wasn't that long ago that therapists specializing in relationship issues when treating someone who had had an affair, would strongly advise that they disclose the affair to their partner.  A major assumption spurring this recommended action was that secrets act as a wedge between people and that emotional intimacy would be seriously compromised if the affair was not shared and put into the light of day. Therapists, however, have grown in their wisdom and understanding over time and are always learning from their clients. Not surprisingly, more and more, working with people teaches the lesson that there are few absolutes when it comes to what is the best thing to do in a given situation. Therapists are not interested in what is right from a morality point of view.  Rather, they are foremost concerned with implications and outcomes and in this case, what action will best serve the mental health of participants and the future well being of the relationship. One of the unfortunate negative consequences of the view that one should always tell was that too many spouses disclosed prematurely in an effort to off load their guilt.  In other words, disclosure became the way to try to solve the problem rather than the end of a long road of striving for self understanding and taking responsibility.

It is not that we found out as therapists that telling one's partner was the wrong thing to do but rather that therapists realized that to emphasize this was putting the cart before the horse.  What we came to understand was that far more important than disclosure was that the individual who had the affair face and understand their own behavior.  After all, if there is no true understanding of what caused the affair in the first place then what would prevent the same thing from happening again? Furthermore, of equal or greater importance was that the individual take responsibility for their actions.  Here, what was meant was that the individual do some serious soul searching and be willing to take ownership of their own behavior and any of the implications this might have for them and for their partner.  Few people enter a committed, primary relationship planning to break the promise of monogamy.  For many, having an affair is a major breach of their value system and understanding what caused the rupture is critical to reclaiming their integrity.  For those who are religious or spiritual, one might say that an affair needs to be seen primarily as between that person and God or their higher power and only secondarily between them and their partner.  Interestingly, the partner invariably is on board with this emphasis.  Most often, the person who has been betrayed is very invested in their partner digging deeply to understand their own behavior as this is far more reassuring than any apology could ever be.

Relationship therapists view an affair as either being a result of dissatisfaction with one's relationship, unhappiness with oneself, or both.  If the primary problem that has caused going outside the primary relationship is couple dissatisfaction then it is vital to do some work on the couple relationship, ideally with both parties participating. Unfortunately, an affair often creates a primary crisis and until that crisis is dealt with, it is often impossible to begin to probe couple problems that have typically been around for a long time. As any couple therapist knows, there are few events in life that can lead to such deeply felt injury than knowing that one's partner has slept with someone else or even worse, formed an intimate bond with them and it takes much longer than most people think to heal from such an act of betrayal.  This is a major reason why the spouse who has had the affair needs to take responsibility for their actions.  If they have not, then they easily become frustrated and fail to have the patience necessary to provide the understanding and support required for their spouse to be able to work through all the powerful feelings of betrayal, mistrust, anger and disappointment that an affair so often activates.

It would appear that most of us want to know that we are the most important person in another's life. Experimentation with  "open marriage" in the early 70's did not last long.  Too many people thought they could cope with their partner having sexual relationships with multiple other people only to find out down the road that they were not immune to feelings of jealousy, hurt and anger.  The more recent appeal of being polyamorous (i.e., being able to love many partners at one time) will be interesting to observe as it unfolds.  While on one level, it makes sense that one should be able to love more than one person at one time, will this trend also be a passing experiment that dies out because it fails to meet people's deepest needs?

For more information about Dr. Esses, go to