Bipolar Disorder Assessment and Diagnosis | Living with Bipolar Disorder

Hey there, everybody, and welcome to this presentation on understanding bipolar disorder diagnosis and assessment. I'm your host, Dr. Donnellice Snipes. This is part one of a two part series. Today we're going to be talking about assessment and diagnosis. In the next video, I'm going to be talking about living with bipolar and identifying cognitive behavioral therapy interventions. But in today's video, we're going to explore diagnosis of bipolar disorder and differential diagnosis, which means identifying other disorders which may look like bipolar but are not. So we want to differentially diagnose to make sure we're calling it what it is. There are three different types of bipolar one, bipolar two and cyclothymia. And we're going to talk about each one of those. Well, identify the consequences and comorbidities of bipolar disorder which will need to be addressed. When people have bipolar disorder, yes, they may have the symptoms that are in the DSM for diagnosis, but it impacts their life in many, many different ways. So there are a lot of consequences of their symptoms and there are a lot of other problems or comorbidities that may develop as a result of or in addition to bipolar disorder. And we want to make sure that we're helping people identify what's going on with them and provide effective treatment. So if they've got bipolar and ptsd, then we need to make sure to identify both of those and provide effective treatment for both of them, because just treating the bipolar ain't going to make the PTSD symptoms go away. And finally, I will briefly summarize treatment options. The next video is going to talk a lot more about treatment options and treatment planning and how to live with bipolar. But today what we're really focusing on is making sure that we know what we're dealing with. So bipolar used to be called manic depression, and people with bipolar disorder go through periods where they may experience depression and they may experience mania or hypomania. So being really depressed or being really hyped, and there are periods in between that we call euthymia, which means they're really not super symptomatic of either one. Now, the research has indicated, and clinical practice has indicated that even during those asymptomatic or euthymic periods, a lot of people with bipolar disorder still have a lot of mood lability. And we'll talk about why that is, and I'll give you a hint. It's a lot to do with HPA axis dysregulation, but it's important to recognize that people who, even if they are not symptomatic of major depression or mania. It doesn't mean that they feel good, it doesn't mean that they feel great. And we need to educate the public and other people not to minimize the symptoms that happen in between the major episodes. When somebody experiences depression, they have to have a feeling of depressed mood or a loss of interest in most things most of the day, most days, for a period of at least two weeks. So you can have periods of happiness in there, you can even have an entire day that's happy in there. But most days during a two week period, and most of the time during those days, the person has a depressed mood or just a loss of interest in anything. Low motivation, apathy, whatever you want to call it. Okay? So that has to be there. And then there have to be five other symptoms that can include problems with concentration, guilt and worthlessness, appetite changes, sleep changes, psychomotor retardation, or agitation, which means the person either is kind of operating in slow motion or they're doing things really, really fast. They have persistent thoughts of death or suicide, they have a lack of interest in things and they experience energy loss. Now remember, they only have to have five of these symptoms, so they may not have all of them. And that's okay. Just because they only have five, not all of them, doesn't mean it's any less intense for them. Now the mnemonic that is often used for this is CGASP dye. And it's kind of a morbid mnemonic, but it can help you remember the things that you need to assess for in somebody who is presenting with major depression. Now, differential diagnosis, there are a lot of things that look like major depression and we're going to talk about some, some of them right now. For example, people with PTSD or CPTSD are often going to have difficulty with concentration because they're hypervigilant. And as a result of their trauma, they may experience feelings of guilt and worthlessness as a result of their trauma as well as as a result of their symptoms interfering with their daily life. They can't be the person they want to be. They may have sleep changes because of their agitation. Because of their being hypervigilant, it's hard for them to relax because part and parcel of having PTSD or CPTSD is a sense of a lack of safety and disempowerment. So you can't relax when you don't feel safe in your environment. People with PTSD or CPTSD may think about death or suicide either because that is part of the trauma they experienced, maybe they saw somebody die, or because their symptoms are so intolerable that those thoughts may come to them. A lack of interest in things or apathy is very common in people with PTSD or CPTSD because they are hypervigilant, they're anxious all the time and all their energy is going to fight or flight. It's hard to have interest in other things, which can be exhausting. And that leads to energy loss on top of the fact that they're not sleeping well, which also contributes to energy loss. So you can see that somebody with PTSD or CPTSD may likely also have concurrent major depression. And we don't want to rule it out. We want to make sure that if they've got major depression or bipolar disorder, that and ptsd, that we're treating both of them. People with borderline personality disorder may also have mood lability like we talked about. They may have difficulty feeling happy because they are stressed a lot. They're constantly borderline. They're walking this tightrope, this borderline between feeling safe and feeling like they're in danger. So they are often very anxious they can have which contributes to hypervigilance and difficulty concentrating. They often have feelings of guilt and worthlessness because they don't feel like they're lovable. Sometimes they'll switch back and forth from thinking that feeling like they are all that to feeling completely worthless. One of the characteristics of bipolar, I'm sorry, a borderline is switching back and forth between extremes of idealization, devaluation, so really, really loving something or approving of it and really, really hating something. Sleep changes are not uncommon to see in people with borderline personality because they have a lot of abandonment anxiety. We see a lot of behaviors that are indicative of thoughts of death or suicide in people with borderline personality. Oftentimes as a result of their emotional dysre, they are attempting to cope in the only way they know how through what we have identified as non suicidal self injury. But non suicidal self injury can go too far. So we do want to take that seriously. But we also want to recognize that people with BPD borderline personality can have a lot of symptoms of bipolar disorder. And it is not uncommon to have somebody with both bipolar disorder and borderline personality. People with premenstrual dysphoric disorder or seasonal affective disorder may also have symptoms of depression, hence the reason they're called depressive disorders. However, this is not a major depressive major depression. This is a different type of depression. So we do want to Evaluate what triggers this particular episode. Now, they have found an increased rate of premenstrual dysphoric disorder in people with bipolar. And they have found more rapid cycling in people, in women, people who are biologically female, that they suspect may be a result of hormone fluctuations. We do want to be aware of that. Hormones can trigger bipolar cycles, but we also want to recognize, is it unipolar pmdd? Premenstrual dysphoric disorder is what you would call unipolar depression. If they have mania or hypomania episodes in their history, then we really want to start looking towards bipolar or where the hormone fluctuations may trigger an episode. Seasonal affective disorder can happen anytime, but typically happens when people, when the light starts to go down, like during the winter, when people are getting less vitamin D and their circadian rhythms get kind of wonky because there are so few hours of daylight. And some people go to work when it's dark, they leave work when it's dark, so their brain can't figure out when it's supposed to be awake. And that can actually throw the entire circadian system into an uproar again, that is depression as a result of an identifiable trigger. If they don't have symptoms other than during seasonal affective disorder, then we definitely want to look at that diagnosis. Additionally, just like premenstrual dysphoric disorder, seasonal affective disorder is a unipolar diagnosis. So they will not have a history of hypomania or manic episodes. Bereavement is another condition that has depression as a core feature of it. We need to recognize that people who are grieving may experience all of these symptoms. And you can have a major depression diagnosis and bereavement at the same time. If that major depression existed prior to the grief episode, or if there are prior episodes of major depression that were unrelated to this grief episode, then you may have a concurrent diagnosis. So you want to look at what's causing these symptoms. Is it specifically attributed to a particular loss or is there a history of other depressive episodes? Substances can also cause depressive symptoms. When somebody uses depressants, guess what? They are going to have more difficulty concentrating and may feel more tired, may have sleep changes. There are a lot of symptoms of depression that you see in people who are intoxicated with depressant type substances. Now, on the other hand, people who abuse stimulants when they are crashing off the stimulants, like your cocaine or your amphetamines, they will often experience very intense depressive feelings and depressive Episodes, but that is a direct result of a substance. Again, you have to look, is this person experiencing, experiencing these symptoms only when they are using or coming down off you detoxing, or have they had other episodes that are independent of the substance being in their body? So we cannot make an accurate diagnosis as to whether they are experiencing bipolar disorder or major depressive disorder until the substances are out of their body or by a good clinical history. If we know that there have been substance freak periods where they have had these clinically significant symptoms. And finally, psychotic disorders, your schizophrenia, your schizophreniform disorders, schizoaffective, may need to be addressed because they have depressive characteristics as part of them. People with major depression may have psychotic episodes if they have significant depression. And we need to figure out, is this psychotic episode part of a psychotic disorder like schizophrenia, or is it a symptom of major depressive disorder? It's going to be really important to examine family history as well as what triggers it for the particular individual and when the psychotic episodes happen. You know, we're going to want to, we're going to want to talk about that. The point being here, with, even just with psychiatric diagnoses, there are a lot of things that have depressive symptoms as part of what they are, and there are a lot of things that can be, can co occur with depression. So they may have depression and BPD depression and PTSD depression and substance use disorder or depression and all of the above. Now we're talking just about depression here because depression is half of bipolar. And it is really important to do a thorough assessment of the person to ensure that you are dealing with unipolar depression or bipolar depression because the treatment is different. Now a lot of the treatment differences are between bipolar disorder and unipolar depression. A lot of those differences have to do with the medications, typical antidepressants, your selective serotonin, reuptake inhibitors, etc. Can actually trigger a manic or hypomanic episode in somebody with bipolar disorder. Likewise, a lot of your over the counter antidepressant substances like St. John's wort or Sami can also trigger a manic or hypomanic episode in somebody who has bipolar depression. Bipolar depression is not the same neurochemically as unipolar depression. So what works for unipolar depression psychopharmacologically is not going to be effective for somebody who has bipolar in general. Now remember we said that bipolar has two poles. We just talked about the depressive pole. Let's talk about the manic pole. When we're talking about bipolar disorder. Mania is when a person experiences elevated mood and just enhanced optimism and they're on top of the world for at least seven days or any duration if they have to be hospitalized. So it could be only two days if they are so elevated that for some reason they are hospitalized. Or instead of an elevated mood, they can have an irritable mood. And this can happen when somebody is manic and they don't get what they want, they can become very irritable. And this is what more, more often results in hospitalization because it's almost like a temper tantrum. Somebody who gets blocked from accessing something that they're seeking can become very irritable and even aggressive when they're denied access. The person, as I said, has to have this elevated mood or irritable mood for seven days or hospitalization. Then we want to look at symptoms. Distractibility. Insomnia, which is an insomnia in mania, is not that they can't get to sleep and they're desperately wanting to get to sleep. Insomnia and mania is not needing sleep and the next day having plenty of energy. So somebody who's in a manic or hypomanic episode doesn't have a need for sleep, as opposed to somebody who's depressed, who may really want to sleep, but they just can't seem to get to sleep or stay to sleep. Grandiosity. A person who is in a manic episode may feel like they're 10 foot tall and bulletproof. They may think that they're all that and a bag of chips. It may look a little bit like narcissistic personality disorder because they think they're all that and they aren't shy about telling you there's a flight of ideas or racing thoughts. A lot of people when they're manic will talk really fast and they won't give other people an opportunity to talk. So it can be. They can monopolize conversations. They can engage in goal directed activities, especially goal directed activities with poor judgment. A lot of times when people are in a manic episode, they are going after things that are going to produce pleasure. It's like what looks like it's going to be the most fun right now? What can I do? I'm seeking an adrenaline rush. I'm seeking a dopamine rush. So that goal directed behavior is often towards pleasurable activities. But sometimes they can engage in specific goal directed behavior, something that they wanted to do. Maybe they decide all of a sudden that hey, I'm going to remodel the basement. And that's all they do. They just get immersed in remodeling the basement all hours of the day and night. That's all they will do that you can't get them to switch gears. Their speech may also be pressured. Again, they're speaking fast, their thoughts are all over the place. They're very tangential and they're speaking very fast. And then thoughtlessness. This is an increase in pleasurable activities with the potential for painful consequences. The person in a manic episode, as I said, is really seeking that adrenaline rush, is really seeking that pleasure rush, that dopamine, those endorphins. So they may engage in things like sex, spending, substance use or other adrenaline producing activities like reckless driving or skydiving or even shoplifting and things like that. Anything that's going to provide them a rush is potentially appealing to somebody who is in a manic episode. Now mania can be misdiagnosed for a variety of things. Generalized anxiety disorder has a lot of similar symptoms. When people have generalized anxiety, they tend to be kind of hyped up. Now they're not feeling all that and super good about themself and grandiose and high self esteem. You're not going to see that. But you may see that they're more distractible when we are anxious. When we're hypervigilant, we tend to be more distractible. Think about the squirrel that's in the middle of the road. So there's a high level of anxiety, can have a high level of distractibility. Insomnia in generalized anxiety is more of an inability to sleep because they're so revved up, because they're so stressed, not because they don't need it, but because they just, they can't shut their mind down. They're really, really stressed. The person with generalized anxiety may have a flight of ideas or racing thoughts. Generalized anxiety means they're anxious about a variety of things. It's not one thing in particular. So their thoughts may bounce from this thing they're stressed about to this thing they're stressed about to this thing over here that they're stressed about. That's not uncommon. And when they start thinking about those things, it amps up their anxiety and they often start thinking catastrophically, which can increase their fight or flight reaction. So they may start thinking and talking even faster because they're getting into that catastrophic oh my gosh, the world is going to end place. They may engage in more goal directed activities because they're trying to stop the anxiety so if I do these things, maybe if I focus on all these health behaviors and I become very rigid in what I do, then I will be able to avoid abandonment and avoid getting sick and avoid all these other things. But their goal directed behaviors are specifically oriented to reducing their anxiety. Whatever they're doing is trying to reduce their anxiety. It's not goal directed for pleasure, it's goal directed to make the pain stop. People with PTSD or cptsd, just like you see, they often have some depressive symptoms because of their hyper vigilance. You see, there's a theme here. They may continue to have distractibility, they may continue to have inability to get quality sleep, insomnia. It's not that they don't need it, they just can't get it. They may have that flight of ideas or racing thoughts. Many of the same symptoms that you see with generalized anxiety for the same reasons. The flight of ideas or racing thoughts are all about how can I stay safe in this environment? I don't feel safe anywhere. People with ADHD or other impulse control disorders may also have bipolar or get misdiagnosed with bipolar because adhd, they may have distractibility in opposite oppositional defiant disorder. They're not listening to their caregivers, they're being oppositional. Well, in both cases, if the child is distractible, if they're having a hard time staying focused, they may not be being willfully oppositional, they may just not remember. With people with ADHD and oppositional defiant disorder, we may see some mood lability, we may see some activities that are pleasure focused. And people with adhd, interestingly enough, we tend to think of them as not being able to stay focused. But sometimes if it's something that they're really interested in, they can get hyper focus. So you may see hyper focus in people with adhd, npd, BPD and apd. These are some of your cluster B personality disorders, narcissistic, borderline and antisocial. And what we really want to look at here is what are the symptoms? And impulsivity and mood lability are the main commonalities between personality disorders and bipolar disorder. But we also want to look at what causes, what do we think causes personality disorders in people? Personality disorders represent a long standing way of reacting or responding to the environment, which indicates they developed this behavior or this way of responding as a child. So we want to figure out why that happened and give you a hint. Oftentimes it's trauma. So when we are making those diagnoses, we do want to be sensitive to the fact that this person may have experienced a lot of trauma. And we want to be sensitive to the fact that they may have bipolar disorder and not just say, well, they're being grandiose and they're being oppositional and they are, they talk a lot. They won't give anybody else a turn to talk. And they are thoughtless in their behaviors and they do whatever they want. So they must have a personality disorder. We really want to back up and look at motivations. What is the function of these? Is there a lack of empathy? Is there intentional manipulation of other people? People with bipolar disorder are not intentionally manipulating others most of the time unless they have concurrent diagnoses. People with bipolar disorders in a manic episode are run by a, you know, unrestrained motor, if you want to think of it that way. And they are just, they are seeking energy, they're seeking pleasure, they are just all over it. And that is a very important difference. And people who abuse substances, especially stimulants, will often look like they're in the middle of a manic or hypomanic episode. So we need to make sure that they are free of substances before we start making a diagnosis. Now, the mnemonic for mania is, is dig fast. And again, that stands for distractibility, insomnia. Again, it's a decreased need for sleep, not a lack of ability to get it. So distractibility, insomnia, grandiosity, flight of ideas, activities that are goal directed, speech, that's pressured, and T stands for thoughtlessness. And that is engaging in behaviors using really poor judgment. Because if you thought about it, you'd recognize those behaviors stand a good chance of producing painful consequences. Now, there are some caveats, I guess, in the diagnosis of bipolar. It's not super simple. Hypomania is when somebody has three symptoms of mania for a period of four days. It's not the seven days. And they're not clinically significant. They never result in hospitalization. And the person can function. There's a definite alteration in their presentation, but they are able to function during a hypomanic episode. Rapid cycling is something else we hear about a lot. And when somebody rapid cycles, it doesn't mean like every 30 minutes, which is a misconception that a lot of people have. Rapid cycling means four or more mood episodes within a 12 month period. This can be four depressive episodes, it can be four manic episodes, it can be any combination therein. Another misconception with bipolar is that people alternate. They go, depression mania, depression mania. No, it is very random. Which moods get triggered. And working with somebody with bipolar disorder, many times, you can identify particular triggers for each pull, but it is definitely not an expected depression. Mania alteration. A mixed episode may include elements of the other pole. And mood lability is really common in people with bipolar. Even during a significant episode, they may have symptoms of the other, and that is what people often call rapid cycling incorrectly. People who are having a depressive episode who have a burst of manic energy, if you will, or a burst of mania during that period are still in a major depressive episode. They're in a mixed episode at that point. Generally, one pole, if you will, will predominate, but you may have some breakthrough symptoms. Again, it's important to recognize that during those periods where they're not in the middle of a clinically significant episode, they may still have subclinical symptoms and some mood lability in there, and that needs to be addressed as well. Some people with bipolar disorder may only have an episode once every few years. Now, I know a lot of people that I work with are like, oh, my gosh, wouldn't that be wonderful? Unfortunately, the people who only have an episode once every few years often aren't diagnosed at all. And that's one of the places where we often miss diagnoses because they chalk it up to a one and done or they don't look for. For patterns in what's going on. It is important to ask people about historically, not just in the past year or in the past five years, but over the course of their life, have they had other depressive or manic episodes. Suicide among individuals diagnosed with bipolar disorder is approximately 10 to 30 times higher than that of the general population. That's big. That is really big. Which underscores the fact that it is so important. Even if you think you're diagnosing somebody who's presenting with PTSD or who's presenting with borderline personality disorder or substance use disorder. That's their primary diagnosis. Do not miss a bipolar diagnosis. One of the most dangerous times for somebody with bipolar disorder is actually when they're coming out of a depressive episode and they start getting their energy back. It doesn't mean that they're not in danger the rest of the time, but it is important to recognize that when you are treating somebody, maybe you're treating them for ptsd. You missed their bipolar disorder when they started seeing you for the ptsd. They were really depressed, and now they're starting to come out of it, and you're like, score. We're making progress here. That could actually be one of the most dangerous times for them. I mentioned there are three different types of bipolar disorder. Bipolar one, the person has to have at least one full on manic episode during their lifetime, not during the year during their lifetime. But a depressive episode is not required. So if somebody presents and the only symptom they've had is mania, then they qualify for bipolar 1 disorder. If they present to you and they've had at least one major depressive episode and one hypomanic episode, then they qualify for bipolar two. Now major depressive is pretty clear hypomanic. Remember, it doesn't have to cause significant impairment in functioning. So we do want to screen for hypomanic. So major depressive plus hypomanic is bipolar 2. Remember, euthymia is the first feeling that they get when they are between episodes, if you will. It's. And sometimes euthymia can look a little hypomanic Y because the person is so relieved to finally have their energy back, they're like, oh, I'm back. So we do want to carefully differentially diagnose that and not diagnose somebody with bipolar 2 who actually has unipolar depression and just really good euthymia. Cyclothymic disorder or cyclothymia is when the person has hypomania and we already talked about what that was. A less intense version of mania and persistent depressive disorder that lasts for at least two years. Persistent depressive disorder is what we used to call dysthymia, which is the depression version of hypomania. It's kind of like hypodepression where the person's symptoms are not clinically oppressive, but they are present, the person has difficulty feeling happiness and it goes on. It's a low grade depression, if you will, that lasts for at least two years and they have to have during that two year period at least one episode of hypomania. Physical comorbidities. People with bipolar disorder have a higher than average risk of developing cardiovascular disease. And some articles posited that this could be because they tend to be more. More often they tend to be smokers, they tend to have a poor diet and they tend to be more sedentary. Well, let's see, why might that be? Well, smoking for a lot of people is something that they use to help them cope with distress. And somebody with bipolar, especially with mood lability, even between episodes, maybe struggling to find anything that can help them feel steady. So smoking may be a self medication tool. Diet and generally the diet is poor. And it's high in fats and high in refined sugars. Both of those increase serotonin and increase dopamine. And that could be something that a person does again as self medication to help themselves feel better. When they are feeling unmotivated, when they're feeling exhausted, when they're feeling depressed, they may self medicate with food and sedentariness. Well, if you are having difficulty sleeping, if you are experiencing fatigue, exhaustion, psychomotor slowing, or if you're coming down off of a manic episode, you're probably going to be exhausted. So the person may have different levels of sedentariness depending on where they are in their cycle. If they're in a major depressive episode, they're probably extremely sedentary. If they are in between episodes, they may be exhausted. If they've got mood lability, their mood is, you know, kind of all over the place. That's exhausting. So they may be more sedentary because they're exhausted. And if they are coming down off of a manic episode, then again they may be exhausted and more prone to sedentariness. Type 2 diabetes often co occurs with bipolar and the research suspects that that may be because of lifestyle factors. Addiction also co occurs with bipolar disorder. Many people try to self medicate their undiagnosed bipolar or even their diagnosed bipolar disorder with addictive substances. Some of that can be because they don't want to take the medications that are available because they make them feel too crappy. And some of it may be because they haven't found or they haven't gotten the right prescription. And some of it may be because they're just not diagnosed yet. Addiction is something we definitely need to be concerned about. When people are in a depressive episode, they may lean towards addiction to make the pain stop. When they are in a manic episode, they may be more prone to addiction because it produces a rush of dopamine and feel good chemicals. And when they're in between the if the body has built up a tolerance, they may be maintaining their levels, if you will, their neurotransmitter levels by continuing to use. Interestingly, PCOS or polycystic ovarian syndrome also has a high CO occurrence with bipolar disorder, which lends more support to the notion that in some people who are biologically female, hormone swings may contribute to bipolar disorder. We know that hormones, testosterone, estrogen in particular impact the availability of other neurotransmitters, including norepinephrine and serotonin. So when people's gonadal hormones get out of whack. And with pcos, it's particularly progesterone and estrogen, it can affect the levels of their neurotransmitters. And their brain, the way it's wired, may be more sensitive to that which could trigger an episode. People with bipolar have shown in PET scans that they have altered structural and functional brain connectivity. Their brain actually is wired differently and responds differently to stimuli. They may have increased oxidative stress. Well, oxidative stress happens when the body is under stress because of poor diet, because of that HPA axis, that fight or flight stress response system being higher and turned on more. So people with oxidative stress tend to experience increased inflammation and tend to experience more mood symptoms because inflammation impacts, again, cortisol levels as well as the levels of various neurotransmitters. We know there's a direct connection between inflammation and depression. And there may be some evidence in people with bipolar disorder for a connection between oxidative stress and manic episodes as well. Oxidative stress can be handled to a certain extent through stress management and lifestyle behaviors that remove as much stress from the body as possible and ensure that the body has plenty of antioxidants and all that other stuff to deal with any oxidative issues that occur, any free radicals that do occur. Circadian rhythm dysregulation is also common in bipolar disorder. Well, let's think about it. People with mania don't need sleep. So when they're in a manic episode, they're certainly not going to bed at nine and getting up at five or six, whatever. People with depression have difficulty getting quality sleep and often have difficulty staying asleep, so that messes up their circadian rhythms. And then even in between episodes, people with bipolar disorder often have difficulty getting to sleep and staying asleep because of the stress and the guilt and the other stuff, the emotional turmoil that they often experience. Dopamine alterations are also common in bipolar disorder. And what do we know about addiction? Addiction triggers a rush of dopamine. We also know that as dopamine goes up, serotonin can go up. So alterations in dopamine are going to affect the levels of serotonin, gaba, and norepinephrine in the system, which impact mood, impact depression and mania, HPA axis dysfunction. They've actually found that people with bipolar disorder, and if you've seen my other videos on HPA axes, this won't be a surprise. People with bipolar disorder, when they have hypercortisolism, when their HPA axis is just turned Wide open, and their cortisol levels are just through the roof. They tend to be in a more agitated manic episode or manic place. When they are in a depressive episode, they tend to have too little cortisol. Now, cortisol is our stress hormone, but it's also a motivation hormone. Cortisol, we need it. It peaks in the morning, gets us out of bed, and it declines throughout the day. We need cortisol for motivation and everything else. So when people don't have enough cortisol, it's hard to get out of bed in the morning. It's hard to get moving, to do anything. So we do see this. We know that when the HPA axis is activated for too long, it actually undergoes alterations in order to sort of protect the organism from running too hot for too long, if you will. And what I call this is the Flat and the Furious. When there is no major threat going on, the HPA axis that's been overstimulated will turn down its sensitivity. So not much bothers it. Not much triggers the release of excitatory neurochemicals, which you may think, well, that sounds great, so I'm not going to get freaked out so easy. Well, yeah, but those same neurochemicals are also what are responsible for helping you feel pleasure. So when the sensitivity's turned down, you just don't feel much of anything. You're very anhedonic, to use a clinical term. But when there is a threat that is sufficient enough to actually tip off that HPA axis that's not as sensitive anymore, then there's a flood of cortisol and a flood of adrenaline. So the person goes from being flat and not feeling much to being furious or terrified. There is no in between, There is no moderately peeved. So it is not uncommon to see emotional dysregulation in people with bipolar. And as HPA axis dysfunction can be addressed, I won't say it can be completely fixed, but it can be addressed by helping the person address their triggers and reduce their stress and feel safer and more empowered. That way they're not constantly in fight or flight mode. We want to help them get to a place where their fire alarm, if you will, only goes off at the appropriate times, and it's not constantly going off and bombarding them. And with a lot of people who are diagnosed with bipolar disorder and are on mood stabilizers and there can be medication induced fatigue, and that is important because it can be significant and severe. And we need to help them advocate for themselves with their psychiatrist or Prescribing physician. What can I do to minimize the negative impact of this medication? One of the main reasons for treatment non compliance in people with bipolar disorder is, is the extreme fatigue. And many doctors will have people move their medication to the afternoon, so it's most intense in their system when they're sleeping, and they can wake up a little bit better in the morning. So they have the morning and the early afternoon hours where they're feeling pretty okay. Other doctors may switch medications. There are a variety of things that the doctor can do, but it is important that we encourage people, if their medication is impairing their quality of life, to advocate for themselves with their prescriber affectively and cognitively. People with bipolar disorder often experience, in addition to bipolar disorder, just underlying anxiety and stress in general about life and bills. Because when they're in their episodes, when they're having a major depressive episode or a manic episode, it may impair their ability to work. It may get them fired, it may get them arrested. You know, things happen when they are in clinically significant episodes. So they may constantly worry about, well, how am I going to maintain a roof over my head and food on the table and everything when I don't even know when this next episode is going to hit me and what's going to happen? They may have anxiety about abandonment because people with bipolar disorder, because of the mood swings, even between clinical episodes, because of the mood mobility can be challenging to live with. And it's challenging for them to live in their own skin. And it's even more challenging when they're trying to explain it to somebody who just doesn't get it, who thinks that, okay, between episodes you're supposed to be fine. Well, that's not how it is. So there can be a lot of abandonment issues because partners do not fully understand what's going on. They may also have anxiety about episode onset. They don't know when the next one's going to happen. So they're afraid to make plans, they're afraid to do anything. And they're kind of trapped in this fierce circle because they want to live their life, but they don't know what tomorrow's going to bring. And it's really important for us in treatment to help people start focusing on mindfulness. And if they do make plans, because people want to make plans for vacations or holidays or whatever, making those plans, but also having backup plans in case they are having an episode. And there are a lot of things we'll discuss in the next video. Anger is another Common feeling. It can be at others for preventing them access to something that they want in the middle of a manic episode. And they're kind of a force to be reckoned with. They can have anger at others for not understanding or anger at others for being, quote, normal. You know, you don't understand what it's like to live with this. And, you know, you should have to live with it too. I shouldn't be the only one. So there can be a lot of anger that needs to be processed. And there can be anger at life, which is part of the grieving process when the person recognizes that they have a chronic illness. Bipolar disorder is a chronic illness. And people will often have to grieve the fact that they are not going to have the storybook life that you see on, you know, ABC sitcoms or whatever. They're going to have challenges in life. Now, for some people, it can feel like a relief when they get the diagnosis because they're like, okay, finally things make sense. But then there's also a grief that follows when they're like, okay, now, now that I have this, I don't want it. How do I integrate this? People can develop PTSD as a result of attachment disruption, especially if their bipolar onset was when they were children. But at any age, if they are regularly experiencing abandonment, it can be very traumatic for people. And they can also develop PTSD as a result of traumas that they experience during manic episodes. Maybe they were reckless driving during a manic episode and they got into a car crash and you know, it was a significant one. They also have issues with emotional dysregulation, guilt, hopelessness and helplessness. All of those things need to be attended to environmentally, as I mentioned earlier, they may have difficulty maintaining stable housing. Employment, finances, and just in general, staying safe. Well, not especially during a manic episode, during either end of the clinical episodes. Depression, when they can't don't have the energy to get up and go to work, so they may lose their job. Or mania when they are all about fun and pleasure and they don't bother to show up for work. And then in between, their exhaustion contributes to, as we saw, a host of other issues that can impair their immunity, make them call in sick for work, be less productive, lose their job. So housing is an issue. And we need to help people figure out how to make sure that they've got safe, stable housing, employment, reasonable accommodations. Go to the Job accommodation network. It's askjan.org I believe, but it's Ask Jan for job, job Accommodations, finances. Now, in addition to having difficulty maintaining a job, sometimes, if the symptoms are severe, people who are in a depressive episode may self medicate by unrestricted shopping, shop therapy, whatever you want to call it, and that can be detrimental. People who are in the middle of a manic episode may just start charging things like, crazy, spending money like it's water. There needs to be a plan in place so that the finances are always safe to prevent unrestrained access in the midst of an episode, because people can't always predict it and go, oh, I feel a manic episode coming on here. Here are the credit cards. There needs to be a place, so work with a financial advisor to figure out what, what strategies you can take to protect your finances when you are in an episode. Relationally, people who have bipolar, as I mentioned, often experience abandonment. They may experience abuse or exploitation when they're depressed. Bad actors may tell them that they deserve the abuse that they're getting. They may get a lot of verbal abuse. They may even tolerate physical abuse because somewhere they feel they deserve it. And it's important to address that abuse and help them get safe. They also may be exploited especially well during a depressive episode. A bad actor may say, well, if you want me to stay around, then you've got to do all these things. You've got to buy me all these things, whatever. In a manic episode, the bad actor may see that the person is not using good judgment and use that opportunity to get whatever they want. Alienation and feeling misunderstood is common in people with bipolar disorder. So we want to help them figure out how to communicate to others what their needs are, what their experiences are and what they, what they feel so they can feel more connected. Support groups are great, but also helping them communicate with the people in their life that don't have bipolar to improve those relationships. People with bipolar may just withdraw from relationships, period, because it's just too exhausting and too painful and too disappointing all the time. And people with bipolar who are biologically female are at much higher risk of developing postpartum depression, which will impact the attachment or can impact the attachment with the infant once it is born. So it's important if you're working with somebody who has bipolar disorder who is pregnant, to prepare for that and to mitigate that as much as possible. Assessment areas. When we are doing an assessment on somebody with bipolar disorder, we want to figure out, we want to know about the age that they had their first episode, the conditions of onset, and the type of the first episode. This gives us an Idea about what their first experience was like. Now, if somebody's first episode was depressed versus manic, but they've had both types, you know, it's not going to change what their diagnosis is. If they've had a full manic episode, they get a bipolar I diagnosis. But we do want to explore this may give us an idea about what triggers these episodes and things that we can do to help the person mitigate them. We want to explore the predominant polarity. If they say seven out of every ten episodes are depressive episodes, okay, well, that helps us a little bit in identifying what symptoms we focus on first in counseling duration and severity of the episodes. This can help us identify if treatment is being effective. It's not necessarily going to prevent all episodes or. But our goal is to reduce the duration and severity of episodes that people do have. Ideally, we help them also increase the time between episodes by practicing good lifestyle behaviors and good cognitive behaviors that reduce stress and avoid triggering inflammation and other things that may trigger a bipolar episode. We want to ask them what are their triggers for episodes? Bipolarity, what triggers your depressive episodes? What triggers your manic episodes? What triggers your mood lability when you're between episodes? What triggers you to just, you know, kind of have an extreme response? We want to talk about their treatment history and effective interventions. Again, bipolarity, what works when they're in a depressive episode may not be as effective, especially when we're talking about counseling and cognitive behavioral may not be as effective when they're in a manic episode. We also want to talk with them about the medications they're on. Maybe they're on one particular medication that seems to really help minimize their manic episodes, but it's not doing anything to help with their depressive episodes or vice versa. We're not prescribers, so that's not going to alter our treatment plan that much. But we do want to encourage them to note that and advocate for themselves with their prescriber. We want to ask about a history of suicidal, violent, agitated or aggressive behavior. These are things that we need to create safety plans for and it also helps us in determining the severity as well as impact of the prior symptoms. We want to ask about other diagnoses and trauma history in terms of treatment. As I mentioned, medication is going to be a part of most people's treatment regime because bipolar disorder does have a significant biochemical component to it. Additionally, they have found research based approaches through nutrition and A1C or blood sugar management. Reducing oxidative stress, maintaining blood sugar levels can Reduce the number of episodes circadian rhythm regulation with what they call chronobiological treatments. Some of those are behavioral and some of them are medicinal. Melatonin has been used for some. And other stronger aids to help people get to sleep have been used in certain circumstances in order to help people reset their circadian rhythms after an episode and sometimes even help them maintain their circadian rhythms during as much as possible during an episode. Stress management, mindfulness and vulnerability. Awareness and prevention are also really important because we know that stress increases the likelihood of a clinical syndrome or a clinical symptom. Increased functional self efficacy as people start to feel more in control and they start recognizing, hey, there are things that I can do to help control my moods a little bit more, to help deal with this a little bit more, that can improve my quality of life. A lot of times hope and optimism start to go up. I mean, it just makes sense when you feel more in control of your own body, you feel more optimistic and more empowered and safer. And finally develop plans to address specific symptoms that the person has. Not everybody has all the symptoms. So we want to say which symptoms do you have? Which ones are most problematic for you? And then let's talk about what works and what doesn't work to address those symptoms. Approximately 4% of U.S. adults have bipolar disorder. While the exact causes are unknown, it appears there's a significant contribution of both. Nature in the form of genetics, nurture in the form of stress environments, lifestyle behaviors, etc. People with bipolar disorder are frequently misdiagnosed. They're diagnosed with having something else completely, most often unipolar depression. When they've actually got bipolar depression or what I call under diagnosed, they've got multiple diagnoses and only one, the bipolar is being addressed when they actually have other things, or only the ADHD is being addressed when they actually also have bipolar disorder. We need to make sure that we really survey all the symptoms and make sure we account for everything that the person's experiencing. Additionally, misdiagnosis or missed diagnoses can contribute to an increased impairment as a result of inappropriate treatment. Like a person with bipolar disorder being prescribed antidepressants or lack of treatment. If we miss the diagnosis completely, then they may not be getting treatment for it, which can cause them to feel like treatment doesn't work and helpless and hopeless. Once diagnosed, a treatment must focus on addressing the individual symptoms and helping them develop a rich and meaningful life. That includes a diagnosis of bipolar disorder. It's something that's a chronic illness, so how can they have a rich and meaningful life and also have bipolar disorder.