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<- Back to 2006.12.13.
Like most mental disorders, bipolar disorder is diagnosed
symptomatically. This is done with a book called the DSM. The
idea is, if you spend 100 years listening to people complain
about their mental states, you find the complaints tend to fit
into groups. Those groups are given names like "schizophrenia",
"bipolar disorder", or "unipolar depression", and written in the
book. This is something of a black art, but until we understand
the mind better it's all that can be done.
Interestingly, there are some gene sites implicated in certain
types of bipolar disorder, and as gene sequencing becomes
affordable an objective test for the disorder may become a
reality. And gene sequencing is getting orders of magnitude more
affordable (than it was with techniques like gel electrophoresis)
lately, thanks to the development of "gene chips". See for
instance, 23andme.
Generally speaking it is best to avoid any diagnosis from the
DSM. It only makes sense to take one on if doing so helps you.
For me, I was shocked to find an accurate description of problems
I've had since I can remember concisely written in a book. It
was like somebody had read my mind. So that was interesting. I
then went to a shrink to get a professional opinion, to mitigate
against problems associated with self-diagnosis.
The DSM is constantly changing as new data is gathered.
Disorders like schizophrenia are broken up into subtypes, or
given new names entirely. There are several subtypes of bipolar
disorder, and it's a good first step to find out which one you're
dealing with. In acute cases it can be obvious. In others, it
may be necessary to observe mood swings over a period of time.
My doctor recommended I keep a mood log. Every time you notice
you're feeling great or shitty, write down the date and time.
After a month or two, you may see a pattern. The duration
between highs and lows is one of things that distinguish the
subtypes of bipolar disorder. A shrink can help you with this.
The diagnosis itself isn't terribly important, as the treatments
aren't terribly differentiated (despite any claims to the
contrary). What's more important is gathering an awareness of
your problem.
Awareness is probably the single thing that's helped me the most.
I will recommend two popular books:
The Eden Express
This is by Kurt Vonegut's son, who went crazy with bipolar
disorder on a commune in the '60s, got institutionalized, and
then recovered completely, went to medical school, and is
currently a practicing pediatrician! An amazing story, and a
very lucid account of the illness by a doctor.
An Unquiet Mind
Another good one, written by a female psychiatrist with the
disorder.
Beyond introspection, there is the discipline of the body. A
steady routine for the body is a crucial element of treatment.
Even with drugs, the long-term effectiveness of treatment hinges
on your daily routine. In rough order of importance...
* Enough sleep, at consistent times. This may 7, 8, or 9 hours
a night. Find what works for you.
* Regular exercise, especially cardiovascular exercise, but
anything is better than nothing. A 15-minute walk every-other
day is a thousand times better than nothing.
* Reasonable diet. Eat enough, avoid pigging out on sugary
foods, and if you don't eat meat, try adding it to your diet.
* Spiritual practice can help. Meditation, gardening, singing
in a choir.
* Best to avoid caffeine. If you're an addict, start by having
no caffeine after noon. Then switch from coffee to tea. Then
you can try eliminating it entirely. If you have trouble with
one of these steps, just go back a step, no big deal. Again, an
ounce of awareness is worth a pound of prescription.
* In the winter, consider using a light box. My doctor loaned
me a Brite Lite IV. I then bought their LED model, but I didn't
think it was nearly as good as the (florescent) Brite Lite. But
I did find the "Port-a-Sun" from lighttherapyproducts.com to be
about as good as the (more expensive) Brite Lite.
If your case is severe (you're in immediate danger of suicide or
crashing your car) introspection may have to wait, and you may
not capable of sticking to a routine. In such cases I believe
temporary institutionalization is the best option, in theory.
Unfortunately, in real life institutions may not live up to
theory (but many are effective, and I believe this is primarily
because they help patients stick to routines like the above).
And they're expensive. You might consider moving in with family
or close friends, at least temporarily, as a more affordable
measure to help establish a routine.
That brings us to drugs. Take them if you have to. Stop taking
them when you can.
The first thing to understand is that almost every psychiatric
drug available is used for bipolar disorder. This means we don't
have a clue how to treat bipolar disorder. There's one
exception: lithium. And it's a big exception. In fact, it's the
most 'specific' drug in all of psychiatry. It's life-saving for
acute type I bipolar disorder. It can be hell to take, though.
Don't take it unless you've had warnings from family members and
close friends that the alternative is ruin.
If you take lithium, let your doctor manage the dose. Find a
doctor you can communicate well with. If you can't find a good
one before you feel you have to start treatment, resolve to
switch if you can find a better one in the first 6 weeks of
treatment. Ask the other docs what they think of your current
treatment when you interview them. Don't interview too many.
After 6 weeks, try to stick with your doc until you've been off
lithium with no problems for a year.
If you're not a candidate for lithium, you're a candidate for,
like I said, just about every other psychiatric drug in
existence. Many doctors will tell you something like 'finding
the right combination of drugs is an ongoing process'. But
unless they're a fucking clinical genius, this is B.S. Here's
what I recommend:
Start with Lexapro. Ask for a low dose, move up to one or two
higher doses at most, if necessary. Back off *slowly* if it
doesn't work or when you try to stop taking it.
My shrink told me SSRIs like Lexapro were contraindicated for
bipolar disorder because of the risk of inducing mania. However,
theory suggests, and evidence is favorable that they should be a
good first-line treatment for mild to moderate bipolar disorder.
If Lexapro alone isn't doing the trick, try Neurontin, either
instead of Lexapro or in combination with it, on the advice of
your shrink. If you aren't a candidate for lithium but would
like to try drugs, you can effectively demand these particular
drugs.
After you've been through all that, you should know what to do
about your drug therapy. I don't think anticonvulsants like
Lamictal have a very good therapeutic profile for bipolar
disorder, despite the fact that they're 'in' at the moment. And
I don't think antipsychotics are a good idea at all, unless
you're acute and lithium isn't working or is causing intolerable
side effects.
There are some case studies and hand-wavy ideas supporting the
use of cannabis in bipolar disorder. At least it makes a good
active control for introspection (as long as you see it as
medicine, and not a party drug or way to get 'wasted').
Cannabis can be used as an acute or chronic therapy. If you
notice you're depressed or in a 'black mania', a couple of puffs
on a small pipe may give you a chance to snap out of it. As a
chronic therapy, try eating a small amount of cannabis caramel at
the same time every day, 15-30 minutes before a meal. As always,
be wary of mood swings, and don't start chronic cannabis therapy
when you're starting or stopping (or changing the dose of) a
psychiatric drug.
I've saved the best news for last. If you have any mood
disorder, the following may be an effective therapy: fish oil.
Even if it doesn't help your mood, it's still good for you! It
can be taken along with any/all of the above drugs.
Fish oil has been subjected to a number of studies. Based on a
careful review of these, here's what I recommend: take one
teaspoon of Nordic Naturals Arctic-D cod liver oil shortly before
breakfast or lunch and another just before bed. Do NOT use any
other kind of fish oil.
Zinc deficiency can be ruled out with something like this. Take
one per day, with/after a meal (or it could upset your stomach).
One more thing that's very important: the "kindling effect". The
idea is, every time you experience mania, black mania, or severe
depression, you 'burn' the experience into your brain. One way
to think of it is: we tend to get better at what we practice.
Unless you want to become an expert on feeling like crap, it's
best to try to control your moods... the sooner the better. This
is the biological reason why awareness and treatment are so
important; chances are that if you continue with mood swings,
they'll get worse. And while mania may feel fantastic, it cannot
last. Sooner or later it will give way to depression. It also
damages the brain in ways that are now observable in brain scans.
Letting go of mania was heart-breaking for me. It's still the
one thing that haunts me.
You have a right to peace of mind. Don't accept mood swings.
Learn to recognize them and prevent them.
Good luck,
-Carl
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clumma@gmail.com