Analogies, especially ones using non-mental health subject matter that are easily recognizable by the patient, can be helpful in explaining diagnostic concepts, treatment goals, and the expectations of response. For the hypomanic patient with bipolar or cyclothymic disorder, analogizing their condition to sitting on a raft in the middle of an ocean storm is particularly illustrative.
THE OCEAN STORM
Your life has been a marked series of ups and downs as if you were sitting on a raft in the middle of an ocean gale. When the wind whips up, you are tossed from the peak of high waves to their trough. The strength of the weather, the length of the storm, and the turbulence of the waves can feel quite unpredictable. Although the ride may be exhilarating at times, it can also be very frightening. At times, it may feel as if the raft will capsize, and you are hanging on for your very life. While at the bottom of the trough a large wave may splash over you and engulf the raft to the point that you may feel suffocated or as if you are going to drown. As terrifying as this situation may feel, without warning you may be taken back up to the peak of a wave and feel as if you are again riding the crest, on top of the wave, only to crash again.
Our treatment will attempt to smooth out the waves to a gentle swell, such that you will remain comfortable sitting on the raft without fear of being tossed overboard or drowning. By working together, we will minimize the likelihood that you will be unpredictably taken to heights, which you cannot control, only to fall again. As you adjust to calmer seas, you will be better able to clearly view your surroundings and assess what course of action and direction you wish to take. Do you wish to paddle toward a ship in the distance? Paddle to a nearby island? Or rest comfortably in the sun? In any case, it will feel much more under your control. No one’s life is ever a totally calm sea; however, an increased sense of control will feel empowering.
Another analogy, which can be useful when using mood stabilizers and antidepressant medication as well as explaining the risks of administering antidepressants alone, is that of a seesaw or a teeter-totter.
Using medication in elevated mood or mood swings is like balancing a teeter-totter. When in a depression, the left end of the seesaw is down. When in the midst of unstable mood episodes, the teeter-totter often moves up and down with seeming unpredictability. When the seesaw is in the down position and an antidepressant alone is added, the lower end may rise. It may help transiently, making you feel better but often this positive effect is unpredictable. Either the seesaw falls again (you revert to the depressed state), balances briefly (your mood is transiently even) or can zoom up off the ground in the high position (spiral into a hypomania or mania). In this latter state, you may feel elated for a period of time, but this is not likely to last, as you crash to the ground again. At other times, the frequency of the oscillations increases. Therefore we use medications to stabilize mood and keep the seesaw level. When mood stabilizers alone are insufficient to eliminate or reduce depressed periods, a specific mood elevating medication may also be carefully added.
Many patients with elevated mood have lived with their condition for years, even a lifetime, without a diagnosis. Some may have the sense that they have a condition, which could never be positively affected by treatment. When periods of depression and low functioning are intermingled with periods of hypomania, patients (and those around them) may develop inaccurate explanations for their erratic behavior and lack of consistency. Impulsive business
and social decisions, overspending, and other money mismanagement and poor judgment may be attributed to lack of discipline, personality weakness, or simply “not caring.” These evaluations may be made by the patient himself or by the patient’s family, and invariably lead to decreased self-esteem and negative assessments by others.
When the diagnosis of hypomania or cycling is made and mood is sufficiently stable, it can be extraordinarily helpful to “re-view,” that is, view the patient’s history again in light of the new diagnosis. In doing so, it may be clearer to patients that some of their erratic and excessive behaviors—personally, financially, sexually, or otherwise—are symptoms of their illness. It can be quite relieving to understand that such behavior does not automatically mean the patient is a “bad person” or has a fundamentally flawed personality. They have had the behavioral symptoms of an illness that can be treated. This is not to say that all negative behaviors can be ascribed to hypomania or illness. On a person-by-person basis, it is necessary to sort out what may be illness-related behavior and what may be referable to other personality characteristics and/or other causes. It may be similarly helpful to invite the spouse, children, parents, or other family members for a session and explain directly the relationship between hypomania and problematic behaviors. A meeting such as this may provide a useful context for the patient’s family to understand their loved one and assess these problematic activities in a less negative way.
“Re-viewing” family history
It is not uncommon when identifying a patient’s cycling mood disorder to find other close biologic relatives who have been similarly diagnosed or have a presumptive diagnosis based on their behavior. Therefore, a similar analysis of the patient’s close blood relatives may be useful in helping the patient understand negative behaviors as part of an illness instead of viewing the relatives as being “mean”, “weird” or “thoughtless”. It would be an advantage to evaluate a patient’s relative in person to establish a cycling mood diagnosis. Even when this is not possible however, patterns of family behavior may be sufficiently classic or similar to the patient’s own behavior to classify them as symptomatic of manic/hypomanic episodes. Excessive anger and irritability, sexual acting out, poor financial decisions, or inability to hold a job in the context of major mood swings may be interpreted for the patient as relating to that relative’s own cycling mood episodes. Even abusive behavior may be partially “re-viewed” and reinterpreted in light of an absence of anger control that can often occur in the context of hypomania or mania. Although not removing the necessity of psychotherapy for the patient, it may be quite helpful to understand that an abusive parent, for example, was ill and not just “mean.”
“Re-viewing” from a new perspective
A third way of “re-viewing” is to help the patient see his/her own mood state and actions from “the outside” rather than from his own internal perspective.
Patients may see the world solely from their own perspective, unable to absorb feedback from others and act “with blinders on.” Helping patients to get a more balanced view of themselves can be helpful in changing this view and modulating behavior. When hypomanic, patients with elevated mood often believe that their ideas are “meant to be,” “perfect,” “sharply focused,” or ideal. Although valid at times, the more hypomanic an individual becomes, the higher the likelihood that such notions are unique to the hypomanic person but viewed differently by others. When re-viewed later, behaviors or ideas that “seemed right at the time” are often viewed as overly impulsive, or frankly impossible.
Although it would be optimal if such perspective could be achieved when the patient is most hypomanic and therefore most at risk, this may be difficult. Obtaining a more accurate perspective may only occur after the lowering of mood with medication. One psychotherapeutic technique useful in obtaining perspective is drawn from the field of psychodrama. A “two-chair technique” involves having the patient sit in a second chair, not the usual chair where the patient sits. The patient and the therapist together then view the patient’s behavior as if he or she was a third person in the room sitting in the empty chair. Comments and dialogue are conducted in the third person; for example, “How would you characterize his (patient’s name) behavior?” “What risks is Jill taking?” “Let’s compare the benefits of how Frank is acting with the risks he is taking.” “What would Jennifer’s husband think of what she’s doing?” “How would you advise Matthew if you were his best friend?” “Let’s assume that you were Anna’s supervisor. What if any corrective action is necessary and how would you tell that to her?”
After such a series of questions, the patient then reverts to his usual chair and the therapist and the patient discuss possible changes in perspective as a result of this exercise. With new insights, a specific behavioral plan can be put in place with a higher potential for success.
Mood recognition and charting
One might assume from all that has been written about elevated and depressed mood in this book that patients are acutely aware of their mood state. This is hardly the case. Some individuals may be aware of their behavior, energy level, and mood, whereas many are oblivious to these parameters. Although unrecognized mood/behavior states are more prevalent at the elevated end of the spectrum, they can also apply to depression, particularly dysthymia. During a hypomanic episode, patients often do not recognize marked changes in activities, moods, and routines that are readily apparent to others. One goal of therapy is to help individuals recognize specific mood-related behavioral cues, especially those that serve as “red flag” warnings of incipient mania or depression. A particularly effective technique in this recognition is the use of graphic charting.
Lifetime mood charting in patients with a cycling disorder is extremely useful. These charts can be self-completed or constructed during a therapy session by therapist and patient together. Such charts depict a long-term
picture of the patient’s mood history, focusing on significant mood episodes, whether depressed or elevated. Periods of psychiatric treatment or hospitalizations are noted. In addition to significant dysfunctional moods, it is useful to indicate milder deviations including periods of euthymia, temperamental hyperthymia, dysthymia, or subsyndromal traits. This graphic information is helpful in diagnosis and treatment planning, especially in determining a medication regimen (see Chapter 7
). Lifetime charting can illustrate long patterns of mood swings and, therefore, is useful in the “re-viewing” of the patient’s life as noted earlier in this chapter.
Shorter-term graphic charts, completed by the patient between therapy and medication management appointments, can be organized by the day, week, or month. Although many formats have been used for graphic charting, the most typical chart will be completed for a 1-month period during which the patient rates his mood on both a graphic and numeric scale, the number of hours of sleep, and the presence of any life events which might affect mood (see Figure 6.1
). Women will include menstrual cycle data and observe for any correlation with mood changes. All medications taken are noted down, along with dosage and any side effects. Charts may be customized to track other target symptoms including irritability, binge/purge episodes, anxiety and panic attacks, headaches, or other specific physical pain. These too are rated on a numeric scale.
Yearly charting is helpful in highlighting any seasonal changes in elevated or depressed mood. Even with significant mood stabilization, when followed over time, seasonal changes may clearly emerge. A very common seasonal pattern is a progressive elevation of mood in the spring, reaching an apex in the summer, and then falling in autumn to a depression in winter. Other seasonally related patterns show depressions regularly appearing in the summer or mood elevations each spring and fall.
Most patients find the opportunity to self-chart as a way of becoming actively involved in their own care. Charting can be an especially helpful graphic tool for patients who are not particularly sensitive to their mood and activity changes. Additionally, medication management and compliance can be enhanced by these graphic and objective reports of changes in the patient’s mood state and activity.
Occasionally, there may be resistance to mood charting. Patients may worry that they do not know what constitutes “normal” and are concerned that they will give a false impression of their condition. Reinforcing that learning and recognizing one’s moods is a gradually learned skill, and the fact that there is no “right or wrong” to charting can be reassuring. Other patients, especially those newly diagnosed, may decide that attempting to recognize, analyze, and rate their feelings is a waste of time. Such patients would not complete their charts or would have “forgotten” to bring them. Gentle persuasion and the therapist’s skill in utilizing these charts will help most patients to eventually comply.
Figure 6.1 Daily mood chart