 This episode was prerecorded as part of a live continuing education webinar. On-demand CEUs are still available for this presentation through all CEUs. Register at allceus.com slash counselor toolbox. I'd like to welcome everybody to today's presentation on a strengths-based biopsychosocial approach to recovery from bipolar disorder. So we're going to talk a little bit about what bipolar is, what causes it, and how to mitigate it. Helping people understand their own bipolar, because what triggers it for John may not trigger it for James. Help them identify their own warning signs, because bipolar episodes just like depressive episodes and manic episodes often don't come from completely out of the blue. If we look backwards, we can see where the person was beginning to resume some unhealthy lifestyle habits that were making them more vulnerable. We'll look at the symptoms of depression and mania and real quickly review bipolar one versus two and look at some co-occurring disorders and interventions. Another thing I added to this presentation was a little short piece on differential diagnosis, because I often see people who are diagnosed either only with bipolar when there's also attention deficit disorder present or they're diagnosed with anxiety when it's really bipolar disorder. So we're going to talk about how people might mistakenly diagnose one for the other and how to kind of try to ferret that out a little bit. One way is using the online assessment measures. There's another measure we're going to talk about in here too. So we care, because uncontrolled bipolar puts people at risk for suicide, addictions and addiction relapse, even if somebody doesn't have an addiction when they are in a manic episode, they can be more likely to engage in potentially self-injurious behaviors, not for the purpose of self-injury, but just because they're looking for even more of a rush. And when they're in a depressive episode, they can also be at risk for addictions because they're looking to feel better in some sort of way. So a lot of it we're talking about, well, with depression, we're talking about self-medication with mania, we're just talking about what they perceive as something exciting. And people often in manic episodes engage in extreme risk-taking behavior. We don't want our clients to go down any of these paths, so we want to be aware of what might trigger it. And I don't think I talk about it anywhere else in the presentation. It's important to be aware that for suicide, when somebody is coming out of a depressive episode, somebody who's bipolar, well, or unipolar depression, but when they're coming out of the depressive episode and they start having more energy, is actually when they're at greater risk of suicide than when they're at their absolute bottom. Not saying they're safe at their absolute bottom, but we don't want to get complacent when somebody starts feeling better and assume that they're out of the woods. Poorly controlled bipolar disorder can leave people feeling hopeless and helpless. If they have bipolar one and they have at least a full-blown manic episode, but maybe more, they may not mind that. They may because it disrupts their life. The depressive episodes tend to be when patients usually present when they've got bipolar disorder. So we want to look at what's going on with them and help them see how the bipolar disorder disrupts their life because that can go a fair way to encouraging medication and treatment compliance. Well-controlled bipolar, like well-controlled addiction, help a person feel happy, optimistic, motivated, and energized. The key is helping them manage their vulnerabilities, take care of their body so they have enough energy to do things, but also making sure that they get their medications right. Some of the mood stabilizers can be flattening and make people feel more exhausted. And it's important, it's vital that they openly communicate with their psychiatrist or physician about the medications if they are, if the side effects are so significant that it's impairing their quality of life, which means they're likely to be medication non-compliant. So we want to make sure that if they're feeling too flat that they talk it over with their medication provider. Bipolar disorder is a brain disorder. You know, sometimes with like depression, we can look for situational causes. For anxiety, we can look for some situational causes. We can look for some cognitive stuff. We know in bipolar disorder there is something going on in the brain that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks. Many very successful, well, let me go back to that. So just to be clear, generalized anxiety, panic disorder, depression, they also can have a brain organic component to them, but not always. Sometimes you can have those from a situational cause. Whereas bipolar disorder, we know that there's something that's not quite right with the balance of the neurotransmitters for most people with bipolar. Okay, so who has bipolar? Lots of people. You'd be surprised. Mel Gibson, Demi Lovato, Axl Rose, Brittany Spears, John Claude Van Damme, Mark Vonnegut, and Amy Wanhaus to name just a few that I came across, you know, doing some internet research. Lee Thompson Young and Robin Williams were also both quite successful and revered in their fields, despite if you want to call it losing their battle with bipolar. So why do I bring that up? Because a lot of times people, when they are given a diagnosis of bipolar disorder, feel very isolated, feel very unique. And I want them to realize that there are a lot of really successful, awesome people who have bipolar disorder. You know, once it's managed, then people can live a stereotypical life. I work really hard to avoid the word normal, because what's normal for one person may not be for another. But we want to look at, they can live a very high quality, active life. Bipolar disorders caused by imbalances in neurochemicals, especially dopamine, serotonin, and norepinephrine. The imbalances could be genetic or triggered by sex hormone changes or stress hormone changes. So they may be at a steady state, but when there's a particular stressor, some sort of change or other thing, and it depends on the person, it can throw those neurotransmitters out of balance enough that it causes either a manic episode, a hypomanic episode, or a depressive episode. More than one in 50 adults are classified as having bipolar disorder in any 12 month period. They encourage people when they're walking around the store, when they're walking around the grocery store, when they're at church, when they are sitting in a meeting at work with, you know, 50 other people. At least one person in that group has bipolar disorder and or will be diagnosed with it in a year. I want them to recognize how common it is. I want them to start looking around and thinking when they're driving on the road in rush hour traffic, you know, every 50th car they pass, somebody in those 50 cars probably had bipolar disorder. To help them realize, again, it's not a weird diagnosis. It's actually pretty daggom common. Among patients seen in primary care settings for depressive and or anxiety symptoms, 20 to 30% are estimated to have bipolar disorder. A lot of times primary care physicians misdiagnose bipolar disorder as either generalized anxiety or unipolar depression. So it's, you know, 80% of the time, 70, 80% of the time they're right, but the other 20 to 30% you've got this person who is going to continue to struggle and get really frustrated because the treatments for generalized anxiety and depression are generally SSRIs and SSRIs can trigger manic episodes, can make the mood mobility worse. Bipolar disorder is still under recognized primarily due to misdiagnosis as unipolar depression and that's not just in primary care. That's also in, you know, our field because if we see somebody who has unipolar depression, you know, they may not have had a manic episode yet. Likely they have, but they may not have had a manic episode yet or they may not report it or if it's a hypomanic episode, they may not really note that as something problematic. And yes, diagnosis of mental health conditions is out of the scope for a lot of GPs and a lot of them will tell you that. A lot of them will say, I, if you've been diagnosed before, I can help you continue your medication. But there are so many nuances to psychological diagnosis. I really want you to get an evaluation from a psychiatrist in order to better make sure that we're getting you started on the right path because nothing is more frustrating to somebody who is struggling. And again, generally they present in a depressive episode. Nobody is, nothing is more troubling for somebody who's presenting and struggling than getting on medication and not feeling like it's working. One of the things they see, and I'm jumping ahead of myself, is when somebody who has bipolar disorder is started on an SSRI, one effect could be to set off a manic episode. Another effect could be to have really rapid improvement. And you know it takes four to six weeks for the SSRIs to really get in there. But they tend to have really rapid improvement in days unfortunately that improvement doesn't last. And then they tend to go back into a depressive episode and they start to feel even more defeated. I want clients to understand this. If they start talking about that pattern where they've been on antidepressants and it works for a little while but then it doesn't anymore. You know, that may just be the wrong medication for them. Their case is not hopeless. So we know the symptoms of depression, apathy, feeling down, empty, hopeless, low energy, decreased activity, sleep changes, worrying, difficulty concentrating, forgetting things a lot, changes in eating habits, and feeling tired or slowed down. And how is this different than low energy? I've had clients ask me this before. And what I try to, the way I try to differentiate is energy is your desire to get up and do things and feeling like you can. When people are feeling tired or slowed down, it almost feels like they've got a 50 pound rucksack on their back or their arms and legs feel like they're just lead and it is exhausting to even get up and walk across the room, go to the kitchen, go outside. So there's a difference. There's energy to do things and then there's just feeling like you're filled with cement. Mania, people feel very up high or related. Now, after people come out of a depressive episode, even unipolar depression, there's a period of mild, very, very mild euphoria and we don't want to mistake that for hypomania or mania. They're just feeling good. They're like, oh my gosh, I see the sun again. I see colors. How awesome is this? And then, you know, it kind of levels out but you don't have a crash. It's kind of a really good and then a, okay, contentment. People in a manic episode have a lot of energy and increased activity levels. They often feel jumpy or wired, you know, like they can't settle down. They want to sometimes but they can't. They're wide awake and they're just looking for something to do. They have trouble sleeping. They talk really fast about a lot of different things. So they're jumping around and when we talk about ADHD in a minute, we're going to talk more about these symptoms. They may be agitated, irritable or touchy. Not everybody who's manic is in a good mood. So they can be manic but really agitated. They feel like their thoughts are going really fast and think they can do a lot of things at once. People, especially in a hypomanic episode, often find themselves taking on three, four, five, six projects and not being able to complete them, you know, when they come out of their hypomanic episode, they're like, oh my gosh, what did I get myself into? But there's no sense of time in a manic or hypomanic episode. And they can, especially in a manic episode, engage in risky and reckless behavior. So mixed bipolar includes symptoms of both manic and depressive symptoms at the same time, which can be really confusing to clients. They're up, they feel like they're wired, but they have no, they're flat. They have apathy and just that lack of pleasure and anything. They may feel very sad, empty and hopeless and energized. Bipolar one, now the big difference is bipolar one has at least one full blown manic episode. If there hasn't been one full blown manic episode, then we're going to look for bipolar two, where you have hypomania and major depressive disorder. Bipolar one can have either major depressive disorder or persistent depressive disorder. So the big difference is if there's a manic episode, they're number one. Bipolar one patients experience depressive symptoms more than three times as frequently as manic or hypomanic symptoms. So yeah, when they hit a manic or hypomanic period, it's not a wonder they feel pretty good and they don't want it to go away if they experience it three times more often. Bipolar two patients experience depressive symptoms approximately, hold your horses, 39, that's not a mistake, 39 times more often than hypomanic symptoms. So people with bipolar two can have 39 depressive episodes before a manic episode. Now, unfortunately, the body is not that consistent where we can go, okay, 38, 39, you're due for a manic episode. But we do know that both types of bipolar depression is experienced a lot more frequently than mania or hypomania. So common misdiagnoses, generalized anxiety disorder, how do you differentiate? Because some people when they get anxious, they get really revved up and they feel like they're wired and they can't sleep. The goal directed activity in generalized anxiety disorder is often related to an anxiety theme, like if they think that there's a problem with their finances or if they're, you know, whatever they're worried about. Their activities and their thoughts generally race in that direction, they're not all over the place. They're pretty directed in more or less. And their mood is often irritable and energetic versus elated. Now, again, just because somebody is irritable doesn't mean it's anxiety. We want to look specifically at what is causing the sleep disruption and what are the themes of the thoughts that the person is having, the racing thoughts. Because if, you know, something's going bad at work, you hear there's going to be layoffs. Somebody can get really anxious and go, well, if I get laid off, then I'm going to lose my job. Then I'm not going to be able to pay the house payment and I'm da-da-da-da-da-da-da and go in this rapid cycle of catastrophe and get themselves all worked up and then not sleep. Then they start trying to figure out, okay, what do I need to do in order to make sure I can pay the house payment? What do I need to do to make sure I can do this? So anxiety disorder, pretty focused. ADHD, approximately 60 to 70% of people with bipolar disorder also have ADHD. And 20% of people with ADHD have bipolar disorder. So you can draw your own Venn diagram if you want. The take home message is we don't want to assume that they're mutually exclusive because if you've got somebody with bipolar disorder, you can get that controlled. But then if they've still got the ADHD symptoms going on over here, they're going to often feel frustrated. Now, what's the difference? People with ADHD often have hyper-focus. That's one of the hallmarks. This may happen on deadline pressure or when wrapped up in a compelling book, project, or video game. And so you can see where there's a trigger for it. Hyper-focus may cause a decreased need for sleep and look like increased goal-directed activity, but is often short-lived in people with ADHD who feel exhausted when the hyper-focus fades. So we want to look for number one, was there something that triggered this hyper-focus? Could be a video game, could be a really awesome book, or even a Netflix marathon, whatever it is. And once that hyper-focus faded, did they feel exhausted? If so, we're probably looking more towards ADHD than bipolar. A manic episode is independent of external circumstances. You know, it's not where somebody gets a project and it sends them into a manic episode. There's a lot less control and predictability in people with bipolar disorder. And people with bipolar often want to go to sleep or relax, but describe feeling as if they can't wind down, which can go on for a week or more. So we're looking at duration, we're looking at what triggers it. If they report, let's go back to here, sometimes having manic episodes that there was no trigger and they lasted a long time, but they also report manic, goal-directed activity under deadline pressure or, you know, they can have all these symptoms, which means you're looking at ADHD and bipolar disorder together potentially. In ADHD, people often interrupt or talk too much without noticing because they miss social cues or because they lose focus on the threads of a conversation or the lines going six ways till Sunday. I had a friend of mine one time who had ADHD. She was in graduate school with me and she gave a presentation on it one time and we were talking and she was presenting. And as she was presenting, somebody started flicking the lights on and off. And all of us were looking around at each other going, this is annoying. So a while later, you know, 30 seconds or a minute later, somebody turned on a radio, not really loud but low in the background. We're all looking at each other. And then she started doing something else after that. Oh, she turned on a fan. So the fan was oscillating and blowing in our faces. And finally she's like, is this annoying? And we were like, yeah, that's annoying. It's hard to concentrate. And she said, this is what life is like for somebody with ADHD many times because we have difficulty filtering out what's important to pay attention to and what's not. So we're paying attention to everything. So that made it a lot more understandable to me, which was helpful later when my son was diagnosed with ADHD because, you know, it helped me tailor his learning environment. So people with ADHD kind of get lost and they're paying attention to so much they can miss the social cues. People experiencing manic bipolar episodes are often very aware that they're changing topics quickly and sometimes randomly, but they feel powerless to stop or understand their quickly moving thoughts. So they're just trying to keep you in the loop in everything. And they may notice that you're getting uncomfortable or irritated or impatient, but they don't feel like they can stop. Racing thoughts, you know, all these kind of go together, but kind of not. People with ADHD report racing thoughts, which they can grasp and appreciate but can't necessarily express or record quickly enough. Think about a time you got really excited about something. And you just had all these ideas whenever we get a new grant that comes in. I'm in charge of or I used to be in charge of writing the grant. So I get the grant and I read through it and I'd start identifying all the different things that we could do in order to, you know, get this grant. And it would be hard for me to keep my pencil going fast enough to keep up with my ideas. And, you know, I don't have ADHD and, you know, that was perfectly normal, but I was excited. And so my mind was racing. People with ADHD can do this a lot, you know, not just because of a grant coming in. People with mania, the racing thoughts flash by like a flock of birds overtaking them so fast that their color and type is impossible to discern. I loved this explanation because it's just like you have this whole massive birds coming in and then going out and you didn't have a chance to even notice what they were. People with mania often feel that way. They don't can't grab any of those thoughts and hook on to them. They're just in and out. So helping people differentiate, make sure that if they've got anxiety and bipolar, if they've got anxiety and ADHD and bipolar, bless their hearts, that we're attending to all of their presenting symptoms and issues. So what do they do to treat bipolar? Um, well, we're going to get down into that in a minute. Sorry, got ahead of myself. Things that can trigger a bipolar episode. Medications. Antidepressants, as I said, can propel a patient into mania. Captopril, which is an ACE inhibitor, something that's used for high blood pressure, can also trigger a bipolar episode. Corticosteroids. Certain immunosuppressant medications. Levodopa, which increases dopamine, you may see patients with schizophrenia or Parkinson's taking levodopa. And methylphenidate or dex-methylphenidate, which are ADHD medications. All of these different categories of medications can potentially trigger a bipolar episode. Do they trigger it in every single person? No. So that makes it even more difficult, but it is important to be aware. If somebody has bipolar, when they start taking medications that they need to be conscious, cognizant of their symptoms so they can, you know, identify early onset of a depressive or a manic episode. Circadian rhythm desynchronization can trigger or look like bipolar disorder. Hyperthyroidism can look like a manic episode. That means too much thyroid. You know, a lot of times we talk about hypothyroidism and depression. Hyperthyroidism gets people too revved. In children, mania can be misdiagnosed or look like oppositional defiant disorder. And substance use, both intoxication and withdrawal, but more specifically intoxication, can also look like mania or depression depending on whether they're taking stimulants or depressants. So it's important to make sure that the person when they're being assessed is substance free. You know what medications they're on. They've had a physical to rule out any hormone causes. Thyroid is a hormone. And look at their circadian rhythms. If they happen to be visually impaired, that can cause problems in circadian rhythm. If they are shift workers, that can cause problems with circadian rhythm. So let's make sure we don't label something as bipolar and start treating as such before we've ruled out everything else. Bipolar distinguishing factors and let's see, let me see if I can get that to open for me right now. Well, anyway, spontaneous hypomania, premorbid, effective temperament, particularly hyperthymic or cyclothymic. So before somebody had an episode that they presented with, do they have a history of being, remember dysthymic is feeling blue, low, unhappy. Hyperthymic is more elated and cyclothymic is rapidly switching. Moodlability, increased mental or physical energy even during depressions. You know, obviously, you know, we talked about the mixed episode. If there's a family history of bipolar disorder or a good response to lithium for unipolar depression or bipolar, that's a risk factor or a hallmark that you might be dealing with bipolar in this client. If they have treatment emergent hypomania, mania or mixed states. So as soon as they start medication treatment, generally SSRIs, they have an uncharacteristically rapid response followed by a crash again. And or they have more than two failures on antidepressants. Now we want to look at what that means because antidepressants work differently for different people. Somebody can be on and I'm going to use the trade names here just because I don't have all of the generics memorized. I'm not promoting any particular trade name, but people could be on Lexapro or Paxil and feel like they can't wake up. People can be on Prozac and feel like they've got more energy. Some people are on Zoloft and don't feel any energy change. Some people feel lousy. But antidepressants, we want to look at what the failure means. Did it fail to improve the mood or were the side effects so bad that the person had to switch? If it was the side effects, that's not really classified as a failure because the person wasn't able to stay on it long enough for that antidepressant to really get in their system. Now I do want you to see the mood disorders questionnaire. And that's in this article here, but there are all of these questions that you can have people just complete at assessment and it helps you identify if they've had a manic or hypomanic episode. So have there ever been a period of time when you were not your usual self and you felt so good or hyper that people thought you were not your normal self. You were so irritable that you shouted at people or started fights. You felt much more self-confident than usual. You got less sleep than usual and found you didn't really miss it. You were much more interested in sex than usual, spending money, got you or your family in trouble. You can go through all the rest of the questions and they identify yes or no to each of these. Once they do that, if they did check yes to more than one of the above, have they ever happened during the same time period? If yes, then again, we're probably looking at one of the bipolar's. And finally, how much of a problem did any of these cause for you? And if it's a minor problem, then we may want to look for other things. This does not diagnose bipolar, but it is an excellent screening instrument to give you an idea about whether you need to look in that direction. Have clients keep a life chart ideally for three to six months where they chart their sleep, their dietary habits, their exercise, their life stressors, hormones for women, and any bipolar symptoms that they're having. Now when I have clients chart this much, I create a really simple fill-in-the-blank chart like for sleep, number of hours, did you feel rested, yes or no? Dietary habits, I have them keep on their mobile device. For exercise, did you exercise yes or no? If so, how much or for how long? Really simple things so they can complete the chart in under five minutes, otherwise they're not going to do it. For the bipolar symptoms, I have check blocks. Did you feel depressed? Did you have difficulty sleeping? So it's easy. It's very, very simple for them to fill out. And it's also simple for me to evaluate when I go through it. Encourage people to understand their bipolar because everybody's presentation is going to be a little bit different. Have them identify, you know, are there cognitive patterns, negative thinking patterns that contribute to their depression? And if so, how do they handle those? In the past, when they felt depressed, how did they change their thinking or what did they do to help themselves be a little bit more optimistic? And also looking at cognitively, what have they got going for them? Are they intelligent? Are they creative? Are they, you know, build on those? If somebody is creative, you know, I'm not. So it's wonderful to see creative people. But for somebody who's creative, one of the greatest things they can do to work with their depression is art therapy. You know, it's very therapeutic for a lot of people. So find their strengths and use those to help them resolve their current presenting symptoms. Physically, encourage them to get adequate sleep. Avoid opiate and sedative medications, alcohol, and any sort of over-the-counter herbs, including gensing, Sammy, 5-HTP, without talking to their doctor first. Encourage them to eat a good diet. They may already be doing some of this. So how much they change at one time is going to vary between the person and what they're motivated to change. Remind them not to change too much at once. Let's just do one or two things right now, and then you can work on two more things once you have those underway. Situationally, have them do a coping skills inventory to figure out how do they cope when things get stressful, and have them identify triggers for their bipolar. What types of situations make you feel depressed? What types of situations have you noticed might seem to trigger a manic episode? Some people, when they get really stressed about something, there's that anxiety, the stress of that and having the HPA axis activated can trigger a manic episode for them. So encourage them to, in their chart, they're going to be keeping track of what might be contributing to triggering and mitigating bipolar symptoms. So if they're getting good sleep, eating a decent diet, their life stressors are pretty low and they're not having any symptoms, well, we know what they can do. Interpersonally, have them identify supportive friends, help them learn about interpersonal behaviors that trigger them and ways to deal with those interpersonal behaviors. So if when somebody tends to be in a manic episode or even in a depressive episode, if they tend to be irritable, think about, have them look at what behaviors trigger their irritability, trigger their anger, and figure out a plan to deal with it in order to minimize the impact that being on one end of the spectrum or the other, mood-wise, might have on their relationships. Anger is normal, irritability is normal, don't get me wrong. But when somebody is in a depressive episode or a manic episode, that irritability can be intensified tenfold and people may be taken aback by it. Environmentally, encourage clients to look around their environments and look at what they can do to make their environment cheerful, calm, and safe. What does that look like for that particular person? Those are things that they can do because when you felt calm and safe before, what was different? Or what was the same? What helps you feel cheerful? We just recently had the inside of the house repainted because it was time, but I've always felt more cheerful, especially during the winter when there's less sunlight, when I have a light yellow color on the walls, like straw, not bright yellow. And that helps me feel a little bit more cheerful, which is in contrast to all the black that I put in there, but whatever. It works for me, and that's how I feel comfortable in my environment. Encourage clients, especially when they're feeling like they're heading toward a depressive or manic episode, to eliminate negativity from social media and from television media. If it stresses them out to watch the news, do they have to watch the news? What will happen if they go for a month without watching the news? And in their real-life environment, encourage them to try to eliminate as much negativity as possible. And that can be altering how they deal with interpersonal relationships, that can be looking around and finding things that stress them out and addressing those. There are a lot of different things, but we want to look at it biopsychosocially. For mania, we still want to build on strengths. Encourage them to become aware of any medications they're taking and how those medications affect them. This can include stimulants, thyroid medications, Sammy and 5-HTP. Encourage them to avoid stimulants when possible and don't combine them with caffeine. If they put ephedra, for example, in combination with caffeine, that used to be a really common combination in pre-workout supplements. That can really get somebody revved up. So we want to make sure that they're aware of the effect, not only on their body, but the likelihood that that could also trigger a mood episode. Have them identify warning signs and interventions. Sometimes, like I said, that for people with bipolar disorder, the depression and or the manic episode may seem like it comes from out of the blue. And sometimes it may, but 99% of the time when I've traced it back with clients, they weren't taking good care of themselves. They were either taking on too much at work or they weren't getting enough sleep or they weren't eating well. Or there had been something that had changed from when they were doing well and they felt good to when they started feeling like they were heading down towards an episode. Some patients may try to identify triggers for manic episodes in order to increase those. We want to encourage them not to do that because that's like driving your car with the RPMs up at five indefinitely. That's not good for your car. Eventually, something bad's going to happen. So we don't want them to rev themselves up that much. We need to help them find that happy medium where they're content. There are three or a four on a scale of one to five and they're feeling good. For some clients, when they start feeling depressed, they notice thinking changes and have difficulty concentrating. This is a warning sign. You know, they may not feel completely depressed yet, but they may be waking up in the morning going, Yeah, not so sure I want to get out of it. They may have low energy changes in sleeping or eating, irritability, sadness, negativity, resentment, withdrawal. And environmentally, they may notice that they're in area becomes more disorganized or they may just not be caring as much about personal hygiene. These are all things that they can identify early on and say, You know, it looks like maybe I need to take a little bit better care of myself. And it's hard for clients. It's hard for a lot of us to listen to our body and go, Okay, I really wanted to do XYZ, but my body is telling me that maybe I need to rest. For mania, warning signs can include racing thoughts, heightened creativity. That's one that for people to be aware of, especially if you're dealing with somebody who's naturally creative, they may thrive during this periods of heightened creativity and really get upset when you start suggesting that they may need to temper that in order to stabilize their mood, they're going to have to cut the top off the highs and raise the bottom on the lows. Physically, they may have difficulty sleeping or sitting still. They may feel elated, excited, irritable or thrill seeking. You may have some anger outbursts, frustration with others. And environmentally, what I've seen with patients, especially with full blown mania, it really varies on what they do. Sometimes they are cleaning like crazy. And other times it looks like a whirlwind absolutely hit the room. But so it's usually extreme. So treatment compliance. We want to encourage clients to do a Decisional Balance Exercise. And I generally break it down so it's shorter. What are the benefits of eliminating depressive episodes? If the person was no longer depressed, how would they feel emotionally, mentally, physically, and how would it impact their family and friends? Now, a lot of times this one's easy to fill out. The drawbacks to eliminating depression. This can be harder to fill out because they're like, well, I don't see any drawbacks. Okay, we can leave that for now. Sometimes patients come to the awareness that if they're no longer depressed, they may not get as much attention and people may expect more of them, which is really anxiety provoking. But this area usually doesn't have a whole bunch of stuff in it. And then we want to ask them, what are the benefits of eliminating the mania? Emotionally, mentally, physically, and socially. This one's a little harder, not as hard as the drawbacks to eliminating depression. A lot of times clients can see the benefits of eliminating the manic episodes because they don't have the periods. I mean, they have the highs and those are awesome, but they don't have the periods where they have the lows and they don't feel like they can do as much. They don't have the loss of time. They don't kind of come out of it and realize that they're completely overwhelmed because when they were in the manic episode, they took on 17 things. So there are a lot of things that clients may identify as benefits to eliminating the mania. But we also want to talk about the drawbacks to eliminating it because, like I said, for some people that's when they're their most creative. And if they're a writer or an artist or a musician, this may be the time when they are feeling like they're uber selves. So they don't want to get rid of it. And it's terrifying to them to think that they might not be able to tap into that. We can talk about ways to tap into their creativity when they're not manic. And, you know, there are techniques that they can use in order to get that focus that they so desire. But it depends on the person exactly what you're going to use. If we don't address all of these concerns about eliminating their mania, treatment compliance is going to be lower because people will just, they'll miss it. They'll miss it a lot and they'll want to feel that high again. So general techniques and ask clients, how do you deal with it? Up until now, when you felt depressed, what have you done that's helped you feel better? Even for 10 minutes or an hour or half a day, you know, maybe it didn't work the whole time, but or it helped you feel instead of feeling just devastated. You felt sad, you know, it helps you feel a little bit less intensely depressed. Build on that. Ask them what they're willing to do. Some clients are going to look at you and go, no, I'm not going to do that. I'm not going to do that. Keep your journal. No, not going to do that. Okay. So what are you willing to do? I tell my clients a lot of times, I'm going to suggest things that you may not think fit for you or work for you or you're not going to do. Well, I'd rather you tell me number one that you're not going to do it. And what I'm more concerned about is what you're going to do instead. If you don't want to keep the journal. Okay. How are we going to be able to notice changes and find connections between your eating, your sleeping, your stress levels and and your mood episodes? You know, help me. Let's figure out a way that we can, we can do this. And they may come up with something, you know, basically I state what it is that I want to do or accomplish. And why, why it's important. And I say, is there another way we can accomplish this? When I work with clients in recovery, sometimes they don't want to go to 12 step meetings. Okay. If you're not going to go, then what are you going to do instead? Because you need to have some social support. You need to have something to do besides sit alone in your apartment from the time you get off work until the time you go to work the next day because that's a dangerous period. Encourage clients emotionally to practice mindfulness because it does prevent episodes from sneaking up. If they start feeling run down or tired or off, you know, sometimes I hear that word. I just feel off. Okay. That's when you need to stop and check in with yourself and go, what's going on? How do I feel? What do I need? And mindfulness also encourages behaviors that prevent vulnerabilities. When people check in with themselves, they may say, you know what? I'm really tired today. I need to rest. And that's a good thing because it keeps them from becoming vulnerable and potentially triggering an episode. Stress reduction. Encourage clients to identify and eliminate or mitigate stressors. So what stressors do you have? And they can write them down on a list. They can, a lot of times if I'm doing an individual, I'll have somebody write down on our big whiteboard, all of their stressors. And then we go through them one by one and say, okay, can this one be eliminated? If so, how? And the client will start making a plan for how they're going to start eliminating stressors. If there's a stressor that can't be eliminated, maybe they don't get along with their in-laws. And periodically the in-laws come to visit or whatever. Okay. Well, you can't eliminate that. So how are you going to mitigate that stressor before your in-laws come? What can you do? Or maybe it's less stressful if you go to their house instead of them coming to yours. So we talk about different things. We talk about time management because in those manic and hypomanic episodes, people can take on too much. And then they feel a little overwhelmed when they're steady state and they feel really overwhelmed if they're in a depressive episode. I do want to point out, and I think most of us know this, people don't usually cycle from a manic to a depressive to a manic like that. They can have a depressive episode and then be asymptomatic for anything for months and then have another depressive episode or a manic episode. So it's important to recognize that most people who are bipolar don't rapidly cycle and there are periods of remission or asymptomatology in between. Cognitive processing therapy can also help people mitigate stressors when they start feeling overwhelmed, encouraging them to identify what thoughts they're having that are contributing to them feeling stressed or overwhelmed. And then looking for the facts for and against that thought. If they're feeling like they've got too much to do, what are the facts for it? What are the facts against it? If they do have too much to do, then they need to figure out how to address it. But this helps keep people from getting stuck in emotional reasoning where every time they feel stressed or they feel depressed or they feel anxious, they think there's something to be dysphoric about. Encourage people to identify their anger management triggers. They differ for everyone. They need to develop a plan for de-escalation and begin addressing their anger triggers to maintain control of their own energy. They need to identify if driving in heavy traffic stresses you out and makes you irritable and angry. Well, okay, how can you address those triggers? Maybe driving a different way or maybe putting on your favorite music really loud in the car or whatever it is that you can do to mitigate that anger. Anger takes a lot of energy. Everybody's energy is precious, but people with bipolar disorder, stress and excess energy drain can potentially trigger an episode. So we want to help them conserve their energy. So yeah, they're going to get angry about some stuff, but help them identify what's worth getting angry about and using their anger energy for and how to deal with the rest of it. So they have more energy to enjoy life. We've been talking about the negatives, but let's look at the positive. They need to infuse happiness. Have them make a list of what makes them happy and do more of it or be around it more. Encourage them to schedule a belly laugh every day. And there are Reddit forums. There are YouTube videos. There are places they can go to get a good old belly laugh. But it helps release endorphins and release some of the calming neurotransmitters. Have them keep a good things, silver lining or gratitude journal. And it doesn't have to be prose. You can have them identify at the end of the day three things, three good things that happened that day or three things they're grateful for. Or when things go bad, they say, I got demoted at my job today. All right. Well, what's the silver lining to that? It didn't get fired and maybe have less responsibility now. I don't know. But there are different ways you can approach it, but encouraging people to be cognizant and try to embrace the dialectics. There's going to be bad in life, but help them focus on the good to reduce dysphoria. Mentally address cognitive errors, all or none thinking, focusing on only the positive or negative, using feelings as facts and focusing only on a small piece. When something happens, maybe you turned in a group project and your boss sent it back and said, uh, no, try again. Some people will take it very personally and focus only on the fact that the boss sent it back with feedback. Instead of, okay, it wasn't just me participating in this project. So, you know, all of us need to contribute to it again. And, you know, yes, it was given back to us, but we get a second opportunity. So it's looking at a bigger piece of the puzzle. Encourage clients to develop their self-esteem and view failures as lessons. Applaud courage and creativity and nurture their inner child. I have an inner child. My inner child comes out a lot more than some people would really like to admit or really like to see, but that's okay. You know, on Saturday morning, it is not uncommon for me to be watching cartoons in the living room. My kids are teenagers. I can't say I'm watching it with them anymore. I like Yogi Bear. I'm sorry. I'm weird that way. But, you know, sometimes at the end of a long week of being serious and everything, I just kind of need to regress for, you know, half an hour or two hours. Encourage people to nurture their inner child and don't be afraid to be silly. Don't be afraid to laugh or do something goofy. Physically, encourage clients to increase exercise. It increases serotonin levels, reduces stress, helps balance hormones and neurochemicals, and may combat some medication side effects. Exercise is anything that moves the body. Gardening, cleaning, going to the gym, of course, walking the dog, playing soccer with the kids, anything like that. So, what is it that they like to do, or at least they're willing to do? Nutrition provides the building blocks for the neurochemicals, so people need to have quality proteins. And a nutritionist friend of mine suggested, always try to have three colors on your plate at every meal and use a salad plate, which is smaller instead of a dinner plate, because it tricks your brain into thinking that you're getting more food. As Americans, we tend to eat way more than we actually need. And try to avoid mindless or comfort eating. When people start comfort eating, a lot of times they're not being mindful. They're eating to deal with stress instead of acknowledging the stress and dealing with it. So, yeah, they're infusing themselves with carbohydrates and fats and getting the serotonin and dopamine flowing. But when all that goes away, whatever was causing the stress is probably still there. So, they're either going to have to stress eat again or deal with it. So, encourage people to be mindful in their eating. Sleep helps the body repair and rebalance, and sleep deprivation is known to trigger both manic and depressive episodes. Too much sleep or sleeping at the wrong times can also mess up circadian rhythms. So, keeping naps to a minimum of 45 minutes one time a day if the person has to take a nap is important, so they don't get into that really deep sleep. And preferably trying to avoid naps for the most part of a 15-minute power nap where you're closing your eyes and you don't ever completely drift off has been shown to increase focus in the afternoon. But naps where you're laying down and getting under the covers, that tends to mess up circadian rhythms. If people are on medication for their bipolar, which they probably will be, have them work with their doctor to adjust the dosages, dosage times to fit their schedule. So, if they have a medication that makes them feel really sleepy, maybe they take it right before dinner. So, it's worn off completely by the time they get up in the morning. And it'll be up to the person to work with their doctor. I had one client who took Saracwell and she ended up having to take it at 2 in the afternoon in order for it to be out of her system enough where she felt alert when she woke up at 6 o'clock the next morning. So, it's going to differ for different clients. Again, encourage them to discuss any negative medication side effects with their doctor and not to expect a pill to do everything. The pill can help stabilize the moods, but if you're taking this pill, but then you're still pulling the rug out from under it by not sleeping and using cocaine or whatever, it's likely the pill is just not going to be able to do it all. Interpersonally, support groups are really helpful. Chat rooms, if the person is either in a rural area, work shift work, can't get to an appropriate support group. Not all communities have support groups that are embracing of all different types of people. So, it's important to recognize even though there may be a support group, the person that you're working with may not feel comfortable with the people that are in that particular group. So, chat rooms can be helpful. In the know, family and friends. And I say in the know, these are people who have to understand or have to know that the person has bipolar disorder. And be aware of their warning signs, their triggers, their symptoms, what helps. So, they can be supportive and facilitative. Environmentally, clients can explore things that improve their environment, different pictures. Temperature can also be a big thing. If you're too cold or too hot, it can make people irritable. Certain essential oils can help increase energy such as peppermint, rosemary or lemon. Calming essential oils if somebody tends to have some anxiety going on. Lavender, chamomile, valerian. Valerians kind of, they say woody. Some people think it stinks to high heaven. Some people love it. Catnip is the same way. Yes, stuff you use for your cats. You can get it in essential oil and it's actually a sedative type essential oil for humans. Bergamot, it's a pretty mild smell. Rose is helpful. Rose geranium is a little bit less expensive. And frankincense are all supposed to help with calming. So, if somebody's hypomanic, having difficulty winding down, anxious, whatever, some of these may help. Memory triggering include ginger, cloves, cinnamon, orange and jasmine. What works for one person is not necessarily going to work for another. There are studies out there that show certain essential oils have effectiveness at anxiety reduction and depression improvement. But it's really going to be up to that person. And I found that when a person smells something, if it smells noxious to them, then it's probably not something that they need. If they smell valerian and they're like, oh my gosh, that stinks. Okay, that's not triggering what their brain needs. Their brain knows what it needs. I do the same thing with my rescue animals. You know, I let them take a good whiff of it. And if they like it, they'll stick around and they'll sniff it some more. If it's not what they need, then they'll go somewhere else. I tried for our donkeys when we first got them into rescue. I tried lavender because I thought, you know, that'll help them calm down. They hated it. They liked valerian. So I learned that for them, they preferred that particular essential oil for whatever way it works in the brain. And encourage clients to visit a store that sells essential oils because they have testers and they can sniff them to see which ones work for them. And essential oils also smell different from different manufacturers. So it's important again for them to figure out places that they can get their essential oils and try to stick with the same company once they find one that really works. Organization can help. Another thing that's really important with people with bipolar is to manage impulse items. When they go into a manic or hypomanic episode, especially, and they're prone to engage in risk taking behavior or less restrained behavior, car keys need to be somewhere where maybe they can't access them if they're known to go out and drag race or, you know, drive 100 miles an hour just to see how it feels. Credit cards. That's a big one. Credit cards need to be somewhere. Some of my clients will freeze their credit cards in a block of ice so they can't get to them. And they can't see the numbers in order to read them and put them in on their phone. This can help prevent unrestrained spending, especially at 2am or something when the infomercials are on porn sites. If the client happens to have a attraction to porn sites, having those blocked because it's really easy to get sucked into those. Same thing with video games and alcohol and other drugs. Alcohol, a lot of people have in their house. So if this is a dangerous impulse item for somebody, making sure they have it locked up somewhere. So if they do and have a hypomanic or manic episode, they can't drink. Same thing with certain medications, especially the benzos and the opiates. If you can keep it locked up somewhere, all the better. And during the day, keep it light and bright. Try not to be in an office where it's really, really dark. Some people can't help it. I mean, if you're a nurse and you're working in the neonatal intensive care unit, it's going to be dark most of the time. And there's nothing you can do about that. But if you can help it, keep the lights on. If you don't like fluorescent lights, get lots of stand-up lights that you can put around to keep it bright so your brain knows that it's time to be awake. Co-occurring disorders, depression can co-occur with bipolar. I mean, you can have, obviously, part of bipolar is depression. So when somebody is in a depressive episode, suicidality, high risk, and addictive behaviors and self-medication, we want to watch out for, just like we would for unipolar depression. With mania, we want to help the person become aware and look out for explosive anger, which can get them into legal trouble, relationship issues, etc. Heightened libido, which also can get them into legal trouble and relationship issues, etc. And any other risk-taking that they do, because when they're in a manic episode, it's like they're, this is a bad idea filter is completely turned off. Or it's switched on the other way and it's the, let's try this filter. So helping them understand that when they're in that manic state, it's important to have safeguards. So when they come out of it, they haven't done something that they're going to end up regretting or have to undo. So bipolar is caused by neurochemical imbalances, especially among serotonin, dopamine, and norepinephrine. The symptoms and presentation vary widely, depending on the person. It's more important to address each symptom than to address bipolar as a whole. You know, we want to look at what symptoms is this person presenting with and how can we help them manage those? The medication provider is going to be managing kind of the bipolar as a whole and trying to stabilize the mood. But we want to help them start addressing their individual symptoms so they can feel as happy, healthy, and productive as possible. Help them address each symptom, identify warning signs, and eliminate or mitigate triggers and vulnerabilities. Remember that treatment compliance is a huge issue because mood stabilizers tend to flatten those highs and people miss it. The most dangerous times for suicidal ideation and people with bipolar disorder are when they're coming out of a depressive episode or, and I didn't mention this before, or during a mixed episode. Remember mixed, they can be depressed and have high energy both at the same time. Ensure people with bipolar disorder have a crisis plan and people who interact with them daily who are aware of their warning signs and symptoms. Because sometimes if they're not being mindful, and most of us are guilty of not being mindful all the time, sometimes these symptoms can creep up. So if they have people they interact with on a daily basis who are in the know and can say, you know, John, it seems like you're starting to destabilize a little bit. Then John can take a look at it. People with co-occurring addictions also need to be aware that a bipolar episode can trigger an addiction relapse and vice versa. So they need to be aware and have an extra special relapse addiction relapse prevention plan for when their mood symptoms arise. If you haven't already signed up, please remember that addiction and mental health counseling and social work continuing education credits are available for this presentation and are accepted in most U.S. States, Canadian provinces, Great Britain, Australia and South Africa. Go to allCEUs.com slash counselor toolbox and click on the link counselor toolbox CEU spreadsheet to easily locate the course based on this presentation. Okay, are there any questions? Now remember, we're not having class tomorrow, but we're having class on Thursday and that is just chock full of stuff that I've never actually presented before. So there is no repeat possible there. Oh, and then next Tuesday, we're going to be talking about enhancing social justice and why that's important for recovery.