The Untold Stories: Diagnosing and Giving Language to the Illness

Often a process or the path is complex, convoluted, and at times completely convoluted from simply getting to the location of the core or the original thought of to type the first prescription. In bipolar disorder specifically is a chameleon. Things are rarely distinct and definitively present as a straightforward text-book "episode" of either profound mania, then profound depression, and this occurs and is present not only on the business end of the illness, but also on the primary business end of the illness; the absence of something to channel the experience: instead one simply sees "just tired/exhausted," and procedures seem to be to vague suggestions for possible approaches and where not to channel a patient in primary care with 85 other patients and very limited time. Or, it seems to fit with another modality suggested by the psychology literature which simply does not categorically fit unipolar depression or any kind of mood spectrum:: "I'm just tired I guess I am just not sure why" which is indeed a deeply humorous representation of an ungainly state. 

Often depression crashes the party and you just do not want to answer the question or open the door and let the harried night like guest ruin your get together, and because there is not much space left the guest has removed everything else from the plate. The "highs" of mania is exhilarating, productive, and innovative escape, and respite from depression and all the ever-gravitating upward pulling weighty leaf swirling stagnant sensation of the depression. And you feel those waves smooshing along the edge of room waiting to start carrying and siphoning away the emotions, good times, and spontaneous bubbling experience you are feeling and experiencing in the moment. The euthymic/hypomanic stage comes first. Not euphoric, grandiose, evidence less mania that gets you into trouble through hospitalization or local news, even destructively on social media... and no "really too much" animating, too cheery or shopping oriented yet (and you can get on the scales pretty quickly)- hypomania is social but somewhat less than admirable in your own self-reflection. Hypomania is pretty much a subtle balancing act of being "wired"; or having less need for sleep but yet generally well-being; planning on making an extra social connection; and always bringing some level of questionable irritability with you around as life becomes quickly muted yet still somewhat "palpably heavier". You feel sharp, awake, easily engaged, prolific... until you do not. You mentally tip to "freak out" for some unknown reason with all sorts of frustration and irritability that boils over to rage and now you have multiple unfinished projects, however, full completion feels heavy sleep debt, and now you think you pivot to "ground one" year after year decline.

These things can happen for a few years or ten. Years of emotional devastation bear witness to the life you designed collapsing in front of you, but the unclear undefined factor that nags your thoughts, goes, unchanged.There are instances when depression causes you to be described as "lazy" and in episodes of mixed or hypomania you are described as "difficult or volatile". The internal dialogue quickly turns into "I am no good", or "why can't I just be consistent, what makes everything so hard for me?!" For many, the episode in living with the diagnosis of Bipolar Disorder brings with it a sense of relief, but also fear. The name in and of itself conveys so much to the culture and is already so laden with stigma and misconceptions. There is a safety that comes with a label, despite the stigma related to it - you are not "weak willed", you are not is some indefinite immoral state, you are not simply not caring enough to not let yourself fall apart. In this moment, you see all the disrupted, distracted, disillusioned definitions and pieces of yourself attached to a painful, and awful cohesive identifiable image, and you are given a label and that label comes with a plan to manage your labelled self. [Whatever that means should be understood]

The Neuro-complexity of Mother Natures Perfect Medical Remedies

As if we have talked /  briefly discussed the "pillars" of treatment, the experience of living with out the episodes of Bipolar disorder, as a practice, is almost always compounded in therapy.Managing medication is more like a symphony. The management of medications is less of an orchestration, while each medication plays alongside other medications without losing the experience of being an orchestration, rather than believing it is one actual magic bullet. This is the craft of psychopharmacology.

For that matter, if a well tolerated comorbidity, a basic mood stabilizer, like Lithium or Valproate, would warrant augmentation with an atypical antipsychotic for the desired effect for that patient or patients, to alleviate this symptom or symptoms of a diagnosis they have and/or have developed. For instance, a patient tolerating his/her spirits under control while on Lithium, and noting the anti-suicidality properties, indicates to me this patient continues onto a safe medication management plan. The same patient may also take a low dose of Quetiapine at night for residual anxiety, while providing good sleep (a necessary portion to prevent mania).  Meanwhile, another patient may utilize Lamotrigine as the main medication addressing their depressive episodes, concurrently with typical doses of an Aripiprazole for manipulation of hypomania, even if mild. Nothing stays the same, no one remains constant, nothing in life remains constant and/or still. In fact, if some life stressor occurs, like losing your job; or the process of getting a divorce (and etc), can also necessitate a reasonable increase in what is being prescribed and/or the addition of medications (temporary or otherwise).If the patient is expecting a baby, a review of all medications will be done, weighing the opportunity for benefit and increased risk potential for some medications, along with weighing the risks of having untreated mood episodes. The transitional period during and after having a baby, where hormonal changes and lack of sleep provides for the perfect storm of relapse during recovery, also increases the risk significantly if the patient has a significant prior history of mood disorder. Based on history then paying close attention in and during this transitional period will be important and possibly even making medication and or dosage adjustments if warranted. The importance of the relationship between psychiatrist and patient is particularly relevant in this context. It is the patient, who owns their brain and body, who is experiencing these fluctuations in mood and mental functioning, from medication, a reduced dose, an increased dose, or from the use of another medication for the first time or simply allowing the patient to experience a new sense of improved mental health due to the medication. The subjective nature of the patients observed experience, or lack thereof, is far more valuable than vague or precise conjecture on whether the psychiatric medication is "working" by the defined psychiatric criteria of the psychiatrist.For a patient, it will matter if someone said, "I slept 8 hours last night, but when I woke up, my brain was racing." Or, "I feel less depressed, but I feel so flat, I feel like I was watching my life from behind a window.", because these subjective comments quickly become the most salient data for a psychiatrist to draw upon, enough so that a judgment call can be made about whether the woodwinds should be played again, or if the strings were too loud in the session or classroom.

The Close Conversation with Side Effects: Quality of Life Tradeoffs

For instance, listing side effects in a list; weight gain, sedation, tremor...is not representative or informative of the close and ongoing conversation that people living with side effects experience in their daily lives. It is not simply annoying. It is a constant feeling of coming and going of negotiating a trade-off of quality of self and life, with the literal medication dosing and intensity effect.  

For example, weight gain is likely the most noted medication side effect for patients, and it might only be "a few pounds" that you, your family, a friend, or spouse, may declare would "come off" by the new year. No. You are talking about, more like implicitly agreeing to add 30, 50, 80, or far more pounds that literally alters a person’s relationship to their body, and for some, their relationship to food as well. The medication is potentially saving your life from mania or even worse psychosis, or simply vote on what is becoming a troubling fleeting mood or thought since lean season. However in the meantime, the medication might make you feel like a stranger to yourself looking in the mirror. Then there is the agreement of a second health issue aside from weight gain and a pre-diabetic label, and the even ongoing decrements in the bouts of depression and, or, more global or relative loss of confidence in relationship to how and what one might have, on a near dial, with during an episode. 

This is not a willpower issue, as some might say, because the medication might alter and adjust your physiology, finance the very most profound and overpowering cravings you may have yet experienced for sugar alone. And now you are in battle with a weight loss mechanism, but you tell yourself it is not merely the information designed to land you in the a work against self way, it is biology now. 

There is also cognitive dulling, often referred to as "brain fog." If you are a thinker, someone proud of their thinking abilities like quick wit, or creative thinking, you may feel like you are lobotomized in some ways. The words are right there, on the tip of the tongue, but won't come out. You have read the last paragraph four times, and still have yet to comprehend it. What was once quick, almost associative thinking, that was a super power in hypomania, is now like thick molasses. There is that feeling, "is this stability?" Am I just enough? Did I trade in my fire for a chance to live in whatever variety of the word exists?"

The concrete fallout becomes your everyday cue. While you may have minor hand shakes while on lithium, the outside of the person isn't informed each time they spilled coffee, or rambled their way through unfettered cognitions that led to full bodied laughter. The insatiable thirst, in combination with your urgent need to use the bathroom. Then the dry mouth from medications, alongside increased cavities. None of these are alarming side effects, but less than ideal of course. The acne, the thinning hair, and the sexual issues, one of each of those could wreak havoc on you, and they each could probable generate a faint threat to that "normalized" existence, that you might have at just gotten back.Making the choice to remain on the medication has aspects that are not just the choice you might ponder, but a choice you are reevaluating each and every day you take the pill. You are, in essence, exchanging possibilities for the guaranteed experience of being present to some degree with your child, co-worker, or next-door neighbor in a given society as long as you can keep your body/mind together in the course of the day and, hopefully, feel the comfort of an experience since whatever day you have felt comfort in.

And that is why it is usually at least somewhat of the most relieving act of sacrificial kindness for someone to say, "at least it is better than crazy" or something other thoughts might just suggest semi-off handedly for your unintended detriment. An experienced psychiatrist means that. They are not just for safety's sake gathering information on your lithium on lithium levels and asking about your weight, thirst, or tremor. They do it for value it may have beyond those first behaviors to do some detective work in not only recommending "safeguard" medicine, like Metformin to prevent you from having the side experience of metabolic disease, but to ask if you would be, for example, thinking about just marginally decreasing the dose a tad bit and closely monitoring side effects and tolerability. They listen to whatever experiences you are going loose in the world at is while also, as discussed, introducing a path back in.

The Fine Art of Psychotherapy; alternative conversation!

Size of ship metaphor here - if drugs are the anchor, therapy are sails and rudder in this location or location. Now that the ship is not being thrown about by hurricane winds, it is time to learn how to use the sails. It is going to be an engaged process, but it will be a process that ends with learning a skill, and there are certain modalities for skill in therapy that are quite applicable to bipolar disorder. Strengthening skill sets can be almost universally beneficial to via Cognitive Behavioral Therapy (CBT) because CBT is designed to help the person break out of unhelpful thought patterns that can spark or sustain significant shifts toward either end of the bipolar continuum. When experiencing depression, CBT diminishes the value placed on the cognitive triad of hopeless, worthless and helpless. When the person begins to experience analogous reliance on mania, CBT influences their thinking, can help guide the person back to reality, and can help check in on disruptive thoughts of impulsive outcomes of grandiosity, e.g. "is maxing my three credit cards on the business I thought of while the previous night was sleepless a fresh creative insight or my illness speaking?" CBT is a way to try to stop the thought and add a layer of contemplation, via behavioral alternatives. Interpersonal and Social Rhythm Therapy (IPSRT) is arguably the most gracefully personal intervention in the management of bipolar disorder (BPD). IPSRT works on a still simple, elegant and common sense idea: if the daily rhythm is stabilized, the mood stabilizes. IPSRT knows there is great value in dealing with the boring, ordinary and pragmatic elements of a person's life, wake time, meal time, exercise time, social stimulation, etc. At its basic level, IPSRT takes seriously sleep deprivation as a signifier of a new episode with sleep being the nuclear option.The therapist collaborates with the client by offering meaningful and predictable structure for the client to be able to live their life, not as if it were a prison, but as it is meant to be scaffolding. Because the scaffolding is what protects the person. The scaffolding will assist in rebuilding resilience to the stressors in life that sometimes produce that intense fluctuation of mood. IPSRT will assist with relationship difficulties that often accompany mood episodes, and provide opportunity to rebuild and create healthier ways to be with other people. 

Family-Focused Therapy (FFT) works from the premise that BPD is a family issue. Untreated episodes, undoubtedly, tear families apart, hurt people, and confuse, leading to anger and resentment. FFT treats family members and brings them into the intervention, in a relatively psychoeducational process. It helps family members to understand that mad, manic, hurtful things that can be said during mania or while withdrawing from behaviors, are in fact hurtful but many times are related to the illness not the person's true attitudes, feelings, and influences toward others in the system. It can be helpful for families to learn to recognize signs of compromise, how to communicate, and learn to create an environment to support one another as a family working as a team instead of feeding the fire. 

Navigating the Maze of American Healthcare: A Practitioner's Perspective

The hope for individualized and responsive psychiatric care will often be an ongoing tension with the American Healthcare system.The maze consists of  caught rules, caught money, and caught frustrations.

Costs of Meds. Costs can truly be extraordinary. You might be paying for example, for necessary meds which could go above $1,500 a month, that's for a med that is like Latuda or Vraylar for example, a brand name, novel atypical antipsychotic. Remember, your insurance can also give you a co-pay which can be hundreds of dollars for meds similar in kind. "Do I put my money towards rent, or the co-pay for the meds I have to take for my symptoms and/or recovery.?" Some drug manufacturers are providing co-pay assistance cards which has been helpful for many but truth is that it is usually a limited benefits timeframe and there are too many people who meet too many criteria. Prior authorization: Here again is another bureaucratic insurance process in an attempt to manage or reign in costs, with unbelievable stress and often long wait times. Your psychiatrist using reliability of experience determines Drug A is the best, and safest, but according to the insurance policy patient has to try unsuccessfully Drug B, C, and D so that Drug A can be authorized. So.... your psychiatrist has to take time to do one of two things, to either call the insurance company or to put in writing what medications they are justifying as a logical med for you it could simply be a matter of filling out a few forms, from their perspective. In a very unstable and tenuous moment of your life. And it may take days and or weeks for the insurance company to authorize.Nonetheless, the notice regarding denial of authorization for your care from the insurance company is still minimization of your suffering and diminishes the overall authority of your provider as psychiatrist's practice. Finding a Psychiatrist for a 15 medication check appointment. Finding a psychiatrist you would like to get and who treats bipolar disorder and/or will take new patients and/or your insurance covers is difficulty (you can aka spend so much time getting an appointment you actually do not get treatment for an acute or systemic disorder, and potentially make the likeliness of yet another failure to locate a psychiatrist cause so likely I should navigate an episode or crisis). Typically, at least folks are waiting and can take 3 months for a first appointment. But again at least for psychiatrist, in general that'"s appointment length is generally a short appointment for medication check of 15 minutes. At best expect at least the short 15 minutes, and if that appointment is significant at least related in two ways, recent past steady episodes, as well as previous lifetime episodes at least periods of episodes less chronic, no one don't believe I should say expect because I don't know if that means I a repetitive appointment, to the extent or to get something like acuity rating as someone else knowledge oh is 15 minutes at best short board line considering if it is a REST psych therapy rate because 15 minutes would take 45 minutes at any case if not doctor because under serious the circumstance of creating something serious.Another usual appointment would just vary if we had to set aside 15 minutes for a medication check, for serious episodes the next part of the lab check, for review with the psychiatrist expect another medication check appointment for 15 minutes, depending on your particular plan...And the potential non-stop effects of neuritis create a whole other navigation.

A med check is to essentially get you the medical symptoms in check for compliance if no feelings happened and/or side effects pop up and/or symptoms begin to change then get a new prescription or lab results referenced or planned additional med check appointment, then you would likely be billed about 15 minutes for the med check.

In living with bipolar disorder is, at a minimum, a "lifestyle." and we even relate to living with a person. The dealing with bipolar disorder should be thought of as a "marathon", and not "sprint"; it is a chronic condition that at some point in time will evolve into some level of self-change or self-care change. It used to be a matter of managing symptoms of bipolar disorder and now we have to emphasize, "How do we create a life that is valuable enough and good enough to have sufficient depth to withstand all the tremors of the chronic illness?"

This process has matured into the mindfulness of self-mindfulness.You will start to see early warning signs or prodromal symptoms: the symptoms/synonyms that tell you if you are approaching a transition, i.e., if you are entering a manic episode you may start to speak at lightning speed, or you feel a very strong compulsion to get out of bed at 2:00 a.m. to clean your house. If you are in a depressive episode, your prodromal symptom may be the thought process that you need to cancel out any and all social engagement because relying on a very feasible and self-perpetuating logic your friends did not like you in reflection. Learning to get in tune with prodromal symptoms is like a sailor getting aware of the changes in the wind and alerting themselves before getting blown overboard. This might involve calling you doctor ahead of time to slightly adjust medication protocols or increasing your commitment to sleep hygiene, or deciding to try some form of therapy interventions. 

You will develop self-awareness, and start to develop a "wellness toolkit." Each of your toolkits may (and probably should) jobs a little differently, but they will have some baseline fundamentals that you will need to be stable/restorative.... You will think through what you want your non-negotiables to be, sleep hygiene, exercise, being intentional/challenging yourself about any processed foods you eat regularly, etc. Of course you will also make sure that you include some soul nourishing/groun nding exercise(s) in your toolkits - maybe daily meditation and/or mindfulness exercises, etc. For some, wellness might be a version of the creative arts (i.e., drawing, painting, writing, music) in their toolkit. And for some, wellness may be developing nature experiences, caring for a pet, or being treated/staying in a peer support, non-judgment group like the DBSA (Depression and Bipolar Support Alliance).

And maybe the answer would be to blending both practices.... Bipolar disorder is really only one strand in the complex and beautiful tapestry of who you are. It is not one complete tapestry. You are not “a person who has bipolar” one day, nor would you describe two friends as “two people who have bipolar.” You are a parent. You are an artist. You are a friend. You are a business person managing with the illness of bipoar to reality. The medications, the therapies, the tools, the dietary lifestyle modifications are not the cage but the frames for the other various significant parts of you to flourish and bloom in full. It will require, however, ongoing, great courage, patience, and self-love to cultivate a life you will feel is indistinguishable. You will feel a life not diminished by the disorder, but fully viable and looking to pursue any experience of moving through the darkness of built experience, positively indifferent to one's own experience of lightness.