Episode 4: This is Bipolar

Clip00:00:01

Pauline: When you’re on your own natural high, you are connected to everybody and everything and it’s a bit like people describing psychedelic experiences where there’s universal love and connection. You want that high and you’re prepared to do anything for it.

00:00:18

Dr. Diane McIntosh: This is what bipolar mania can feel like. Because it feels so good, the person experiencing it doesn’t see it as a problem to be solved. For them, the euphoria is a thing to celebrate, to enjoy, and that’s the problem. Not too many people seek out a doctor when they’re feeling that good. You’re feeling smarter and sexier and funnier than you ever have, which is what makes bipolar disorder so incredibly difficult to diagnose. So difficult in fact that the guest you’re about to meet, she wasn’t diagnosed for over 40 years.

I’m Dr. Diane McIntosh. You’re listening to PSYCHEDUP. On this show each episode will focus on one mental illness. Today, it’s bipolar disorder. As a psychiatrist, I want anyone experiencing any of these illnesses to be able to hear these stories and know there is a path ahead. My goal is to educate, destigmatize and inspire. Welcome to PSYCHEDUP.

Here are the bipolar basics. The term bipolar is exactly as the name suggests, two mood poles, sort of like the North Pole and the South Pole, but all in one disorder. Major depression is often referred to as unipolar depression, and that’s because there’s only one pole, the depression. But bipolar disorders are a collection of mood disorders that usually include episodes of depression, but also episodes of extremely elevated moods. If it’s a severe elevation, a severe high, it’s called a manic episode. But if it’s a milder high, it’s called hypomania or little mania. Mania and hypomania differ in severity. So when you’re manic, you have all of those same symptoms of hypomania, smarter, sexier, funnier, but you also can be psychotic, which means you have false beliefs and you can also require hospitalization because you’re at risk to yourself or other people.

 You can feel great when you’re experiencing a mania or a hypomania, but the people around you, the people closest to you, what they see is chaos, nonsensical behavior, disorganized behavior, and also dangerous behavior. People who are manic and hypomanic are often extremely irritable and it’s impossible to communicate with someone when they’re manic in a rational manner.

00:02:44

Clip: I give up.

00:02:44

Dr. Diane McIntosh: So the lower pole of bipolar disorder is often called bipolar depression, but it can look just like any other major depressive episode. With sadness or loss of interest as well as change in appetite and sleep. Sadly, most people who have bipolar disorder spend at least half their life experiencing symptoms, most of which are depression.

 To get a sense of what it’s like to live with bipolar disorder, I’d like to introduce you to Pauline.

00:03:11

Pauline: I’m a sixty-two-year-old mother and grandmother, but I’m here to talk about my mental health.

00:03:18

Dr. Diane McIntosh: Pauline remembers her struggles starting a long time ago.

00:03:21

Pauline: I became melancholic as a teenager. I remember being utterly miserable in first year university and then I got severely depressed.

00:03:33

Dr. Diane McIntosh: So just like Pauline, bipolar disorder most often starts in the teen years with episodes of depression. And over the years she continued to have bouts, but things really didn’t come to a head until Pauline’s third child was born and she started taking medication to treat her depression symptoms.

00:03:52

Pauline: And so that’s when I flipped.

00:03:55

Dr. Diane McIntosh: Pauline described being flipped, as if she was living someone else’s reality. It was a manic episode. Pauline’s mental health started to really rapidly decline, but she had no idea it was happening.

This is one of the problems with missing a bipolar diagnosis. Antidepressant medications can provoke mania or hypomania in a patient with bipolar depression, which is exactly what happened to Pauline.

00:04:23

Pauline: I know I’m in trouble when I see a man on a park bench and he has a full-length amputation, and I think to myself, if I just go up and sit on the bench and kiss him, I’ll make him better. So there’s this sense of having healing powers. I mean, it’s delusional, obviously, and it’s grandiose. You elevate yourself to a place of power and privilege, which is really irritating for people who have to live with you. Your friends and colleagues love you. You’re grandiose, you’re generous, you’re flamboyant, you’re creative and humorous. However your family sees the greasy underbelly of bipolar which is irritability, impulsivity, entitlement, selfishness, and risk-taking.

00:05:15

Dr. Diane McIntosh: Pauline is describing psychotic symptoms, specifically delusions, which are false beliefs. They’re commonly grandiose. You think you’re a God or Jesus or you have some special or unique power or gifts. These often occur during manic episodes.

What also comes with mania is risk-taking, which also makes it so dangerous. Uncharacteristic, illicit drug use, spending way too much money, money you don’t have, or inappropriate or unsafe sexual activity. A manic episode is a potentially life-threatening event.

So when you’re feeling smarter and sexier and funnier than ever and you’ve spent most of your life feeling depressed, you’re not going to see your doctor. The only reason you’re going to go in and look for some help is when you’re depressed, and that’s the trickiest part of this bipolar diagnosis. You go and see your doctor when you’re depressed, so what do they see? Depression. And the result is that bipolar disorder is misdiagnosed more than 90% of the time. It takes on average 10 years and four different clinicians before the right diagnosis is made.

 Pauline was no different. And because the bipolar wasn’t being properly treated, she self-medicated.

00:06:35

Pauline: It could be any substance. It could be crystal meth, it could be heroin. For me, alcohol was very convenient. So when I wasn’t being adequately treated for my bipolar, I drank.

00:06:49

Dr. Diane McIntosh: Needless to say, addiction issues mixed with a bipolar disorder, it’s a recipe for disaster and heartbreak.

00:06:57

Pauline: My children were really worried about me. They taped little messages on my bottles. Mommy, you promised to cut back. Mommy, something terrible’s going to happen to you. Mommy, you make me cry. These little messages, I mean, I could still. I still can’t believe that I didn’t pay attention to these notes. I didn’t throw them away. I just moved them from one bottle to the next, to the next for two more years.

Suddenly you realize, okay, I’m going into the basement again to get my bottles. And this is my secret privilege, my illicit lover. Alcohol was stabbing me in the back and I had to turn around and face it and I got sober. And then I guess I relied more heavily on my mania for my well-being.

00:07:48

Dr. Diane McIntosh: At this point, Pauline still wasn’t being treated for bipolar disorder.

00:07:52

Pauline: The bipolar didn’t catch up with me, the mania didn’t catch up with me, until 10 years ago. 10 years ago I was sleepless in pain with arthritis and I tailspinned into a psychotic episode where I was confused and I was behaving strangely.

00:08:14

Dr. Diane McIntosh: Acutely ill patients like Pauline was at the time, they often lose insight. They actually don’t know that they’re behaving in a strange or disturbing way, but then once the symptoms are gone, they often recollect what they did. That’s really hard to live with.

00:08:29

Pauline: I remember collecting knives and you can imagine what that looks like if you’ve got a confused person collecting knives.

00:08:37

Dr. Diane McIntosh: Pauline never had plans to hurt herself or anyone else, but regardless, her family was understandably concerned.

00:08:45

Pauline: My family got me to hospital and I was tied up and I was treated under the Mental Health Act, which very likely saved my life.

00:08:58

Dr. Diane McIntosh: Pauline was hospitalized for a month. Now, this is not where I want people to end up, but sometimes it’s necessary, in fact, it’s life-saving. Once there, Pauline finally was diagnosed with bipolar disorder and she got the treatment she needed.

To really talk about treatments, I want to bring in my friend and colleague Dr. Randy Mackoff. As a psychologist Randy knows all about talk therapy, whereas as a psychiatrist, I specialize in prescribing medication. As always, thank you for being here, Randy.

00:09:32

Dr. Randy Mackoff: Oh, thank you Diane. I’m pleased to be here. I’m thrilled to be here.

00:09:35

Dr. Diane McIntosh: Randy, one of the things that I think is really challenging when someone is experiencing a mania is that they lose their ability to recognize the reality. They lose their insight. And I’m wondering how you deal with that in a psychotherapeutic relationship. Can you deal with it when someone has no insight, they don’t recognize how ill they are and how disruptive their behaviors are?

00:09:59

Dr. Randy Mackoff: Oh, it’s really difficult to deal with them in a psychotherapeutic relationship from a talk therapy perspective, because it really runs risks of alienating the relationship between myself and the patient or a psychologist and the patient when you’re saying, ” Hey, look at, what you’re experiencing is actually harmful not just to you but to others in your life.” What I have experienced is sometimes they’ll just walk away from that. And that scares me because that then leaves them just afloat in some respects.

00:10:27

Dr. Diane McIntosh: You can’t talk someone out of a mania, is I think the point here. That if someone is manic, they need treatment and often they need hospitalization because they could have psychotic symptoms. So your role when someone is manic is what?

00:10:42

Dr. Randy Mackoff: My role is to look for those moments of lucidity in some respects. And at that point being able to say, ” Hey, let’s connect you with a psychiatrist. Let’s connect you with your family doctor.” But it’s getting that person to say, “Okay, I’ll speak to a psychiatrist. I’ll outsmart the psychiatrist. I’m faster thinking the psychiatrist, but okay, I’ll speak.” That’s why it’s really important to maintain that relationship, not become confrontational.

I’d love to hear from you because I really value and trust your knowledge in this area. If you could just give me an explanation about the different medications and what the considerations are for them.

00:11:20

Dr. Diane McIntosh: There are two big groups that are most commonly used. One are called mood stabilizers, and then there’s a group called anti-psychotics. Many clinicians start with the mood stabilizers, and in that group would be medications like Lamotrigine or lithium, Divalproex or Epivals. I just want to make the point that only about 30% of people rock on lithium. That’s their drug. And when it works, it can be remarkable. It’s often used in combination as well. It’s got a lot of really good data including reducing the risk of suicide. And very few drugs in psychiatry have that science behind them. But it’s also a challenging medication to take. You have to have regular blood work and you have to be very careful about taking it at the exact dose and having those levels regulated.

Whereas the antipsychotics can be extremely effective but also come with side effects. So my job, once again, is trying to find that combination, the right dose, the right medication combination to help that patient to be asymptomatic and back to full functioning.

00:12:24

Dr. Randy Mackoff: It’s intimidating for people and they’re feeling like, okay, I’ve got this diagnosis of bipolar and I’m really, really scared. And yet at the same time, one of the fears is hospitalization. I don’t want to bash hospitals because hospitals can keep people alive for sure, but hospitalization sometimes is a very negative experience for a lot of people. So my goal is what can we do to keep this person out of the hospital, get them the proper treatment and help them understand that life has a lot to offer and it’s not going to be disrupted and the medication can be really, really beneficial.

00:13:00

Dr. Diane McIntosh: Part of that is making sure they’re on the right medication that they tolerate. When someone is manic, when they’re high, often we give them medication that tries to slow things down and that can be sedating. In an acute episode where you’re high, being on a sedating medication is very common, but it’s not forever. And in fact, if you’re sedated all the time, that’s a fail.

It’s why it’s so important for patients to have a voice. My job is to stop the big highs and prevent the lows simultaneously and help people to find a place where they feel equanimity. That’s a challenge. It takes time to find that right combination because each brain is unique and everyone has their own needs. And then you layer on top of that bad experiences, that I found medication too sedating or caused this problem or that problem and so they are fearful. Often they’ll come into my office and say, ” I don’t want any medication because I hate it and it’s bad for me. And my beautician said I shouldn’t be on it anyway.” Or, ” I read Dr. Google.” And there’s a lot of reprogramming around, hey, we’re partners here. You drive this ship. I’m just an educated navigator here. I know these waters, but you make the decision. That’s why it’s so important for me to partner with psychologists or therapists that get that and will work with me through that in helping to navigate those waters.

00:14:23

Dr. Randy Mackoff: One of the things that I’ve experienced is that when someone is either depressed or, in this situation, in a manic episode with bipolar disorder, they can be drawn to using substances that either exaggerate the feeling or are trying to medicate the feeling.

00:14:39

Dr. Diane McIntosh: You are absolutely right, Randy. This is a critical challenge. Misusing substances can be part of any phase of bipolar disorder. Maybe you’re self-medicating because you’re feeling so depressed. Maybe you’re manic and uncharacteristically and impulsively using recreational drugs. We know the illicit drug supply can be tainted with fentanyl, but an impulsive drug user is unlikely to consider that fact, and this can be deadly.

Frustratingly, my own patients who have used recreational drugs when they’re acutely ill are often seen by healthcare providers through the lens of addiction only. Meaning, their psychiatric disorder or other physical health disorders are missed. In short, the doctor sees the drug use but not the underlying cause.

When someone is also using recreational drugs, I am extremely cautious when trying to establish a diagnosis. One of the worst offenders is cannabis, specifically THC. Science has clearly demonstrated that high potency THC is pro-psychotic, especially in a young developing brain. In vulnerable individuals, THC can actually modulate the genes associated with psychotic disorders, provoking their onset. So a doctor might see a patient who’s using cannabis and has psychotic symptoms and think, okay, they just need to stop the cannabis and the psychotic symptoms will go away. But because THC actually changes the way the brain functions, the way the genes are transcribed can actually cause the onset of a disorder and stopping the THC is not enough. The disorder then will continue on and require other treatment to be well-managed.

Just to be crystal clear, THC should never be considered a treatment for any psychiatric disorder, whether it’s bipolar disorder, depression, anxiety, insomnia, it is not an effective treatment. Full stop.

00:16:36

Dr. Randy Mackoff: Yeah, absolutely. And from a psychologist perspective, it’s really about having people not become self-loathing because they have been using the substances, but at the same time not encouraging the continuation of the use of substances. And most definitely, it’s a challenge.

00:16:53

Dr. Diane McIntosh: One last point I wanted to make was that, often what we view as therapists, as psychiatrists as being important is not always what the patient thinks is important and we need to strive to have those conversations to ensure we understand what matters to you. Often I’m very symptom focused, but when you talk to patients, what matters more to them is their quality of life. Are they able to function the way they were before? Are they back to work, back to life, back to love? Those are the things that are most important. And I think we recognize the importance of working together to help patients to get to where they want to be.

 Randy, as always, such a pleasure talking to you. I really appreciate your time.

00:17:35

Dr. Randy Mackoff: And I really appreciate being here and I love learning from you, Diane. Absolutely fantastic.

00:17:46

Dr. Diane McIntosh: Having bipolar, it’s not a choice, but accepting treatment is. For so many years, Pauline was not properly diagnosed. Her lows were considered depression, but those highs, they were something she associated with her real self and she didn’t want to lose them. The pull of mania is so hard to resist. It’s so difficult to decide to stop feeling that good, especially when so much of your time is spent depressed.

00:18:15

Pauline: I could only think of it as a root canal to my soul, that I was just going to be sucked dry of everything that was me, my identity, what was uniquely my contribution to the world. You’re addicted to your euphoria and just like an addiction to alcohol, you have compulsions to be that way and you are out of control and you continue using or being in that state despite negative consequences.

00:18:45

Dr. Diane McIntosh: But once Pauline was out of hospital and feeling strong again, she knew it was time for a change.

00:18:51

Pauline: It’s very humiliating to be committed under the Mental Health Act, so that is a huge motivation to taking your medications as prescribed. I don’t want to ever have to go back to hospital, especially like that. And the second thing is the depression. I was really exhausted and I never want to feel like that again.

00:19:16

Dr. Diane McIntosh: Now, when Pauline starts to feel high, she tells the people around her. She can feel herself starting to slip, and rather than allowing herself to be swallowed up in an episode, she turns to her medical team.

Aside from the immediate damage of bipolar disorder, there are serious long-term consequences. Every episode, whether it’s a high or a low, causes structural and functional brain changes. The longer the patient goes without an accurate diagnosis and without proper treatment, the more episodes they’ll have. And that means more damage to the brain, making the disorder a lot harder to treat and deepening the functional impairment.

It’s the cognitive symptoms in particular that are really challenging and they come from that chronic untreated bipolar. Symptoms like poor motivation.

00:20:12

Clip: Whatever.

00:20:13

Dr. Diane McIntosh: An inability to get moving or to get started with things can become really impairing over time. And those chronic cognitive problems, they can’t always be fixed.

00:20:23

Pauline: And this is the part that’s really tough for me is that I was manic for so long, I am at risk for early dementia. Simple as that. I burned my brain and it may not be there for me later on. And I’m having some changes with aging and everybody says, ” Oh, well, I’m going through that too.” But I suspect that I will struggle a little bit more as a result of neglecting my brain for so long.

00:20:51

Dr. Diane McIntosh: But rather than sit and worry about what might come, Pauline is working to destigmatize mental illness.

00:20:58

Pauline: It has taken me quite a while to be free with sharing my diagnosis and my story. I’m fine with all the medical stuff, but the psychiatric stuff is very laden. There’s a great quote by Rachel Naomi Remen. She says, ” I think I serve people perfectly with parts of myself I used to be ashamed of.” And I think that says it very well for me. That the more work I do to improve services and understanding, the less I feel dragged down by stigma. In fact, I like to think I outshine stigma, but that sounds manic.

00:21:40

Dr. Diane McIntosh: Okay, folks, this is what I want you to know. This is my Shrink Wrap. Pauline’s openness in sharing her story is so important in fighting stigma because it is one of the biggest hurdles in treating any mental illness. Over the years, we’ve worked to use better words and terms when describing conditions in the mental health space. But one place where we need more work needs to be done around the term antipsychotic. How scary is that?

This class of medication is used to treat bipolar disorder, but also a number of other conditions including depression. But it sounds so awful that I’ve had patients actually refuse to take them based on the name alone. I get it. We need other words for antipsychotics. It really is a misnomer and has negative connotations. It’s like a bad word. So many of us know living with a mental illness is already hard enough. We need to do everything we can do to remove baggage from our language around it.

 Pauline’s path to the life that she now has, it wasn’t smooth. Looking back, there are things she would change.

00:22:54

Pauline: I would like to have got treatment sooner. I would like to not have self-medicated with alcohol, but I really lucky I didn’t really lose anything irreparable. I kept my family. I kept my job, I kept my friends. I didn’t drink and drive. I wasn’t violent with my kids. I mean, there’s so many things that could have happened. I was pain in the butt, but it could have been a whole lot worse.

00:23:20

Dr. Diane McIntosh: So Pauline, she can’t change the past, but she can control her present. And she has. Once she was given the opportunity to think clearly and to make her own choices, she made the best decisions for her and for her family with no regrets.

00:23:38

Pauline: I didn’t know that I would find the real me on the other side of all that. I’ve been sick most of my life, up and down. I like to think that this is who I really am, and I’d like to stay like this for a little bit longer.

00:23:58

Dr. Diane McIntosh: This is PSYCHEDUP an original podcast from RAPIDS Health. If you know anyone who has bipolar or you love someone who does, please share this episode with them. And if you think you might have bipolar disorder, please reach out to your primary healthcare provider and ask for help. And if you like what you heard, please follow and rate the show. It helps other people who might need or want some guidance find it. Until next time, I’m Dr. Diane McIntosh.