Trusting Your Moods with a Mood Disorder

First published Psych Central

https://blogs.psychcentral.com/triple-winner/2017/03/trusting-your-moods-with-schizoaffective-disorder/

I have a thought and mood disorder called schizoaffective disorder. It is similar to bipolar disorder, in that I have mood swings with periods of mania and depression.

When I was treated for my first severe manic episode I was heavily sedated and slowly titrated down on the medications. When I got to a dosage where I was no longer sedated, and my symptoms were under control, I started to feel okay, good even.

 

It scared me. “Would I feel too good?” I voiced my concerns to my psychiatrist and he reminded me I usually have other symptoms that precede mania. I think most people do.

You could go through a list of symptoms and see which ones are typical for you that would be noticeable.

Do you spend a lot of money?

Are you impulsive?

Do you talk fast?

Do you start lots of projects?

A lot of people monitor their sleep. I often have trouble with insomnia, so that isn’t a particularly good indicator for me. One thing is that I get irritable. I am usually pretty mellow, so if I start snapping at people that is a good sign that something is off. My psychiatrist also told me if people are looking at me strangely that is a warning sign. I am not sure if he meant I do strange things or I get paranoid, which I do, and get suspicious.

Isn’t everyone entitled to an off day, though? Sometimes when I am upset at someone, it is for a good reason. A lot of people imagine others think poorly of them, once in a while.

It would help to have someone I trust, tell me if I didn’t seem right. I have trouble with trust, though, when I am symptomatic. I think everyone else has the problem and I am fine. I am working on that, because I know it is important. Otherwise, you can have a great list of warning signs, but deny them. “I’m not talking fast, you are just listening slowly”.

Once you notice these warning signs, what do you do? That is a million dollar question.

This is where it is best to consult with your doctor and find out when they want you to contact them.

It is also good to come up with a  Wellness Recovery Action Plan (W.R.A.P.) to prepare.

It is good to catch things early, but you don’t want to be worrying every time you have a bad, or good, day.

Where are you in “recovering” a life that is meaningful to you?

The biggest loss after I was diagnosed was my poetry. Before my diagnosis, I wrote a lot — I filled a ring binder with it. Two inches of verse, mostly free. Then I stopped because I believed that going to readings and writing it made my condition worse. And I believed that I lost the ability to write it. I did not stop, but my output was meager and sparse. One poem a year. Some years I wrote nothing. But a part of me yearned for the truth and beauty of a fine image. So last spring, I conducted an experiment. Thanks to a psycho-stimulant that gave me a renewed ability to focus, I cautiously began to compose free verse and haiku. To my joy, I did not explode into mania. I was not writing long intense blogs as had been the signature of my mania and I did not lapse into consequent depressions. So I have begun thinking: If I can handle poetry what about spirituality? Could I attend a church without turning into a prophet? Could I handle being a member of a congregation and not its priest? So I have been contemplating where to go, what denomination suits my temperament. That is the next signpost.

The Benefits of Bipolar Disorder

When I am manic, I get things done. That is as long as I am not running to the top of the inside stairs and down again seeking something that I cannot remember. Then it is The Great Eater of Time. My depression helps me to see what projects I have taken up that are pointless wastes like the schemes of making a million quickly by stuffing envelopes at home. I can detect what is rigged: I will not spend hours trying to win games that cannot be won or spend money on hobbies that I will never get around to finishing. I have ships in a bottle that I have not pulled the rigging up. I bought these in hypomania.

Depression has a wisdom about it, bitter at times, with a predictive power and insight into the motives of some men and women. I do not trust certain people when I am in depression: This often proves a smart thing.

Then there is the stillness that comes, a beautiful blue film that falls gently over my consciousness calling for silence and appreciation of the moment. If I shut down the voices that hector me for a moment, I find the peace that the racing thoughts of mania do not permit. I may feel fatigued, but I am not agitated as I am in a mixed state. Depression is a better place in the mind than mania or the vicious mixed state.

Ends of a Mood Swing

My mania feels like a fishing line pulled taut to the breaking point.

My depression feels like I am that same fishing line let to fall in a curled mess and tossed to the bottom of the sea.

My mania feels like omnipotence — the power of God — channeled through my neck, my spine, my limbs, and my eyes.

My depression feels like my failure to be of any effect, like I have botched things up, crippled animals, alienated friends, brought evil into the world.

My mania feels like I can do great things, that I have a destiny that will change the world — bring peace, soften stone hearts, make people live in harmony.

My depression feels like a hole that sucks in everything good, that is no place to hide from despair.

My mania gives me energy to glide up the last spine leading to Everest’s summit and dive without a bathyscaphe to the bottom of the Challenger Deep.

My depression makes me stay in my house dreaming dark dreams.

My mania makes me love all humankind — especially women — and spark with anger if the purity of that love is questioned.

My depression makes me the lover of my pillow, my sheets, and my blanket, a friend of the curtained darkness, the noises of the day, and the deep emptiness of the night.

Conference of DBSA California, 2016

I have just returned from the conference of the Depression and Bipolar Support Alliance of California. Between keynote addresses and workshops, here are the things I attended (for some, I have notes).

Keynote speaker for Friday morning, stand up comic David Granirer, on “I’m OK But YOU Need Professional Help: Creating Recovery – One Laugh At A Time!” For obvious reasons, I didn’t take notes for this one.

Adult Suicide Prevention Training (presenter Liam Mina, MSW): Liam Mina is a social worker with Didi Hirsch, a Southern California organization founded in 1942, which works on suicide prevention. After the death of Marilyn Monroe, in which they were involved in a “psychological autopsy,” they started getting phone calls, not about Monroe, but from people who themselves wanted help. So they established the first suicide hotline in the US. Now they have 24/7 service in English and Spanish, along with texting and chat for the deaf, and Korean and Vietnamese from 4:30 pm to midnight Pacific time. 90% of suicide is associated with mental illness, but 50% are not in treatment. Responding to warning signs of suicide: Build rapport, assess risk (ask directly, and for people who do say that they are thinking about suicide assess degree of risk by asking about plans and with scaling questions), establish safety (make a plan, connect to resources, ask to repeat back plan).

Ask the Pros: Kent Layton and Himasiri Da Silva. This always popular session allows people to pose questions to a clinical psychologist (Layton) and a psychiatrist (Da Silva). Topics included what to do in a crisis, what to do if you’re allergic to all the meds, what are the effects of different strains of marijuana, the difference between ADHD or ADD and bipolar disorder, whether ketamine is recommended for treatment-resistant depression (and the same question for Lexapro), what about food supplements, and the DSM-V.  A few notes from the answers: Medical marijuana isn’t recommended for bipolar disorder. Useful supplements include fish oil (omega-3) and folic acid (not in place of medication, but alongside it). Da Silva feels that the DSM needs to build in more bioevidence; bipolar disorder had a large genetic component. As time goes on the DSM will become more biologically and evidence based. If you’re in crisis, keep showing up and suiting up, get up even if you can only manage a walk around the block, and don’t give up even if getting your meds right takes trial and error.

Bipolar Disorder: A Family Affair (presenter Angela Paccini): I didn’t take many notes on this one. It focused a lot on family stories, in the interest of showing what knowing roles and triggers and providing support looks like.

Bipolar Disorder – The Future (presented Da Silva): There have been four eras in psychiatry: The Asylum Era, the Psychodynamic Era, the Psychopharmacology Era, and what we are now entering, the Molecular Neurobiology Era. We still draw on what was learned in earlier eras (e.g. psychotherapy, especially CBT and DBT, helps, as do medications developed in the psychopharmacology era), but a new improvement in treatment is our understanding of pharmacokinetics and pharmacodynamics. Medications don’t provide chemicals in the form effective in the brain; first they need to be processed by the liver. Here, pharmacokinetic genes, such as CYP450, are important. The CYP450 system involves 57 enzymes responsible for drug metabolism, primarily in the liver. People can be normal, fast, or slow metabolizers, and a genetic test can show which you are. For example, only 55% of people metabolize Seroquel normally, while others metabolize faster than normal (and therefore see less effect) or slower than normal (and therefore see more side effects). Medication interactions are important (for instance, the estrogen in birth control pills can speed up the breakdown process for Lamictal). So is folate, and some people, with a variant form of the MTHFR gene, lack the ability to metabolize folate and may need, instead, to take methylfolate. Genesight offers genetic testing. Da Silva also talked about evidence based practices governing which medications should be given first (ones for which there are large scale studies supporting efficacy and few side effects).

Saturday morning keynote speaker: Antoinette Brunasso spoke on Coping with Depression and Bipolar Disorder: The Impact on Self and Family. This was a very good talk, at a level easy for a lay person to understand, largely around developing what Brunasso calls a “solid, flexible sense of self,” one that allows you to tolerate anxiety, and avoid reacting to conflict by reflexively caving, avoiding, or locking in your position, but rather work through the conflict toward a solution that works for both partners. How “fusion” can lead a spouse to get stuck in the same place as the bipolar or depressed spouse, and how developing a healthier sense of self can help you work through marital conflicts better even when one of you is also dealing with mental illness.

Reflective Functioning and Mentalization in Relation to Bipolar Disorder (presenter Nazare Magaz): Mentalizing is the capacity to imagine inner states in self and others. It can be affected by your early attachment process, which can lead either to secure attachment or to less secure forms (anxious avoidant, anxious preoccupied, disorganized); if you are a therapist, both knowing your own attachment style and recognizing that of your patient can be useful (don’t crowd someone whose attachment style is anxious avoidant). In bipolar disorder, ability to mentalize drops when you go into episode. Signs of mentalizing: You can imagine multiple states of mind that could lead another person to behave as he or she does. If you can only think of one possibility, you may be falling out of the open, curious state you need to mentalize, and instead in a place of psychic equivalence, where you have a thought about what another person is thinking and then assume it’s true. What do you do when someone else is in a place of psychic equivalence? You need to empathize with that person first. How do you develop mentalizing ability? By being around and learning from people who have it.

Lunchtime keynote speaker: David Miklowitz, on Child and Adolescent Mood Disorders. I didn’t take notes on this one, because having notepaper around a lunch table is awkward, but I did live tweet some of it after I had eaten.

Happiness with music (presenter Mike Sullivan): We played ukeleles. I didn’t take notes.

Trauma Effects – Depression and Bipolar (presenter Christine Monroe): Trauma is always part of psychotherapy. It’s part of life. This talk covered: What is trauma? How does PTSD compare to bipolar disorder (e.g. flashbacks to traumatic event compared to depressive ruminating)? What events can lead to PTSD? What puts people at risk? References: Ross Rosenberg on trauma levels. Dan Siegel on parenting. Evidence based treatments: Trauma focused CBT, exposure therapy (start mild), relational therapy, and, a particularly good therapy for PTSD, EMDR.

And that was my last workshop. I condensed my notes a lot for this post, so I may, if I find time, have a longer post on one or another of the individual sessions.

 

 

Jargon

Maybe we are so accustomed to familiar jargon, we don’t recognize symptoms if they are described in other ways.

I was having some symptoms. I have been doing well for a long time and they frightened me. I was hearing my voice (not a hallucination) but it was repeating the same words over and over. Nothing scary, more like I was rehearsing lines.

I was also starting to mumble the words I was saying. I found that listening to music was good because I started saying the song lyrics and that was better.

I would try to explain this to friends, hoping they would sympathize, and maybe give me some tips to deal with it. Instead they would say things like, “Oh, I’ve done that before” and shrug it off like it was no big deal or “Maybe you are talking to yourself because you are lonely”.

Instead of helping I ended up frustrated, leaving wanting to bang my head against a wall. It was hard. I knew they were trying to be helpful and maybe normalize my experience, but I found it invalidating.

And the more anxious I would get, the worse the symptoms would get, the more anxious I would get and it snowballed. My psychiatrist seemed to understand what I meant and made some changes to my medication. Now, it is getting better and I am getting calmer and it gets better and the snowball melts.

Recently I saw another friend. I told her I hadn’t been doing well, some thoughts. She said “racing thoughts?” I thought, that is the closest thing to what I am trying to describe, so I said “yes”. Finally I found a friend who could somewhat understand.

Review: Touched with Fire

Medication. Once you have been on it for a little while, you begin wondering if you need it. Some — like me — fiddled with the dosages. Others stop taking it at all. Those with an artistic temperament, especially poets, don’t like seeing their most valuable kind of intelligence stripped away from them so that exercising their craft becomes harder. Because Art is more important to them than their relations with their families and friends, they step boldly beyond sanity and give themselves over entirely to their illness — until life becomes unmanageable.

It is understandable why people seek to go back to mania, particularly those of us with an artistic bent. Personally, I found writing poetry came easily to me. I not only had the focus, but I also had the sense of association that one needed to choose words to convey specific, charged meanings. If I had had a lover afflicted with the same, my output of love poems would have been enormous.

We all think we are brilliant in mania, but a great many manic artists are at best banal. A few like the poet Robert Lowell needed mania to keep an edge in their poetry. Others like Shelley sought out doctors to get help quelling their mood swings. These famous names — along with that of Vincent Van Gogh and many others — tempt some to

Touched with Fire steals its title from Kay Jamison’s classic book of the same name. (Jamison isn’t mad. She appears as herself in the movie at one point, desperately trying to set one of the characters straight on the issue of whether to take his meds or not.) It tells the story of two young people who meet while locked up in a psych ward. Like many such relationships, there is a wind storm of shared stimulation that transcends sex and common love.

They are bad for each other. They sneak down into the basement of the ward in the middle of the night to talk, write, and make art together. This nightly rendezvous makes them wildly orbit each other, like two Kuiper Belt objects stuck in mutual admiration. When they are separated, they grow wilder at first, then crash into depression, their bodies digging out craters of morbid, energy-less, angst. When they get out, they stop their meds again and head out on an extended road tour which nearly costs them their lives when he drives their car into a river.

Both Katie Holmes and Luke Kirby deserve praise for their portrayals. She is the intellectual, the one who retains the ability to reason while he is the wildman who chants rap. It is Holme’s character who eventually sees the light; Kirby’s cannot resist bipolar disorder’s attraction. Griffin Dunne puts in a great performance as Kirby’s much maligned father whose bipolar wife abandoned the family. He and Holmes’ parents show part of the damage that unrestrained mania can have on families. Kay Jamison is a surprise appearance, as the goddess to who Kirby and Holmes turn when they must confront their mania. It is clear who understood Jamison’s message better in this confrontation. Jamison is often portrayed as an apologist for medications by anti-psychiatrists, but here she makes the case that too much medication is a bad thing and cites her own experience.

Touched with Fire gets it right. Nowhere have I seen the excitement of mania so brilliantly exhibited. We’ve needed films like this just as we have needed the recent Infinitely Polar Bear and Homeland because they tell the truth about us and show that we are human. We are not Jasons — we are children of the light.

If you miss it in the theaters, rent the dvd.

Crossing Zones

Travel is one of the greatest dangers facing someone with bipolar disorder. The majority of medical evacuations from overseas happen when someone enters a manic or a psychotic state. I am no stranger to these issues: I have noticed that when I cross the country to attend DBSA conventions, the combination of the excitement of the convention and the messing up of my sleep cycles — especially when I am compelled to wake up earlier — often conspire to pushing me into a slightly manic and obnoxious state.

So when we made plans to visit my brother-in-law in Senegal, I took the time to confer with all my doctors but especially my GP and my psychiatrist. In addition to the necessary shots such as typhoid and yellow fever, we bought medical evacuation insurance for me. I also discussed my plans at length with my psychiatrist, particularly since I would find myself not merely in one different timezone, but four — Salt Lake City, Paris, London, and Dakar. Together, we hatched out a plan which involved my taking an extra tablet of carbamazepine while I was gone. Two days before my departure, I began taking the increased dose — two first thing in the morning, one with dinner, and one at bedtime.

Not even the hint of mania afflicted me. I kept my temper, didn’t laugh too much, kept my bearings, and didn’t engage in compulsive spending. We stuck to our plan in London and Paris, not doing too much in a day and always discussing our expenses as we went along.

When I came back, I felt so good on the new dose — who in their right mind misses the rages? — I asked my psychiatrist if I could stay at that dose. She let me under the condition that my drug and white blood cell levels were closely monitored at least in the beginning to be sure that they didn’t destabilize me. Four months after my trip, I continue to do well.

If you live with bipolar disorder, you can learn this from my trip. First, talk to your psychiatrist and consider raising your dosages of your mood stabilizer. Second, take pains to adjust your sleeping schedule. For two weeks before I left, I starting setting my going to bed time an hour ahead of when I usually woke until I was getting up at Paris time, about mid-afternoon. When I arrived at Orly, I felt fine. When we arrived in London that evening, I went right to sleep and woke up shortly after dawn. I wore a sleep mask and ear plugs to minimize disturbances. I used an alarm clock to wake myself and it worked. I jumped out of bed and I enjoyed each day. My regimen kept my mind stable. My sanity never wobbled.

The Flatland Dilemma in Interpreting Bipolar Mania.

People in mania are known for flights of fancy and the rapid association of ideas. Of all the forms of intelligence that we may possess, it is only the ability to recognize analogies and build associations that suffers when we go on mood stabilizers. I think it can be a mistake for outsiders to believe that this ability leads to wild, random, and unusable linkages in our mind. I find that my ability to write poetry — meaningful poetry — suffered after I started taking lithium; I lost insights. Of course, many other more negative traits like my irritability, grandiosity, and racing thoughts disappeared so I consider it a net gain.

The things we bring back from our adventures in mania land aren’t all rubbish. Poets such as Shelley and Byron depended on their manic states to generate compelling material. Some scientists have conceived startling new concepts. Isaac Newton is a classic example of a maniac whose insights transformed the science of his day and enabled him to revolutionize mathematics with his invention of calculus. The trouble comes when we try to bring our insights back from the fine and private place of our sickness.

William Knowland’s Flatland — which was written to explain the difficulties inherent in Faith — presents a useful allegory for our struggle to explain what we have found. Imagine a two dimensional figure, say a square. Imagine that it is you. Your perceptions are limited to two dimensions, so while you can make out one dimensional figures such as lines and points, you cannot appreciate three dimensional ones. If you were one dimensional, squares would appear as lines to you. Angles and other aspects of the square would invisible.

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The Night of The Cut *Graphic Self Harm Trigger Warning*

******TRIGGER WARNING: Anorexia somewhat and EXTREMELY GRAPHIC SELF HARM******

DO NOT READ THIS IF YOU ARE EASILY TRIGGERED BY SELF HARM ESPECIALLY IN GRAPHIC DETAIL.

You have been warned.

This is probably the single most important story in my life. It led to a cascade of events: hospitalization, my correct diagnosis of bipolar, getting kicked out of school, and finally getting the real help I needed.

It was 6am when I finally asked my ex-boyfriend for my knife back. We aren’t on speaking terms and we are clear that we can never be. We’re either together or not. And together is awful, dangerous, addicting, full of love, full of hate.

Today I see him to get it back, so I stress out about it of course. I overthink what I will wear. I felt the need to show him how much my appearance has changed, how much have changed. Both of which are major improvements.

Should I go laid back in my cute dorm-room college girl get up all from Victoria’s Secret? Or should I go with my traditional assemble which people describe as “edgy” because its boots and leather jackets and what not?
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