Getting My Brain Back -- I'm Still Excited by BDNF

Learning has been fundamental to my mental health recovery. It started with this blog itself. I wanted to know What the hell happened to my brain?!!! So I read the research and used ProzacMonologues.com to keep track of my notes.

For a while I added piano to my recovery regimen. Not for music therapy, but for brain development. Okay, I didn't keep at it. I can sort of play Desperado. But it did get me a few more miles down the road.

Lately I am learning a new language. Five minutes a day of Irish on Duolingo -- I don't expect to be fluent any time this decade. I don't need to be fluent. For those five minutes a day, I am building my brain.

Which is always a good thing.

I did a search in my blog for BDNF. And found something I wrote in 2011, right after I wrote that review of Ellen Frank's Treating Bipolar Disorder. Now you, kind reader, have no idea the struggle it took back then to write these paragraphs. I am proud of it both for the accomplishment and for the content itself. I present it to you again:

Getting My Brain Back -- In Praise of BDNF

Interpersonal Social Rhythms Therapy: Good, Bad, and Ugly (Mostly Good)

Following #bipolar on Twitter for the last few years, I am often dismayed. So many people seem to spend so much time struggling with their medications and so little time focused on anything else that could help.

Don't get me wrong. Medication is an important tool for managing bipolar disorder. But it can't do the whole job. Education and life style changes are crucial for getting off the roller coaster of constant med adjustments to address the episode du jour.

I decided it was time to revisit my 2011 review of Ellen Frank's Treating Bipolar Disorder. It was a four-part review. The last three posts describe the treatment itself, Interpersonal Social Rhythms Therapy, IPSRT.

Part I laid the educational foundation, describing the relationship between circadian rhythms (our interior physiological clocks) and mood disorders.

Part II outlined Frank's Social Zeitgeber Theory and the treatment that proceeds logically from it, a process of establishing regular daily rhythms that set our interior clocks and keep them running on time. (Zeitgeber means timekeeper.)

Part III explained how work on interpersonal issues helps people reduce stressors and prevent disruptions to their social rhythms.

This last post will pull together my appreciation, my reservations and my hopes for future directions.

Social Zeitgeber Theory

How Does Interpersonal Therapy Help People with Bipolar Disorder?

Ellen Frank - Treating Bipolar Disorder, Part 3

Lately I have been reposting my 2011 review of Treating Bipolar Disorder by Ellen Frank. It was originally recommended to me by a friend who was researching hypomania. Part I described the basis of Interpersonal Social Rhythms Therapy (IPSRT) in circadian rhythms that control the many physiological symptoms of mood disorders. Part II outlined the Social Zeitgeber Theory and described the early stages of the therapy process, history taking and stabilizing social rhythms. Today I pick up with the later stages, interpersonal therapy and maintenance.

Interpersonal Social Rhythms Therapy came to Ellen Frank in an epiphany on her birthday, July 14, 1990. Personally, I like that. I especially like that it was the day that she participated in a conference for people with bipolar, and listened to them.

Frank and her colleagues were already using interpersonal therapy for people with recurrent unipolar depression. Their theory was that certain life events, particularly losses could result in lost social zeitgebers, (timekeepers), with subsequent disruption of circadian rhythms, leading to eventual relapse into another episode of depression.

IPSRT took up from there as an adaptation specifically for people with bipolar disorder, integrating the work on issues (as in, you've got issues) with greater focus on behavioral changes to achieve and maintain daily rhythms, time of rising, time of first human contact, work, main meal, etc. The purpose of IPSRT is to help people achieve stability and then to avoid relapses into either depression or mania/hypomania.

Why Do People Relapse?

How the Social Zeitgeber Theory Works, for Good or Ill - IPSRT

This -- this system is the gift I wish I could give to the people I meet on Twitter who struggle with their bipolar, who are in endless rounds of medication adjustments and medication failures and medication despair. Medication isn't the only thing you can do. I'm not saying quit your meds. I'm saying, add social rhythms therapy. Originally posted in 2011:

Ellen Frank - Treating Bipolar Disorder, Part 2

So you have bipolar. You know you have bipolar. You are way past the denial stage. You are into the pulling out your hair, screaming with frustration stage. Or maybe moved on to despair stage. Because:

1. The medication sucks.
2. You keep getting sick again anyway.

But contrary to what everybody has been telling you, medication is not the only thing that works. It may be essential to your recovery and continued functioning. But you can do better if you do more. From my last post:

IPSRT [Interpersonal Social Rhythms Therapy] is one of three psychotherapies tested by the National Institute on Mental Health in its recent major study of best practices for treatment of bipolar disorder. The Systematic Treatment Enhancement Program for Bipolar Disorder, STEP-BD discovered that Patients taking medications to treat bipolar disorder are more likely to get well faster and stay well if they receive intensive psychotherapy.

Do I have your attention? Today we continue with Ellen Frank's Treating Bipolar Disorder, in which she describes this therapy of her invention.

What Happens In IPSRT

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.