A Hard Pill to Swallow

Imagine you're a 20 year old university student without any prior history of bipolar symptoms. Thus far, you've been on top of your game—attendance at an elite university, excellent grades, numerous organizational involvements, great friends and a future that looks exciting. Your sustained efforts have paid off and in the absence of unforeseen derailment, it seems there's not much that's going to stand in your way.

And then you're hit with your first full-on manic episode.

It's a hell of a ride for a couple of months—mostly enjoyable—but eventually everything comes crashing down. Your intensity becomes too much to manage. You're academics slide because you can't focus your efforts on things so mundane. With your intensity being what it is, you find that friends pull away because they're frightened or irritated. And then there you are on an inpatient psych unit, facing the havoc brought by a psychiatric tornado that seemed to come out of nowhere.

But was it truly nowhere? What about your older sibling's bouts of depression or the eccentric uncle who was always volatile or intoxicated, or worse—both. Yes, the genetic connections are there, but until recently there's been no indication that you too might be affected by their heritability.

After five days you're out of the hospital and home, having taken a medical withdrawal from school. You're told that the tornado was actually a manic episode indicative of bipolar disorder. You're also told that if you regularly take the prescribed mood stabilizing medicine, get regular sleep and stay away from drugs and alcohol, you've got reasonable chances of being able to return to school and carry on with your life. You also learn that this bipolar disorder won't likely go away. This new regimen you're facing isn't just a short-term approach designed to cure something. No, it feels more like having to use a wheelchair because you can no longer walk, let alone run. You feel knocked down and you wonder if you'll ever get back up.

You do decide to try. You enroll in only three courses. You back off of the high intensity commitments that characterized your previous semesters. You do your best to have things remain slow and steady. But in achieving this medically advised turtle pace, you also feel like you've lost your previous version of you. Instead of your gregarious self, you now feel tentative, embarrassed and ashamed. You wonder what people are saying about you behind your back. You know that something is different between you and others. Your twice daily doses of medicine are also painful reminders of a reality you desperately want to reject.

The hardest part of your bipolar adjustment entails the cognitive dulling you experience from the medications you're taking. It feels like the intellectual edge that allowed your mind to move with such agility has been filed off. Thinking outside the box is something you only vaguely remember—it's not something you feel capable of doing now. In fact, you now feel confined within a box constructed from combined elements of your own depression and the side effects your medication. You and your psychiatrist are not even clear about what proportions they each represent. This is a far cry from where you ever imagined you'd be.

So why buy it all? Why agree to these mind-numbing drugs and a lifestyle which squashes social pleasure? Why not say the hell with it, and try to return to a more modulated version of your former life? After all, you're pretty self-aware, aren't you? If things start getting out of balance, you'll know; you'll see it... won't you?

Well, maybe. But you didn't a few months ago. At least not until it was too late.

The mental health professionals you're working with tell you that with this bipolar diagnosis, you've got a strong chance of relapsing if you choose to abandon your medicine. You've also discovered something through your on-line research called "the kindling effect" which implies that manic episode relapses create a slippery slope in the direction of more frequent, more acute and less manageable future relapses.

As much as you may feel stupid lately, you're not. You recognize that the medical advice you want to disregard, may be accurate. And if it is, the risks of ignoring it are considerable and potentially life-altering. Are you really willing to throw the dice or do you need to accept the limitations you're currently faced with and adjust to the reality that life has just taken you in a direction that was totally unanticipated?

The answer involves the word "currently."

A depressed mood state following mania is a common occurrence. And in the midst of depression one's cognitive filter usually paints a bleak picture. Think about it—depression and optimism are inherently contradictory. The reality of bipolar recovery is that once you gradually accrue improved mood stability, mood will improve. Furthermore, once you move beyond stages of early recovery, medication doses can be adjusted and specific medications can even be altered. Finding effective medication combinations with low side-effect profiles is a realistic goal for you and your psychiatrist. Just because you feel like your psyche has been hit by a hammer during the initial phase of post-mania treatment, it doesn't mean you'll be living with a brain that is permanently bruised.

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If you are successful in developing better sleep hygiene and significantly decreasing substance use, you'll also discover that these aren't such bad adjustments. Living without hangovers is a good thing as is feeling consistently rested. The challenge here isn't so much in the realm of behavioral change, but more, a matter of finding others whose lifestyles are consistent with the new choices you are making. While that will not happen overnight, it can occur over time.

I'm reminded of a student football player/fraternity member who had to make enormous lifestyle changes following two consecutive hospitalizations due to manic psychosis. Once he stopped his partying and instead began to work at developing himself as a scholar, he found that he truly enjoyed the experience of expanding his knowledge base. Much to his surprise, he actually liked becoming a serious student. He also liked the other students he began to connect with who shared these values. And quite separate from the bipolar issues, he discovered that his commitment to academics was a more positive contribution for his future than were the narcissistically driven fantasies of becoming a pro football player. Essentially, his progression away from mood destabilizing behaviors formed the foundation of a more successfully enduring and gratifying future.

For those of you who have gone the direction of higher education, the onset of bipolar disorder is not a sentence involving perpetual struggle. It does represent a shift of lifestyle and identity. It does mean you've now got a particular set of vulnerabilities that you'll need to learn how to manage. And that is a hard pill to swallow.

The life that still awaits you is not second class. It is what you make it. The important thing to keep in mind is that your adjustment to bipolar disorder is a gradual process and the losses of your recent months can and most likely will be offset by many future gains.

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Russ Federman, Ph.D., ABPP is Director of Counseling and Psychological Services at the University of Virginia. He is also co-author of Facing Bipolar: The Young Adult's Guide to Dealing with Bipolar Disorder (New Harbinger Publications). www.BipolarYoungAdult.com