There is a new effort to promote complete remission as the goal of treatment for people with bipolar in disorder and I am fundamentaly opposed to it. I have written about the topic many times, so I will repost the article that had the most discussion:
I wrote an article some time ago that I deviously titled “Why I Am Against Bipolar Meds” because I wanted to attract and call out both extremes in the debate. I argued for a moderate stance and we had a good discussion with all points of view respectfully considered.
My friend Dr. Nassir Ghaemi wrote an article recently in response and clarified some important points. Dr Ghaemi is the Director of the Mood Disorders Program at Tufts Medical Center in Boston and is familiar with my work; he quoted some of it in his recent book, “A First-Rate Madness: Uncovering the Links Between Leadership and Mental Illness.” The discussion from his article went further into the med controversy, but also veered into new territory that I would like to address: My opposition to remission as the end goal of treatment.
One particular reply from Dr. Ghaemi gets to the crux of my issue; “In a substantial minority of people with bipolar disorder, about one-third, lithium produces complete remission of all symptoms. They never have another bipolar episode, and sometimes symptom, the rest of their lives. My point is, though, that even with full remission of all symptoms, people often need to make other efforts to get to functional recovery in life, repairing relationships and resuming work or other activities that they had not been able to complete in the past due to the interference of bipolar symptoms.”
As I am familiar with his work, I understand the point of view, but am concerned that some might misinterpret this to mean something different from what I believe he intends. Such a view is certainly not compatible with the premise of “A First Rate Madness,” so I am pretty sure Dr. Ghaemi does not mean what it may sound like to some. I am hoping this article will help clarify it …
Bipolar in disorder combined with anger is a very dangerous mix. The disordered person tends to become very volatile and can explode into a rage with little provocation. It is best for the person to avoid anything that might trigger anger until the disorder is in remission, but even then an angering stimulus can trigger another manic or depressive episode with anger as one of the troubling elements.
Bipolar people who have their condition in order have learned important lessons that can be applied to most of our experiences. For example, since we understand bipolar so well that we can function highly during depression and mania, we can also handle more intense states of anger without losing control.
As with every experience, most people can usually function fine when anger is at a very low intensity, but when the intensity of anger increases beyond their comfort zone they begin to lose the ability to choose their response to it. They act in ways that are less than optimal. They may even become a danger to themselves and others if the anger becomes too intense.
Individuals and organizations throughout the world are dedicated to the important work of removing the stigma that affects people with depression and bipolar disorder. Unfortunately, too many of them are replacing one type of stigma with another type that is making the situation worse. While advocating for others to stop judging those who suffer from the conditions, they are causing a self-stigma that increases and prolongs the suffering.
My friend Andy Behrman says, “If we want to eradicate stigma, we must first understand what stigma is: ignorance, fear & discrimination.” Of the hundreds of statements about stigma, this one captures it the best for me. Everything else is an offshoot of these three core problems.
There is certainly an incredible amount of ignorance surrounding depression and bipolar disorder. Even if we were able to clear up the many misperceptions about either condition, there is so much more we need to know to fully understand them. Depression and bipolar disorder affect every part of our lives (physical, mental, emotional, spiritual, social, and career/financial) and most people are aware of only a fraction of any of the parts.
We can be afraid of many things, but the worst fear is of the things we are ignorant of. The combination of fear and ignorance is so powerful that many people think fear is just another word for ignorance. They even have an acronym for it: FEAR – False Evidence Appearing Real. But when we understand fear and the role it plays in our condition, we can use it as a tool instead of letting it destroy us.
When most people talk about stigma, they are mostly concerned with discrimination and the role that ignorance and fear play in creating it. Discrimination holds us back from accomplishing what we are capable of because it robs us of opportunities that are available to others. We end up with a diminished life that is far below what should have been.
I learned about stigma soon after my first diagnosis with bipolar disorder. I began going to support groups to try to learn as much as I could about the condition and was told that I needed …
The part of our minds that most people identify with is the part that silently talks to us with a running commentary. We listen to it all day long. Let’s call it “The Talker.”
“The Talker” prefers pleasure over pain, happiness over sadness, winning over losing, health over sickness, and any of the other judgments that help us navigate our lives. Although it plays a critical role that we cannot live without, “The Talker” is stuck in the duality that makes us judge one thing better than another. It does not allow us to experience the world without judgment.
The central principle of mindfulness is to look at experiences without judgment. Adherents of mindfulness often speak of the part that practices mindfulness as “The Watcher.” It lives outside of the duality and sees everything as equally valuable. Mindfulness is a wonderful practice that increases awareness of what is really happening because “The Watcher” does not ignore or accentuate details based on preferences.
Unfortunately, many claim that mindfulness leads to happiness. As happiness and sadness are judgments based on preferences, this breaks with the whole concept of looking at our experiences without judgment. Mindfulness practiced properly does not lead to happiness; it leads to a greater awareness of whatever you are experiencing whether you like it or not.
We get a lot of calls from parents who are looking for help with their bipolar children. We make great progress within the first few visits, but too often run into an underlying issue that needs to be addressed. While the bipolar issues are certainly part of the problem, the family dynamics are a bigger issue.
Since the child has usually been diagnosed before contacting us, the parents assume all conflicts will be resolved as soon as the child is no longer in disorder. All issues are seen as being caused by bipolar disorder and the rest of the family is completely innocent; it is as if the diagnosis suddenly made everyone else perfect.
This does not happen when the parents have been diagnosed with any psychological issues. The parents recognize their own issues that need to be addressed and how those issues play a role in the conflicts. Even if the diagnosis is completely different from bipolar disorder, there is a recognition that nobody is perfect and we all have room for improvement.
Some call it ‘state specific memory,’ but after ten years and thousands of interviews I prefer to call it ‘bi-cycling delusion.’ It is the delusion that comes with the bipolar cycles and a primary reason people remain in disorder even with the best intentions.
Bipolar is a cyclical condition. We cycle through depressions and manias, sometimes reaching intensities that cause a crisis for us. We also periodically cycle into remission. It might be easier if the cycles were predictable, but for many of us they are completely random.
For far too many of us, each cycle has a state-specific delusion that keeps us from moving toward Bipolar IN Order. We all know about delusions that come with intense states of depression and mania, but it is the delusion that comes with remission that holds many back the most. It fools them into thinking they have bipolar under control when in reality they are just in one of the cycles.
I attended a great presentation at the APA annual conference in San Francisco about Achievement, Innovation, and Leadership in the Affective Spectrum. Four distinguished panelists gave presentations about their research into why people with bipolar disorder tend to exhibit advantages in some parts of their lives. They said it was the first time ever that the APA had such a discussion and it was a great honor to be a part of it.
First up was Sheri Johnson, PhD, who teaches at UC Berkeley and does basic research on mania. Her talk was about how people with bipolar disorder are more reactive to rewards and goals in their lives. They tend to work harder toward such goals and refuse to give up long after “normal” people do. Dr. Johnson is currently conducting studies to understand the greater reactivity to success in this population, using paradigms drawn from neuroimaging, emotion, information-processing, and impulsivity literatures. She is also considering other psychological traits that might relate to outcomes in bipolar disorder, including stress reactivity, emotion regulation, and social dominance. She believes that figuring out why mania is linked to success will lead to better ways to predict manic episodes.
Please check out our newest video – Eight Essential Steps To Freedom From Bipolar Disorder – This is from the keynote presentation at the annual conference for the California Association of Marriage and Family Therapists – Please comment and share with anyone you think might be interested.
When I look at how they account for time in the DSM-V, I wonder if they know anything about depression or bipolar. They know time plays an important role, but they don’t seem to understand the role that time plays whatsoever. By the way they define it, you can have a very low intensity depression for 14 days and it’s called depression, yet an intense depression for 13 days doesn’t count. This makes no sense at all, yet is the only accounting for time they provide.
Properly accounting for time takes an understanding of the relationship between time and intensity. You cannot learn that relationship by asking people a brief checklist of common symptoms as is done in the currently popular assessments. You need to know the right questions to ask.
I learned the right questions by doing more accurate assessments that include asking about the relationship at different intensities between awareness, understanding, functionality, comfort, and value mentioned in the previous articles in this series. This led to a deeper understanding of how to ask about time.
The most important question to ask about time is how long before each level of intensity causes one to lose functionality. When we base the answer on a thorough functionality assessment, we understand the relationship between time and intensity in ways the authors of the DSM completely miss.
Although intensity is a major factor in predicting how long one can remain highly functional, there are many others equally important. If one is not aware of the lowest intensities of depression or mania until functionality has already been lost, for example, there is very little time to do something about it and avoid another crisis.
Assuming you are not deeply depressed right now, try to remember the time when you were in the deepest depression of your life. Can you see any way it might have changed your life for the better? Did it make you more sensitive to the feelings of others? Are you better at helping others during their difficult times because you have had the experience yourself? Are there things you learned from being deeply depressed? Are you a better person because of the experience? What is the value in having been through it? On a scale from one to one hundred, how would you rank the value in having been deeply depressed?
These seem like unusual questions to some people. Wouldn’t we be better off trying to forget our depressions and get on with our lives? Can’t we just hope that depression remains in the past and we never have to face it again? Ignoring past episodes may sound like a better approach, but refusing to take a hard look at depression or mania leaves us ill prepared for the next time it comes. Unfortunately, if depression or mania happened before, it is likely to happen again.
Looking at how we value depression and mania is an important part of any assessment; a part that is sorely missing in most protocols. The laundry list of symptoms in most assessments belie an incorrect assumption that the items are all seen as negative.
We have been asking the above questions (and many more) for several years now and have learned a great deal about the role value plays in depression and mania. Although our data is not yet extensive enough to make final declarations, there are many surprising trends that are too important to delay sharing.