This is the second part of a two-part blog presenting the revised book chapter—"Going to College With Bipolar Disorder," included in the book Healthy Living with Bipolar Disorder, published by the International Bipolar Foundation. The revised second edition of the book will be available in the early part of 2017
Accepting the Diagnosis: The Most Difficult Challenge of the University Years
Most students with bipolar disorder don’t want it. That's not to say they don't value their experience of mild hypomania where they feel energized, optimistic, and cognitively turned on. Think about it; there’s a lot of brilliant creation that has occurred throughout history as a function of bipolar mood elevation. But the full picture isn't as desirable. Depression is depressing. An unpredictable mood creates a roller coaster-like reality. And full mania usually wreaks havoc. Again, most students don’t want it.
But isn't that so for the many difficult and painful things in life? Imagine one has been diagnosed with Type I Diabetes where daily blood level monitoring and insulin shots are an integral part of maintaining healthy functioning. Diabetic university students usually don't welcome this daily regimen; however, they generally comply because the alternative is far too detrimental to their well-being.
Similarly, when a student’s parent dies from cancer during the student’s first year of college, the event will usually take an enormous emotional toll. No one is really prepared to lose a parent at age 18 or 19. But the student’s life doesn't end because of parental loss. The student usually endures a painful period of bereavement. It's also probable that the student will successfully continue forward once figuring out how to live with the new reality of having a deceased parent.
Whether we're considering the loss of optimal physical health or the loss of a loved one, we generally do find ways of adapting and moving forward, but not without loss and adjustment. In many respects, this is what maturation is all about.
Late adolescence is a time of striving toward goals and ideals. Going to a good school, finding a fulfilling major, exploring emotional and physical intimacy, and developing options for gratifying and rewarding employment are dominant themes for late adolescent and young adults. As we progress through the lifecycle we all have to accept some modifications to our hopes and dreams. An ideal life exists in fairytales and movies. It doesn't exist in our lived realities. For most, these modifications of hopes and dreams typically occur somewhat later in life, when it gradually becomes clear that adolescent fantasies and adult realities aren’t a close match.
The college student with bipolar disorder needs to adjust expectations at an earlier age. The predominant lifestyle norms of university life won't work for the bipolar student. Indeed, they’re a recipe for instability. In order to work with this, the bipolar student needs to try to embrace his or her diagnosis; not because it's desirable, but because it’s real and to some degree, unchangeable. Denial won’t make it go away. Denial of bipolar disorder will temporarily allow students to do what they want. But when such choices disregard aspects of bipolar stability then there’s the inevitable price to pay for brief forays into denial and temporary wish fulfillment.
The necessary psychological adjustment for the bipolar student entails letting go of their ideal self - that person the student was striving to become - and accepting the realities of living with the bipolar diagnosis. This adjustment is a painful one and it usually isn’t achieved quickly. Just as with the process of grief, it needs to be revisited again and again, in order to gradually be replaced with a deep sense of acceptance. It actually is a process of grief: grieving the loss of that person that one wants to be.
So what does this look like in practice? Maybe it means working hard to find others whose lifestyle revolves around recreational activities other than drinking and partying. Maybe it means getting a physician’s letter documenting the need for a single dormitory room in order to have more control over “lights out” time. Maybe it even means getting some additional help or study skills coaching in order to develop really good study habits and effectively distribute one’s academic load over the duration of the semester. These are all important pragmatic approaches.
Beyond pragmatism, the real work underlying all of this entails the emotional process of coming to terms with the diagnosis. This is also where some good psychotherapy can be very helpful. Ultimately, once the reality of “being bipolar” is comfortably integrated into one's identity, then the pragmatic pieces will fall into place without a lot of difficulties.
Unfortunately, most students are not ready for this kind of acceptance during their late teens. In fact, for some, the reality of bipolar disorder is so not what they want, that they intentionally try to reject the whole ball of wax. It’s not uncommon for some to say, “I’ll deal with this all once I’m out of college!” Well, yes, they may have to, but what’s the price they will have paid for their deferment?
Neuroscience research involving the long-term course of bipolar disorder points to a phenomenon where the long-range prognosis for the course of one’s bipolar disorder is a reflection of the degree of instability that occurs early on with the disorder. In other words, early mood instability left untreated = long-term difficulty with continued instability, whereas early instability that is successfully contained = better chances for longer-term stability. This is referred to as the kindling effect (Post, 2007).
Think of a sprained ankle. Once an ankle is badly sprained it makes the ankle more susceptible to future sprains. Each successive sprain lowers the threshold for the kinds of physical stresses that will lead to subsequent sprains. The brain is not all that different. Vulnerabilities towards bipolar instability, especially when they are disregarded and simply allowed to occur, actually lower the threshold for future episodes of instability. This means that the strategies of those who want to wait until later years before they seriously deal with their disorder are significantly flawed. Once the neural circuitry of the brain is primed for longer-term instability, the individual doesn’t get to return to late adolescence for a redo.
The impact of the kindling effect is further illustrated through the results of a 2016 journal article (Joyce, K., Thompson, A., and Marwaha, S., 2016). The article reviews 10 different bipolar treatment outcome studies. The authors conclude, “There was a consistent finding suggesting treatment in earlier illness stage resulted in better outcomes in terms of response, relapse rate, time to recurrence, symptomatic recovery, remission, psychosocial functioning, and employment “
So accepting one’s diagnosis and adjusting accordingly is a big deal! The intent here is not to paint a picture of doom and gloom or to frighten one towards a preventative position, but more to draw attention to what's really at stake. When students are in the midst of their college life it's not easy to maintain a healthy perspective on the bigger picture. For college students with bipolar disorder, this very perspective may be essential to living a life that’s well-grounded in stability, effective functioning, and fulfillment.
The Appropriate Use of Academic Parachutes
An academic parachute refers to those supportive processes that can be put in place to assist a student during times of functional difficulty. When used appropriately, an effective parachute will also help a student land on his or her feet while avoiding the reality of a more devastating crash landing.
One of the frustrating aspects of living with bipolar disorder is its unpredictability. Even with the right combination of medications and lifestyle modification, a student can find that the stresses of academics and college life can still turn things upside down. Given this potential, it's prudent for bipolar students to know what kinds of parachutes are available to them.
The Americans with Disabilities Act requires that institutions of higher education provide assistance and necessary accommodations to students with diagnosed disabilities. As a function of this requirement, nearly all universities have an office that serves students with physical, psychiatric, and learning disabilities. Typically this office is referred to as Disability Support Services. Clearly, no college student wants to consider themselves as having a “psychiatric disability,” but there are times when bipolar symptoms can be just as disabling as any other condition.
If a student was in a wheelchair due to cerebral palsy, there wouldn't be much question as to whether some special assistance would be needed for that student. His or her classrooms would all need to be wheelchair accessible. If a student's arms were affected, it would also make sense that the student receive copies of comprehensive class notes. In other words, some accommodations would need to be made to assist the student to participate equally in the educational process along with other nondisabled students. Why should bipolar disorder be viewed any differently?
Strong symptoms of depression and/or hypomania can absolutely impair work productivity. The different medications used to help stabilize a student may also have unwanted side effects such as drowsiness, impaired attention, and concentration, or even the intensification of agitation. The process of trying to return to a stable mid-range mood after a period of depression or hypomania is not always a simple one. Here's where a good connection with a college’s Disability Support Services, as well as one's academic Dean, can make an important difference.
Through these services, it is usually possible for students with bipolar disorder to receive accommodations such as flexible class attendance requirements, extended work submission deadlines, and receipt of class notes when a student is not able to attend class. Usually, the main hurdle to receiving this help is not the institutional system itself. More often than not students are reluctant to swallow their pride and ask for help. Clearly, this is an echo of the kinds of issues raised in the discussion of accepting one's diagnosis.
A student’s academic dean can also be an effective advocate when communicating with professors around issues of disability-related performance difficulties. A good example involves medically excused late course drops. Most schools have an initial period of time each semester where students can add or drop courses without consequence. Occasionally a student may recognize that his or her performance in a particular course is more negatively impacted than performance in other courses. Sometimes this will not become apparent to the student until after the add/drop date. In these instances, when accompanied by appropriate medical documentation, academic deans can sometimes play an important role in facilitating exceptions to standard course drop policies.
Beyond the helpful advocacy roles provided by others, one of the best strategies is for a student to meet with professors and share the realities of his or her bipolar condition. It's even more helpful when this is done proactively, early in the semester, rather than waiting until the point where it feels like the semester is a lost cause. In most instances, university professors are more than willing to be flexible and supportive of students as long as they perceive the student’s sincerity and all claims are backed up by appropriate documentation.
There's also the occasional outcome where the semester does become a lost cause. A ten-day hospitalization occurs and the student doesn't return to effective stable functioning until a month later. A hypomanic high derail a student’s productivity for the entire first half of the semester. By the time things have smoothed out the possibility of catching up with missed work is unrealistic. A student enters college in late August and does quite well, but hits a wall of depression by mid-November. The student’s energy, motivation, and ability to concentrate are all greatly diminished and the challenges of completing the semester are only compounding the depressive symptoms. In instances such as these, a full medical withdrawal from enrollment can be a wise decision.
The official notation on one's transcript is simply “Withdrawal,” or something quite similar. There is nothing on an academic transcript that reads, “Withdrawal Due to Psychiatric Instability.” By taking this course of action a student is also able to protect against the strong negative impact of Ds and Fs upon their overall grade point. Such can be especially important if long-range goals are to gain access to a competitive graduate school or some other post-baccalaureate professional program.
It's not uncommon that when discussing these choices with students, their response is something like, “but that will put me behind the rest of my class!” Well, it may. But there’s always the potential of making up courses during summer school or doing the kinds of two-week intensive courses that some universities offer just following the winter break.
It's important to recognize that getting an education isn't a race to the finish line. Some will get there ahead of others while some will take longer. That’s life both in and out of college. There’s no official established formula for success in higher education. It's also a given that by the time students reach midlife, they're not going to be looking back on their college years and thinking that things would have been so much better if only they had graduated one semester sooner!
We’ve often heard the phrase uttered by adults, “My college years were the best years of my life!” Typically when this is expressed we’re seeing some degree of retrospective distortion. No doubt, the college years do involve some wonderful experiences. But if the truth be told, they are also years of high stress and high complexity. Even for those without any psychiatric diagnosis, the transition from late teens to early adulthood is no walk in the park. For those transiting this phase of development while trying to manage their bipolar disorder, the experience is more like a trek through the Himalayan peaks. There are amazing highs and dangerous precipices. The journey requires good preparation, excellent conditioning, extra gear, and well-developed skills. It’s also a time to connect with the best guides you can obtain. There will be setbacks. There will even be times when adverse conditions seem overwhelming. However, if the bipolar student is able to successfully commit to the journey and accrue many new life skills in the process, the experience will add to the foundation of stability that is needed to live well with bipolar disorder.
Copyright Russ Federman, 2016
Joyce, K, Thompson, A and Marwaha, S. 2016. Is treatment for bipolar disorder more effective in illness course? A comprehensive literature review. International Journal of Bipolar Disorders. 4:19.
Post, R. 2007. Kindling and sensitization as models for affective episode recurrence, cyclicity, and tolerance phenomena. Neuroscience and Biobehavioral Reviews. 31:6. 858-873
Baethge, C., Hennen, J, Khalsa, H.K., Salvatore, P, Mauricio, T. and Baldessarini, R.J. 2008. Sequencing of substance use and affective morbidity in 166 first-episode bipolar I disorder patients. Bipolar Disorders. 10:6. 738-741