David J. Miklowitz, Ph.D., is a professor of psychology at the University of Colorado and a nationally recognized expert on bipolar disorder. The creator of a family focused psychotherapy for the disorder, he is also the author of a highly regarded book of practical advice for patients, The Bipolar Disorder Survival Guide: What You and Your Family Need to Know (Guilford, 2002). He discussed with us how patients can lessen the impact of the disorder on themselves and their lives.
Medication and Psychotherapy
Medication has to be combined with psychotherapy wherever possible. There is a need to learn self-management—illness-management skills. People need to learn to recognize when they're starting to cycle. And to get preventive intervention—sometimes medical, sometimes behavioral—when starting to cycle into manic or depressive episodes. You don't learn that from medication.
In addition, people need to learn about stress triggers. What events or changes in one's life bring about these mood cycles or contribute to them? In college, for example, students are in constantly shifting sleep-wake cycles, but it is known that depriving someone of a night's sleep can bring about manic symptoms. Experiences of loss or rejection can be associated with depression; family conflict can be associated with relapse. Patients need to be aware of and know how to cope with all those situations.
Another issue psychotherapy addresses is acceptance of the illness. Many people do not take the diagnosis of manic-depression seriously. They may take prescribed medication for a while and then go off, precipitating a relapse or worse. Psychotherapy helps a person accept that they have an illness, that it's likely to be recurrent, and that they need to learn to manage it both behaviorally and physiologically.
There are basically three forms of therapy for bipolar disorder that are validated by research.
Family-focused therapy, which involves patient and family, since family dynamics affect the outcome of mood conditions, and educates them about the disorder and trains them in communications and problem-solving skills.
Interpersonal and Social Rhythm therapy, which helps patients learn to manage their sleep-wake cycles and regulate their daily-living routines.
Cognitive Behavioral therapy specific to bipolar disorder, which helps patients restructure not only the pessimistic thinking associated with depression but the unduly optimistic cognitions of mania; patients often say things to themselves like "I've got to have it now or something terrible will happen if I don't get what I want this moment," or they underestimate the risks of doing something and overestimate the benefits.
Proper Medical Treatment
It's increasingly difficult in these days of managed care for patients to get proper treatment. Plans may dictate certain doctors, who may or may not be expert in mood disorders. Alternatively there may be a doctor expert in managing bipolar patients but is booked for several months when a patient is in need of finding outpatient care quickly. The people who do best with bipolar disorder latch on to a doctor that they trust and see over time, through the ups and downs, who monitors them and experiments with new medications where necessary. Seeing a doctor for 15 minutes every couple of months is not good enough for managing this disorder. That's why it is increasingly necessary for patients to learn illness-management skills.
Getting a Life Back
Once mood cycles are under control, patients face the challenge of getting their life back. They may no longer be symptomatic but they may have trouble holding a job or having a relationship. Sometimes that's because there are residual cognitive problems that don't disappear right away—with memory, attention, vigilance, concentration. Further, some medications can affect cognitive functioning. In addition, following a manic episode some people have a mild or moderate depression even though they are no longer characterized as cycling, which makes it harder for them to regain the level of functioning they had before the episode.
There are many things patients can learn on their own to minimize the chance of manic or depressive episodes. One crucial tool is mood charting, keeping track of mood states on a regular basis. People who observe themselves in an objective way every day—rate their mood, record daily activities and amount of sleep—will see patterns that identify the triggers for their ups and downs.
Is it alcohol or drugs? Sleep patterns or stressful arguments? Work demands or changes in medications?
Many bipolar patients have trouble with a 9 to 5 routine. That is ironic, because a predictable schedule keeps them on a regular sleep-wake cycle. But sometimes they do better with jobs that provide some flexibility of hours or allow them to do some work at home.
They also run into the puzzle of whether to tell co-workers about the disorder. I recommend that they tell someone at work only if they want that person to help them in some way and knowing that they're bipolar is necessary for that help. For example, perhaps you've had several episodes, are finally stabilized and get a job—but know that you could cycle into mania and that one of first signs is that you stay late at work or get physically intrusive with other people. You could acquaint a co-worker that those are your early signs, and to please point it out to you if you are doing any one of them.
But to tell someone you're bipolar just to get it off your chest can backfire.
Alcohol and Substance Abuse
Bipolar patients are extra prone to alcohol and substance abuse disorders by quite a margin; 60 percent of people with bipolar disorder have a history of some sort of substance abuse, compared to the general population rate of 10 or 15 percent. The cycling of the disorder involves either the craving for drugs and alcohol or self-medicating.
Patients usually describe their substance use as self-medication. But when you're manic you crave more of everything—more food, more sex, more excitement, and more alcohol or drugs, including marijuana, to accentuate the high. Sometimes substance abuse treatment is needed in addition to medication aimed at mood stabilization.