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?
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
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
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.
Published November, 2007