by David J. Miklowitz
Guilford Press, 2002
Review by Jack R. Anderson, M.D. on Oct 3rd 2003
This book is crammed full of useful information for bipolar patients, their family members, therapists, friends, lovers, employers and anyone else interested in bipolar disorders. Philosophers with a deterministic bent might take exception to the accounts of bipolar patients who discover that, despite the limitations of their illness, they are still able to use their decision-making capacity--their free will--to minimize the effects of their mood swings on their lives.
The author has an impressive educational and research background and has earned numerous awards for the outstanding quality of his work. The insights he shares with us were not acquired simply by reading the voluminous literature on bipolar disorder, although his doctoral and post-doctoral studies required enough of that; during more than fifteen years of clinical practice and research, Miklowitz has been personally involved in the care and treatment of hundreds of bipolar patients and their families.
Part I, "The Diagnosis and Course of Bipolar Disorder," describes the symptoms of bipolar disorder, how it is diagnosed and explains how difficult it is for some individuals to accept the diagnosis, which they consider tantamount to "a life sentence."
Throughout this section of the book, the author, rather than defining concepts, gives examples of actual episodes of depressive and manic behavior, unusual thoughts, suicidal ideation, sleep disturbance, and impulsive, self-destructive and addictive behaviors. This reviewer counted more than twenty-five separate examples of individuals with bipolar disorder, who were quoted and described, adding substance and verisimilitude to the four chapters of this section.
In this introductory part of his book, the author begins his emphasis on the active part the patient should play in his own diagnosis and treatment. Rather than unequivocally accepting whatever diagnosis is offered by his doctor, the patient is given a self-administered checklist to be used in arriving at his own diagnostic impression and is advised to question his doctor about possible diagnostic errors. He is given a list and descriptions of other psychiatric disorders often confused with bipolar disorder to assist him in the diagnostic dialogue with his doctor. Differential diagnoses to be considered include: Schizophrenia; ADHD: Borderline Personality Disorder; Cyclothymia; Recurrent Major Depressive Disorder; and Substance Induced Mood Disorder.
In Chapter 4, "Is It an Illness or Is It Me?" Miklowitz advises patients to accept the diagnosis once it is firmly established rather than trying to manage their feelings by rejecting or underidentifying with it. However he also warns against overidentifying and provides the patient with another self-administered checklist to help him differentiate between personality traits and normal mood swings on the one hand, and symptoms of mania or depression on the other.
The three chapters of Part II, "Causes and Treatments," discuss the genetic and experiential factors that combine to bring about bipolar disorders; how medication and psychotherapy can be best used by the patient to control his symptoms; and how to win the many arguments he has with himself about the need to continue taking medications despite their inevitable side effects.
As he did in Part I, the author continues to emphasize the importance of the patient's assuming control of his life, rather than turning it over to medication prescribers, psychotherapists, family members, or other caretakers.
To help understand the genetic component of his disorder, the patient is shown the family pedigree of a known bipolar patient and is given forms to use in drawing his own pedigree. There is also a form to use in determining what role stress has played in the causation and course of his disorder.
Patients are discouraged from blaming their parents for their genetic contribution to the disorders, or other family members for their contributions in the form of stress and conflict. Rather than wasting time and energy in finger-pointing, or bemoaning the fact that they have a disorder, patients are encouraged to learn how to best use available treatment modalities to minimize the symptoms and to find success and satisfaction in their lives despite their disorder.
Chapters 6, "What Can Medication and Psychotherapy Do for Me?" and 7, "Coming to Terms With Your Medication," provide a wealth of detail about different kinds of psychotherapy and medications, giving equal emphasis to the positive treatment effects and negative side effects. To re-emphasize the importance of patient-participation in all treatment modalities, Miklowitz lists the objectives of psychotherapy for persons with bipolar disorder. He also provides a form to be used by patients to keep a daily record of side effects they may experience with all medications prescribed, and another form entitled "THE PROS AND CONS OF TAKING MEDICATION." where the patients can list the reasons to take the medications, their disadvantages, and things the patients can do to improve their situations, like taking more responsibility for their own regimens.
Part III, "Self-Management," is divided into five chapters: "How Can I Manage My Disorder?--Practical Ways to Maintain Wellness;" "What Can I Do If I Think I'm Getting Manic?" What Can I Do If I Think I'm Getting Depressed?" "Dealing With Suicidal Thoughts and Feelings;" and "Coping Effectively in the Family and Work Settings."
This final section of the book is nearly as long as the previous two sections together.
Patients are given very detailed instructions as to how to manage their lives successfully, despite the negative consequences of their disorders. They are given a list of risk factors that increase their chances of becoming ill, such things as family distress, drinking alcohol or using drugs, sleep deprivation or missing medication; and another list of protective factors that help protect them from becoming ill, such as keeping charts of their moods, going to bed and getting up at the same time every day and staying on their programs of medication and psychotherapy.
Pages 209 and 210 contain a form entitled "CONTRACT FOR PREVENTING MANIA." The patient is encouraged to put everything he has learned so far into this written contract for relapse prevention. He then lists the early warning signs of a manic episode he has previously identified; the circumstances under which these symptoms are most likely to occur; and what he should do when these circumstances arise, to avoid a full-blown manic episode. Then he signs this contract and arranges for his physician, therapist, family members, friends, lovers and any other interested parties to provide their signatures.
The chapter on depression contains similar recommendations for recording prodromal symptoms, initiating preventive measures before a clinically identifiable depressive episode develops, and enlisting all social and professional members of the patient's core circle in the prevention plans.
In the chapter on suicide, the author quotes from various professional publications: ""By some estimates, people with bipolar disorder are at 15 times the risk for committing suicide of people in the general population. Up to 15% of people with bipolar disorder die by suicide; as many as 50% attempt suicide at least once in their lives." Miklowitz emphasizes: "Suicide Prevention involves decreasing your access to the means to commit suicide and increasing your access to support systems (doctors, therapists, family members and friends)." As with the chapters on mania and depression, this chapter includes the outline for a written plan with specific instructions as to what can be done by whom, when and where to prevent suicide.
The final chapter on how to adjust to family and work settings gives patients realistic advice as to how they can maintain employment and preserve satisfying relationships with significant others. Details include advice as to how to maintain satisfactory sexual relations despite the impact of manic or hypomanic overactivity or the loss of libidinal drive during depression.
All-in-all, this book is so well written and so full of useful advice as to how to plan and organize a life, that it could be profitably studied by anyone, whether or not he or she has bipolar disorder or knows someone who does. I believe that if any one of us would take the time and energy to put into practice Miklowitz's advice about keeping detailed records of our feelings and relationships and taking responsibility for maintaining and improving them, we would have more successful lives. As for the meaning of "successful," I prefer Thoreau's evocative lines:
"If the day and the night are such that you greet them with joy, and life emits a fragrance like flowers and sweet-scented herbs, is more elastic, more starry, more immortal,--that is your success."
The frequency and types of prior
Is it possible to prevent a