Podcast: Navigating the Ups and Downs of Bipolar Disorder

Episode Transcript

Jenn: Welcome to Mindful Things.

The Mindful Things podcast is brought to you by the Deconstructing Stigma team at McLean Hospital. You can help us change attitudes about mental health by visiting deconstructingstigma.org. Now on to the show.

Jeff: Hello and welcome. My name is Jeff Bell and on behalf of McLean Hospital, I’d like to thank you for joining us today. Our focus today, bipolar disorder, BD, as it is often called, is both common and treatable. But left untreated, BD can create enormous challenges for those who are living with this condition. In addition to prompting mood swings, it can impact sleep, self-esteem, appetite, focus, even physical health.

Over the next hour, we’re going to talk a lot about mood swinging. So I think it’s important to start with a key distinction. Mood shifts are a part of life, right? We all experience what it’s like to go from being happy to feeling sad and the other way around. But for the millions of people living with bipolar disorder, these shifts can be intense, jarring swings between deeply depressive states and episodes of mania.

The good news, again, is that BD is treatable, and that is what we want to focus on today. And to that end, I want to bring into the conversation, Kirsten Bolton. She is a licensed independent clinical social worker, and since 2008, she has been working with patients and their families in McLean’s division of psychotic disorders. Kirsten, thanks for joining us.

Kirsten: Thank you. It’s great to be here.

Jeff: Well, we’re thrilled that you’re with us. And I’d like to begin by asking you to give us the big picture, an overview of bipolar disorder, if you would, including some of the vocabulary associated with it, which, let’s face it, can be confusing at times. What exactly is BD, and how does it impact those living with the disorder? Let’s start there.

Kirsten: Sure, sure. So sometime in the 1960s, bipolar disorder really got its current name. And was differentiated from unipolar disorder. One of the hallmark kind of indicators of bipolar disorder is what is called mania. And mania is a discrete period of time where an individual has an increase in goal-directed activity, and an increase in what’s called expansive mood. Sometimes someone can also be irritable during that period of time.

But one of the biggest hallmarks of a manic episode is lack of sleep and not needing to sleep. So you might ask someone, you know, “How long has it been since you’ve slept?” And they might say, “You know, it’s been three or four nights.” And then you say, you know, “Are you tired?” And typically the answer is, “No, I don’t need to sleep, I’m full of energy.”

So in bipolar disorder, someone experiences both these kind of intense, you know, heightened mood states. And then also the opposite of that, where someone tends to experience episodes of depression as well.

Jeff: So there are different types of bipolar disorder. Can you walk us through those? Bipolar one versus bipolar two, for example?

Kirsten: Yeah, yeah. I think generally, bipolar two disorder can be thought of as a lighter version of bipolar one disorder. One of the biggest differences between those two diagnostic categories, is that in bipolar one disorder, you have to have not slept for a full week. And the symptoms are really interfering with your ability to function. Like someone typically can’t hold down their job, might require in-patient hospitalization because the symptoms are so severe.

With bipolar two disorder, the length of lack of sleep is only four days versus an entire week. And it’s not impacting your functioning at that point. Someone might be what’s called hypomanic, which is a lesser intense form of mania that’s found in bipolar two disorder. And they actually might be doing quite well. You might be pretty successful at work, you know, during that period of time might be pretty productive. So it’s not really impacting your level of functioning at that point.

Jeff: Is one of the two more prevalent than the other?

Kirsten: That’s a really great question. From what I’ve gathered, they’re almost the same in terms of prevalence. Maybe bipolar one is a little bit more prevalent than bipolar two, but they’re pretty much diagnosed at the same rate.

Jeff: Does one form of BD ever morph into the other?

Kirsten: Yes. So if in general, and I think you mentioned this at the beginning, if bipolar disorder is left untreated, it does tend to worsen. So if bipolar two disorder, you know, is left untreated or for whatever reason, you know, just isn’t well controlled, the chances are that it could very much turn into a worser form of the illness.

Jeff: Okay. How about cyclothymia, if I’m saying that right, is that also a form of bipolar disorder?

Kirsten: Yeah, that’s a great question. So cyclothymia is a little bit different. Cyclothymia, I do think that in about 15 to 50% of cases of cyclothymia, someone does end up with a diagnosis of either bipolar one or bipolar two disorder.

So it is pretty common that it could morph into something more significant. But cyclothymia is kind of an entity in and of itself. It’s characterized by... You have to have really experienced these mood fluctuations for a two-year period of time. And the mood fluctuations don’t meet criteria for a full manic episode or for a full depressive episode.

And it’s really important with cyclothymia to rule out other issues that might be causing those mood fluctuations such as substance abuse. You know, attention like ADHD or ADD, or borderline personality disorder.

Jeff: Question came in from the audience, and it’s an important one, “Are there always episodes of depression in bipolar one, or is it possible to only experience mania without depression?”

Kirsten: Yeah, that’s a really good question. It is possible, but it’s very rare. You know, I would say probably 1% of people, maybe even less than that, will actually experience mania and just mania. Some people don’t experience... Like I believe about 80% of people will experience an episode of depression after an episode of mania.

But that depression can be variable. So some people go into really dark, deep depressions, and they kind of know that that might be around the corner. Some people might not identify as saying, “Yes, I really am in a depression right now,” but, you know, to other people around them they would appear to be in a slight depression.

Jeff: Kirsten, as we mentioned in our lead into you, mood swings themselves are common. They’re everyday for all of us. And it can make kind of difficult for somebody, a loved one for example, to recognize in somebody else whether these are mood swings, or they’re signs of something more serious like bipolar one or bipolar two. What kind of guidance can you provide us in terms of that recognition?

Kirsten: Yeah, I think one of the biggest factors is that, you know, it really does impact someone’s ability to function, especially in bipolar one disorder. I think it’s also really, really, really important, again, one of the hallmark features of mania and of bipolar disorder is lack of sleep, but not needing sleep. You know, it’s pretty common.

Sometimes people go a night without sleep, right? Or two nights without sleep. But most often people feel pretty tired after that. Or, you know, pretty irritable or pretty downtrodden. Again, with episodes of like true episodes of mania, someone will really say to you, “I don’t need to sleep anymore. It’s just not part of what’s required for my physical body to kind of need that.”

Jeff: What are some of the other signs of a manic episode?

Kirsten: Yeah, a lot of times people experience what’s called grandiosity. Or thinking that maybe they can achieve goals that are much higher than what their capacity could be. Or they might think that they have, you know, kind of powers that otherwise they wouldn’t normally think that they possess. There’s something called goal-directed activity, where someone might be really focused on one particular project. Like, you know, “I’m going to paint my entire house like over the next 24 hours,” or something along those lines.

Sometimes, and we might get to this more in the conversation, sometimes people can experience psychosis during episodes of mania. And that can be indicated by auditory hallucinations, referential thinking, which is really common with bipolar disorder, and grandiose delusions. So someone might actually believe that they are going to become maybe the CEO of a company that they just started working at. Something along those lines.

Jeff: Definitely want to talk more about psychosis. So hold that thought for just a moment ‘cause we have a nice follow-up question to what you were just talking about here. It sounds like someone needs to go without sleep for long periods of time to be diagnosed as having bipolar disorder. Can you speak to people who experience mania but aren’t awake for a week at a time?

Kirsten: Yeah, sometimes people can experience more irritability with mania, which I think is really important to point out. That like it’s not always this really pleasant experience. Sometimes people can also have what are called mixed episodes, where you’re experiencing both mania and depression at the same time. And so you actually might be able to get some sleep, but it’s not restful sleep, and you’re still feeling pretty tired. But you also might have some of that revved, you know, kind of manic component going on at the same time.

But, you know, sometimes people are able to get some sleep, like especially with hypomania. You know, someone might be sleeping, but it’s going to be less than what they normally get. So if you’re someone that sleeps eight hours a night, you know, maybe that would be reduced to about two to four hours per night. So there’s a lot of variability in how people can experience sleep, you know, during a manic episode. But classically it’s that, you know, “I don’t need to sleep,” and your body kind of doesn’t require that.

Jeff: What about the other side of this equation, the depressive episodes? Do they look like depression that we might be more commonly seeing in the population? Just generalized depression?

Kirsten: Yeah, yeah, actually yes. It does, it does look the same. One of the, you know, biggest problems with people getting appropriately diagnosed with bipolar disorder, is that a lot of people go to their mental health treatment providers saying, you know, that they’re experiencing symptoms of depression. And, you know, sometimes people get put on SSRI medication, which actually can catalyze a manic episode, or can cause increased levels of irritability and agitation for someone that actually has an underlying bipolar diathesis. So it is pretty common. And especially when that kind of, the first onset is depression versus mania.

Jeff: Is the speed of the mood change itself significant in the diagnostic process?

Kirsten: Yes, it is. Yes. You know, with bipolar disorder, you know, the episodes, they do have to be discrete, and they do have to be really identifiable. You know, in my experience, people can experience mania for several weeks to several months, sometimes even up to almost a year. So they can be very long. I know that there is also a lot of information out there and a lot of talk about rapid cycling, which I don’t have as much experience with.

But that is, you know, a diagnosable type of bipolar disorder. But in my experience, the episodes are very... They’re discrete, you really can identify, you know, when they started and when they’ve ended.

Jeff: Before we move on from sleep, another question came in, which I think is a terrific one, I would imagine that such long periods without sleep would wreak havoc on someone’s ability to function or have a major impact on their cognitive abilities. Can you speak to how these episodes impact people living with BD?”

Kirsten: Yeah, absolutely. I’ve heard so many people talk about bipolar disorder as a disorder of sleep. I have, you know, patients that I work with who, you know, after one night of sleep might really start experiencing more symptoms. And I think sleep is just one of those cornerstones that is so important to really pay attention to if you have a diagnosis of bipolar disorder. I think the second part of that question was kind of like, you know, how much does this impact someone’s life? And it really can, it can wreak havoc on someone’s life. It can be very disruptive.

Jeff: You mentioned psychosis, and that’s such an important part of this equation as well. What does that look like for somebody living with bipolar disorder? And is it different from bipolar one versus bipolar two?

Kirsten: Yeah, that is a great question. You can have psychosis with both. Usually when someone is experiencing a manic episode with psychosis, it is affiliated with bipolar one disorder. And it can, you know, it can be anything... There’s a broad spectrum of psychosis. So, you know, there could be some light kind of psychotic symptoms that are kind of sprinkled here and there. Or there could be really full-blown psychotic symptoms, where someone has very serious delusions, you know, that are very fixed until they wind up getting treatment.

Jeff: Let’s talk about the diagnostic process itself. How does a professional go about diagnosing bipolar one, bipolar two, or any of the other associated disorders? Are there specific criteria for an official diagnosis?

Kirsten: Yeah, yes, there are very specific criteria for the diagnosis. So with bipolar one disorder- Well, I’m going to back up a second.

Jeff: Sure.

Kirsten: You only have to have one episode of mania in order to be diagnosed with bipolar disorder. And I will say a lot of people struggle with that. With bipolar one disorder, the length of the amount of time that you go without sleep is longer. So with bipolar one disorder, you need a week without sleep. With bipolar two disorder, it’s only four days without sleep. And again, with bipolar one disorder, a big differentiator is that loss of ability to function. With bipolar two disorder, that isn’t a differentiator. I will say anecdotally, like as a clinician, time is also really helpful.

You know, some... It’s really variable. Some people, you know, have a very rapid onset of a manic episode. And, you know, six weeks later are in-patient, and are like really confused, and it came on so suddenly. Sometimes it takes years for people to receive a diagnosis of bipolar disorder.

But there are very specific criteria and it’s very important, especially if someone comes into your office saying that they’ve experienced depression, to really dig in and really find out if they’ve also experienced symptoms of mania. Because again, you could really wind up in kind of a difficult situation if you get prescribed the wrong medications.

Jeff: Yeah, this sounds like a very complex diagnosis. And I wonder if you have found anecdotally in the professional world that there is confusion. That there are misdiagnoses that more awareness can help address?

Kirsten: I do, I do. I think that... With bipolar disorder in particular, it does happen pretty frequently. People can be misdiagnosed with schizophrenia when they’re having an episode of mania with psychosis. And honestly, as I’m thinking about it, it’s not necessarily because... It’s not... It really takes time I think, to be able to appropriately diagnose this.

So, you know, when someone’s presenting to you in a depressive state, or someone’s presenting to you in an acutely kind of psychotic manic state, you know, they’re looking a certain way, but you really have to gather as much history as you possibly can, you know, in order to make a more appropriate diagnosis. And I think it’s really, really important to not like slap a diagnosis on during that period of time, and to really let things evolve.

Jeff: Question from an audience member, “I have been told that sometimes patients are too young to be diagnosed with bipolar disorder. Is that true?”

Kirsten: I think it’s really important to be wary of diagnosing children with bipolar disorder. But children can be diagnosed with bipolar disorder. It’s just that there’s a lot of other factors that can go into, you know, children having mood fluctuations. I mean, first of all, as you’ve been talking about the whole time, children have mood fluctuations, you know, constantly, very constantly and very rapidly, especially teenagers.

ADD and ADHD are actually comorbid with bipolar disorder. And so children, you know, might be struggling with ADD or ADHD, and it’s important to rule that out. You know, you of course want to be wary when it comes to prescribing children, you know, these kind of heavy medications like mood stabilizers and antipsychotic medications that are indicated with bipolar disorder as well. So it definitely is diagnosable, but it just... I think you just have to be careful.

Jeff: Is there a typical age at which someone is diagnosed with bipolar disorder?

Kirsten: Yeah, yeah. So typically the onset happens in early twenties.

Jeff: Early twenties. Okay. And before we move on from the diagnosis, I believe I read at one point that sometimes there’s a physical exam as part of the process of the diagnosis. Is that the case? Not one that you’ve run across?

Kirsten: Not that I’ve run across. You know, when I first started working here at McLean Hospital, every young adult that came in with a first onset of mania and/or psychosis, would have a workup. Like a first episode workup, which included an MRI. But now that those MRIs weren’t revealing anything, you know, kind of indicative, and so that’s not part of the protocol anymore.

It is important to get medically—Like a lot of people, like when your body goes without sleep, a lot of people don’t eat when they have episodes of mania. A lot of people engage in risky behavior during episodes of mania. So it is really important to get checked out by a doctor. But there’s no like physical exam that’s going to help us understand if someone’s experiencing bipolar disorder or not.

Jeff: Well, that’s good to know. Thank you for clarifying that. What about the root causes of bipolar disorder? What do we know about the physiological origins of all of this?

Kirsten: Yeah, yeah. I think at this point it’s really felt as though there’s a genetic biological component for sure with bipolar disorder. And there’s also environmental factors that can perpetuate bipolar disorder, including trauma, especially trauma is a huge one, as well as substance use.

Jeff: We’re going to get to treatment of BD in just a moment here, but I want to ask you about BD in children and teens. And whether or not it presents differently for teens and young kids than it does for adults.

Kirsten: Yes, yes it does. And full disclosure, I only work with adults. I’ve only... I have really rarely worked with children and adolescents, but yes, it does present differently. And it’s again, hence why it’s very important to have someone that specializes in bipolar disorder with children and adolescents that is providing care and really has that lens.

Jeff: Yeah, I can’t help thinking that it must be very important to educate educators about bipolar disorder, because they can be a frontline source of recognition in the classroom, for example.

Kirsten: Yes, exactly. Exactly, yes. Yeah, there’s a lot of hope out there, right? That the younger that we can, you know, identify, you know, someone that is at risk of developing bipolar disorder, the quicker we can mobilize support. And, you know, hopefully increase the chances that that person will be successful moving forward.

Jeff: Let’s talk a little bit about the treatment process itself. Generally speaking, how treatable is bipolar disorder?

Kirsten: Yeah, you know, generally speaking in my experience, bipolar disorder can be very treatable. It really can be. You know, I think it really is with a combination of medication, especially at first, I think medications tend to be much more important in those early phases of the illness. As well as finding, you know, good mental health providers that someone feels really comfortable and safe with. It’s really- Oh sorry, go ahead. You were going to ask a question.

Jeff: No, no, no, please, you go.

Kirsten: Oh, I lost my train of thought.

Jeff: Well, let me go ahead and jump in with this question then, and then we’ll continue to kind of drill down on the treatment process itself. What happens if someone with BD goes untreated? The flip side of what we’re about to talk about?

Kirsten: Yeah, so there’s research actually that was done here at McLean Hospital that really demonstrates if bipolar disorder is left untreated, it morphs into more of a schizophrenia spectrum kind of picture. And someone’s level of functioning really tends to decrease over time quite significantly. The episodes tend to get worse, they tend to get more acute, you tend to not bounce back from them as quickly as you would when you were younger.

Jeff: So again, that speaks to the importance of these awareness campaigns to let people know what they should be looking for.

Kirsten: Right, exactly.

Jeff: You mentioned medication. What should we know about medication and its use in terms of treatment for bipolar one and bipolar two, and whether there is a distinction between the two?

Kirsten: Yeah, absolutely. Yeah, so, you know, mood stabilizers are the class of medication that is most indicated for the treatment of bipolar disorders. There’s three medications out there that I experience people using the most, which is lithium, Depakote, and Lamictal. Those are kind of all the- Like lithium and Depakote are really the tried and true gold-standard medications that are often the first go-to when someone’s experiencing bipolar disorder.

Antipsychotic medications are often used in the treatment of bipolar disorder as well. And sometimes, you know, certainly at the beginning phases, and we’ll probably get into this a little bit more, but if people with bipolar disorder really start noticing, again, that their sleep is starting to get a little bit off, it can be really helpful to have a kind of a medication that they know is a real go-to that can really help to get that sleep nipped in the bud as quickly as possible. And sometimes people take antipsychotic medications to help with that, and there are other classes of medications that people will take to really help with sleep.

Jeff: Has the medical approach changed much over the years in terms of what medications are being used and how they’re being administered?

Kirsten: Yeah, yeah. I mean, actually I don’t think the medications themselves have changed so much. I think one big shift was lithium used to be much more difficult to tolerate physiologically. And that has really improved over the years. So lithium is much safer to take, and is much easier to tolerate.

And then there are always, you know, newer medications that are kind of out there that are, you know, being marketed towards bipolar disorder. You know, that are worthy of trying as well too that might have less side effects.

Jeff: I’m imagining how difficult it must be to address both episodes of mania and depressive states with medication. Are they used differently than medications, different cycles, or is the whole idea to even things out along the way?

Kirsten: Yeah, yeah, that’s a great question. So acute mania is much easier to like treat, basically, and to get kind of under control than depression from bipolar disorder. So, you know, usually when someone is an acute manic episode, antipsychotic medications, mood stabilizing medications, can really get sleep under control pretty quickly, and can really help to bring the mood down.

But then around the corner, can be a real insidious dip into depression. And there isn’t as much that can be done in that phase. ECT can be often used during a depression, and other medications can be kind of tweaked. You know, sometimes psychiatrists will use SSRIs, but that can be a slippery slope, because those can be really contraindicated in bipolar disorder as well.

Jeff: Can you speak a little bit more about ECT for those who aren’t familiar with that term?

Kirsten: Yeah, absolutely. Sorry. Yeah, ECT stands for electroconvulsive therapy. We have an ECT service right here at McLean Hospital. And one of the most effective things that ECT treats is depression.

So when someone is having a bipolar depression, sometimes it can be indicated to receive ECT. And sometimes that can be a pretty robust treatment that can really help more immediately than, say, upping a lithium dosage, or going on lithium, or another mood stabilizer at that point.

Jeff: Is talk therapy part of the process?

Kirsten: Absolutely, absolutely. Talk, talk, talk, talk, talk, talk, talk. I think talk therapy-

Jeff: Tell us about how that looks, what it looks like.

Kirsten: Yeah, it’s so important. You know, during manic episodes, a lot of people do things that they really regret. You know, a lot of people engage in risky behaviors. A lot of people have, you know, this kind of disinhibition where they might joke around in ways that they don’t usually.

They might say things to colleagues at work that they wouldn’t normally say. And everything seems fine during that episode, but after, when someone comes out of the manic episode, there can be a lot of remorse, a lot of guilt, a lot of pain that has happened that really needs to be processed. And it’s really important to have a professional or someone that’s there that’s non-judgmental, right? That’s there to kind of help process everything and digest it. But again, not to be in that kind of judgmental space.

Jeff: Kirsten, we have a lot of questions coming in. A laundry list and I’m going to get to them in just a moment here, but let’s keep moving forward a little bit with the big picture of all of this. How common is it for someone with BD to experience other mental illnesses at the same time?

Kirsten: Yeah, that’s a great question. It’s very common. Very, very common. A lot of people with BD have comorbid substance use. Particularly alcoholism, stimulants, cannabis. A lot of people with bipolar disorder also experience ADD and ADHD, which is really, really tricky.

Because medicines for ADD and ADHD are also contraindicated in bipolar disorder. They’re often stimulants that can make mania worse. A lot of people also experience personality disorders as well as bipolar disorder, which is very common. And anxiety. Obsessive compulsive disorder as well can be mixed in sometimes too.

Jeff: So it’s real important to break out, tease out what’s what in terms of diagnosing somebody with these multiple challenges?

Kirsten: It is, it is, absolutely. Yeah. And it’s important, you know, as a clinician to, you know, if you feel like you really can’t address, you know, maybe one of those other issues like the substance use that’s going on to be able to try to mobilize some of those resources for someone as well too.

Jeff: And you touched on this, but we often hear about someone with BD misusing drugs or alcohol. What should educators, professionals, and concerned loved ones know about that in terms of watching for these symptoms?

Kirsten: Yeah, yeah, that’s a great question. So I mean, a lot of people use substances to kind of self-medicate with bipolar disorder. For example, a lot of people turn to alcohol to help tamp down a manic episode. And so I think it’s important just to know, you know, also that it might not be... That person really might be self-medicating to try to control something that is really bigger than just the substance use that you’re seeing.

Also, you know, unfortunately, the substances don’t help. They might be a temporary band-aid, right? And they might help in that moment, but they’re not going to help long-term. And so to really have, you know, hopefully, you know, to develop language with that person that’s going through an episode to say, “Listen, when you start drinking for example, this probably means that there’s something else going on. So let’s try to fix what else is going on so this doesn’t spiral out of control.”

Jeff: I’m going to tackle, start tackling some of these questions that are coming in, ‘cause they’re fabulous. “Is it common for there to be a connection between traumatic events and a new diagnosis of bipolar disorder?”

Kirsten: Yes, absolutely. Absolutely. 100%. Even good life events like weddings can trigger very first manic episodes. So it is, it is very common. You know, some people might be going through a particular difficult time in their life and maybe had no history of any sort of mental health issues, and all of a sudden lo and behold the right kind of ingredients come together to catalyze something like that. So it is common.

Jeff: We have had several professionals ask us today about the challenges that come with evaluating patients with severe mood swings. Do you have any suggestions for clinicians that will help them differentiate between bipolar disorder and disorders that may also include significant changes in moods such as borderline personality disorder?

Kirsten: Yeah, that’s a great question. It’s very hard, I can say. And you know, I think I’ve already said this, but time is very important. I think it’s important for clinicians to not make hasty decisions. And to kind of slap diagnoses or put diagnostic criteria kind of on someone before you really know that you feel very strongly that this is going to be helpful for that person.

You know, there are really true like hallmark indicators of bipolar disorder. So I think it’s really important to kind of always go back to those tried and true signs, and to really like get the DSM out, and to like really look through that criteria. Someone really might have both, they might have bipolar disorder and they might have borderline personality disorder. You know, I think also something that’s really important is to really look at someone’s ability to function. You know, regardless of diagnosis.

So like when someone’s presenting to you, you know, it’s good to think about diagnoses and what possibly could be going on, and what sort of treatments might be out there, but then also to say, “Well, how is this person really functioning?” You know, what can we do to just kind of get this person functioning better? You know, outside of looking at it through the diagnostic lens.

Jeff: I’ve been wanting to ask you about self-awareness and a question came in that I think frames this very well, “How often do you meet patients who have a clear lack of insight into the fact that they are struggling with their mental health or are resistant to treatment?”

Kirsten: Yes. What was the beginning of that? I just want to make sure I heard it.

Jeff: Just how often you meet patients who have a clear lack of insight into the fact that they are in fact struggling with something like bipolar disorder?

Kirsten: Yeah, it’s very, very common, especially with mania. Especially, because, you know, mania can be a pretty pleasant experience. Even if mania is coupled with some negative experiences, like increased irritability, sometimes people experience some paranoia, you know, more often than not, people don’t want their manic episode to end. And might not have a lot of insight into the fact that they are experiencing a manic episode. A lot of times when someone switches into more of a depressive episode, that’s where the insight really starts coming. You know, you don’t need to have insight necessarily in order to have a good outcome with bipolar disorder.

There’s a great book out there called “I’m Not Sick, I Don’t Need Help” by Xavier Amador, that really talks about the relationship of insight and prognosis. And I also think, you know, in my experience, like, when it comes to the insight question, it’s really being able to work with someone over a long period of time. And to really to be able to develop a trusting relationship. You know, to be able to say, “Listen, you know, I think you might be maybe tipping into some of a manic episode, you know, what can we do about this?” Or to have developed enough trust where someone can reach out to you and say, “Listen, I think something is off. You know, what are some of the tools that we can use to try to get this more under control?”

Jeff: A question came in about disruptive mood dysregulation disorder. Is that a form of bipolar disorder?

Kirsten: I don’t really have much experience with that particular disorder.

Jeff: Fair enough. We’ll circle back to that at some other point. For those who live with these disorders, or live with someone who lives with one person who is living with this disorder, I didn’t phrase that very well, but I think you know what I mean, it’s best to know when someone might be heading towards having an episode. What are some of the early signs of a manic or depressive episode? Something that might send up a flag?

Kirsten: Yeah, yeah. Two big things that really stand out to me are lack of sleep and increased kind of energy. Like increased kind of euphoria. But typically that doesn’t happen until the lack of sleep really starts to happen. And I will say, in my experience, I really think it’s the person themselves that’s going through it, that really has that very first inkling as to, you know, “Something might be unraveling here.”

And it’s really helpful, like if language can be developed between that person and their support network, you know, to know like, okay, what are the indicators that this could be an episode coming on? Versus, oh, like you’re just having a bad day. Or you’re having a really good day. So it is notoriously difficult, I will say, to find those very, very early indicators. Because I really think that they tend to be kind of more intrinsic with the person that is diagnosed.

Jeff: Let me get to a couple of these very specific questions, Kirsten. Eye movement desensitization and reprocessing therapy, EMDR, or ketamine? Ketamine rather. Are they used in treatment of BD?

Kirsten: Yeah, yeah. My experience is that they’re not, you know, kind of go-to. You know, number one kind of indicated treatments. EMDR is often used for trauma processing. And so for sure, if someone has experienced a lot of trauma and has bipolar disorder, EMDR can be an effective treatment. I would recommend that the person be kind of stable before engaging in trauma processing therapy.

And then ketamine treatment. So ketamine can be really effective with the treatment of depression, but it’s really contraindicated if someone has ever experienced psychosis. And so my thought would be it’s probably not, you know, kind of one of those tried and true treatments for bipolar disorder, and it would be a good idea to contact a ketamine, you know, provider to inquire. But again, if you’ve had psychosis, then that wouldn’t be an appropriate treatment.

Jeff: We’ve had several questions come in about anger around bipolar disorder, and the use of abusive language, for example, as it relates to manic episodes. Is that common and what recommendations do you have for those supporting somebody living with BD?

Kirsten: Yeah, yeah. I’m really glad that someone brought that question or brought up that topic. And I apologize if I’m using terms in this webinar that are offensive. I really... I think that the most important thing is to use the language that the person that has the diagnosis wants to use. It really, in my opinion, doesn’t matter what language- You know, if someone is saying, “I have bipolar disorder and I’m having mania,” you know, it really doesn’t matter as long as someone is able to communicate kind of what their experiences are and to get the support that they really need.

It can be a big turnoff for, you know, a lot of people out there to be labeled with bipolar disorder or to be labeled with mania. And I really get that, there’s a lot of stigma out there. But I really... You know, I would hate for that to impact someone’s ability to seek treatment, and to hopefully find treatment professionals that might be open to understanding that.

Jeff: What do you find some of the common myths about BD are, I mean, the way it’s portrayed in the media or elsewhere?

Kirsten: Yeah, that’s a really, really good topic. I... One of the things that I think irks me the most is when mania is kind of depicted as this kind of like magical, like special like kind of thing. Like there’s a show called Homeland. I don’t know if you’re familiar with that, but the...

Jeff: Carrie Mathison?

Kirsten: Yes. Yeah, yeah. So, yeah, the lead character experiences bipolar disorder. And I haven’t watched the whole thing, but the parts that I’ve watched, you know, she’s often like figuring out these deep mysteries, you know, and like all of these cases, like when she’s having an episode of mania. And I don’t think that that’s often the case. A lot of times when people are experiencing mania, their thoughts are racing really quickly. And someone might have the experience that they’re able to think through things more rapidly, or have like a lot more insight kind of into the way that problems work. But that’s really probably not the case.

That person is probably pretty crippled by like the amount of racing thoughts that are going on. And it’s probably not possible to really accomplish this, you know, working out this major CIA investigation or, you know, whatever is going on. Yeah, a lot of times media also portrays medications like in the wrong ways. And I don’t know, sometimes they just make it seem more glamorous than it actually is.

Jeff: In terms of overall awareness of bipolar disorder, what’s the trend line? Do you find that people are becoming more cognizant of what to look for around these disorders and more treatment is out there? I mean, are things moving in the right direction from a professional standpoint?

Kirsten: Yeah, I would say with bipolar disorder, there was another movie as we’re talking about movies, “Silver Linings Playbook” that came out, I don’t know, six or seven or eight years ago maybe.

Jeff: Yeah.

Kirsten: That I think did a lot of good actually to raise awareness. I work with a lot of young adults, and a lot of young adults were really happy when that movie came out, who we were diagnosed with bipolar disorder.

I think, you know, one of the other trends that I’ve been seeing is a lot of people may be like over-identifying with the diagnosis of bipolar disorder or maybe, you know, saying, “Oh, because my moods fluctuate, like I must be really bipolar.” That’s kind of like entered, you know, some of the vocabulary that gets used, like kind of like in the mainstream. And I think that’s kind of a slippery slope. Because it really is a, you know, a significant diagnosis in and of itself.

Jeff: Well, that reminds me of a question I wanted to circle back to and that’s this, if you think that you might be struggling with bipolar disorder or someone that you love is, what’s the next step? What’s the first step?

Kirsten: Yeah, I mean, I would say the first step is working with that person to agree to see a mental health professional. And that can be tricky, but, you know, sometimes some language that might be helpful is, you know, “Why don’t we go see someone now before this gets so out of control that you don’t have a choice?” Right?

Like, if you’re really seeing someone like level of functioning, being impacted, or their ability to really stay safe in the community, you know, I really want people to seek treatment and come into treatment when it’s on a voluntary basis. Right before it kind of gets out of control and, you know, they don’t have a choice anymore. And maybe the police get involved, or they’re kind of brought into the hospital involuntarily, ‘cause that’s not fun for anybody.

Developing language I think is really important to really use the language that your loved one is bringing to you. Even though you might, you know, have a sense in the back of your mind, “Okay. Like, I think I’m putting together the pieces and this seems kind of like classic kind of bipolar disorder.” But a lot of people don’t respond when you say, “Hey, you know, I think your bipolar disorder is acting up again and, you know, like, let’s kind of go get this fixed.” So, you know, again, just kind of developing like a common language.

Jeff: Talk about what people can expect to... The life that people can expect to live once treated with bipolar disorder?

Kirsten: Yeah. I really want people to have hope.

Jeff: Absolutely.

Kirsten: I have a lot of hope. I really do. I will say that the beginning years of bipolar disorder tend... If you get diagnosed, you know, in your early twenties, kind of like on this kind of classic spectrum, it’s hard, you know? It can be really hard. And there can be a lot of bumps in the road and a lot of challenges, but don’t give up.

It gets better over time. It really does. If you stick with, you know, the medications, you know, just a well-rounded healthy kind of lifestyle, a structured lifestyle, it really can get better. I’ve heard so many people tell me, you know, six months to a year after their first episode, “Wow. I don’t even, you know- I don’t even, like... I feel completely back to myself again. Like, I can’t believe that that happened to me.”

Jeff: Hmm. It’s so important to pass along that hope and I’m glad that you’ve just done that, Kirsten. Also important to pass along resources for families, friends, and caretakers of those living with BD, what’s available for them?

Kirsten: Yeah, I do think it’s very, very important for caregivers to seek their own support. So individual therapy I always recommend for caregivers. There’s a wonderful organization out there called the Depression Bipolar Support Alliance or DBSA.

There are chapters of DBSA in almost every state. There’s a very robust one here in Massachusetts. There are a lot of books out there. There’s workbooks for bipolar disorder, and there’s also memoirs out there. A lot of people are talking about it more. And I highly recommend reading those. That other book I mentioned, “I’m Not Sick, I Don’t Need Help” is a great book also for a lot of caregivers to read.

I think burying it and not talking about it and being more isolated is one of the- You know, I understand why it happens to a lot of caregivers, but to really fight against that. Because, you know, you really need to be your best self in order to be able to support your loved one that’s going through it.

Jeff: Well, I tell you, Kirsten, the questions just keep on coming in, and I want to take what time that we have left here just to kind of run through some of them and see what we can get answered here. “If psychosis is not present, are the medications typically used for bipolar one and bipolar two generally the same?”

Kirsten: Oh, yeah, that’s a really good question. So not necessarily. If someone isn’t presenting with psychosis, mood stabilizers, in my experience, are the number one kind of indicated treatment. However, there are psychiatrists out there that do use antipsychotic medications as a primary treatment for bipolar disorder.

But from my experience, it doesn’t tend to work as well as those kind of tried and true mood stabilizers that we talked about. And the hope is, you know, if someone’s mood, you know, can be more better controlled, right? You know, they won’t have those episodes of psychosis. Because the psychosis usually comes when the manic episodes get into its more severe form, or depressive episodes get into its more severe form.

So the theory is like if you can stabilize the mood with a mood stabilizer, you won’t need hopefully an antipsychotic medication. But they can be used, especially acutely. Like, if someone really needs some sleep, antipsychotic medications can be very effective.

Jeff: We’ve had a viewer ask for some more information about ECT. You mentioned that earlier on, “Is it possible for ECT to trigger manic episodes, and has it been proven to be effective overall for people living with bipolar disorder?”

Kirsten: Yeah. Yeah, that’s- Thank you so much for bringing that up. It can happen. ECT can trigger a manic episode. And so that’s why it’s, you know, first and foremost important to go meet with the ECT consultant and to disclose your full history of bipolar disorder. And also to have- So if the ECT consultant says, “Yes, you know, I think you’re a good candidate for ECT to be keeping an eye on the mania, you know, for yourself and also for the people around you.”

There’s a really good book out there called “Shock” by Olympia Dukakis. She doesn’t experience bipolar disorder. I believe she has more depression and substance use issues, but that’s just a great educational book out there, just like on the nuts and bolts of ECT. And ECT can be really helpful with bipolar disorder in general. It has been proven to be an effective treatment. But again, you have to be careful about the mania.

Jeff: We’ve also had a request for some more information about neuropsychological testing. You touched on this early on. Where is the field right now with that?

Kirsten: Yeah, so neuropsych testing can be really helpful for sure. And oftentimes there is between eight and 12 hours of neuropsych testing that is available through your insurance company. So it’s worthy to see if you have that benefit.

It’s important to remember that, you know, neuropsych testing is, you know, a snapshot of one particular moment in time, right? And that it can give you a lot of information for that one particular moment in time.

But, you know, the longer that you, you know, really know, you know, about the mood fluctuations, or the longer that you work with a mental health professional that can really help you track how this looks over time, I think the better. So I wouldn’t like base, you know, like... Like, again just to keep it in mind that it’s just one snapshot and it doesn’t kind of base the rest of your life. Right? Or you shouldn’t base the rest of your life around that testing.

Jeff: Kirsten, you talked about the possibility for people living with bipolar disorder to thrive. And that’s such an important way for us to wrap all of this up here. Talk a little bit about some of the self-maintenance, self-care that people living with BD can use for themselves. Whether it’s charting their mood swings or whatever else you’d like to share.

Kirsten: Yeah, yeah, absolutely. Yeah, you know, again, and I’m sure a lot of people listening to this would probably agree, in my experience, sleep. Sleep is the cornerstone always. So, you know, making sure that you have developed a good sleep hygiene regimen, right? And you’re getting, you know, consistent good sleep every single night. If you miss sleep, that you have an immediate backup plan.

So sometimes, you know, people usually develop a threshold. You know, a lot of the clients I work with will say, “Okay, if I go one night without sleep, it’s fine. If I go two nights without sleep, that’s not okay. And I’m going to take an as needed medication that has been prescribed to help get sleep under control.” I really do think that a good structure, a really consistent daily routine can be vital.

Especially if you’ve been going through kind of the more acute phases of bipolar disorder, I would not want like that structure to prevent someone with bipolar disorder from like taking a trip around the world, or, you know, exploring career options that might not be so structured. But no matter what, just kind of trying to find a way to keep kind of that consistency.

Jeff: We have covered a lot of ground in 55 minutes and I want to give you the last word here. What haven’t we talked about that you do want to share in terms of important messaging around bipolar disorder?

Kirsten: Yeah, I guess, you know, it really... It is individualized. There’s a very broad spectrum of how bipolar disorder presents. You know, there’s a very kind of classic ways that bipolar disorder presents, right? And I think I’ve kind of hit upon a lot of that throughout this conversation. But just to put out there that it is nuanced for sure.

I really want to put a plug in for people, you know, to understand that it is really hard work. And that I’m not trying to minimize that. You know, bipolar disorder can be very serious, and it can be really hard work to try to get it under control. But if you put that hard work in, the outcome is going to be great.

You know, the harder the work, you know, listening to the people around you, listening to the treatment professionals. You know, and that your life can be really fruitful. Just because you have this diagnosis, it’s not this like doom and gloom kind of situation.

Jeff: And that’s a great place to wrap things up. Kirsten, thank you so much. You’ve done a phenomenal job today of debunking some myths around bipolar disorder, and sharing some critical information about awareness and treatment processes and so forth. And can’t thank you enough for your time today.

Kirsten: Thank you so much, I really appreciate it. I had a great time.

Jeff: Kirsten Bolton, our guest today. And thanks to all of you for tuning in. We will remind you that there’s a lot more information available about bipolar disorder on the McLean Hospital website. Have a great day, everybody.

Jenn: Thanks for tuning in to Mindful Things! Please subscribe to us and rate us on iTunes, Spotify, or wherever you listen to podcasts.

Don’t forget, mental health is everyone’s responsibility. If you or a loved one are in crisis, the Samaritans are available 24 hours a day at 877.870.4673. Again, that’s 877.870.4673.

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The McLean Hospital podcast Mindful Things is intended to provide general information and to help listeners learn about mental health, educational opportunities, and research initiatives. This podcast is not an attempt to practice medicine or to provide specific medical advice.

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