There is no one medication or treatment approach for bipolar disorder that works for everyone. The symptoms of the illness in a specific person are often as unique as the individual, and treatment must be carefully individualized to each patient and his or her particular symptom pattern.
Confront and Accept the Illness
There is no cure for bipolar disorder, only treatment, and management. It is a relentless illness whose symptoms inevitably and repeatedly return to torment its sufferers. The only way to keep it at bay is for the patient to be relentless as well – relentless about getting needed treatment and sticking to it.
Human beings have an almost unlimited capacity to explain away the obvious. People who don’t want to confront serious physical illnesses can ignore and explain away even the most alarming symptoms: the middle-aged man with a history of high blood pressure who doesn’t pay attention to his repeated episodes of chest pain (“Oh, it’s just heartburn; must have been something I ate”), the woman who feels a lump in her breast and tells herself, “It’s probably just a cyst, I’m sure it will go away.” Confronting a possibly life-threatening illness is perhaps the most frightening experience we can face. Small wonder we sometimes put ourselves through some impressive mental gymnastics to avoid the confrontation.
When there are no physical signs of illness, no pains or lumps or dizzy spells, it’s perhaps easier to convince oneself that the symptoms of illness are something else. As we’ll see, stress can indeed play a role in precipitating an episode of a mood disorder, but it’s not the cause. Stress doesn’t make people manic or send them into major depression unless they have bipolar disorder. Neither does drinking too much or sleep deprivation or the loss of a job or the end of a love affair or the hundred other things that you can convince yourself explain your symptoms better than a diagnosis of bipolar disorder.
People with bipolar disorder can go through years of denial and anger about their illness. But there’s a gap between complete denial and complete ability to confront and accept this illness. Unfortunately, people sometimes try to hold on to the notion that nothing is seriously wrong by refusing to take the problem seriously. This is especially easy and especially problematic in bipolar disorder.
In bipolar disorder, the patient ultimately determines how well any treatment is going to work – because it is the patient who puts treatment recommendations into action. It is the patient who will determine whether he or she takes every dose of medication, or just 90 percent of the doses, or 50 percent, or even less. The patient will determine how many appointments are kept with the doctor and therapist and how many are missed, and how many are shorter than scheduled. It’s so easy to let your guard down, let treatment lapse in little ways, and convince yourself that missing a dose of medication here or there, having that second beer, or ignoring a string of sleepless nights, isn’t really important. To do so is to turn away from rather than confront this disease, and often the turning away springs from ambivalence about the need for treatment: less than complete acceptance of the diagnosis. Not to accept, not to confront, this illness puts treatment success in jeopardy, because in bipolar disorder as perhaps in no other serious illness, it is the patient who administers the treatment most of the time.
The Kindling Hypothesis
There is a lot of research that lends support to the kindling hypothesis in bipolar disorder. Emil Kraepelin noticed that early in the course of his manic-depressive patients’ illnesses, their mood episodes often came on after a stressful event in their lives: “In especial, the attacks begin not infrequently after the illness or death of near relatives…Among other circumstances, there are occasionally mentioned quarrels with neighbors or relatives, disputes with lovers…excitement about infidelity, financial difficulties…We must regard all alleged injuries as possible sparks for the discharge of individual attacks.”
These observations have been borne out in later studies: initial and early mood episodes in patients with bipolar disorder are often related to psychological stressors, but after several episodes, the illness can take on a life of its own, and episodes are more likely to arise spontaneously. This is now called the kindling phenomenon in bipolar disorder: a match held to a pile of wood will often start a small flame that quickly dies out, but if the process is repeated often enough, a fire is kindled, and no more matches are needed.
These observations mean several things for persons with bipolar disorder: (1) psychological stress can make a person with bipolar disorder more vulnerable to having a mood episode, and (2) as the person has more and more episodes, the symptoms can be triggered by smaller and smaller amounts of stress. However, (3) there may be a “point of no return” where the illness has become sufficiently “kindled” that stress management no longer has much of an impact, and episodes occur spontaneously and more and more frequently.
Persons with bipolar disorder should make peace with the idea of taking medication every day for the foreseeable future. This is an especially hard thing to do with this disease. The idea of taking medication to control one’s moods and mental processes is a daunting one. Remember, however, that in bipolar disorder the medication allows the patient to be in control of their moods rather than the other way around.