Do Your Meds Work? There's More You Can Do to Treat Bipolar

Ellen Frank: Treating Bipolar Disorder - A Review

Ellen Frank changed my life. When I was diagnosed on the bipolar spectrum, and hadn't found a medication regime that I could tolerate, her Interpersonal and Social Rhythms Therapy gave me a way to get a handle on my wildly fluctuating condition.

She and I corresponded in 2011, as I was writing a four-part review of her book and her therapy. I published with her assurance that I got it right.

I was over the moon when she agreed to endorse Prozac Monologues: A Voice from the Edge. She wrote:

Brilliantly written, engaging from the first page, Prozac Monologues is a bit like a great evening at a first-rate comedy club…except that it is deadly serious.  Goodfellow’s painful and all too common journey to finding the right treatment for her bipolar disorder points her to the ultimate realization that doing well with this illness requires the right medication, the right psychotherapy, and the specific lifestyle modifications that support wellness.

Ellen Frank, Ph.D.Distinguished Professor Emeritus of Psychiatry, 

University of Pittsburg School of Medicine

Pretty cool, huh! She even wrote privately to her listserv to recommend it.

So many people I read on Twitter struggle to manage their bipolar disorder. I figure it's time to bring this four part series out again. So here is Part 1 - from April 4, 2011.

Medication And Mental Illness

Medication for mental illness is just like medication for anything else. It works better when you don't ask it to do all the work itself.

In the case of bipolar, once lithium and the chemical imbalance theory came along, the thinking was that medication was the only thing that worked. Therapy by itself certainly didn't. I wonder if therapists, worn out by their bipolar patients, were simply relieved to believe that medication was the only thing that worked. I wonder if therapists today, worn out by their recurrent depression patients, are secretly relieved to terminate when the diagnosis changes to bipolar, because medication is the only thing that works.

Frankly, there is a lot of wishful thinking out there in pharmacotherapy land. If only our brains were a chemical stew and the illnesses of the brain could be treated by adjusting the recipe. If only.

But people with mental illness, especially people with bipolar, can't afford the wishful thinking behind the better living through chemistry fantasy. Sometimes the medications do work. But not as well nor as often as your doctor would like to think.

I have a friend who is a psychiatrist. He challenges his colleagues who keep trying to solve this noncompliance issue, to get their patients to comply. He reminds them, if the medication (antidepressants, in this example) worked for 40% of those who took it in the trial, and the placebo worked for 30%, that means only one out of ten people benefit from the medication itself. So what's the big deal about nine who quit?

He says they just look at him funny.

Treating Bipolar Disorder by Ellen Frank

This same friend, God bless him, loaned me a book about a psychotherapy designed specifically for bipolar disorder titled, appropriately enough, Treating Bipolar Disorder. The author Ellen Frank, professor of psychiatry and psychology at the University of Pittsburgh School of Medicine and director of the Depression and Manic Depression Prevention program at Western Psychiatric Institute and Clinic, and her colleagues invented Interpersonal Social Rhythms Therapy (IPSRT), a kind of mash-up between talk therapy and regulating circadian rhythms.  It gets my next few posts.

In A Nutshell... 

IPSRT [is] a treatment that seeks to improve outcomes that are usually obtained with pharmacotherapy alone for patients suffering from bipolar I disorder by integrating efforts to regularize their social rhythms (in the hope of protecting their circadian rhythms from disruption) with efforts to improve the quality of their interpersonal relationships and social role functioning.

Questions Work Magic: How They Change the Brain

Quick - What does a lemon taste like?

I know what a lemon tastes like. Tell me something else instead:

What just happened inside your mouth?

David Hoffeld asks another one: Want to know what your brain does when it hears a question?

His article from the website FastCompany.com explores the neurological consequences of hearing a question. Questions temporarily hijack the brain. Did you immediately think about lemons? First, serotonin is released, causing the brain to relax. Next you get a hit of dopamine. The question takes over your thought processes while you think about the answer. The technical term is instinctive elaboration.

The hijacking doesn't last forever. The person who was asked the question can choose to ignore it, can argue against it, can go off on a tangent - though for people with ADHD or bipolar disorder, a question that interrupts our train of thought may cause us to derail.

But Hoffeld cites a number of research studies that document when you ask somebody whether they are going to do something, you increase the probability that they will do it - buy a car, vote in an upcoming election, even donate blood.

Questions not only alter your perception. They can even alter your chemistry. Chances are, when you read the lemon question, you started to salivate.

Why Writing Bar Tales of Costa Rica is Good for my Mental Health

Mindfulness

Mayo Clinic describes mindfulness as a type of meditation in which you focus on being intensely aware of what you are sensing and feeling in the moment, without interpretation or judgment. Practicing mindfulness involves breathing methods, guided imagery, and other practices to relax the body and mind and help reduce stress.

For some of us, these meditation exercises, "close your eyes, focus on your breath..." are difficult, frustrating, and stress inducing. Particularly for people with a trauma history or ADHD, mindfulness can be a land mine.

For others, the whole enterprise sounds like woo-woo mental health. Add some essential oils and affirmations - who needs therapy or, God forbid, medication?

But there's more to mindfulness than nonsense.

The same Mayo Clinic article identifies several mindfulness practices. Three could be taken as basic concepts:

• Pay attention
• Live in the moment
• Accept yourself

How does that work out irl - in real life?

Let me tell you about my recent five week stay in Costa Rica. First, the back story:

Prozac Monologues

My first book, Prozac Monologues, began with a hypomanic episode during an earlier trip to Costa Rica. I wrote a series of comedic monologues in an effort to not be mindful. The monologues danced around the memory of a recent Prozac-induced traumatic experience. It began with a bizarre thought, and moved on to some other weird stuff: dissociation, thought broadcasting, paranoia, and the like. 

Years later, once I was correctly diagnosed with bipolar disorder, I added edgy essays about that experience and everything I learned about bipolar disorder while trying to figure out what the hell happened to my brain. Like many memoirs, Prozac Monologues is a hybrid of my story and my issue. Sheila Hamilton's podcast, Beyond Well, captures it. Here's the link. It's also a great read and now available on audio.

Bar Tales of Costa Rica

So what about Bar Tales of Costa Rica? My second book is exactly what the title promises: the stories I heard while sitting in bars in Costa Rica. That sounds like a very different book. Am I a genre hopper?

Yes and no.

via GIPHY

Bar Tales is about a milieu, a place and the people in it. It is not about mental illness. There are passing references to my own. But that's not the point. No references to research. No descriptions of recovery strategies. Stories heard in bars - it's a very different book.

Still, it is a sequel. It picks up where the monologues left off. In the first book, my wife Helen and I thought about moving to Costa Rica. Several months later, we did buy a little house in Playas del Coco. Didn't quite move there, but we spend several weeks there every year.

That's where I continued to work on Prozac Monologues. It's also where I gathered my bar tales, most of them at my sister's hotel and restaurant, the Pato Loco, which means "crazy duck." Other sites included El Bohío (referenced in the first book), Pacifico Beach Club, Coco Palms, and Soda Navidad.

You could call the second book a segue to the first. I turn a corner. That would be a right turn that leads me out of my neighborhood Los Canales, on to the Boulevard de Iguanas, and over to a whole new cast of characters: Patricia, Bruce, Andy, Sydney, Monique and André. Bar Tales is about their stories.

So why is this book good for my mental health?

As I am polishing these tales for publication in the spring of 2024, I spent several weeks in Coco for research. Research.

I wasn't sitting in bars, gathering tales - though inevitably a couple got added to the collection. This time I was gathering sensations. Physical sensations.

Trauma and Sensations

Sensations - these are at the heart of my mindfulness technique.

• The person who has experienced trauma sometimes gets stuck in the past, reliving a loop of troublesome sensations. And let me tell you - being suicidal, as I was, is traumatic.
• Or, in the face of current strife and stress, that person might dissociate - disconnect from present anxiety by going numb.
• Or, based on deeply rooted thought patterns about bad things that happened in the past, the person faces the future with dread, anticipating - and pre-experiencing - a repeat of negative experiences.

Each of these are ways that we lose or escape the here and now. I think of here and now as my worst subject.

The thing is - here and now is where joy lives.

Let me repeat that.

Here and now is where joy lives.

So my research, gathering sensations, experiences in the present, kept me anchored in here and now.

And it filled me with joy.

What color are the rooster's feathers? - bronze head and breast, black legs, wings of teal and red.

What sound do the geckos make? - chk, chk, chk. How about the howler monkey? muffler dragging on concrete!

What do mangoes smell like when they are sitting in the field near my house in the hot sun? - like a fortified sweet wine.

What does carne en salsa taste like? Beef stewed in a rich vegetable sauce with hints of smoke when Juan cooks it all day in an iron pot over a wood fire under the mango tree.

What does it feel like to walk in the surf? Caressing waves, then grit in my sandals.

I walked around town with my phone in my hand, making voice memos, describing these sights, sounds, smells, tastes, and sensations. My mind fixed on the present, there was no room there for regrets about the past or anxiety about the future.

Health Benefits of Mindfulness

Mindful meditation has been demonstrated to reduce anxiety, depression, stress, pain, insomnia, and high blood pressure.

There are many ways to do mindfulness. A review of literature published in Clinical Psychology Review, Effects of Mindfulness on Psychological Health, summarizes the context of mindfulness practice in its Eastern and Western versions and its application in a variety of psychological treatments.

What I offer here is one simplified self-help practice for addressing panic and anxiety, a disciplined version of what I called my research:

Focus on your environment.

• Name five things that you see right now
• Name four sounds that you hear
• Name three things that you feel
• Name two things that you smell
• Name one thing that you taste

Yeah, don't get hung up on remembering whether it's three feelings or three smells. I don't remember the order of the sensations and made it up.

The point is to redirect the catastrophizing brain, to pull it into the here and now. Remember - here and now is where joy lives.

This practice isn't the cure all to my mental health issues. And I doubt it will cure yours. But it gives our poor brains, exhausted by the three alarm fires that usually occupy them, a break. It turns down the temperature and lets a different input in.

And that's a good thing.

Why Get Diagnosed with ADHD - And Introducing Jesse Anderson

Am I the oldest new member of the ADHD club? At age sixty-nine, why bother with a diagnosis and treatment?

That was the attitude of my new and now former primary care provider. She said that the prefrontal cortex develops out of ADHD in adulthood, or that people learn workarounds for its difficulties.

She didn't ask about my prefrontal cortex, or whether I had found workarounds. She thought I should just not worry about what I can't do.

As I said, former care provider.

But back to that question - why bother?

Two reasons:

Treatment for ADHD works

Sure, over those many years I developed some workarounds, ways of coping with the challenges of my neurologically divergent (ND) brain.

But they weren't alway sufficient. There were key times in my life when I failed to reach my goals because I couldn't get started, because I couldn't keep going, because I couldn't maintain concentration, because I couldn't remember, because I couldn't turn down the emotional interference that I experienced as a consequence of all the other symptoms. SHAME! Loads of SHAME!

My workarounds got me a certificate in congregational development. But I am not the Rev. DOCTOR Willa Goodfellow, because - I couldn't.

And yet today, I still have more I want to do, big things for which my workarounds have not been sufficient in the past and are not now.

But that pill, that tiny pill, that fraction of a pill after I cut it with my pill splitter, because for me it never takes much. . .

It was like the window opened, the sky was clear, I sat down, like I am right this very minute. . .

And I worked.

That's all. I didn't speed. I didn't stay up late. I didn't go down to the schoolhouse to score some more tabs off a sixth grader.

I simply worked. My brain was clear and in gear. And I got the job done.

There are things I want to do, books I want to write and promote, podcasts on which I want to be a guest, deadlines I want to meet. And one little fraction of a pill has opened the window for me.

Treatment works.

Community for people with ADHD helps

That's the second reason to get diagnosed, community. Just like any other challenging condition, the people who have it can help each other. Breast cancer, kidney cancer, Parkinson's, depression, bipolar, alcoholism, arthritis, eating disorders - whatever you've got, hanging out with others who have it too is huge. Community offers support, reassurance, information, and resources.

Once I knew I had ADHD I no longer felt like I was keeping a shameful secret - my failure to do what everybody else on the planet could do and what I expected myself to do.

And then I discovered others.

Twitter is a godsend for all things diverse, including neurologically diverse. It's where you find the people like you. Because there are people like you.

So if you have or wonder if you have ADHD, head for the bird app. This link will take you to the posts that people have tagged with #ADHD. That's a start.

Jesse Anderson

And this link will take you to Jesse Anderson on Twitter.

Jesse has a newsletter filled with ideas and strategies to help people with ADHD manage our time, energy, and motivation - those workarounds that we all supposedly discover on our own by the time we are sixty-nine. We don't all have to reinvent the wheel by ourselves!

Jesse has a podcast called ADHD Nerds that's just getting started. Personally, I am glad that they come in at around thirty minutes. Because who has the attention span for those ninety minute podcasts? - Not somebody with ADHD! Four episodes so far. I hope he finds it interesting enough to keep it going, because I find it interesting enough to keep listening.

And he's writing a book, Refocus: A Practical Guide to Adult ADHD. Not out yet. When it is, I'll drop a review. But get this - he is inviting input about what should be included. So go to that website; see what's already in the table of contents; send him your own thoughts.

So yeah, folks, even if I am the oldest kid in class, I am glad to have gotten here. I really like the consequences - being able to get stuff done, stuff that matters to me.

And finding my peeps. You rock!

photo of old lady and last meme from memes.com

photo of window to the sky, taken in the Dingle_Peninsula,_Co._Kerry,_Ireland by Maoileann, used under creative commons license

photo of handshake by shark, used under GNU license

How Do You Keep Your Eye on the Ball - Maintaining Attention with ADHD

First step: Get started.

That was the topic of my last blogpost, dealing with the activation aspect of ADHD.

Following my own advice, just now I did two quick little internet tasks and crossed them off my list. Got a dopamine hit off that, like taking one bite of a piece of pie. So now I have a long task in front of me, writing my next blogpost on attention.

Oops, damn. Just took a break to eat a banana. And then I started a timer on one of my games. And now I'm remembering it's a friend's birthday and I haven't sent a card yet.

via GIPHY

NO! I will get back to the blogpost. Ugh. Even with a med on board, this is hard.

So. How do I keep working when my friend really deserves a birthday card and I really want to send it?

Here are my tricks:

How Do You Get Going? Working with ADHD

Screens for ADHD measure five clusters of symptoms: 

• organizing and activation for work
• sustaining attention and concentration
• sustaining energy and effort
• managing affective interference (emotions that get in the way)
• utilizing working memory and accessing recall.

The DSM checklist assumes that ADHD is a diagnosis for children. If you didn't have it as a child, you don't have it now.

Well, okay. I am not qualified to quibble with the American Psychiatric Association about how many angels dance on the head of a pin and when they showed up for the dance. But the problem of diagnosis is this: I can't remember which of their criteria I demonstrated in my childhood. And my mother certainly never noticed any struggles that her brilliant and perfect daughter may have experienced in the early 1960s. I mean, she didn't even notice suicidal depression...

So what do I make of that DSM assumption?

CHADD - Children and Adults with Attention-Deficit/Hyperactivity Disorder has this to say about diagnosing adults:

There's That Squirrel Again! How Do I Know if I Have ADHD?

There is a reason why I haven't posted in months. My latest diagnosis -- ADHD -- Attention Deficit Hyperactivity Syndrome -- the adult version.

I have a fistful of posts in my draft file that were never finished before they seemed beside the point. That is not an unusual state for me. Many years ago my brilliant brain was unable to write the doctoral thesis for which I had already conducted extensive field research and had a thorough outline. Periodically I would write whole chapters in my head. But when the laptop was in front of me...

via GIPHY

I was stuck.

We'll see how this post goes.

Diagnosis

Wait a minute. Don't I have bipolar disorder? Where did this new diagnosis come from? What are the chances a person could have both?