Untreated Bipolar Disorder & “The Kindling Effect Theory”: What may cause rapid cycling and episodes without triggers

in My Work & Research by Robin Mohilner June 9, 2011 0 comments

Six years ago, when I was in graduate school, I studied something called “The Kindling Effect Theory”.

NONE OF THIS IS FACT.

These are simply ideas that scientists have been exploring to try to make sense of how bipolar disorder may work if left untreated.

In the brain you have cells called neurons.

These cells are how the brain communicates and causes action to occur.

Action can be a thought, a feeling, a behavior and any form of human functioning.

One activated neuron alone, “firing” (which means sending a message) cannot create significant change in the brain.

Action takes place in the brain when large numbers of neurons are activated and firing the same message together.

There is a theory that says, “What fires together, wires together.”

This “wiring together” doesn’t necessarily take place the first time neurons all “fire” together.

For example, when you are learning a new routine that you want to make a habit, it takes a significant amount of time and effort to pay attention before you are able to do the routine without even thinking about.

That process of paying attention and/or practice and time is how your brain wires itself together so that you don’t have to think and eventually don’t even need a trigger…you simply just DO the routine without even thinking and sometimes accidentally.

Have you ever started driving to a place you don’t normally go but it is on your way to someplace you go ALL of the time, and you completely pass the new place and don’t even realize it until you end up at the place you always go.

That is because the brain has it wired in, it doesn’t need you to pay attention in order to do the habit. In order to do new things, you have to be paying attention.

Another saying that fits this theory is, “What you focus on grows.”

Where you put your attention, the brain wires itself together.

How this may work for mania and depression

Initially, when mania and depression come into people’s lives, they require a trigger to ignite the neurons in the brain to take action.

For example, these neurons are saying to each other, “Okay guys, when there is excitement and a sense of urgency about something that Robin truly wants to take action on, that is our cue to turn on the ignition of mania.”

However, in their meeting to discuss this they bump up against a challenge and say to each other,

“How do we do this?

We haven’t done this many times before.

Let’s make a plan…what will we do first?

Hmmm…

Let’s give her an abundance of energy and let’s make her obsess on her goal!

Great idea! Then let’s make it so she can’t stop and can’t sleep!

Yeah!!!”

Because my brain does not have a routine or habit for mania and depression. It takes my brain a while to figure out how to do it. This is as far as my brain is able to get in the mania before I have intervene.

My brain is not wired for mania and depression, but it IS wired for intervention.

Between Lithium and my own effort of practicing intervention of mania on myself for 15 years, my brain is wired for intervention.

Intervention is a habit in my brain. It still takes effort, but no where near as much effort as it did years ago.

What might happen in a brain that goes untreated without intervention?

THIS IS NOT FACT. THIS IS BASED ON THE KINDLING THEORY.

“What fires together, wires together.”

Initially, mania and depression will need a trigger to set the brain into action causing it to do the thinking, feeling, behaviors and bodily functions of mania or depression.

As more episodes occur without intervention, the mania and depression pathways that are created in the brain by the neurons wiring together become HARD-WIRED. As a result, a trigger is no longer needed in order for the brain to ignite mania and depression. This could cause rapid cycling.

Here is a way to understand it…

Imagine the Grand Canyon.

Do you know how it became that incredible canyon?

It started just a trickle of water. (The slow melting of glaciers)

A trickle of water eventually became a stream. The stream carved a pathway into the earth that it now flows. Streams from several sources come together to form a river. The river carves itself deeply in to the mountain. When there are heavy rains or significant melting of glaciers, the river flooded and washed away land, carving itself deeper and wider into the land and moves with greater ease.

When mania and depression function as a stream…

Catching and treating mania and depression early means that you have caught it when it is like a stream in the brain. The mania has a trigger, like a stream that has one specific source, it easier to intervene. Medication may work more effectively and therapeutic interventions may have more success.

Like a stream is not deeply carved into the earth, when mania and depression function like a stream, they are not hard-wired in the pathways of the brain.

When mania and depression function as a river…

…There are many sources feeding into the river. There may not be an identifiable trigger for an episode.

When mania and depression act as a river, it is a sign that they are more hard-wired in the brain. This means that the brain has a defined and an efficient pathway that it uses for mania and depression.

By the neurons functioning as a river in the brain, it may cause both mania and depression to occur at the same time. This is known as rapid cycling.

How do you intervene when mania is flowing like a river?

Intervening the river may mean building a dam by using medication AND learning how to PAY ATTENTION AND RECOGNIZE when the mania and depression rivers are flowing and persistently.

You can say to yourself…

“I am having an episode right now. What I am feeling and thinking and wanting to do may not be a reflection of who I am and my current reality. I must do what is best for me by not responding to these feelings and thoughts. Instead, I will wait this out until the storm passes and I can see clearly and make choices that are in my best interest.”

It is VERY HARD to go against what your feelings and thoughts are telling you. BUT if you do it persistently, you could possibly develop an new river for your brain (neurons) to flow in (by firing and wiring together).

How long does it take to go from a mania and depression stream to a river?

No one knows.

Each person is different.

There is no way to know how many episodes it takes for the brain to HARD-WIRE mania and depression. However, if you experience mania and depression without triggers it may be hard-wired in your brain.

The sad news

Unfortunately, if someone never seeks treatment or waits so long that the pathways in their brain for mania and depression are like the Grand Canyon…meaning that the brain pathways have been flooded so much by mania and depression that it has eroded the brain….medication and intervention may not work.

This is painful for me to write. I always want to give you hope. But the reality is that there are many people out there who may not be able to be helped.

Therefore, if treatment is working for you, even if just a little…DON’T STOP.

Bipolar disorder can get worse by having episodes.

Do whatever you can to prevent episodes before they happen.

When you are triggered, intervene, seek out help from your psychiatrist and therapist and let them know that it is URGENT. Tell your psychiatrist, “I MUST INTERVENE NOW.

SUICIDE: Warning Signs, Interventions, Survivors Guilt & What to do if you are experiencing suicidal thoughts and feelings

in My Work & Research / Suicide Prevention by Robin Mohilner June 8, 2011 0 comments

Suicide – Warning Signs

NOTICE: Severity of symptoms.

Is depression or mania so severe that it is disrupting one’s ability to function and take care of oneself. This is an alert to ASK if someone is having suicidal thoughts and feelings.

ASK: Are you having suicidal thoughts? Do you have a plan to commit suicide?

If someone has suicidal thoughts/intentions and has a plan, it is necessary that you take action in the interventions below.

NOTICE: Have they isolated themselves?

Isolation is a HUGE warning sign of danger. Usually suicide occurs in ISOLATION.

NOTICE: Are they participating in activities that put their life in harm OR do they have beliefs about their own abilities that could put their life in harm?

Suicide is NOT always intentional. Sometimes suicide is an accident. It is common for people to accidentally commit suicide when mania is present because of the experience of omnipotence / invincibility.

NOTICE: Are they giving away their belongings or saying “Goodbye” to people.

This is common behavior for people who are preparing to stop living.

Many people commit suicide on an impulse because they cannot take the pain any longer.

It is important to check in with people and understand how they are coping and tolerating the pain of mental illness or circumstances in their lives.

The key is if someone has a plan for suicide and a means to carry it out, they are lethal to themselves.

I can’t stress this enough: Suicide happens in ISOLATION. A key to prevent suicide is to prevent ISOLATION.

Interventions to Prevent Suicide

INTERVENTION: Do NOT let someone that is suicidal be alone.

This may mean having family members and friends perform a 24 hour watch.

It does require for people to remain in consistent contact with their loved ones by having check-ins through-out the day and night until stability is reached for the person at risk for suicide.

If someone is still threatening to attempt suicide or attempting suicide even with all of the support of their family and friends….they should be voluntarily or involuntarily hospitalized. You can do this by calling 911.

INTERVENTION: Talk about suicide with the person you are concerned about.

Many people are afraid to talk about suicide…talk about suicide with them anyway.

Talking about suicide will NOT cause or help someone to commit suicide, unless you give them ideas about ways to kill themselves and the means to kill themselves.

INTERVENTION: Inform them that suicide is a permanent solution for a temporary problem.

It is so easy to forget that pain is temporary, even if it lasts for a very long time. People forget this. You MUST remind them by talking about suicide.

INTERVENTION: Sit beside them. Be with them.

Join them in their pain. Sit beside them and just be with them and listen to them if they feel like talking…if not, just hold their hand.

You don’t have to DO anything to prevent suicide. You just have to BE there…be with someone who is suicidal.

Unfortunately, if someone truly wants to commit suicide…there is nothing you can do to stop them. In the moment they get alone, they will commit suicide.

If someone you know has commit suicide. I want you to know that it is not your fault. It truly is not your fault.

Survivor’s Guilt

When someone commits suicide it changes the lives of everyone who cares about them. It does irreparable damage.

The people left behind often blame themselves. “If only I had been there! If only I had known how badly they were hurting! If only I had done something!”

I want you to know it is NOT your fault.

You did not know. You could not see it. You cannot be responsible for what can’t see and don’t know.

You did the best that you could with the resources you had available to you at the time.

Currently Having Suicidal Thoughts & Feelings

If you are currently having suicidal thoughts and feelings. Fight it! Do not isolate yourself. Tell someone.

Tell someone, “I am in danger. I need your help. I cannot be alone right now.” If they ask you why, “Right now I have the desire to take my life. I need you to help me stay alive.”

If you are having suicidal thoughts and feelings, I want you to know that

YOU ARE NOT A BURDEN.

Your life matters.

Suicide is a permanent solution for temporary pain…

even if the pain has lasted for a really long time.

Get Help

http://www.suicidehotlines.com/

How to choose a therapist & What to expect in your first session(s) of therapy

in Information / My Work & Research / Readers Questions by Robin Mohilner June 8, 2011 0 comments

In this article I will share with you the common practices of therapists in their first session(s) as well as give you some ideas of how to choose a therapist that could be a good fit for you.

We will explore:

Finding a therapist • Assessment • Confidentiality • Your first session • What to expect from therapy

Finding A Therapist

There are many ways to find a therapist:

Direct referral from a physician or psychiatrist.
Referral from a friend
Websites that are “Therapist finders”
Your own research

Do your research:

There are several different “Theoretical Orientations” that therapists practice from. Many therapists practice from multiple modalities, but to be an educated consumer, it is important to have an understanding of a therapist’s emphasis because it will have a HUGE effect on how you do therapy together.

There are several theoretical orientations, I will share with you three main theoretical orientations of psychotherapy.

Psychodynamic theoretical orientation primarily focuses on problems in your past experiences, what happened in your childhood primarily in you key attachment relationships (ie. parents, siblings and any prominent relationships that served as building blocks in your life), and draws a connection with your present problems or issues and emphasizes feelings. This orientation consistently asks “How does it make you feel?”

Cognitive-Behavioral theoretical orientation primarily focuses on how your thoughts affect your feelings and behaviors/actions. This orientation believes that it is not what happens to you that determines your quality of life, but it is how you think about what happens to you and how you respond to it.

Post-Modern (Narrative Therapy & Solution-Focused Therapy) theoretical orientation is one of empowerment that holds the perspective that people have strengths, abilities and resources that once we develop our gift at using them, we have the ability to resolve problems in our lives now and in the future.

The focus of therapy is on the stories people tell themselves about problems and the effects of those stories on people’s lives. A post-modern therapist emphasizes understanding the problem, but focusing your attention and growth on what you want instead of the problem.

Postmodern therapists believe that “You are NOT your problems. You are in a relationship with your problems.” For instance, “You are not depressed. You are affected by depression. You are an intelligent and capable person who happens to be affected by depression right now or is currently in a relationship with mania (mania is powerful and causes you to do all sorts of things).”

The therapist does not take the stance of “the EXPERT”, instead you are the expert of your life (you are the only one who has lived it) and the therapist uses their expertise to collaborate with you and share a process with you that may help you develop your strengths and abilities. This form of therapy is highly collaborative and transparent.

I could go on and on with post-modern therapies….

YES…I am biased. My foundation and training is as a Post-Modern therapist. However, I have integrated Cognitive therapy and Psychodynamic therapy into my practice and use anything that works for my clients.

Assessment

Most therapists will want to collect a significant amount of personal information about you in order to do a thorough assessment.

It is important that we have an accurate medical history so that we can make necessary referrals to be able to rule out any medical cause for dysfunction in your life.

It is also important that we have an understanding of your current symptoms – their onset, duration, intensity and history (have you experienced them before). This is how we diagnose (make sense of a problem you are experiencing) as well as determine if it is in our scope of practice and competency to be able to help you.

We want to know about your support system both for your own safety and so we can provide resources and referrals.

We will ask you about medication history, drug history, suicide attempt history and abuse history.

Often times people are not honest about this from the get-go because it is very hard to share this history AND it makes sense to fear judgment, stigma, shame etc.

There are many therapists who will not take on new clients who have current drug use or have a history of suicide attempts or current suicidality because it is NOT in their scope of competence and requires more availability and urgent care.

In your first few appointments, your therapist will likely explore this information with you in a formal assessment.

Confidentiality & HIPPA Agreement

In California, it is the law that in your first appointment the therapist goes over with you “Confidentiality” and the ‘HIPPA Agreement”.

Everything that is shared in therapy is held CONFIDENTIAL, but there are exceptions to confidentiality that you MUST know.

If a therapist suspects current or previous CHILD ABUSE (physical, neglect, sexual, emotional), we are legally mandated to report it to Child Protective Services.
If a therapist suspects current or previous ELDER or DEPENDENT ADULT ABUSE (physical, neglect, sexual, emotional, financial), we are legally mandated to report it to Adult Protective Services.
If you tell your therapist that have the intention to HARM a specific identifiable person, we are mandated by law to make reasonable efforts to warn that person and notify the police. (In California)
If you are suicidal (you have the intention to commit suicide and a plan to carry it out AND therapeutic interventions are not working) it is our ethical responsibility to contact the psychiatric emergency team (PET team) to have you hospitalized, even if it is against your will.

In Your First Session

Now that all of the legal and ethical stuff is out of the way

It is all about the relationship

Things for you to pay attention to to determine if you have a good fit with your therapist.

Do you feel comfortable in the therapist’s presence?

In my opinion, the therapist is NOT supposed to be intimidating. You can expect yourself to have walls up when you first meet and to feel anxiety.

A therapist’s presence should feel good, provide containment and feel safe once you build trust.

Do you like the therapist? Do you respect the therapist?

It is important that you like your therapist’s personality and respect them. No therapist is a perfect person who lives by everything they say all of the time (or even much of the time)…nonetheless, it is important that you VALUE THE WAY THEY THINK.

Do you feel that the therapist gets you?

I cannot express how important this is! If you share things that are very important to you and the therapist doesn’t acknowledge it and asks a question that changes the topic to what they think is important…THEY DON’T GET YOU.

I am adamant about this because there are so many people who refuse to go to therapy because they have had this experience. I was one of them.

I believe that a good therapist will check in with you and make sure that the conversation is useful for you and that you want to be having it.

Do you believe the therapist can help you?

It is pretty common for people in their first session to “dump” out all of their feelings and experiences with the therapist.

The challenge with this is that it feels good in the moment, but the trust is not there in the relationship so it makes most people feel so vulnerable that they won’t come back to therapy.

Trust is not something you automatically give your therapist. Trust must be earned.

I recommend honoring your boundaries and taking your time in therapy. Your boundaries and walls are there to keep you safe.

I believe we should change our boundaries and walls only when we have something of more value to replace them with. In your first session, you have not created that something of value yet.

What To Expect From The Process of Therapy

Therapy will open up wounds in order for them to better heal and it will be painful at times.

Therapy will affect the way you think and feel about yourself and your life.

Therapy will affect your behaviors and actions.

Because you are growing, therapy will affect all of your significant relationships.

I hope this is useful.

To choose me as your therapist, if you reside in the state of California, please contact:

Robin Mohilner

(310) 339-4613

email: thrivewithbipolardisorder@gmail.com

How the stories we tell ourselves about ourselves get in our own way & Ways to do something about it. Strategies for thriving with bipolar disorder

in Activities / Daily Living / Ideas: Ways to Thrive / My Stories / My Work & Research by Robin Mohilner June 2, 2011 0 comments

The stories we tell ourselves about ourselves have so much power.

One of the great lessons I have learned in my life is that what happens to us matters far less than the stories we tell ourselves about it.

The stories we tell ourselves shape how we think, what we believe about ourselves, the choices we make and the actions we take.

When I was first diagnosed with bipolar disorder, I told myself the “I am crazy” story. Here’s how it worked:

“I am crazy.” This is who I am. It is my whole story.

How this story affected my thoughts: “It doesn’t matter what I think. I am crazy.” and “I am bad.”

How this story affected what I believed about myself : “I have no responsibility and no expectations for myself or from other people. I don’t have to do anything because I can’t. I am crazy.”

How this story affected my choices: “I can’t do….” “I can’t be…” “I can’t try….” “I can’t choose.”

How this story affected my actions: I stayed on the couch in a fetal position with my face buried in the corner. I spoke to no one.

You can take out the word “crazy” from the “I am crazy” story and replace it with several other words and get the same exact effects and results.

This type of story drains away all self-esteem and self-worth. It steals our ability to take responsibility for our lives and have expectations for ourselves. It robs us of qualities that give us strength and courage. It does not allow space for resilience and persistence. This type of story causes us to accept mediocrity.

If you have these kinds of stories in your life, I invite you to throw them away and re-author your stories.

On my Facebook page, Thrive With Bipolar Disorder, I shared an example of a form of storytelling that I do when I am feeling stuck, scared or judged.

Here, I will share some ideas for how to re-author the stories we tell ourselves about what happened to us and about ourselves.

Re-Authoring Stories

Part 1: Deconstructing the Problem Story

When I help people re-author stories the first thing I choose to do is listen to and understand the story they have been telling themselves.

I want to understand the role the story serves in their life and what makes the story a problem to them.

For instance, with the “I am crazy” story. The role of this story in my life was that it defined my identity and who I could be. What made it a problem was that it sucked the life out of me, as seen above.

I want to know how the story was invited into a person’s life.

In my “I am crazy” story, the story was invited by a medical expert putting a label on me and telling me that I had to take medication for the rest of my life in order to fit into society.

It is important to explore the effects a story has on a person.

The effects of the “I am crazy” story on me were:

I had no expectations for myself.
I took no personal responsibility for my choices and actions.
I had no self-esteem, self-worth and self-respect.
I felt useless and incapable of being anything.
I felt that I was bad.
I was afraid of myself.

I choose to know what the person does to support the story they tell themselves. What actions and routines support the story.

In my “I am crazy” story, I refused to get off of the couch. I did not want to go to school for the life of me, not because of what the kids would think, but because I no longer believed I had a functioning brain and was capable of doing anything with my life.

My routine was to wake up, get on the couch and bury my face in the corner.

This carried over from my depression. As I was coming out of the worst depression ever, I continued the behaviors that I had while I was experiencing full blown “I know longer feel alive” depression.

I explore what the problem story steals from peoples’ lives.

My “I am crazy” story stole my will to live. It stole everything I believed about myself up to the point that I had my manic episode. Until then, I believed I could be anything when I grew up and I was a great student and daughter.

This story stole my confidence, my courage, my intelligence, my creativity, my hope, my dreams….

Together we explore flaws in the problem story, times when the problem story is wrong about people and times when people have the upper hand. We look at evidence that uncovers other possibilities and alternative ways of understanding the problem story.

When I explored this with myself, the problem story went from “I am crazy.” to “What I experienced during those handful of months in my life was beyond my control…it was crazy AND I have the ability to do something about it.”

Here was the evidence that I am not crazy. For the entire fifteen years of my life (I was 15 soon to be 16 when full-blown mania came into my life) I was a very good student, I had friends and sort of the ideal teenager to my parents, I never got in trouble.

After the full-blown mania and depression and after I got stable on my Lithium…I still could read. I still could write. I still could speak my mind coherently and my thoughts were relevant and intelligent. I still was a kind, warm, compassionate and loving person. I still was playful, funny and loved to laugh. I could still feel my feelings and was on a dosage of lithium that left me always slightly hypomanic (throughout much of my twenties).

Once we are able to identify the possibility that the problem story may no longer fit, I explore with people what gets in the way of letting the problem story go. Together we slowly work on what hold’s people back.

In my case, I was afraid to let the problem story go because I did not trust myself. I was scared of myself that at any point in time I could go into full-blown mania and crash into a lifeless depression.

One of the things that often keeps people stuck in their problem story is that they don’t have a different story to replace it with. They don’t have a story that they want instead. With this as a challenge our goal shifts from understanding the effects of the problem story to creating people’s preferred story.

In the Part 2 of this blog we will explore this process of creating a preferred story.

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