A blog about the different types of loss and how to cope.Ambiguous vs. Unambiguous Loss

When I looked into my loved one’s eyes during one of her first manic episodes, I did not recognize the eyes staring back at me.  Equally heartbreakingly, I felt that she did not recognize me. And so it began: a cycle of highs and extreme lows, agitation and depression, characteristic of bipolar disorder. While bipolar disorder affects each person differently, in her case, the depression has often lasted longer than the manic state, sometimes lasting years. During these polarized periods, one of the hardest parts was the feeling that “she” was lost to me – she whose counsel I trusted and valued so much, and she to whom I could be my most honest and vulnerable self. The person who replaced her in these periods was either highly agitated and manic, or depressed and despondent – unable to provide the type of support or nurturance I might be craving.  In those periods, though she was still there in her body, I could not expect much from her – it was all she could do to keep her own spirit alive or stable and had little to give anyone else. And though I understood this on an intellectual level, it was hard to escape the mixed feelings of sadness, helplessness, disappointment, and frustration.

It wasn’t until years later that I was finally able to put a name to this feeling: ambiguous loss, a term coined by the social scientist Dr. Pauline Boss in the 1970s. Ambiguous loss refers to losses that do not have the type of clarity and finality that an unambiguous loss like death has. Ambiguous loss lacks closure and results in grief that is unresolved and confusing.  According to Boss, there are two main types of ambiguous loss. The first is physical absence with psychological presence. This may include a missing person due to abduction, war, or natural disaster. The second type is physical presence with psychological absence. This may include losing someone to Alzheimer’s disease, dementia, addiction, or severe mental illness. Something like divorce can also result in ambiguous loss, where the family unit that once was is no longer.

Frozen grief: “leaving without goodbye” and “goodbye without leaving”

A loss of any kind can be hard, but Boss contends that ambiguous loss can be particularly challenging because of its lack of closure and resolution. For example, in the case of a missing person, those left behind may feel like they must make the excruciating choice of either living in a state of perpetual uncertainty but holding onto hope, or deciding to inject some resolution by mourning and attempting to move on. Everyone will respond differently to such ambiguous loss and everyone must find a way to cope in a way that makes sense for them. Regardless, the overarching uncertainty of the situation often leads to prolonged grief and feelings of anxiety and helplessness.  Boss calls this “frozen grief” and highlights the pain behind “leaving without goodbye” (as in the case of missing persons) and “goodbye without leaving” (as in the case of losing someone to a condition like dementia).

How to cope: revising expectations and adjusting to a new reality

So how can we cope with ambiguous loss? Boss recommends naming the ambiguous loss and labeling the situation as such as a first step in acknowledging and validating the experience and the associated host of feelings.  She also encourages people to find ways to live with the uncertainty and the changes brought on by the loss by revising your own expectations to reflect the new reality (as opposed to being in denial).  For example, the wife of a formerly active husband who has been diagnosed with Alzeheimer’s disease may now have to revise her expectations that they will continue to live the active lifestyle they had grown accustomed to, filled with outdoor activities and travels.  She may have to learn to revise her expectations that though they may be able to enjoy some quiet moments together she would have to fulfill her needs for the outdoors and social engagement in a new way – by perhaps dedicating a day in the week where she can take part in such activities while her husband is in the care of someone else.

As she grows into the new reality, she can hopefully find moments of joy and hope in this new phase of her life.  This may take time and grieving of what once was – and that is absolutely to be expected.  The key will be to learn to not only accept the uncertainty but also be able to take empowered action so that her focus shifts away from the uncertain aspects in her life (for example the progression of the disease) to aspects that are within her control (for example how she chooses to take care of herself or the support system she creates for herself).  The support system she builds may include support groups of people going through similar experiences, friends, family, and/or a therapist, who can help her work through the range of emotions she is likely to experience.  In my practice, I work with grief – ambiguous and unambiguous – as it impacts not only individuals but also in couples and families.

Any loss, ambiguous or unambiguous, can be traumatic. As the preeminent trauma researcher and psychologist Peter Levine has said: trauma is not what happens to us but what happens inside of us in the absence of an empathetic witness – and a support system can serve as that empathetic witness.

Back view of hiker looking at mist-shrouded hillsImpulsivity, mood swings, irritability, high and low periods, patterns of troubled relationships—these symptoms often indicate bipolar, but they can just as easily appear in people who have borderline personality (BPD).

Neither condition is uncommon. Approximately 2.6% of adults in the United States live with bipolar. Estimates for BPD vary, but it’s believed somewhere between 1.6% and 5.9% of adults in the U.S. live with this condition. Many people have a dual diagnosis, or both conditions.

The resemblance between the traits characterizing each issue and the possibility of co-occurrence has led some professionals to question whether BPD is a subtype or variation of bipolar. The general consensus among mental health experts, however, is that while these conditions often present with similar features, they are two separate mental health issues that can usually be distinguished in a few key ways.

It’s during periods of mania that bipolar may be most suggestive of BPD, as manic episodes often involve thrill-seeking, impulsive, or aggressive behavior.

Bipolar vs. Borderline Personality

A mood disorder, bipolar is primarily characterized by shifts between high-energy (manic) states and low-energy (depressive) states. Bipolar-related mood changes can range from mild to extreme, and they’re typically accompanied by changes in a person’s energy and activity.

Not every person who has bipolar will experience a classic manic episode. These episodes generally last several days and frequently involve increased activity and productivity in schoolwork, work-related tasks, or creative pursuits. Feeling very energized or charged, with little or no need to sleep, is common.

People living with bipolar II experience milder manic periods known as hypomania. Cyclothymia, a subtype of bipolar, involves hypomanic and depressive periods that don’t meet typical bipolar criteria. But mania is a symptom specifically linked to bipolar, so having even one manic episode indicates bipolar in most cases.

It’s during periods of mania that bipolar may be most suggestive of BPD, as manic episodes often involve thrill-seeking, impulsive, or aggressive behavior. Impulsive actions might include risky sex, excessive spending, or substance abuse, along with other behavior that isn’t typical. Rapid cycling bipolar may particularly resemble BPD, as mood fluctuations happen more frequently than with typical bipolar.

Frequent manic episodes could also contribute to relationship difficulties, since the way a person behaves during a manic episode could have a negative impact on the people close to them. For example, during a manic episode, a person in a monogamous relationship may cheat on their partner or decide to redo all of their home furnishings and max out multiple credit cards in order to purchase new interior decorations. A person who uses drugs during a manic episode could face legal consequences, especially if their actions while under the influence of drugs cause harm to others.

But with BPD, particularly untreated BPD, emotional shifts tend to be sudden and happen frequently. BPD is a personality disorder, so the associated traits don’t simply relate to mood changes, they’re persistent behavior patterns. Extreme, all-or-nothing thinking patterns also help characterize this condition. For example, a person with BPD who experiences mild criticism at work may become very upset and distressed. They may feel they’ve failed and fear they’ll lose their job.

Another characteristic of BPD is difficulty interpreting emotions. People often view neutral or other expressions as negative, and this misinterpretation could lead to conflict or strained personal relationships.

Similarly, a minor disagreement with a partner could lead someone to believe they’re unlovable and the relationship is over. They might end the relationship first, fearing rejection. Relationship conflict can also trigger devaluation of a partner who was previously idealized, depending on the circumstances. With devaluation, feelings of anger, disdain, and contempt may abruptly replace feelings of love and happiness in the relationship.

Lifetime suicide risk is high with either bipolar or BPD, while recurring non-suicidal self-harming behaviors as well as multiple suicide attempts are common with BPD. Cutting and other self-harm doesn’t necessarily indicate suicidal intent. Research indicates many people with BPD self-harm as a way of coping or as a way of feeling something during a period of dissociation.

How Do Treatment Approaches Differ?

These two conditions have separate underlying causes, though people with a family history of either bipolar or BPD have a higher risk for that condition.

The causes of BPD aren’t fully known, but it’s believed to develop from a combination of factors. A tendency to experience extreme emotionality, which can also run in families, is believed to contribute, especially in people who’ve experienced abuse, trauma, and neglect. Brain chemistry is a significant contributing factor to bipolar, though environmental factors can also increase risk.

Correct diagnosis is important, because treatment approaches vary depending on the condition. It’s important to understand that therapy alone typically can’t treat mania in people living with bipolar. It may also not be enough to treat severe depression in some people.

Therapy can help address some symptoms and challenges of living with bipolar, but in most cases people with typical bipolar will need medication to help stabilize mood shifts. Untreated mania and depression can have serious emotional and even physical health consequences, so it’s important to seek, and continue with, treatment.

Mood stabilizers such as lithium won’t help BPD symptoms. In some cases, bipolar treatment might even make certain symptoms worse. There’s no medication that specifically treats BPD. The typical treatment is dialectical behavior therapy, though other therapy approaches such as schema therapy can also have significant benefit.

Can Bipolar and Borderline Personality Co-occur?

A person experiencing symptoms of both bipolar and borderline personality may have both conditions.

A person experiencing symptoms of both bipolar and borderline personality may have both conditions. This isn’t uncommon, in fact. A 2013 review of multiple studies on the two conditions found that around 10% of people diagnosed with borderline personality also had bipolar I, while about 10% had bipolar II as well as BPD.

Living with untreated borderline personality and bipolar can cause significant distress, in part because the two conditions may play off each other.

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) recommends mental health professionals avoid diagnosing personality disorders during untreated mood episodes. Taking a detailed mental health history that looks back at patterns and symptoms over a longer period of time can help differentiate the two conditions.

Between manic and depressive episodes, people with bipolar generally experience fairly normal moods. Months or even years could pass between high and low periods, especially when treatment is effective at managing symptoms. So once a mood episode has stabilized, diagnosis may be somewhat clearer. When a manic or depressive mood seems to respond to treatment but symptoms of emotional dysregulation persist, a dual diagnosis is likely.

Treatment for Co-occurring Bipolar and Borderline Personality

Living with co-occurring BPD and bipolar may be more challenging than having either condition alone, especially if it takes time to get an accurate diagnosis. Bipolar-related mood swings, when combined with more frequent and rapid changes in emotional state, can make daily life difficult and negatively affect work, school, and personal life. People living with bipolar and BPD may feel even more unstable or unable to control what’s happening around them than those living with only one of these conditions.

While treatment such as therapy can be very helpful for reducing symptoms and improving quality of life, the recommended treatments for each condition differ. This makes an accurate diagnosis essential for successful treatment.

For bipolar, therapy may involve learning to recognize mood triggers, developing ways to cope with bipolar symptoms, and working to reduce the effects symptoms have on daily life. The combination of mood stabilizing medication and dialectical behavior therapy may be recommended for people with both bipolar and BPD, since DBT is generally the ideal approach to therapy for BPD. This therapy involves developing the skills to manage and cope with difficult emotions and practicing positive ways of relating to others.

For people experiencing BPD-related distress during a manic or depressive episode, mood stabilization is an important first step. Research suggests BPD symptoms may improve slightly once mood has stabilized, which can increase the chance of successful treatment. It’s also essential to talk about suicidal thoughts or self-harm, since these may be more likely in people with both conditions than people who only have bipolar.

Psychotic symptoms such as hallucinations can also occur during a manic episode, and these can be dangerous. They’re not as common with BPD, but they do occur, so it’s important to discuss any hallucinations, delusions, or magical thinking when a person presents with symptoms of both conditions.

Finding a Therapist for Bipolar or Borderline Personality

For some mental health concerns, diagnosis may not significantly impact treatment since symptoms can still be addressed in therapy. But when bipolar and BPD, which sometimes present similarly, are misdiagnosed for each other, treatment may be less effective. Symptoms of both conditions can further complicate diagnosis. Some mental health professionals may fail to recognize the presence of both issues, particularly if they’re less experienced with the differences between the two or unaware bipolar and BPD often occur together.

When seeking a diagnosis or working to address symptoms of both bipolar and BPD, it’s recommended to seek support from a therapist who has experiencing helping people with both conditions. While other trained, empathic therapists can certainly provide compassionate care, a therapist who specializes in working with people living with these conditions may offer support that’s designed to address specific symptoms of these conditions. This may be especially important when beginning therapy for the first time.

References:

  1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders, fifth edition. Arlington, VA: American Psychiatric Association.
  2. Bipolar disorder. (2017). National Alliance on Mental Illness. Retrieved from https://www.nami.org/learn-more/mental-health-conditions/bipolar-disorder
  3. Bipolar disorder. (2018). National Institute of Mental Health. Retrieved from https://www.nimh.nih.gov/health/publications/bipolar-disorder/index.shtml
  4. Borderline personality disorder. (2017). National Alliance on Mental Illness. Retrieved from https://www.nami.org/Learn-More/Mental-Health-Conditions/Borderline-Personality-Disorder
  5. Borderline personality disorder. (2017). National Institute of Mental Health. Retrieved from https://www.nimh.nih.gov/health/topics/borderline-personality-disorder/index.shtml
  6. Fenske, S., Lis, S., Liebke, L., Niedtfeld, I., Kirsch, P., & Mier, D. (2015, June 26). Emotion recognition in borderline personality disorder: Effects of emotional information on negative bias. Borderline Personality Disorder and Emotion Dysregulation, 2, 10. doi: 10.1186/s40479-015-0031-z
  7. Ghaemi, S. N., Dalley, S., Catania, C., & Barroilhet, S. (2014). Bipolar or borderline: A clinical overview. Acta Psychiatrica Scandinavica, 130(2), 99-108. doi: 10.1111/acps.12257
  8. Kvarnstrom, E. (2017, October 5). Borderline personality disorder misdiagnosed as bipolar disorder: Differences and treatment. Retrieved from https://www.bridgestorecovery.com/blog/borderline-personality-disorder-misdiagnosed-as-bipolar-disorder-differences-and-treatment
  9. Linehan, M. M., Korslund, K. E., & Harned, M. S. (2015). Dialectical behavior therapy for high suicide risk in individuals with borderline personality disorder: A randomized clinical trial and component analysis. JAMA Psychiatry, 72(5), 475-482. doi:10.1001/jamapsychiatry.2014.3039
  10. Paris, J. (2004). Borderline or bipolar? Distinguishing borderline personality disorder from bipolar spectrum disorders. Harvard Review of Psychiatry, 12(3), 140-145. doi: 10.1080/10673220490472373
  11. Zimmerman, M., & Morgan, T. A. (2013). The relationship between borderline personality disorder and bipolar disorder. Dialogues in Clinical Neuroscience, 15(2), 155-169. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3811087

A young couple wearing white shirts lie side by side on spring grass.More than 4 percent of Americans experience bipolar at some point during their lives. During manic episodes, a person with bipolar may have surges in energy, an elevated mood, and sometimes a sense of invincibility. Around 40% of people with bipolar also experience hypersexuality.

When a person’s sex drive is significantly higher than their partner’s, it can cause stress and conflict. In a person with bipolar, difficulties with impulse control can exacerbate these common relationship issues.

Couples in which one partner has bipolar hypersexuality may worry about the effects of bipolar. But bipolar hypersexuality does not have to undermine a relationship. A 2016 study found that when it comes to establishing and maintaining relationships, people with bipolar have similar outcomes to people without mental health issues. Couples may, however, report differences in sexual satisfaction as the person with bipolar experiences mood cycles.

What is Bipolar Hypersexuality?

Most people with bipolar experience cycling moods. This includes times of depression (characterized by low energy, sadness, and hopelessness) and times of mania (characterized by periods of exuberance and high energy). Some people become more interested in sex during mania.

Hypersexuality is not a medical diagnosis. The American Psychiatric Association (APA) rejected its including in the latest version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Other organizations, such as the American Association of Sexuality Educators, Counselors, and Therapists (AASECT) also reject the diagnosis. This is because religion, cultural influences, gender norms, and a couple’s own history all influence their views on what is acceptable sexual behavior. No specific frequency of sex or sexual thoughts is in itself harmful or excessive. What seems very excessive to one couple might be completely normal for another.

Couples concerned about hypersexuality should instead look at changes over time and how those changes affect their life. It is common for couples to differ in their understanding of how frequently they should have sex. Some signs that one partner may be experiencing bipolar-related hypersexuality include:

Does Bipolar Hypersexuality Increase the Risk of Infidelity?

Most couples are in monogamous relationships, so an episode of hypersexuality may trigger fears of infidelity. Consensually non-monogamous couples may have other concerns, such as dishonesty about sexual relationships, unsafe sex practices with other partners, and sexual risk-taking.

While there are many studies on bipolar and sex, research on bipolar and infidelity is limited. Estimates of infidelity in bipolar relationships can vary wildly.

There is no right amount of sex to have and no wrong way to feel about sex as long as all involved parties consent. In a 2005 review, 40% of participants with cyclothymia reported “episodic or unexplained promiscuity or extramarital affairs.” However, the study’s definition of sexual excess included “overt bisexuality” and “sexual activity many times per day.” Neither of these factors fall under the category of infidelity, meaning the actual rate of extramarital affairs was likely lower.

A 2016 study compared sexual behavior of people with bipolar to those without bipolar and found very different results. Researchers found no significant difference in sexual risk-taking between bipolar and non-bipolar participants. Sexual risk-taking included items such as “sex with strangers” or “recreational substance use during sex.” The study did not measure infidelity directly though.

There is little evidence to suggest bipolar, or even bipolar hypersexuality, is a significant risk factor for infidelity. Other factors, such as age or gender, seem to play a much larger role. However, hypersexuality may affect couples in other ways, such as creating chronic conflicts over libido.

How Bipolar Hypersexuality Can Affect Couples

Many couples struggle with differences in libido. The effects of these differences depend on each partner’s views about sex, relationships, and intimacy. Some common themes include:

Coping Strategies for Couples with Bipolar Hypersexuality

Treatment for bipolar can help with feelings of hypersexuality. Couples can also adopt a wide range of coping strategies. Those include:

How Therapy Can Help Bipolar Hypersexuality

Sex often goes hand-in-hand with shame and guilt. Thus, many couples may struggle to talk about bipolar hypersexuality. The person with bipolar may feel simultaneously guilty about their desires and angry about their partner’s inability to match their libido. This can leave them feeling ashamed and unloved. Their partner may feel frustrated or even intimidated by constant sexual overtures. They may worry their partner will leave or be unfaithful, triggering feelings of insecurity and anxiety. Some may judge their partner for their sexual feelings, leading to poor communication and escalating shame.

Couples counseling can offer hope. The right therapist works to help both members of a couple feel safe talking about their emotions and sexual needs. In so doing, therapy can:

Individual therapy can help people with bipolar understand their diagnosis and better manage their emotions. It may help the partners of said individuals identify the ways bipolar affects their lives and their relationships.

Many couples find that a combination of individual and couples therapy works best. If you would like get help for bipolar hypersexuality, you can find a therapist here.

References:

  1. AASECT Position on Sex Addiction. (n.d.). Retrieved from https://www.aasect.org/position-sex-addiction
  2. Auteri, S. (2014). What you need to know about…hypersexuality. Retrieved from https://www.aasect.org/what-you-need-know-about-hypersexuality
  3. Bipolar disorder. (2017, November). Retrieved from https://www.nimh.nih.gov/health/statistics/bipolar-disorder.shtml
  4. Downey, J., Friedman, R. C., Haase, E., Goldenberg, D., Bell, R., & Edsall, S. (2016). Comparison of sexual experience and behavior between bipolar outpatients and outpatients without mood disorders. Psychiatry Journal, 2016(1). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4852112
  5. Kopeykina, I., Kim, H., Khatun, T., Boland, J., Haeri, S., Cohen, L. J., & Galynker, I. I. (2016). Hypersexuality and couple relationships in bipolar disorder: A review. Journal of Affective Disorders, 195(1), 1-14. Retrieved from https://www.sciencedirect.com/science/article/pii/S0165032715306649
  6. Toussaint, I., & Pitchot, W. (2013). Hypersexual disorder will not be included in the DSM V: A contextual analysis. The Medical Review of Liege, 68(5-6), 348-353. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/23888588
  7. Wang, W. (2018, January 10). Who cheats more? The demographics of infidelity in America. Retrieved from https://ifstudies.org/blog/who-cheats-more-the-demographics-of-cheating-in-america

Person wearing red scarf and black coat sits on back of bench and looks out at lakeIn August of 2014, in the middle of the night, a phone call came: My son was unresponsive and was being transferred to the hospital. I remember the 30-minute drive to the hospital, trying to get to my son, took forever. I knew nothing but what his friend had hysterically tried to explain over the phone.

When I arrived at the hospital, and they took me to his room, he seemed so small, surrounded by a machine and tubes. The doctors were unsure whether he would make it. At that point, he was only alive because the machine was breathing for him. They didn’t know how much he had taken, only that it was some combination of a deadly mix. His friend repeated over and over, “He was trying to stop the voices. I tried to stop him.”

Thankfully he made it through. After three days in the hospital, he was sent to a “stabilization unit” to receive treatment. Three days later, they released him to his father to took him back to Seattle to get the help he needed. But that help never came. Instead he stayed in a small apartment with his stepmom, smoking weed and snorting coke with shots of vodka. After two weeks, she put him on a plane back home because she didn’t want to be bothered.

I immediately made an appointment with a psychiatrist, who diagnosed him with bipolar 1 disorder and social anxiety. He told the doctor he heard voices and used drugs to quiet them. I asked if the doctor thought this could be addiction as well but was told no.

I struggled to keep him on his medications and encouraged him to find gainful employment in order to be able to care for himself, but he said he felt “better” and stopped taking the meds. After two more inpatient stays that lasted 2-3 days, he was released with a new group of medications that were very expensive. My struggle to keep him on these meds never stopped.

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One night I heard a noise and instinctively went into his room, where I found him hanging in his closet by a belt. I cut him down to find he was still breathing. I had got to him in time, but he was combative. I had to hold him down until help arrived. This led to another inpatient stay, one that lasted 11 days. There was no follow-up care provided, though he was prescribed several more medications that would continue to empty my checking account.

Life Changes

My relationship with my mate ended abruptly because they thought I should do things differently. But frankly, I knew nothing of what I should do. I had no clue of how to fix this situation or keep it from compromising my life. I went on, because I had to, but my lonely path became even lonelier. I was afraid to leave my house other than to go to work. I was afraid to pursue a relationship. I had deemed life with myself as a solo player to be my only option because I had no idea what to do. All I wanted to do was save my son.

Over the next two years, my son would make numerous visits to stabilization units. These always resulted in the same outcome: a month or so of him being stable, then he would go off his medications. I begged for help, from the doctors, from his psychiatrist, from anyone who might be able to help my son.

But no one was able to help.

I spent those two years waking to every sound, feeling like a prisoner in my own home. I worried he would harm me if I didn’t give him money. I was robbed multiple times, and although I called the police and told them the crime was committed by my son, nothing ever came of it. He continued to steal from me, and he would not leave. If he did, he came back when I was gone to steal whatever else he could find, but still, the police did nothing.

My health was affected significantly. I was exhausted, experienced trouble with my bowels, and lost weight and sleep while I tried to maintain my career. I missed work through my efforts to help my son and lost relationships as I struggled to cope with the challenges my son was facing.

I had no one to help me through this dark, lonely world. I watched in fear, with a tortured soul, as my son self -destructed before me. I locked myself in my bedroom, after hiding sharp objects so he couldn’t get to them. My attempts to kick him out failed because he was on my lease and I was too embarrassed to approach my landlord to have him removed. The police would not help me, and professionals shamed me for wanting to walk away, telling me he needed family support. I was losing myself, taking medication to help me stay even.

Trying to Move Forward

The final straw came when a drug dealer showed up at my door threatening to kill my son and his family if he didn’t pay up. I chose to move an hour away, still close enough to commute to work, but far enough away to feel safe from this nightmare. Leaving my son homeless was all I could do at that point, in order to save myself. I pushed on trying to find myself again, though I was full of guilt.

He moved in with his sister, who was experiencing addiction to painkillers after years of kidney disease. Soon enough another call came. She had called the police, knowing he had an outstanding warrant, and he went to jail the night before Thanksgiving. I felt relieved knowing he was safe there, but pained nonetheless. I stand alone trying to fight, not just for him but for myself. I ask myself, what kind of mother turns her back on her children?

He got out of jail right before Christmas with a promise to go to Narcotics Anonymous and a sober living house, but I knew it would never happen. Then another call came. My sweet boy, who would give anyone the shirt off his back, who loved his Momma and said he wanted to get better, couldn’t keep a job and was in and out of his sister’s house. What’s more, he had decided he had no choice but to do drugs. He robbed a convenience store and was charged with robbery in the first degree, a felony offense.

My heart broke at the news. Guilt filled me, and I couldn’t breathe. I didn’t think he would survive prison. He wasn’t “tough,” he was a skinny boy who would hurt no one. He would die there, or at least his spirit would .

The judge ordered rehab at a place about an hour away. A place that, if I wanted street drugs I could walk in and get whatever I wanted from the residents, who were supposed to be in a rehab program. The people running the place could care less if these residents succeeded. They didn’t offer meetings to attend, just a pool table and a TV. After 30 days, residents could go to a doctor to get medications, but before that, they were on their own. So, my son, who received no medications for his bipolar or anxiety, surrounded by people trading their psych meds for caps and other things, relapsed. He ended up back in jail after testing positive for Seroquel, and was given another 30 days, after which he would return to rehab.

Continuing the Fight

Meanwhile my health is poor, and my relationships with others are compromised because I can’t cope. I went to see a psychiatrist to try to develop better coping methods, so I could help my son without compromising myself. She told me he was grown and told me I needed to cut him off. She went on to try to dissect my brain, but I received no support on how to cope with and support an adult child with addiction and mental health conditions.

I stand alone trying to fight, not just for him but for myself. I ask myself, what kind of mother turns her back on her children? Meanwhile, I continue to struggle with a daughter who is addicted to painkillers and is going to lose a battle with kidney disease. I tried to separate myself but my concerns for my grandchildren keep me from cutting the ties—she has two small children and a third on the way. I lie awake at night, fearing the call telling me she has passed on. All I know to do is to cut her off and pray for the best, but the thought of doing so paralyzes me with fear for my grandchildren.

My inability to cope consumes me. It affects my ability to live freely, to have a relationship without it being compromised. I do a lot of self-blaming. I ask myself, how did two of my three children end up battling addiction and mental health concerns? I was an attentive parent. They saw me work, attend college, and take care of them. How does this happen? How do I avoid not being consumed with sadness? How do I reduce the effects of my guilt and keep from self-destructing myself?  How can I have a normal life, when my soul is so tortured?

This is a lonely place to be. I have no resources and no support. No other parent is involved, and my only family is an older sister who has young children.

Today, I am facing the destruction of another relationship. I blame myself and can’t cope, and these feelings turn to self-bashing, withdrawing into isolation, and another loss. It can consume me, although I have made huge steps in the last few months. But these aren’t enough to save me from more losses, more sadness, and more darkness that may be what ultimately takes my life. I am afraid the stress will kill me. I have been sick for months and have lost nearly 50 pounds. But I don’t know what else to do.

What can you do, when you have tried everything? I have sought out counseling only to be slapped in the face with, “Cut the ties. They are adults.” From other sources, I hear family support is the key to success for those experiencing addiction and mental illness.

So, what to do? Though I have no help or support, I know I am not alone in this place. I chose to share my story to both try and seek help, and to help others who feel as I do know that they are not alone in their pain, either.

Woman looking out windowThere is a paradox when it comes to bipolar mood episodes in terms of the treatment versus the prevention of episodes. On the one hand, the treatment of mood episodes can be rigorous, prolonged, and unsatisfying for people with bipolar and those around them. However, there are things people with bipolar can do to empower themselves in managing and, in some cases, staving off mood episodes.

Here is a focused outline on three self-guided components for living with bipolar: sleep, self-care, and support.

1. Train Yourself to Sleep

Your body responds to natural circadian rhythms. Based on a 24-hour cycle, a person’s physical and mental processes (e.g., mood) are affected by the changes of light and darkness. Setting the same wake and sleep schedule can dramatically improve your mood. Try to go to bed around the same time each night (even weekends) and get up around the same time in the morning. To do this, utilize these sleep hygiene tips.

Establish a routine to wind down in the evening. Pay attention to what time it is, so there is room to slowly navigate the dental routine, preparing for tomorrow’s workday, and the contact lens storage process. Avoid projects and other mentally taxing activities. Instead, read a novel, take a shower, or do some light stretching in the evening. Using alcohol, nicotine, or other drugs can disrupt nighttime habits, which consequently leads to increased stress and less capacity to manage it. Finish eating at least two to three hours before you go to bed, and abstain from caffeinated beverages in the evening. It takes approximately six hours for caffeine to leave the body, so a reasonable rule would be switching to decaf by 4 or 5 p.m.

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When you are ready to hit the sack, use your bed for two things: sleep and sex. This means not binging on Netflix or writing a dissertation from the confines of the bed. Train the body to know that when you are getting into and lying in bed, it is time to fall asleep. You do not want to be alert in front of a screen or stimulated by a task you are doing while in bed. Consistent, alert activity in bed teaches us to be awake; when we do want to go to bed, the brain is confused as to whether dreamland is approaching or to perk up for Breaking Bad.

Similarly, do not submit to long periods of insomnia (no more than 10 or 15 minutes at a time). Although seemingly counterintuitive, this goes back to the idea of training the body. After 10 to 15 minutes of not being able to fall asleep, do not continue counting sheep; go to another room and get a glass of water, read a brief article or part of a book, and wait until you are a little sleepy before returning to bed. This reminds the body that the bed is for sleeping. Life can get in the way, but aim for seven to eight hours of sleep per night.

2. Practice Regular Self-Care

Recent research shows that exercise is at least as effective for relieving depression as antidepressant medication. It also comes with a lot of less intrusive side effects (i.e., feeling relaxed, improved sleep and energy levels). Exercise regularly and make sure to finish a few hours before bedtime. Our bodies did not evolve to sit in office chairs for 12 hours per day, so getting your heart rate up or simply going for a long walk is a great stress release.

The more one understands about contributing factors to bipolar episodes, the more empowered he or she is to take preventative actions. You can develop a lifestyle management routine around your specific needs for mental health.

In addition, the mind, which regulates the flow of energy in our bodies, needs time to regenerate without stimulation. Develop a mindfulness practice or other type of spiritual process that you really value as necessary for mental well-being.

Prayer or meditation is best practiced in the morning after waking up. This establishes an intention for mindfully approaching daily life. Sit in silence while paying attention to your breathing for 20 to 30 minutes (start in smaller increments). Mindfulness group practices and classes are ever more ubiquitous and offer instruction to guide your work. Practicing these techniques within a community can be especially powerful. Contemplative activities are not rooted in gaining or self-improvement, which drive our identification with productivity. It is a commitment to sustaining a healthy lifestyle for the betterment of your relationships with others. Being curious and actively aware of the present will elicit awareness to subtle symptoms while decreasing impulsive behaviors.

A simple tracking sheet for mood and anxiety levels as well as self-care initiatives is a constructive way of monitoring behavioral and mental changes. Use a spreadsheet and leave it next to the bed or, if applicable, next to your daily supplements and/or medication box. Quickly note on a scale from 1 to 10 (1 being depressed and 10 equaling manic symptoms) what your mood was for the previous day. You can do this for anxiety levels as well. Also, note whether you exercised or practiced other self-care (yoga, meditation, etc.) and any significant events (interpersonal issues, medication changes, etc.) that took place. Over time, you will have a noteworthy amount of data to compare the actions you have been taking with changes in your routines, moods, and levels of stress. Utilize the correlations you find and make predictions about what you need to do—or not do—in order to stay on top of emerging problems.

The more one understands about contributing factors to bipolar episodes, the more empowered he or she is to take preventative actions. You can develop a lifestyle management routine around your specific needs for mental health. This includes clues to early warning signs and possible factors you have identified that get you into psychological trouble.

3. Lean on Others for Support

The effects of bipolar rarely occur within a vacuum. When a person tries to manage it alone, it can consume the person. Like any stressor or bothersome life event, the symptoms of bipolar pull on relationships. This becomes a systems issue that requires the support of others. Wright et al. (2009) state that “family members and friends are generally good observers and may be able to recognize the subtle changes in behavior, emotions, and thought processes that signal the onset of mania.”

Having individuals in your life who are aware of your historical battles raises the likelihood that mood changes will be identified before complete manifestation. Talk to people who are close to you when you have medication or drug-use changes, feelings of depression, or energy changes, and allow space for them to discuss your routines or behaviors. Appreciate their information and knowledge while assuming they love and want the best for you. Transparency will alleviate the concerns of others and lessen the burden you feel for managing the prevention of mood episodes.

It is essential to develop close relationships with your health providers so they have a longitudinal vista into your mental health. If you wanted to see how your face aged over time, you could take a selfie on a daily or weekly basis and run the images through a video program. Similarly, regular meetings with a psychotherapist will foster insight, but also enable the psychotherapist to notice subtle changes in your mental health presentation. A psychotherapist typically takes a “snapshot” of you each week—or two—and, akin to a series of selfies, compares and contrasts the “images.” This clinical timeline is examined with you in order to make correlations and inferences about mood episodes as well as behavioral changes. A disciplined regimen of psychotherapy is necessary to understand our habitual processes. You become aware of the holes you continuously fall into despite seeing warning signs.

If you can regulate your sleep, monitor internal changes, and stay physically active—while also training your mind—you and your therapist might not have much to talk about.

References:

  1. Archer, A.J. (2013). Pleading Insanity. Bloomington, IN: Archway Publishing.
  2. American Psychiatric Association. (2013). Diagnostic & Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
  3. Kirsch, I. (2010). The Emperor’s New Drugs: Exploding the Antidepressant Myth. New York: Basic Books.
  4. Kirsch, I., Deacon, B.J., Huedo-Medina, T.B., Scoboria, A., Moore, T.J., & Johnson, B.T. (2008). Initial severity and antidepressant benefits: a meta-analysis of data submitted to the food and drug administration. Public Library of Science Medicine 5 (2): 260-268.
  5. Miklowitz, D.J. (2014). Bipolar Disorder. In: D.H. Barlow (ed.) Clinical Handbook of Psychological Disorders: A Step-by-Step Treatment Manual. (5th ed.). New York: The Guildford Press. 462-501.
  6. Murray-Swank, A., & Dixon, L. (2005). Evidence-Based Practices for Families of Individuals with Severe Mental Illness. In: R.E. Drake, M.R. Merrens, & D.W. Lynde (eds.). Evidence Based Mental Health Practice. A Textbook. New York: W. W. Norton & Co., pp. 425-452.
  7. National Institute of General medical sciences: basic discoveries for better health. Circadian Rhythms Fact Sheet. Content reviewed November 2012. Retrieved from: http://www.nigms.nih.gov/Education/Pages/Factsheet_CircadianRhythms.aspx
  8. Siegel, D.J. (2010). The Mindful Therapist: A Clinician’s Guide to Mindsight and Neural Integration. New York: WW Norton & Company.
  9. Wright, J.H., Turkington, D., Kingdon, D.G. & Basco, M.R. (2009). Ch. 8 Mania. In: Cognitive-Behavior Therapy for Severe Mental Illness. An Illustrated Guide. Washington, D.C.: American Psychiatric Publishing, Inc. pp. 181-209.

holding paper x over mouthAccording to the U.S. Department of Health and Human Services, as many as one in five Americans will experience a mental health issue at some point in their lives. Of the nearly 60 million Americans who experience mental health concerns each year, many will never seek treatment for a variety of reasons including social stigma, cultural norms, and lack of access. In fact, a recent report published in the journal Psychological Science and the Public Interest found that an estimated 40% of individuals with serious mental health concerns either never receive care or start an intervention program without completing it.

The stigma surrounding mental health issues can be a significant barrier to care. Unfortunately, many people unknowingly contribute to the stigma simply with their everyday language choices. A poor choice of words not only stigmatizes, stereotypes, and creates unrealistic assumptions about certain people, but also can trivialize serious mental health conditions and their accompanying experiences.

While society tends to tread lightly around language concerning disabilities, race, or religion, it seems that we do not apply the same sensitivity to language involving mental health. For example, while you might be a little taken aback by someone who uses the word “retarded” to refer to a poor decision, you likely wouldn’t think twice about someone calling a peculiar behavior “crazy” or saying out loud that someone’s “OCD” is the cause for an orderly office.

Help Us Erode Stigma during Mental Health Awareness Month

With May designated as Mental Health Awareness Month in the United States, we would like to encourage you to think twice about the language you use and how it may affect those one in five people who may be your neighbors, coworkers, and friends who experience mental health issues.[fat_widget_right]

Show respect and consideration for those experiencing mental health conditions by avoiding these common stigmatizing phrases we hear in our daily conversations:

‘I’m So OCD.’

All too often people say “I’m so OCD” when referring to simple habits they may have regarding organization, such as arranging books a certain way on a bookshelf or keeping one’s own environment immaculately clean. True obsessions and compulsions can be quite debilitating, involving persistent, unwanted thoughts, rituals, and behaviors, all of which are out of a person’s control.

As many as 27% of people experience some form of obsessive-compulsive behavior. By using the term to describe tidiness, we popularize the experience and make it appear less severe than it actually can be. Next time you find yourself tempted to say someone else is being OCD or claim it as an explanation for your own behavior, consider how you might more accurately share your observation or insight.

‘I Can’t Focus; It’s My ADD.’

It’s not uncommon to hear people refer to themselves as ADHD or ADD when they are inattentive or easily distracted. Today’s high-tech world seems to be characterized by ever-shrinking attention spans, and it seems that people are always fiddling with their smart phones and jumping from one topic to another. However, this is not the same thing as attention-deficit hyperactivity.

Though these types of behaviors may be related to a lack of focus, an actual diagnosis of ADHD is far more complex.

People might casually refer to distracted behavior as ADHD or even go as far as to say that they’re ADHD when channel surfing or changing the radio station before a song finishes. Though these types of behaviors may be related to a lack of focus, an actual diagnosis of ADHD is far more complex and has less to do with boredom and more to do with genetics, neurotransmitters, and electrical activity in the brain. In fact, a major distinguishing characteristic of ADHD is impulsivity, which probably isn’t present in most cases where people erroneously claim ADHD as the source of their inattention.

‘My Ex Is Such a Psycho.’

At some point, you’ve probably heard someone refer to a past lover (or friend, or roommate) as a psycho. People typically use this phrase to refer to someone engaging in erratic or irrational behavior, which in reality is far from psychotic.

Psychosis is a serious mental health condition by which a person loses contact with reality and may experience hallucinations and delusions. An estimated 3% of people experience psychosis, which makes it far less prevalent than the many people who claim to have psychotic past lovers might indicate. Try not to downplay the seriousness of this condition by using the term frivolously.

‘The Weather Is So Bipolar Today.’

Sure, it may snow in the morning, warm up for an hour, and then snow again all afternoon, but it is impossible for the weather to literally be bipolar. Likewise, it’s highly unlikely that your friend having a few ups and downs today is actually experiencing the often debilitating symptoms of bipolar. Using the term bipolar in these contexts misrepresents the experience and can minimize the condition.

A person experiencing bipolar is likely to experience serious shifts in mood that may range from dangerously euphoric to suicidal. These drastic changes can seriously hinder one’s life if left untreated. Instead of using the term bipolar, consider describing the weather as unstable or unpredictable, and referring to your friend as being in a bad mood or having a hard time.

‘This Makes Me Want to Kill Myself.’

You fail your math exam and you exclaim in frustration, “I just want to die.” Or something else mildly unfortunate happens and you casually say, “This makes me want to kill myself.”

According to the Centers for Disease Control and Prevention, suicide is the 10th leading cause of death in the United States with almost 40,000 Americans dying from suicide each year. People who commit or attempt suicide do not necessarily want to die; rather, they may want to be free of pain.

If you find yourself upset with your circumstances and wanting to express your frustrations, be mindful of your word choice in this matter. It’s very likely someone in your vicinity has been touched by suicide in some way.

‘Stop Being So Paranoid.’

Paranoia is a symptom of many mental health conditions and can be detrimental to a person’s life. True paranoia can cause people to have serious trust issues and unwarranted fear and anxiety, as well as feelings of persecution and exaggerated self-importance.

When you find a friend may be worrying too much or over-analyzing something, avoid using the term paranoid and replace it with other descriptive words such as mistrusting or fearful.

‘I’m So Addicted.’

You might find yourself saying something like, “I’m so addicted to this TV show” to mean that you really enjoy it. But most likely, you are not truly addicted to it. Addiction is a serious mental health issue that can destroy lives, both of the person addicted and that person’s loved ones.

There’s a considerable difference between appreciating or enjoying something and being addicted to it. Be mindful of this distinction when you speak.

Although more than 23 million Americans experience some form of substance abuse, up to 40 million additional Americans are indirectly affected by it. These numbers do not account for non-substance addictions such as gambling, spending, or sex addiction.

There’s a considerable difference between appreciating or enjoying something and being addicted to it. A person experiencing addiction may want to stop engaging in an addictive behavior, but may feel unable to do so regardless of its continued negative consequences. Be mindful of this distinction when you speak, so as not to disparage the serious problems addiction can cause.

‘That’s Crazy/Insane/Mad/Nuts.’

It’s becoming far too common to use the word crazy and related synonyms lightly. People may think that using these terms to describe behavior that seems odd, eccentric, or strange is harmless, but it can be damaging to the self-esteem of those experiencing real mental health conditions.

The stigma alone is enough to make people feel isolated, keep them from seeking the treatment they truly need, or cause them to completely deny their symptoms altogether. But these terms, often used in a manner that belittles those who actually experience mental health issues, reinforce the dangerous stigma of mental health issues by painting them in a derogatory way.

Words Have Power; Think Before You Speak

Avoiding stigmatizing terms and phrases that cause shame, minimize experiences, and misrepresent reality can help eliminate a major obstacle to treatment. It’s not simply about being politically correct, requiring that you tiptoe around your words; the point is to simply stop and think about what you say and be mindful of how your choice of words may affect others.

If you would like to learn more about how you can raise awareness of mental health conditions and help remove stigma, check out our blog this month or visit Mental Health America for more information and resources about Mental Health Awareness Month.

References:

  1. Corrigan, Patrick. (September 4, 2014). Stigma as a Barrier to Mental Health Care. Association for Psychological Science. Retrieved from: http://www.psychologicalscience.org/index.php/news/releases/stigma-as-a-barrier-to-mental-health-carhtml
  2. Mental Health America. May is Mental Health Month. Retrieved from: http://www.mentalhealthamerica.net/may
  3. Mental Health America. Mental Health Information. Retrieved from: http://www.mentalhealthamerica.net/mental-health-information
  4. Schumaker, Erin. (April 17, 2015). It’s Time To Stop Using These Phrases When It Comes to Mental Illness. The Huffington Post. Retrieved from: http://www.huffingtonpost.com/2015/04/17/mental-illness-vocabulary_n_7078984.html

For those dwelling in climates prone to the dark, chilly days of fall and winter, it is widely understood that along with changes in the natural world, seasonal shifts in mood and temperament are also likely to occur. These shifts may be more drastic and debilitating for some than for others, and when seasonally induced woes weigh too heavily on a person, he or she may be diagnosed with conditions like depression or seasonal affective disorder (SAD). While such diagnoses have become quite common, people are just recognizing consensus among researchers that a person’s season of birth appears to increase the chances that a person will develop these or other mental health conditions.

Typically, a person’s birthdate is given astrological significance in the form of a zodiac sign, but not necessarily predictive powers when it comes to psychological well-being. There was a time not so long ago when the study of astrology was considered to be of scholarly and scientific value in treating physical maladies, but few modern-day doctors still refer to the celestial bodies when determining diagnoses and treatment conditions (Wolfson, 2013). However, a connection between season of birth and certain mental health conditions has been observed by a number of researchers in recent years. The primary finding of this vein of research is that being born in the fall, winter, and spring increases the chances of mental and emotional instability.

The most widely researched correlation is the heightened likelihood of developing schizophrenia if a person is born in the darker, colder months of the year—winter, primarily. Over 200 studies have confirmed this correlation since 1929 (Wolfson, 2013), including one study which revealed that being born in the Northern Hemisphere in either winter or spring may increase the tendency toward schizophrenic symptoms (Davies, Welham, Chant, Fuller Torrey, and McGrath, 2003).

In this particular study, researchers compared winter/spring versus summer/autumn births using data from eight preexisting studies of 126,196 people who had been diagnosed with schizophrenia and 86,605,807 “general population births.” The subjects were located in 27 sites across the Northern Hemisphere, and the positive correlation between schizophrenia and winter/springtime birth as well as latitude-based weather conditions was reported as “small but significant” (Davies et al., 2003).

Further studies reveal that a similar connection exists between season of birth and SAD. Pjrek et al. (2004) discovered a notable link with being born in the fall and winter and experiencing “melancholic depression” during those times of year as an adult. This finding inspired additional research that explored and confirmed the apparent correlation of SAD and season of birth (Pjrek et al., 2007).

Yet another study conducted in England examined the correlation between season of birth and schizophrenia, bipolar, and recurrent depression in “the largest cohort of English patients collected to date” (Disanto et al., 2012). Once again, they found that those born during darker days and colder temperatures were more likely to develop these conditions later in life. Specifically, cases of schizophrenia and bipolar were found to be at their peak in those born in January, and at their lowest rate of occurrence in July, August, and September births. A slight deviation from the fall-winter-early spring correlation was their discovery that those born in May appeared to be particularly susceptible to recurrent episodes of depression.

Overall, the message seems to be that a large portion of the population is primed to experience what are commonly known as mood disorders from birth; ultimately, the only ones who are not at a high inborn risk of developing these conditions are those whose birthdays are in the sunshine-rich summer months. This has led some researchers in England to theorize that vitamin D deficiency—whether in the biological mother or in the child after birth—factors in to these findings (Disanto et al., 2012). So the explanation for this phenomenon could be as simple as less exposure to sunlight depriving a person of sunnier brain chemistry from birth. These same researchers also posit that environmental exposure to viral or bacterial strains on the part of the mother during these times of year may play a part in their children’s psychological development.

Another widely held theory, shared by neuroscientist Chris Ciarleglio in a recent article published in The Atlantic, suggests that “developing in a certain season seems to imprint your circadian clock,” which is known to have a strong influence on mental and emotional well-being (Wolfson, 2013; Foster and Roenneberg, 2008).

Of course, it remains to be fully understood how much of our mood-related makeup and behavior is hardwired at birth, and how much of it is determined by outside factors like family, childhood experiences, education, and financial lack or privilege. Regardless, the findings of these studies spark intriguing inquiries regarding what, exactly, it means to experience depression, schizophrenic hallucinations, and swings in emotional state characteristic of bipolar—plus how much can or should be done to prevent these conditions if they are, in fact, imprinted at birth.

References:

  1. Davies, G., Welham, J., Chant, D., Fuller Torrey, E., and McGrath, J. (2003). A systematic review and meta-analysis of Northern Hemisphere season of birth studies in schizophrenia. Schizophrenia Bulletin, 29(3), 587-593. Retrieved from  http://schizophreniabulletin.oxfordjournals.org/content/29/3/587.full.pdf
  2. Disanto, G., Morahan, J. M., Lacey, M. V., DeLuca, G. C., Giovannoni, G., Ebers, G. C., Ramagopalan, S. V. (2012, April 4). Seasonal distribution of psychiatric births in England. PLOS One. doi: 10.1371/journal.pone.0034866. Retrieved from http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0034866
  3. Foster, R. G., and Roenneberg, T. (2008, September 9). Human responses to the geophysical daily, annual, and lunar cycles. Current Biology, 18(17), R784-R794. doi: 10.1016/j.cub.2008.07.003. Abstract retrieved from http://www.ncbi.nlm.nih.gov/pubmed/18786384
  4. Pjrek, E., Winkler, D., Praschak-Rieder, N., Willeit, M., Stastny, J., Konstantinidis, A., and Kasper, S. (2004, October). Seasonality of birth in seasonal affective disorder. Journal of Clinical Psychiatry, 65(10), 1389-1393. Abstract retrieved from http://www.ncbi.nlm.nih.gov/pubmed/15491243
  5. Pjrek, E., Winkler, D., Praschak-Rieder, N., Willeit, M., Stastny, J., Konstantinidis, A., and Kasper, S. (2007, October). Season of birth in siblings of patients with seasonal affective disorder. A test of the parental conception habits hypothesis. European Archives of Psychiatry and Clinical Neuroscience, 257(7), 358-382. Abstract retrieved from http://www.ncbi.nlm.nih.gov/pubmed/17902009
  6. Wolfson, E. (2013, November 15). Your zodiac sign, your health. The Atlantic. Retrieved from http://www.theatlantic.com/health/archive/2013/11/your-zodiac-sign-your-health/281358/

Negative self-views and self-appraisals are commonly associated with depressive symptoms. Individuals with major depression, as well as those with depression related to bipolar, often experience low self-esteem, feelings of worthlessness, and overall negative self-concept while in their depressive states. In contrast to these feelings, high levels of self-esteem, goal attainment, and motivation are often evident preceding or during manic episodes.

But according to the results of a new study led by Hana Pavlickova of the School of Psychology at the University of Wales Bangor, negative self-beliefs can also predict manic episodes in people with bipolar. Pavlickova theorized that the comorbidity of both positive and negative affect might exist during periods of no symptoms and also during periods when symptoms were present. Understanding how this overlap affects each mood state could help determine when manic or depressive episodes might occur and also could provide opportunities for intervention prior to those episodes.

For her study, Pavlickova evaluated 253 participants with bipolar several times over the course of 18 months. She looked at depressive and manic symptoms and how self-esteem, self-appraisals, internalization, externalization, and other behaviors influenced the symptoms.

The results revealed that self-esteem was most strongly associated with both mood states. In particular, low self-esteem was linked to depression and high self-esteem to mania. However, negative self-esteem, although highly predictive of depressive symptoms, also indirectly predicted manic episodes. Pavlickova discovered that although cross-sectional data indicated a direct association between negative self-esteem and depression, longitudinally, negative self-esteem was weakly but clearly associated with mania.

She explains this finding by suggesting that individuals with bipolar may overcompensate for feelings of negative self-worth by actively avoiding any depressive emotions and engaging in high levels of externalizing, which could provoke manic behaviors and symptoms. These results are novel in that they demonstrate the overlapping relationship of negative self-evaluations in bipolar. Pavlickova added, “In terms of clinical implications, the findings accentuate the importance of the therapeutic management of negative self-concept shared by both depression and mania in bipolar disorder.”

Reference:
Pavlickova, H., et al. (2013). Symptom-specific self-referential cognitive processes in bipolar disorder: A longitudinal analysis. Psychological Medicine 43.9 (2013): 1895-907. ProQuest. Web.

When a psychiatric client is in remission, it usually means that he or she is no longer experiencing clinical levels of symptoms related to the original issue. For instance, people with depression may be classified as being in remission when they have more periods of positive affect than negative affect, when they do not ruminate and when their eating and sleeping patterns return to normal. However, according to a recent study led by Rico S. C. Lee of the Clinical Research Unit of the Brain and Mind Research Institute at the University of Sydney in Australia, individuals who meet clinical thresholds of remission may not simultaneously achieve cognitive levels of remission.

Research in the area of cognitive remission is scant. Some studies show that cognitive deficits rebound at the same time symptoms decrease, while others reveal that clients who are in remission from symptoms still report feeling impaired in specific areas of their lives. To determine if cognitive deficits persisted in the absence of clinical symptoms, Lee assessed the cognitive capacities of 93 young adults with psychosis, depression, or bipolar at baseline and approximately two years later. The results revealed a direct relationship between cognitive and functioning and later impairment. In this study, the participants who had stronger cognitive abilities at baseline had higher rates of employment, better qualities of life, fewer disabilities, and more satisfaction in relationships than those who had cognitive impairments.

Visuospatial, working, and verbal memory, along with the ability to switch attention at baseline, were all predictive of better global functioning two years later. Lee noted that cognitive functioning at baseline did not predict symptomology at baseline or later on, and baseline symptoms did not predict later symptom severity or cognitive functioning. This suggests that clinical symptoms and cognitive functioning affect the course of these illness in unique and independent ways. Lee added, “Taken together, these results strongly suggest that a traditional, or sole, focus on symptom factors is inadequate in characterizing prognosis and recovery.”

Reference:
Lee, R.S.C., Hermens, D.F., Redoblado-Hodge, M.A., Naismith, S.L., Porter, M.A., et al. (2013). Neuropsychological and socio-occupational functioning in young psychiatric outpatients: A longitudinal investigation. PLoS ONE 8(3): e58176. doi:10.1371/journal.pone.0058176

Woman looking out train window

Dialectical behavior therapy (DBT) is a comprehensive, evidence-based treatment approach used to treat individuals with a wide variety of issues, including relationship conflict, anxiety, depression, bipolar, self-injury, eating issues, and substance abuse. Developed in the 1980s by psychologist Marsha M. Linehan for the treatment of borderline personality disorder and chronic suicidality, this method has since been adapted and utilized to help clients with much less severe issues. The therapy can help clients who exhibit extreme emotional reactions, helping them develop self-acceptance while also learning coping skills to better regulate their emotions and handle distress. DBT uses both individual therapy sessions and group skills training, as well as telephone coaching between sessions.

The DBT model combines a behavioral therapy approach with eastern mindfulness practices. In one sense, the term dialectical refers to the goal of synthesizing the extreme opposites inherent in the rigid “black and white” thinking of many clients who have trouble regulating their emotions. “Dialectical” also applies to the core DBT principle of practicing acceptance strategies while implementing change strategies, in the process of reducing and modifying self-destructive behaviors.

This type of therapy is very support-oriented; it helps clients identify their strengths, build new skills, and increase their self-esteem. DBT focuses on cognitive issues by indentifying destructive thought patterns and replacing them with more neutral and accepting internal dialogues. It is designed to be a nonjudgmental collaboration, with the therapist and client working together to increase emotional awareness and understanding, minimize negative thought patterns and behaviors, and develop new coping and problem-solving skills.

The four modules of dialectical behavior therapy:

In the case of adolescent treatment, Dr. Alec Miller has adapted Dr. Linehan’s model to incorporate parents attending skills training groups with their teens. There is an additional module, “walking the middle path,” which focuses on helping parents and their children understand each other’s viewpoints and reduce conflict and invalidation.

The five functions:

Dialectical behavioral therapy was designed to fulfill five primary functions:

Stages of treatment:

The course of DBT generally flows through three stages:

Who can benefit:

Though DBT originally was developed to treat more severe issues, such as borderline personality disorder, suicidal behaviors, and self-harm, the treatment has become a widely respected method for treating clients who exhibit the following, much milder traits and issues:

Dialectical behavior therapy has proven to be a very effective tool to help people manage intense emotions, change negative thought patterns, and decrease self-destructive behaviors. Individual therapy sessions focus on current detrimental behaviors in the client’s life, while group sessions involve learning skills from the four modules: mindfulness, interpersonal effectiveness, distress tolerance, and emotion regulation.

Important Notice

GoodTherapy is not intended to be a substitute for professional advice, diagnosis, medical treatment, or therapy. Always seek the advice of your physician or qualified mental health provider with any questions you may have regarding any mental health symptom or medical condition. Never disregard professional psychological or medical advice nor delay in seeking professional advice or treatment because of something you have read on GoodTherapy.