The Highly Effective Bipolar
This is a write-up of a talk I gave at a mental health conference, November 2017.
About Me
I am diagnosed Bipolar type I. For my mental health journey, see my earlier post.
After dropping out of school, and about a year of grief, self-care became my highest priority. In this post, I will illustrate for you how that came to be, and what that looks like for me.
My goal for this post is first and foremost to provide help, support and tips for folks who do have a MH diagnosis. But I also include enough context in this post that it should be insightful and educational for those who do not have a MH diagnosis as well.
What is Bipolar Disorder?
Before we get into my coping mechanisms, let’s first define our key term: Bipolar Disorder.
From my favorite bipolar book:
Bipolar disorder is a biological illness that causes unusual shifts in your mood, level of energy, and ability to function in different aspects of your life (for example, working or going to school, taking care of yourself, maintaining relationships). The illness used to be called manic depression because it was thought that people with the illness would fluctuate only between episodes of highly elevated, euphoric moods and episodes of major depression. More recently, doctors have realized that the illness is not quite that black and white — that there are many moods that actually occur on a spectrum […].
Usually, people experience periods of ‘normal’ mood between these episodes, when they are neither manic nor depressed. While many people return to a fully functional level during these periods, many also continue to experience some symptoms.
We all have times in our lives when we feel sadness, we may have trouble coping, or we feel overwhelmed. The mood shifts that occur with bipolar disorder, however, are very different from the normal ups and downs that everyone experiences at times. The symptoms of bipolar disorder are much more severe[…].
Bipolar mania symptoms include:
Elevated mood, scattered thoughts, feelings of euphoria, racing thoughts, agitation, spending large amounts of money, driving fast or dangerously, inability to sit still, rapid & unpredictable emotional changes, socially unacceptable behavior, ignoring responsibilities, feeling paranoid, little need for food, decreased need for sleep, irritability, talking very fast, inability to relax, lack of control, poor judgement, confused thoughts, seeing or hearing things that aren’t there.
Bipolar depression symptoms include:
Persistent low mood, difficulties falling asleep, social isolation, problems with memory, irritability, decrease in motivation, feelings of hopelessness, low self-esteem, restlessness, tearfulness, loss of enjoyment in activities, poor concentration, thoughts of suicide, persistent guilt, mental confusion, difficulty making decisions.
The Bipolar’s Key to Success
The key to leading an effective life with Bipolar Disorder is keeping oneself in the middle mood state, a normal mood state.
As a bipolar individual, once you have launched into either a full-blown mania or full-blown depression, it is incredibly challenging to get yourself out of it. This is because your perception of the world, and your perception of yourself changes so drastically from mood state to mood state that it is almost impossible to recognize when you are in an abnormal mood state, or find any motivation to correct for it.
We must therefore always be alert for the onset of an episode (mood state), and correct for it before it becomes full-blown. In this way, we lead an effective life.
The Bipolar Hierarchy of Needs
Over the last 10 years, I have been constructing a Bipolar Hierarchy of Needs for myself. This hierarchy is completely of my own division, extrapolated from Maslow’s hierarchy.
My Bipolar Hierarchy of Needs has helped me to generally sustain the middle mood state (normal) and avoid both depression and mania.
Each of the levels of my hierarchy are things that I have found are critical to sustaining that normal mood state. The idea of the hierarchy is that before you can achieve a level, you must first achieve the level below.
For the rest of this post, I will present my tips on how I achieve and sustain each level. For some of the levels, I will not go into much detail about why they are necessary, because there is plenty of literature on this already.
INTROSPECTION
Introspection is the first level because without it, it is hard to rationalize self-care.
How to achieve:
What worked for me was journaling and mood-charting — the latter being most effective. When you can see your shifts on paper, it helps you to recognize and rationalize what’s going on.
The easiest way to mood chart is to set up a google form. You can then export as a spreadsheet and do things like…
Every day I would self-evaluate on the 5 variables listed above (and some others not pictured). After a year, I plotted my data. Above is a plot of my mood state for the first year of treatment after my first full-blown manic episode. As you can see, after a year of treatment, my average for each of the variables was generally much closer to 0 (normal).
This is one of my favorite things that has ever come of therapy. It solidified my disorder and its patterns, my need for self-care so clearly in my head, and gave me hope of improvement.
TIP: If you do want to set up a mood chart, I recommend also tracking things like alcohol consumption, sleep, food, and other things on this hierarchy in tandem.
FOOD
Though our appetite is substantially smaller in a bipolar mood state, we still need to eat the same amount of food. This is an incredible challenge — first you must be able to accept (while in an altered mood-state) the need for food even though you are not hungry and have no desire for it, and then you must force yourself to eat.
Food is something that every bipolar individual struggles with on a regular basis. And if we do not eat, then we cannot sleep. If we cannot sleep, we are likely to plunge ourselves into a bipolar episode.
Thus, food comes before sleep in my hierarchy — you cannot sleep effectively on an empty stomach
For me, I may not want to eat at any point on my mood spectrum. But the two states where my lack of desire to eat is most profound is:
- mania: too much going on, too much to do, no time for food, I don’t need to eat anyway, I’m superhuman.
- depression: I don’t care if I die here in my bed, what’s the point of eating anyway, it’s too hard to make food, I’m just going to lay here.
How to achieve:
For mania, what has worked best for me is to gamify the meal:
- Make it a race: Can I make food in less than 3 minutes? It’s a challenge, which is usually enticing enough in a manic state. My food consumption is also time-boxed then, so I know I won’t “waste” too much time.
- Set yourself up with a reward after: 5 more bites before I can finish that project I’m obsessing over.
- Help yourself get the food down: I have a glass of water with whatever food I try to eat in a manic state. One sip of water per bite helps you eat faster and with less effort.
- Make something easy: What I usually make is toast with a can of tuna and chopped up tomatoes. If it is anything more complicated, I will lose interest in making food before I even start.
For depression, what has worked best for me is always having pre-made or easy-to-make food in the house:
- Protein shakes: I’ve got protein shakes that come in a can. I keep some under my bed, and in easily accessible places in the kitchen. Usually after drinking one or two of those I will have enough mental energy to make something more substantial.
- Frozen food: usually frozen waffles or chicken nuggets, I always have some in the freezer. Microwave. Eat. Nom.
- Comfort food: the important thing here to keep in mind for depression is that any food is better than no food. There is no need to beat yourself up if the only thing you can get down is ice cream.
- Pancake mix: another good one to have around: pancakes include egg, sugar— substantial and tasty meal.
TIP: You can get all of these things delivered to your door via Amazon.
SLEEP
Sleep is absolutely critical to mental health. For bipolar individuals, a lack of sleep is a recipe for mania.
The challenge with sleep for bipolar individuals is that a lack of sleep one night will render sleep the next night even more challenging. And the longer one goes on in this cycle, the harder it is to break out of, and the more profound your mania becomes.
The key to sleep is to avoid this cycle all together (never get too little sleep), and to have a strategy for breaking out of a cycle when it does happen.
How to achieve:
I’ve tried so many things over the years to get consistent sleep:
- melatonin
- warm milk before bed
- turkey and peanuts
- excessive water before bed
- excessive exercise
- no sugar or no caffeine after noon
- chamomile tea
All of them together work pretty well. Not perfect though.
I would still have nights where I’d lay in bed for 5+ hours, unable to fall asleep, and a manic episode lasting anywhere from a few days to a few months as a result.
TIP: I recently started taking a low dose of Seroquel before bed. It is amazing. I have been getting the most consistent sleep of my life since I started taking it. Seroquel knocks me out consistently ~2h after I take it.
REALITY CHECKS
The first reality check that I ever had was my dog, and it was for auditory hallucinations. It went like this:
If my dog is not barking, then the thing I am hearing must be a hallucination, because my dog barks at everything.
My hallucinations have died down over the years, so I do not use this reality check much anymore. More recently, I have used reality checks to help me recognize the onset of a mania:
If I am feeling too impatient to:
- Finish a conversation
- walk my dog
- Eat
RED FLAG.
If I am obsessing over something such that I lose track of all time and space (ie. 5, 10, 15 hours sitting in the same spot, doing the same thing).
RED FLAG.
If I am extremely frustrated when people interrupt me.
RED FLAG.
If I find that all people are moving or speaking way too slowly.
RED FLAG.
How to achieve:
The key for coming up with your own reality checks comes from introspection. After collecting data on your mood states, as well as any environmental and social factors that may have contributed, it becomes easy to see trends in your days leading up to an episode.
Once you have pinpointed things that always occur before an episode, or during an episode, you can more easily come up with ways to identify these these trends even when you are in an altered mood state.
SOMETHING TO CARE ABOUT, BE PROUD OF
Everyone needs to feel good about themselves, but especially us individuals with mental illness.
Pride gives us a reason to keep moving forward, to keep fighting.
How to achieve (what worked for me):
- Try to only do things that make you happy.
- If you must do something that does not make you happy, try to find a reason to be happy about it.
- If you cannot find any reason to be happy about it, reconsider whether the task is absolutely necessary.
What happened for me as a result of this flow: things that I loved I started doing a lot, and I got really good at. And this gave me something to be proud of.
SOLIDIFY A ROUTINE
A routine (and at the root of this, a consistent sleep schedule) is imperative to maintaining stability.
It is important to find a routine that you can stick to every day, which incorporates your strategies for all the previous levels of the Bipolar Hierarchy of Needs.
How to achieve:
- Learn to “say no” to social events because they interfere with your routine. For me this just came with practice. Over time, after sitting with the anxiety and the FOMO, it became easier (see exposure therapy). If you must go to events, or if theses events fall under the blanket of things that make you happy from the previous section, try to only go for a few hours. Set an alarm on your phone for when it is time to leave.
- Don’t be on-call (this is when an engineer can be paged at any hour of the day or night if a system goes down). You have a medical reason not to do this, so don’t let it interfere with your routine.
SOBRIETY
Sobriety is so close to the top of my hierarchy because it is one of hardest levels to achieve, in my opinion.
Substances make our illnesses much harder to control, and greatly increase the likelihood of an episode.
How to achieve:
Note that there are a number of sobriety groups and resources out there, namely AA and Smart Recovery. I did not personally use a group, but they are effective for many.
For me, what’s worked in terms of sobriety:
Amphetamines:
- Stopping cold-turkey during a work vacation (holiday) worked best for me.
- My main fear upon quitting was that I wouldn’t be able to do anything without adderall (my amphetamine), I wouldn’t be able to work. This was not true at all. It took me a few weeks to be back to full productivity, and my moods have been much more stable since.
Alcohol:
- Acamprosate is a short-term drug that my psychiatrist prescribed for me for alcohol withdrawal. It worked very well, and I have now been sober from alcohol for over a year (no longer taking Acamprosate).
- Not going out with friends when they will be drinking (at least in the beginning)
- Else, having a buddy who will not drink with you.
Marijuana:
- There is a supplement called NAC (N Acetylcysteine) that works well for marijuana cravings. You can buy it at Whole Foods or other health food stores.
RADICAL SELF ACCEPTANCE AND SELF LOVE
There are many forms that radical self-love takes for me with respect to my bipolar disorder + my employment at Google:
- It is OK to cry at work.
How to achieve:
Find good places to cry ahead of time.
For me it’s in the parking lot, or if I can’t make it there in time, the bathroom.
I know others who cry in a Google shower (I am incredibly fortunate to work at Google).
Having a plan will solidify crying as an OK thing to do at work.
2. Take care of yourself first, always.
How to achieve:
We must accept that if we put other people or companies first, or their impression of us first:
- we will show up at less than 100%
- we will not be our best nor our most successful self.
- we will, overall, be a less effective employee for our Company.
We must remember, that even though it is hard for our peers and managers to see, we have a disability.
- Call it a “chronic illness”.
- Call therapy “doctor’s appointment” or “appointment with specialist”.
I have used all of these terms before. These more-general terms legitimize your illness and need for self-care for your manager and team, and in turn, for yourself.
Stay home if you are not feeling 100%. Your anxiety, hallucinations, paranoia — you do not have to deal with them at work.
If being at work is at all going to make your symptoms worse, you should not go to work.
And finally, always remember that you are the most important person in your life.
