What is Bipolar Disorder?

According to the Diagnostic and Statistical Manual of Mental Disorders-5 [DSM], bipolar disorder is a serious mental health condition marked by radically opposite states of mood. These moods may occur in phases, also called episodes.

The manic episode is typically marked by feelings of grandiosity or heightened self-esteem. People experiencing this phase may seem to be in a “high”. They may be unusually energetic, have little need for sleep, may talk excitedly, get easily distracted, and often recklessly pursue pleasurable activities. In contrast, the depression episode is marked by intense sadness, dejection, lack of energy, apathy and lack of interest in pleasurable activities. Typically, between both episodes, there may not be any symptoms.

A mild to moderate level of mania is called hypomania. Hypomania may feel good to the person and may be associated with good functioning and enhanced productivity. So even when family and friends learn to recognise the mood swings as a possible mental disorder, the person may deny that anything is wrong. Without proper treatment, however, hypomania can convert to a manic episode or major depression.

Because bipolar disorder tends to run in families, researchers have been searching for specific genes that could be linked to the disorder. Recent research shows that the MLC1 gene could be associated with schizophrenia and bipolar disorder in southern India. [Verma, Mukerji et al, 2005]. External environmental triggers could also set off the disorder or worsen existing symptoms. Stressful life events, substance abuse, seasonal changes, sleep deprivation are all potential triggers for either mania or depression.

What does the treatment involve?

Bipolar Disorder is a bio-chemical condition, therefore psychotherapy is not the first line of treatment. The professional to visit immediately, if one suspects the illness, is a psychiatrist. The psychiatrist will assess the history, symptoms and overall functionality of the person and accordingly prescribe medication.

Mood stabilizers are medications that help control the highs and lows of bipolar disorder. They are the cornerstone of treatment, both for mania and depression. Lithium is the oldest and most well-known mood stabilizer [recommended by APA Practice Guidelines]. Psychiatrists may also prescribe benzodiazepines, anti-depressants or anti-psychotic medications based on the persons’ symptom presentation. Adhering to the medication guidelines prescribed by the doctor is crucial to recovery.

Deciding to seek psychotherapy for bipolar disorder

Although psychotherapy is not the first line of treatment for bipolar disorder, medication offers only partial relief for patients. Seeking a trained psychologist can make a marked difference towards treatment adherence, relapse prevention, symptom management and leading a better quality of life.

However, just visiting a professional is not enough. Psychotherapy is hard work and is not just about “talking and listening”. The person needs to work within and between sessions to gain insight into their problems, change their activity level, daily schedule, mood, thinking and social relationships. The psychotherapist works with the person to change those negative thinking patterns that reduce their motivation to make these changes. It’s important to note that just meeting a counsellor will not be helpful, unless he or she is able to help you manage the illness effectively. You need to meet an accredited and trained psychotherapist, someone who will actively work to alleviate the symptoms.

How does psychotherapy help in bipolar disorder?

Psychotherapy teaches the benefit of adopting a rational stance when faced with difficult situations. The idea is that if one is upset by their problems, they now have two problems:

1. The problem
2. The upsetness.

In the initial phase of therapy, there will be an assessment. During this phase the therapist will take an extensive history, including timelines of the episodes. Some information that the therapist will seek:

• Age of onset of the illness
• Progression of symptoms over time
• Description of specific depressive symptoms
• Description of specific symptoms during elevated mood
• Description of sleep patterns and physical energy in each of the different mood phases
• Approximate duration for each of one’s mood phases
• Presence of suicidal thought and accompanying risk factors
• Impact of symptoms upon interpersonal relationships

Sometimes, along with bipolar disorder the person may also be diagnosed with another condition, eg: a personality disorder. Therefore, the therapist may conduct a psycho-diagnostic evaluation to rule out if there is any other mental illnesses. The therapist will also make a note of the medications the person is taking and monitor the psychiatric intervention, as also recommend any other medical interventions if needed.

The therapist will then provide “psycho-education”, which essentially means educating the client and the family about the illness. This will include explaining the symptom profile, the depression negative triad, brain physiology, the need for both medication and psychotherapy etc. Psychotherapy will also involve some family education, so that the family can learn to recognise symptoms, and how to adopt behavioural strategies to manage the mood episodes.

Psychotherapy will next involve the core phase, i.e. treatment of symptoms. This will include the following:

• Regulating daily schedule
• Keeping mood charts to note daily mood fluctuations
• Restructuring negative thinking
• Promoting adherence with medication regimens
• Reducing risk of suicide
• Identifying triggers that increase the risk for relapse
• Mediating any hospitalizations

Identifying the prodromal symptoms

The most important benefit of psychotherapy is helping the patient and the family detect “prodromes”.

The word prodrome comes from the phrase, “running before”, and refers to the period that precedes a mood episode. In bipolar disorder some environmental triggers may precede a mood episode. These triggers may include seasonal variation, certain stressors [such as disagreement with spouse], work overload etc. Although bipolar moods are not always “predictable”, identifying a certain set of triggers that typically precede a mood episode can prevent episodes from occurring and establish overall smoother management of the illness. The therapist can help the person analyse previous mood episodes, keep daily mood charts and use those logs to identify themes in triggers.

Support groups

Lastly, psychotherapists will guide their patients and families to seek out the help of support groups for bipolar disorder. Sharing within these groups, where other members report similar experiences, can not only reduce shame and guilt but also offer a different perspective on coping.

Bipolar disorder is a complex condition, with a long and often uncomfortable ride for both the patient and their loved ones. Seeking the right professional help can help the person not only manage their illness well, but also motivate them to seek their highest potential, and live their life with dignity and satisfaction.

The post Here’s why you should consider psychotherapy for bipolar disorder appeared first on Complete Wellbeing.

Here are five common questions people have about seeing a counselor.

Why Do I Need Counseling Therapy?

We, each of us, have individuals temperaments, life experiences and emotional thresholds, so there is no single formula to decide when to seek therapy. But what we can say in general is that whenever you find yourself feeling overwhelmed by a certain situation—failure, grief, loss, sickness—you might consider seeking counselling therapy.

“Why can’t I just talk to my family and friends instead?”, I hear you asking. Indeed you can; not everyone needs to seek professional counselling for their situation. Close friends and family are a sturdy sounding board and their support helps through many a life situations. But you must keep in mind that people known to you will tend to relate with you from their own filters; plus, they will also approach the situation based on their past experiences with you. If these people are a part of your current problem situation, their biases will be a part of the solution or advice they offer to you. A therapist, on the other hand, is trained to look at, and provide, an unbiased view of the situation.

Can a Counselor Solve My Problem?

To correct a widespread misconception, counseling is not about providing solutions to one’s problem. The job of a therapist is to assist and enable a counselee to view the situation from a rational viewpoint and alter thoughts and emotions that cloud or impede such rationality. Don’t expect your therapist to alter the external situation—often that is impossible. However, what a competent therapist will do is assist you in changing your internal thought process. The process of counseling is always driven by the counselee with the counselor assisting in providing structure, exercise and guidance only.

Can a Counselor Make Difficult Decisions for Me?

Another life situation that may warrant counseling therapy is when you find yourself at a cross road in life. Certain decisions seem too daunting to make and appear to have huge emotional, physical, financial and social considerations. You may feel that you just can’t afford to go wrong. Such situations generally occur with young individuals where experience is limited, and risks seem much bigger than they actually are. Procrastination, avoidance and self-doubt are the most natural by-products. While a therapist is not a solution provider, s/he can help you rationalize the process of decision-making and make the most informed choice, with the awareness and readiness to take in stride the expected or unexpected consequences.

Can a Counselor Help Me to Deal With Physical Conditions Too?

Yes. There are physical or medical health conditions that may warrant counseling support. Chronic health issues and life threatening diseases undoubtedly take a toll on one’s emotional, mental and social health. Counseling therapy helps the counselee by building resilience and offering fresh and different perspectives about disease and pain.

Not only the patient but the caregiver too may feel the need for emotional support. Take the example of cancer; while medical management is required to treat the disease, counseling helps the patient and family members deal with the fear, anxiety and depression that accompanies the prognosis. A mother, whose child is battling cancer, or an aged spouse accompanying every dialysis cycle, often suffer in silence and experience burnout. These caregivers need the same amount of emotional and mental support to get through the struggle as the patient.

What Should I Expect in a Typical Counseling Session?

• Typically, the first session or two are spent in establishing a rapport between the therapist and the counselee. This may vary from a single session in case of a responsive counselee to several sessions, like in case of children or reluctant individuals.
• Early sessions are about the counselee picking up on the most obvious problem or issue to be dealt with and through this, both the counselor and counselee explore the underlying irrational thoughts, beliefs, and behaviors of the counselee. This is important because the end result is not just a solution to the existing problem but an empowered rational individual.
• One needs to keep in mind that, in most cases, counseling therapy targets the internal change in a counselee even if the issue seems external because that is the only variable under control. So, if you are seeking counseling to bring about a change in people and situations around you, you are likely to be disappointed. Counseling works to alter the way you view and deal with the difficult situation.
• The duration of the counseling therapy depends upon several factors
  • Responsiveness of the counselee
  • Ability of the counselor to invoke trust in this association
  • Readiness to put in work to find the desired result
  • And lastly, the ability to accept what needs to be changed and what cannot be changed [I teach all my counselees to recite the serenity prayer before every session as part of this acceptance]

Also read » Counsellor calling

Conclusion

To conclude, the complex nature of modern life casts a doubt over our ability to manage and move through life happily and peacefully. It is when life seems unbearable or too complex that counseling support provides the much-needed perspectives.

The post Common Questions About Seeking Counseling Therapy appeared first on Complete Wellbeing.

When I left India in 2001, with “just” an MBBS—unfortunately, being a general practitioner can be a challenge if you want to be able to earn enough for three meals a day—the government of India did not recognise an MD from the United States. So, pursuing a speciality in the US and coming back to India to practise was not an option. But since I was going to the US, I decided that I might as well pursue psychiatry, as it was something I had always wanted to do. I graduated from Duke University and I began practising in the US for a while before relocating to India. Thankfully, by the time I was back, the rules had changed and I was allowed to practice after registering with the appropriate authorities.

In for a surprise

I assumed that armed with a degree from a reputed university and four years of psychiatric practice under my belt, I could swoosh in like Zorro and get a job anywhere I wanted. In my practice, I had seen a lot of cases of Post Traumatic Stress Disorder [PTSD], so the altruist in me offered to volunteer with the military services. Unfortunately, the armed forces were not keen on hiring me. So I began thinking about joining a private hospital and contacted a number of them, but without success.

So there I was—a qualified and experienced psychiatrist, in a country with more than a billion people, where 20 – 30 per cent of them suffer from anxiety or depression and yet I could not find a job. My faith in Zorro began to wane. Was I wrong to move back? Should I have stayed in the US? Was I going to stay unemployed for the rest of my life in India? My fears were exhausting. Eventually, I did join a private hospital [where I currently practice], but not before working for three years at The National Institute for Mental Health and Neuro Sciences [NIMHANS]. During my tenure there, I learnt fascinating things about the Indian mindset, aspects that were very different from my experience in the US. I went through a whole new learning process.

There I was—a qualified and experienced psychiatrist, in a country with more than a billion people and yet I could not find a job

Indians don’t like seeing a shrink

I learned what it means to have neither the money nor the access to mental healthcare. I learnt that in India, people with psychiatric issues go through immense and prolonged suffering before they seek help. And once they came to you, they want to be fixed quickly [even though their problem might have started a decade ago]. I learned that even though many people are depressed and even more have all kinds of anxiety disorders, most are not aware of their problem. Others don’t know about treatment options. A significant section of the population cannot afford even basic mental healthcare. The most heartbreaking thing I learned was the stigma associated with mental health due to which most prefer to suffer in silence. I found that literacy does not make it any better. Even educated people hesitate to seek out mental healthcare. People would rather see the heart specialist or the neurologist than a shrink!

It isn’t that people in the US always seek help on time. There are issues even in the developed world but they talk about mental illness a lot more than we do and are generally more accepting of it.

On the brighter side, what uplifted my spirits during my camps was that some of the patients [in spite of not being literate and having very little support] would follow the advise of my team and would see a tangible improvement. The gratitude these people expressed on getting better was overwhelming and motivating—I found myself getting back into the groove, thanks to these patients.

What my patients taught me

I know that I have learnt more from my patients than I could ever learn in my residency or in books and I should acknowledge them. We often get cases that are straight out of a textbook, but no matter what kind of a patient, every “case” is a person who has unique problems and is suffering.

In the US, I met patients who saw me every week for therapy. I call it therapy and so would the patients but a part of me wonders if they came so that we could just talk. I loved hearing about the lives they lead, the houses they live in, their relationships and their heartaches. I heard as they spoke about their holidays and the trips they made with their family. For the one hour I spent with each of my patients, I found myself absorbed into a life that was painful even though it was not mine. Many of them suffered from serious mental illnesses and were disabled as a result. Some of them were old, well into their 60s. A few even told me how they missed being manic, energetic and ecstatic.

The most heartbreaking thing I learned was the stigma associated with mental health due to which most prefer to suffer in silence

But when I started working in India, these stories only got more challenging. The women I met in my rural clinic seemed to have a common theme of an alcoholic husband, 2 – 3 kids, no support and domestic violence. Many of these women worked just to put food on the table and did not rest from the moment they woke up to the time they went to bed. Their resilience astonished me.

A case of attempted suicide

I remember how a mother and a father brought their 20-year-old married daughter who had attempted to kill herself the day before. The whole family was in tears and they talked about how unsupportive the girl’s husband was. He was in another relationship and he provided neither financial nor emotional support to his wife and two children. On finding out about the affair, the young woman attempted to hang herself and was stopped just in time by her mother who happened to walk into the room.

I sat in a crowded noisy OPD [300 patients on any camp day] wondering how I could help this family, especially the young woman even as I struggled to keep myself from breaking down. I counselled her and her parents on that hot sweaty afternoon, over the noise, the din and the curious onlookers. I told her things I would tell a friend who came to me for advice. I counselled her about the power of the soul, the self and reminded her of her love for her children. I hope it helped.

Being a psychiatrist in India is not easy. I see people every day that look like me, dress like me and speak my language, in my accent and have problems that are just like everyone I know in my own life. It is really hard not to get angry at the couple that won’t stop fighting and start loving, it’s even harder not to cry when a son comes into my clinic with his mother and says to me that his mother sees no reason to live anymore because her 22-year-old daughter just died in a road accident because a lorry would not slow down while she crossed the road.

Fixing life is difficult

There are illnesses and then there is life. Mostly what I see in my practice is people whose lives are not what they want it to be. Occasionally, I see an illness too. It’s easy to “fix” the illness but fixing lives—that’s a whole different ballgame.

As I conclude, I am reminded of one professor at Duke University who underscored the power of kindness in transforming lives. In my experience I have found that therapy is about working with gratitude, acceptance and kindness and teaching the same to my patients.

The post Confessions of a psychiatrist in India appeared first on Complete Wellbeing.

Sacrificing daughter’s wishes for societal norms

This is just what Prakash and his family were trying to do, at the cost of their daughter’s happiness and their grandson’s future—“to save face”. Prakash’s daughter Jyoti was 19 when she gained admission to a college in the US. Though Jyoti had shown maturity well beyond her age, she was denied permission to go abroad by her family for fear that she was too young to be left alone in a foreign country. Jyoti lost her scholarship and with it, her dream of studying further.

Jyoti’s family, though well-to-do, were bound by tradition. They did what many such families do—made their daughter rush to tie the knot through an arranged marriage. In many arranged marriages, the girl in particular, has no say in the matter. In her case, every decision was taken by the parents. When everything had been finalised, she was asked what she thought of the boy and his family. Jyoti knew it was just a formality to evade any responsibility if things did not work out.

In a world of billions, how many are we going to satisfy?

Discovering that your partner is a schizophrenic

So Jyoti married Suresh, a software engineer. In less than a week, Jyoti found something strange about Suresh’s behaviour. She heard him talking to himself and often saw him standing in front of the mirror, having conversations with his reflection. She found this very odd but kept her counsel. When his behaviour began to disturb her, she spoke to her parents who advised her to check whether Suresh was on any medication. Jyoti discovered that her mother-in-law would add a little medicine into Suresh’s coffee every morning. When Jyoti reported this to her parents, she was asked to note down the name of the medicine Suresh was being given.

Jyoti’s father was told by a psychiatrist that the medicine was usually prescribed to those suffering from mental illness. The doctor said it was difficult to make an assessment without meeting the man, but he suspected Suresh could be suffering from schizophrenia and he explained what the disease was. Jyoti’s father was troubled and asked if she could get the prescription and the name of the doctor who started the medication. Jyoti found out that Suresh had been visiting a well-known psychiatrist in Delhi. Prakash then met the doctor who confirmed that Suresh was schizophrenic; he then said that Suresh would have to be kept on medication for as long as was necessary.

In Suresh’s case, the disease was reflected in the unconventional way he dressed and the grandiose statements he made. Even more noticeable, while most software engineers carry their laptops in a bag, Suresh used a big box. In this, he would carry not just his laptop but CDs with all his software. He also constantly saved all his data, music and spiritual lectures on pen-drives. In fact, he carried his entire office along with him. It was just a matter of time before he was fired.

What will people say?

The family blamed Jyoti for all the ills her husband faced. When Jyoti came to see me, enough of a mess had been created in her life because of the ‘what will people say?’ mindset followed by her parents. “Stay in the marriage, otherwise what will people say?” “Don’t say a word to anyone, including your friends, otherwise what will people say?” “Look after Suresh, he is your husband, otherwise what will people say?” The situation got compounded when she got pregnant. Caught between her parents’ diktats and her in-laws’ accusations, Jyoti felt helpless. Abortion was out of the question because she was too far along. Her parents told her that her life would be lovely once the ‘bundle of joy’ arrived. As a counsellor I knew that the new arrival could also suffer from the disease as it grew up, since schizophrenia could be hereditary.

When I saw Jyoti the first time, she too suffered from the ‘what will people say’ mindset. This attitude was reinforced whenever she would go back to her parents to get away from the stressful environment at home. She would not join her parents when they visited friends or attended events, worried about what people would say when they knew she had been away from her husband for two months.

Terminating my sessions

After two months of weekly visits to me, I asked Jyoti and her father if there was anything they could change in the behaviour of Suresh and his mother. The reply was that they had no control over them—one was mentally sick and the other had an aggressive stance on the subject. I then used an analogy I often apply to bring home the point—if you were to continue to travel on the same track, you would visit the same station you had been visiting in the past.

I suggested they change tracks in order to get to a different destination. They insisted I choose the track for them, but that is not for the counsellor to decide. The most I could do was add to the choices that can be made by the counselee. Both Jyoti and her father fell back into the ‘what will people say’ approach and I had to regretfully terminate counselling.

Counselling is a joint venture between the counsellor and counselees and if any in this joint venture cannot add further value to the process, there is no point labouring over it.

To my surprise, Prakash later set up another appointment. After a couple of sessions with me and other doctors about Suresh’s chances of recovery, he finally concluded his daughter should get a divorce. Jyoti filed the case only to face the wrath of Suresh’s aggressive mother. She believed that the source of all the problems were Jyoti and her parents. In this narrative, you will observe there has been no mention of Suresh’s father. Whenever the subject of Suresh’s condition came up, he would be missing. He would go up to the roof of the house or step out to attend to some urgent work.

Maybe he knew the truth—only he can tell. But the sad part is that while all this was going on, Jyoti and her family continued to harp on the cursed ‘What will people say?’ attitude. Unfortunately, Jyoti’s 12-year-old son got stuck in the mire and became a loner.

History repeats itself

I happened to meet Jyoti a couple of years later and learned that on the advice of her parents and relatives, she had withdrawn her application for divorce. She told me that since her brother was of a marriageable age, everyone felt a court case would be a slur on the family and the chances of his finding the right bride would suffer. She mentioned she had taken over the duty of adding the medicines to Suresh’s coffee—a task previously performed by his mother. She also told me she and her son were both undergoing treatment for depression—a heavy price for keeping others happy.

Let this case be the reminder that running our lives on what people say is a zero sum game. If we spend our time and energies on other people’s reactions we will end up going nowhere.