Dr. Patrick McKeon presents Bipolar Disorder

so let's start with symptoms it's useful i think to have a model in your mind of what constitutes bipolar disorder even if it's a load of rubbish but the point is they're so the the problem with depression and bipolar disorder is the symptoms can be very diffuse they can affect every area of the body every area of the mind and there's a lot of different ways the condition can manifest so the purpose behind this is really to try and strike some sort of order in it i think it's reasonable to say that the core thing that happens within bipolar disorder is that there's a variation in the rate of thinking that is central to the condition inhalation it's speeded up in depression it's slowed down so it's useful to think of it in that sense that there's a wheel in the brain that rotates at a certain rate don't go looking for it don't ask for x-rays for it but just pretend it's there when somebody is depressed it slows down and because it slows down the person has difficulty finding words the flow of conversation or thoughts in the person's mind won't come because of that they have less to say in conversation the person's whole driveness within their body then begins to change because those thoughts and the way it branches out into the brain itself determines how the person moves their rate of movement becomes slowed down they're less expressive in their face the person's eyes begin to get dead the person is vacant they're looking into space they're there but there's nobody at home type of look about the person and they walk much more slowly so we all have a certain rate of which at which our thinking goes and it's only when it changes in that way upwards or downwards into being slowed down or speeded up that it begins to affect so much of the person's emotional and physical being so with this slow down thinking then the next thing is the person has difficulty creating a spin-off in their mind onto the visual display unit we have a visitor display unit in our mind and we use it all the time but we're not conscious of it terribly much if i said to you what are you doing after the meeting this evening what are you doing for the weekend have you had a holiday yet if not where are you thinking of going what are you thinking of doing hopefully some picture shoots up in your mind now that picture in our mind is extremely important but what you'll find is when people are depressed they can't get a an image up onto that picture and when you say to that person how do you view the future they will say things like it's bleak it's blank or there's nothing there and sure enough that's exactly what's happening there's actually nothing on the screen because there's nothing on the screen the next thing that follows from that is the person lacks energy because energy is a figment of our imagination if we see something there like something exciting that we're interested in we will pursue it if there's nothing there our energy flags that's why for example we have more energy on a friday despite working hard all week we've got the weekend on the screen whereas on monday morning when we should have plenty of energy having rested for the weekend if you do the person feels fatigued so that is an extremely important part of the phenomenon the next thing is that because the thinking wheel is rotating so slowly the person can't absorb information it's almost as if information is coming at this wheel through the brain all the time from the external world and if we saw those as little bits of information they have to be strong onto this wheel and then they eventually get in words to the memory wheel and that memory stores wheel information but the point is if this outer wheel in a sense is going so slowly it's not sucking up enough of this information therefore the person can't uh pull information out of the system so in other words as people would say well i could you try and explain to me what happens when you're depressed what the person would say is i see the words there but i can't assimilate them i can't take them in and that's basically what's happening it's just because this wheel is is slowed down now do remember what i'm saying might turn out to be a load of garbage and disproven but i've been saying it for 20 or 30 years and it still is reasonably valid as a central aspect of mood disorder the next thing is that when a person is depressed they're thinking you see normally we think ahead a certain amount we think of what we're going to do later this evening what we might have to do tomorrow what we might be doing at the weekend when a person gets depressed they say they can't do that and what happens is as an alternative the thinking becomes introspective so the person then becomes extremely conscious of themselves and how others see them maybe socially conscious social anxiety or they become very aware of their body the size of their nose their ears whether they've got pimples their weight something that the person will focus or if somebody is quite depressed it'll focus on maybe um they've lost some weight recently maybe they end up concluding they've got cancer so these things play on a person whereas normally when a person is in the full state of their health their thinking is out here it's not in on their body okay and the other thing then is that people tend to think about the past rather than the future and they think about the past in a negative way so normally we say that anything is made up of either positive or negative thoughts when we are in good form we look back at the past and we say the good old days when people were lighter there's less traffic on the road jobs were more plenty and so on and so forth but we forget that maybe tb was rampant i know it's back again but not as bad as it was um there was less social welfare support unemployment was just as high immigration was rampant and so on so there are good and bad points in every era but when we're in good form surprisingly we actually tend to look more on the positive side when people become depressed that actually gets cancelled out and this one goes up in neon lights and frequently it's in on the person's own being they're looking at maybe something that they've done in the past that they feel guilty about ashamed about maybe something that they construe as being an evil act and it's just that the person's total focus is on the past we all have maybe fleeting thoughts about things in the past that we're not proud of or feel embarrassed about but when a person gets depressed that sort of total focus on the past becomes comes the issue does that make sense yeah so we have in a sense most of the symptoms of depression what happens in elation then is the direct opposite the wheel is going so fast the person has an experience of raising thoughts they can't switch off their mind to go to sleep and even if they do switch it off for a while so they'll wake up earlier because the wheel is banging on again the person has plenty of thoughts and is projecting them into the future so it has a thousand and one different things here on the visual display unit and these things attract the person such that they're jumping from one thing to another to another if you're talking to somebody like that rather than staring into space their mind their eyes are dancing because the person's eye is flicking as it were from one picture to another as if they were watching a series of photographs just floating across their mind the person has tremendous energy because there's all these pictures to chase after and they will frequently lose weight initially they have no difficulty absorbing information from their environment and will actually be better than average in that sense of being able to pick up information but once the mind starts going at a certain rate it can it's going too fast for the information and the person is constantly watching the pictures in their mind and watching what you're saying to them and most of what you're saying the person just can't recollect so often when people are going through a bad period of elation they've difficulty being able to recall much of actually what happened during the elation they might remember some row they had with somebody or maybe having to be hospitalized but if you ask them well how long were you in hospital the person might say a week you take out their old records might have been six months so um and it's not that their memory was knocked with medication or anything else it's just a process of the uh the elation so now just very quickly if we move from that to some way of helping you get a hold on signs and symptoms so that you can recognize it within yourself or within within others and we have this mnemonic that we use or at least i use i don't know who else uses it to remind myself of the symptoms of depression so if you can't festival for two weeks you must be depressed f stands for feeling in other words being depressed anxious flat or empty any of those words will do why am i putting anxious there well remember that anxious people who are anxious by nature when they get depressed they simply get more anxious and they will insist they're not depressed but behind that anxiousness you'll see all the sleep disturbance the poor appetite the impaired concentration and so on this typical of depression okay so it's just their lead symptom is often different e is for energy when people get depressed they become fatigued and that fatigue is such an important part of it that for many many people it is the key symptom again many people who get the depression of bipolar disorder experience the fatigue as the predominant symptom they will insist they don't feel depressed they will say it's as if somebody fill my boots with lead my brain with cement in other words nothing is moving they're just zapped in that way s is for sleep now when people are depressed what they do is they tend to oversleep or have broken sleep one thing they tend not to have this is important is trouble getting to sleep if a person with bipolar disorder is in a depressed state as it is thought but they're having a lot of trouble getting to sleep the chances are that it's not a low because it will contradict our understanding of the racing mind okay in other words if somebody has trouble getting to sleep in the context of a so-called depression one needs to ask well actually are they depressed or is it that they're going through an unpleasant high i'll come back to that in a moment t is for thinking that's the slowing down of the thinking that i mentioned in other words slow spoken slow movement and difficulty with concentration in other words the machine has slowed down i is for interest where the person loses interest in the world around them we we develop an interest in the world around us because we make an emotional link it's almost as if we can let out one of those ropes from the thinking wheel and envelop something we look at something we either we have an affinity for it or a repulsion from it but it creates a feeling within us and that's where interest comes in other words that the people we're close to things that have meaning for us in life things that we are enthused about they all diminish but they begin to diminish with the things that are most important to us so it might be for somebody their favorite tv program for somebody else it might be the football they follow or they lose interest in their favorite sport or whatever it may be for other people it's a personal relationship and sometimes a person will come and say i'm fed up with my job i want to get out of here boom but in fact that may be a manifestation of the person being depressed i'm not saying their job is perfect but the point is every day day in day out they've coped with that job and gotten on with it and felt a sense of okayness with it but when a person gets depressed for some people that will be the first manifestation that they're depressed for other people it'll be that they're no longer in love with the person they once loved whatever the important relationship is with them for them in their life and again when that person comes out of that depression that relationship goes back to the way it was so lack of interest in food sex religion sport hobby relationship whatever it may be next is v is for value the value a person puts upon themselves we all have a certain level of self-esteem self-worth and that begins to dip when somebody is depressed when somebody's mildly depressed it might be that they don't feel terribly worthwhile it's just a vague thought rattling around the back of their head when somebody gets more depressed it may be i'm a hopeless individual be better off if i wasn't around the place or the person may think at another value level that they're financially bankrupt or that their health is bankrupt in some way that they've got cancer or something else so some notion of poor work but it doesn't have to be sort of totally emotional worth it can be as i say financial health wise or something like that it lodges in the person's brain and then at the more extreme end the person can be in a sense deluded about their sense of poor worth believing and being absolutely convinced that they're wicked hopeless individuals that should be put down literally or been absolutely convinced they've got cancer when there's absolutely no evidence whatsoever that they have it just lodges in the person's head is for eggs many people with bipolar disorder when they get depressed will experience physical ailments and that arises because there's a tension build up in the body when people are depressed we have muscles all over our body from head to toe in our eyes ears gush heart you name it and that tension in the muscle in those parts can produce very common symptoms like headaches across the forehead tension in the chest low back ache an old football injury or some sort of injury sporting injury can act up at that time because that injury is being pulled by the muscles on either side and it becomes emphasized for the person and l is for live not wanting to live in other words feeling suicidal now in brief if somebody has five or more of those symptoms for greater than two weeks they're said to have depression so i'm just putting that there is a list that helps you deal with it because quite honestly it's unlikely that somebody is depressed if they don't have some of the fast symptoms never mind the other ones in other words there's a disturbance of feeling energy sleep or thinking okay now inhalation you get the complete opposite the person will say they've never felt better anxiety's gone out the window they've tremendous energy they've trouble getting to sleep and awakening early in the morning but the getting to sleep is is very characteristic sometimes it's the first symptom of power violation the person's thinking is speeded up the person might feel that their head is going to explode they've got so many thoughts they've interested in a thousand and one things and they're jumping from one unfinished task to another the person will overestimate their own worth they would have grandiose thoughts or delusions in other words where they become convinced that they have some enormous power to change the world politically religiously or whatever the person's eggs go out the window sometimes you'd see people who get high and might be quite disabled physically with arthritis and their stature might be down like this and then you'd see them when they're high you actually wouldn't recognize them because they might have gained about a foot and a half in height so it can be dangerous in that sense because somebody with a heart problem or respiratory problem will be overdriven by the mind and their heart our lungs aren't able to facilitate that and very often when somebody's high suicide is not something that's going to be on their mind necessarily and they may have a sense that they're going to live forever now what i want to do is to put all of those signs and symptoms now in a slightly different context and the context is this that we can divide any of those states into mild moderate and severe so in a mild depression of bipolar disorder the only thing a person might feel is tired unrested that the concentration is poor and they're lacking confidence so it's actually quite mild the person frequently will not use the word depression to moderate describe is pretty much all of the signs and symptoms i've given you severe depression by definition the person is quite disabled but in addition they're much more likely to have psychotic experiences where they feel they're wicked evil damned cancer bankrupt and frequently the person's intense belief like that is a serious thing because the risk of suicide at that stage is extremely high likewise with elation mild dilation is so mild only maybe the next of kin the person if if that person happens to be living with the individual with the illness will spot it moderate relation close friends will begin to see the person isn't well the spot the high and it's only with the more marked elations that actually acquaintances people at work will realize there's something wrong but the big issue here is that the person with the elation frequently doesn't see it and that's the big aspect of management of bipolar disorder is spotting the elations because if elations aren't spotted any depressions that follow uh just don't seem to make sense well where does it come from why did that start i was fine i was actually feeling very good and then suddenly this depression came from what's that all about well the secret is go back and find out and identify the elation because if you're overlooking that you won't be able to deal with the depression now the next thing within signs and symptoms that we need to deal with is just this conflict of when somebody is going through a high a big high like this it can often be a very pleasant experience but no matter how pleasant it is for most people there'll be moments during it where they feel very distressed you might see somebody one moment and they're quite high full of the joys of life tremendous energy enthusiastic positive nothing seems impossible to them you might see them five minutes later and they're distressed bothered agitated weepy and feeling awful but when you look at the person you know that well it couldn't be anything other than something that's changed within them because it happened so suddenly there's no preceding thought nobody has said anything to them there's been no communication to them from the outside world and bang this happens so that unpleasant you can still see it as part of the elation but for some people that will happen right throughout this period and what the person will say is i feel depressed or they might say anxious or they might say frightened in a paranoid way but depression would be the most common word the person will use but when we look at the person they seem quite different to the person who's in this depression and the difference is here if you look don't listen to what you're hearing for a moment to switch off what's going in through the ears you will find that the person is agitated restless the eyes are darting they have trouble getting to sleep at night they're irritable or angry in other words they've got that sort of wound up state whereas in a depression proper those don't exist the person tends to be worse in the morning if there is a difference between day and night they tend not to have trouble getting to sleep at night they're all slow down their eyes are staring into space the person is flat so we call this a mixed mood state or an unpleasant high or dysphoric hypomania dysphoric means just an unpleasant mood hypomania now there's enormous debate within uh research and clinicians worldwide on this and any of you that are familiar with this area recently the american psychiatric association brought out a way of trying to re-categorize this and it hasn't had clarified matters i think if you keep it quite simple really that it's it's kind of an unpleasant mood state and the mood may be depression anxiousness or fearfulness or a mixture of all three and flitting from one to the other every few minutes or every few hours but behind it there's a driveness there's an agitation that is not part of depression the person complains of depression so when somebody says to me or uh one a staff member would say sons was very depressed the next thing you would be on the lookout for within the context of bipolar disorder is it a quiet depression or that side of oil in other words is the person agitated because why is it important because with this if you treat this with antidepressants you just put them up there you make the situation worse whereas in fact that person will respond literally within hours to some type of anti-elation therapy some type of thing that will bring the mood down whereas here obviously that same type of medication would worsen it is that clear enough okay so let's move on now and just briefly deal with causation everyone here who has any experience of mood problems either directly themselves or with a family member will have their own view on why people get mood problems and they're all valid i've got to look at it from a broader perspective in terms of what the research evidence is and see how that tallies with other people's experience of it the first thing to say to you is that in a general sense bipolar disorder appears to be a genetically inherited phenomenon that runs in families i know that's not a pleasant prospect or idea for people but they're the the broad facts the research would show that if you'd imagine it like this that if this is a bar that has to be complete before a develop a person develops bipolar disorder that on average the contribution to bipolar disorder is 70 genetic and 30 percent environmental but that is the average it's like the average height of males in the country is whatever 5 10 it doesn't mean every male is 510. there will be some people who have a genetic contribution of 90 percent they may tell you of a brother or sister or both a parent or two several aunts and uncles first cousins on one side of the family or indeed sometimes on both sides of the family who have this condition and when you ask what was it that triggered their illness they might say well there wasn't terribly nothing particularly much it might have started we say in with the depression in in late october early november which would suggest maybe a seasonal or a manic episode that happened may june july some time like that so the seasonal change or flight travel or change of night shift or something like that that triggered their mood so in other words quite an innocent everyday type of environmental phenomena that most people can take in their strides sorry in in this group here then there would be people who for whom it is the other way around that it's 10 genetic and 90 percent environmental before the develop bipolar and in that instance it may be that the person has had umpteen different um upsetting events prior to it maybe a death in the family a road traffic accident been put on steroid medication for a chest infection multiple losses threats in the person's life increasing amount of work and it's the multiplicity of all that that brings the person right up to the barrier and unleashes maybe a small genetic tendency within the person and thus the illness but the average when you're taught up the 90 10 the 10 90 the 70 30 the 30 70 when you talk them up that's what what comes out what is it from a genetic point of view that's relevant where are the genes there's been a lot of research done over the past 20 years and nothing terribly substantial has come out of that to date what we do know is that there's no one single gene that is the cause of bipolar disorder it's a multiplicity of small genes that probably act in some cascading way within the condition it's much the the genetics of bipolar disorder what we do know is that it's much more complex than the genetics of diabetes which in a celsius complex or even blood pressure or coronary artery disease but many of those conditions do have several different aspects of it so there's still a long way to go and one of the things that's emerged from this research is that maybe our understanding of bipolar disorder isn't as good as we might think it is in other words that we conceptualize it in a certain way but do we actually fully understand the symptoms do we know what how patients who have these conditions see it and how much of it is a projection of our own imaging of what their symptoms might be unto the condition so there's an awful lot of work that has to be done in terms of going back and looking at how we interpret these things from an environmental point of view are there certain environmental factors that contribute there are things such as medications steroids certain treatments that are used for parkinson's certain medications that are used for blood pressure can have an effect on mood within bipolar disorder we also know that stimulants such as caffeine certain hallucigenic agents people with bipolar disorder or a tendency a latent tendency on release tendency are much more likely to have an adverse effect to those substances losses in childhood are somewhat important but not as important as people with the condition would say now i know that sounds contradictory but let me put it this way to you that often what happens is that people with mood disorders will often grow up in families where other members of the family have mood problems maybe sometimes not diagnosed mood disturbances but that environment created by the parents or others elder people in the family determines that environment that the person grows up in but most of the research still points to the the major contribution to the condition being due to the genetics maybe it'll take 10 20 30 years before we fully understand the genetics of these conditions so the next thing just briefly to deal with is the impact of these conditions on um the family one of the most important things to realize is that mood disorders by their very nature are disturbances of emotion and what links us to the people in our family are our emotions so the first thing that becomes manifest when somebody becomes depressed or a later is that it causes a wave within that relationship that wave is picked up at a very uncanny level even before the person is intellectually aware that the person is unwell the person senses it let me give you an example okay if i'm treating somebody with quite a bad depression and a slow the person is slow to recover and they're coming along quite frequently for outpatient visits and there's a family member coming along with them i can sometimes see that the person is improving not because i can see any change in the person but the relative is beginning to get depressed or agitated and lo and behold within days you will actually see the person with the depression improving now i don't think it's a response it's like oh i better get better uh john is getting very upset with me and um the relationship is in danger or whatever i think it's that the persons at an emotional level have tweaked that there is a change in the person who is depressed they can sense an improvement and it almost unconsciously gives their emotional brain the carer or the relative permission to somewhat lay down tools and take a break on this one okay so if a useful way to conceptualize it is that if if we are in a sense emotional jelly beans and this is our emotional being let's say a person with the condition and a relative there's a very close interface we know the do's and don'ts in relationships we know that so-and-so doesn't like the door left open we know that you better clean up after you at the countertop or you know there are 1001 different things that determine our manifestations of our relationships when somebody gets depressed what tends to happen is they shrink emotionally they withdraw and what do they do then they would say so-and-so's withdrawn from me because they'll feel that void they'll feel that emptiness thus the person will either attack the relative and say you don't seem to care for me anymore or they will sense that there's a void in the relationship or they would cling to the person where they're running around and somebody said going out to the line when they brought the clothes just to make sure they're not separated from the person phoning them at work whatever it may be and that's often difficult then for a family member to cope with when somebody goes high what happens is they expand in that emotional sense and that emotion then impinges on the relative they're louder they're more demanding more insisting the volume of the voice has gone up all of that intrudes on the person and they sometimes they can't work out what's going on what's all that about they just feel extremely uncomfortable within themselves and that then causes conflict within the relationship so that's sort of in a very simplified way the sort of dynamic that happens within relationships now what then happens is this that once the family member realized that the person is unwell when they've tweaked it there's something not right here they want to do the right thing they want to read about the condition they want to bring the person to get help a person might want to go to get help but the person will be patient relative will be patient sympathetic supportive and encouraged the right thing that goes on for a number of months or sometimes years takes a while quite a while very often in the beginning to get a complex mood problem sorted out partially because the person who is unwell is rejecting the phenomenon rejecting help or not being able to access it in an appropriate way that family member that relative is still there at it through thick and thin doing their very best but then as time goes on they begin to get a bit annoyed about things they would say things like you should try this you should have you gone to yoga have you tried pilates omega-3 acupuncture all these suggestions all fine in themselves there's nothing wrong with them but what they're representing at that stage is a sense of agitation where the family member is becoming impatient and that impatience is a sense that things are beginning to change if that doesn't work that sort of agitation often family members begin to distance they don't want to hear they're listening as it were but not actually listening at the same time when the person gives account of how they got on with their visit to the doctor or what's happening at work or whatever the latest problem is that the person brings to them and eventually gets to the point where they just walk away from the situation now often we would hear them as clinicians from patients how awful family members are how could they do that how could she do that how could he be so mean well what's basically happening is nothing different than any of us would do if we're in the same situation and indeed i've seen it i've seen people who've had the mood problem themselves come in and complain to me about how awful their family members are and maybe x number of years down the road the is on the other foot the one time patient is now the carer the former relative is now somebody with depression and lo and behold you can remind the person do you remember what you used to say you know so we all do it that's the point simple you know a gadget that goes wrong at home what do you do you go get out the booklet you read about it you try and press the right knob and turn this and plug it in and plug it out and do all the things that you're advised to do it doesn't work what happens then you begin to get agitated you hit a slap right and then eventually you walk away if they don't make them the way they used to blast the it industry or whatever it may be so we we all respond in that way to situations like that so it's no different so the important thing the important thing here is to try and keep family members on board in terms of the management of it because when we come to look at management the key thing in management of bipolar disorder is early recognition of the condition good knowledge we go through a list of things but the key thing is it's very very hard to treat this condition if you're the only member on the team you need it support from people around you but but sort of kind of technical support were the specific jobs to do in terms of helping you spot early symptoms of relapse spot particularly the emergence of a high because if that can be caught and switched off within days or within hours the person doesn't end up having to go to hospital which they may have to do if it's let drift for four or five days they don't lose their job they don't end up breaking up their relationship upsetting or causing difficulties and ripples in their life that they can't often put back together again okay so just going to park that to one side for a moment and deal a little bit with medication and it's just a few broad principles i think it's true to say that the management of the depression of bipolar disorder or of the marked highs and lows has primarily got to be with medication there is no evidence anywhere of any type of intervention which on its own is likely to be effective or more effective than medication now again i know that's something that people have difficulty getting their heads around but if it's a case that you want to control or be in charge of what's happening in your head you've got to look at what tools are available and have a proven ability to work medication is by no mean foolproof but for many many people it is still the most effective thing that turns their lives around that does not mean to diminish in any way the importance of other things once the medication is in place but it's very difficult for somebody whose mind is racing if not impossible to sit down and benefit from mindfulness when they're depressed for example if you send somebody who has severe depression to mindfulness they just can't take it in now that's bad enough but even the worst thing in a one way another way is that it gets a bad name within that person's head and when the mood actually improves and you recommend mindfulness to say no i can't go back to that it was such a horrible experience so as the same with cbt same with psychotherapy one has got to be very careful that the broad aspect of the mood is brought under some sort of control before you start putting in place many other therapies that can be very helpful learning about the illness psycho-education relaxation therapy the importance of diet the importance of sleep routine eating habits alcohol all these things they're all important but the percentage contribution of each one of them isn't as big as you might imagine you might read about them a lot they might take up that amount in the document you're reading medication might take out that much and it's then very difficult for the person themselves who are trying to inform themselves about the condition to have a balanced view of what actually works right next thing is the focus on treatment is trying to stabilize the mood rather than jump in head first in treating a depression or treating inhalation now they have to be treated of course but the whole emphasis from a management point of view is realizing that there are different patterns to the illness there is what we call bipolar one and this is where the person has a big high a big high means literally one that's bad enough to warrant admission to hospital or quite a disruptive influence on the person's life in other words where they've bust up a relationship because of the high they've gotten into trouble at work and they've run into major financial difficulties it's been evident to the family and maybe neighbors and friends that the person went through a period of very definite unwellness and then it's followed by a low we know for example that the most effective treatment for treating that condition and for preventing its recurrence is lithium lithium doesn't always get a good press because it's a cheap drug it's an old drug but it's still as of last year and the year before research papers have come out indicating that it is more effective and safer than any of the other of the mood stabilizers on the market it doesn't because again it doesn't make big money for drug companies there's nobody advertising it or publicizing it or paying people to write articles on it and so on so it's just one of those phenomena so to conduct any of these drug trials outside drug companies basically nobody's got the money to do it but the evidence is there it's not for everybody but for probably well over 90 of people who have this sort of pattern where it's a high followed by a low been well for a number of months and then another episode and then another episode lithium is the most effective treatment in those instances now it needs careful management i'm not going to go into that in terms of blood tests and renal function and so on but most people who go on with him and for whom it works they get 50 60 years out of the treatment and it's it's pretty effective the next type of mood problem that needs to be identified briefly are not a separate type in in many ways but one i think needs needs a title in itself and that's where the person has unipolar i.e one pole mania by the way the word mania means speed it up so somebody must have thought about the speeding up process and depression actually means slow down that was the original meaning of the word when they came out in other words because that's what was grossly obvious to people when they first present well when people began to study it you know what is the big difference the big difference is so-and-so is very quiet withdrawn they say nothing this other person doesn't stop talking can't sit still and so on now the point about this is this group maybe only 20 30 will settle with lithium alone and others mean need what we call anti psychotic mood stabilizers and they're things like give the spelling uh these are things like zyprexa risperdael in other words basically those drugs are also used as antipsychotics but when they're used in this instance is to quell the elation the big problem for people who have recurring episodes like this is it's very difficult for the person to come down fully enough out of the condition to be able to absorb the information in terms of the damage they're causing in their lives in other words when somebody comes down out of a high if they're going to a depression they can assimilate that information and they can then it dawns on them how disruptive the condition has been in their lives and they can begin to make preventative approaches towards engaging a relative in terms of spotting relapses taking their medication getting tablet boxes being careful about alcohol coffee all these things but somebody who is not sort of they come down to a normal mood but sometimes after a tragedy or something significant gone wrong in life like a high if a person's mood doesn't come down into a little bit of depression they don't feel the pain and thus they need to change does that make sense to you yeah so that's a real real problem and it often until the person is hit very hard by a few hard knocks with this condition over a number of years it's only then that the person begins to realize what's what's happening now the next type of pattern i'm going to refer to because of it's it's quite common would be where a person has what we call unipolar depression maybe an episode in their teens 20s late 20s and the interval between them is getting shorter but then maybe in their 30s 40s and 50s what's beginning to happen is that each time the person has an episode there's a little high afterwards but as time goes on that high gets more marked and that then at a later stage can go on to frequent cycles of mood now this is untreated or treated when say inadequately treated but so for example if somebody's having these recurrent depressions and they're not treated or they're treated with antidepressant medication if you follow that person up over the years their mood will move from recurring unipolar depression to what we call bipolar 2 and that's where the person has lows generally followed by highs but the highs aren't too bad so they're they're lesser highs they're not as disruptive but the big issue with those highs is that that high determines the next low okay so to stop that you've got to switch off this one okay so it's again it's a cyclical phenomenon and that then as i say merges with rapid cycling moods where a person is having four or more episodes of mood swings in the year now traditionally lithium isn't terribly effective there so what's often most effective are the mood stabilizing anti-convulsants and there are things like epilim integritol and the michtel to a lesser extent so we try and avoid using antidepressants in these instances for example if somebody has a recurring unipolar depression but they have a family history where there's somebody with bipolar disorder we know that that person is increased risk of having highs and therefore you use antidepressants very sparingly if you have got to use them you use them for a brief period and then try and stop using them and very often those sort of recurring unipolar depressions can be stabilized with one of these compounds or or with lithium [Music] and as i'm not going to go beyond that with with medications because it's a whole separate token itself but i'd be quite happy to take questions at the end on it how are we doing time wise five minutes five minutes okay so uh we'll maybe move on then to um the two last sections one is just general maintenance on what it is a person needs to do to try and make sense of all of this well the first thing is if you want to beat it note when we're faced with something that's awful our initial response is bury your head turn our eyes away avoid it bring your head around try and look at it squarely in the face you have got to show the lead get the information get it into your head give yourself time to assimilate it curse as much as you want don't kick the cat and give it a chance you know try and face up to it take ownership of it don't run away from it secondly i suppose i suppose no one i'm talking about both in an intellectual sense and in an emotional sense not not not just intellectually i the facts about it the figures why it happens etc that's all the intellectual side the emotional side is is takes years for people to come to terms with it i'm always amazed when people say ah it's a great illness not too bad i always say to myself well they ain't depressed today in other words things are on a bit on the upside um so it's it's not an easy condition for people to be with either as a personal experience or in terms of family so it's it's it's important to give yourselves time to to address that and very often people benefit enormously from counseling or psychotherapy as a way of helping digest that process because it is in many respects a type of grief people have got to go through in addition to the illness so [Music] acknowledger in other words don't don't deny it in the sense of keeping your family outside i don't want event to do with this i don't want you involved in the care don't be coming and checking up on me as soon as i'm out of this place i'm off to brazil their head will follow them to brazil so they better get used to it in other words acknowledging the condition again takes time it's it's not by any means easy the third thing is let family in and give them time families will often blame themselves for the condition and say if only i did such and such or if only i was stricter if only i got that bike for christmas or i did this that or the other but you know these are relevant things but you see that's what happens when people because they've got to go through a grieving process and assimilation and getting used to it and they will blame themselves or somebody because always you know when something goes wrong oh there's always somebody to blame and but that blame can be outrageous it can be and it's almost always in fact poorly directed and that's the problem and it's for it's important for people to to realize that always when something goes wrong there's blame it's either directed outwards or inwards we either blame ourselves or somebody else but it's it's trying to see what that anger is and trying to put a bridle on it and put it to good good effect a family need emotional support going to a support group meeting with others talking about it uh so the most important thing that a person can do i think is letting the family into the problem because then there's a team and that team then can work together quite effectively to overcome this when people have a family member involved it the person has less hospitalizations less relapses less loss of job less breakup of relationships better productivity better lifestyle it's just it's so important to try and keep that keep that going so that if you see family getting to the point of impatience or agitation they're still on board at that stage it's when they're looking at you blankly and they appear to be hearing but there's nobody at home that's when the trouble starts so the next phase after that then is the spotting phase i'm putting a line there just to emphasize the importance of this this is a term derived by aware members about the condition people very often can spot a depression because it's painful people can't spot an elation because it's actually pleasant no matter how technically qualified the person is in psychiatry psychology social work whatever it is if that person becomes high they won't see it it's it's a given it's only if it's unpleasant that they're going to spot it because the mind will rationalize itself it'll say oh i only got three hours to sleep last night why well i had so much to do or i think i drank too much coffee before i went to bed there'll always be a reason and the slightly high mind is great for coming up with quite imaginative reasons to explain why the person is managing for the past month on two to three hours deep at night now there are three ways you can spot a relapse you can take the ordinary signs and symptoms they're there in literature books videos whatever it may be and they're they're all useful and not not knocking them but when it comes to the key issue of their use of usability they're not particularly good the next way of spotting a relapse is to know what your personal sign is or what we mean by that is that when somebody is high or low their behavior changes and it'll often change in a way that's personal to them so somebody might for example wear a certain item of clothing when they're high or a different type of clothing when they're low but particularly when somebody's high that clothing might be sort of uh stand out either in color or in its design or whatever um that you know people just see it in my love where the person who's high actually doesn't see it themselves this is well i like this item i like this pullover or i like this skirt or whatever it may be but the family know immediately that the person's mood has changed nothing has been said just the item of clothing or it may be some people have often said who don't smoke will suddenly start smoking um and so on so there are personal signatures like that that the family know so it's important that the person is aware of what that signature is but that they don't abuse the information because often what will happen is the person knows they're high because they realize they've just gone into the shop and bought a sticker two or three cigarettes that's all they need two or three but they conceal it from the family okay the only foolproof way of working out where the person's mood changes is to have a relative who helps spot that relapse now people would say well i'm not that's too going too far that's like mind control but the point is if you don't put somebody on your team that's going to help you spot this at an early stage it means the elation can do what it wants so you taking control as a good manager and saying i want you to tell me if you notice my mood is slipping so enrolling a relative whose judgment you trust who is strong enough to stand up to you if there's a bit of high there and can tell you what's what and you have given them permission that if they think you're high that they take the car keys away or the credit card or tell you to stay off work or get you to the doctor whatever it may be you're giving them permission in a well state to do that should that happen and that is the key issue now what happens is once that goes into place is depressions get nipped in the bud number one number two is all the consequences of those don't happen and number three is the subsequent depressions get prevented okay maybe not immediately maybe takes a while to catch up with it but you know the big issue in treating um very often these bipolar phenomenon is not so much that they're untreatable at times they can seem like that but they're not the problem is that the the person themselves of the condition gets in the way and because they're unwell it's very difficult for them to access the treatment so there's a big gap time lag between the onset of the condition and the successful resolution of it you can speed that up enormously by having a family member or friend or somebody close to you preferably somebody who lives in the same house or apartment or whatever maybe um now number six alcohol know your limit for many people uh one drink taken three nights in a row can be enough to alter the mood for other people larger amounts are okay but quite honestly if a person is going beyond two drinks maybe two or three times a week they need to ask themselves you know where where is this leading to because again remember the people with mood problems and the anxiety and the sleep disturbance and the poor concentration and the hurt feelings alcohol and being addicted to it it becomes all too easy so once it goes beyond a certain point a person needs to draw a line under it uh i'm sure i've forgotten a lot of things like tablet boxes graphing your mood in other words it's if your mood is not at a good level try and get some good way of graphing it or keeping a daily diary of your mood because it's invaluable you can't be going along to an outpatient clinic and saying how you've been over the past three months with any degree of reliability unless you're keeping a record can any of you tell me what way you were feeling last tuesday evening i don't mean yesterday now we let that one off last year's day i can't anyway so it's it's it's an impossible task and all of your treatment and changes in treatment is going to be determined by your answer to that question it's it's it's it's absolutely vital that these things are logged now the final bit that i want to mention is family members when a person recovers from an episode of depression or elation or both it's important that they realize that they need to go back and talk to the people in their lives who they may have hurt during the period of elation or depression or cause problems for our worries for because what tends to happen is this if a person has a number of these episodes and each time family don't want to upset the person by saying okay you should have seen the way you were or the disruption you caused or the how frightened we all were for your welfare or whatever it may be that gets swept under the carpet because the family don't want to bring it up and the person themselves with the condition are embarrassed about it is mortified eventually there's enough dirt swept under the carpet that somebody's going to trip up over and what actually happens is the key person in the family who is supporting that person begins to walk away from the situation as i said first they get agitated but then they walk away and the last person to realize what's actually happening is the person themselves with the condition it's important to face up to the hurt that the illness has caused it's not that anyone is blaming you but ultimately the person with the condition has to take ownership of it and go and face people and say the relatives would say oh no forget about that if you don't allow your relative to let out their hurt feelings that's what causes the damage it's not an intellectual exercise you must allow them to talk about it you mustn't make excuses you mustn't say well just it's it's they have to be allowed to in a sense go through a mini grieving process rather than burying all this stuff inside it's not a case of blaming the person with the illness it's actually trying to facilitate keeping the support that's necessary in the person's life such that their mood remains stable and the final thing i just want to go to is just a little thing about the importance of regularity in the life of somebody with bipolar illness what's coming through from research more and more these days is that the whole importance of circadian rhythms and rhythms in the brain and the effect that they have on a person's emotional and physical well-being when light comes through our eyes it sends a message to what's called the supra suprachiasmatic nucleus and that's simply a clock now that's a big clock in terms of the amount of nerves that are there that clock then regulates a whole orchestra of clocks throughout the body in the brain heart lungs got they all go at a different rate this one control controls mainly what's called the circadian rhythm and that's a clock that runs on a 24 hour and 10 minute cycle but it's based on the light that comes in here it regulates it but so do other things like social contact the time you have a meal at how much exercise you take during the day the amount of food you eat and what's come out of research is that it's blue light that is important so it was all you know the standard teaching was that we like came in through rods and cones and went into the brain and regulated things in that way but it's now realized that all of this system is dependent on a different type of photosensitive system in the retina and that that photosensitive system determines 80 of the control over this which in turn controls all of the other rhythms in the body now that might be a long way of getting around to the point and the point is this that the most important thing you can do from regulating these rhythms is go to bed on time get up eight hours later no matter how you're feeling drag yourself out of the bed try and not nap during the day and have your meals at fixed times so for people with sleep problems unless that's been done because if see so many people will come along and say they've er a sleep problem i only get let's see let me think of one i had the other day somebody who came and said what was he saying oh yeah he wakens up every morning at 2 a.m and he's awake from 2 until 4 then goes back to sleep for an hour and he shattered all day so if one took that at face value that's that's it but if then you find he says he comes home from work in the evening and he snoozes for about a half an hour i called in his wife how long does he snooze for well when he comes in he snoozes before the dinner and he wakens up in time for his supper and then goes to bed so from the time he if you take the time he started at and measured it to the time he awakens during the night that is his eight hours okay so the point is the reason he's shattered during the day is that he's going on a transatlantic shift job every night okay so it's it's regulating that because it does affect concentration energy enthusiasm and mood okay so it's just something that i think you're going to hear more and more about because it's been shown that downing tools in terms of not exposing yourself to click click click on the television or flick flick click on your ipad or whatever it is with all that bright light coming at you and a stimulatory effect is important so the people need to sort of wind down for an hour or so before they go to bed so that the brain isn't being stimulated in that way for many people who don't have mood problems that mightn't seem that important because they seem to cope with it but again you've got to come back to this thing that people who have bipolar disorder their brains are much more as sensitive to the effect of light change to coffee to stimulation and so forth so that it's they've got to work a little bit harder at protecting it and then obviously the other big thing that's come through again and again from research is the importance of regular exercise that it is a very effective form of preventing depression and keeping a person's mood stable the evidence is that it only i mean much of the evidence would suggest that it is as effective as many antidepressants in terms of helping a person smooth get up now it can be hard for a person to do that obviously when they're depressed but even starting in small ways it can prove effective 20 minutes beyond my time thank you

Channel: Aware

Views: 171,335

Keywords: Bipolar Disorder, Symptoms, Treatment, Depression, Aware

Id: fHGTuqiaAYw

Length: 79min 16sec (4756 seconds)

Published: Mon Jul 22 2013