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Murphy Bill is DBA (dead before arrival)

6/19/2014

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The death of the Murphy Bill: On being the national spokesman
Larry Drain


The Murphy Bill as we know is dead.  The Republican leadership in the House announced a change in strategy.  They basically decided to toss in the towel on the more controversial parts of the plan and try to see if they can move forward on elements that seem to have a greater consensus behind them. There may be CPR efforts yet but it appears done.

It was a bill in trouble from the start despite the massive pr campaign that tried so hard to say it wasnt so.  It managed to unify groups that might not agree on what kind of reforms they wanted, but were absolutely sure what they didnt want and that was the Murphy Bill.

Part of the problem was Murphy himself.  He assumed that as "the only psychologist in Congress" he was the obvious and deserved national spokesman for mental health reform.  He wasnt.  Being a psychologist certainly didnt qualify for the role.  Neither did being a member of the House of Representatives.  It seemed that Dr. Torrey annointed him and for some reason they both thought that mattered.  In the end it was hard to know where he started and Dr. Torrey ended and that was perhaps a fatal flaw.

He didnt understand that leadership was built or that it was a two way street.  He alienated people who had lived mental health reform their entire adult lives.  He thought it was about them joining him and never seemed to know it was the other way around.  And he never realized that trust was everything and that when he snuck AOT into the medicare bill he destroyed his chances of trust with people whose support he needed.

He was naive.  The only people who believe federal laws change everything are federal lawmakers and most of them know better.  To say that his law was going to prevent the next shooting was simply ego.  He believed his own press clippings and his posturing before the dead were even buried just seemed like rank opportunism.

Mental health reform is an ongoing effort by many, many people with different values and priorities.  Sometimes it is its own worst enemy.  People who cant stand each other have a hard time standing together for anything.  Murphy I hope has to some degree taught people they can find unity despite their differences.  And maybe the fragile unity borne of him will be the biggest take-away from the entire thing.

He may indeed try again.  He probably will.  Dr.  Torrey most surely will.  He has won many, many short term victories and will doubtless win more, but the big prize has eluded him again. He is not the national spokesman he has annointed himself to be either.

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Borderline Personality Disorder relations with BP

5/8/2014

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Differentiating Borderline Personality Disorder from Bipolar Disorder
By BERNADETTE GROSJEAN, MD

Borderline personality disorder (BPD) and bipolar disorder frequently co-occur (numbers range from 8% to 18%), although they are distinct clinical entities (Paris J et al, Compr Psychiatry2007;48(2):145–154). A proper diagnosis guides the most effective treatment, but you’ve probably faced the difficult challenge of diagnosing these conditions, which share several clinical features.

BPD can be described by four types of psychopathology: affective disturbance, impulsivity, cognitive problems, and intense, unstable relationships. What’s most important—in addition to seeing that your patient meets DSM-IV criteria for BPD—is to establish that patterns of affective instability, impulsivity, and unstable relationships have been consistent over time. Thus, obtaining a detailed history is crucial. Also, the key features we see in BPD, such as dissociation, paranoia, and cognitive problems, are often affected by the patient’s environment and, particularly, his or her relationships. A patient might have a history of rapid and sudden deterioration when relationships change—such as threatening suicide after a breakup or severe mood swings when separated from her family. Generally, the more intense or significant the relationship is, the greater the risk of chronic stress and mood dysregulation.

Many of the same features are seen in patients with bipolar disorder, such as dysphoria, hyperactivity, impulsivity, suicidality, and psychotic symptoms. As a result, borderline patients with this cluster of symptoms are often misdiagnosed with bipolar disorder, possibly because of the effectiveness of psychopharmacological treatments for such symptoms. In fact, a more thorough assessment might show that these patients actually suffer from a personality disorder. In one study, more than one third of those misdiagnosed with bipolar disorder met DSM-IV criteria for BPD (Zimmerman M et al, Compr Psychiatry2010;51(2):99–105).

In BPD, mood changes are generally short-lived, lasting only for a few hours at a time. In contrast, mood changes in bipolar disorder tend to last for days or even weeks or months. Mood shifts in BPD are usually in reaction to an environmental stressor (such as an argument with a loved one or a frustration in the waiting room), whereas mood shifts in bipolar disorder may occur out of the blue. Some clinicians consider BPD an “ultrarapid-cycling” form of bipolar disorder, but there’s little evidence to support this link (Gunderson JG et al, Am J Psychiatry 2006;163(7):1173–1178). Patients with BPD might rapidly cycle through depression, anxiety, and anger, but these mood shifts rarely involve elation; more often, the mood shifts are from feeling upset to feeling just “OK.” Likewise, the anxiety or irritability of BPD should not be mistaken for the mania or hypomania of bipolar disorder, which usually involve expansive or elevated mood.

At a more existential level, patients with BPD—particularly younger patients— often struggle with feelings of emptiness and worthlessness, difficulties with self-image, and fears of abandonment. These are less common in bipolar disorder, where grandiosity and inflated self-esteem are common, especially during mood episodes. And while both conditions may include a history of chaotic relationships, a patient with BPD may describe relationship difficulties as the primary—or sole—source of her/his suffering, while the bipolar patient may see them as an unfortunate consequence of his behavior.

A pattern of self-harm and suicidality often serves as a cue for diagnosing BPD (but are not necessarily required). But both can be seen in bipolar disorder, too. In BPD, suicide threats and attempts may occur along with anger at perceived abandonment and disappointment. Patients often explain these impulses as a way to be relieved of pain, or to “stop their thinking,” more so than to end their lives, per se. Patients with BPD may experience “micropsychotic” phenomena of short duration (lasting hours or at most a few days), including auditory hallucinations, paranoia, and episodes of depersonalization. However, patients generally retain insight, and can acknowledge that “something strange is happening” without strong delusional thought. When psychotic symptoms occur in bipolar disorder, they happen in the context of a mood episode, they tend to last longer, and patients may be unable to reflect on their behavior.

Accurate diagnosis of BPD and bipolar disorder can be difficult, but it’s essential for proper treatment and optimal outcome. Remission rates in BPD can be as high as 85% in 10 years (Gunderson et al, Arch Gen Psychiatry 2011;68(8):827–837), particularly with effective psychotherapeutic treatments (Zanarini MC, Acta Psychiatr Scand 2009;120(5):373– 377). Unfortunately, such treatment is not always available. Some medications can be used in BPD, such as an SSRI for impulsivity, severe and persistent depression and/or suicidality, or an atypical antipsychotic for recurrent dissociative symptoms or disinhibition. However the only consensus seems to be that medications should be used as adjuncts to psychotherapy (Silk KR, J Psychiatric Practice 2011;17(5):311–319). The long-term use of a mood stabilizer or atypical should be reserved for known cases of bipolar disorder.

TCPR’s VERDICT: Clinicians sometimes think of a BPD diagnosis as pejorative (chronic and untreatable) and may be reluctant to disclose it, but patients and their families often find it helpful to be informed of the diagnosis. Similarly with bipolar disorder, accurate diagnosis often determines prognosis and effective treatment. For the clinician, however, it’s imperative that you make the proper diagnosis in these two often overlapping, but fundamentally quite distinct, conditions in order to optimize your patients’ outcomes.

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Target Zero by DBSA

4/28/2014

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Target Zero to Thrive This April

DBSA targets raising expectations for mental health treatment.

A month-long social media campaign, Target Zero to Thrive, challenges mental health care professionals, researchers, and individuals living with or affected by mood disorders to raise treatment goals to complete remission—to zero symptoms.

Of course the first priority for treatment is ensuring a person living with depression or bipolar disorder is out of crisis. However, too often the end goal established for successful long‐term care is for the person to maintain a stable mood. Better, or even stable, is not always well. Every person deserves the opportunity to not just survive but thrive, and to do that we need to ensure true wellness is the end‐goal for mental health treatment.

Consider this, successful treatment for cancer proceeds with the goal of removing every cancerous cell—to achieve complete remission. Why then, do we consider treatment for depression or bipolar disorder to be successful when symptoms persist, even if the person is considered to be stable?

The cost of settling for reduced symptoms is simply too great. It is, in fact, a matter of life and death—for when symptoms persist, individuals who have mood disorders are:

  • at significantly greater risk of relapse(1)
  • more likely to experience significant functional impairment, making the day‐to‐day demands of job and family challenging, and too often, debilitating. (2)
  • more likely to have life‐threatening co‐occurring conditions, such as heart disease, hypertension, and diabetes—a huge factor in why individuals with mental health conditions die, on average, 25 years younger than those without mental health conditions (3)
  • at a higher risk to die by suicide (4)

DBSA President Allen Doederlein shares, “Living with a mood disorder can damage hope and lower expectations; so a person may not expect or think they deserve a full life. We, as peers, clinicians, researchers, and family, need to help them expect and achieve more—by raising the bar for treatment. Targeting zero symptoms may seem like a formidable goal, but there are over 21 million reasons and Americans living with depression or bipolar disorder to make it a goal worth pursuing!”

(1) Am J Psychiatry. 2000 Sep;157(9):1501-4.
Does incomplete recovery from first lifetime major depressive episode herald a chronic course of illness?
Judd LL1, Paulus MJ, Schettler PJ, Akiskal HS, Endicott J, Leon AC, Maser JD, Mueller T, Solomon DA, Keller MB.

(2) J Clin Psychiatry. 2007 Aug;68(8):1237-45.
Mood symptoms, functional impairment, and disability in people with bipolar disorder: specific effects of mania and depression.
Simon GE1, Bauer MS, Ludman EJ, Operskalski BH, Unützer J.

(3) Bipolar Disord. 2004 Oct;6(5):368-73.
Burden of general medical conditions among individuals with bipolar disorder.
Kilbourne AM1, Cornelius JR, Han X, Pincus HA, Shad M, Salloum I, Conigliaro J, Haas GL.

(4) Psychiatr Serv. 2013 Dec 1;64(12):1195-202. doi: 10.1176/appi.ps.201200587.
Does response on the PHQ-9 Depression Questionnaire predict subsequent suicide attempt or suicide death?
Simon GE, Rutter CM, Peterson D, Oliver M, Whiteside U, Operskalski B, Ludman EJ.

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on the value of having a partner

4/15/2014

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The power of two


Your partner can become a pillar of strength when you work together as a couple
By Barbara Boughton, BP Spring 2013



There’s no doubt that the nature of your relationship with a “significant other” has a major effect on managing bipolar. Research now shows that having a supportive partner may be just as important as medication and psychotherapy in preventing relapse, according to Sagar Parikh, MD, a professor of psychiatry at the University of Toronto.

Likewise, the stress of high-conflict relationships or the emotions that accompany breakup and divorce can sometimes exacerbate symptoms of the disorder, Parikh says.

So what can you do to make your partner an ally in recovery?

The first step, says Parikh, is education—for both of you.

The more that both partners know about symptoms, treatments, and coping strategies, the more they can work together to address common challenges. Reading and online research, workshops presented by mental health organizations, discussions with mental health practitioners, and peer support groups are all good ways to get informed.

A partner or spouse who is up to speed on what it takes to live with bipolar will find it easier to understand when you ask for support.

The next step is learning to discuss matters relating to your illness openly and honestly.

For one thing, being able to share what’s going on in your life and your head provides your partner with a context for any irritability, sadness or high spirits you exhibit. For another, it gives you both a touchstone for recognizing early signs of a mood shift.

Elizabeth and her husband, Rory, who have been married since August 2012, have a conversation at least once a week about any symptoms Elizabeth might be experiencing.

“Regular communication is really important,” says Elizabeth, 32, of British Columbia. “We talk about what I’m feeling and things that he notices about me. Sometimes, it’s hard for me to see the forest for the trees, especially if I’m not feeling well.”

Rory’s feedback provides her with a reality check, Elizabeth says.

“Last year I had a manic episode and Rory realized something was wrong when I told him: ‘I want to go on a 5K run.’ I’m a pretty sedentary person, so for me that’s out of character. It gave Rory a clue that I might be experiencing mania,” she recalls.

In most intimate relationships, it’s important to make significant others aware of red flags, according to David Miklowitz, PhD, a professor of psychiatry and director of the Child and Adolescent Mood Disorders Program at the Semel Institute for Neuroscience and Human Behavior at the University of California–Los Angeles.

“People with bipolar disorder can make a list of symptoms and behaviors that they know indicate early signs of a manic or depressive episode. The partners can then refer back to these lists in order to spot early symptoms,” Miklowitz says.

comfort levelWith education and experience, partners often become adept at spotting subtle signs, Miklowitz notes—sometimes before the person with bipolar does. 

“Then the question becomes: If your partner spots early signs of mania or depression, what do you want them to do with that information?” Miklowitz says. 

“Do you want them to call your doctor? Do you want them to go in with you for a therapy session, or encourage you to take your medicines? Some people like that kind of active support from their partners, and some do not.”

In some cases, Miklowitz says, intervention from a spouse can be seen as “too parental or too controlling.”

The bottom line is this: In order to tell your partner how to be helpful, you first need to know what kind of help you want. That’s highly individual, so every couple will find a different fit. After a disturbing interaction with a friend or boss, one person may simply want to vent while another seeks advice on how to resolve the situation.

Bill, 67, has never looked for a lot of hands-on involvement from his wife, Telle. The couple lives in California, and has been married for 20 years. 
 
“The main way that Telle has supported me is through her acceptance of me—and that’s been very important to me and our relationship. She knows that I can stand on my own two feet, and she doesn’t judge me,” says Bill, a retired refrigeration pipe fitter.

What Bill appreciates are Telle’s understanding and compassion for his symptoms, her trust that he is working to get the best treatment he can, and her emotional support when he’s had to be hospitalized.

Still, Telle has occasionally taken an active role in Bill’s care. In May 2012, Bill became delusional while being assessed at a hospital for a blood clot in his lung. Telle spoke to his psychiatrist, who arranged for Bill to be admitted for psychiatric intervention. 

If your partner does take an active role, Miklowitz says, it’s important to understand that the person will probably make mistakes.

“It’s crucial to give your partner some leeway, especially in the beginning of a relationship, when they’re just getting to know you and the effects of your illness. They’re not trying to control you. They’re just trying to help, and they don’t always know how to best do that,” he says.

talking pointsOnce you are clear in your own mind about what role you’d like your partner to take, Miklowitz notes, it’s crucial to be direct in expressing your wishes—and also to listen to what your partner has to say.

Miklowitz recommends asking “clarifying questions” to make sure you understand your partner’s point of view. To doublecheck that you’re interpreting correctly, practice repeating back what the other person said—a technique known as reflective listening or mirroring.

Nancy Poirier, MPs, a clinical psychologist at the Douglas University Institute for Mental Health in Montreal, stresses the need to express your wants and feelings with compassion.

With mirroring, for example, first reflect your partner’s viewpoint, then express understanding and empathy to validate how the other person feels.

In addition, she says, “both partners should be careful to use ‘I statements’ rather than blaming the other person in talking about the bipolar disorder. The important thing is for both partners to feel understood.”

As far as practical approaches, Poirier recommends developing a relapse prevention plan that details early warning signs of a mood shift and how to respond. The Elizabeth and Rory’s plan includes a list of people whom Rory should call to get Elizabeth treatment and/or medication, as well as the name and contact information for the hospital where she’d like to be treated.

As a further step, Poirier notes, you and your partner can write a contract about what each of you will do when warning signs appear. A document you signed when well may be more effective against denial when you’re ill than a partner’s reminders.

There are other small but helpful ways partners can counter symptoms, she says. During a manic phase, reduce stimulation by decreasing light and loud music in the household, and keep credit and cash cards inaccessible. During a depressive phase, let more light into the house, encourage exercise, and gently urge completion of at least one pleasant activity each day.

On a day-to-day basis, agree on a system that keeps encouragement from feeling like nagging. Again, this will vary from couple to couple. Some might be comfortable with a daily check-in about medication compliance, for example, while others will prefer a more emotionally neutral chart system that both partners can refer to.

Couple’s therapy can be an effective way to develop strategies for coping with the disorder together, Miklowitz says.

“The counseling should help the couple solve problems that arise around the symptoms of bipolar disorder, and learn to communicate effectively about them,” he says.

In addressing specific issues, Miklowitz adds, it helps to realize that you may not get everything you want.

“You have to be willing to compromise,” he says. “You have to start with the assumption that everyone—you and your partner—are doing their best.”

“Doing your best” might involve taking as much responsibility as you can for your recovery and well-being, Poirier points out. For your partner, that might mean cutting you a little slack for symptomatic behavior.

Elizabeth says that when she succumbs to what she calls her “ooh, shiny!” syndrome, Rory usually accepts the impulsive action as part of her illness.

When she bought several hundred dollars’ worth of tea towels, she recalls, Rory commented that they were now stocked up for a few years. When she took their cat to the vet and came home with an extra kitten, Rory “accepted the kitten with open arms,” she reports—and they now have a rule that they only go to the vet’s together.

“He isn’t a pushover,” she says, “he just knows that in the spring, I pull a few whoppers and that is OK.”

In fact, she says, Rory took the news of her diagnosis better than she did. They were dating at the time, Elizabeth says, and Rory made it a point to find books that would be helpful.

“He never judged me for having bipolar,” she adds. “I’m very lucky to have found Rory.” 

-------
Barbara Boughton, a freelance health and medical writer, writes for Reader’s Digest, Medscape.com and other outlets. She lives in the San Francisco Bay area. 



Learning when a hug can helpWhen Heather and Ken first met in fall 2002, Heather certainly wasn’t in the mood for romance. She was experiencing serious depression and “very resistant to dating,” but Ken waited patiently.

“When we did start dating, I was very forthright about having bipolar disorder, and he was very understanding,” recalls Heather, 44.

Now Heather’s relationship with her husband is a rock that steadies her when symptoms crop up. In Heather’s case, that’s often behaviors that signal depression—not getting out of bed, failing to eat healthy foods, and crying a lot.

After nine years of marriage, Ken has come to understand what his wife needs when she is ill. And Heather made it a priority to communicate to her husband about what kind of support she finds the most helpful.

“Sometimes it’s just the simple things that are important,” Heather says. “A hug from Ken can be very grounding when I’m having a difficult time. He also knows when to give me space, such as when I get irritable, angry, and when I lash out.”

Perhaps more importantly, Ken and Heather have an agreement that they’ll promptly address any worrisome symptoms.

Heather admits she’s not always receptive when Ken spots signs of depression or hypomania, such as being quick to anger or spending too much on online shopping, yet she will usually agree to call her doctor.

“Couples therapy has also helped us,” she says. “We’ve learned not to blame each other when we discuss sensitive issues such as my bipolar disorder, and to respectively express our feelings. Sometimes that may mean taking a break or even going to different rooms when a discussion becomes too heated.”

She adds, “What has been most important is for both of us to realize that I’m more than the identified patient in our relationship. I’m Heather, a wife who is more than her illness, and who needs and wants hope and love from her partner.”



In sickness and in healthDan and Dolores have weathered 43 years of marriage—and Dan’s bipolar swings. 

Dan, now 73, was accurately diagnosed in his late 20s. He and Dolores were contemplating marriage, and she accepted the news along with the man.

“He was a real charmer and had a wonderful sense of humor,” Dolores remembers.

Dan was in a stable period when they met, but shortly after the wedding he slipped into depression. For the next decade, he cycled from months of mania marked by reckless spending and anger, to months of immobilizing depression, to stretches of stability that might last half a year. He went through a series of jobs, never keeping one for long.

“I was ill and non-productive and she was the provider and caretaker,” Dan says.

Dolores held down several part-time jobs, taking their two children to work with her because they couldn’t afford child care. The couple went through two bankruptcies.

“It was painful and it was devastating, but I didn’t leave because I don’t believe in divorce,” says Dolores, 75. “But even in the most difficult moments, Dan’s sense of humor would come shining through.”

They held on until Dan found the treatment he needed at Washington University. An equally important turning point was their decision to start a peer support group in 1980, which became one of the founding chapters of what is now the national Depression and Bipolar Support Alliance (DBSA).

The work not only helped his wife become more educated about the disorder, Dan says, but through running meetings “she gained many skills in talking with me in a very helpful and therapeutic way.”

“We learned how to communicate even around tough topics—and not blame the other person,” Dolores adds.

Dolores admits to “mixed feelings” about their marriage over the years, but says that their life improved as their ability to address Dan’s health got better.

“He has changed in a really positive way over the years,” she says. “And our communication strategies just got better and better. We feel so blessed now.” 


Another definition of partnerPeople who are single may find a family member who becomes a partner in recovery. For Jackie that’s her dad, Larry.

“We’ve become an amazing team at managing my bipolar I,” explains the 25-year-old. “We even have a special binder that we keep on the coffee table that has copies of the most important papers about my illness and how we should handle things.”

The binder includes a list of her medications and what they’re for, contact information for her doctors, steps to take in various crisis situations, even copies of some of her homework from psychotherapy.

Jackie has found the skills she’s learning in dialectical behavior therapy especially helpful in managing her symptoms. When she comes home from group, she shares new information with her father. Also really helpful, she says, is “both of us reading everything we can get our hands on about bipolar. We test out new techniques for managing things to see what works best for us.”

For example, Jackie now keeps track of when (or whether) she’s taken her medications on a dry-erase board that hangs on the fridge. The chart not only reminds her to take the meds, but also keeps her father in the loop without having to bug her.

Jackie, who was diagnosed at 14, has seen a huge change since her father started educating himself. When she’s in a mood shift, they’re able to talk through what may have triggered it and how to get her back in balance. When her dad learned that people with mental illnesses sometimes use cigarettes to cope with stress, he stopped insisting she quit smoking. Instead, he encourages her to cut back.

“Before he started reading he didn’t understand nearly as well as he does now, which really goes without saying,” she reflects. “We fought a lot more and he really didn’t ‘get’ me. Now we fight less and he’s much more compassionate to what I’m enduring.”

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