The Bipolar Spectrum

8/14/2019 The Bipolar Spectrum

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CONTENTS

1. The great pretender

Part I- the diagnosis and the illness

2. bipolar illness: making the diagnosis3. clinical depression-not!

4. bipolar and adhd

5. unstable mood and personality disorder and sometimes ptsd

6. cutters- adult division

7. adolescent cutters and the risks of antidepressants8. sequential diagnostics and prioritizing treatment

9. schizophrenia and bipolar disorder10. bipolar and obsessive compulsive disorder

11. stress and genetics

12 mild versus severe13 resistance to the diagnosis

Part II- treatment

14 the role of psychotherapy

15 working with your doctor: self-monitoring16 self-care17 medication strategy: treat activation first!

18 anti-activation medication group 1-lithium

19 multiple medications20 anti-activation medications group 2 anticonvulsants

21 anti-activation medications group 3 atypical antipsychotics

22 anti-activation intervention ect23 bipolar depression depression or mixed?

24 Bipolar depression step 1

25 Antidepressant atypicals

26 Antidepressant antidepressants27 Treating multiple diagnoses

28 Pregnancy

29 FAQs30 Residual symptoms and side effects

31 Family matters

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1. The Great Pretender

Suppose the thermostat at home is set for 70 degrees. When the temperature

drops to 68 the furnace goes on. When the temperature reaches 72 degrees the furnace

shuts off.

If your thermostat is defective, though, the temperature might have to drop to 40

before it turns on the furnace, and the temperature might have to rise to 90 before it shuts

off. Youll be putting on sweaters at one moment, and changing to shorts and a t-shirt the

next.

Now suppose that you have a full climate control system. Along with a furnace

you have central air conditioning with its own thermostat and controls. And lets say we

dont know if the air conditioner thermostat is working properly or not.

At times the furnace and the air conditioner will both be on at the same time,working against each other. You house might be cooling off or heating up, depending on

which system is stronger, but either way your utility bills will skyrocket.

If the temperature is 80, and both the furnace and the air conditioner are on,

fighting each other, you know the furnace control is messed up because it should have

shut off the heat. But you cant know about the air conditioning control in that scenario.

It might be working fine, and switched on only in response to the high temperature

produced by your heating system.

At other times neither system will be working, while the temperature in your

home drifts down to 50 or up to 85 depending on the weather outside. If the temperature

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goes down to 55 without the heat turning on you know your furnace control is messed up,

but, again, you cant tell about the air conditioner.

Sometimes just one of the systems will be on. The house will be warming or

cooling, but you cant predict how extreme the temperature is going to get.

Your furnace works fine, and so does your air conditioner. The problem is in the

controls. You have a problem regulatingthe temperature in your home.

Bipolar disorder is also a problem with regulation, not too different from the

disordered climate control system Ive just described.

Before discussing in more detail what bipolar disorder is, however, I want to clear

up some misconceptions. First, bipolar disorder is not manic-depressive

illness. This is like saying fruit is not apples. Fruit may be apples, but it may be

guava, or blueberries, or even tomatoes. Manic-depressive illness is the most famous

type of bipolar disorder. But classical manic-depressive illness is rare, and its terribly

misleading to focus on it.

This book is about the bipolarspectrum, a term we use to emphasize that bipolar

disease is a much broader illness than most people realize, an illness with many, many

different ways of expressing itself. When I say bipolar or bipolar illness or bipolar

disorder, I mean to include the whole bipolar spectrum.

Second, although the term mood swings is commonly associated with

bipolar disease, it means different things to different people. Some people use that

term to mean periods of elevated mood alternating with depressed mood, but other people

use it to mean a quick temper, or irritability. Some people mean switching between a

normal mood and depression, or a depressed mood and anger, and still other people mean

an easily changeable, orlabile, mood. Any or all of these might be produced by a bipolar

disorder, but none of them necessarily means that someone has bipolar disorder. In

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general, psychiatrists use the term mood swing to describe the classic manic-

depressive-style swing between euphoria and depression, so Ill use the term only in that

sense.

Everyone with bipolar illness does have an unstable mood. Sometimes well tell

patients with milder forms of the illness that their diagnosis isunstable mood disorder

not an officially recognized diagnosis -- in order to offer a label they can accept more

readily than bipolar. But bipolar illness isnt the only cause of unstable mood, just a

likely cause.

Third, most people with bipolar disorder have never, ever been

euphoric. People think bipolar illness means having classical mood swings: elevated

moods euphoria alternating with depression. Wrong.

I think ofbipolar illness asa disturbance in the regulation of two

processes: an activating process and a depressive process. Think about

your furnace and your air conditioner and a problem in one or both of their control

systems.

In the dramatic, classical, form -- manic-depressive illness -- the activating

process includes euphoria, but in most bipolar disorders activation rarely if ever

manifests itself as euphoria. Instead activation usually shows up as racing or multiple

thoughts (Ill explain these terms later), agitation, hyper feelings and irritability, and most

often comes with a depressed, not an elevated, mood. Technically the diagnosis of

mania requires eitherelevated mood orirritability. In fact its almost alwaysirritability, but for historical reasons the term mania commonly makes people think

euphoria. Thats why I prefer the term activation. Its mood neutral. It doesnt

imply anything about euphoria or depression.

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The depressive processusually shows up as a depressed mood, but occasionally

it shows up as just de-activation: extreme lethargy and increased sleep, but without a

depressed mood. Let me repeat: there are people who are in a state of depression

without being depressed in the ordinary sense. They tend to have very low energy and

motivation, and sleep 14 to 16 hours a day, but they dont feel down, blue, sad or

whatever other synonym you care to use for the everyday sense of depressed. This

form of non-depressed depression is almost always part of a bigger bipolar picture its a

passing, depressed state of someone with bipolar disorder.

The two processes behind bipolar illness vary over time. And the two processes

can vary independently. If they take turns, and are extreme enough, and last long

enough, we call it classic manic-depressive illness. But Ive seen people in whom the

two processes go through every combination you can think of. Sometimes theyre

euphoric; sometimes theyre depressed with racing thoughts; sometime their mood is

normal but theyre irritable and hyper; sometimes theyre depressed without raciness; and

sometimes their mood isnt bad but they cant make the effort to do anything and theyre

sleeping 16 hours a day. The same person can experience all those states over time, but

most sufferers have an individual pattern which only includes a few of the possibilities.

So bipolar illness is a different disease than most people think, even most

professionals. Its more variable and more common than almost anyone realizes, and it

can be extremely hard to diagnose. One study done in 1992 showed that 73% of

patients with bipolar disorder received the wrong diagnosis when first evaluated. Think

about that: three out of four patients with a serious, potentially life-threatening illness

went to an expert and received the wrong diagnosis! In 2000 another study

demonstrated that diagnostic accuracy had improved: only 69% got the wrong

diagnosis.! [see http://www.dbsalliance.org/PDF/BPHowFar1.pdf] At this rate of

progress well get it right3 out of 4 times by the year 2088.

The average bipolar patient today was in treatment over 8 years and was seen by

3.3 psychiatrists before getting the right diagnosis. Forty-eight percent of people

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currently diagnosed with bipolar disorder were treated by five or more mental health

professionals before getting the right diagnosis. To make matters worse, delaying

diagnosis, and thus being sick longer before proper treatment, makes the future long term

course of the illness worse, even once its properly treated.

This book is being written to help people who are being misdiagnosed and getting

the wrong treatment. And this book is being written to help people understand their

treatment once they have been properly diagnosed.

So what is this illness anyway? And why is it so easily overlooked or

misdiagnosed?

First, I want to emphasize that bipolar disorder IS an illness, a biologically based

disease. Psychiatric illnesses are disturbances in the functioning of the brain. Since the

brain is the organ of thinking, feeling and behaving, these illnesses manifest themselves

in disturbed thoughts, feelings and behaviors. Whoever coined the phrase chemical

imbalance should get an award for cleverly capturing a notion of biology that people can

easily grasp, although we know these illness are far more complex than that simple

phrase conveys.

Psychiatric illnesses have a basis in both genetics and experience. If one

identical twin has schizophrenia, for example, the odds that the other twin will also have

it are 50-50. Since identical twins have identical genes, you might guess that if one twin

had schizophrenia, the other one would also. But, although theres a strong genetic basis

for schizophrenia, genes arent everything. If one identical twin has bipolar disorder, the

odds for the other twin having it are three out of four. Pretty high odds, but not 100%,

because experience, usually in the form of stress, also plays a role in bringing on the

illness.

The fact that stress is a factor doesnt make the illness any less real or any less

biological. If someone with diabetes eats Twinkies all the time, the physiological stress

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of the sugar may make their diabetes harder to manage. Similarly, psychological stress

causes physiological changes: an acute stress, BOO!, will cause a release of adrenaline,

elevate the pulse and blood pressure, change the distribution of blood flow, and so on.

Chronic stresses lead to physiological changes.

Whatever the triggers, however much stress versus however much genetic

predisposition, if youve got bipolar illness youve got to treat it. Sometimes people will

come in with symptoms, an illness, and when I make a diagnosis and recommend

treatment theyll say But Im only depressed [and not sleeping, not eating, unable to

enjoy things] because I got fired or got divorced or got cancer or whatever. And Ill

reply thats like someone saying, My legs only broken because I fell down the stairs.

It doesnt matter if its because you fell down the stairs or you got hit by a car; youve got

a broken leg that needs treatment. In the same way, youve got to treat psychiatric

illness.

But what is bipolar illness? What does it look like? Lets describe a few of its

forms:

The most famous form is actually quite rare. Its what used to be called manic-

depressive illness, now one subtype of bipolar disorder type I. Psychiatrists used to think

this was the only kind of bipolar disorder, and so we thought bipolar illness was rare. In

manic-depressive illness someone might look perfectly normal for a while, until theres a

mood swing. Usually the high comes first, although it can go the other way around. The

high is characterized by an elevated mood -- euphoria -- although there may also be some

irritability -- a great mood til something happens, then POW an ugly anger. The person

is speeded up, pressured, talking too fast for others to understand comfortably. Racing

thoughts not just a busy mind but

yourmindisgoingsofastthatifyouhadtosayitoutloudyourtonguecouldhard

lykeepupwithit. Increased sex drive, spending a lot of money, making a lot of phone

calls, infectious humor or anger. When I was in training, working in the Emergency

Room, if I walked in to see a patient and within 30 seconds I was either laughing or

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angry, I learned to think: bipolar. People who are high dont sleep much; they arent

tired. They dont eat much; theyre not hungry. And they go like that for anywhere from

minutes to months, depending on the individual, until they burn out and crash.

Fly now, pay later. Everything goes into reverse. Instead of being up, theyre

down. They may be depressed in the sense of sad or gloomy, but maybe not. They can

just have extremely low energy, be lethargic and apathetic. Not depressed, just listless.

Instead of being speeded up theyre slooowwwed dooowwwnn. Instead of not needing to

sleep, they want to sleep 14 or 16 hours a day. Instead of not being hungry they want to

eat a horse.

So theyre up, then theyre down, then they work their way back to normal, and

then they do it all over again. Thats manic-depressive illness, and its now called bipolar

type I as long as there has been at least one manic episode severe enough to be disruptive

to that persons life, and that episode lasted at least one week. If it was less than a week,

the illness goes into a wastebasket category: bipolar disorder n.o.s. [not otherwise

specified This duration criterion is just one of the many problems with the official DSM

diagnostic categories.]

Bipolar type II is characterized by hypomanic episodes -- less disruptive, briefer,

often entirely overlooked highs that last at least four days but less than one week and

significant lows. This form of bipolar illness is frequently misdiagnosed as clinical

depression.

Often missed as well are mixed states, up and down at the same time. People in

this condition have the worst of both worlds: all the energy of the activated state but none

of the fun -- an uncomfortable energy. Theres an agitated mixed state restless,

jumping out of your skin, irritable, agitated, angry, miserable, hard to sleep, impossible to

relax, yuck. Its like being in a car with its motor racing, the pedal to the metal, but the

brakes are locked and youre going nowhere and you begin to smell something burning.

This is a very uncomfortable set of feelings, and sometimes leads to suicide. Theres

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another type of mixed state I call wired and tired someone looking entirely listless

but having the feeling of a motor racing inside, draining all their energy. Here the motor

is racing but the car is in neutral and so theres no observable action and no smoke, just a

waste of gas. These states are often misdiagnosed as clinical depression, sometimes as

anxiety disorders. Also people often try drugs or alcohol to deal with these feelings, or

sometimes they cut themselves or engage in other self-destructive behaviors.

Remember, bipolar disorder is apparently a combination of two processes.

Theres an activating process that rarely produces euphoria, but more often just shows up

as raciness with irritability or agitation. Most bipolar patients have never, ever been

euphoric. Mania means activation, not necessarily euphoria. The second process is

de-activating and/or depressive. This almost always has elements of depressed mood, but

it doesnt have to. It may just show up as a lack of energy. Remember, these two

processes can each vary independently. If they take turns and are each fairly extreme

then we say its bipolar type I, or manic-depressive illness. If they take turns and the

activating process is mild and brief but the depressions severe, we call it bipolar II. But

far more often they dont take turns, they can mix and mingle in constantly changing

ratios, looking at one time like a low-energy depression, another time like an irritable

depression, another moment like a high-energy productive state, another like hostile,

angry agitation. Or perhaps the elevated phase was decades ago and relatively mild,

when the person felt good and was energetic and s/he only ever slept 4 hours a night until

s/he started getting miserable and s/he hasnt felt good since.

The fact that an activated period may have only occurred years in the past is part

of what makes the diagnosis hard. And the fact that a DSM diagnosis may require a

patient to be very specific about the duration of episodes that may have occurred years

earlier is another reason why the official DSM categories are not worth much in clinical

practice.

When people talk about their problems they dont mention the good parts of their

lives, by the way. How can a high energy period, a productive and active period, be part

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of the problem? They emphasize the miserable, the unproductive, and the parts that get

their husbands or wives or parents or bosses pissed off at them. Theyll only talk about

the apparently good parts if theyre asked very specific questions that most mental health

treaters dont know or dont bother to ask. And this is part of why the diagnosis is

missed.

Lets start with some examples of bipolar disorder that was disguised as other

problems. The two people described below came to my offices over 10 years ago,

looking for help for a problem that surprisingly turned out to be a bipolar disorder in

disguise. They were among the first patients in whom I started seeing the breadth of the

bipolar spectrum.

Brad

Brad was in his early 30s, looking for help with his drug and alcohol problem.

The drugs were stimulants mostly speed and cocaine -- but also marijuana sometimes

and of course some alcohol, but the way he combined them was unusual. A lot of people

who use cocaine or speed hate coming down from the high, not so much because of

missing the high, though thats true enough, but because coming down they feel awful---

jangled, restless, crummy. Alcohol and marijuana are depressants, drugs that usually

have a sedating, calming effect. So after using stimulants like cocaine many people use a

depressant like alcohol to smooth the way down. This guy, though, did it differently.

He used cocaine or speed for weeks on end, then alcohol and marijuana for weeks, then

went back on stimulants again. This pattern had felt fine for years, but lately he was

having trouble: he couldnt feel right. And besides it was starting to cost too much

money, and was beginning to get him in trouble with his girlfriend. So he figured it was

time to clean up. He told me how for weeks or even months at a time he would feel

sluggish and depressed. That was when he wanted cocaine or speed. And then for weeks

he would feel hyper, jittery, anxious and racy, and sleep only a few hours a night. Thats

when he would use alcohol and marijuana to calm himself down. When I told him that

his main problem wasnt drugs or alcohol, but bipolar disorder, he wasnt all that

surprised: he suddenly recalled that his aunt was manic-depressive.

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Charlie

Then there was a Charlie, in his forties, with a long, long history of heavy alcohol

use, up to a quart of vodka a day. Hed been sober at times but never for long; hed had a

few detoxes but relapsed quickly each time. When he came to see me after his most

recent detox, his mood seemed ok and he agreed to join our practices relapse prevention

therapy group. Hed never really tried outpatient treatment before, yet he managed to

connect with the group leader and stick around for several months with only minor slips

a drink here or there but no out-and-out relapse. It was during one of those group

meetings when he said he really wished he could relax, if only he could stop his thoughts

from racing.

He told us that hed had periods of racing thoughts ever since he was a teenager,

and he couldnt sleep at all during those times. He said that he was irritable most of the

time, angry but not depressed. He never slept very well and went through his days

feeling that he hadnt gotten enough sleep. He felt agitated, stirred up, and unable to

relax. Only alcohol made him feel calmer. There were drinkers on both sides of his

family, and an aunt had tried to commit suicide. He relapsed again and needed another

detox before I began treating him with mood stabilizing drugs for bipolar illness.

After seeing a few cases like that I began looking more closely for bipolar illness.

My practice partner, Doug Berv, had some similar experiences and soon he and I were

running a two-person seminar on bipolar illness, discussing our cases. (Our practice has

several locations, so our seminar was conducted via voice mail exchanges.) Doug has a

buddy from his residency years who conducts research on bipolar illness, so when we got

stuck, Doug would call his friend and then relay his friends answer on my voice mail.

And so it went for about a year. That was roughly 1995.

As a result of our discussions about cases in which bipolar illness had been

masked by other problems, we began to take a harder look at our patients, especially at

our drug and alcohol patients. We knew that substance use could obscure or even

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partially treat mood swings (as was the case with Brad). In fact it was probably the mood

problems that got these people into substance abuse in the first place. But most of these

patients didnt have mood swings as clear-cut as Brads: they had just bits and pieces of

the classic manic-depressive pattern. All wed been taught about in training was

something called manic-depressive illness, characterized by clearcut mood swings. But

some of the people we were treating had symptoms of mania and symptoms of depression

all mixed up, mish-mashed and fluctuating in seemingly random ways. They didnt have

that classic episodic high-low, high-low we had been taught to look for. If there were

enough bits and pieces, however, we decided to call the patient bipolar anyway, and then

tried to figure out which of the official bipolar diagnoses fit the best.

Theres an official list of diagnoses in a book called the DSM, diagnostic and

statistical manual, which has to be used in order for a patient to receive medical

insurance benefits (a nightmare for a different book). Sometimes wed use the code

296.6, referring to a mixture of mania and depression simultaneously. Most often none

of the official categories fit very well, and so we wrote the diagnosis as 296.80, the code

for bipolar disorder not otherwise specified, a wastebasket category for people who

wouldnt fit in the usual pigeonholes.

As we got into the habit of looking for the bits and pieces of bipolar symptoms

with our substance abuse patients, we started to recognize clues for the illness in other

patients as well. Lacking specific definitions for the various manifestations of bipolar

illness that we began to diagnose, we had a growing population of patients diagnosed

with bipolar n.o.s. (not otherwise specified).

While bipolar hid behind the drugs and alcohol in our substance abuse patients, it

was frequently masked as depression in other patients. In smaller numbers, it lay

underneath anxiety or presented as anger problems, or as self-destructive behavior.

Almost no one came in to our office and said they wanted to be treated for bipolar

disorder.

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Occasional patients diagnosed themselves as having bipolar disorder because

they were having mood swings, but most of these patients were in fact experiencing

periods of depression or anger, not the mood swings referred to by mental health

professionals that might indeed suggest a diagnosis of bipolar disease. Certainly nobody

ever came in and said they needed help because they were feeling too good.

I actually believe that the statistics I quoted earlier about what a poor job the

psychiatric profession does in diagnosing bipolar illness, as bad as they are, are overly

optimistic. These statistics were gathered from patients who finally didget diagnosed,

whose symptoms were finally clear enough to meet what are probably overly narrow

diagnostic criteria. If we could get statistics that included all the people with illnesses in

the bipolar spectrum who arestillundiagnosed, who have neverbeen treated properly

and perhaps never will be, the rate of successful diagnosis of bipolar illness would be

even worse.

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The fact is, too many people dont get better: drug and alcohol users especially,

and people with treatment resistant depression to name a few. The druggies and the

drinkers relapse all the time, dropping out of treatment if they ever got into it in the first

place. They might get some clean time, but somehow, sometime, they go back to using

their substance of choice. The people with difficult to treat depression are always being

given the next antidepressant on the list. Maybe they get better for a while, and then they

get depressed all over again. So they take more, or go on to the next drug, or the next

combination of drugs, only to see the same pattern of response and deterioration all over

again. Ultimately the person gets discouraged and drops out of treatment for a while, or

goes on to another psychiatrist with another bright idea, then another psychiatrist, and so

on.

We, like our colleagues, always found explanations, excuses more accurately, for

our treatment failures. We could blame the patient. For example, like most mental health

professionals who are not substance abuse specialists, we used to look at the drug users

with some disdain, thinking of them as defective, manipulative people. Somehow it was

their own fault that they were abusers.

Of course we were the victims of our own preconceptions both in our view of

our patients and in our diagnoses. We were falling for the obvious. The alcoholics and

addicts we diagnosed as having a substance abuse problem. Duh! Everyone knows how

hard that is to change! And the refractory depressives problem was tough illness.

These patients met all the criteria for a diagnosis of clinical depression. The problem was

that the available treatments, through no fault of our own, werent good enough -- you

cant win em all.

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Turns out that often our approach was wrong from the get-go. We were making

the wrong diagnosis. So of course we were offering the wrong treatment. Unfortunately,

many of our colleagues are still making the wrong diagnoses, and thats part of why we

are writing this book.

10 brief stories of misdiagnosis

First, we learned from alcohol and drug abusers. Lets look at the two cases we

began with:

Brad, mentioned earlier, had an obvious problem with addiction. He abused

amphetamines and would drink about a pint and a half of hard liquor over the course of a

day, but his main drug was cocaine. He binge snorted about an eighth ounce of coke

once a week or so. He started with alcohol at about 14, marijuana at 16, occasionally

used mescaline for a while, but then started with stimulants, his favorite type of drug. He

used alcohol and cocaine or amphetamines for about 14 years after that. His two

marriages had been destroyed by his drug use. He went to an addiction treatment

program and to Cocaine Anonymous, but it didnt help.

Charlie, also mentioned earlier, was a 43-year-old guy with a wife and 2 kids. He

had used both drugs and alcohol for about 10 years from the age of 15 to 25. Then he

settled on alcohol alone for the next 13 years, drinking about a quart a day. Finally his

wife asked him to leave and he became depressed, thinking about suicide. He clearly had

an alcohol problem, and needed detox. Perhaps he had a clinical depression as well.

Wrong.

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Next, the treatment resistant depression. It turns out that a treatment history of

5 psychiatrists and 20 medications most likely means its not a clinical depression in

the first place. Wrong diagnosis leads to wrong treatment.

Rebecca was in her late 50s and had seen several psychiatrists since she first

began treatment 6 years before. She was "probably like this all [her] life" - depressed,

anxious, jittery, sad, but not teary. Nothing was pleasurable or fun: in the past she could

enjoy some things at least some of the time, but she often felt like she was just going

through the motions. For the last year she hadnt enjoyed anything at all. She

sometimes thought that it would be easier to be dead, but she never truly contemplated

suicide. Shed been given at least 4 different antidepressants, but they made her sleepy or

jittery or, oddly, sometimes sleepy and jittery at the same time.

After learning about unstable mood from our substance abusing patients and from

the refractory depressives, we began to see it among patients with apparently ordinary

depressions. Of course you dont see it if you dont look for it.

Linda had problems with depression as long as she could remember. She was first

treated in 10th grade with psychotherapy, and first given meds after an overdose attempt

at age 17. She took Prozac 20mg with some benefit for a while, then stayed at that dosewithout much benefit, and then switched to Zoloft 50-100mg. That really helped but she

developed side effects, feeling shaky, so she stopped the Zoloft. She got depressed all

over again. But the shakiness, it turned out, wasnt really a side effect it was agitation,

and depression wasnt exactly what she was experiencing it was a mixed state.

Sally was 40. Her primary care doctor had given her tranquilizers on and off to

help with her anxiety attacks, which came and went. After 6 years of this, she began to

feel depressed. She talked to a therapist, while her doctor prescribed an antidepressant.

It seemed to help some, at least for a while. She was on the antidepressant for over a

year, not feeling quite right.

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Teri was 32. She had some panic attacks in her mid 20s, and used Valium

briefly. The panics went away after 2 years. In her late 20s her mother died, then an

aunt, then her grandmother. She went to a therapist who recommended Prozac, but she

didnt really want medications. She used some Xanax (a tranquilizer also called

alprazolam) which helped some. She felt more depressed and then took an

antidepressant, Paxil, for about 2 months. That helped her mood only a little. She had

trouble with her sleep and was losing weight, typical of a clinical depression. Wrong

diagnosis.

Mary was sent by her obstetrician. She had had her second child a few months

earlier, and now she was depressed and irritable. She cried every day, felt constant

anxiety, had thoughts of hitting people in her frustration, and couldnt enjoy a thing. Sheand everyone she had talked with thought she had a post partum depression. Wrong

again.

Then the anxiety disorders:

Abby was a 48 year old woman who had begun having anxiety attacks at the age

of 9, although she didnt know to call them that until much later. The panics seemed to

subside through her teens, but after she had her first child the panics worsened, and shegot depressed as well. A psychiatrist gave her a tranquilizer, a standard treatment for

anxiety attacks. The tranquilizer helped some with the anxiety, but she remained

depressed. Another doctor suggested she try an antidepressant, Elavil, which didnt help

but caused a lot of side effects. Later she was given Prozac, which made her more

nervous. She wasnt getting better and the reason was that she didnt in fact have a panic

disorder and it wasnt clinical depression either.

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Carole had debilitating anxiety which dated back to age 16. After marrying she

didnt leave her house for two and a half years. Only when she got pregnant and had to

see an obstetrician did she go out her door, shaking, accompanied by her husband. She

started doing a bit better, but got worse again after having her second child. Even now, in

her late 20s, she could hardly leave her house unless accompanied by a family member.

She had repetitive fears of vomiting. She couldnt shop for food, she couldnt go to a

restaurant, she couldnt drive. Her mood was ok; she wasnt depressed, just terribly

anxious. She was tried on various antidepressants with antianxiety and/or

antiobsessional actions (Prozac, Zoloft, imipramine, Serzone, Luvox, and nortriptyline),

and on anti-anxiety medication as well (Klonopin/clonazepam and Xanax/alprazolam).

She needed something different.

David had obsessive thoughts and some depression as well. He had had violent

thoughts running through his mind as long as he could remember. He felt guilty and at

that the same time knew it was irrational: he thought that he had somehow made an old

girlfriend pregnant even though they had never had sexual relations. If he did something

with his right hand, he had to do the same thing with his left. He was sad all the time,

crying and thinking of suicide. He was hospitalized because of his suicidality, but the

hospital didnt do much good. He was given the antidepressant and anti-obsessional drug

Anafranil together with a tranquilizer without much success. Prozac seemed to help a bit

at first, but he needed more. But high doses of Prozac made him agitated, so he was

given antipsychotic drugs to calm his agitation. He still didnt feel right.

These ten people all had some sort of bipolar disorder. Sometimes the diagnosis

was subtle, sometimes it had taken time for the important symptoms to emerge or become

clear, but for the most part all ten had been misdiagnosed because no one had asked the

right questions.

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In fact it took us quite a while to see what was hidden. We knew that substance

abusers had about a 70% rate of dual diagnosis: a combination of a drug or alcohol

problem and an underlying psychiatric illness usually, we thought, depression, an

anxiety disorder or attention deficit disorder. There was the occasional bipolar substance

abuser, usually with an unclear, mixed up pattern of symptoms that didnt fit into any of

the usual bipolar categories, but smelled bipolar once our noses had become more

educated. Once we started seeing it in our alcoholics and druggies, we started noticing it

in people with difficult depressive illnesses, and then we started seeing it occasionally

lurking behind what were obvious anxiety disorders and depressions.

So we came to define an atypical form of bipolar illness, atypical in the sense that

the classic bipolar symptoms were not as obvious or pronounced or well organized as wehad been taught to define them. However, these symptoms were sufficient to destroy

lives.

And for all that weve focused on this illness, we STILL miss the diagnosis. I say

that because there are still patients for whom we make another diagnosis, and later realize

that their problem is really bipolar illness. Only by about the summer of 2001 could I say

that I was changing as many diagnoses from my mistaken label of bipolar illness to

something else, as I was changing diagnoses from my mistaken label of something else to

bipolar illness. Finally, after about 5 or 6 years of studying bipolar illness, I was equally

likely to make errors in either direction. (Nobodys perfect, so by looking at this kind of

correction-of-error rate I can finally say that I am not systematically, consistently

underdiagnosing bipolar disorder.)

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Why did we miss the truth for so long? Youd think we would have known

better. We had each been in practice for 13 to 15 years before we got together to form a

group practice at the start of 1991. We were experienced and knowledgeable Ivy League

grads, trained in psychiatry at Yale and on the Yale clinical faculty. But our roles

changed as the new group practice geared up. We were now doing just biological

psychiatry, medication treatment, full time. We saw many more patients than when, in

the old days, we were also doing psychotherapy. Seeing many more patients, we were in

a much better position to learn from them.

We had also been hobbled by our traditional thinking about bipolar illness. We

thought bipolar illness meant manic depression, and that was a rare problem. Very few

patients came in with classic highs and lows. In medical school we had learned twoimportant medical maxims. One was when you hear hoof-beats, dont think of zebras,

which was a way of saying that rare illnesses really are rare, and that common diagnoses

should be thought of first. And we also learned Suttons law. Willie Sutton was a

bank robber in the 1930s. When he was finally caught someone asked him why he

robbed banks. His answer: Because thats where the money is. If an illness looked

like a depression, walked like a depression, and quacked like a depression, it was, we

thought, a depression. We thought wrong.

It is especially for all the still misdiagnosed people and their families that we are

writing this book, and also for the people who are finally getting the right diagnosis and

treatment after all these years, and for health professionals who struggle to sort out the

symptoms of this disease. We offer this book as a field guide for patients and.

professionals alike, as the field of psychiatry wakes up to the many and varied forms of

bipolar illness, the great pretender.

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Part I the diagnosis and the illness

2. Bipolar illness: making the diagnosis

history

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In the last chapter I described bipolar illness as two processes -- an activating

process and a depressing or de-activating process. They can vary independently, mixing

and mingling in any possible combination. One key word here is vary. Symptoms

change over time, so the diagnosis requires looking carefully at a persons history, not

just looking at the current symptoms. The only clear-cut activated state might have been

five years ago or twenty years ago, for example, but its important to find out about it. In

fact it might be the key to understanding whats going on currently.

Its important to keep in mind that bipolar illness usually starts young. Thirty

years ago the most common age of onset was in the 20s. Now the most common age of

onset is in the teens. We dont know why, but its getting earlier and earlier. Part of this

may be better diagnoses, but another part is that ALL the common psychiatric illnesses

are becoming more common, and ALL of them are getting earlier in onset. Theres an

epidemic of psychiatric illness. My own theory is that, having evolved in simpler times,

we were not made to cope with this complicated, fast-paced, and stressful world weve

created. When I was a child I went out and played after school. When my oldest

daughter gave up the piano at age ten, I remarked that she had already given up more

activities than I had had in my entire life. Anyway, whatever the reason, bipolar is in

general an illness that starts early. Depression, on the other hand, is in general an illness

that starts later, an illness of 40 year olds, not 14 year olds.

But a 14-year-old CAN have a plain vanilla depression. The question though is

whether it stays a plain vanilla depression later in life. Researchers have compiled what

they call life charts of people with bipolar illness: graphs representing the history of

someones mood extending over a lifetime. These sometimes show a depression early in

life, perhaps in adolescence. Then another depression in the early twenties. Then

another depression. Then a manic episode followed by a depression. And so on. You

get the picture: a simple depression early in life can be the forerunner of bipolar illness

later.

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An antidepressant drug study was done at Washington University in St. Louis,

trying a new drug on pre-adolescent children with depression. In order to make the study

as clean as possible, any child with any hint of bipolar symptoms or any family history

of bipolar illness was eliminated from the study. The antidepressant didnt work, by the

way, but thats not the point of this story. Two years later one of the researchers decided

to see what had become of the children in the study: one third of them had since been

diagnosed with bipolar illness. This is one third of a group in which every effort had

been made to ELIMINATE any hint of bipolar illness. And this was only two years later.

The number diagnosed with bipolar disorder could only rise given more time. Other

studies have come up with similar numbers, saying that roughly 30-50% of children with

depression later go on to develop bipolar disorder. These numbers use diagnostic

standards that I think are overly strict, so I would guess that at least 50% of youngsters

with depression later develop bipolar spectrum illness. Or perhaps it would be more

accurate to say that depression is for many youngsters merely an early manifestation of

bipolar illness.

This may sound like pure semantics but it has implications for treatment.

Antidepressant medicines can make bipolar worse, or bring it out earlier, or even bring it

out when perhaps it would not have appeared at all. Given the odds of later being

diagnosed bipolar, should a youngster who looks depressed, just depressed, be given an

antidepressant, or would it be wiser to start a trial of mood stabilizers? No one has a

good answer to this question yet.

Antidepressants have been in the news in recent years, accused of causing suicidal

thinking and suicidal behavior in youngsters. My interpretation of this is that all of those

kids were bipolar but misdiagnosed as depressed, or they were in fact just depressed but

destined to become bipolar. The antidepressant then caused agitation and activation

combined with depressed mood, a mixed state, and so the kids got suicidal.

The typical story of these cases is instructive. The kids are taken to primary care

doctors who prescribe antidepressants. Perhaps there is some initial brightening of mood,

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what the parents or referring clinicians thought was attention deficit disorder. Every new

patient was given a kiddy SCID. The SCID is theStructuredDiagnositicInterview for

Diagnosis, and the kiddy SCID is a SCID thats been adapted for children. Someone

suggested going back over all the kiddy SCIDs they had accumulated, to see what was

there. They were surprised to discover that 16% of the children met criteria for a

diagnosis of bipolar. Part of the surprise was that they knew that other academic centers

also used the kiddy SCID. Why hadnt anyone seen this before? It turned out that the

other centers left outthe bipolar section of the kiddy SCID because everyone knewthat

children couldnt have bipolar disorder.

I cant think of a better example of how easily we mislead ourselves when we

dont bother to ask all the questions. So what are the bipolar questions? DIGFAST.

DIG FAST

In order to diagnose mania remember, think activation not euphoria there

are a set of criteria that need to be met. There are seven symptoms and you need 3 plus

euphoria, or 4 plus irritability, to make a diagnosis of mania. Remember that someone

who is bipolar is not necessarily manic NOW, so these are standards to apply to any

episode of activation at any time past or present. The seven symptoms can be

remembered with the mnemonic dig fast.

D = Distractibility

Distractibility is not exactly the same thing as poor concentration: its just one

form of poor concentration. People who are depressed often have trouble concentrating

because their thinking is fuzzy and vague. They cant get started thinking about

something. Their minds are empty. People who are activated have too much flying

around in their heads, so their attention flits from subject to subject. Attention deficit

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disorder is also characterized by distractibility, and someone can have both bipolar

disorder and attention deficit disorder, so distractibility alone is certainly not enough to

make a diagnosis. Later in this book Ill return to the topic of attention deficit and bipolar

disorder. Patients experiencing bipolar depression (not a mixed state) often report that

their minds feel empty or slowed.

I = Insomnia

Insomnia in this diagnosis does not necessarily mean an inability to sleep. People

who are activated sometimes dont NEED to sleep; they dont DESIRE sleep. In the

extreme case, they stay up around the clock, possibly for days at a time. I had a patientwho drank a fifth of scotch every night so that he could sleep for five hours. More

common is just a diminished need for sleep: four hours are plenty! This sounds too

jaunty to convey the possibilities. In clinical depression, people also usually have sleep

problems trouble going to sleep, frequent awakenings during the night, waking up early

and not being able to get back to sleep. But a bipolar patient who is mixed, both

activated and depressed, may be sleeping only 5 hours and feeling tired all the time,

complaining that s/he wants to sleep but cant. If the person has other symptoms of

activation, the diagnosis of bipolar may be clear, but at times it may be hard to figure out

which kind of insomnia this is.

G = Grandiosity

In the extreme, someone with bipolar illness may be psychotic and think they

have special powers and can fly, for example. More common is a pattern in which you

just feel you can do SO MUCH! You can take on that project at work, and volunteer at

church, and arrange to take your uncle to the hospital, and plan that big dinner for friends,

and pick up the kids after school, and so on and so forth. I had one teenage girl tell me

she just had this feeling that she could do anything she wanted to do that she was

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capable of anything and was permitted to do anything. So what she did was punch her

mother. I had a 14 year old boy who nonchalantly asked his mother for the car keys

because he wanted to go the mall.

F = Flight of ideas

Another phrase for this is racing thoughts. Sometimes people think they have

racing thoughts when really they just have a lot on their minds. Theres this, theres that,

oh my god what about the other thing, and so on. Racing thoughts are not merely busy,

theyre FAST:yourmindisgoingsofastthatifyouhadtosayitoutloudyourtonguecouldhard

lykeepupwithit. Or-maybe-it-isnt-that-fast-its-only-this-fast-but-its-

still-pretty-fast-and-you-dont-have-to-be-talking-this-fast-but-only-

thinking-this-fast.

Sometimes people say they dont have racing thoughts but they have multiple

thoughts: several thoughts SIMULTANEOUSLY. This is something I learned about

from one of my patients. I was treating a teenage boy who I thought was bipolar, but I

couldnt nail down the diagnosis. I asked repeatedly, over a period of weeks and months,

about racing thoughts. I asked again and the boy said, with exasperation: I toldyou I

dont have racing thoughts. I do have six of them though. I said Really? Tell me

about that.

The usual stream of thought is like traffic on a one-lane road with traffic moving

at 60 miles an hour. If theres a lot on your mind, theres a lot of traffic. If there are

several things on your mind, the traffic will be mixed: theres a truck, a car, a car, a van,

another truck. If your thoughts are racing then the traffic is moving 100 miles an hour. If

you have multiple thoughts then youve got a 5-lane highway. Having multiple thoughts

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is like having three different televisions tuned to different stations, as opposed to channel

surfing on one set. Anyway you look at it, theres a whole lot of thinkin goin on.

Sometimes its hard to distinguish racing thoughts from anxiety. People who are

acutely anxious, especially those with panic attacks, may feel flooded by their thoughts,

mostly their fears and worries, and may confuse this with racing thoughts. If a patient

only experiences raciness during anxiety attacks I tend to discount the symptom. But

since people with a bipolar disorder can experience anxiety as part of their activation or

as a separate symptom, it is sometimes hard to tell the difference.

A = increased Activity level

Activation implies a high level of energy, and often this energy gets a lot done.

Do you ever feel like you can do the work of two or three people? Usually this means

a high level of goal directed activity: there is an intention to accomplish something, and

sometimes something actually does get accomplished. The activity can be disorganized

by distractibility, however, so sometimes little is actually achieved. Sometimes the

increased energy starts feeling uncomfortable, like Im tired but I cant stop dancing.

Sometimes it shows up as restlessness and agitation, a feeling of wanting to jump out of

your skin. And at a certain point activity can get too fast and become disorganized:

running around like a chicken with its head cut off.

S = pressured Speech

This just means talking fast. Do people ever say, Hey, slow down, youre

talking too fast?

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T = Thoughtlessness

This is the reach. You know how a lot of mnemonics have a reach? A word

thats twisted to make the mnemonic work? T is a reminder that people who areactivated are thoughtless: not in the sense of inconsiderate, but more heedless or

impulsive. They dont stop and think. They spend too much money, often in splurges or

spending sprees; they are promiscuous. This is another criterion in which I think the

DSM is too limiting. The DSM requires impulsivepleasure seekingactivities --

classically spending and promiscuity, or poorly thought-out and grandiose impulsive

business decisions. In my experience the most common impulsive behavior in bipolar

disorder is violence hitting people, throwing things, breaking things, punching holes in

the wall, kicking the cat.

duration, number of symptoms, and N.O.S.

To be called a manic episode the symptoms need to persist for at least 7 days, and

they must be severe enough to be disruptive. To be called hypomanic, an episode needs

to last at least 4 days and not be severe enough to be disruptive. If symptoms last only 2

days but are severe, they technically do not constitute either a manic or hypomanic

episode. If symptoms last twenty minutes out of every waking hour, as I had one patient

tell me, they dont fit either pigeonhole. If the symptoms occur about two days a week,

they dont fit. And so on. This is one reason many patients are bipolar NOS not

otherwise specified.

If someone is depressed and irritable, has never been euphoric, but is also

distractible, has clear-cut racing thoughts and feels like s/he cant sleep enough but has

no other symptoms of activation, s/he doesnt qualify for the official diagnosis: this adds

up to irritability and only 2 or 3 symptoms depending on how you count the insomnia.

Frequently these patients have been diagnosed with clinical depression in the past, but

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have not responded to prior treatments. I think this is a bipolar spectrum illness and

mood stabilizers, not antidepressants, are the way to go. This is another patient I

diagnose bipolar nos.

For me, racing thoughts is the most important symptom in making a diagnosis of

bipolar. If there are clear-cut racing thoughts I feel pretty confidant making the

diagnosis, even if other symptoms are missing. If there are no racing thoughts, I might

still make the diagnosis but I dont feel entirely comfortable about it. Im just not

completely convinced when there are no racing thoughts.

Some people think a bipolar patient with the label nos must have a milder

illness than someone labeled bipolar bipolar I or II. This is simply not true. For example,

the depressed and irritable patient with clear raciness but not enough symptoms to make a

diagnosis of mania may be severely suicidal or even psychotic. The person who is

activated for only 3 days at a time every week may be unable to function in work or

school, and has his life totally disrupted. These people are quite ill but just dont fit the

pigeonholes of the DSM.

beyond DIGFAST

Remember that all this needs to be looked at over time, longitudinally. These

symptoms come and go, in episodes that can last from minutes to months. Appetite often

varies along with sleep: diminished appetite with diminished need for sleep. But it

doesnt have to be this way. High energy can be goal directed, but it can also come out

as agitation, wired feelings, and restlessness. This agitation may lead to violence.

Irritability is not specific for bipolar disorder, though. It can be a part of depression

or of attention deficit hyperactivity disorder. The irritability of bipolar illness can get

driven by the high energy and so may be expressed in more extreme forms, for example

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road rage with true violence. I had someone come in who had been riding around with a

gun in case someone pissed him off, and another person who impulsively but deliberately

rammed another car when the driver annoyed him. More often, though, irritability will

just show up as mouthiness, temper, and displays of anger.

Mania can increase sexual energy and sex drive. People who are manic and

euphoric are charismatic, full of energy and life and charm and jokes. Combine this with

some grandiosity and impulsivity and you get promiscuous behavior. Sometimes I

wonder about some politicians who are charming and highly energetic and promiscuous.

Chronic hypomania? Of course someone may be promiscuous without being manic: it

could be psychologically, not biologically, driven.

Agitation and irritability can sometimes be treated with alcohol, or perhaps

heroin. Gambling and risk taking may sometimes be driven by grandiosity and poor

judgement, but this is more clearly a reflection of bipolar illness if it occurs in an episodic

pattern. Bipolar disorder can cause psychotic symptoms, most likely paranoia but

possibly other delusions or even hallucinations.

Again, these behaviors can have other causes. The diagnosis is based on a pattern

of symptoms and behaviors, not on any one thing.

family history

Even if the pattern of symptoms is unclear, a family history of bipolar disorder is

certainly suggestive. So is a family history of suicide and to a lesser degree depression or

drug and alcohol abuse. There is strong evidence of a genetic component for bipolar

disorder but many patients are unable to name a single blood relative with any psychiatric

problems whatsoever. The genetics of bipolar disorder is complex, presumably involving

many genes in combination. If you think of someones genes as a hand made up of

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cards dealt from each of their parents hands, you can imagine a situation in which

neither parent has a bipolar combination of cards, but the cards selected from each parent

come together in a combination thats just wrong, producing the illness.

trials of treatment

Worse comes to worse, and the diagnosis is still unclear, it may be worth having a

trial of treatment with some of the medications well be discussing. Sometimes Im left

diagnosing mood disorder but not being clear what kind. The drugs used to treat

bipolar illness will not make depression worse, but the drugs used to treat depression may

worsen bipolar illness. So if in doubt, try stabilizers first.

3. Clinical Depression not!

Sometimes its quite difficult to see bipolar illness underneath what looks like an

obvious clinical depression. I had one patient, for example, whom I treated for many

years for what I thought was a chronic refractory (difficult to treat) depression. She

would get depressed and I would adjust her antidepressants, increasing something she

was on or adding something new. Shed feel better but soon have medication side

effects. Id lower the dose of something and shed do well for a while, til her mood

deteriorated once more. Eventually I added the mood stabilizer lithium, but not as a

mood stabilizer. I added it as a booster, or augmentation agent, for the antidepressants.

That helped for a while, but soon we were back on the same merry go round.

Finally I remembered my own rule of thumb, that a patient whos seen 5

psychiatrists and been on 20 antidepressants is bipolar until proven otherwise. There was

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little evidence for a bipolar diagnosis except for the fact that when she felt bad her sleep,

never more than five and a half hours, would diminish even further. It was impossible for

me to tell, however, whether her insomnia was inability to sleep or diminished need for

sleep. Finally we decided on a trial of treatment with Depakote, a mood stabilizer, in

addition to lithium as well as the multiple antidepressants she was taking. She got better,

and since that time has been significantly more stable than before, requiring less frequent

and less extreme med adjustments.

Shes still on a slew of medications and the question arises: does she truly have

bipolar disorder? Beats me. Im just glad that shes doing better. I still hold my breath

when she comes into my office and I ask how shes doing: I can never take her stability

for granted. Someday I suspect that well have genetic tests and functional MRI scans

that will help make the diagnosis, but in the meantime we do our best coping with the

limits of our knowledge. One thing is sure, however, and that is that whatever she has,

its no run of the mill, routine depression.

Depressed mood in the setting of a bipolar mixed state is far more dangerous than

depression alone. One older study showed a suicide rate of 15% for bipolar disorder.

This number is probably too high, because the data was collected when the only people

getting the diagnosis were severely ill, usually hospitalized, patients. With a broader

definition of the illness, and with better treatments available, the mortality wont be as

bad, but its bad enough. The data showed that people with untreated bipolar had 30

times the general populations rate of committing suicide. With treatment that rate was

still 6 times the general rate. The agitation and depression can be tremendously

uncomfortable; people feel like they want to jump out of their skins. They may, instead,

kill themselves. The other problem is the T in digfast: thoughtlessness or impulsivity.

Feel awful, want to be dead, grab a gun, bang, as quick as that. When I hear of a family

history of suicide I think its likely that the relative in question did not have clinical

depression, but had bipolar illness.

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Bipolar and ADHD

Occasionally someone will come in saying that they have attention problems.

Perhaps they were diagnosed in childhood with attention deficit disorder (ADD) or

attention deficit hyperactivity disorder (ADHD). Perhaps they had been given Ritalin,

and perhaps it had helped. But perhaps they have bipolar disorder instead.

The diagnosis of attention deficit disorder is made by looking at a checklist of

symptoms. Attention deficit disorder, with or without hyperactivity, is not something

that is developed later in life; its something youre born with. There must be evidence of

attention problems by the age of 6 or 7, the age that school begins. The most common

symptoms are distractibility, carelessness, difficulty sticking with complex or demanding

tasks, avoiding demanding tasks, losing things, restlessness, boredom, irritability,

changeable moods, appearing as if driven by a motor (a quote from the DSM

diagnostic guide), impulsivity. Sound familiar? One study showed that people with

bipolar disorder had more symptoms of attention deficit disorder than people with

attention deficit disorder did.

Does this mean that every person with bipolar disorder has attention deficit

disorder? No, not really. It just means that sometimes its hard to know if someone with

bipolar disorder also has ADD or ADHD. What needs to be done is to make the bipolar

diagnosis if appropriate and defer any conclusions about ADHD. Then treat the bipolar

disorder. Then go back and re-evaluate the attention issues.

Ive had bipolar patients who thought they had ADHD discover they could

concentrate just fine once their racing thoughts were controlled. On the other hand, Ivehad people who were no longer activated but still had the attention issues that lead to an

ADHD diagnosis, and who did much better with, for example, Ritalin along with their

mood stabilizers.

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4. Unstable mood and personality disorders and sometimes

PTSD

Borderline personality disorder is a diagnosis thats sometimes used as an

epithet by mental health professionals. Thats because people with this disorder are often

so difficult to treat, so frustrating, so manipulative. They somehow know how to get to

their treaters, emotionally. Theyre unstable and their relationships are unstable. Theyre

inappropriately extreme in their emotions, impulsive and often self-destructive, quick to

anger or even violent. They have an unstable sense of themselves. Often, you wont be

surprised to hear, they really have bipolar spectrum disorder.

I dont know what percentage of people diagnosed with borderline personalities

actually have bipolar disorder. But I think its a big enough group that clinicians need to

do a better job looking for the diagnosis. After all, someone with bipolar disorder can be

unstable, impulsive, so uncomfortable that they can become self-destructive, irritable and

even violent.

Theres a complicated wrinkle in making this diagnosis: you can have both. Ithappens that many people with borderline personality have been victims of abuse,

physical and/or sexual abuse, in childhood. Its believed that these experiences can

interfere with the normal development of personality, so that a young childs primitive

and extreme notions of self, relationships and the world never get to become more

complicated, nuanced and mature. So whos doing this abuse? Often its an unstable,

drug or alcohol abusing, violent parent. This raises an interesting question: was this

parent perhaps bipolar? If so, that helps us understand (not excuse) the parents behavior.

And did this person with borderline personality disorder therefore inherit a bipolar

tendency along with being exposed to extreme stress interfering with normal

psychological development? And so does this person perhaps have both disorders,

intertwined? Also of course the trauma can cause post-traumatic stress disorder (PTSD),

with intense anxiety, flashbacks, and dissociation or spaciness. In fact, in our practice we

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have several patients with bipolar disorder, PTSD, borderline personality and, usually,

substance abuse problems all at the same time. Treating this combination isnt easy, but

its a whole lot easier if the bipolar piece has been properly diagnosed and treated. Of

course its also possible to have both bipolar disorder and a personality disorder without a

history of abuse.

Examples:

Barbara was in her late 40s when she first came to see me. She recalled

problems with depression back to early childhood, and she had started her first course of

psychotherapy, the first of many, when she was 13. She was given medications,

antidepressants, for the first time in her early 20s, and had been on antidepressants most

of the 25 years since that time. She drank regularly, sometimes heavily. She had been

hospitalized once, after cutting her wrists. She tended to get spacey, or dissociated, when

she was depressed, tearful, and suicidal. She had lifelong sleep problems. She rarely

enjoyed much of anything. Every few weeks she felt restless for periods of a day or two,

with increased energy and an increased ability to do things, but accompanied by an even

worse mood than usual, a combination of depression and irritability. It was unclear to

both of us whether she ever had racing thoughts, whether her sleep was just crummy or

reflected a diminished need for rest, or whether she any other symptoms of bipolar

activation. After her periods of increased energy, though, for the next few days she

would feel more depressed but less irritable, and would spend more time in bed and sleep

10 hours a night. In sum she did not have good evidence of a bipolar disorder, but her

mild cycling, if indeed thats what it was, was suggestive. She was adopted and so we

had no family history to help with the diagnosis.

Chronically depressed, she had given up on medications being of very much use

and didnt want to experiment. It took a long period of knowing each other before she

would agree to try new meds, and years of fiddling with various medications for her to

end up on the six (thats right, six) medications she is currently taking. Between these

meds and the excellent psychotherapy shes been getting from someone in our practice,

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she is somewhat better: dissociating less, not drinking, no longer cutting herself,

somewhat less self-destructive in her thinking, sleeping more consistently. But still

pretty miserable a lot of the time.

Sorry about that, but I wanted to include an example that reflects the unfortunate

reality of some of these cases. They can be HARD: difficult, complicated. In this case

were still trying to get it right after four years of treatment together. Making the right

diagnosis is key, but its not the whole story. Theres also figuring out the right

treatment. Dont get me wrong, THE OVERWHELMING MAJORITY OF PEOPLE

WITH BIPOLAR DISORDER CAN BE VERY MUCH BETTER WITH TREATMENT.

Those ten cases of misdiagnosis described earlier, for example, also happen to be ten

cases of people feeling really good when properly diagnosed and treated. But sometimes

its very hard. We will return to these issues when we discuss treatment in more depth,

later in this book.

One diagnostic issue that may at times be difficult is distinguishing PTSD (post-

traumatic stress disorder) from bipolar disorder. One characteristic of PTSD is

heightened states of arousal and severe anxiety. This can produce a picture of pressured,

sleepless misery than can be mistaken for a bipolar disorder. Sometimes it is only after

years of treatment that this can be sorted out.

Another common confusion is sorting out whats going on with adolescents who

have irritability and behavior problems. Studies have shown that 80% of these kids

respond to Depakote, a mood-stabilizer. So do they have bipolar disorder? Unclear.

6. Cutters adults

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One typical form of self-destructive behavior is cutting wrist cutting, leg cutting

(to keep the cuts hidden), arm cutting (wear long sleeves). This kind of cutting is not an

attempt at suicide. Instead, self-inflicting wounds serves as a distraction from other sorts

of pain, or perhaps as a way for someone who is emotionally numbed to feel something,

anything at all. This behavior is most frequent in women who have been diagnosed as

having borderline personality disorder, and in adolescents of both sexes, for whom no

diagnoses may have yet been made.

Examples of adult cutters:

Nancy was in her early 40s and had first sought help in early 20s. She had been

in and out of therapy ever since, for twenty years. She had gotten medications from her

family doctor at times, as well as from various psychiatrists over the years. She had been

on at least five different antidepressants and three different tranquilizers. She abused

pain medications, had been detoxed once, but became re-addicted almost immediately

afterwards.

We could make a good guess at the diagnosis with this information alone, based

on the five-psychiatrists-and-twenty-medications rule, but lets go on.

She cut her arms whenever she was upset, which was often. She was depressed

and cried frequently. She felt tired all the time, but hyper as well. She talked very fast

and when questioned said she had racing thoughts most of the time. She had spending

sprees, and periodic highs, which ended in her mood crashing. For 15 years she hadnt

slept without the help of a tranquilizer or pain pills. During her most depressed periods

she slept 10 or 11 hours a day and felt even more exhausted than usual. Nancy was

adopted and didnt know anything about her family history. Having read this far, youre

wondering why it took 20 years for someone to make the diagnosis. Answer: no one had

ever asked the bipolar questions, they only asked the depression questions.

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Ellen came to see me to treat her eating disorder, her depression and her anxiety.

She had been hospitalized four times because of her eating disorder anorexia alternating

with bulimia (binge eating and purging by vomiting and/or using laxatives). Her

problems went back to early adolescence when, at age 12, she first became anorexic. For

the next few years she was either anorexic or bulimic, seeing therapists but not getting

better. Finally she was given Prozac, which helped a lot, so much so that after a while

she stopped it and found she could go without it. A year later, however, she became

depressed again, but the Prozac didnt work as well the second time around. She dropped

out of treatment until, in her early 20s, her weight became dangerously low and she had

her first hospitalization. About two hospitalizations later she started cutting, having

picked up the idea from some fellow psychiatric inpatients.

She was depressed, with suicidal thoughts but no immediate plans to kill herself.

Her concentration was poor. She had no racing thoughts but had multiple thoughts most

of the time. She was irritable most of the time but occasionally had wonderful moods

lasting up to a day, followed by her terrible periods of depression. She could sleep as

little as 3 hours a night for 3 days running, during which time she felt restless, anxious

and depressed. She spent a lot of money at these times but didnt like the feeling: I feel

tired and a lot of energy at the same time. I cant slow down. She was multitasking

and doing ten things at once. At the end of these periods she would sleep 12 hours a

night for the next two days. Diagnosis: bipolar disorder. Again: why did it take so

many years to get the diagnosis? No one asked the right questions.

This is not to say that every adult cutter has bipolar disorder. But enough do so

that its an important possibility to consider.

Consider, too, Ellens early history of eating disorder and depression, which

responded well, at least the first time around, to antidepressant treatment. Certainly no

one diagnosed her as bipolar at that time, and it must have all looked very

straightforward. But there is no record that anyone asked the bipolar questions at that

time. And either way theres a problem. Perhaps she had bipolar symptoms at that early

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time, too, in which case missing the diagnosis and giving her antidepressants was really

poor treatment, since although the antidepressant may help in the short run, it might have

made things worse long-term (more on the effects of antidepressants later). On the other

hand, maybe she didnt have any bipolar symptoms at that time and we have another

instance of an adolescent depression being a precursor to bipolar illness later in life,

raising still broader questions about whether its ever a good idea to give adolescents

antidepressants.

7. Adolescent cutters and the risks of antidepressants

This brings us to the problem of adolescent cutters. These kids are far more

diverse than the adults, and can have behavior problems, anxiety disorders, depression or

bipolar disorder.

Mary Ann was a 9th grader having some problems with her schoolwork. Her

teachers wondered if she had a learning problem. Or was she depressed? She saw a

therapist and revealed that she had been cutting herself regularly for over a year, cutting

only on her legs so she could conceal it. She had started cutting more frequently in the

last few months, almost every day. She described very mild mood swings, with periods

of one or two hours of feeling really, really good, followed by down periods lasting

several days. It wasnt clear whether the ups were anything beyond normal excitement or

pleasure over happy events. She had some irritability, but only with her parents. (What

adolescent doesnt?)

Although she could still enjoy things, her mood had been deteriorating further

over the prior few months, and she was starting to cry regularly. She had started having

thoughts wishing she were dead and a few days before seeing the therapist had her first

thoughts of suicide. She had never had racing or multiple thoughts, and never

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experienced periods of excess energy. Her concentration had deteriorated along with her

mood, but was not distractibility so much as an inability to think. She had a longstanding

sleep problem, difficulty falling asleep and only five or six hours of sleep, but slept nine

or ten hours on weekends. Perhaps her sleep problem was just anxiety. Her appetite had

always been normal. She was adopted and so we had no family history to help.

So what did we have for a bipolar diagnosis? Think DIG FAST. D, distractibility

not quite. I, insomnia in the form of diminished need for sleep not clear. G,

grandiosity no. F, flight of ideas no. A, increased activity or energy level no. S,

pressured speech no. T, thoughtless, impulsive acts yes, her cutting. There was no

way we had enough evidence for a bipolar diagnosis, but her mild mood swings were

suggestive. I made the diagnosis of depression with anxiety, with a rule out, i.e.

possible alternative, of bipolar disorder, along with another rule out of a personality

disorder.

I prescribed an antidepressant after having a long talk with her and her mother

about the possibility of bipolar disorder emerging. She started the antidepressant and

began to feel at least somewhat better. But about six weeks into treatment she took an

overdose of her antidepressants. She said she didnt really want to die, but just to get sick

and avoid school. The fact that she told her parents about the overdose immediately after

taking the pills lent her story some credibility. She told me the she was having mood

swings, by which she meant very rapid mood shifts. When her mood was up she was

truly euphoric and, to some degree, grandiose. Then her mood would plunge for no

reason and she would want to die. She was having racing thoughts on and off

irrespective of her mood. She now was having periods of pressured speech. These

swings were getting worse, more rapid and more extreme, but she had been having them,

she said, for weeks or months. It wasnt clear whether these swings were just more

extreme versions of the mild swings she had been having for a long time, or were

something qualitatively different. What was clear was that she had bipolar disorder. I

stopped her antidepressant and started a stabilizer, Depakote. Within a few months she

was feeling fine, on a combination of two mood stabilizers, Depakote and lithium.

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Some psychiatrists think that if bipolar symptoms only emerge when someone is

given antidepressants, then that person doesnt really have bipolar disorder. In my

opinion those psychiatrists are wrong. Right or wrong, though, however you label those

patients, they have to be given stabilizers before antidepressants can even be considered.

Was it a mistake to start an antidepressant? Antidepressants can make bipolar

disorder worse, but there was little evidence for a bipolar diagnosis. My experience is

that even with really good evidence it is hard to convince adolescents and parents that a

youngster has a bipolar disorder. They dont want to hear it. And I thought bipolar was

only a possibility, a rule out. Its always easy to know what to do in retrospect, but

given the evidence at the time I had little reason to do anything other than what I did. I

do think its important to alert teenagers and their families to the possibility of bipolar

symptoms being triggered by the antidepressant. At least youve got a chance to catch

the problem before it spins entirely out of control.

Still, we have those life charts showing early depressions with bipolar illness

emerging later in life. And depression is a disease of forty year-olds, not fourteen-year-

olds. Should adolescents with depression and no good evidence of bipolar disorder be

given stabilizers as their first line treatment? How about depressed adolescents with

just one or two bipolar symptoms? A family history? This position has little or no

support among practitioners. I dont do it myself, but I wonder if someday, when the

proper research is finally done, this will be standard practice.

As Im writing this, I just spent some time reviewing all the adolescent cutters

Ive seen in the last two years. Its impressive how many question marks there are in my

notes. The typical case has some depression, some anxiety and some situational

problems, difficulties with the parents, some deterioration of schoolwork. There is rarely

clear evidence of bipolar disorder. But there is rarely a clear picture of anything. There

are a lot of rule outs in my diagnoses. Early trials of antidepressants and later trials of

stabilizers. Patients stopping their medications and returning months later to start over.

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Or just disappearing from my practice. This may be a commentary on adolescents who

cut themselves, or perhaps its a commentary on me and my ability to help them. Id like

to think its the former, and I think it is, as there are a reasonable number patients like

Mary Ann who, even if things are confusing at the start, end up doing really well.

More cases:

Kelly, a 15 year old, had problems with irritability and anger which had started

about six months before she came to see me. The irritability lasted a few hours to a day

or two, and then went away, but then she felt blah, low energy and mediocre mood.

That would last one or two days, and shed just sit around during those periods. When

she was angry she punched holes in the wall. She had started cutting herself a few

months prior to seeing me. Her moods were labile, varying widely and quickly. During

the periods of irritability she had pressured speech, broken concentration, high energy,

and slept only three or four hours. During the blah periods she slept ten or eleven hours

a night, felt mildly depressed and had some passive wishes for death but no true suicidal

thoughts. She still couldnt concentrate well but she didnt feel at all racy. Shes now

fine on a low dose of lithium. This sounds so straightforward, and indeed it was because

I asked the bipolar questions. Someone who did not ask the bipolar questions would have

diagnosed her with depression and given her an antidepressant.

Jennifer had been cutting her wrists and forearms for a few months before her

father happened to notice the cuts. Her parents took her to a therapist who suggested

evaluation by a psychiatrist. As a young child Jennifer had always been very sensitive,

easily upset by criticisms or disappointments. For years, though, she said she had been

feeling more and more numb, and she started cutting herself in order to feel something.

She had felt depressed for as long as she could remember. And she lookeddepressed,

one of the most depressed-looking kids I had seen in 25 years of practice. She said she

had used to think about dying, but that those thoughts had gone away a few months ago

as she got still more numb. She had racing thoughts all the time, and sometimes multiple

thoughts, but she said her concentration was ok. Her parents were surprised to learn that

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she only slept two or three hours a night. She went to bed at a normal hour and they had

assumed she was sleeping, but she wasnt. She said she was not really tired. Her

energy was always low. She had no impulsive behavior other than her cutting, no

irritability and no periods of elevated mood.

Now, remember the official DSM criteria for the diagnosis of mania: 3 dig fast

symptoms plus euphoria or 4 dig fast symptoms plus irritability. So Jennifer, had 3

digfast symptoms -- insomnia, flight of ideas, thoughtlessness. But she had never been

either euphoric or irritable, so she never met criteria for mania and so she never met

criteria for bipolar disorder. The official criteria are in fact of only marginal use out here

in the real world. Most bipolar patients end up with a diagnosis of bipolar disorder

n.o.s. (n.o.s. = not otherwise specified): the wastebasket category for people you want to

diagnose with bipolar but who dont fit in the usual pigeonholes. The DSM sucks.

8. Sequential diagnostics and prioritizing treatment

Dawn was in her late 30s when she came to see me. Her first course of treatment

had been in her teens, after she had gotten into alcohol and drugs binge drinking and

heroin. Earlier in her life she had been physically and sexually abused. She described

feeling pressured all the time, doing everything fast but getting nothing done. Her energy

varied from high to higher. She had periods of racing thoughts lasting up to a week at a

time, accompanied by increased irritability. She slept four or five hours a night. She had

never been either euphoric or depressed she was just irritable in varying degrees. She

had been given Prozac and felt high for a few weeks, then had a few weeks of being tired

with increased sleep, then had no e

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The Bipolar Spectrum

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