Sleep and the Bipolar Mind

The list of symptoms for bipolar disorder as it appears in the DSM IV states that people with bipolar disorder are more likely to have problems sleeping and lack of sleep is both a cause and a symptom of bipolar disorder symptoms. Sleeplessness is a symptom of mania and although feeling tired is a symptom of depression, so are changes in sleep, which might result in sleeplessness or in sleeping too much. Not being able to sleep is also symptomatic of a mixed bipolar state.

Before or early in a bipolar episode you may experience a change in your sleep patterns, whether in quantity of hours, or the quality of your sleep – not feeling rested or frequent waking – that allow you to make the changes necessary to prevent an episode or mediate its length and severity through changes in behaviors that influence sleep. Being aware of these changes and recording them and the behaviors that accompany them will help you and your healthcare provider take the necessary steps to bypass an episode.

Once bipolar disorder has been treated people are less likely to have sleep problems. Having insufficient sleep can cause hypomania, depression and mania. Sleep loss is also a symptom of depression, mania and hypomania and thus is a significant issue for mental well-being that should be monitored by people living with bipolar disorder.  Even if you need medications to sleep you can have a better quality sleep by taking the following steps which may even help you reduce your reliance on sleep medications.

1. Develop a sleep routine to keep your circadian rhythms in order. This means going to bed and waking, and taking any medications at the same time every day, including weekends. This gets your body in a pattern of knowing when to feel sleepy and when to wake and allows you to get the amount of sleep your body needs for you to feel rested in the morning with the energy you need for your day.
2. Sleep in a cool, dark, quiet room on a comfortable bed. If there are lights or noises that annoy you then sleep with an eyeshade and/or earplugs. Or perhaps you want the soothing noise of a particular sound or music collection. Make sure your bed, pillow and linens are comfortable.
3. Exercise regularly to give your body a reason to be tired. Complete your exercise at least 2 hours before bedtime so that your body is not overheated or have an elevated heartrate near bedtime
4. Avoid caffeine, nicotine and alcohol. Caffeine and nicotine are stimulants and alcohol may help you fall asleep but interferes with sleep patterns to make your sleep less restful.
5. Relax before going to bed. Do relaxing activities before going to bed such as meditation or reading or knitting and avoid doing anything in bed but sleep and intimacy. 

Monitoring your sleep patterns may help you know what factors are helping you sleep and what factors are keeping you from a good night's rest. For a sleep log: §  http://www.helpguide.org/life/pdfs/sleep_diary.pdf

Other sleep resources: 

'Sleep Matters: The Impact of Sleep on Health and Well-Being' which is downloadable from http://www.mentalhealth.org.uk/publications/sleep-report/.

'Your Guide to Healthy Sleep' and it is available free at http://www.nhlbi.nih.gov/health/public/sleep/healthysleepfs.pdf. 

National Sleep Foundation (www.sleepfoundation.org)

American Academy of Sleep Medicine (http://www.sleepeducation.com/)

National Minority Mental Health Awareness Month

July is National Minority Mental Health Awareness Month.

So instead of creating original content for this entry, I will simply add links for sites where information and resources can be found about mental health issues among minority communities.


National Alliance on Mental Illness

American Psychiatric Association

National Network to Eliminate Disparities in Behavioral Health: Webinar

National Latino Behavioral Health Association

Black Mental Health.net

National Asian American and Pacific Islander Mental Health Association

HYPERGRAPHIA - the compulsion to write in bipolar disorder

It was not easy finding a 'reputable' definition of hypergraphia so I will accept the one from About.com as it is comprehensive and consistent with other definitions found in various more reputable sources.


A Definition
About.com definition (not the most scientific of sources):
Hypergraphia is a condition in which a person feels an overwhelming compulsion to write. People with bipolar disorder, especially during mania or hypomania, may find themselves writing for hours at a time, not necessarily realizing that this is unusual. It may take the form of journalling, creative writing, or copying page after page of a book. Hypergraphia may also be associated with temporal lobe epilepsy and schizophrenia, as well as certain brain injuries. 


The Experience of Hypergraphia
I realized that my hypergraphia was associated with both  hypomanic and depressive episodes but in different ways. When I am hypomanic I get creative and write all sorts of things - poetry, magazine articles, blogs, academic articles, abstracts, and long emails to friends. I also find myself entering notes into my blackberry, when I dont have access to paper or a computer. When depressed, I write dark poetry but have no other creative productivity. When I am hypomanic I have no desire to write poetry. My brain is just not so inspired. So in my search to understand this pattern, I found some interesting information I wanted to share with you and I would love to hear your stories.


What the Scientists Dont Say
It was not easy to find information on this condition. It did not show up in a search on the Merriam Webster online dictionary. A search on the website of the National Institutes of Mental Health (NIMH) and the Mayo Clinic also resulted in no entries. No books could be found in my school library database but In the PsycInfo and Medline databases it is primarily associated with temporal lobe epilepsy.


However there are some well known experts in psychiatry and neurology who have been writing about the behavior from personal and scientific perspectives.


What Some Scientists Say
The Midnight Disease - is a book by Alice Flaherty,  a neurologist at Massachussetts General Hospital. She found herself writing compulsively both after the death of premature twin boys and the birth of healthy twin girls later diagnosed herself with hypergraphia. She believes that this behavior is attached to extreme moods that are found in people with manic depression and other people with brain disorders and brain injuries. 

Peter Whybrow, MD, Director of the Semel Institute for Neuroscience and Human Behavior at the University of California in Los Angeles and a specialist in mood disorders, was reported in the The Guardian (March 17 2004) as saying that manic depressives with a predisposition to chronicling their lives or composing poetry are likely to engage in voluminous writing in their darkest hours.disorders.

Dr Kay Jamison, a professor of psychiatry at John Hopkins University, was quoted in The Guardian (March 17, 2004) as saying that "Two aspects of thinking are pronounced in both creative and hypomanic thought: fluency, rapidity and flexibility ... and the ability to combine ideas or categories of thought in order to form new and original connections."

Mood Disorders and Creativity

In a conference at the Library of Congress (Depression and Creativity, Feb 3, 2009 - click link for video), both Dr Jamison, Dr. Whybrow discussed the controversial and long-standing (pre-Grecian) conversation about creativity and mood disorders. The symposium also included Dr. Terence Ketter who is chief of the Bipolar Disorders Clinic at Stanford University, whose research focuses on the relationship between creativity and madness. Though most artists and creatives do not suffer from mental illnesses but many creatives, especially poets, suffer a disproportionately high rate of mental illnesses, particularly depression and bipolar disorder. Dr Jamison refers to Mendelssohn, Virginia Woolf, Van Gogh as creatives with mood disorders. She argues that during periods of depression people are less productive and are more productive when they are manic or hypomanic.


The Advantages and Disadvantages of Hypergraphia

The great thing about hypergraphia for an academic is the productivity. However it is frustrating that there are often so many ideas that cannot all come to fruition. It inspires insomnia. But the indulgence to these intense desire to write is that it compensates for depressive episodes where dark moods interfere with the discipline to complete ideas.

Manic depression has its advantages and disadvantages and though hypergraphia is both blessing and curse (depending on its expression), in a world where productivity is valued, I have no cause to resist its lure or try to medicate it away. There is beauty in seeing words that come from my brain. And one can only hope that others share the same view.

Note: This was written in a hypographic period during a hypomanic phase.

Violence and Mental Health Stigma

The Headlines

Gunman: a life full of rage, a shocking final act

This was the headline in the Seattle Times on Wednesday May 30, Ian Lee Stawicki shot and killed 5 people in 2 locations in Seattle and then turned the gun on himself. As the news reports became one never ending roll of updates, and spread around the world, it was soon discovered that Mr. Stawicki had been showing signs of mental illness and his father suspected he had untreated manic depression (aka bipolar disorder). Once again violence and death became linked with bipolar disorder even though these events are relatively rare. 

The Other Face of Bipolar Disorder and Mental Illness
Most people who have bipolar disorder are like me and so many people I know: they  are employed, have successful careers and families. We are the face of bipolar disorder and mental illness but this is not the face we see in the public sphere. National organizations like the the National Alliance on Mental Illness (NAMI) - which has more than 1100 local chapters in all 52 states,  and the newly founded Seattle-based Professionals Affected by Mental Illness (PAMI) include members that represent a wide variety of jobs and careers and levels of education.

For some reason, we who have a mental illness have not joined the 'anonymous' movement (perhaps Mental Illness Anonymous - MIA). Perhaps if we went to meetings where we would stand up and own our issues we would get praised and supported for staying symptom free. And when we went out in public we could talk about getting our 1 year medal and be supported for our efforts.

The Stigma of Mental Illness
Instead we hide in closets of society's making with our own support. So that when people talk about the mentally ill they think of people who are homeless shouting at the moon or just another mass killing; but most people do not think about their boss, friend, neighbor or cousin. The TV shows such as Law and Order, Criminal Minds or CSI do not help our image any. But if our image is to change we have to change it.

Because the public links 'danger' to those of us with mental illness, many who are affected with mental illness often refuse to seek help because of the stigma that is attached to being ‘one of them’. We have to step out and show the world that with available, accessible and high quality care we can manage our symptoms and function well, just like those with diabetes do. 

It is also a sign of stigma that we say ‘mentally ill’ to describe someone with mental illness as we do not say ‘cancerous’ to describe people with cancer. We are much more than the parts of our brain that do not function as they should. The reality is that mental illness is physical – unless my brain is not part of my body.


Mental illness is also stigmatized within the health professions because if someone with a mental illness is receiving health on the public dime (Medicare or Medicaid) then it is most likely that they will access care only when they are "a danger to self or others" and the kind of care that could prevent or ameliorate symptoms before a crisis is simply not available or if available, it is only for the lucky few. Feeling mentally unwell is not enough to get care because healthcare is such a precious commodity in this country - whether public or not.

Why We Should Step Out of the Stigma Closet
If women had not stepped out of the secrecy and shame of losing a breast we would not have the movement for research, support and for public education. They had to let everyone know that breast cancer affected women of all colors, classes, creeds, nationalities etc. 

If our only view of the mentally ill is one of limited achievement or of rare violent episodes that end up on the front pages, then the newly diagnosed are at risk of not achieving their full potential because they have no idea of what that may be. Nor do their families or their employers.

Who Are the Mentally Ill
We are a diverse group of people whose biochemistry has gone awry, just as it has for people who suffer from other biochemical disorders. Why stigmatize me because of my brain when my brain works well in so many other ways (such as compassion, humour, and complex problem-solving?

We are friends, family, colleagues and even your healthcare providers. Just like any other illness, it does not discriminate and everyone has a unique experience that is not summarized by scary headlines.

As more people ‘come out’ as mentally ill we can reduce the fear, change stereotypes and give hope to people who are affected by a mental illness. Employers can also see that we can be productive employees who have illnesses that can be treated effectively with the right support.

Coming Out
To those of you out there who are dealing with mental illness, take a brave step and tell someone. The more diverse the faces and lives of the mentally ill, the less shame and stigma we will experience and the more resources will be put into helping to understand and treat one of  the most debilitating health conditions.

For more  information on bipolar disorder and other mental illnesses and ways to advocate for mental health services contact: Depression and Bipolar Support Alliance, National Alliance on Mental Illness, the American Psychological Association and the National Institute of Mental Health

The Nutrition Of Sanity: Using food to reduce the intensity and frequency of bipolar symptoms

People living with mental illness know that the little pills that come along with sanity make a difference to feeling good or bad. But it is good to know that food, yes food, can also help our brains function at a much more even keel. What we put in our mouth really does matter to whether or not our moods stay in check.

First, without thinking on what type of food we should eat, we should generally eat a healthy meal several times a day. That is a meal with lots of color: fruits and vegetables. But what foods and vegetables make our brains healthy while making our bodies happy.

In keeping with one of the principles of this blog, I will not make a long list (I can add more later) nor use technical scientific language nor give you a long page to read. If you know of other nutrients, other research or I have misrepresented something, please let me know by sending me a note in the comments section. And follow me on my Psychology Today blog as well where I write more generally about mental health.

So here are some nutrients to consider. I will acknowledge that I use Vitamin D and Omega 3 supplements in addition to other pharmaceuticals, as recommended by my doctor. I think they make a difference in reducing the amount of medication I need but who knows. My body utilizes these micronutrients for other good things so it can't harm.

1. VITAMIN D. Free from the sun but in the winter its harder to get and the 'stay-out-of-the-sun' recommendations from the dermatologists may be interfering with our manufacture of this very essential micronutrient. One of the side effects of taking anti-epileptic drugs is to reduce Vitamin D in the blood (Ovsiew, 2004) which can lead to osteoporosis in people living with mental illnesses who take atypical anti-psychotics like olanzapine for the treatment of bipolar disorder. At the very least, being in the sun will make you feel better whether science understands exactly how it works or not. Vitamin D3 is found in fatty fish and because it is so important to our bodies it is added to many foods such as milk and some juices.

2. OMEGA 3 Found in cold water fish and seeds such as flaxseed, omega 3 fatty acids are not only great for glowing skin but lubricates our brain's machinery and keeps it running smoothly.  Omefa 3s can be found in cold water fish, like salmon and vegetable sources such as flax and chia seed. Jerome Sarris (2011) and a team of researchers did an analysis of studies that looked at 'nutraceuticals' and how their effect on bipolar disorder symptoms and found that though there were mixed effects of omega 3's on symptoms, there was a mostly positive effect on depression but not on mania.

3. COFFEE AND ALCOHOL: Avoid these substances because they have been overwhelmingly proven to alter mood in ways that are unclear and as our moods are already problematic, it is best to avoid these so that we can also get good sleep at night. If you really need a cup of brewed beans to get you started in the morning it is best to drink before noon so that the effects wear off before night.

4. L-TRYPTOPHAN: Sarris et al. (2011) and his team found that this nutrient had a positive impact on moods. This amino acid is used by the brain to make serotonin that is mainly linked to depression. Some foods that contain L-Tryptophan include nuts, seeds, eggs, meat, fish, tomatoes and cheese among other foods.

References
Ovsiew, F. (2004). Anti-epileptic drugs in psychiatry. Journal of Neurology, Neurosurgery and Psychiatry, (75) 12, 1655-1658

Sarris, J., Mischoulon, D., Schweitzer, I. (2011). Adjunctive nutraceuticals with standard pharmacotherapies in bipolar disorder: A systematic review of clinical trials. Bipolar Disorders, 13 (5-6), 454 - 465.