Just What Is Bipolar Disorder?
Catherine Zeta-Jones, Carrie Fisher, and Demi Lovato are among the celebrities to recently share with the public their struggles with bipolar disorder. Just what is Bipolar Disorder?
First, we should take a look at the big picture. Psychiatric diagnoses fall into several main categories, which include mood disorders, anxiety disorders, personality disorders, psychotic disorders, substance-related disorders, and others.
Bipolar disorder is one type of mood disorder. Others include depressive disorders, dysthymic disorder (a milder form of chronic depression), and cyclothymic disorder (frequent periods of highs and lows that are not severe).
There are different types of bipolar disorders; the two main types are Bipolar I Disorder and Bipolar II Disorder. Both include symptoms of mania or hypomania and may include periods of depression.
Bipolar I is the more severe type. People who have this disorder experience manic episodes - distinct periods that may be marked by expansive mood, need little sleep but feel well-rested, may develop grandiose notions, hallucinations, delusions, racing thoughts, pressured speech, intense activity, and poor judgment.
Such disturbances cause marked impairment in sufferers' work, home, and social functioning. Actress Carrie Fisher told USA Today, "A manic phase is not predictable... The last time, I hacked off my hair, got a tattoo, and wanted to convert to Judaism." People who have Bipolar I Disorder may also experience episodes of depression.
Bipolar II Disorder is a milder version of Bipolar I. Sufferers may experience symptoms similar to manic episodes, but are less severe. These are called hypomanic episodes. People who have Bipolar II do not
have hallucinations or delusions, and their symptoms are not severe enough to markedly impair their work or social functioning.
Bipolar I and II are thought to manifest in people who have a genetic predisposition. Even so, some stressors can worsen the symptoms, but they can be minimized. For example, Catherine Zeta-Jones told the press that stress from her husband's illness worsened her Bipolar II symptoms. She wisely obtained treatment soon after her husband's medical condition improved. Another common problem that can recipitate or worsen bipolar symptoms is a lack of quality sleep. Quality sleep is much more important than most people realize. In our country, people often sacrifice sleep in order to take care of other matters.
Mood-stabilizing medications are usually very helpful in treating these disorders. However, practicing good daily self-care can be one of the best deterrents in minimizing hypomanic episodes. This involves maintaining a healthy sleep schedule, using good talking/listening boundaries in interactions, maintaining self-esteem without going "one-up" or "one-down," and minimizing stress.
Thanks to the recent rash of celebrities talking with the press about their struggles with bipolar disorders, more people in the public may feel safer seeking treatment for their illnesses.
Shelley Uram, MD is a Harvard trained, triple board-certified psychiatrist who speaks nationally and internationally on topics related to psychological trauma, the underpinnings of depression/anxiety, and spirituality. Dr Uram conducts lectures, workshops, and seminars to audiences across the United States and co-facilitates lectures and workshops with Pia Mellody. At The Meadows, Dr. Uram conducts many of the patient lectures, provides ongoing training and consultation to the medical and clinical staff. Dr. Uram is a Clinical Associate Professor of Psychiatry at The University of Arizona College of Medicine, and treats patients at her office in Phoenix Arizona.
The following is excerpted from a presentation, "Eliminating Resentment... Solidifying Recovery," given as part of The Meadows' Michigan Lecture Series on November 10, 2010, by Dan O'Neil, MALLP.
The word "resentment" has two parts: "re," which means "again," and "sentment," which is "to feel." So resentment is to feel again, or a feeling that is re-sent. Resentment is the internal revisiting of old wrongs or mistreatments. Resentment operates by mentally replaying, reliving, or reexperiencing actual or imagined injuries from the past. Resentment is the recycling of past anger, hurt, or pain. Resentment is a deep, reflective displeasure at the conduct of another.
Resentment is actually secondary to the original feeling. For example, if we are hurt by someone, we feel the hurt. Resentment begins when we replay, refeel, and remind ourselves of that original hurt. Resentment is fueled and fortified by errors in thinking. Assumption, justification, blaming, and playing victim are common thinking errors used to solidify resentment.
Resentment is then held onto, fostering increased bitterness and a grudge. Resentment takes on a life of its own and is often more severe than the original hurt. "I resent that" is more intense and threatening than "I feel hurt" or "I feel insulted."
There is an old story about two monks who meet up with a woman in their travels. One of the monks helps the woman across a river, even though monks are forbidden to touch females. The next day, the other monk bursts into a rage, exclaiming, "You should not have carried that woman across the river!" The other replied, "Perhaps I shouldn't have, but you are still carrying her." Resentment is hanging onto the anger inside.
Resentment can be collected at anytime from anywhere. Resentment can be born from others telling us what to do, how to run our lives, what we need, how we should act or feel, and what they think is best for us. Resentment can rise if we are lied to, abused, judged, falsely accused, or discriminated against. Resentment can be created when others abuse their power or deprive us of what we need.
When resentment harbors past anger, hurt, or pain, it impacts how we think, feel, and behave in the present. You may pout or fume. You may have a furrowed brow, gritted teeth, bodily aches and pains, or a fake smile. Resentment can be a factor in depression, sarcasm, cynicism, agitation, isolation, and lethargy. Appetite and sleep disturbances can be by-products of resentment. For those with addiction problems, cravings can arise from efforts to avoid or soothe the pain of harbored resentment.
Resentment happens when we continue to rent space in our heads to those we have worked so hard to evict. Resentment is self-torture. Resentment is like peeing your pants: No one is affected as much as you are.
Eliminating resentment is essential in developing a healthy attitude about yourself and your future successes. Eliminating resentment about the past will allow you to thoroughly enjoy the present.
Eliminating resentment will allow you to better ward off depression, fear, isolation, and other negative thoughts. Eliminating resentment can help keep you free of the mental traps that trigger escape into addictions.
Before resentment can be eliminated and possibly addressed with the offender, clarification is needed. The original feelings and underlying resentment have to be identified and described. This is best done by clearly writing about the original feelings. Asking three questions will help start the resentment clarification process:
Question #1: Why is it necessary for me to keep refeeling the original feeling?
You may be using resentment to replicate some family drama. You may be mentally confusing people in your present life with people in your past life. It is easier to harbor resentment than to feel insult, rejection, fear of inadequacy, or injury. Resentment gives an illusion of strength, and it seems to make you look better than others.
Question #2: How did I contribute to the situation?
You may have allowed it to happen. You may have made it worse. You may have been able to prevent the situation. Take a look at the other person's point of view (empathize). Admit if the fault is yours.Forgive if it is theirs.
Question #3: What did I learn from the situation?
Resentment will be there until you know your part and learn from it. Look for a positive lesson. The best time to learn about resentment is when feeling resentful. Resolution comes when feelings and understanding unite. When you fall down, pick something up.
While working to eliminate resentment, avoid collecting any new issues that could turn into resentment. When you feel hurt, slighted, etc., talk to the person in a timely manner. Begin sentences with "I feel" instead of "you did."
Keep resentment away by practicing forgiveness. Forgiveness is for the forgiver. It is not forgetting, but letting go of hurt. Practice not keeping score; an eye for an eye makes the whole world blind. Live and let live. Tolerate your own mistakes.
Dan O'Neil, MALLP, is a therapist at the Birmingham Maple Clinic in Birmingham, Michigan. He has worked for more than 35 years with teens and adults in individual, group, and family therapy.
Shelley Uram, M.D.
January 4, 2011
The Meadow's Overview of the Core Issues and how they relate to our psychological and behavioral symptoms is the most encompassing model I have worked with. This model accurately captures our nature at birth, and how the chronic psychological "bumps and bruises" through our formative years can distort our underlying nature. Ultimately, many of us develop psychological and behavioral symptoms that are directly rooted in these early psychological traumas. These symptoms can include inflexible or inadequate coping mechanisms, addictions, mood and anxiety disorders, personality disorders, etc.
Depressive conditions very commonly develop from these earlier childhood psychological traumas.
There are currently over 21 million American adults diagnosed with a depressive disorder, or almost 10% of all American adults. These numbers do not include the many, many more who have not sought professional help. This is a staggering number of people!
When someone feels the pain of depression, they want relief; the state of depression feels very uncomfortable and negative. In our country, the vast majority of people who go to a doctor for depressive symptoms are treated with antidepressant medication.
Many people feel significant relief within a few to several weeks after starting the medication. Later on, if the depression recurs, they will likely, once again receive a prescription for antidepressant medication. Eventually, many patients are instructed to remain on this medication for years to come in order to prevent a recurrence of their depression.
One of the current popular recommendations from our national and local psychiatric associations is that psychiatrists should treat patients with medication, striving towards a goal of 100% relief of symptoms. Most patients are happy with feeling so much better; however, they have not addressed the underlying issues that initially lead to the depressive state.
Why does this matter? Why should we address the underlying issues behind the depressive state if medication takes away the symptoms?
In my opinion, we are all ultimately trying to master the challenges that show up in our lives. There is a subtle "push" in all species to keep on evolving their mastery skills and ability to cope. We develop better mastery skills with our relationships, health, life stressors, etc. We all stumble and fail at times; sometimes we are flat out stymied by life circumstances. Ultimately, we want to come to some kind of terms with the challenges that show up in our lives, and feel more at peace with them.
In my opinion, many people who suffer from depression are in a "stymied" state of dealing with life challenges. Very often, it is their coping skills that are not adequately flexible or mature enough to successfully deal with the challenge. They are left feeling overwhelmed or "shutdown". In this condition, they are simply not able to master the circumstances at hand.
In my opinion, if a patient is overwhelmed by their symptoms, antidepressant medication may be helpful to alleviate some of the symptoms. The patient can then enter into a "working zone" of being able to actively participate in psychotherapy, and eventually reach a new level of mastery in dealing with their life-stressors.
I think it is wise to utilize antidepressant medication if it is an adjunct to the patient MASTERING the underlying issues.Unfortunately, the trend in our country is to replace the psychotherapy with only symptom relief through medication.
If a person's coping skills are not maturing, they are just as vulnerable to another bout of depression as they were the first time. Research has actually shown that a person is even more vulnerable to further depression episodes with each new episode of depression.
In my opinion, we psychiatrists should tailor our medication prescribing to meet their ideal needs in psychotherapy. For example, if a patient ideally needs to experience some sadness or anxiety in order to be motivated to master the underlying issue in therapy, I think it is appropriate to let them have some of their symptoms, but to a tolerable degree.
I view some depressive or anxiety symptoms as a "barometer"that tells us how we are doing inside. Instead of automatically silencing these depressive or anxiety "signals" with medication, these symptoms can frequently be utilized to motivate us to dig deeper in psychotherapy.
The Meadow's Overview of the Core Issues, is an excellent diagnostic and treatment model upon which to base psychotherapy. It is from this model that mental health professionals can analyze where a patient is psychologically "stuck", and in what therapeutic directions to move. In patients that medication would serve the purpose of alleviating certain symptoms that would stand in the patient's way of utilizing this psychotherapy, then the two treatment modalities could become a unified and useful treatment approach.
Exceptions to the above would include patients who are not interested in mastering the underlying issues and improving their coping skills. If a patient clearly wants to just have the symptoms removed, I do not see a problem utilizing only a medication approach. Other possible exceptions include patients who suffer from other disorders, such as psychosis, Bipolar I disorders, Schizoaffective disorders, etc. When patients have reached an extremely distressed state and have thoughts of harming themselves or others, then the medication route is often helpful in bringing some relief, after which the psychotherapy can play an increasingly important role.
©2011 Shelley Uram
The Meadows is pleased to announce the launch of our new blog, addictionrecoveryreality.com, featuring articles by some of the most well-respected and innovative experts in the treatment and recovery fields of drug addiction, alcohol addiction, gambling addiction, depression and anxiety, relationships and childhood trauma.
Contributors to the blog include leaders in the treatment of addiction and trauma: Pia Mellody; John Bradshaw, MA; Bessel A. van der Kolk, MD; Peter Levine, PhD; Maureen Canning, MA, LMFT; Jerry Boriskin, PhD; and Shelley Uram, MD. These experts write about a wide range of addiction-related topics.
If you are interested in writing for addictionrecoveryreality.com, please send submissions to firstname.lastname@example.org.
Note: This article was originally published in the Winter 2007 edition of MeadowLark, the magazine for The Meadows alumni.
Techniques for Managing Post-Traumatic Stress Disorder
By Lara Rosenberg
This article is based on a workshop that Lara gave February 13 - 14, 2006, in Sri Lanka hosted by the INGO RedR. The workshop is focused on staff working with individuals, families, and communities that have experienced or continue to experience traumatic events. It was an introductory workshop of particular value for staff having community experience, but limited or no psychological training. It was assumed that participants had prior knowledge of stress.
Stress affects us in many ways: cognitively, affectively, physiologically, and behaviorally. "Stress" is a broad term. It's part of all of our lives; each individual has his own ideas of how to define it. There are many definitions given to stress, but the important underlying factor is that stress results from a change in one's environment and requires an adjustment. The environmental changes that require us to adapt and adjust are known as "stressors" they can include anything out of the ordinary. Many think of stress as only negative, but it can be positive and necessary to our healthy development. The ways in which we adapt to our environments leave some stimulated and others with feelings of fear, nervousness, and confusion, which lead us to either solve or avoid a problem. Change always brings extra pressure, as individuals have to adapt to new circumstances.
Humans and animals are born with the capacity to react to threatening situations in adaptive ways; the "fight or flight response" allows individuals to experience resilience in response to danger. Bessel van der Kolk (1994) describes the fight response as hyper-arousal or protest and the flight response as freezing or numbing sensations, which allow individuals to avoid consciously experiencing the event.
Trauma is caused by a stressful occurrence "that is outside the range of usual human experience, and that would be markedly distressing to almost anyone" (Peter Levine, 1997). Post-traumatic stress disorder (PTSD) causes one to experience a prolonged or delayed reaction to an intensely stressful event. According to The DSM-IV Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition, PTSD occurs when an individual experiences a threat (actual or perceived) of death or serious injury to self or others with a response of "intense fear, helplessness, or horror." PTSD can occur in adults and children from all socio-economic backgrounds. Most people who are exposed to a traumatic, stressful event experience some symptoms of PTSD in the days and weeks following exposure. According to the National Center for PTSD, data suggest that approximately 8 percent of men and 20 percent of women exposed to trauma develop PTSD; of that group, 30 percent develop a chronic form that persists throughout their lifetimes.
The World Health Organization (WHO) states that the prevalence of mild and moderate common mental disorders in the general population is 10% and can increase to 20% after a disaster. As stated by Dr. Daya Somasundaram from the Department of Psychiatry at the University of Jaffna, Sri Lanka (WHO, 2005), "WHO estimated that 50% may have problems and 5-10% have serious problems needing treatment. One [non-WHO] survey found 40% post-traumatic stress disorder (PTSD) in children," referring to people in Sri Lanka. Other data suggest that the mental health burden in Sri Lanka is even higher. Dr. Roy Lubit (2006), as well as Pia Mellody, a pioneer on the effects of childhood trauma, stresses that the full impact of trauma may not be experienced until a child reaches adulthood, engages in adult relationships and responsibilities, and develops more sophisticated cognitive capabilities.
The National Center for PTSD states that one of every three disaster survivors experiences some or all of the severe stress symptoms that may lead to lasting PTSD, anxiety disorders, or depression. Severe stress symptoms are extreme attempts to avoid memories and feelings. In order to numb their emotional pain, individuals will stay unusually busy, withdraw, and exhibit addictive behaviors. Violent behaviors often become prevalent.
Individuals can experience severe depression as part of PTSD, suffering a complete loss of hope, self-worth, motivation, and purpose. Some might experience disassociation, feeling outside of oneself as if living in a dream, or may become vacant for periods of time. Intrusive re-experiencing can occur through terrifying memories, nightmares, or flashbacks. For some, hyper-arousal manifests in panic attacks, rage, extreme irritability, or intense agitation. Other manifestations include severe anxiety, paralyzing worry, extreme helplessness, obsessive and compulsive behaviors, and feeling responsible for the event. Children often re-experience traumatic or stressful events through recurrent memories, nightmares, and play. Some children become very aroused, exhibiting nervousness, irritability, anger, disorganization, or agitation. Children also shun thoughts, feelings, or places that evoke memories of the event. Occasionally, they experience a loss of developmental patterns or skills, separation anxiety, bed-wetting, and learning difficulties. An 8-year old boy in Sri Lanka could not see for 10 weeks after enduring the terrifying experience of the tsunami, in which he lost his mother and home. This example of physical impairment demonstrates the freezing response described by Bessel van der Kolk (1996), as well as Peter Levine (1997) in his Somatic Experiencing® work.
Disaster stress may revive memories of prior trauma; pre-existing social, economic, spiritual, psychological, or medical problems can intensify. Individuals at higher risk for severe stress symptoms and lasting PTSD include those who have been exposed to other traumas, such as abuse, assault, or combat. Chronic poverty, homelessness, unemployment, or discrimination will often intensify the traumatic event, as can chronic illness and psychological disorders.
Most likely to develop PTSD are those who experience stress at a greater intensity, with unpredictability, uncontrollability, and real or perceived responsibility. Factors such as genetics, early-onset and longer-lasting childhood trauma, lack of functional social support, and concurrent stressful life events also contribute to the disorder. Those who report a greater perceived threat, suffering, terror, and fear are at risk for developing PTSD, and a social environment that produces shame, guilt, stigmatization, or self-hatred can affect sufferers as well.
Individuals experiencing PTSD face an increased likelihood of co-occurring disorders such as alcohol/drug abuse and dependence, major depressive episodes, conduct disorders, and social phobias. According to the National Center for PTSD, "In a large-scale study, it was found that 88% of men and 79% of women with PTSD met the criteria for another psychiatric disorder." Some experience difficulty in their psychosocial functioning, with profound problems in their daily lives. Concurrent prevalent physical problems include headaches, dizziness, chest pain, and other aches and pains. Often medical doctors treat only the symptoms, without considering PSTD development.
At the same time, stressful or traumatic experiences can facilitate personal growth. In treating sufferers, it is most important to restore safety in their lives, build coping strategies, and reduce pain. It is necessary to find out how they are coping with the situation and stress. Healthy coping mechanisms should be slowly introduced if behavior patterns reflect unhealthy habits such as smoking, drinking, or staying unusually busy. When dealing with disclosure, it is important that a secure and confidential environment is maintained. Humanitarian aid workers should teach survivors of trauma that they are not alone in order to help reduce a sense of isolation and rebuild trust. The aid worker should acknowledge and validate the person's feelings and experiences by offering comfort and support.
Aid workers should assume people are doing their best to cope and should empower them to feel as in-control as possible. Victims should not be asked to reveal emotional information, but if they volunteer it, helpers should listen. Access to mental and physical health services should be provided. In addition to reducing anxiety and depression, valued and meaningful goals help individuals regain hope and purpose. Improved access to education and employment opportunities encourages achievement. It is important to restore individual dignity and value, create opportunities for pleasure, and foster connections by maintaining or re-establishing communication with family and the community. Expressing oneself through journaling, reading, or becoming aware of experiences helps to release stress. Eliminating self-blame for what is occurring allows people to grow. Relaxation methods such as walking, breathing, meditation, yoga, prayer, and listening to music also promote healing, as do self-care behaviors such as brushing teeth, showering, and taking care of one's living environment. Small goals should gradually lead to a focus on the big picture.
The majority of trauma survivors will prove resilient; their feelings of fear and anxiety, along with urges to avoid or relive the experience, will decrease over time. Everyone handles life experiences differently, and it is necessary to allow each individual to heal at his or her own pace. The experience will always be a part of this person's life; however, the possibility of growing from the experience becomes more attainable when anxiety is reduced.