Q:  1) Viewing BP as the Hibernation Cycle Gone Awry? 2) Mood Charting with "MAPS"  3) Thoughts about Suicide in Bipolar Disorder?

Dear Doctor Phelps,
I have three questions, but first, thank you.  After years of being told I was bipolar, I accept the diagnosis at the tender age of 51, thanks to your book.  Because my first hypomanic episode was prednisone induced and because I have remained functional, I had my doubts.  Because I did not present with the typical highs and lows as described in textbooks and the DSM, I just couldn't see it.  Because I've been a behavioral health  and forensics nurse for 23 years, I dug my heels in deeper.  Now I realize that it's no different from a cardiologist developing heart disease.  Now I accept this challenge in life.  And mostly I like the way my brain works.  There are some gifts hidden in this "disorder".  Incidentally, I view bipolar as the hibernation cycle gone awry.  What's your take on that?  

The Mood Chart is fantastic.  At the hospital where I work, we use a system called MAPS to chart consumers' progress.  This was developed by our staff and is an anacronym is for Mood, Anxiety/Agitation, Pain (physical and psychic), and Safety.  I just wanted to share with you this system because the self-harm/suicide factor was included.  I've noticed that a number of people in a mixed state get intrusive thoughts or images of self-harm or death.  Or there is that chronic suicidality that waxes and wanes.  The brain gets hijacked, sometimes at a very early age, causing it  to "default" to suicidal thinking.  It becomes a way of life, and sufferers don't realize that the hijacking has taken place until years later. It seems to allow for compartmentalization and the ability to continue to function that appears in mixed bipolar, like, "Should I go to work today or commit suicide?"  When paired with agitation-fueled impulsivity, this can have disasterous results, as we all know too well.  These have been my observations.  Am I on target? 

I know that this assessment tool was designed for an inpatient acute care setting, but it seems applicable in an outpatient setting as well because of the very nature of the bipolar spectrum.  What I have come to do and to also teach consumers is that these thoughts may come up, but just let them roll off onto the side of the oad--like, "Oh, that's a symptom of the bipolar.  I don't need to act on these feelings, these pictures.  They will pass.  I'll call my doctor for a possible med adjustment.  I'll use diversion.  I'll do relaxation exercises," etc.  It's not intended to constantly bring up suicide, but rather to acknowledge it and put it in its place.  What do you think about tracking this particular symptom?

Thanks,


Dear J. --

Taking your points in turn:

1. Bipolar disorder as a hibernation cycle gone awry -- you are quite right there. Much of the recent research on the nature of bipolar disorder has focused on the biological clock. Lithium, for example, has been shown to act directly on the biological clock (amongst its several actions; here is a little essay about that clock on my website). Seasonal affective disorder, which is much more common in people with bipolar II, and is almost a version of bipolar disorder at itself in some ways, is very clearly similar to a hibernation mechanism (e.g. a preference for high carbohydrate meals that can raise blood glucose when little has been eaten for a long time (in a cruel twist of fate, something about mood disorders seems to send a signal akin to starvation, in terms of how the body's metabolism is changed)).

2. Mood charting can be very useful for people who are trying to establish a pattern of changes in their mood and energy over time. As you know, there are several different versions of "mood charts" out there. Your hospital is using one, as you describe. He might have been referring to the electronic one on my website, or the paper version. I have met several doctors who are really quite religious about requiring patients to keep these records. Because I have the luxury of spending quite a bit of time talking with my patients, compared to many doctors, I have tended not to use these on a regular basis, but instead when we are watching for some pattern of change, or the absence thereof.

3.As for thoughts about suicide in bipolar disorder: you are correct again that mixed states have a higher likelihood of producing suicidal thinking. In some respects, this is just intuitively obvious: depression itself is bad enough, but depression combined with a very agitated state of mind, with intense, incessant and unavoidable thoughts about how bad things are -- indeed about how bad the person him or herself is, often -- can lead to a very high risk of suicidal thinking.

And you are right also in describing one of the ways that people can cope with these thoughts, namely by recognizing them as a symptom, not a reality such as they present themselves to be. For example, "my life is a disaster, it will never get better" is very likely to be a moot-dependent thought that shows up during phases of depression. If people can recognize it as such, and handle it just as you describe, the thought loses a lot of its power. Nevertheless, I try to remember what it might be like to be living with those kinds of thoughts on one's head, especially when they are incessant, and rapid, and seemingly inescapable. Under those circumstances, the "sidestep" maneuver you describe can be very difficult, and very frustrating, to have to employ it over and over again.

At that point, we are fortunate to have medications that can very quickly attenuate that kind of thinking (though not without some significant side effects and risks in many cases, unfortunately). I think mood experts are recognizing more and more than antidepressants can actually induce this kind of agitated depressive thinking, which opens another potential strategy if an antidepressant is in place when this kind of thing is happening, namely tapering the antidepressant (I think we are learning slowly that "paper" is the key word here: yanking the antidepressant out under these circumstances can keep things from settling down, or make them worse sometimes, ironically.

As for tracking suicidal thinking in particular, it is certainly highly appropriate in your hospital setting, as that is often one of the markers for improvements sufficient to allow a patient to get back into his or her outside life. For our patients, there is actually sort of a trade-off in monitoring for suicidal thinking: when it is not a safety issue, I think some patients find it tiresome to be asked about it. This is particularly so in people who have thoughts about suicide in the background much of the time: in some such patients, I have found it useful to focus on working toward the future, and on progress in changes that make such thinking less likely. So, to answer your question, this too needs to be individualized, at least for people who are not in the hospital.

Thank you for your questions and your comments.

Dr. Phelps