The Bipolar Dilemma: More Thoughts on Cycling

John McManamy Health Guide
  • Last week, I proposed that we conceptualize bipolar as a “cycling” illness where we transition through overlapping “phases” rather than as an “episodic” illness where we ping-pong back and forth between discrete symptomatic “states.”


    In essence, we treat the cycle rather than the episode and its symptoms.


    This is hardly a new idea, but it has yet to catch on in practice. In a comment, Tabby noted that her first doctor told her, “we have to treat the cycle, not the symptoms,” then he proceeded to load her up on meds.




    It’s not my place here to second-guess how doctors treat their patients, but I am entitled to call out individuals on their egregious failure in logic. Tabby’s doctor, of course, only gave lip-service to the cycle. Then he proceeded to pharmaceutically carpet-bomb the two “poles” in bipolar at once.

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    This is the conventional wisdom that I have heard espoused by numerous bipolar experts at endless psychiatric conferences, namely: Put the patient on combination meds - one med to deal with keeping mania in check, the other to deal with keeping depression in check.


    This is hardly treating the cycle, much less acknowledging the dynamic that drives our illness. We’re simply boxing in the symptoms - mania and depression - from both ends, typically with a lot more than just two meds, typically at full strength.


    There may be justification for this strategy in individual cases, but I strongly question its use as the default long-term option. For one, we have no scientific evidence base to justify its use. Long-term clinical trials, much less those involving combination meds, simply do not exist.


    As for treating the cycle, I match psychiatry’s lack of evidence and raise it with my own personal experience. Really, it’s just common sense, namely: We need to pay close attention to whatever may throw off our cycling patterns.


    Let’s start with sleep. Sleep, of course, is the mother of all cycles. So goes our sleep, so go our moods. Indeed, you can make a case that bipolar is the downstream effect of bad sleep. None other than Frederick Goodwin, co-author of Manic-Depressive Illness, suggested this to me in an interview several years back.


    Needless to say, nothing throws off sleep like being badly stressed. Stress, of course, will get those racing thoughts going, which, needless to say, guarantees a sleepless night. Cycles within cycles. Now we are true sitting ducks.


    Meds can be part of cycle-maintenance, but the true backbone to staying healthy, I submit, is what I call my Holy Trinity: sleep hygiene, stress-management, and mindfulness Mindfulness is all about anticipation: if we can see it coming, before it happens, we may be able to do something about it.


    We also need to be paying close attention to the million-and-one things that affect our cycles: our diets, lack of exercise, the weather, on and on ...


    In the final analysis - no matter how vigilant, no matter what we do - it may be that our delicate watch works simply cannot hold up under the wear and tear of our present lives. The psychiatric response is yet another adjustment to the meds cocktail. The tough choice may be reappraising our goals in life and making the necessary changes, no matter how painful in the short term. 


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    There are no easy answers, there is no magic solution. I simply suggest that you begin thinking in terms of “cycling” rather than “bipolar.” Tell me what you come up with.


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Published On: May 11, 2014