Jan 26

Dangers of Mania

Dangers of ManiaA cheerful young woman comes in for a consultation and soon we come to a topic that can be remarkably frustrating for all: trying to explain the dangers of mania.

She is only mildly manic.

It’s true she often gets into arguments that don’t really make much sense and she has been smoking more marijuana and hooking up with an unusual number of young men, but she isn’t doing anything clearly dangerous.

And she is very charming and funny. And self-confident.

We all feel that we understand ourselves better than others do. How to explain to her that what’s happening is the progressive shutting down of the medial prefrontal cortex, the part of our brains that searches for evidence of risk and warns us away from doing thingsMedial Prefrontal Cortex and Mania that are risky. The brain cells that ordinarily monitor for painful outcomes are going to sleep. And the more energized, or manic, she becomes the less aware she will be of risks.

It is what is called a positive feedback loop. Because she is not aware of risk, she doesn’t really understand why she needs to pay attention to sleep, or take medications so that she can get to sleep. And, as a result, she gets more manic. And as she gets more manic she becomes even less aware of harmful consequences of her decisions.

This is why it is important to moderate mania before it becomes clearly excessive. By the time it is causing a person to make dangerous choices it may be too late to intervene. By then the manic person is no longer able to process evidence of potential risks.

Learning to live with hypomania and mania often means creating a plan for identifying when the “danger zone” is approaching. This is where some kind of memo to oneself (for example contained in the Wellness Recovery Action Plan) can be useful. Describing as clearly as possible what things are like when intervention is necessary.

When you are reaching a risky level of mania do you…

  • Need less sleep – If so how much sleep is necessary. For many people sleeping 5 hours a night for more than one night can be a warning sign.
  • Do you feel more energetic and more active – Do you take on new projects, clean the house from top to bottom, these are good things but several days of unusual energy can also be a warning sign.
  • Are you more self-confident – As the risk monitoring part of your brain shuts down you will feel that you can tackle bold new projects, at first this is a blessed relief from the normal hypervigilance of that part of the brain, but are people you know now warning you to be careful?
  • Do you feel more sociable (are you making more phone calls, going out more) – This increased communication with others is such a good predictor of mania that it is sometimes possible to predict mood shifts based only on call logs, or twitter or facebook posts.
  • Do you want to travel and/or are you travelling more
  • Do you tend to drive faster or take more risks when driving – This is obviously a sign that the risk part of your brain is less active.
  • Spending more money or too much money is often one of the first signs that you are entering the danger zone.
  • Planning more activities or projects and having more ideas, or feeling more creative doesn’t sound risky – But tackling too many projects leads to a bigger crash when it turns out that it isn’t possible to complete those projects.
  • Feeling more flirtatious and/or being more sexually active is also something that in a small amount can be a positive – But too much can lead to risks.
  • Other signs are thinking faster, making more jokes or puns when you are talking
    Being more easily distracted – One of my patients would suddenly notice the “very loud” clock in my office when he started to get energized… Sense data becomes more compelling. Colors seem more vivid. Sounds richer. Again, a little of this can be wonderful.
  • Do your thoughts jump from topic to topic – Are these changes in direction becoming difficult even for you to keep up with. Do you find it annoying to talk to others because they seem so slow?
  • Are you more impatient and/or do you get irritable more easily, in fact, can you seem exhausting or irritating for others – One of the risks of mania is that it can lead to burnout in even those who care for you the most, and it can be hard to recover some of those friendships.
  • Do you smoke more cigarettes, take more drugs, or drink more alcohol – Many of these substances act synergistically to increase mania and impulsive decision-making.

Paying attention to these warning signs, and developing a plan for reaching out to others (your psychiatrist or therapist, or trusted family members) when they start to appear, so that you can benefit from their additional perspective on what is happening, can make all the difference between experiencing a mild period of increased energy without harmful consequences and a manic episode with long term negative effects on your life.

For More Information

Tricked by Mania – Bipolar Hope

Dealing with Denial

Positive Change or Mania?

Crisis Prevention


Jan 25

Frequent Lying and Biology

Frequent Lying BiologyFrequent lying and its biology is the subject of a fascinating article in Nature Neuroscience.

Scientists have shown that the brain’s fear and alarm circuitry (the amygdala) is usually triggered when one lies (even lies of omission or “white” lies). They’ve also shown that reducing this response by giving someone medications that affect the amygdala increases the likelihood that a person will lie.

But people who lie once have a somewhat smaller response to the next lie and this process of adaptation continues, seemingly indefinitely. They were also able to show that the reduction in response in the fear and alarm circuitry from one lie predicts the likelihood that in the next conversation a person will lie again. In other words the changes appear to be causal rather than just correlational.

They also found that this progressive increase in lying behavior occurred only for self-serving lies. The reduction in alarm response circuitry when lying didn’t have any effect on lying to help or protect others.


Garrett N, Lazzaro SC, Ariely D, Sharot T. The brain adapts to dishonesty. Nat
Neurosci. 2016 Dec;19(12):1727-1732. doi: 10.1038/nn.4426. PubMed PMID: 27775721;
PubMed Central PMCID: PMC5238933.

Jan 24

Darkness Treats Mania?

Darkness Treats ManiaBright light is one of the most rapidly effective treatments for depression and may be helpful for depression even in people without a clear seasonal pattern (winter depression). A recent study suggests that it may also be true that darkness treats mania.

The portion of the light spectrum that affects circadian rhythms the most strongly is blue light, which is why the GoLite, which only puts out blue light, is so effective in treating seasonal depression. The authors of this study examined whether glasses that blocked blue light might be helpful in treating mania.

Blue-blocking glasses have an antimanic effect

Preliminary data has suggested that there are antimanic effects of “dark therapy.” The authors of this study looked at the question of whether orange colored glasses (blue blockers) have the same effect.
24 hospitalized patients with mania, who also received usual anti-manic medications, were randomized to wear blue blocking glasses (BBs) or clear-lensed glasses from 6 p.m. to 8 a.m. for 7 consecutive days. The glasses were taken off when the lights were out.

The study looked at the impact of this intervention on physical activity measured with actigraphy (you probably carry one of these with you since most smart phones measure physical activity this way) and daily ratings of mania by clinicians.

Less medication was needed in those who wore the blue blocking glasses.

Mania scores were significantly lower after 3 days of BBs and continued to improve through 7 days. There was a very large effect size (number needed to treat (NNT), >1.5). NNT is one of the most useful ways of assessing the impact of an intervention. The smaller the number the greater the effect of the treatment. To put this finding into context, the NNT in all trials of atypical antipsychotics for mania was 5. In other words, in this one small study, BBs were much more effective than atypical antipsychotics.

Individual symptoms improved as well, especially irritability and racing thoughts. After the second night, average activity was lower.

Two patients using BBs experienced emerging depressive symptoms.One improved after decreasing BB duration by 2 hours; the other stopped it for one night, and mood rapidly elevated. One patient and three healthy controls reported headaches.


Henriksen TE et al. Blue-blocking glasses as additive treatment for mania: A randomized placebo-controlled trial. Bipolar Disord 2016 May; 18:221. (http://dx.doi.org/10.1111/bdi.12390)

For More Information

Blue blocking glasses for those who wear prescription glasses.

Blue blocking glasses for those who don’t wear glasses.


Jan 21

Facebook Friends May Save Your Life

Facebook Friends Reduce MortalityFacebook friends may help you live longer. This is the surprising result of a recent study that received a lot of attention, and which some of you may have thought was a marketing ploy. However, the study was published in the prestigious journal the Proceedings of the National Academy of Sciences.

Here is a summary of the study and the findings from the abstract…

“Friendships and other offline social ties have been repeatedly associated with human longevity, but online interactions might have different properties. Here, we reference 12 million social media profiles against California Department of Public Health vital records and use longitudinal statistical models to assess whether social media use is associated with longer life.

The results show that receiving requests to connect as friends online is associated with reduced mortality but initiating friendships is not. Additionally, online behaviors that indicate face-to-face social activity (like posting photos) are associated with reduced mortality, but online-only behaviors (like sending messages) have a nonlinear relationship, where moderate use is associated with the lowest mortality. “

The meaning of the first result is a bit unclear. The authors found that initiating friendship requests with others was not associated with reduced mortality. However, having others approach you to be Facebook friends and accepting those requests was associated with a significant reduction in all cause mortality. This showed up as reductions in death from causes as varied as infections, heart disease, diabetes, liver disease and homicide.

But did this really mean that being on Facebook was helpful or did it reflect the fact that people who accept more friendship requests have more requests for friendship from others. In other words did it just show that people who were more popular lived longer, presumably whether they were on Facebook or not.

The second set of findings was a little bit more suggestive of a benefit from certain kinds of Facebook activities. Posting photos with helpful and the more photos you posted the better. But posting messages was not necessarily helpful. Those who posted no messages had higher mortality than those who posted a moderate number of messages, but those who seem to spend all their time online posting messages also had a higher mortality than those who posted a moderate number of messages.

Which raises the question of whether posting on a photo-based site such as Instagram would be even more strongly associated with health…


William R. HobbsMoira BurkeNicholas A. Christakisand James H. Fowler. Online social integration is associated with reduced mortality risk. PNAS 2016 113 (46) 1298012984; published ahead of print October 31, 2016, doi:10.1073/pnas.1605554113

For More Information

Facebook Causes Depression

Social Media Makes Moods Go Viral


Jan 18

Chronotherapy and Getting Up Early

The Dead Sea before dawnGetting up early is one of the best ways of counteracting depression. This intervention has been shown to have a robust antidepressant effect (it is called Chronotherapy). But it can be a challenge making a change in your sleep cycle, especially if you have always been a late riser. And especially when it is winter and it is dark and cold and rainy outside.

This article will talk about how to get up early.

If you want to read more about why you might want to make this change here are some articles on the topic:

For most of my life I felt sure that I was naturally an “owl” – late at night was my best time of day, and I hated the morning. It was only when I had to start getting up to take care of my daughter that I made a serious effort to change this pattern.

I now know that you can change what seems like a life long pattern.

But if you don’t have the motivation that comes from needing to take care of your child, how can you make the change?

For the last ten years I have been collecting tips.

1. Prepare

Many people think that the key to making a change is something called “willpower.” I don’t believe it. I can tell who is going to succeed and who is not by listening to how they have prepared for the change. It has very little to do with willpower.

Get your bedroom and house ready for your morning awakening. Think about how you can quickly enter a world that is welcoming.

Light.jpgLight. How can you have plenty of light, even if it is winter and you are getting up before dawn? I recommend buying a bright light (a therapy light) or a dawn simulator to put at bedside. That way you don’t even have to get out of bed to start the day – although you do have to open your eyes…

Coffee and Breakfast. Prepare the coffee maker, and get some special food for breakfast. Cup of cappuccinoOne of the things that got me through the transition to waking early was buying an espresso machine that allowed me to have a ritual special cup of latte in the morning.

Clothing. Set out your clothes so that you don’t have to figure out what to wear. If you want to go exercising in the morning this can be especially important. The idea is to have things ready so you don’t have to think… just roll out of bed and into your clothes.

Activity. Create a compelling plan for what you will do in the morning. At the beginning, it Runningmay be helpful to set up an engagement that will be hard to miss. Arrange to meet someone for breakfast, or go for an early morning walk. Even a phone check in with a friend or relative back East can be a motivation.

A Wake Up Call. If you have trouble because you have learned to hit the “snooze” button without even waking up, consider changing your wake up alarm… maybe have that friend back East be the one making the wake up call. Or use one of the free internet phone reminder services, like Wakerupper.com.

Here is an idea that combines activity and a wake up call… sign up for a morning workout or morning run with a friend, or a trainer.

This may sound like a lot of work, but the more you do the night before the better your chance of success.

2. Set a Realistic Goal

You are more likely to succeed if you are not trying to change your wake up time too much. Few people can wake up two hours earlier, and a half an hour change may be the ideal first step.

The point is, you want to change the pattern of behavior first (sleeping until the last minute)… once you are confident that you can make some change, you will find it a lot easier to build on that early success and move the rest of the way to your desired wake up time.

3. Go to Sleep with the Plan in Mind

It can be surprisingly powerful to go to sleep thinking about what you plan to do when you are woken up in the morning.

Don’t Think. Get Up. The longer you think about whether you should get up or not the less likely you are to succeed. Most of what we do when we are lying in bed thinking about getting up is a futile internal argument that tends to deplete our energy and motivation. Make the decision that you will get up and do something before you try to decide whether to stay awake. For example, decide that you will get up and slip on your work out clothes before you think. Or that you will turn on the coffee maker.

Here are some more thoughts to consider –

Jump out of bed. Yes, jump out of bed. With enthusiasm. Jump up and spread your arms wide as if to say, “Yes! I am alive! Ready to tackle the day with open arms and the gusto of a driven maniac.” Seriously, it works.

Put your alarm across the room. If it’s right next to you, you’ll hit the snooze button. So put it on the other side of the room, so you’ll have to get up (or jump up) to turn it off. Then, get into the habit of going straight to the bathroom to pee once you’ve turned it off. Once you’re done peeing, you’re much less likely to go back to bed. At this point, remember your exciting thing. If you didn’t jump out of bed, at least stretch your arms wide and greet the day.  

4. Use the Morning Time Well

Don’t turn on the computer or glance at your phone and check your email. Email is an energy drain. And don’t watch the news, also a source of pessimism rather than optimism in the morning.

Do something health and pleasurable. Go for a morning walk. Meditate. Eat a healthy breakfast. If you want to convince yourself that getting up in the morning makes sense you need to treat yourself well in the morning.

Here are some other ideas –

Drink a glass of water. You’re dehydrated from not drinking any water all night. Drink a full glass of water if you can. It’ll make you feel more awake.

Meditate. Even just for 3 minutes. It’s such a great way to start your day — doing nothing, just sitting, and practicing mindful focus.

Write. Or do some other kind of creating.

Exercise. Go for a walk or a run, or do a home workout. Even just 10 minutes.

Enjoy a cup of coffee or tea. Either one of these makes the morning better.

Use Circadian Rhythms

All of us cycle through relatively regular 90 minute cycles of deeper and lighter sleep throughout the night (relatively regular… the usual range is 90+/- 10 minutes and disturbances in the night can have a big impact on how regular the cycles are.

In theory, finding a way of aligning your wake up cue with this natural sleep rhythm may make it  easier to get up. A number of products try to use that fact to choose the best time to wake up. But we aren’t sure how effective they are, although there are lots of enthusiasts on the internet…

WIthings Aura is the ultimate geek’s toy, combining a light and sound alarm clock with a REM sleep sensor that you tuck under your mattress.

Other options include the Beddit Sleep Monitor, Jawbone’s Up3 or Up4 wrist monitors and an app on your cell phone (like the ever popular SleepCycle) which monitors movement on your bed if you lie it next to you on the bed while you sleep.

Having worked with a number of people who have tried all of these variants, I am not impressed with how durable the results are.


Jan 07

Why Do I Have To Have a Regular Schedule?

Young hooded boy“Why do I have to have a regular schedule” was the lurking question that hung over my conversation with Ann.

She didn’t actually ask me that question but I could see that there was a rebellious child hiding in the corner of the room who was making the conversation we were having about getting regular sleep much less productive than it could have been.

The evidence about the ability of strong and regular circadian patterns of activity and sleep to help manage mood is increasingly strong. A recent post on Mood and the Brain’s Clock highlights just one of the studies on the subject.

I’m not going to focus on that evidence or even on the question of what the ideal schedule should be. I’ve talked about that a lot in other blog posts and I’ll reference some of them at the end of this one.

What I do want to talk about his the process of rebellion and how it affects us once we are no longer children.

All of us, to a greater or lesser extent, remember feeling frustrated with our parent’s seemingly irrational demands and requests.

And a certain amount of rebelliousness is inherent in the creativity which is one of the hallmarks of bipolar mood.

Variations on this theme are pretty common in my experience working with people with bipolar. My struggle as a clinician is to try to avoid accepting the parental role. Not to take responsibility for trying to change another adult’s behavior.

This may be particularly important if the person I am coaching grew up in an unstable environment, perhaps with a bipolar parent, for example.

Children growing up in a world of changing rules may have learned to avoid change of any kind. Just to wait and see.

If I am not very careful my conversation with Ann will become a power struggle between an authoritarian doctor and a free-spirited patient. Or between an irrational and authoritarian doctor and a patient who is not sure which recommendations should be followed and which resisted.

I need to avoid tapping into this pattern because in reality what is happening is no longer an external struggle. The struggle is between the person and his or her body and brain, or between the person and his or her bipolar moods.

An expression from the 1970’s comes to mind: “Don’t try to fight the river.”

Or in terms that are very relevant to this website, don’t try to fight the tides or even the waves of mood… instead surf them, use adult knowledge to create a better life with bipolar.

For More Information

Getting Up Early

Sleeping at the Right Time

How Light Affects the Brain

Staying Up Late

Take Action… Why Do I Have to Pick Up My Room?


Dec 27

Starting the New Year Right

Starting Off the New Year Right: 5 Areas of Your Life to Implement Self-Care

Fireworks on fourth of July in Seattle WashingtonAs we start off the new year it’s important to remember the value of taking care of ourselves and engaging in regular self-care. Our mood, anxiety, substance use and relationships can be greatly impacted by stress levels and self-care is an important way of supporting ourselves in both reducing and managing stress as it arises.

Take some time to ask yourself what ways you already practice self-care and what ways you want to start practicing more self-care. This can be a great way to start creating healthy habits in the new year. Ask yourself, which areas of your life are you best at implementing self-care strategies and which areas do you have goals around growing self-care practices:

  1. Physical Self-Care: eating regular meals, eating healthy meals, regular exercise, regular medical check-ups, getting medical care when needed, regular sleep routine, taking time off when needed
  2. Psychological Self-Care: making time for self-reflection, seeing a therapist, writing in a journal, reading, practicing mindfulness, being curious
  3. Emotional Self-Care: Spending time with others whose you enjoy, staying in contact with important people in your life, asking for help when you need it, giving yourself affirmations and praise, re-reading favorite books or favorite movies, identifying comforting activities, places or people and accessing them, allowing yourself to cry, allowing yourself to laugh, playing with children and/or pets
  4. Spiritual Self-Care: meditating, praying, singing, having experiences of awe, contributing to causes you believe in, reading inspirational literature, making time for reflection, finding spiritual connection or community, spending time in nature
  5. Professional Self-Care: taking breaks during the work day, taking time to chat with other co-workers, identifying projects that are exciting and rewarding, setting limits, arranging your work space so it’s comfortable, negotiating your needs (vacation, pay, benefits)

Creating balance in our lives and finding ways of caring for ourselves is essential in managing our well-being and mental health. Remember, by taking the time to care for yourself, you are able to be more present in caring for those you love and work towards your long term goals.




Dec 12

Coping with the Holidays – Gina

Coping with the Holidayscoping-with-the-holidays: Having a Plan

The holiday season can be a time of increased stress. It is often said to be the “happiest time of year” when in fact, for many of us, it can be one of the most challenging times of year. Know, you are not alone if this is the case for you.

Whether it is a work party, family gatherings, finances, the loss of a loved one, loneliness or pressures around the upcoming new year, it can be helpful to come up with a plan of ways you can cope to supporting yourself in managing your mood, anxiety, substance use and potential conflicts ahead of time.

Coping ahead of time means to anticipate problems that are likely to occur and problem solve in advance so you are not taken off guard or surprised when they occur. You have a plan in place to support you in getting through those hard times!

Some questions that could be helpful to ask yourself are…

What are things I can do on a regular basis to help manage stress throughout the holidays?

  • Regular exercise, healthy eating, spending time with close friends, meditation, creative activities, journaling, taking breaks for yourself, positive self-talk, etc.

Who can I call if I am having a hard day?

  • Identifying people are helpful in different situations and let them know that I might reach out

How will I manage potential relationship conflicts?

  • Try role playing ahead of time with a trusted friend
  • Use DBT skills such as DEAR MAN

o   Describe the situation. Stick to the facts.

o   Express how you feel about it using “I” statements.

o   Ask for what you want.

o   Reinforce the other person. Explain positive effects of getting what you want.

o   Being Mindful. A clear and calm mindful approach is more likely to be accepted.

o   Appear confident. Use a calm tone of voice. Look people in the eye. Speak clearly.

o   Be willing to Negotiate. Discuss options and be willing and open to other suggestions.

Remember you are not alone in experiencing the holidays as a stressful time. By working to put plans in place, you can lessen the weight of some of the challenges you face as you approach the new year.


For More Information

Stress and the Holidays

Sad Christmas

Dec 10

Depression and Reward Insensitivity

Closeup of a golden coinsWhy do some people get depressed and what can be done about it? Studies of brain response to rewards suggests that there is a strong link between depression and reward insensitivity. People who are at risk of depression literally don’t react to rewards in  same way as other people.

A large study of adolescent girls without any history of depression found that the lack of the usual brain response to rewards (a reduction in EEG measured reward based electrical activity in the brain) was a significant predictor of depression independent of the current mood of the girls.

In girls with no history of depression, and no current depressive symptoms, a diminished response to reward predicted depression within the following year and a half.

The picture below shows the difference in brain response in girls who did and did not develop depression in the follow up period. reward-response-and-risk-of-depression

As you can see, there is significantly less response in the brains of those who went on to have depression.

This study fits with two other recent studies using a different technique (functional brain imaging using fMRI) that finds that the lack of response to reward often predicts later depression.

What if you think that you may be someone who responds less to reward than others (glass half empty rather than glass half full)?

There may be a way of teaching your brain to notice positive and rewarding stimuli more. This technique is called cognitive bias modification.

It turns out that a relatively simple computer program can help you to notice smiling happy-facesfaces, and there is evidence that using this program regularly reduces both depression and anxiety.

This is the basis for a set of apps from a company called Mental Mint that target depression and anxiety.

These apps are available for both iOS and Android.

For More Information

Attentional Bias Modification Prevents Depression


Electrocortical Responses to Rewards and Emotional Stimuli as Biomarkers of Risk for Depressive Disorders.” American Journal of Psychiatry, 173(12), pp. 1163–1164

Blunted Neural Response to Rewards as a Prospective Predictor of the Development of Depression in Adolescent Girls.” Brady D. Nelson, Greg Perlman, Daniel N. Klein, Roman Kotov, and Greg Hajcak. American Journal of Psychiatry 2016 173:12, 1223-1230
Stringaris A, Vidal-Ribas Belil P, Artiges E, et al: The brain’s response to reward anticipation and depression in adolescence: dimensionality, specificity, and longitudinal predictions in a community-based sample. Am J Psychiatry 2015; 172:1215–1223 Link
Hanson JL, Hariri AR, Williamson DE: Blunted ventral striatum development in adolescence reflects emotional neglect and predicts depressive symptoms. Biol Psychiatry 2015; 78:598–605 CrossRef, Medline

Dec 03

More Happiness

Child in the seaWe all need to be reminded about ways that we can bring more happiness into our lives. Rick Hansen has devoted his professional life to understanding the neuroscience of happiness and has created a set of tools that can help.

His course “The Foundations of Wellbeing” has helped many people I know to experience more pleasure and joy in daily life, to have more loving, satisfying relationships, to feel less stressed, worried, or blue, and to be more mindful, grateful, and hopeful.

A young woman I have worked with watched one of the videos from this series and told me how it significantly improved her awareness of the good moments and the happy moments in her life and as a result her mood has lifted out of a chronic and pretty severe depression.

I recommend it as a gift that you can give yourself. And if you follow the link below you can save 180$ off the course if you sign up by December 12th, 2016.

For More Information

Many of the posts on this were inspired by things Rick has to say about creating more satisfying lives.

Rick Hanson – Trust in Love

Hardwiring Happiness

The Loving Brain

Nov 26

Technology and Bipolar

colin-deppColin Depp recently gave a presentation on technology and bipolar as part of the excellent International Society for Bipolar Disorders monthly (free) video lecture series.

You can find out information about these video lectures on the ISBD website. I encourage you to sign up to get updates.

Back to Dr. Depp’s lecture.

He discussed a number of topics of interest to people with bipolar including online therapy and mood charting, but he particularly focused on his research designed to help people develop strategies for managing their own moods.

I’ve long been interested in this idea and have worked with a couple of patients to record video messages which they can play back to themselves when they find that they are in an energized or depressed state.

Dr. Depp’s Prizm project was an effort to help people with bipolar to create self-advice that could then be available to them outside of therapy sessions.

Each person enrolled in the trial met with a therapist who conducted a guided interview asking them about their future goals, and about how their moods change, and what symptoms are early warning signs of mood changes. They then created messages that were embedded in an app.

The Wellness Recovery Action Plan Wellness Recovery Action Plan is a related idea. It is a way of creating an action plan for coping with mood changes, a plan which not only includes recommendations for how you can cope, but also ideas for what your loved ones can do to support you and a place to outline your preferences for treatment when in a crisis.

The WRAP process is much more detailed and that’s part of what can make it difficult for people to complete (although there is an excellent mobile app that makes the process a bit easier).

The idea contained in all of these approaches is that when people are in a stable and workable mood, they are often in the best position to come up with plans for self care.

In addition, plans that we develop for ourselves have much more credibility and match our personal values better than plans that professionals or family members may come up for us when we are in a crisis.

Unfortunately, the Prizm project was effective only while people had access to the app.

Dr. Depp’s original idea had been that through this process people would develop skills for dealing with moods that would affect how they coped with their bipolar even after the research project was completed. That turned out not to be true, but the idea of self messages and developing your own action plan for depression or mania is still a good one.

Here is the full video.


Depp CA, Ceglowski J, Wang VC, Yaghouti F, Mausbach BT, Thompson WK, Granholm EL. Augmenting psychoeducation with a mobile intervention for bipolar disorder: a randomized controlled trial. J Affect Disord. 2015 Mar 15;174:23-30. doi: 10.1016/j.jad.2014.10.053. PubMed PMID: 25479050; PubMed Central PMCID: PMC4339469.

For More Information

Wellness Recovery Action Plan


Nov 20

Hamster Brain

hamster-brainA young woman who has been making good progress tackling the problem of severe depressive episodes suddenly is having trouble managing the opposite end of the mood spectrum.  She gets energized and is consumed with getting stuff done. She is unable to stop until she is exhausted and she crashes.

I call this state of mind “hamster mind” because it is like the endless spinning of a hamster in a cage.  Running endlessly and unable to stop. If one thing is done the hamster mind moves instantly on to another task.

In this state of mind what would often be most helpful would be to engage in mindfulness meditation.

But the brain in hamster mode views the idea of a mindfulness practice as something  alien and incomprehensible, like writing in Egyptian hieroglyphics.

The idea of sitting for two minutes without really trying to accomplish anything seems absurd and the hamster brain will repeatedly put off the task in order not to have to deal with that absurdity.

This is a good time to try a two-minute mindfulness exercisetwo-minute-meditation

Go to Calm.com. Select “Under the Sea” as the background sound. Then click on “Begin.” Scroll through the choices until you hit “Calm” and select it and then begin a two minute guided meditation.

Two minutes is short enough that even the most frenzied and hyperactive brain will have a hard time distracting you from doing the task.

Now set an alarm and in an hour or so do the same exercise again.

Four minutes is a small commitment of time. But the effect can be profound.

The first two minutes usually don’t achieve very much because your mind quickly wanders and becomes involved in thinking about things that need to be done as soon as the two minutes are up.

However the first two minutes sets an almost unconscious foundation for the next two-minute exercise. The second time you listen to the guided meditation you will more quickly and thoroughly enter into the mindful state as the sound of the narrator and the background music serves as cue to remind you how to re-enter that state.

When you are trapped in hamster mind two two-minute mindfulness exercises can have more impact on how you function than a half an hour guided meditation at other times, not because you enter into a truly deep meditative state but rather because a very small dose of mindfulness when you’re in hamster mind can make a big difference in terms of how you’re functioning.

When you’re in hamster mind your brain is trying to make you function at a hundred ten percent of your capacity. This quickly leads to burnout.

Those two two-minute mindfulness exercises allow your brain to slow down to about ninety percent which is a much more sustainable pace.

For More Information

The Power of a Minute

Mindfulness Apps

Nov 18

Avoiding Heartbreak in a Relationship

woman-sadAn attractive, intelligent young woman asked me, “Why can’t he show me any love, what is wrong with me?”

The two of them have been having a difficult time recently and she was feeling sad about how their relationship had changed in the last several months. She told me that she was in the shower crying about this when her partner came in and got angry with her.

They had a fight. She asked why he couldn’t show any compassion. He said he wasn’t sure that he loved her and ended up going to bed by himself. They never resolved the argument.

I was very concerned that he was unmoved by her sadness.

“Maybe he is not the right person for you to be with,” I wondered out loud. She said she was not ready to break up with him.

We talked some more and I got a bit more of the story.

She had reached out to him earlier in the evening asking him to be close to her and he had not responded as she had hoped. She got upset and went to take a shower and was in the shower for a very long time.

What she didn’t know was the while she was in the shower, he had been cooking a special meal for her and renting a special movie for the two of them to watch after dinner.

He went into the bathroom to ask her to come to dinner, and that is when the conversation took place.

A little background helps to understand what happened that night.

She had been hurt very badly in a past relationship and her parents had had a turbulent divorce when she was growing up. As a result, although she was objectively a very attractive woman, she carried with her a feeling that she might truly not be lovable.

His mother was depressed when he was growing up.  As much as he tried to win her love, nothing he could do was enough to make her happy with him. He carried the idea that nothing he could do would ever be enough. avoiding-hearbreak-in-a-relationship

She felt she might be unlovable, even though she was attractive and very successful.

He felt that his love might be inadequate, and that he would never be able to have a happy relationship with a woman.

The standoff seemed to have no solution.

But that was because both of them were immersed in their own private fears. Fears that had relatively little to do with the current situation.

If the relationship ended she would have no trouble finding another man who might be a better match for her.

And although she might ask for lots of reassurance from him sometimes, the truth was that relatively little affection made her very happy, so his was not an impossible task.

But in the moment of conflict neither of them could see that.

I proposed that she take three steps to try to change the situation.

  1. Recognize moments of overwhelming emotion and take a break. The situation in the shower was such a charged experience for both of them that neither one was really paying much attention to the other person’s reactions in the moment. Both of them were immersed in their own private fears. This happens to all of us at times, and in those moments it is best to take a break rather than plunge ahead into another argument. I suggested that she work on noticing when she was feeling powerful sadness and that she take a “time out” if his response to her feelings seemed to be making things worse.
  2. Notice the ways that your partner shows love. I thought it would help both of them to feel better if she would pay more attention to the ways that he expressed love. He tended to want to do things for her, and that kind of loving was not what she was really looking for, but it was his way of showing his caring, and she needed to notice that more.
  3. Withdraw from the relationship when your partner is uncaring. Although he would get angry and say he did not love her, his behavior suggested otherwise. He was profoundly affected by her sadness. But she would get so hurt that the two of them would end up angry with each other, both saying things that led to more hurt feelings. I suggested that when she was feeling he was not being caring that she should distance herself from him. If she did that, I thought, he would notice, and end up showing his love (as he was trying to do, in point of fact, in the moments before the argument).

These three steps draw on the experience of working with many people in similar situations.

States of overwhelming emotion need to be mastered before dialog can happen and two people feeling triggered are not going to have a constructive discussion.

One of the most powerful ways of changing a relationship is noticing the small positive changes that someone else is making.

Another powerful way of changing a relationship is simply being uninterested and detached from the other person when that person’s behavior is destructive.

For many people, as for these two, fighting is more harmful than helpful.

Nov 15

Coping with Political Uncertainty


Coping with Political Uncertainty After the Election

Many of the people that I work with on a regular basis have been experiencing symptoms of depression and anxiety related to the recent election results.

Unfortunately, mental health professionals are no better as news analysts than the so-called professionals. I have been struggling a little bit trying to figure out what to say to these people.

Coping with Political Uncertainty – Lessons from Natural Disasters

For those who are experiencing significant anxiety symptoms, perhaps related to their own past experiences of vulnerability, I have been encouraging a news holiday (much of what passes for news these days is nothing more than speculation and therefore likely, because of its uncertainty, to increase rather than decrease anxiety). This is much the same advice that I give to people with PTSD symptoms after a natural disaster.


That advice I believe is good but it seems inadequate…

So what I’ve been doing is collecting stories from the people I see to uncover patterns of healthy or unhealthy adaptation to the news and to the resultant uncertainty about the future.

Here are some of the themes that I have encountered.

Focus on Your Values

In the midst of a world of uncertainty, one of the most effective strategies is to focus on your values. Why should this be the case? If you find yourself out of touch with the values of those in power doesn’t focusing on those values make you feel more vulnerable? Researchers who have looked into this say that reminding yourself of those values and recommitting to living your life in accord with your values actually increases your sense of control. You can’t influence how others act but you can choose whether or not you act from your deepest felt values. The act of choosing to do so increases your sense of control over your life and reduces your sense of anxiety and depression.

Sense of Purpose and Health

Acceptance and Commitment Therapy Part 1: Acceptance and Willingness

Take Control – Be King of Your Castle

Taking the theme of focusing on what you can control further, this is a good time to examine the question of how effective you are being in managing your life. Be King of your castle.

One of the things that we know from working with people with chronic depression is that there is an insidious process that takes place as the result of depression that involves losing awareness of how one’s own statements and actions influence what happens to us. Over time we find ourselves feeling that people’s responses to us are things that we have no control over. We feel that way not because it’s true but because we begin to pay less attention to the ways we can influence or change the outcome of the conversation.

In our companion website, Gateway Psychiatric, we have written quite a bit about the Cognitive Behavioral Analysis System of Psychotherapy (CBASP). The whole purpose behind this approach to therapy for people with depression is a systematic focus on increasing awareness of how what we say to others and how we say it and how we interpret their responses to us matters in a profound way in terms of what happens in our life.

Chronic Depression – What You See Depends on Where You Look


Seek Connection

As natural as it might be to pull away from people, especially if they want to talk about the election (and you don’t want to) this is a good time to focus on strengthening your relationships with your best friends and closest family members. Connection and intimacy reminds us of what truly matters… but when you do get together try not to spend all your time rehashing politics. Talk about how you’re feeling and perhaps what you’re doing to cope with the events.

Friends and Purpose

Throw Yourself Into Self Care

One of our patients took up running in a serious way right after the election. With so much anxious energy present in his body he thought that it might be a good way of getting stronger and taking care of himself while using up some of that anxious energy which otherwise would get in the way of deep sleep at night. This is an excellent time to throw yourself into self-care. Improve your diet. Begin a vigorous exercise regimen. Start regular short meditation or relaxation exercises. Instead of sleeping in get up early and get outdoors…

Getting Up Early


Direct Your Anger

Anger serves a very important purpose in motivating us to take action when action is needed, but as Freud knew quite well, anger without direction without some constructive purpose can easily be turned upon ourselves and lead to depression and hopelessness. Use that angry energy to take on one small project that is consistent with your values. One of our patients decided this past week to start volunteering in a woman’s shelter. There are many possibilities and this might be a good topic for one of those conversations with a close friend or family member.


Nov 06

Psychotic Experiences in Normal People

Worldwide Study Finds some People without Mental Illness Report “Psychotic” Experiences

Psychiatrists tend to assume that certain experiences are a clear sign of mental illness. These experiences include psychotic experiences such as hallucinations (hearing voices, seeing visions) and delusions (beliefs that are contrary to “consensual reality” for example the belief that one is being plotted against, or that thoughts are being removed from one’s brain, or one is being controlled by others…).

A new study published in JAMA Psychiatry shows that people who do not have a psychiatric disorder in the general population sometimes experiences these symptoms too.

This fits with the results of an earlier (1998) study of 15,000 Americans that found that 5% of people in the general population experienced hallucinations in a year. And of those, only half appeared to have a psychiatric condition.

In the current study, researchers from the University of Queensland in Australia and Harvard Medical School analyzed data from the World Health Organization World Mental Health Surveys that included more than 31,000 adults to assess the lifetime prevalence of psychotic experiences among the general population.

5.8 percent of those surveyed reported having at least one psychotic experience in their lifetime, with hallucinatory experience being the most prevalent at 5.2 percent compared with delusional experience at 1.3 percent. Psychotic experiences were more common among women (6.6 percent) than men (5 percent), and higher among individuals who lived in middle-income (7.2 percent) and high-income (6.8 percent) countries than those in low-income countries (3.2 percent).

Psychotic experiences were infrequent, with 32.2 percent of respondents with lifetime psychotic experiences reporting only one episode and 31.8 percent reporting having experienced two to five episodes.

These results point to the fact that unusual experiences are not necessarily a symptom of psychiatric disorders.

For more on psychosis in the general population, see the Psychiatric Services article “Treatment Seeking and Unmet Need for Care Among Persons Reporting Psychosis-Like Experiences.”


McGrath JJ, Saha S, Al-Hamzawi A, Alonso J, Bromet EJ, Bruffaerts R, Caldas-de-Almeida JM, Chiu WT, de Jonge P, Fayyad J, Florescu S, Gureje O, Haro JM, Hu C, Kovess-Masfety V, Lepine JP, Lim CCW, Mora MEM, Navarro-Mateu F, Ochoa S, Sampson N, Scott K, Viana MC, Kessler RC. Psychotic Experiences in the General PopulationA Cross-National Analysis Based on 31 261 Respondents From 18 Countries. JAMA Psychiatry.2015;72(7):697-705. doi:10.1001/jamapsychiatry.2015.0575

lHonig G et al. Auditory hallucinations: A comparison between patients and nonpatients. J Ncrv Ment Dis 1998; 186:646-51.

Nov 01

Anxiety and Bipolar

For many people with bipolar anxiety is a bigger problem than mood swings.

It is not that unusual for someone with bipolar to report that their first “symptom” of a psychiatric nature was the onset of anxiety early in childhood.

Let’s take a look at this information again…bipolar-and-anxiety

90% of people with bipolar have an anxiety disorder diagnosis.

2/3rds have had panic attacks.

Nearly 40% have generalized anxiety disorder.

50% have a phobia.

Roughly a third have posttraumatic stress disorder.

And there isn’t a big difference in the frequency of anxiety in bipolar 1 or bipolar 2.

Treatment of mood swings and depression often helps the anxiety. But for many additional treatment for anxiety may be necessary. And psychotherapy is probably the most effective treatment for most of those people.

For More Information

Treating Anxiety – An Update by Kelsey

Accepting Uncertainty

Medications for Anxiety



Oct 31

4 Ways You Can Help a Loved One Cope with Addiction and Mental Illness

Mental illness and addiction co-occur more than some people may think. People with a mental illness are more likely to abuse substances while those with addictions are likely to either develop the symptoms of a mental illness or a full-blown mental illness. If there is someone in your life struggling with these two problems here are a few ways you can help them.

Get Them Help

Your first priority in helping your loved one is to seek out professional help. If left untreated, both addictions and mental illnesses can only grow worse as time passes and, while their support network helps, they cannot replace the aid a therapist or rehab program offers. There are many different forms of therapy, meaning there is something out there for everyone.

Talk to your loved one about some of the programs you think they would benefit from, enjoy, and be able to afford. You may find it challenging to convince them to get help at first, but don’t give up. They will be grateful when their life is back on track and their illness and addiction are under control.

Become an Exercise Partner

Once you have secured professional help for your loved one, you can turn your focus to making their daily life better. Exercise is one of the most effective things a person can do on their own to battle the symptoms of a mental illness and, in turn, an addiction.
Many mental health issues cause a person to lose the motivation necessary to engage in positive activities. By becoming an exercise partner, you can help ensure that they are doing what the need to do to stay healthy.

Plan Fun, Substance-Free Activities

Many people recovering from addiction find that substance-free activities are difficult to come by. Alcohol is often present, and the people in attendance may not know of your loved one’s recovery efforts.
Instead, take a little time to find fun, sober activities. This will not only prevent your loved one from believing sober life is boring, but it will also teach them what things they can do that will not make recovery harder. Some good examples of enjoyable and enriching activities include hiking, visiting a museum, or taking art classes.

Be Open and Understanding

Discussing a sensitive topic like mental health and substance abuse can be uncomfortable. However, it is very important that your loved one does not feel as though they need to be ashamed of their struggles. Listen to their thoughts and feelings as calmly and judgment-free as possible. Simply knowing they can talk when they need to can do your loved one a world of good.

Helping a loved one through mental illness and addiction is not easy. However, it becomes easier with the help of a trained professional. Be sure that your first step is to get them help. From there, you will be able to encourage beneficial activities such as exercising, eating well, and being more open about their thoughts, feelings, and issues. Even when things seem tough, remember that your love and support is doing them good whether they realize it or not.

By: Jennifer McGregor


Image via Pixabay by Erdmann-Crew

Oct 29

Dealing with Denial

denialSomeone you love is no longer the same. They may be moody, angry at times, irrational, paranoid or they may act in ways that are harmful to themselves or to you.

Trying to help loved ones deal with this situation is one of the most perplexing and difficult things that I do as a professional.

The boyfriend of a young woman who recently flew off to Latin America to study the violin, abandoning a promising job, and having an affair with an older man in the process, comes in trying to figure out how to respond to her adamant denial that she has any psychiatric problems.

The wife of a middle-aged man who has become convinced that he alone has the knowledge to save the world and now, instead of spending time at work or with his family, hands out leaflets in downtown San Francisco reluctantly decides that she has to divorce her husband who refuses to accept treatment.

These are just some of the poignant stories that I have heard over the last few months.

Writer Julie Fast wrote an article on this topic for BP Hope in 2011 which is one of the most commonly read and commented upon articles on that website.

She had some points to consider:

Find the sweet spot. Are there periods when your loved one is more open to discussion? Often people are more receptive during a mild depression…

Set expectations. If a loved one with bipolar is living with you, you have the right to set expectations for behaviors such as drug use, drinking, yelling, staying in bed all day, staying out all hours and, yes, refusing treatment… It will be up to you to decide the consequences if your expectations aren’t met.

Understand the challenges… No one chooses to have bipolar disorder. People in denial can be very unpleasant and it’s easy to walk away from them, but don’t forget they are suffering…. Go ahead and say you understand that it must be hard to have someone tell you what to do. Say that you can tell the person feels misunderstood. People in denial may get angry or refuse to reply, but they have heard you. 

Hold on to hope. I’ve known many people who accepted treatment after years of denial, often when loved ones learn simple strategies and get them help at the right time. It isn’t easy to hang on until then. Nothing with bipolar disorder is easy! But bipolar is treatable, even for those who currently refuse to admit they are ill.

I think her point about timing is an important one, as is the embedded idea that, in most situations, dealing with denial is something that is likely to take weeks or even months and having realistic expectations (and also taking care of yourself in the process) is an important part of achieving success. Too many people alternate between a sense of urgency about getting the problem taken care of and interspersed periods of not talking about it at all. Find your moment to talk about it but also don’t pretend that the problem doesn’t exist even when it might not be timely to bring it up.

It is helpful to conceptualize the process of dealing with denial as one that involves a marathon rather than a sprint.

The idea of setting expectations touches upon another important point. For most people what they most care about is people’s behavior. This is something that is objective and less likely to be a topic of disagreement than the more abstract notion of “being bipolar.” Focus on the behavior is often helpful and more realistic than focusing on “insight” about what is going on. To put it in a different way, it’s okay if the person takes medication or agrees to see a mental health professional just “to please you.” That is often the first step.

Dr. Xavier Amador is another writer who has written books on the subject (I Am Not Sick I Don’t Need Help) that I often recommend to loved ones as a starting point.

For More Information

Julie Fast’s article

Xavier Amador’s website

The Problem of Denial: How to Help Loved Ones with Substance Use and Other Destructive Habits

Denial: I’m not Bipolar, Doctor

Oct 24

Friends and Purpose

friends-and-purposeMaff Potts spent his professional life working with charities for the homeless in England. But he was frustrated that all of his work did not seem to be changing outcomes for the people he was working with.

The result of his reassessment is a program that focuses on addressing what Maff feels are the two psychological problems that bedevil the homeless… and affect many of us who are not homeless as well: the lack of purpose and the lack of friends.

He set up a charity called Camerados to try to address these two issues. Their first projects are a series of drop in centers called Living Rooms which are located in some of the worst urban areas in England.

We ran across his work in an article in the Washington Post. Quoting from that article…

Inside a library in a depressed seaside town in Northern England is a room converted into a cafe designed to look like a grandmother’s homey living room.

On any given day, there might be an elderly woman playing Scrabble with a man in his 20s. There might be a homeless man making coffee for a mother whose daughter recently died. Seated on the vintage-looking couches and armchairs there will be strangers sharing stories, offering counsel and friendship.

This community open space seeks to address the central issues that commonly lead to homelessness, addiction and poor health: Isolation and a lack of purpose.

Over the years during his work on homelessness, when he met people in their darkest moments, some talking openly about suicide, Potts began asking them to do him a favor. One man mentioned he’d been a painter, so Potts started talking about how the reception area could use redecorating and asked the man for his advice. The man ended up offering to repaint it himself. The task gave him a purpose, a reason to keep living.

“The thing that led to a lasting transformation was when they helped somebody else,” Potts said. “That was the magic moment.”

So Potts started thinking there must be a way to improve the lives of people who are struggling not by making them feel like they’re always recipients of charity, which can be demoralizing, but by giving them a space to help others — and by extension, themselves.

These are powerful ideas, not just for the homeless, but for all of us. Watch this video for more.

For more information

The Washington Post article

Camerados website

Sense of Purpose and Health



Oct 19

Blessings of a Bipolar Crisis

jayson-blair-docA mental health crisis, once it resolves, can leave people with a sense of overwhelming anxiety that co-workers, distant friends, family, and strangers might find out about what happened.

Jayson Blair, however, never really had the opportunity to worry about that… His was an extraordinarily public mental health crisis.

In an article in Bipolar Hope he talks about what happened…

“I was a reporter at the New York Times and I fabricated and plagiarized articles, was forced to resign from my job, and had constant reminders of my misbehavior through the comments of loved ones, articles about the scandal, and television shows where the topic was widely discussed.”

For those of you who a. re long time readers of the New York Times, this version of the story may not seem familiar, because what was reported at the time was a story of straightforward plagiarism and poor review of stories by his editors. The Wikipedia article on Jayson summarizes the aftermath of the controversy this way:

The New York Times reported on Blair’s journalistic misdeeds in an unprecedented 7,239-word front-page story on May 11, 2003, headlined “Times Reporter Who Resigned Leaves Long Trail of Deception.” The story called the affair “a low point in the 152-year history of the newspaper.”

Jayson Blair is African American and much of the commentary and discussion at the time focused on whether, as the result of its commitment to affirmative action, the New York Times had promoted him inappropriately. His editor,  Jonathan Landmann, was quoted as saying, “”I think race was the decisive factor in his promotion. I thought then and I think now that it was the wrong decision.”

Reading the story now, with the knowledge of Jayson’s bipolar diagnosis the story of reckless fabrication, charm, sloppy writing, even his excessive use of cocaine at the time, makes better sense as a story of a bipolar crisis.

In the article Jayson writes about how a crisis may have silver linings.

The 8 blessings he describes are:

  1. Defeating delusional denial – “it is hard to ignore the concerns of loved ones who can restate the stories (so easy for us to forget) about our reckless and dangerous behavior in acute manic or depressive episodes.”
  2. Fighting minimization – “Even when we remember what has happened, it is easy to forget how far outside the bounds, or how dangerous certain behaviors are to us and others.”
  3. Boomeranging deflection – “Before I was diagnosed, I used to tell a colleague that everything would fall into place if I had a new boss, or if someone else changed.”
  4. Partners in education – “When others know about our acute bipolar episodes, they usually reach for the shelves and pick up books such as Kay Redfield Jamison’s An Unquiet Mind: A Memoir of Moods and Madness.”
  5. Combating complacency – When you haven’t had an episode in a while it may be tempting to forget how bad things were.
  6. Eliminating enabling – “Loved ones can find the creative aspects of bipolar charming. But this attitude can be enabling for the person who has bipolar until the damage done in acute stages becomes apparent to everyone.”
  7. Added support – When problems are public it is easier to get support from others.
  8. Partners in advocacy – “Once other people see you suffer through acute episodes, they are more likely to join in your efforts to help others who have bipolar.”

For More Information

Eight Gifts of a Bipolar Crisis

Starting Bipolar Treatment – Dr Suzanne A . Black and Mr. Stuart Jessiman

Effective Communication – how and when to talk about bipolar with others.

For more about what happened…

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