Beyond the DSM: Three Ways to Manage Other Issues of Bipolar Disorder

Medication is approved for a mental illness if it reduces symptoms, the symptoms listed in the Diagnostic and Statistical Manual (DSM).

Did you know that there is more to bipolar disorder than: 

an episode of depression 

elevated or irritated mood, inflated self-esteem, decreased need for sleep, pressure to keep talking, flight of ideas, distractibility, increase in goal-directed activity, psychomotor agitation, and excessive involvement in pleasurable or risky activities?

These are merely the outward and visible signs of what is happening inside the brain. These are how the doctor can tell that you have bipolar disorder.

But even after you suppress these symptoms, you still have a variety of neurological dysfunctions that affect your thinking, your energy metabolism, and your health.

Psych meds do not address all these other issues. They are a piece of treatment, an important piece. But suppressing symptoms, while it relieves the anxieties of those around you, does not fix your life.

What am I talking about, and how come you weren't told this stuff when the doctor wrote the script and your family member told you to take the damn pill already?

First, what I am talking about:

In a person with bipolar disorder, a whole series of mis-timings and misalignments in our internal and external cycles results in a failure to rebalance. And I don't mean just mood. It's not just up and down.

The list of these mis-timings and misalignments includes:

  • Dysregulation of hormones, neurotransmitters, and immune system
  • Irregularities in communication within and between brain cells
  • Disrupted wiring among the networks that connect the thinking, feeling, evaluating, and reacting parts of the brain.

A number of these issues persist beyond the individual episodes of depression and mania/hypomania that the medication is intended to reduce.

Here are three examples, and how to reduce the damage they do.

Dysregulation of hormones, neurotransmitters, and immune system

Let's look at cortisol, the get up and go hormone.

Cortisol fluctuates throughout the day. You can trace the fluctuations in a curve. In a healthy brain, a high level of cortisol gets you out of bed and out the door in the morning. Throughout the day, you get an extra boost in response to stress, when you need more energy to deal with whatever the issue is. In the evening, the level dials down so you can go to sleep.

In the bipolar brain, the curve is flattened. It has similar highs and lows, but not high enough in the morning, making for a sluggish start to the day, followed by too high at night, making for sleep difficulties.

These flattened cortisol curves persist even in remission.

Is there a pill to change this pattern? Your mood stabilizer or antipsychotic may make you sleepy at night. But what about the morning?

Here's an idea - live with it. Plan on it. Build the cortisol curve you have into your schedule. I get up at least an hour before my spouse does. She doesn't expect me to participate in meaningful conversation until I have been up for two hours.

At the other end of the day, I start signaling to my brain that it is time to dial down two hours before bedtime. Routine soothes the savage beast. No super-stimulating television, no news, no Facebook right before lights out. I treat my limbic system, the source of all that cortisol, gently.

Irregularities in communication within and between brain cells

Mitochondria are the little critters inside our cells in charge of energy production.

These little critters are not as efficient in bipolar brains as in non-bipolar brains. This is a problem particularly in the hippocampus, the part of the brain in charge of memory and mood regulation. Inefficient energy production in the hippocampus means that this part of the brain shrinks and cannot do its job as well as you would like.

How do mitochondria produce energy anyway? They use the fuel that we provide by what we eat. So what kind of fuel makes for happy, healthy, productive mitochondria? Can you guess?

Is it this?

Or is it this?

Hmm, I'm going to let you figure out that one yourself.

I'll just add that the wrong fuel produces waste products that poison the mitochondria, like burning "dirty coal."

Disrupted wiring among the networks that connect the thinking, feeling, evaluating, and reacting parts of the brain

One part of the brain really does need to hear from other parts of the brain on a regular basis to function well. For people with bipolar, there is static on the line between the prefrontal cortex (the thinking brain) and the limbic system (the reacting brain). The result can be a hasty judgment, an emotional upheaval, and an impulsive reaction when thought can't catch up in time to modulate a response.

Practice the pause.



And it does take practice, to pause after the stimulus to give the message from your intelligent self time to reach your self-protective self before you act.

Victor Frankl put it this way:

When I was writing my book and working with a developmental editor, every time she gave me feedback, every damn single time, my first reaction was She doesn't understand. Why am I paying this person who just doesn't get it?

I learned to say I'll think about that. Then I would breathe. Then I would remember that I was paying her to give me feedback. No, she wasn't being mean; she was using her own expertise. Then I would think about how to use her feedback. I seldom took her suggestion exactly. But I did figure out how to address her concern in a way that was true to my vision. And I made the book better.

Thanks, Brooke. Thanks, breath.

How come your doctor didn't tell you this stuff?

Ah, well. Just like the gap between your prefrontal cortex and your limbic system, there is a gap between what the research has been saying about bipolar disorder for decades and what is actually taught in medical school. Your doc didn't tell you, because nobody told your doc.

The focus on treatment of mental illness is still on addressing the crisis and reducing symptoms, not healing the brain.

Well, the symptoms are indeed problematic, sometimes life-wrecking. But once you get those under control, if you think things still aren't working for you the way you would like, you are not crazy. And the solution is not to tinker with your meds.

The solution lies in all the life-style measures that address all the other, out of sight dysfunctions of the brain. Regular schedule, healthy eating habits, exercise, self-awareness.

Oh, and education to learn what your doctor didn't tell you.

It's not easy. But when you start putting this stuff into place, it gets easier.

Remember, I'm rooting for you.

Graphic of corticosteroid-binding globulin in complex with cortisol from the Protein Data Bank, in public domain

Picture of mitochondrion by NIH, in public domain

Photo of donuts by lucianvenutian, used under Creative Commons license

Photo of fruits and vegetable at Pike Place Market by Eric Hunt licensed under GNU

"I Don't Believe in God Anymore. Just Don't Trust the Guy"

Job 42 - A sermon

Fourteen years ago, I wrote an essay titled, I don't believe in God anymore. It was a response to my grief about my mental illness, the loss of my self-image, my sense of confidence as a person who could rely on the state of my own mind.

I wasn't suicidal at the time. But I was acutely aware that chances are I would be again in the future, because I have a remitting, recurring condition. It appears, it gets better, it flairs again. And suicidal ideation is one of its symptoms, a particularly cruel symptom.

I felt betrayed. Betrayed by God.

I mean, I had given my life, my energy, my health to serving God. And all of those things had been taken away from me. Me!

Okay, I know that bad things happen to good people. Bad things happen even to saints. But, damn!

It wasn't about mental illness so much as it was about grief, grief for the loss of what I thought I knew about myself, what I thought I could count on, my brain, most of all.

And I thought I could count on God, too. So, I wrote, I don't believe in God anymore. Just don't trust the guy like I used to.

Job had a different response to his grief. He never said, I don't believe in God anymore. He continued to challenge God to be the God he thought he knew. But there are ways that the book resounds powerfully for me.

And maybe for you.

It is a book about grief, about loss, about a world that has been turned upside down, and taken so much that we held dear with it. And many of us have lost. Many of us grieve. Even if not as vocally, as vociferously, as Job.

A job, a career that meant the world that was taken from us. A love that ended. A beloved who has died. A child who went another way. A child who never was. A secret loss that is not spoken.

And of course, we are surrounded by global loss, nearly five million people dead now worldwide from this pandemic, even more millions who are permanently disabled, the underbelly of this pandemic that we have not yet explored. Inevitably, maybe more painfully, the millions become one and one and one, not numbers out there, but individuals, people we can name.

Collateral losses, a social fabric that is falling apart, families at odds with one another, a collapsing health care system, a government that is not able to fulfill one of its basic functions, because public health, public anything ultimately comes down to what Dr. Fauci said, I just don't know how to convince people that they ought to care about each other.

And I'll tell you, as a priest, it is embarrassing to be confronted so graphically with the failure of the Church's mission to teach people to follow Jesus.

It is embarrassing when the Church fails to speak, because somebody called it a political agenda, to care about each other, to give up something of ourselves, as Christ did, who did not count equality with God a thing to be grasped, but emptied himself, taking the form of a servant, for the sake of another.

And I could go on. But you get the picture. And you wonder why I am pushing it in your face, that we are experiencing devastating loss and incredible grief, both publicly and personally. We want to forget. We want so desperately to forget.

Our ministry development team process got cut short in the second unit, a foretaste of our grief to come. There are six units. The design is to read through the Bible, book at a time, considering the issues that each book raises for how the people of God live together. Job gets his turn in the third unit, pastoral care, where the process asks the participants to examine in themselves how very hard it is to listen to somebody else's pain when you can't fix it.

We don't read much of Job on Sunday mornings. Preachers dodge the book. It used to be, we didn't read the book on Sunday mornings at all. So many of us think of it as this problematic part of the Bible that starts out disturbing - this bizarre test of a righteous man, to find out just how much he can endure, the loss of his fortune, the deaths of every single one of his children, and then this miserable, miserable skin disease.

Then it turns depressing.

If you have ever tried to read it, you know that he goes on and on and on with his complaints. His friends did listen to him for two weeks. And they don't really get credit for that, that they sat with their friend in his anger and his terrible grief for two whole weeks.

But they did. They did their best with the pastoral care training they had. Until it just ran out and they started saying all those things that we say, trying to make the pain go away, if not Job's pain, then at least our own.

  • This is a test; God is testing you.
  • God has a plan; you just don't see it yet.
  • What could you have done differently?
  • Happiness is a choice, you know; just choose to be happy.
  • Or - this will make you stronger.

See, it is so hard to look into somebody else's abyss and not back away.

It is so hard to look into somebody else's abyss and say instead the truth, Damn! This is hard. I don't understand why this is happening to you. I want to make your pain go away and I can't. But I will not abandon you. I will not abandon you.

Job is not the only one in the Bible who grieves. Out of 150 psalms, forty-two are psalms of lament. They speak of grief, of loss, failure, betrayal.

The Israelites were not like Americans. They did not expect that they would always win, that they would leave the field victorious, happy. In their worship, they could speak of their sorrow.

That's not part of our culture in the United States. We can speak of our rage, but not our failure.

American culture presses to the ending of the book of Job. See, there are two parts to the book, this fable of a righteous man who was tested, who endured the test, and was rewarded by all those good things we heard at the end of the reading this morning.

Oh yeah, that's another thing that people say,

  • Don't fret; you can still have another child.

But somebody came along later, took that fable and said, Nonsense! Listen to Job! Let him have his say.

I mean, even Jesus got his say, hanging on the cross, My God, my God, why have you forsaken me?

Let Jesus, hanging on that cross, have his say, My God, why have you forsaken me?

And then have your own say.

That's what the book of Hebrews is about. Because he has been there, he has been here, he knows what is in our hearts. Consequently, he is able for all time to save those who approach God though him, since he always lives to make intercession for them.

There he is up on that cross, praying the words that we would pray, that we do pray, when we pray what is truly in our hearts.

You have forsaken me. I don't believe in you anymore. I can't trust you.

That's not part of our culture in the United States. We can speak of our rage, but not our failure. So I know that I break the taboo when I said, I don't believe in God anymore.

How do I end this? How do I resolve this unbearable tension?

How did the book of Job resolve it?

There are two endings. The last words we hear are from that ridiculous fable: It's okay. He got his fortune back. He had more kids. And gee, the next daughters were even prettier than the ones who died!

So - what? Pass the test and you'll get your happy ending, too?

The poet who wrote the bulk of the book, the big middle, went in another direction. For thirty-seven chapters, Job challenged God to be the God he thought he knew. The God he thought he knew. After thirty-seven chapters - and congratulations if you really do sit with Job and let him have his say - if you get through them all - in chapter thirty-eight, finally, God shows up.

And God says, Who is this that hides counsel without knowledge?

Like, Who do you think you are?

Where were you when I laid the foundation of the earth?

Have you commanded the morning since your days began?

Do you give the horse his might?

Is it by your wisdom that the hawk soars?

Well, that goes on for a while. God has God's say, and keeps saying it, until ultimately Job succumbs, I have uttered what I did not understand. . . I repent in dust and ashes.

I take two things from what God has to say.

First, I take comfort by putting myself in my place. Whatever my misery is, and it is great, at times it has nearly overwhelmed me, yet I am small. The universe is vast. And starting at chapter 38, that universe, and God's creation of it, is worth reading.

When I in awesome wonder consider all the worlds Thy hands have made, I see the stars, I hear the rolling thunder, Thy power throughout the universe displayed,

Then sings my soul, my Savior God to Thee! How great Thou art, how great Thou art!

This misery that surrounds me, that once blocked out every single person who loves me, and horse and hawk and mountain and Cliffs of Moher and stars around me, this misery is small. It is held, I am held, in something vast, something that turns out to be magnificent, and powerful.

And maybe, just maybe, what holds that vastness, and me in it, and you, and you, turns out to be love.


And the second thing that I take from the book of Job, and from that long dark night that Job traveled, that I have traveled, and perhaps you, too - 

I just don't know as much about God as I used to.

God says, Who is this that hides counsel without knowledge? Who do you think you are?

With Job I have to answer, I have uttered what I did not understand, things too wonderful for me, which I did not know.

And I still don't know. I don't know as much about God as I used to.

And I don't know how you feel about a priest who didn't wrap it all up in a bow for you, because I can't wrap it up in a bow for me.

I think love has something to do with it. So, all I can do is choose, as best I can, to follow the one who has gone the way of love.

I choose to follow Jesus.


Should Every Primary Care Patient Be Screened for Depression?

Depression affects about one person in five across their lifetimes. It is a significant source of disability, loss of productivity, and impaired relationships, and a major risk factor for suicide. A study from the 1990s revealed that, in the absence of routine screening, primary care providers at an HMO in Washington state missed the diagnosis in approximately 35% of patients who had depression.  

It seems common sense, doesn't it, that routine screening for depression would improve care by better diagnosis and follow-up treatment?

Actually, no. Despite more widespread practice of routine screening in primary care settings in the US in recent years, and despite subsequent increase in the use of antidepressants, the benefits have yet to show up.

Real Suicide Prevention or Self-Satisfied Nonsense?

It's Suicide Prevention Month/Week/Whatever again. Those of us who are or have been suicidal know suicide prevention as a year-round, full time job. Those of us who are or have been suicidal have a whole lot of experience at preventing suicide. Is anyone interested to hear from us? Some of the following came from an earlier post. It bears repeating, 'cuz evidently even some bright people have some strange ideas. Like:

Suicide is not a choice

The way people talk, you'd think we sit down and make a list, pros and cons of suicide. Then based on our calculations, we make some kind of decision. She chose to end her life. Or, How could he have been so selfish.

This is called the volitional theory of suicide, suicide as an act of will. The suicide prevention approach that addresses it is to weigh in on that list of pros and cons, like Jennifer Michael Hecht's book, Stay.

You know -- Suicide is a permanent solution to a temporary problem. Or, Think of what you'll miss out on. Or, whatever. In other words, how dumb or short-sighted or irresponsible or selfish you must be to decide to kill yourself.

Resisting COVID Depression, One Song at a Time

Who knew COVID would last this long? Did you, like me, feel a bit of hope last spring? We had the tools; we got the jab; the numbers started falling.

But . . . not everybody got the jab.

Then . . .

Now? Children are thrown into a virus laden cauldron while state legislatures pass laws prohibiting measures that would reduce the spread of a pandemic. Nurses are dropping like flies. A guy died in an emergency waiting room this week because there was no room for him in ICU.

And people with a high school diploma and an internet connection know better than the medical community. Instead of heeding the pleas of their doctors, they are taking horse-deworming medicine. Our local feed store has run out of it.

I guess next up--the horses start dying.

So, it looks like this thing is going to be with us for a while.

Prejudice, Not Stigma: How People with Mental Illness Get Crap Health Care

Eight years ago I published an article titled Doctors' Prejudice Against Mental Illness. It lays out the reasons why it is so damn hard for doctors to learn. Here is a paragraph from that original rant:

Similarly, people with other mental illnesses as well often do not receive routine standard of care for a whole host of conditions, including screens for infections, dental care, metabolic syndrome, even blood pressure checks, even while receiving medications that put them at risk for all of these health complications. As a consequence, the death rate gap between people with mental illness and the rest of the population is growing.

The link in the second paragraph is to a World Psychology article, a review of the literature documenting the crap health care that people with serious mental illness receive, with the consequence that we die an average of ten years sooner than people without mental illness.

The difference in lifespan is only slightly due to suicide. For the most part we die of the same things everybody else dies of, heart disease, cancer, that sort of thing. We just die sooner because our heart disease and cancers are not detected as early, nor treated as aggressively, as everybody else's.

Surviving Heat Waves with Bipolar Disorder

Did you know that more people are murdered at 92 degrees Fahrenheit than any other temperature? I read an article once. Lower temperatures, people are easy-going, over 92 and it's too hot to move, but just 92, people get irritable.

That's what the sheriff said in an opening scene of It Came from Outer Space. Set in Arizona -- even in black and white, you could feel the heat rolling off the sand. And throughout the movie, they attributed people's reports of strange sightings to heat-induced lunacy.

As I read that quote from 1953, I think -- 92, if only!

Everybody is irritable right now in -- how shall we put this? -- the coolest summer we will experience for the rest of our lives. Everybody is exhausted. But some of us more than others.


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