February Membership Meeting Write-Up by Raceal McWhorter, MA, MFTI, Art Therapist

Bipolar Disorders: Diagnostic and Clinical Considerations
presented by Sara Vicendese, LMFT
Sponsored by Steve Unruh, LMFT Unruh Mediation

Therapist around the room looked up with expressions of dismay when bipolar disorder was mentioned. Sara Vicendese' presentation helped to remove that sense of dread and gave me a sense of hope and confidence to treat clients with bipolar disorder. Her goal to help us gain confidence in our ability to work with individuals with a bipolar diagnosis and familiarize us with available quality support and consultation services, was achieved.

Sara provided an overview of what bipolar disorder looks like in the room. bipolar disorder is characterized by extreme mood swings severe enough to disrupt a person's life. The highs can be extremely high and the lows extremely low. An individual who exhibits symptoms of bipolar I, can present with clinically significant manic episodes; and equally significant major depressive episodes. A patient with bipolar II disorder experiences major depressive episodes as well and during the manic phase of the disorder his or her mood is not as elevated. She also described Dysthymic Disorder characterized by at least two years of a depressed mood, which does not meet the criteria for major depressive disorder; and cyclothymic disorder is characterized by at least two years of manic and depressive episodes that do not meet the diagnostic criteria for a hypomanic, manic, or a major depressive episode.

How bipolar looks in the room may include features such as -- 1) rapid speech patterns, flight of ideas, and racing thoughts, difficult to follow; 2) grandiosity, extreme self-confidence making statements such as, "I am the prettiest girl in the room, everybody wants me, I'm going to be so successful" – or, at the very extreme end of the spectrum, "I can move the clouds outside because I am God-like;" 3) decreased need for sleep, "I normally sleep eight hours but now I only sleep for two and I feel great;" 4) psychomotor agitation; 5) increased goal-directed activity with grand self-expectation, "I'm going to write a book this week and it's going to be a best seller;" 6) risk taking, driving fast, spending money recklessly;" 7) disruptions his or her life, "I lost my job (because of my mood), or "I'm getting a divorce," (because of my mood).

Before diagnosing bipolar disorder, it is important to assess for and rule out substance abuse, medication, or medical conditions that can mimic bipolar symptoms. An overactive thyroid can look like mania and an underactive thyroid can cause symptoms of depression. People experiencing mania or depression may experience psychotic symptoms. However this not necessarily an indication he or she has schizoaffective disorder. In order to determine if an individual's symptoms are related to schizoaffective, he or she must have come down from an episode and had two weeks without mood symptoms with persisting psychotic features during the buffer period, the delusions must have persisted at least one year, and the symptoms are not caused by the afore mentioned rule outs; substance abuse, medication, or medical condition.

Sara mentioned, ADHD is commonly misdiagnosed as bipolar disorder in children. The ADHD patient is distracted; bouncing around with a million ideas, however there is no cyclical change in mood. She stated, one must assess for elevated mood. Vicendese recommended UCLA Child & Adolescent Mood Disorder Program (CHAMP) to help with diagnostic evaluations; and she pointed out insurance is accepted there, as well as services may be without a fee through the research program.

Sara indicated the Diagnostic Interview for Genetic Studies (DIGS) or The Mini International Neuropsychiatric Interview (MINI), found online are helpful tools to help learn the clinical language for assessing mood disorders. I volunteered to assist Sara in performing a role play to illustrate appropriate and effective assessment questions. Her scripted questions and answers clearly demonstrated the different levels of elevation of moods present in patients with bipolar disorders. The person with bipolar will often exhibit a look of recognition relative to the familiarity of the symptoms referred to in the clinician's line of questioning.

Sara informed the group she is passionate about helping clinicians identify and diagnose bipolar II disorder, explaining it is often overlooked because the manic episodes may not be perceived as dangerous and the depressive symptoms may not be intense and may appear unnoticeable. She cautioned, we do not want to over diagnose or medicate, but warned we must be careful not to under diagnose or under medicate because the pain is real for the client. It is important not to misdiagnose because the symptoms do not appear extreme.

Bipolar disorder can, in some cases have a genetic link in families. However, this does not mean one or all members of a family will have it. If a parent has bipolar disorder, children may have a higher risk which could be early onset, however, there is no guarantee one or all of the children with have the disorder. Sara indicated there may be a psychosocial element related, in which stressful events, particularly trauma has been linked a diagnosis of bipolar disorder. Substance use and alcohol may worsen symptoms and interfere with prescribed medications.

Sara encouraged members not to "tip toe" around diagnosing bipolar disorder because we don't want to label the patient. She pointed out it has been her experience that many clients are relieved when they are finally diagnosed with bipolar disorder; because it allows them to identify what has been bothering him or her for years. Once a diagnosis is clear a patient understands he or she has a medical disease and medication can help manage that disease. On the other hand, Sara reported the knowledge of the disorder can be overwhelming or may trigger apathy and the client may not work to manage his or her symptoms or seek healing. Sara stressed it is important also to follow the patient's lead and assist him or her with grieving the diagnosis. If the patient is able to internalize that he or she was sick when thinking about activities in which he or she engaged during manic episodes; he or she may find relief from some the shame that emerges from that guilt and the pain of not knowing.

Sara provided us with data including; NAMI statistics from 2008, which show 80% of bipolar patients have contemplated suicide, 15% complete and 50% attempt. If a person is in a full blown manic episode, it is unethical not to try to stabilize them. One must consider that unstabilized, he or she may carry out plans for suicide or harm themselves or others.

To treat Bipolar Disorder, Sara suggests we lend our minds to a patient who is in a manic episode while honoring their experience. When a client exhibits signs of a skewed reality, it is important to acknowledge his or her reality but it is equally helpful to tell him or her of the reality we are experiencing. She demonstrated, stating, "I care about you, but are you willing to go with my reality although it not your truth right now?" She suggested we speak to the patient as if we are another part of them; as though he or she is talking to him or herself. Sara further suggested an exercise of asking the client to write empathetic letters to the manic or depressive part of him or herself. Other tools she offered were, teaching patient to create and use a mood chart labeled with his or her own words to assist with recognizing an episode before it emerges and prepare to do what they can do to prevent it from manifesting, She gave an example; creating a number scale where level one or two indicates I am feeling down or very down; a level five may mean, "I'm okay; level eight is "I cannot keep up with things, and level nine means, "I need to be hospitalized.

Vicendese explained support systems are important and clinicians can help by providing psychoeducation related to how to support a loved one with his or her illness. Sara shared, it is important for therapists not to think it is their job to prevent the client from having another episode and understand, instead, relapse is part of recovery. She discussed the importance of medication compliance is to stabilize moods and understanding why a patient may not want to take his or her medication. Some patients want to experience the mania to numbed out or gain weight.

Sara concluded the presentation with a lively Q & A and provided a valuable list of available resources for assistance with diagnosing and treating persons with bipolar disorder.

Raceal McWhorter, MA, MFTI, Art Therapist, currently works at Tarzana Treatment Center's Youth Residential Facility with Probation Youth who have history of severe substance abuse and trauma ranging from child abuse; physical/sexual to CSEC (Commercial Sexual Exploitation of Children). Raceal can be reached at 714.679.0759 or via email, or website; racealmc@gmail.com; www.raceal.com.