Managing Problems Associated with Bipolar Disorder

Dr. Eric Bellman has over 20 years of experience working with people who have bipolar disorder. The discussion focuses on channeling your manic energies in a positive manner, medication non-compliance and dual diagnosis issues.

David HealthyPlace.com moderator.

The people in blue are audience members.

David: Good Evening. I'm David Roberts. I'm the moderator for tonight's conference. I want to welcome everyone to HealthyPlace.com. Our topic tonight is "Bipolar Disorder: A More Detailed Look". Our guest is Dr. Eric Bellman.

We are going to take a look into some of the details of Bipolar Disorder. We'll be covering medication non-compliance, self-medication, and how to channel your manic energies. If you need general information about Bipolar Disorder, here's the link to the HealthyPlace.com Bipolar Community.

Our guest Dr. Eric Bellman, is a clinical social worker near Los Angeles, California. He has over 20 years of experience working with bipolar individuals in psychiatric hospitals, group homes, and in private practice. Dr. Bellman has performed everything from psychological work-ups of patients to treatment.

Good evening, Dr. Bellman, and welcome to HealthyPlace.com.. From reading the bulletin boards posts in our bipolar community, one gets a sense that, for some at least, remaining faithful to taking the prescribed bipolar medications is a difficult thing to do. Why is that?

Dr. Bellman: Hello! People often do not take prescribed medication because of the powerful nature of the manic episode. In the flow of experience, the power surge of a true manic episode leads to a sense of grandiosity, mixed with paranoia and disconnection from others. Once we are into huge projects, or the secret life of a manic episode, people absolutely resent the loss of power and the sense of loss of self that medications for bipolar disorder cause.

David: What are the ramifications of coming off the bipolar medications? And I'm referring not only to the medical or physiological issues, but the psychological issues too.

Dr. Bellman: The flip side of not taking medications for a manic episode is a tremendous crash into depression. This leads to a disconnection from one self and all of our important relationships, not to mention our work and our lifestyle. Thus, at the end of the day, we wind up fragmented, with no energy to finish tasks, and a terrible sense of shame that can cycle back into another manic episode, substance abuse or isolation and impulsive actions.

David: A moment ago, you talked about a "sense of loss of self" that having to take bipolar medications may bring about. Can you explain or elaborate on that?

Dr. Bellman: Yes. The person experiencing a manic episode is a universe unto themselves with a flow of seratonin, adrenalin, powerful surges of sensory awareness, grandiosity and paranoia, that minimizes the connection with the world around us and our relationships. In a sense, we are the masters of our own universe. This experience is not recognizable to the very person who is not going through it the next day. Thus, we have such disconnected states of feeling internally, that it is difficult to integrate our sense of our self, especially afterwards when we experience the feedback guilt and shame from others so that we cannot trust ourselves to be consistent or experience ourselves as whole.

David: So, I'm assuming that you believe it's very important to continue taking your medications for bipolar disorder. If that's the case, and it's relatively easy to see, why would anyone want to quit?

Dr. Bellman: People quit because they get caught up in a biologically and externally stressful combination. This combination triggers what causes a manic episode, that again puts us into the world of the manic power surge of the true manic episode. These episodes are marked by feelings of grandiosity, paranoia, huge projects and secret compulsions. These compulsions can include gambling, promiscuity, and buying sprees. Therefore, the manic episode acts as it's own drug and creates it's own internal world that we become addicted to.

David: Here are a few questions, Dr. Bellman, on the topic of taking bipolar medications:

Melody270: Why do doctors take you off of medications, when they think you are doing better, since bipolar disorder is a life-long thing?

Dr. Bellman: There are doses for acute episodes to come down off of. Then, there are what we call "maintenance" doses to help prevent re-occurrences. And then, sometimes we want to take a medication holiday because there may be long-term side effects. Generally, it is foolish to take somebody with fairly frequent episodes or tremendous life stress off of medication. I train people to look for red flags so they can prevent manic episodes by using the following techniques:

For example, I often have my clients keep a note card in their pocket with phrases and thoughts that are red flags as to the beginning of a manic episode. For instance, we might think "I don't feel like sleeping tonight because the great American novel is sitting right inside of me." But even if it is, the flow of creativity is better if we control the manic peaks and valleys.

LeslieJ: Do you ever see anyone being non-compliant when they are in their depressed cycle? You have only mentioned the manic phase. Is that the most dangerous time for us in terms of becoming non-compliant?

Dr. Bellman: Indeed, the depressed cycle involves not only the loss of the up manic phase, but the reality of the wreckage that we just created in our lives and relationships, as well as a biological component. This time is thus ripe for acting our behaviors, suicidal thoughts and substance abuse, and giving up in therapy and on ourselves. Substance abuse also, is antagonistic to most medications for bipolar and we can also fall into that trap too at that time. So, in times of depression, we are indeed at risk, but it also presents the opportunity for reflection and reconnection with our lives, and can be the beginning of an upward movement to change.

David: What do you think about the idea of "mood charting"? Do you find it to be a useful tool and does it help with medication compliance?

Dr. Bellman: I think it is very important to evaluate all the cycles of life, and this is one. I would also pay attention to the family experience genetically in their life cycle and to hormonal and other biochemical cycles in the body as we are learning more-and-more about this illness. Sometimes, I wish it was a hundred years from now when we will be able to computer-simulate the actions of the brain. This also emphasizes why we will always need a therapeutic relationship that is safe to share in the experience.

pookah dedanaan: I take medications faithfully, but still suffer from the highs and crashes. I know the highs are happening, yet, I am unable to regulate it. I know when the crashes are about to occur, and this is the time during which I am more likely to self-injure. Any suggestions?

Dr. Bellman: I hope you are in intensive psychotherapy because I have a feeling that you, like many other people, have multiple situations and stress going on in your life at the same time. Self-injury may not be directly related to the episode but to your experience of your relationships around you. Please explore this in therapy.

David: What about people self-medicating - drinking alcohol, taking drugs to ease the manic and depressive episodes. If that frequent among bipolars? And it probably creates more problems, am I correct?

Dr. Bellman: Yes. Substance abuse is the number one dual diagnosis with bipolar disorder. This happens because people do not even realize they are bipolar, or they want to ease the depression that follows manic episodes. Or again, in the case of methamphetamines, they self-medicate in an attempt to recapture the power of the manic episode.

So, chemical dependency can then become its own problem and addiction, reformatting the brain to experience pleasure through neuropathways that are only artificially induced via chemicals.

A third problem is, that medications for bipolar and chemical dependency cannot co-exist at the same time, so we can subconsciously maintain the addiction to use against any medication.

Finally, the way that the mental health care system is constituted is, there is more powerful political influence involved in treating substance abuse, rather than identifying bipolar disorder, but both must be treated at the same time. Let me give you an example:

Years ago a young woman went to a therapist. She had been living on the streets after a manic episode. Her family stated that she had just been released from a hospital for bipolar disorder. When the therapist saw her, a good connection was made and she was put on good medication for bipolar, but the manage care company took her away from the therapist and put her in an N/A partial hospitalization program. Even though she was three months sober. She went back to the street.

This type of thing is too bad and we need to be aware of it.

David: I'm getting some general questions about bipolar. If you need general information about Bipolar Disorder, here are the links to the HealthyPlace.com Bipolar Community and to the transcripts from previous Bipolar conferences.

Here's a diagnosis question, Dr. Bellman:

okika: Is Bipolar always a difficult diagnosis? I spent nearly 15 years without the diagnosis and correct treatment. Simply, I think, because I 'cycled' so slowly.

Dr. Bellman: Yes, it can be a difficult diagnosis because to get a good and accurate history you need a report from the patient or the family members going back 10 years. Some people do cycle very slowly, which is why therapy is important so we can backtrack life experiences. Often times, that college dropout year was chemical use masking a bipolar episode.

David: So given the fact that alcohol and drugs can give a bipolar person a soothing, or not so bumpy experience, what are the alternatives?

Dr. Bellman: The alternatives are to channel the energy into creativity that we can modulate, while using medications for bipolar, to enjoy true accomplishments in the arts and relationships, in the flow and experience of life.

David: Which brings us to channeling manic energies in a positive fashion. Many bipolars in manic states are involved in spending sprees, hypersexual experiences, etc. What creates those feelings and how can they be controlled?

Dr. Bellman: The unregulated power surge of the manic state releases the inhibitions that surround the primitive drives. This is why the power is so addicting and we need medications for bipolar. They can be controlled by being pre-empted, as I said before, red flags, listening to feedback from others around us to warn us and to help us learn to trust.

Helen: Why couldn't we use cognitive therapy to teach ourselves to do "reality" checks? Are medications the only way?

Dr. Bellman: Helen, I absolutely agree that we need the tools of cognitive therapy as that means that we are maintaining an internal dialog with ourselves and have the ability to step back and have an objective prospective. But, meds are necessary as well during a full-blown manic episode for most people because that would be like asking an epileptic during a seizure to stop.

Judyp38: What about bi-polars who are experiencing mild forms of these so-called "red flags". It is hard for me to determine if they are red flags or not. If the person won't listen, what is the next best step? (for a spouse).

Dr. Bellman: Yes Judy, it is hard to determine the difference between everyday stress and anxiety and true red flags. What concerns me is that the person "won't listen". I think relationship counseling is very important as this is a definite trust issue.

David: But isn't it true of many individuals who suffer from a mental illness, at least at first, that they are in a state of denial. They just don't want to believe it's true.

Dr. Bellman: Yes, and this is very similar to an intervention of an alcoholic, although done more lovingly. There are also issues that may involve family dynamics and secrets that add to the denial. Again, that is why a good history is necessary. But, especially with my teenagers who are bipolar, I find the impact on the parents and their denial almost harder than that of the young person experiencing bipolar. This is one of the most challenging parts of family therapy work.

David: I want to return to channeling your manic energies. Can you give us some specific alternatives to deal with those manic phases?

Dr. Bellman: First off, If you are a musician, artist or a writer, write down your ideas and thoughts and still take medications. Even in the more solo arts, and I include mathematics, engineering and physics in these, we need to stay connected to our colleagues, family and other significant relationships during these times so that two things happen:

One, the energy is dammed and channeled, like a great river that does not overflow it's banks because of the medications and our connections around us with other people. Secondly, we can then actually finish projects because we pace ourselves instead of hitting a manic peak and fragmenting.

David: By the way, if anyone in the audience has some tips that worked for them during manic episodes, please send them to me and I'll post them. Hopefully, that will help some others here tonight.

Here are a few audience responses to what's been said tonight:

okika: I think that when I was 'hypo' my doctors thought this was maybe the correct medication and improvement of my depression. My Diagnosis is actually Bipolar II. I have now been stable AND sober for 6 years.

Helen: I agree about relationships. Maintaining them helps me avoid withdrawal into a distorted inner world and is a good check on whether my behavior is getting inappropriate - "red flags".

derf: If you feel your head tingling or are getting goosebumps from "profound" thoughts, force yourself to sleep.

David: Here are some more questions, Dr. Bellman:

Bemused: What about complete and total trust in a relationship turning all-consuming, not being able to be comfortable at all without that trusted person's physical presence?

Dr. Bellman: For adults, trust and dependency is voluntary, not involuntary. That does not mean that there are not great attachments, loves and soul mates. It just means that there are more evolved feeling states to be explored beyond the dramas of need, abandonment and betrayal. Please explore these in therapy, Bemused.

Bounder: What about the effects of caffeine during a manic episode?

Dr. Bellman: Bounder, caffeine can have a paradoxical effect during manic episodes that relax one. I would look at the heavy use of caffeine as red flags in two ways:

One, that the person is trying to preempt the beginning of a manic episode, or two, there are other stresses in a person's life that can trigger either pole of bipolar disorder.

David: What about sugar and carbohydrates? Would you put that in the category of self-medicating?

Dr. Bellman: Absolutely, as well as compulsive eating, but I am also very careful to get all my patients a good physical workup because there could be thyroid or low blood sugar or other physical conditions and disorders that can mimic bipolar disorder.

kbell: Can you give some example of family dynamics that contribute to the denial?

Dr. Bellman: Yes. If there has been any mental illness, substance abuse, or suicide, or cataclysmic events such as the holocaust, the families are reluctant to accept that the experience could happen again thus "re-opening old wounds". Plus, there may have been criminal activities, physical, sexual or emotional abuse that led to family secrets that the family hoped would die with their generation.

Judyp38: I am not bi-polar but my husband is (for two years only). How do bi-polars want to be treated? Do they take responsibility for their character or should we take into consideration that they are "bi-polar"?

Dr. Bellman: Most people want to be treated as loving human beings and not be looked at as being weird. We need to remove the stigma of mental illness, and perhaps even that phrase. I think the best way to talk about it with your husband is as an epileptic that has seizures that need to be treated with medication.

derf: On a mood scale of 1 to 10, 1 being severely depressed and 10 being out of this world manic, where would you say the most productive and creative BP people operate at?

Dr. Bellman: Five to seven is optimum; again as long as we are creative and connect with others, a little bit on the high side is OK. But keep in mind that research indicates that 0-1 is not most at risk for suicide, but 2-3 is because they have more energy.

David: I want to thank Dr. Bellman for coming tonight and sharing his knowledge and experience with us. I also want to thank everyone in the audience for participating. I hope you found it helpful.

Again, thank you Dr. Bellman for coming tonight.

Dr. Bellman: Thank you, and everyone in the audience. Good night.

David: Good night everyone.

Disclaimer: That we are not recommending or endorsing any of the suggestions of our guest. In fact, we strongly encourage you to talk over any therapies, remedies or suggestions with your doctor BEFORE you implement them or make any changes in your treatment.