Anger is one of those words that discomfort most people. Even though we all get angry, we often want to pretend as if we do not. Rage, on the other hand, is a word that evokes vivid images of spousal abuse, drunken rages, or wild combat. It is a word that most civilized people dare not breath. So, we have euphemisms: "very angry", "riotously drunk", and "seeing red." We almost never label rage for what it is; the extreme anger that is accompanied by an unbridled energy that demands action. Rage is either uncontrollable or almost uncontrollable. Normal anger is white when rage is red; it is controllable even as it simmers. Rage is a fire-brand; it demands uncontrolled action. This is why people in the boxing profession say that rage looses fights; it burns out the fighter with its fury leaving behind a shell of a boxer who cannot box any longer. In the fighting sports rage is the antithesis of control and success. And, young fighters are warned never to get angry in the ring.
I write about anger and rage because they have touch my life. Rage has threatened to consume me over and over. Anger, on the other hand, is a healthy, not so consuming, experience. I write about rage and anger, because they are apart of my experience of bipolar. I wish that all of my experiences with rage could be retroactively converted to experiences of anger. I wish all my future experiences with rage would be converted to anger. Through hard work, I have learned to moderate the rage, to convert it to anger, and to prevent it from getting out of control. I am not always successful, but I will share the tools that I use.
It should be noted that one needs to recognize the difference between anger and rage when it is happening. This is more sophisticated than your run-of-the-mill recognize-your-anger-feelings that is used in therapy. One has to distinguish the minor feelings of frustration from the major rage feelings that threaten self-control. Indeed, the very threat to self-control can be the tip-off that rage is under way.
What goes on physiologically when rage is starting up? Something activates the stress-response cycle. The heart rate increases, paling or flushing occurs, constriction of blood vessels every where except the muscles occur, the tear duct constricts, blood vessels for the muscles dilate, pupils dilate, and there is tunnel vision and auditory exclusions. In the intended circumstance, this all helps one focus on the threat to survival. However, rage, at some ordinary event, is not the intended circumstance for the stress-response cycle. Instead, with rage, this all helps one focus on the source of the trigger. This means that most people with rage can easily recognize their trigger(s), although they may have less success dealing with the stress-response itself.
When I feel myself getting hot-under-the-collar in a rage kind of way, I find intense exercise to be the most useful. I have literally interrupted conversations to sprint as hard as I can around the block. Intense exercise has the effect of directly relieving the stress-response through action--through placing a demand on the dilated blood vessels for the muscles. A sprint, done properly, both is harmless and effective, as sprinting is one of the most strenuous sports in the world. One should exercise care and warm up properly, as in jog for 5 minutes to prepare the hamstrings for the strenuous effort of sprinting at full speed. Another type of intense exercise that I like to use is hitting a punching bag. This is demanding both in terms of accuracy and in terms of the weight of the bag, i.e. a heavy bag. I cannot count the times that I have mentally pasted the picture of a adversary on the bag and walloped it. Aside from sprinting and punching bags, I have done other exercises that come in handy: jumping, push-ups, grip work, and kicking. It is easy to see that my tastes run in the martial direction and having a punching bag handy is useful for me.
The other tool that I have used is deep breathing. Here the task is to slow down when the rage threatens to strike. One must have the presence of mind to breath. One breath, hold it for a 2-count, second breath, hold it for a 2-count, and so on up to a ten breaths. There is abundant evidence that a deliberate breathing pattern slows down the stress-response cycle. Slowly the blood vessels to the muscles stop dilating and the tunnel vision and auditory exclusions cease. Usually this strategy requires stepping outside the triggering circumstance, in order to fully implement the deep breathing.
Since I regularly deal with rage, I cultivate an understanding among my closest relatives that I might take off to sprint at any moment. I encourage them to be understanding of my exercise and deep breathing, and I ask them just to wait for me if I take off suddenly. Through experience, they have all come to understand that I will come back better collected and able to handle whatever circumstance triggered the rage.
Sunday 27 January 2013
Friday 25 January 2013
Caregiver Fatigue
Do care about and for someone with an illness? Are you the primary care-giver? If you answer yes to any of these questions, it might be worth knowing about caregiver fatigue. WebMD describes this as follows:
http://www.webmd.com/heart-disease/guide/heart-disease-recognizing-caregiver-burnout
It's a reasonably serious fatigue from long-term caregiving, and it is correlated with long-term health consequences for the caregiver. There is some evidence that this fatigue is associated with shortened telomeres, likely indicating a shorter life-span.
http://www.pnas.org/content/101/49/17312.long
Nurses, doctors, and people with relatives or close friends that are ill are at risk.
I've watched my Mom deal with fatigue while caring for my Dad who has bipolar. And, I worry about my partner sometimes, because she can get quite strung out from dealing with life and me at the same time. It is important that we all, caregivers and care receivers, keep in mind the costs of caregiving. Maybe we can find a way to give our caregivers a break.
http://www.webmd.com/heart-disease/guide/heart-disease-recognizing-caregiver-burnout
It's a reasonably serious fatigue from long-term caregiving, and it is correlated with long-term health consequences for the caregiver. There is some evidence that this fatigue is associated with shortened telomeres, likely indicating a shorter life-span.
http://www.pnas.org/content/101/49/17312.long
Nurses, doctors, and people with relatives or close friends that are ill are at risk.
I've watched my Mom deal with fatigue while caring for my Dad who has bipolar. And, I worry about my partner sometimes, because she can get quite strung out from dealing with life and me at the same time. It is important that we all, caregivers and care receivers, keep in mind the costs of caregiving. Maybe we can find a way to give our caregivers a break.
Monday 7 January 2013
Mixed States
Mixed states are thought to look different in everyone, and a single person might experience multiple different mixed states. If you think you are experiencing mixed states, the best thing to do is to consult a psychiatrist.
My opinion is slightly non-standard, but I like to think of it this way: mania is an episode centered around feeling good and depression is an episode centered around feeling bad. I believe there are other feelings that can anchor an episode such as anger, or fear. In each case, the trademark of bipolar is that these episodes take an emotion and make an extreme experience. So that anger becomes a rage episode and fear becomes a paranoia episode. These emotional episodes are called mixed, because they are said to have symptoms of both classical mania and depression. For instance a rage episode might be considered energetic and may also involve suicidal thoughts. Or a paranoid episode might be sleepless and may also involve difficulty with concentration.
Recognizing Mixed States
The definition of a mixed state is still being developed. Here is what the DSM IV-TR says:
I believe that mixed states are particularly difficult to diagnose because the subjective experience of the person who experiences them is so much different than the objective experience of an observer. I also believe that this is an instance where language fails to capture the experience and discussion of these things is extremely difficult.
I believe that I experience mixed episodes, both anger-based episodes and fear-based episodes. Detecting the onset of these episodes is critical. Since I have been experience anger episodes, I have long since learned to spot the change in thinking that accompanies it. Fear-based episodes are more challenging, and I have a two-pronged strategy to detect thought changes and cognitive decline. To detect changes in my thinking process, I compare my current thoughts to past thoughts about similar situations. To detect the fear-induced cognitive decline, I use my activity log (discussed in depression). When there is a sudden gap in my productive activities, I try to determine whether the cause is a depressive episode or a fear-based episode, and my overall emotional tenor usually answers this.
Preventing and Treating Mixed States
Similar to mania and depression, drugs are commonly thought to be the best treatment. The appropriate drugs include mood stabilizers and anti-psychotics. There have been a number of studies claiming that mood stabilizers are less effective for people who experience mixed episodes than those who do not. It is not clear why this might be or what to do about it.
Drugs are not the only treatment, it is necessary to employ other coping skills. In this it is best if the person with bipolar takes charge of their illness, as attempts to force the person to comply will likely destroy the very trust needed for success. This can involve contingency planning for future episodes. Discussions with family can cover when family might be requested to aid in decision making. A high level of trust is required to make such discussions useful. (Note, trust will be broken if family involve themselves in decision making without permission.) If family is not available, one can turn to close friends, often termed chosen family. As part of contingency planning, one can decide at which stage of an episode voluntary hospitalization will be sought. Having a plan ahead of time makes implementation easier.
Whereas for depression I mentioned that keeping an activity log could be helpful, I am not sure that is helpful during these episodes. In my experience these episodes get entrenched much faster and much deeper than some depressions. I do, however, find the activity log useful for charting recovery, and it is encouraging to use the log to watch improvements in activity levels and cognitive function.
My opinion is slightly non-standard, but I like to think of it this way: mania is an episode centered around feeling good and depression is an episode centered around feeling bad. I believe there are other feelings that can anchor an episode such as anger, or fear. In each case, the trademark of bipolar is that these episodes take an emotion and make an extreme experience. So that anger becomes a rage episode and fear becomes a paranoia episode. These emotional episodes are called mixed, because they are said to have symptoms of both classical mania and depression. For instance a rage episode might be considered energetic and may also involve suicidal thoughts. Or a paranoid episode might be sleepless and may also involve difficulty with concentration.
Recognizing Mixed States
The definition of a mixed state is still being developed. Here is what the DSM IV-TR says:
A. The criteria are met both for a manic episode and for a major depressive episode (except for duration) nearly every day during at least a 1-week period.There seems to be considerable discussion about how the definition of mixed episodes should be written. Some doctors require a few symptoms from both mania and depression, other doctors require more than a few symptoms. Some doctors will disagree on the classification of a particular symptom, for example, extreme fear and it's cognitive dysfunction, into mania or depression.
B. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
C. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment), or a general medical condition (e.g., hyperthyroidism)
I believe that mixed states are particularly difficult to diagnose because the subjective experience of the person who experiences them is so much different than the objective experience of an observer. I also believe that this is an instance where language fails to capture the experience and discussion of these things is extremely difficult.
I believe that I experience mixed episodes, both anger-based episodes and fear-based episodes. Detecting the onset of these episodes is critical. Since I have been experience anger episodes, I have long since learned to spot the change in thinking that accompanies it. Fear-based episodes are more challenging, and I have a two-pronged strategy to detect thought changes and cognitive decline. To detect changes in my thinking process, I compare my current thoughts to past thoughts about similar situations. To detect the fear-induced cognitive decline, I use my activity log (discussed in depression). When there is a sudden gap in my productive activities, I try to determine whether the cause is a depressive episode or a fear-based episode, and my overall emotional tenor usually answers this.
Preventing and Treating Mixed States
Similar to mania and depression, drugs are commonly thought to be the best treatment. The appropriate drugs include mood stabilizers and anti-psychotics. There have been a number of studies claiming that mood stabilizers are less effective for people who experience mixed episodes than those who do not. It is not clear why this might be or what to do about it.
Drugs are not the only treatment, it is necessary to employ other coping skills. In this it is best if the person with bipolar takes charge of their illness, as attempts to force the person to comply will likely destroy the very trust needed for success. This can involve contingency planning for future episodes. Discussions with family can cover when family might be requested to aid in decision making. A high level of trust is required to make such discussions useful. (Note, trust will be broken if family involve themselves in decision making without permission.) If family is not available, one can turn to close friends, often termed chosen family. As part of contingency planning, one can decide at which stage of an episode voluntary hospitalization will be sought. Having a plan ahead of time makes implementation easier.
Whereas for depression I mentioned that keeping an activity log could be helpful, I am not sure that is helpful during these episodes. In my experience these episodes get entrenched much faster and much deeper than some depressions. I do, however, find the activity log useful for charting recovery, and it is encouraging to use the log to watch improvements in activity levels and cognitive function.
Friday 4 January 2013
Depression
Many people have an image of depression as the monster that keeps a person in bed all day, saps their energy, and colors their emotions blue. This post is about another kind of depression that creeps up on a person, saps their energy, but does not put them in bed. In this kind of depression a person is functional but has little motivation and little ability to accomplish things. Neither of these depression types is more sever than the other, they are just different. I choose to focus on this last type of depression, because it is the kind that I can speak about from personal experience.
Recognizing Depression
Here is a list of symptoms of depression as taken from the Major Depression category of the DSM IV-TR.
- Depressed mood most of the day.
- Diminished interest or pleasure in all or most activities.
- Significant unintentional weight loss or gain.
- Insomnia or sleeping too much.
- Agitation or psychomotor retardation noticed by others.
- Fatigue or loss of energy.
- Feelings of worthlessness or excessive guilt.
- Diminished ability to think or concentrate, or indecisiveness.
- Recurrent thoughts of death (thoughts of suicide)
Symptom (4) sleep disturbances is stereotypically taken as the most indicative of depression. It is understandable that changes in sleep patterns are easy to notice and certain to draw attention. On the other hand, for people that do not experience disruptions in sleep, detecting the presence of depression can be more difficult due to the subjective nature of most of the other symptoms. Particularly if one does not feel very 'blue' as in symptom (1) depressed mood, recognizing depression is challenging.
I am in the category of people who do not experience symptom (4) sleep disturbances. In addition, I do not seem to experience (1) depressed mood or (3) weight gain/loss. This leaves me with the following symptoms diminished interest, fatigue or loss of energy, feelings of guilt, diminished ability to think or concentrate. Now, people that know the DSM and that are counting may have noticed that I did not list 5 symptoms of depression which is the threshold for a Depression diagnosis. They would be correct. Recall also that I have had diagnostic issues, perhaps partly for this reason. Despite this issue, I feel that I have indeed experienced depression.
This leaves me with a problem, how do I detect the onset of depression? All the easy indicators like thoughts of suicide and sleep disturbances are not appropriate. While my strategy may evolve further, I am currently using an activity log to track my engagement in work. This is similar to a time-sheet, but it involves extreme honesty about when I am actually working productively. (This is for my eyes only, so I do not have to worry about a negative opinion from my supervisor.) I track the time that I work productively each day and each week. Then I can watch the trend over time. If I start to become fatigued, uninterested in work, or lack the ability to concentrate, my weekly productive time drops.
You might ask if keeping an activity log is difficult. I find that it is not (of course I sometimes lapse), but I have integrated the activity log with my lab notebook which records my research/work activities. So, the log has a dual purpose. Also, I use a computer to compute statistics like average productivity.
This tool is very important to me, because at the beginning of a depression it is easy to rationalize the symptoms. I will end up thinking that I just need a break to recharge when in reality a break might only make the depression worse. This tool allows an objective view of the time I spend being active and helps cut through the subjectivity of the situation.
Preventing and Treating Depression
For me, the primary prevention and treatment of depression is medications. It has been critical to have the right combination of psychotropic medications and to treat physical illnesses that could cause depression. Additionally, I use a motivational tool which turns out to be the activity log described above.
On the topic of medications, being a person with a bipolar family history of sensitivity to SSRIs, I avoid antidepressants. I rely mostly on the antidepressant properties of Lithium. I have experienced an instance where a failure to treat a thyroid problem appeared to result in depression. So, I also keep on top of my general health.
The motivational tool that I use is the activity log mentioned above. In a bad depression, I try to do at least one activity a day. Once each activity is complete, I log it in the activity log making the log into a sort of achievement wall. I get to feel good about each thing that I accomplish. By continuing to track my active hours each day, I can also see whether the depression is improving which also makes me feel more positive.
The activity log could also be viewed negatively, if one were to focus on how little they accomplished each day. To avoid this, I strongly subscribe to a view of life that everyone can improve from where they are at. This view is typically accepting of whatever activity level I find myself at during a depression, and it helps to keep me focused on improvements, no matter how small.
Does anyone else have depression strategies to share? If you do, please post them in the comments.
Wednesday 2 January 2013
Mania
Mania seems to be one aspect of bipolar that is both the best understood and the most misunderstood generally. It is generally understood that mania is a strong indicator of bipolar, however it is misunderstood that all people with bipolar experience mania. For example, to the best of my knowledge, I have not experienced mania. This makes me less qualified to write a post on this topic. However, since it would be remiss of me to discuss depression and bipolar without mania, here is a post drawn mostly from the literature.
Recognizing Mania
This description from the DSM IV is an objective description of mania which might be different from the subjective experience of it.
A) A distinct period of abnormally and persistently elevated, expansive or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary)
B) During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:
Recognizing Mania
This description from the DSM IV is an objective description of mania which might be different from the subjective experience of it.
A) A distinct period of abnormally and persistently elevated, expansive or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary)
B) During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:
- inflated self-esteem or grandiosity
- decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
- more talkative than usual or pressure to keep talking
- flight of ideas or subjective experience that thoughts are racing
- distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
- increase in goal-directed activity (at work, at school, or sexually) or psychomotor agitation
- excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
D) The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
E) The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication or other treatment) or a general medical condition (e.g., hyperthyroidism)
It seems to me that mania is difficult to recognize without having repeated experiences with it. Even when I saw mania in a close friend I had difficulty discerning their lack of judgement and impulsiveness.
Preventing and Treating Mania
Mania should be treated together with whatever other bipolar symptoms that one has. This is typically done using drugs such as Lithium that act as a mood stabilizer.
It is not sufficient to treat mania only with drugs, as therapy and support from family and friends also plays a large role. In this it is best if the person with bipolar takes charge, as attempts to force the person to comply will likely destroy the very trust needed for success. One should try to identify triggers as much as possible and make contingency plans for future episodes. Involving family in contingency plans can help with determining when the family can make decisions on the behalf of the person with bipolar and when support is wanted or needed. Or perhaps the person with bipolar might request for a family member to have control over their finances with a mutually agreed upon allowance, and with mutually agreed upon ability to revise the agreement.
These sorts of plans and frank conversations help prevent misunderstandings such as relatives refusing to make a monetary loan to a stable person because they mistakenly believe the request is a symptom of mania. Or an even more harmful misunderstanding, relatives may unilaterally decide when a person with bipolar should be involuntarily hospitalized. Planning helps with decide the conditions under which a person will voluntarily be hospitalized or when they might wish to request decision making help from certain trusted relatives.
It seems to me that mania is difficult to recognize without having repeated experiences with it. Even when I saw mania in a close friend I had difficulty discerning their lack of judgement and impulsiveness.
Preventing and Treating Mania
Mania should be treated together with whatever other bipolar symptoms that one has. This is typically done using drugs such as Lithium that act as a mood stabilizer.
It is not sufficient to treat mania only with drugs, as therapy and support from family and friends also plays a large role. In this it is best if the person with bipolar takes charge, as attempts to force the person to comply will likely destroy the very trust needed for success. One should try to identify triggers as much as possible and make contingency plans for future episodes. Involving family in contingency plans can help with determining when the family can make decisions on the behalf of the person with bipolar and when support is wanted or needed. Or perhaps the person with bipolar might request for a family member to have control over their finances with a mutually agreed upon allowance, and with mutually agreed upon ability to revise the agreement.
These sorts of plans and frank conversations help prevent misunderstandings such as relatives refusing to make a monetary loan to a stable person because they mistakenly believe the request is a symptom of mania. Or an even more harmful misunderstanding, relatives may unilaterally decide when a person with bipolar should be involuntarily hospitalized. Planning helps with decide the conditions under which a person will voluntarily be hospitalized or when they might wish to request decision making help from certain trusted relatives.
Tuesday 1 January 2013
Bipolar Episodes
The establishment subscribes to 2-3 types of bipolar episodes:
The first two types of episodes are what give bipolar its a name where the 'bi' refers to mania and depression, and the 'polar' refers to the presumed spectrum on which mania and depression sit at opposite ends. It is fairly easy to see that the name bipolar comes from the traditional description of bipolar I and II. The addition of mixed states is an acknowledgement that there is actually not a depression-mania spectrum for some people, and opens a diagnostic category for the people having episodic bi-polar-like symptoms that are not clearly related to schizoaffective disorder.
What are mixed states?
It is thought that they look different in everyone that experiences them. And, one person might experience more than one type of mixed episode. (Keep in mind that this discussion is not very scientific, as the definition of a mixed episode is still being developed.) I like to think of it this way, and notice that my view is different from the traditional definition: mania is an episode centered around feeling good and depression is an episode centered around feeling bad. I believe there are other feelings that can anchor an episode such as anger, or fear. In each case, the trademark of bipolar is that these episodes take an emotion and make an extreme experience. So that anger becomes a rage episode and fear becomes a paranoia episode.
These emotional episodes are called mixed, because they are said to have symptoms of both classical mania or depression. For instance a rage episode might be considered energetic and may also involve suicidal thoughts. Or a paranoid episode might be sleepless and may also involve difficulty with concentration.
Personally, I find the task of identifying both mania and depression symptoms in an episode to be difficult. I would prefer to see descriptions of multiple types of emotion centered episodes. But we will see where scientific discovery takes mixed episodes. Hopefully we will see progress in the near future.
Does anyone else have thoughts about the distinction between mania, depression, and mixed episodes?
- mania - high of euphoria, activity, grandiosity, impulsiveness, etc.
- depression - low of activity, energy, negative thoughts, suicidal thoughts, etc.
- mixed states - properties of both mania and depression, perhaps including psychosis
The first two types of episodes are what give bipolar its a name where the 'bi' refers to mania and depression, and the 'polar' refers to the presumed spectrum on which mania and depression sit at opposite ends. It is fairly easy to see that the name bipolar comes from the traditional description of bipolar I and II. The addition of mixed states is an acknowledgement that there is actually not a depression-mania spectrum for some people, and opens a diagnostic category for the people having episodic bi-polar-like symptoms that are not clearly related to schizoaffective disorder.
What are mixed states?
It is thought that they look different in everyone that experiences them. And, one person might experience more than one type of mixed episode. (Keep in mind that this discussion is not very scientific, as the definition of a mixed episode is still being developed.) I like to think of it this way, and notice that my view is different from the traditional definition: mania is an episode centered around feeling good and depression is an episode centered around feeling bad. I believe there are other feelings that can anchor an episode such as anger, or fear. In each case, the trademark of bipolar is that these episodes take an emotion and make an extreme experience. So that anger becomes a rage episode and fear becomes a paranoia episode.
These emotional episodes are called mixed, because they are said to have symptoms of both classical mania or depression. For instance a rage episode might be considered energetic and may also involve suicidal thoughts. Or a paranoid episode might be sleepless and may also involve difficulty with concentration.
Personally, I find the task of identifying both mania and depression symptoms in an episode to be difficult. I would prefer to see descriptions of multiple types of emotion centered episodes. But we will see where scientific discovery takes mixed episodes. Hopefully we will see progress in the near future.
Does anyone else have thoughts about the distinction between mania, depression, and mixed episodes?
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