Posted by: thealienist | October 10, 2014

The Bipolar Traps

In the same spirit as I wrote previously in “The Anxiety Traps,”  I see some common traps faced by those who suffer from bipolar disorder.  Some of the traps occur most often in those who find themselves frequently stuck in depressive episodes.  Other traps are built for those in frequent (and especially mild) manic or hypomanic episodes.  Let’s see what it is best to avoid.

One of the most common traps I see in people suffering from bipolar disorder is “the hypomanic trap.”  In these cases, I see people who have experienced the benefits of hypomania.  They feel very energetic.  Their minds are fast and nimble.  They are highly motivated to be involved in their lives.  They have self-confidence and an optimistic outlook.  They are social and talkative.  Many are very productive during these times, and they like it — a lot.  The main drawback of these times is that, along with the benefits of hypomania, there is often irritability and impulsivity.  My patients may not see it as much trouble, especially in the light of the benefits they feel, but family, friends, co-workers, and bosses may see these problems as too severe.

The attractiveness of hypmania for many of my patients is almost irresistible.  Many patients try to adjust their mood stabilizers to achieve this state and stay in it.  I have rarely seen this succeed for long.  These patients are frequently insensitive to their irritability and minimize the harmful effects of their impulsivity.  When they are confronted by their families, they feel that they are being unfairly criticized and that their families are just jealous of their abilities and success.  I have seen families break up and jobs be lost because my patients could not see what the negative side of their hypomania was doing to their lives.  The positive side was simply too strong.

And even when they do listen to their families and take the advise of those who care for them, they have a difficult time.  When they get good treatment, they often feel as if they are thinking and moving too slowly.  They feel under-motivated.  They feel impaired.  Despite their loved ones commenting that “they are back to their normal selves,” they feel that they are unable to live their lives the way they prefer.  Some will tolerate this for the sake of their relationships and their safety.  Many, however, will feel compelled to adjust their treatment to try to achieve that “perfect” feeling of hypomania.  It is a terrible trap.

The other common trap I see in bipolar disorder is one that is made by collaborating doctors and patients.  The patients who are frequently in depressive episodes are miserable in ways that non-depressives cannot understand.  They have frequently tried several mood stabilizers but found that these did not raise their moods as expected.  They want to try the antidepressants that family members and friends have tried for Major Depression, and their doctor, either from ignorance or exasperation, starts them on an antidepressant.

In bipolar disorder, antidepressants can push people into manic episodes in which they can become impulsive and aggressive.  The depressive episode may have been  miserable, but in a manic episode patients can mess up their lives much more thoroughly and more quickly.  In addition, antidepressants can also put patients with bipolar disorder into rapid cycling (more episodes of mania and depression each year) or mixed states (manic and depressive symptoms present at the same time — misery on wheels!).  Thus, in an effort to stop depressive symptoms, some doctors and patients will take medications that make both mania and depression worse and more common.  It is a miserable, but avoidable, trap.

In order to avoid these traps, I encourage my patients to have someone around them who they trust to give them honest and accurate feedback about how they are doing.  Often it is a spouse or another family member.  Occasionally, it is a good, long-time friend.  I tell my patients that sometimes they are the last to know if they are manic or hypomanic.  Often, their family and friends see it long before they do themselves.  If they trust their family and friends to give them honest feedback, they can take action early and avoid manic states that would disrupt their lives.  On the other hand, when they are feeling slow and think that they must be looking and acting drugged, their family and friends can give them some feedback.  Perhaps they have been over-medicated and need to talk this over with their doctor.  Often, however, they will find that their family and friends see no sign of slowness, clumsiness, fatigue, or undermotivation.  The patient has simply become accustomed to the feeling of hypomania or mania and, in comparison, normal feels slow.

These are difficult traps to manage.  Avoiding them relies on trust and an awareness that normal is not such a bad thing to be.

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Responses

  1. I’m sorry but I don’t agree with you here about antidepressants in true bipolar I disorder (as opposed to the personality and anxiety disorders that are so often misdiagnosed these days as “bipolar II”).

    Yes, it the patient is not on lithium or depakote, they can get manic with an antidepressant, but that just means that antidepressants should not be used in this population until an anti-manic drug is on board, not that they shouldn’t be used at all.

    As to them causing rapid cycling, I’ve never seen that happen in 40 years of routinely using antidepressants in bipolar depression. I don’t think that’s just because I’m lucky.

    ~ David Allen, M.D.

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    • True, if you have adequate mood stabilization, you might be able to make use of antidepressants in bipolar disorder. Too often, however, antidepressants are prescribed with suboptimal mood stabilization or, worse still, without mood stabilization at all. I think it is wise to warn patients to avoid using antidepressants in bipolar disorder at least until mood stabilization has been optimized, and then to be aware of possible complications.

      Of course, these decisions are best made with an informed patient and the psychiatrist who knows him best. It is also best made with a psychiatrist who is judicious (as you noted) in discerning between true bipolar disorder and Cluster B personality disorders.

      I appreciate your comment. I have heard presentations by bipolar disorder specialists who tell their peers never to use antidepressants with bipolar disorder. My intent was to urge caution but take a more moderate approach. I, unfortunately, have seen bipolar patients have excessive mood episodes because of inappropriate use of antidepressants by physicians with little mental health training.

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  2. Agreed! If anti-depressants are used inappropriately in bipolar patients, disaster can certainly ensue.

    Thankfully, we can and should get blood levels of anti-manic drugs (they are not really mood stabilizers, as they have never been shown to reliably prevent episodes of bipolar depression, [Lamictal, about which the studies suck, does not prevent mania]) to make sure they are adequate before starting antidepressants in a bipolar patient.

    Since after a first manic episode one can’t be absolutely sure a new patient will respond to a particular anti manic drug (At least 80% do respond to lithium, when they can tolerate it without a lot of side effects, in my experience), I take the added precaution of telling patients to alert and give permission to anyone in regular close contact with them to call me at the first sign of an appearance of a personality transplant – one who might start to look like the Charlie Sheen who started living with two prostitutes and going on the road without an act. I do the same thing with patients who have had their first episode of major depression, especially if they have a clear family history of bipolar disorder.

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