Mental Illness or Post-Traumatic Stress?

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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.

References

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.



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Posted by Paula Hyatt on
How perfect and timely this post is. This morning as I was working with a client who was talking about her husband's manic episode and subsequent diagnosis of bipolar I found myself wondering if he is truly bipolar or merely manifesting behaviors consistent with hyper vigilance from PTSD. I had these thoughts based on another client I work with who has a bipolar diagnosis along with complex PTSD. So it is with great interest that I read this post. Thank you for sharing your thoughts about this.
Posted by Ricky Greenwald on
I think there's quite a lot of this going around. I hadn't heard anyone talk about it until I did on a listserv last week. Then plenty of others chimed in with similar experiences.
Posted by Nancy Rubenstein Del Giudice on
I appreciate this thoughtful post. I had a similar experience of trauma and was diagnosed with Bipolar. I was heavily drugged and given ECT before I had the chance to research. There is not one shred of medical evidence to support the notion of an organic basis for mental illness. I am Educational Director of The Law Project for Psychiatric Rights (PsychRights.org).
Posted by Ricky Greenwald on
Thank you for your comment. I'm sorry for what you went through, and glad you're making something out of it, to help others. Also thanks for posting your organization's web site. Until I can get the blog upgraded to offer a slot for that, putting it into the text of the comment is a good solution.
Posted by Robin Shapiro on
Ricky, I've seen both. True bipolar people tend to show anxiety, OCD, ADD type stuff from early ages, even with good attachment and little trauma. Other folks show the ups and downs but get "manic" only after a trauma that puts them into a mobilized state and "depressed" after too much mobilization depletes the system, causes inflammation, and the body slows everything down to repair the inflammation. (Tons of research on depression and inflammation.) Chronic traumatization: people are retraumatized in PTSD, and go from mobilized (manic) to immobilized (depressed). Clear the trauma and the cycles stop.
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.
Posted by Ricky Greenwald on
Robin, that makes sense to me and is consistent with the range of other symptom pictures I've seen, such as ADHD, Antisocial, anxiety, etc. Some people seem to born with that brain, whereas for others a similar symptom constellation seems to be trauma-induced. Perhaps, as you suggest, the early onset of symptoms pre-trauma (in cases that have pre-trauma) would suggest more of an inherent quality for that person.
Posted by Gerald Fnord on
As I'm a strict materialist, I consider this all 'biological', though it is plain that there might be differing outcomes for differing etiologies... but on the other hand,

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....
Posted by Ricky Greenwald on
You raise some good points. Of course every psychological status has its biological correlates. But that's not necessarily the same as "biologically based." For example, if someone is really wired to be bipolar and develops this, as Robin has described, from an early age, then trauma-focused treatment might mitigate the symptoms, but the person would likely still have bipolar disorder. On the other hand, in these late-onset trauma-precipitated cases, trauma treatment seems to not only make the symptoms go away, but the biological correlates as well.

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!
Posted by Cheryl Keen on
Thanks for the great teaching story. It's persuasively, if cautiously framed.
Posted by Tom Cloyd on
I have for some time screened virtually everyone for a trauma history. If there's diagnosed bi-polar or they seem to qualify for the diagnosis, they for darn sure get a careful trauma screening. I consider it malpractice NOT to do this.

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.
Posted by Ricky Greenwald on
Tom, there's some research indicating that many children diagnosed with ADHD are mis-diagnosed and the symptoms are actually due to post-traumatic stress. There's also extensive research implicating trauma/loss in the development and persistence of most other diagnoses, including anxiety, depression, conduct problems, substance abuse, etc. But the understanding of the role of trauma in major mental health disorders is still emerging.
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