“Adjusting to the personal and social demands of high school, college, and the young adult years is more complex than it has ever been. And for today’s adolescents and young adults with bipolar disorder, the challenges are even greater and the stakes even higher. With their book Facing Bipolar, Federman and Thomson provide us with an important new resource. Based on sound clinical research and the rich experience of two knowledgeable practitioners, the book speaks in a direct and easy-to-understand voice that addresses the everyday questions of those initially facing this disruptive disorder. I strongly recommend this high-impact resource for teens, young adults, and others confronting the reality of bipolar disorder, and for the bookshelves of the counselors, psychologists, and psychiatrists who treat them.” —Alan M. Schwitzer, Ph.D., licensed clinical psychologist and editor of the Journal of College Counseling “Federman and Thomson have written a very thoughtful and pragmatic book. Their poignant stories describe the critical processes of recognition and acceptance while their straightforward advice conveys important treatment strategies required to manage this complex condition. This really is a must-read for young adults coming to terms with bipolar disorder.” —Richard Kadison, MD, chief of Harvard University Mental Health Services and author of College of the Overwhelmed “In my work with college students who occasionally get derailed, I have found that no issue is more perplexing for students and those who love them than the onset of bipolar disorder. Federman and Thomson provide a valuable frame of reference for making sense of the chaos that bipolar disorder can bring to the life of a college student. Students and family members will also find comfort and order in the sound words they provide.” —Penny Rue, Vice Chancellor of student affairs at the University of California, San Diego “Being a young adult with bipolar disorder is challenging, and it’s imperative to seek out good resources to cope successfully. Having read numerous books about bipolar, I’ve not found any others that are as clear and informative as this one. Federman and Thomson have truly provided the information necessary to living a healthy and happy life with bipolar disorder.” —Chadrick Lane, recent college graduate with bipolar disorder, mental health research fellow, and MD candidate contents acknowledgments introduction Chapter One: what is bipolar disorder and how can you tell if you have it? Depression and Mania: The Two Poles of Bipolar Disorder Having Bipolar Disorder vs. Being Bipolar Chapter Two: getting help Hesitation Is Normal Where to Turn for Help Your First Appointment Diagnosis Treatment Recommendations What’s Your Role in This Process? What You Need to Know About Medications for Bipolar Disorder Medications Prescribed for Bipolar Disorder If You're Depressed, Why Can’t You Take an Antidepressant? Why You Shouldn’t Stop Your Medications Chapter Three: how do you accept all this? The Stigma of Mental Illness Defensiveness in Response to Feedback: A Common Reaction Not Wanting to Accept Your Bipolar Reality Vulnerability: An Unfamiliar Aspect of the Emerging Self Wanting to Fit In The Inevitable Tendency Toward Denial The Bipolar Masquerade Anger and Helplessness: The Precursors of Depression Pseudo-Acceptance: A Common Blind Spot Writing Your Own Story Finding Acceptance Chapter Four: what you can do: the four S's of bipolar stability Creating a Structured Life Managing Stress Getting Good Sleep Learning to Self-Monitor Chapter Five: how open can you be about your disorder? Transparency with Others The Notion of a Helping Team The Benefit of Support from Others with Bipolar Disorder Chapter Six: managing your independence Being Involved but Not Overcommitted Alcohol, Drugs, and Partying Continuing Your Psychiatric Treatment Away from Home Academic Parachutes: Course Drops and Full Medical Withdrawals Chapter Seven: looking forward Do You Have to Let Go of Your Hopes and Dreams? Taking Stock of Your Strengths Picking Yourself Up After a Fall Will You Ever Get Better? Creating New Hopes and Dreams Creating New Hopes and Dreams Appendix A: internet resources Medication-Related Websites Stress Management Websites Mindfulness Websites Appendix B: using the sleep, mood, and energy chart References acknowledgments We are grateful that our collaborative work at the University of Virginia’s Counseling and Psychological Services brought us together and inspired us to write this book. Our appreciation goes to Tesilya Hanauer and New Harbinger for taking a gamble on rookies to the self-help realm; New Harbinger’s Jess Beebe and Kia Penso for their excellent copyediting, Drs. Steve Dauer and Tom Horvath for their support, encouragement, and editorial input; the artist Sabina Forbes II and her mother, Sabina Forbes, who brought their personal knowledge of the illness to bear on early chapters; our colleagues at the University of Virginia Counseling and Psychological Services, who provide unparalleled consultations; Drs. Goodwin and Jamison, whose collected body of research in their second edition text was essential to our writing; Stephen Stahl, whose incomparable textbook and educational tools guided our discussion of medications; the annual review course in neuroscience and psychopharmacology hosted by the Foundation for Advance Education and staffed by researchers at the National Institute of Mental Health; and Tracy Federman for making this book better than it would have been without her. To our patients, who have honored us with their trust and granted us the privilege of being allowed into their lives in order to see and understand the realities of bipolar disorder, we dedicate this book. introduction So you’ve been told you’re bipolar, or perhaps you’re wondering if you are. You either have bipolar disorder or you think you do. You’ve learned that this diagnosis can mean a lifetime of troubles. You’ve learned that if you’ve got it, you might have to take medication for the rest of your life. You understand that the disorder is genetic. You understand that people with bipolar disorder sometimes need to be hospitalized. You didn’t ask for this. It wasn’t in your life plan. Perhaps you’ve had times when you felt so down you couldn’t get moving. Keeping up with your work or even getting out of the house seemed impossible. It felt like you were trying to slog your way through molasses with no end in sight. Essentially, your self-esteem was in the pits and you felt awful. Then, there were other times when you felt alert and energized. Sleep didn’t matter a whole lot and your usual challenges felt like a piece of cake. You felt alive! Images, scents, and sounds were so crisp and immediate. Others around you didn’t seem to be moving at the same pace, but it didn’t matter; little mattered. Yes, it was an exciting time and you enjoyed it. But just as quickly as it arrived, it was over, and you crashed back into the depression, back into the molasses. You started thinking maybe you should end your life. You knew those thoughts weren’t you, but at the same time they were you and they seemed the only solution. The confusion was hell. You can begin to see why people say bipolar is trouble. You know this craziness means something is wrong. If you’ve sought help, you’ve probably received plenty of advice about how to manage this disorder. You’ve been told you should see a psychiatrist. And if you have, you’re facing pills. Lots of pills. Take your choice: Lexapro, Seroquel, Depakote, lithium, Tegretol, Lamictal, and others. You’ve been told that while these drugs can be helpful, you’ll also have side effects such as drowsiness, dry mouth, weight gain, dulling of your emotions, and even dulling of your sexuality. And you’ve been told that you may have to take several of them at the same time, forever. Why? If you feel fine or almost fine, why would you have to take these waist-expanding, thirst-inducing, libido-reducing pills forever? What is that all about? They say something is wrong with your brain, your neurochemistry, your genetics. There’s no simple explanation. Bipolar disorder is not a simple illness. It’s a disorder of the brain and of the mind that affects who you are, what you think, what you feel, and how your personality places itself in the world. These are not things you can see, touch, taste, or smell. They say you should get into psychotherapy. A psychotherapist is a different kind of shrink from the one who prescribes the pills; he or she is someone you’ll talk with about how you’re really feeling and thinking—the kind of stuff you just don’t tell anyone. And you may have to do this for a while because you’ve also been told that bipolar isn’t going to go away, no matter how much you want it to. Bipolar isn’t like mononucleosis, which you’d recover from eventually. And beyond the medicine and the psychotherapy, you’re told that you’ll have to monitor your sleep patterns carefully. You’ll have to make sure that you get good sleep—that you go to sleep and get up at consistent times. You’ll have to stop using alcohol, pot, stimulants, energy drinks, or whatever else you’ve relied upon to help you get by. To you it sounds like no partying, no fun, no life. Besides, if you’ve only recently been told that you’re bipolar, you probably think your parents, your loved ones, and the professionals you’ve seen are all exaggerating the bad news. It’s like suddenly everyone is telling you that the sky is falling! And even if you decide to go along with their recommendations and do all that they’re asking, you could still be psychiatrically hospitalized for acute depression, suicide attempts, or manic episodes. And in the middle of all this bad news, you’re encouraged to remain hopeful and not let it get you down. Yeah, right! Okay, let’s get real. It’s pretty unlikely that you’ll simply do what other people expect without really questioning where they’re coming from. You might hope that they’re wrong and look for anything to support that hope. You may want a second opinion. You might also look toward any alternate explanations that will help you make sense of your recent instability. The bottom line is that a diagnosis of bipolar disorder sure as hell isn’t welcome news. In fact, it’s downright frightening, and you’ll most likely do your best to find some way of minimizing it, explaining it away, or outright denying it. Welcome to the resistance and denial that follow the news that you’re bipolar. These reactions are absolutely normal, and so is your desire to run from the diagnosis. And as odd as this may sound, we advise against trying to sidestep your reactions. Intense reactions against the diagnosis are completely to be expected. Our focus will be to help you understand these reactions so that you can learn to deal with them effectively. As you begin to face the reality of being bipolar, you’ll find that one of the toughest challenges is saying good-bye to the person you once thought you would be, especially at a time in your life when you are thinking hopefully about your future. If you’re new to the bipolar experience, you’re probably somewhere between your midteens and your midtwenties, and letting go of your previous expectations about life’s direction is hard. It may be even harder than it was to accept your bipolar diagnosis. Worse yet, you may even find that some people will withdraw from you or drop out of sight once you’ve found the courage to tell them, “I have bipolar disorder.” Let’s face it, some people are afraid of mental illness. Your relationships will be affected. Almost everything will be affected. We know this all must sound pretty grim; it doesn’t need to be. When you move to a new city, you need to know how to have the gas and electricity turned on and the phone hooked up. You need to find the grocery stores and the major department stores. A guidebook is essential, only now it’s the Lonely Planet Guide to Bipolar City you need. You didn’t choose this destination, but this is where you’ll be living. You need to know how to live here. You need to know how to keep your mind stable, how to take care of it, and how to keep it on the right track. In your old world, where you wish you still lived, this isn’t the book you would be flipping through in a bookstore. We understand. We know this is not a book you want to need. In the chapters that follow, we’ll provide you with straightforward, down-to- earth, and easily digestible information about this thing called bipolar disorder. You’ll learn what it looks like, how common it is, how it usually unfolds, what’s involved in treatment, what challenges you’ll face, and what kinds of lifestyle changes you’ll need to make. And if you’re not the one with bipolar disorder, then this book will help you to better understand what’s going on with the person you’re concerned about. Our intent is to make Bipolar City less frightening, less lonely, and less strange. You’ll come to see that it’s a different city from the one you were setting out for, but it’s still quite livable. The hitch is that you don’t get to live there unless you’re able to let go of your expectations about the other place you had hoped to reach. And once you come to terms with this loss, once you’re able to look around and realistically assess what it takes to make a home in your new destination, then you’ll be in a much better position to tackle the reality of bipolar disorder. We hope to help you manage this important transition. So why did we write this book? Because we have both worked in the mental health field since the mid-1970s. Between us, we have more than thirty-five years of experience working with university students. We’ve each treated many students with bipolar disorder, and we’ve come to see firsthand the profound