BIPOLAR DISORDER, TYPE II...WHY IT IS IMPORTANT

Bipolar II disorder [I will refer to this as BP2 for rest of blog] made the news when it was reported that the actress Catherine Zeta-Jones was given this diagnosis.  Most people are aware of bipolar I disorder [BP1] yet BP2 is more prevalent and has significant levels of morbidity [the impact of the illness on one's life] and mortality [it can lead to suicide].  Also, and very importantly, BP2 is often misdiagnosed as frequently people with BP2 initially present to general medical settings and not psychiatric settings where they are likely to be diagnosed with a major depression and treated with antidepressants.  This happens in psychiatric settings as well.

BP2 is diagnosed if someone has had one or more major depressive episodes [MDEs] with at least one hypomanic episode.  In contrast, someone with BP1 has had at least one manic episode and usually one or more MDEs.  Differentiating BP1 from BP2 requires being able to determine if there has been a manic episode vs only hypomanic episodes.  Manic episodes involve periods of persistent and abnormally elevated, expansive or irrirtable mood  lasting at least one week.  Change in mood must be accompanied by at least three of the following if mood is elevated and at least four if mood is irritable. These include: 1. inflated self-esteem or grandiosity, 2. decreased need for sleep, 3. more talkative than usual, 4. flight of ideas or the subjective experience that thoughts are racing, 5. distractibility, 6. increase in goal-directed activity or psychomotor agitation [very restless and anxious], and 7. excessive involvement in potentially dangerous activities.  The manic mood causes impairment in functioning. Hypomanic episodes involve a period of persistently elevated, expansive or irritable mood, lasting for at least four days and it is clearly different from the person's typical depressed mood. The hypomanic mood is accompanied with the same list of possible symptoms as for manic epsiodes and must be clearly a change in functioning and observable to others but not to level of impairment. 

Another very important distinction must be made between BP2 and Major Depressive Disorders [MDD] as they do not involve any hypomanic episodes, while BP2 involves MDEs and hypomanic episodes.  If someone presents with an MDE, the only way to determine if they have BP2 is to find out if they have had any hypomanic episodes in the past.  This can be difficult as often people do not consider hypomanic episodes as problematic or pathologic and may not recall them even with direct questioning.  This is one reason that it can take over ten years to correctly diagnosis BP2.  I have treated people who have had seven different trials of antidepressants with an initial improvement and then worsening of their moods only to try another antidepressant.  This can lead to a lot of suffering and risk of suicidal behavior.  

So, how common is BP2? Lifetime prevalence rates in the US = 1.1%.  It often is associated with panic disorder, substance use disorders and ADHD.  Importantly, the depressive episodes for BP 2 compared to those for MDD were associated with more suicidal thoughts, hypersomnolence [increased sleeping] and higher rates of agitation. BP2 moods are also more seasonally influenced [more depression in later fall and winter].

Therefore, while there are some things that distinguish BP2 depression from MDE depression, the diagnosis still rests on identifying hypomanic episodes.  Be alert for these in anyone you know who has had a MDE as early treatment can make a big difference in quality of life for those with BP2.  

ANXIETY IN NANOSECONDS, WHAT CAN YOU DO?

Over the past several months I have helped a number of people who have had traumatic experiences that keep bothering them even after they are no longer exposed to the traumatic situation[s].  They report becoming very anxious very rapidly when anything reminds them of the traumatic events.  They often have develped a number of good coping skills but they are always having to use them after the anxiety has been triggered.  In trying to understand this, I recalled reading a study that found that the amygdala can respond in nanoseconds when our brains feel that something overwelming may occur.  In other words, the brain continually scans our environment and our reactions looking for potential danger.  If we have been trauatized in the past, our brains will frequently see the possibility of danger and will trigger the amygdala very rapidly.  A nanosecond is one millionth of a second!

I have found that treating the anxiety after it has been triggered can reduce the intensity of the anxiety but not lower the frequency of it.   The problem with treating the anxiety before it occurs is that the medication to reduce the anxiety needs to be present all the time and be well tolerated in between times when there is not anxiety symptoms but also be able to contain the anxiety so the amygdala is not triggered.  I have had success with low doses of atypical antipsychotic medications with monitoring for metabolic side-effects.  I do not know yet how long these medications will need to be taken.

AFTER BEING BULLIED, IT STILL HURTS TEN YEARS LATER

The most recent AACAP News summarized an article by Copeland, etal., in JAMA Psychiatry 20:1-8 that looked at children and adolescents who were bullied or the bullies 10 years later.  This was a follow-up from the Great Smoky Mountain Epidemiological study that was done in wesern North Carolina.  They found that both those who were bullied and those who did the bullying continued to suffer.  Those who had been bullied were still at high risk for several anxiety disorders and depression.  In addition, suicidal impulses were very increased in males who had been bullied and agoraphobia was very increased in females who had been bullied.  For those who had done the bullying, the only increased risk for any psychiatric disorder was for antisocial personality disorder.  

It is important to also mention that the increased risk for psychiatric disorders was related to the bullying and not to genetic or other environmental factors.  This points out the serious consequences of being bullied and also the consequences for the bullies as well.  It is possible that the continuing suffering is related to the development of Post Traumatic Stress Disorders [PTSD] and ongoing symptoms related to the PTSD.  The PTSD is treatable and yet must be recognized as PTSD to help the treatment to be successful. I have treated a number of children and adolescents in the hospital who developed suicidal behavior related to their being bullied.  

I hope that increasing awareness of the severe consequences of bullying will help efforts to stop bullying and treat it as a serious problem that often leads to longterm suffering.  We have zero tolerance for threats of violence in our school systems.  Maybe it is time to have zero tolerance for bullying as well. 

METTA...LOVING KINDNESS?!

In an earlier blog I mentioned research by Ms. Fredrickson and her colleagues at the University of North Carolina at Chapel Hill that involved one group receiving training in metta meditation while a control group did not.  The metta meditation really seemed to help that group feel better and be more positively connected to others.  This type of meditation has also been used to successfully treat people with Borderline Personality Disorder, a disorder that is difficult to treat based in part on the negative and unstable relationships these people tend to have.  

So, what is this Metta?  Metta is described as an attitude that recognizes and respects all sentient beings [all living things capable of having feelings] and wishes them well.  It requires that we recognize that all sentient beings are united in their desire to find fulfillment and escape suffering.  This then allows us to feel friendly, compassionate and even loving to others.   

The practice of developing metta involves first cultivating this attitude and experience of life towards ourselves.  Then toward family members and good friends.  Next toward neutral people and then toward difficult [hard to like] people.  The final practice involves feeling this loving kindness toward people who do very bad things.  It seems that when we withhold our kindness towards anyone, it becomes a weight or burden for us to carry.  I may have mentioned the following story in another blog.  However, since it concerns carrying things I will repeat it.  Two monks were walking down a muddy dirt road and saw a very nicely dressed woman standing  on the side of the road.  She would get her dress muddy if she had to cross the road  One of the monks went over and carried her to the other side.  Five hours later, the other monk asked why he did that.  The monk who carried her stated that he had carried her for 30 seconds while the other monk had carried her for 5 hours.

Here's wishing all of us the joys of letting go of our burdens that keep us from experiencing metta.

CONNECTED TO EVERYWHERE BUT NOT TO EACH OTHER?

Much has been written about the wonders of being connected through the internet to the world and the potential problems of changing how we connect to each other.  My daughter forwarded an article from the NY Times by Barbara Fredrickson about this topic.  Ms. Fredrickson is a professor of psychology at the University of North Carolina at Chapel Hill and she was writing about research that she and her colleagues have completed that is published in a recent issue of "Psychological Science."  They measured the capacity for people to have warm interpersonal connections in daily life by having half of the participants chosen at random participated in a six week workshop on a very old mind-training practice called Metta that is translated as "loving kindness." that teaches developing warmth and tenderness towards oneself and others.  The participants who were exposed to the loving kindness workshop, were more positive and socially connected and also had improved "vagal tone."  

Vagal tone is the connection between your brain and your heart and other organs.  The higher the vagal tone, the better your brain is regulating your internal organs and immune system.  Also, Fredrickson referenced Stephen Porges, a behavioral neuroscientist, who has shown that vagal tone is important to facial expressivity and the abiity to tune into the frequency of the human voice.  Thus, it would seem that a higher vagal tone could improve one's capacity to connect to others, form friendships and be empathic.

So, it might be better to put down the i phone and say hello to someone.