July 01, 2014 at 2:41 PM
How different things will be when we better understand how trauma can affect people!
“Michael” was a mid-40's married professional who had been subjected to extensive childhood abuse. In the course of his work with a particular client, the abuse memories became activated and his first-ever manic episode ensued. After a couple of months, at the urging of his wife, he came for therapy. However, at that time he did not believe that he had any problem. Furthermore, the abuse memories did not bother him and he did not see any point in working on them. This very brief course of therapy ended with an agreement: if certain problematic behaviors recurred, that would indicate that he did indeed have a problem, and in that case he agreed to hospitalization.
He was hospitalized within a couple of weeks, heavily medicated, and over the next several weeks the mania gradually subsided. Then he found himself greatly distressed by the abuse memories, and returned to me for intensive therapy. He spent three days with me, and worked through his abuse memories.
At that time I encouraged him to return when he was off the meds, just to make sure that we had fully treated all the memories (it’s possible that some elements of a memory cannot be accessed in a medicated state). I encouraged him to work with his psychiatrist to reduce or even eliminate the medications to the extent that doing so did not jeopardize his mental health status. I also warned him that he might get different advice from the psychiatrist, and that he would have to make his own decisions.
The following week he called me to update me and ask my advice. He reported that the psychiatrist had told him that bipolar disorder was a “lifelong” condition and that he would need to remain medicated indefinitely. I asked my client, “If it’s a lifelong condition, why didn’t you have it until this year?” I suggested that since the manic episode had a trauma-related onset, and since the trauma had been treated, he might have no further need for manic episodes. I also told him that many psychiatrists are not familiar with effective trauma therapy, and so might not readily understand that his status was actually different now.
Michael called again a few weeks later. He was feeling and doing much better since the therapy, and was making some progress in repairing the damage he had done while manic. He also told me he had found a new psychiatrist who was willing to work with him on reducing the medications that he apparently no longer needed. While this was done cautiously, it was done, over several months.
At 4-month follow-up he reported no further bipolar-type symptoms, although he had some appropriate sadness regarding damage that had been done during his manic episode. He had also made changes in his working style: whereas previously he had routinely over-extended himself to try to “rescue” clients, now he was doing his work in a more professional manner, which paradoxically made him more effective while also reflecting better self-care. Self-initiated positive change is common among individuals who have healed from, and are no longer driven by, their trauma-related wounds.
So is bipolar disorder a biologically based mental illness? Or might it just be a manifestation of posttraumatic stress? I don’t know, and I readily acknowledge that major mental illness is not my area of expertise. On the other hand, I can state with some confidence that this particular client had a manic episode as a post-traumatic stress reaction, and that when the trauma was treated, the so-called bipolar symptoms were gone. Anecdotally I have heard of similar cases from colleagues. So at least some of the time, what looks like a major mental health disorder may actually be an atypical post-traumatic stress reaction.
Onset of major mental health disorder (including but not limited to bipolar disorder) is frequently associated with a “precipitating event” of a traumatic nature; and greater trauma exposure is associated with greater mental illness symptomatology (e.g., Larsson et al, 2013). So why not treat the trauma? In fact, recent research has shown support for this approach in the treatment of people with bipolar (Novo et al, in press) as well as psychotic (van den Berg & van der Gaag, 2012) disorders, with participants experiencing not only reduced post-traumatic stress, but reduced manic, depressive, and/or psychotic symptoms as well. It should be noted that while those two studies utilized EMDR, another study (de Bont, van Minnen, & de Jongh, 2013) found similar results using PE as well as EMDR; and the treatment of Michael was done using PC.
I am not proposing trauma as the sole source of major mental health disorders. However, it should be clear by now that neither is biology necessarily the sole source. There is no reason that trauma should not be treated, whether such treatment “only” reduces post-traumatic symptoms, or reduces other symptoms as well.
In some cases, I suspect that trauma treatment will force the conclusion that the client in question is cured, and that the supposedly biologically-based mental illness was really just a post-traumatic stress reaction. Like with Michael. Who, in case you’re wondering, never did come back for his recommended follow-up treatment. Apparently he didn’t feel that it was needed.
de Bont, Paul A. J. M., van Minnen, Agnes, & de Jongh, Ad. (2013). Treating PTSD in Patients With Psychosis: A Within-Group Controlled Feasibility Study Examining the Efficacy and Safety of Evidence-Based PE and EMDR Protocols. Behavior Therapy, 44, 717-730.
Larsson, S., Aas, M., Klungsøyr, O., Agartz, I., Mork, E., Steen, N. E., Barrett, E. A., Lagerberg, T. V., Røssberg, J. I., Melle, I., Andreassen, O. A., & Lorentzen, S. (2013). Patterns of childhood adverse events are associated with clinical characteristics of bipolar disorder. BMC Psychiatry, 13, 97.
Novo, P., Landin-Romero, R., Radua, J., Vicens, V., Fernandez, I., Garcia, F., Pomarol-Clotet, E., McKenna, P. J.,Shapiro, F., & Amann, B. L. (in press). Eye movement desensitization and reprocessing therapy in subsyndromal bipolar patients with a history of traumatic events: A randomized, controlled pilot-study. Psychiatry Research.
van den Berg, David P. G., & van der Gaag, Mark. (2012). Treating trauma in psychosis with EMDR: A pilot study. Journal of Behavior Therapy & Experimental Psychiatry, 43, 664-671.
Please add a comment
Still, I think some people are born to be bipolar. My brother married into a bipolar family and some of those people have very happy mania and are a gas to be around, until they flip completely out.
0.)...not everyone reacts to trauma in this way, so doesn't this reaction indicate a greater basic competence (perhaps innate) at the behaviours and thoughts it comprises?, and
1.) ...once a behaviour were learned and experienced without fatal consequence, isn't it easier for it to be reproduced, regardless of origin?
My first depressive episode was proximately precipitated by corticosteroid use, but a close relative's was precipitated by a death...and in both cases we thereafter got repetitions without such, I think we're both innately good at depression and have learned how to do it, so habit, or simply just the system's knowing that the state were available, now make it much easier to repeat....
I also agree (as does the research literature) that once you've been depressed, your brain knows how to do that, and might do it more readily at another opportunity. I would go a step further and suggest (also not original) that the selection of a particular symptom constellation is not only a reflection of competence based on prior experience, but also on temperamental tendencies.
That being said, if you look at the actual symptoms comprising a wide range of mental illness diagnoses, most of those are actually post-traumatic stress symptoms. I'll develop this point in a future blog post!
I see some mis-diagnosed "bipolar" that's clearly just PTSD, some that's both, and some that's apparently pure bipolar. One just has to be aware of the possibilities and do careful assessments.
Great to have this article, for validation of the idea that some "bipolar" - possibly even much of it, is not that at all.
I've found the same with ADHD in kids, but don't have enough of a sample to say much about it.
Only when I came to understand that PTSD was in fact the primary issue was I able to learn and grow, leaving a lifetime of disability and becoming fully functional and gainfully employed.
I wish I could shout out to everyone told to have both bipolar and PTSD, that the PTSD should be seen as the primary condition until there is evidence that it has been processed and overcome.
I spend many years thinking that the trauma had been overcome because I was not educated in what PTSD was and I was encouraged to believe that bipolar was the true cause of my suffering.