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.
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.
Thomas R. Insel, M.D., Director of the National Institute of Mental Health, has issued a sharply worded condemnation of the new Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The DSM has long been considered the “Bible” of Psychiatry and has recently been under attack from many angles, but this announcement might be a game changer. It will be interesting to watch how it all plays out.
According to Dr. Insel, “it is, at best, a dictionary, creating a set of labels and defining each. The strength of each of the editions of DSM has been “reliability” – each edition has ensured that clinicians use the same terms in the same ways. The weakness is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever. Indeed, symptom-based diagnosis, once common in other areas of medicine, has been largely replaced in the past half century as we have understood that symptoms alone rarely indicate the best choice of treatment.”
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.
When I first started putting together the protocol for assessing depression and bipolar disorder, I was working with a professor of Psychiatry to make sure the ideas were sound. His advice was to combine both awareness and understanding in the graph to keep it simpler. I am glad that I did not take the advice.
Awareness and understanding are different in ways that matter. Expertise might help someone understand why things happen, but does not necessarily lead to increased awareness. An expert on sex, for example, may be totally unaware that his wife is having an affair. It takes awareness (covered in the first article of the series) to know what is going on whether you understand the phenomenon or not.
It turns out that understanding is more related to functionality (covered in the next article) than awareness. You may be completely aware that you are sitting in a car, but unless you understand how to operate it you cannot drive.
Understanding is not just about knowing the physical, mental, emotional, spiritual, social, and career/financial aspects and their implications, it also includes knowing about the tools. You need to know how the tools work, have proficiency in using them, and understand which ones to use at each stage of bipolar – the disordered stages of Crisis, Managed, and Recovery, and the IN Order stages of Freedom, Stability, and Self-Mastery. I call this functionality-based understanding.
Too many people are holding out those who cannot function as the ones we should be listening to. Those who only know bipolar disorder and have not created Bipolar IN Order in themselves or others have no understanding of what it takes to make it happen. They can learn, but many times their beliefs limit their willingness to do so. They keep insisting it is not possible to be highly functional with bipolar and refuse to consider the evidence that contradicts such beliefs.
Moving From Bipolar Disorder To Bipolar IN Order
Everyone has up and down times. It is a natural part of life. If we observe our lives over time we might say there are two poles that we have; some days we feel on top of the world and other days perhaps on the bottom. That is the basis for the word bipolar and the reason I say that everyone is bipolar. Some may argue that there are people who are unipolar and only experience the up or down side, but even they have a range of experience with a “pole” on each end.
Unfortunately, the word bipolar is generally used to describe a subset of people who have adverse reactions when they go to far toward the high and low poles. Although related to how far from center one is, there is no distance from center that guarantees one would necessarily react to it in an adverse way. It really depends on how far we are from our comfort zone. One person might be perfectly comfortable and highly functional at a certain point from center while another could be so uncomfortable that he/she is literally in danger of suicide. I see the comfortable person as keeping life in-order, while the person in danger of suicide has lost control and is in dis-order. Using bipolar as a term to describe the dis-ordered person is an over-simplification that goes too far. We should at least distinguish the difference between having Bipolar Dis-Order or Bipolar In-Order.
But life is not even that simple. If I just won a marathon, for example, I might be very high emotionally yet completely drained and low physically. To really see where we are on the spectrum from high to low we need to consider all of the aspects of our lives: physical, mental, emotional, spiritual, social, and career/financial. It is probably more accurate at any given time to say that we are really in a “mixed state” instead of somewhere on a straight line between the two poles, so we must see even the expansion of bipolar to Bipolar Disorder and Bipolar IN Order as just a convenient simplification of a much more complex topic.
The Experts Are Asking The Wrong Questions About Depression And Bipolar Disorder.
Over the last ten years I have spoken with thousands of people diagnosed with bipolar disorder. When I ask them to relate their story of how they were diagnosed, a troubling pattern is pretty evident; the diagnosis was very brief and largely irrelevant in regards to bringing any hope to the situation.
Most people I have talked with see the assessment as a life sentence with no path for making life work the way they had hoped for. I wonder where they got that idea?
For the last five years I have been speaking to groups of therapists and doctors. When I tell them assessments are not thorough enough they are often in agreement about others, but believe their own assessments are very thorough and use the best evidence-based tools available.
What tools? The Beck Depression Inventory (BDI) takes about 10 to 15 minutes to complete the 21 questions in a self-report format including the items intended to measure symptoms of severe depression that would require hospitalization. The BDI has been used for 35 years and is reported as being highly reliable regardless of the population. The Hamilton Depression Scale asks only 17 questions. There are others, of course, but none provide the insight needed to achieve Depression IN Order or Bipolar IN Order.
My recent article called “Why I Am Against Bipolar Meds” turned out to be less controversial than I expected. Some people refused to read past the title and that is unfortunate because the vast majority of those who commented said that it was a very fair assessment of both sides of the debate. There were several misconceptions, though, that need to be cleared up.
I mentioned the three stages of Bipolar Dis-Order and the three stages of Bipolar IN Order assuming most of the readers are familiar with the terms and my work. Unfortunately, that was not the case for many readers. In trying to keep the article to under 1000 words, I did not go into detail regarding the stages and what I mean by Bipolar IN Order.
This caused confusion for several Psychiatrists who assumed that Self-Mastery means remission. At the other end of the scale were several people with Bipolar Dis-Order who declared that they were in Self-Mastery when their statements seemed to contradict their self-assessment. It seems greater detail of the Bipolar IN Order concept is warranted.
The primary objective for someone with Bipolar Dis-Order is to lower the intensity of mania and depression and move away from Crisis toward Recovery. Bipolar IN Order is about becoming more functional in an expanding range of intensity and moving from Recovery toward Self-Mastery.