When I ask Maxine how she will handle an upcoming event, she often says “I’m fine” in a fully confident voice. She feels like she can handle whatever is coming up. And yet, in the middle of the event, she often has great difficulty completing the work. And she ends up ashamed and confused.

Last week, Maxine texted me: “I often have grandiose expectations of my abilities, and then I have a tough time when I am confronted by the realities. How can I get better at predicting what will happen, and what I really need?”  

Maxine had a great insight. And since she suspected she was not the only person to have a mismatch between her expectations and reality, she asked if we could talk about it in bipolar group. When we talked as a group, we found everyone had the same questions as Maxine did.

Here is what we learned.

Despite taking her medications conscientiously, Maxine tends to be just a little hypomanic. She often overestimates her abilities, and she underestimates the challenges involved in many tasks.

Another member of our group, Tamar, does the opposite. Tamar is frequently depressed and anxious. Even when she really can perform a task, she underestimates her ability to get it done. Then, once she gets going, she undervalues her performance.

For both Maxine and Tamar (and most people with bipolar spectrum disorder), their dominant moods shape their expectations and their self-evaluations. Since we tend to trust our emotions, it’s hard to challenge those expectations. Working with your doctors to adjust the medication and achieve the best mood stability you can continues to be a very important part of recovery.

But mood dysregulation is not the only thing that makes it difficult for people with bipolar spectrum disorders to develop more realistic evaluations of their abilities and to generate more detailed and effective plans of action.

Bipolar spectrum disorder can affect underlying neuropsychological capacities, including working memory and executive function. Problems in working memory and executive function can make it difficult for people to break down a challenge into separate steps and hard to develop a plan to tackle each part.

Both Maxine and Tamar are smart people. They can easily tell you what they wish to do and why. The situation gets more difficult when they have to work out a more detailed plan. The problems they have with working memory and executive functioning make it hard for them to break each project down into smaller steps, and to figure out if they have the resources and capabilities to accomplish each step. We call this logistical thinking – thinking about the logistics or operational details of the task.

People who are good at logistics can identify a goal, work out what materials they need, envision the activities they will have to do to achieve their goal, anticipate obstacles and plan for them, and get started. They can create a mental map of the steps, processes, and materials involved. The steps and processes can stay in their mind -  just as if they were reading a list on a blackboard. People with good logistical thinking are able to develop a more realistic expectation of their ability to reach their goals, because they can keep the necessary information in mind.

But bipolar spectrum disorder can interfere with your ability to do this kind of planning — to think through the logistics. Often it can seem as if the blackboard in your mind is too small to give you enough room to make a clear list. It can feel as if the ideas and words get erased when you try to “write” something down in your memory.

The situation gets more complicated because most people with bipolar spectrum disorder are not really aware of these logistical functions. They may understand they sometimes have trouble getting things done, but they don’t really understand what is involved. They are not aware of the effects of bipolar disorder on working memory and executive functioning. And they may be surprised by the level of detail that has to go into plans for action, once they have had an episode of bipolar disorder.

In group, we thought about the logistics involved in achieving each person’s goal. We broke the process down into individual steps. We thought about all the materials they might need, all the actions they might take, and all the people they might need to contact.

Each person took a turn mentally rehearsing the activities involved in each step.  This mental rehearsal helped the group members see what they needed to do to accomplish their goals. The rehearsal helped them develop a better sense of how difficult or time consuming the steps might be. 

For example, Maxine is taking a math class. She understands the concepts. But she is having trouble writing down all the notes and formulas the professor puts on the board. Because she understands the ideas in her math class, she did not think it would be as difficult as it was to manage the technical details of the class. But it ended up being quite difficult.

Bipolar disorder doesn’t affect Maxine or Tamar's ability to understand their goals. They can easily tell you what they wish to do and why.

We thought about the logistics involved in achieving each person’s goal. We broke the process down into individual steps. We thought about all the materials they might need, all the actions they might take, and all the people they might need to contact.

Each person took a turn mentally rehearsing the activities involved in each step.  This mental rehearsal helped the group members see what they needed to do to accomplish their goals. The rehearsal helped them develop a better sense of how difficult or time consuming the steps might be. 

For example, Maxine is taking a math class. She understands the concepts. But she is having trouble writing down all the notes and formulas the professor puts on the board. Because she understands the ideas in her math class, she did not think it would be as difficult as it was to manage the technical details of the class. But it was difficult.

As she was brainstorming how to make it better, we talked about the materials Maxine needs to take the notes, and the back-up systems she might use (e.g., recording the class). We discussed how to scan the blackboard, and she described how she is trying to make the notebook paper into grids to help her keep the formulas in order on the page. We discussed how much effort this level of work requires. She needs much more energy and effort to complete the task than she might anticipate.

But it isn’t always easy to do this planning on your own. Your mood and problems with executive functioning can make it hard to slow down and think things through. There is also some new evidence that people with bipolar spectrum disorder may have some difficulty activating the parts of the brain that are involved in this mental rehearsal.

As we went through the logistical steps involved in meeting each person's goals, Tamar recognized she really had gotten started on her projects, and in some cases she had succeeded — despite her doubts. Maxine got better at anticipating the help she might need to get all the notes.

So where you can, don’t just trust your gut. See if you can talk with someone else about  the logistics — all the logistics. Figure out where you might need extra time or extra help. See if you have confidence to get started and make progress, or if you could use a little boost of support. See if working through the logistics helps you create more realistic expectations and get better at getting what you need to achieve your goals.

References

Amerio, A., Odone, A., Liapis, C. C., & Ghaemi, S. N. (2014). Diagnostic validity of comorbid bipolar disorder and obsessive–compulsive disorder: a systematic review. Acta Psychiatrica Scandinavica, 129(5), 343-358.  

Cullen, B., Ward, J., Graham, N. A., Deary, I. J., Pell, J. P., Smith, D. J., & Evans, J. J. (2016). Prevalence and correlates of cognitive impairment in euthymic adults with bipolar disorder: a systematic review. Journal of affective disorders, 205, 165-181.  

About the Author

Elizabeth Brondolo, Ph.D.

Elizabeth Brondolo, Ph.D., is a psychology professor at St. John’s University and the author of Break the Bipolar Cycle: A Day-by-Day guide to Living with Bipolar Disorder.

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