The holidays can be extra difficult for folk living with mental illness. And, yes, mental illness is a real illness. Most everyone knows someone dealing with it in a very real way everyday. So, let’s attempt to raise our awareness to the subtleties of mental illness and attempt to “be there” for our friends, family, and neighbors. Here’s a great article to help us get started!
DBSA Jackson provides a weekly support group meeting for people living with mood disorders. The group facilitators are volunteers with problems of their own. For the past 15 years, these facilitators have proven themselves to be among the "strongest people".
The Depression and Bipolar Support Alliance (DBSA) is the leading patient-directed national organization focusing on depression and bipolar disorder. The organization fosters an environment of understanding about the impact and management of these life-threatening illnesses by providing up-to-date,
scientifically-based tools and information. DBSA supports research to promote more timely diagnosis, develop more effective and tolerable treatments and discover a cure. The organization works to ensure that people living with mood disorders are treated equitably. Assisted by a scientific advisory board comprised of the leading researchers and clinicians in the field of mood disorders, DBSA has more than 750 peer-run support groups across the country. Nearly two million people request and receive information and assistance each year. DBSA’s mission is to improve the lives of people living with mood disorders. For more information about DBSA or depression and bipolar disorder, please visit www.DBSAlliance.org or call (800) 826-3632.
Allen Doederlein, President, DBSA
Steve Brannon, State Director, DBSA Tennessee
Decision on Medicaid Expansion holds coverage for many Tennesseans in balance
By Kristi Nelson
Posted June 2, 2013, updated June 4 2013
It was supposed to be one of the strongest tenets of the 2010 Patient Protection and Affordable Care Act. Instead, it became a political football, a metaphor for states’ rights. After the Supreme Court ruled that the ACA could not force states to expand Medicaid, Gov. Bill Haslam was among those who rejected the Medicaid expansion, instead offering his alternative “Tennessee Plan” for federal government approval.
But whether the federal government and the General Assembly will accept Haslam’s plan remains to be seen, along with how well it will work to cover those who currently don’t have health insurance.
“He’s either politically brilliant, or he’s making one of the worst mistakes he could make,” Rep. Joe Armstrong, D-Knoxville, told the News Sentinel in March.
What the ACA intended
Originally, the Medicaid expansion provision was to give state health insurance coverage to a group of people who made too much to qualify for Medicaid but too little to afford insurance on the health insurance exchanges, even with the planned government subsidies.
It expanded Medicaid to qualify people younger than 65 whose income is below 138 percent of the federal poverty guideline (a little more than $15,860 annually for an individual, a little less than $32,500 annually for a family of four).
It meant that, for the first time, low-income adults who don’t have children could get state Medicaid coverage, and it standardized other qualifications.
Many states, including Tennessee, limit Medicaid enrollment to certain categories of people. To qualify for TennCare, for example, you have to be low-income and pregnant, a child, blind, disabled, aged, or fall under multiple, specific categories.
Tennessee has nearly 1 million uninsured residents, of whom at least 140,000 and maybe more than twice that number, by some estimates, likely would enroll in Medicaid if it were expanded under the ACA guidelines. About three-quarters would have been previously uninsured. Under the ACA expansion, the federal government would pick up the entire cost of new, previously ineligible enrollees for the first three years, phasing to 90 percent by 2020. In Tennessee, federal funds would have amounted to about $1.4 billion in the first year alone.
States could receive federal matching funds for covering additional low-income residents under Medicaid as early as April 2010, with wide-scale enrollment beginning this October and coverage starting Jan. 1, 2014. However, in June 2012, the U.S. Supreme Court ruled that the federal government could not make states expand Medicaid — making a linchpin of the ACA optional.
So far, 20 states have moved forward with Medicaid expansion. Ten have rejected it outright, while 10 others are not doing it now but are looking at alternatives and have not ruled it out for the future (the government gives no deadline, though states waiting much longer to decide stand to lose federal funds for the first year). Three states are still undecided, while seven — including Tennessee — are crafting their own, alternate plans.
On March 27, Gov. Bill Haslam announced that Tennessee would not expand TennCare rolls under the ACA, instead offering up an alternative he called the Tennessee Plan.
“I don’t think just pure expanding of a system that we all agree is too costly for us, is too costly for the federal government to afford long-term, is the right way,” he said then.
The ‘Tennessee Plan’
Haslam’s proposal is that the state use federal funds not to expand TennCare but to purchase private insurance through the insurance exchange for people who would have qualified for coverage under Medicaid expansion.
He outlined the proposal in the broadest terms, including five “key points”:
Individuals identified as being eligible for the Medicaid expansion group would instead be directed to the exchange, where they would be allowed to choose any qualified health plan that offers a certain level of benefits (the Silver Plan).
The state would pay the monthly premiums, matchable with 100 percent federal dollars, for those people to enroll in the Silver Plan.
People in the Medicaid expansion group would be treated like all other people enrolled in the Silver Plan, with access to the same benefits and appeals process as other people in the plans.
People in the Medicaid expansion group would have the same cost-sharing as other Silver Plan enrollees with incomes below 250 percent of the federal poverty guidelines. (On average, Silver Plan policies would pay for 70 percent of health care costs, with the remaining 30 percent paid by the planholder.)
The arrangement would have a “circuit-breaker,” or “sunset,” ending after the three-year period of 100 percent federal matching dollars, and could be renewed only with approval of the General Assembly. (This is true for states accepting the Medicaid expansion as well; they can stop using federal funds and drop the expanded coverage at any time.)
In addition, Haslam would seek to reform the way providers are paid for services, with payment based on outcomes rather than a set fee for services. The money saved, he said, would be enough to cover the state’s 10 percent share of costs after the government’s share goes to 90 percent.
“One option for covering the Medicaid expansion group is simply to add them to the Medicaid rolls, or the TennCare rolls, in our case,” Haslam said of the plan. “We don’t want to do that. There are a lot of federal requirements that come with Medicaid that make it difficult to provide quality care in the most cost-effective way possible.”
But the federal government may not allow Haslam to forgo some of those requirements. While national Centers for Medicare and Medicaid Services guidelines indicate that the main tenets of the plan — using federal dollars to pay premiums for low-income people to have commercial insurance, and reforming payment — meet federal requirements, some of the details don’t align with federal requirements intended to protect Medicaid enrollees.
For example, Tennessee would need to give those with serious health conditions a choice of enrolling in TennCare or private insurance, unless CMS were to grant Tennessee a waiver to that requirement.
The federal government would require supplementation of benefits (sometimes called “wraparound”) to make sure the commercial insurance plans include all services that would be available through Medicaid. Hypothetically, this could be done through a supplemental premium to the Silver Plan insurance provider.
The government also limits co-payments for Medicaid-eligible enrollees.
There is also an appeals process in place, required by past Supreme Court rulings, so that Medicaid patients and their doctors can challenge insurance companies’ refusals to cover “necessary treatments.” Under federal law, Tennessee would have to allow Medicaid-eligible patients this due process.
A federal entitlement program, Medicaid was designed for a population upon whom “poverty imposes special needs and the need for special protections,” said Carole Myers, a nurse practitioner and associate professor in the University of Tennessee’s College of Nursing. “They don’t have the same voice in government as those with different economic statuses and organizational affiliations.”
Haslam acknowledged in April that Tennessee probably would have to limit co-payments and provide the wraparound services for Medicaid-eligible enrollees for the federal government to approve his alternative, but he said he still thinks his overall plan is “workable.”
Haslam’s plan is modeled on a plan by Arkansas, which also wants to use federal matching dollars to pay commercial insurance premiums for those eligible for the Medicaid expansion. But while Arkansas got legislators’ approval before approaching the federal government, Haslam has taken the opposite approach, presenting his plan to CMS first.
Haslam did not ask state legislators to vote on whether to take the federal Medicaid expansion funds this session, though he said he has not ruled out calling a special legislative session later this year to meet federal deadlines for the health exchange enrollment starting in October.
The Medicaid expansion is the only provision in the ACA that provides insurance coverage specifically to those between 101 percent and 138 percent of the federal poverty guideline. If Haslam fails to reach an agreement with the federal government, or does not opt to accept the federal Medicaid expansion plan (which he could still do), that population likely would remain uninsured.
However, the latest word among hospital executives and advocates is that an agreement could be near.
“I think (Health and Human Services) Secretary (Kathleen) Sebelius is really eager to find some alternative plans that meet the goals of the ACA but do so in creative ways and allow states to create plans beneficial to those individual states,” said Jerry Askew, senior vice president for governmental relations for Tennova Healthcare.
Through Tennova’s parent company, Health Management Associates, Askew works with hospitals in seven states. All of them, except those in Kentucky and West Virginia, have said no to the expansion.
“They’re all trying to figure out what to do. It’s really interesting to watch how the state is to meet their individual objectives,” Askew said. As for Tennessee, he added, “It is fair to say that the governor’s plan is being built on principles that the majority in the Legislature would agree with. But it’s not a given. It’s a lot of hard work.”
Consumer-advocate groups and hospitals were in favor of the expansion, especially since hospitals stand to lose money on uncompensated “charity” care that would have been partially covered, at least, if more people were insured through Medicaid. The Tennessee Hospital Association has said the state stands to lose 90,000 jobs and nearly $13 billion.
Having that population continue to go uninsured also means higher costs in the long run, Myers said, as studies have shown that those without insurance are less likely to get preventive or early care.
“When you are resorting to getting care only when it becomes so bad you can’t stand it, and you’re in the emergency room, it’s causing a major human toll,” she said. “We know that intervention on the earliest point of the illness trajectory is the most cost-efficient. The true measure of whether we’re successful in what we’re doing in health care is in whether people have long, happy, productive lives.”
Business writer Carly Harrington contributed to this report.
© 2013, Knoxville News Sentinel Co.
The death of the Murphy Bill: On being the national spokesman
The Murphy Bill as we know is dead. The Republican leadership in the House announced a change in strategy. They basically decided to toss in the towel on the more controversial parts of the plan and try to see if they can move forward on elements that seem to have a greater consensus behind them. There may be CPR efforts yet but it appears done.
It was a bill in trouble from the start despite the massive pr campaign that tried so hard to say it wasnt so. It managed to unify groups that might not agree on what kind of reforms they wanted, but were absolutely sure what they didnt want and that was the Murphy Bill.
Part of the problem was Murphy himself. He assumed that as "the only psychologist in Congress" he was the obvious and deserved national spokesman for mental health reform. He wasnt. Being a psychologist certainly didnt qualify for the role. Neither did being a member of the House of Representatives. It seemed that Dr. Torrey annointed him and for some reason they both thought that mattered. In the end it was hard to know where he started and Dr. Torrey ended and that was perhaps a fatal flaw.
He didnt understand that leadership was built or that it was a two way street. He alienated people who had lived mental health reform their entire adult lives. He thought it was about them joining him and never seemed to know it was the other way around. And he never realized that trust was everything and that when he snuck AOT into the medicare bill he destroyed his chances of trust with people whose support he needed.
He was naive. The only people who believe federal laws change everything are federal lawmakers and most of them know better. To say that his law was going to prevent the next shooting was simply ego. He believed his own press clippings and his posturing before the dead were even buried just seemed like rank opportunism.
Mental health reform is an ongoing effort by many, many people with different values and priorities. Sometimes it is its own worst enemy. People who cant stand each other have a hard time standing together for anything. Murphy I hope has to some degree taught people they can find unity despite their differences. And maybe the fragile unity borne of him will be the biggest take-away from the entire thing.
He may indeed try again. He probably will. Dr. Torrey most surely will. He has won many, many short term victories and will doubtless win more, but the big prize has eluded him again. He is not the national spokesman he has annointed himself to be either.
Thanks for the support
by Larry Drain, hopeworkscommunity
The following organizations have offered support of "Dear Governor Haslam". They have put links to this site or printed the letters on their websites. I really appreciate it. I invite you or your organization to do the same.
Tennessee Health Care Campaign.
Tennessee Citizen Action.
Tennessee Disability Coalition.
Tennessee Chapter Depression and Bipolar Support Alliance.
WRITE GOVERNOR HASLAM TODAY
hopeworkscommunity | June 1, 2014
What is borderline personality disorder?Borderline personality disorder is a serious mental illness marked by unstable moods, behavior, and relationships. In 1980, the Diagnostic and Statistical Manual for Mental Disorders, Third Edition (DSM-III) listed borderline personality disorder as a diagnosable illness for the first time. Most psychiatrists and other mental health professionals use the DSM to diagnose mental illnesses.
Because some people with severe borderline personality disorder have brief psychotic episodes, experts originally thought of this illness as atypical, or borderline, versions of other mental disorders.1 While mental health experts now generally agree that the name "borderline personality disorder" is misleading, a more accurate term does not exist yet.
Most people who have borderline personality disorder suffer from:
According to data from a subsample of participants in a national survey on mental disorders, about 1.6 percent of adults in the United States have borderline personality disorder in a given year.2
Borderline personality disorder is often viewed as difficult to treat. However, recent research shows that borderline personality disorder can be treated effectively, and that many people with this illness improve over time.1,3,4
What are the symptoms of borderline personality disorder?According to the DSM, Fourth Edition, Text Revision (DSM-IV-TR), to be diagnosed with borderline personality disorder, a person must show an enduring pattern of behavior that includes at least five of the following symptoms:
Suicide and Self-harmSelf-injurious behavior includes suicide and suicide attempts, as well as self-harming behaviors, described below. As many as 80 percent of people with borderline personality disorder have suicidal behaviors,7 and about 4 to 9 percent commit suicide.4,7
Suicide is one of the most tragic outcomes of any mental illness. Some treatments can help reduce suicidal behaviors in people with borderline personality disorder. For example, one study showed that dialectical behavior therapy (DBT) reduced suicide attempts in women by half compared with other types of psychotherapy, or talk therapy. DBT also reduced use of emergency room and inpatient services and retained more participants in therapy, compared to other approaches to treatment.7 For more information about DBT, see the section, "How is borderline personality disorder treated?"
Unlike suicide attempts, self-harming behaviors do not stem from a desire to die. However, some self-harming behaviors may be life threatening. Self-harming behaviors linked with borderline personality disorder include cutting, burning, hitting, head banging, hair pulling, and other harmful acts. People with borderline personality disorder may self-harm to help regulate their emotions, to punish themselves, or to express their pain.8 They do not always see these behaviors as harmful.
When does borderline personality disorder start?Borderline personality disorder usually begins during adolescence or early adulthood.1,9 Some studies suggest that early symptoms of the illness may occur during childhood.10,11
Some people with borderline personality disorder experience severe symptoms and require intensive, often inpatient, care. Others may use some outpatient treatments but never need hospitalization or emergency care. Some people who develop this disorder may improve without any treatment.12
Studies suggest early symptoms may occur in childhood
What illnesses often co-exist with borderline personality disorder?Borderline personality disorder often occurs with other illnesses. These co-occurring disorders can make it harder to diagnose and treat borderline personality disorder, especially if symptoms of other illnesses overlap with the symptoms of borderline personality disorder.
Women with borderline personality disorder are more likely to have co-occurring disorders such as major depression, anxiety disorders, or eating disorders. In men, borderline personality disorder is more likely to co-occur with disorders such as substance abuse or antisocial personality disorder.13
According to the NIMH-funded National Comorbidity Survey Replication—the largest national study to date of mental disorders in U.S. adults—about 85 percent of people with borderline personality disorder also meet the diagnostic criteria for another mental illness.2
Other illnesses that often occur with BPD include diabetes, high blood pressure, chronic back pain, arthritis, and fibromyalgia.14,15 These conditions are associated with obesity, which is a common side effect of the medications prescribed to treat borderline personality disorder and other mental disorders. For more information, see the section, "How is borderline personality disorder treated?"
What are the risk factors for borderline personality disorder?Research on the possible causes and risk factors for borderline personality disorder is still at a very early stage. However, scientists generally agree that genetic and environmental factors are likely to be involved.
Studies on twins with borderline personality disorder suggest that the illness is strongly inherited.16,17 Another study shows that a person can inherit his or her temperament and specific personality traits, particularly impulsiveness and aggression.18 Scientists are studying genes that help regulate emotions and impulse control for possible links to the disorder.19
Social or cultural factors may increase the risk for borderline personality disorder. For example, being part of a community or culture in which unstable family relationships are common may increase a person's risk for the disorder.1 Impulsiveness, poor judgment in lifestyle choices, and other consequences of BPD may lead individuals to risky situations. Adults with borderline personality disorder are considerably more likely to be the victim of violence, including rape and other crimes.
How is borderline personality disorder diagnosed?Unfortunately, borderline personality disorder is often underdiagnosed or misdiagnosed.20,21
A mental health professional experienced in diagnosing and treating mental disorders—such as a psychiatrist, psychologist, clinical social worker, or psychiatric nurse—can detect borderline personality disorder based on a thorough interview and a discussion about symptoms. A careful and thorough medical exam can help rule out other possible causes of symptoms.
The mental health professional may ask about symptoms and personal and family medical histories, including any history of mental illnesses. This information can help the mental health professional decide on the best treatment. In some cases, co-occurring mental illnesses may have symptoms that overlap with borderline personality disorder, making it difficult to distinguish borderline personality disorder from other mental illnesses. For example, a person may describe feelings of depression but may not bring other symptoms to the mental health professional's attention.
No single test can diagnose borderline personality disorder. Scientists funded by NIMH are looking for ways to improve diagnosis of this disorder. One study found that adults with borderline personality disorder showed excessive emotional reactions when looking at words with unpleasant meanings, compared with healthy people. People with more severe borderline personality disorder showed a more intense emotional response than people who had less severe borderline personality disorder.6
What studies are being done to improve the diagnosis of borderline personality disorder?Recent neuroimaging studies show differences in brain structure and function between people with borderline personality disorder and people who do not have this illness.22,23 Some research suggests that brain areas involved in emotional responses become overactive in people with borderline personality disorder when they perform tasks that they perceive as negative.24 People with the disorder also show less activity in areas of the brain that help control emotions and aggressive impulses and allow people to understand the context of a situation. These findings may help explain the unstable and sometimes explosive moods characteristic of borderline personality disorder.19,25
Another study showed that, when looking at emotionally negative pictures, people with borderline personality disorder used different areas of the brain than people without the disorder. Those with the illness tended to use brain areas related to reflexive actions and alertness, which may explain the tendency to act impulsively on emotional cues.26
These findings could inform efforts to develop more specific tests to diagnose borderline personality disorder.6
How is borderline personality disorder treated?Borderline personality disorder can be treated with psychotherapy, or "talk" therapy. In some cases, a mental health professional may also recommend medications to treat specific symptoms. When a person is under more than one professional's care, it is essential for the professionals to coordinate with one another on the treatment plan.
The treatments described below are just some of the options that may be available to a person with borderline personality disorder. However, the research on treatments is still in very early stages. More studies are needed to determine the effectiveness of these treatments, who may benefit the most, and how best to deliver treatments.
PsychotherapyPsychotherapy is usually the first treatment for people with borderline personality disorder. Current research suggests psychotherapy can relieve some symptoms, but further studies are needed to better understand how well psychotherapy works.27
It is important that people in therapy get along with and trust their therapist. The very nature of borderline personality disorder can make it difficult for people with this disorder to maintain this type of bond with their therapist.
Types of psychotherapy used to treat borderline personality disorder include the following:28
One type of group therapy, Systems Training for Emotional Predictability and Problem Solving (STEPPS), is designed as a relatively brief treatment consisting of 20 two-hour sessions led by an experienced social worker. Scientists funded by NIMH reported that STEPPS, when used with other types of treatment (medications or individual psychotherapy), can help reduce symptoms and problem behaviors of borderline personality disorder, relieve symptoms of depression, and improve quality of life.32 The effectiveness of this type of therapy has not been extensively studied.
Families of people with borderline personality disorder may also benefit from therapy. The challenges of dealing with an ill relative on a daily basis can be very stressful, and family members may unknowingly act in ways that worsen their relative's symptoms.
Some therapies, such as DBT-family skills training (DBT-FST), include family members in treatment sessions. These types of programs help families develop skills to better understand and support a relative with borderline personality disorder. Other therapies, such as Family Connections, focus on the needs of family members. More research is needed to determine the effectiveness of family therapy in borderline personality disorder. Studies with other mental disorders suggest that including family members can help in a person's treatment.33
Other types of therapy not listed in this booklet may be helpful for some people with borderline personality disorder. Therapists often adapt psychotherapy to better meet a person's needs. Therapists may switch from one type of therapy to another, mix techniques from different therapies, or use a combination therapy. For more information see the NIMH website section on psychotherapy.
Some symptoms of borderline personality disorder may come and go, but the core symptoms of highly changeable moods, intense anger, and impulsiveness tend to be more persistent.34 People whose symptoms improve may continue to face issues related to co-occurring disorders, such as depression or post-traumatic stress disorder.4 However, encouraging research suggests that relapse, or the recurrence of full-blown symptoms after remission, is rare. In one study, 6 percent of people with borderline personality disorder had a relapse after remission.4
MedicationsNo medications have been approved by the U.S. Food and Drug Administration to treat borderline personality disorder. Only a few studies show that medications are necessary or effective for people with this illness.35 However, many people with borderline personality disorder are treated with medications in addition to psychotherapy. While medications do not cure BPD, some medications may be helpful in managing specific symptoms. For some people, medications can help reduce symptoms such as anxiety, depression, or aggression. Often, people are treated with several medications at the same time,12 but there is little evidence that this practice is necessary or effective.
Medications can cause different side effects in different people. People who have borderline personality disorder should talk with their prescribing doctor about what to expect from a particular medication.
Other TreatmentsOmega-3 fatty acids. One study done on 30 women with borderline personality disorder showed that omega-3 fatty acids may help reduce symptoms of aggression and depression.36 The treatment seemed to be as well tolerated as commonly prescribed mood stabilizers and had few side effects. Fewer women who took omega-3 fatty acids dropped out of the study, compared to women who took a placebo (sugar pill).
With proper treatment, many people experience fewer or less severe symptoms. However, many factors affect the amount of time it takes for symptoms to improve, so it is important for people with borderline personality disorder to be patient and to receive appropriate support during treatment.
How can I help a friend or relative who has borderline personality disorder?If you know someone who has borderline personality disorder, it affects you too. The first and most important thing you can do is help your friend or relative get the right diagnosis and treatment. You may need to make an appointment and go with your friend or relative to see the doctor. Encourage him or her to stay in treatment or to seek different treatment if symptoms do not appear to improve with the current treatment.
To help a friend or relative you can:
How can I help myself if I have borderline personality disorder?Taking that first step to help yourself may be hard. It is important to realize that, although it may take some time, you can get better with treatment.
To help yourself:
What if I or someone I know is in crisis?If you are thinking about harming yourself, or know someone who is:
For more information on borderline personality disorderVisit the National Library of Medicine's:
For information on clinical trials
National Library of Medicine clinical trials database
Information from NIMH is available in multiple formats. You can browse online, download documents in PDF, and order materials through the mail. Check the NIHM website for the latest information on this topic and to order publications. If you do not have Internet access, please contact the NIMH Information Resource Center at the numbers listed below.
National Institute of Mental Health
Science Writing, Press & Dissemination Branch
6001 Executive Boulevard
Room 8184, MSC 9663
Bethesda, MD 20892-9663
Phone: 301-443-4513 or 1-866-615-NIMH (6464) toll-free
TTY: 301-443-8431 or 1-866-415-8051 toll-free
Differentiating Borderline Personality Disorder from Bipolar Disorder
By BERNADETTE GROSJEAN, MD
Borderline personality disorder (BPD) and bipolar disorder frequently co-occur (numbers range from 8% to 18%), although they are distinct clinical entities (Paris J et al, Compr Psychiatry2007;48(2):145–154). A proper diagnosis guides the most effective treatment, but you’ve probably faced the difficult challenge of diagnosing these conditions, which share several clinical features.
BPD can be described by four types of psychopathology: affective disturbance, impulsivity, cognitive problems, and intense, unstable relationships. What’s most important—in addition to seeing that your patient meets DSM-IV criteria for BPD—is to establish that patterns of affective instability, impulsivity, and unstable relationships have been consistent over time. Thus, obtaining a detailed history is crucial. Also, the key features we see in BPD, such as dissociation, paranoia, and cognitive problems, are often affected by the patient’s environment and, particularly, his or her relationships. A patient might have a history of rapid and sudden deterioration when relationships change—such as threatening suicide after a breakup or severe mood swings when separated from her family. Generally, the more intense or significant the relationship is, the greater the risk of chronic stress and mood dysregulation.
Many of the same features are seen in patients with bipolar disorder, such as dysphoria, hyperactivity, impulsivity, suicidality, and psychotic symptoms. As a result, borderline patients with this cluster of symptoms are often misdiagnosed with bipolar disorder, possibly because of the effectiveness of psychopharmacological treatments for such symptoms. In fact, a more thorough assessment might show that these patients actually suffer from a personality disorder. In one study, more than one third of those misdiagnosed with bipolar disorder met DSM-IV criteria for BPD (Zimmerman M et al, Compr Psychiatry2010;51(2):99–105).
In BPD, mood changes are generally short-lived, lasting only for a few hours at a time. In contrast, mood changes in bipolar disorder tend to last for days or even weeks or months. Mood shifts in BPD are usually in reaction to an environmental stressor (such as an argument with a loved one or a frustration in the waiting room), whereas mood shifts in bipolar disorder may occur out of the blue. Some clinicians consider BPD an “ultrarapid-cycling” form of bipolar disorder, but there’s little evidence to support this link (Gunderson JG et al, Am J Psychiatry 2006;163(7):1173–1178). Patients with BPD might rapidly cycle through depression, anxiety, and anger, but these mood shifts rarely involve elation; more often, the mood shifts are from feeling upset to feeling just “OK.” Likewise, the anxiety or irritability of BPD should not be mistaken for the mania or hypomania of bipolar disorder, which usually involve expansive or elevated mood.
At a more existential level, patients with BPD—particularly younger patients— often struggle with feelings of emptiness and worthlessness, difficulties with self-image, and fears of abandonment. These are less common in bipolar disorder, where grandiosity and inflated self-esteem are common, especially during mood episodes. And while both conditions may include a history of chaotic relationships, a patient with BPD may describe relationship difficulties as the primary—or sole—source of her/his suffering, while the bipolar patient may see them as an unfortunate consequence of his behavior.
A pattern of self-harm and suicidality often serves as a cue for diagnosing BPD (but are not necessarily required). But both can be seen in bipolar disorder, too. In BPD, suicide threats and attempts may occur along with anger at perceived abandonment and disappointment. Patients often explain these impulses as a way to be relieved of pain, or to “stop their thinking,” more so than to end their lives, per se. Patients with BPD may experience “micropsychotic” phenomena of short duration (lasting hours or at most a few days), including auditory hallucinations, paranoia, and episodes of depersonalization. However, patients generally retain insight, and can acknowledge that “something strange is happening” without strong delusional thought. When psychotic symptoms occur in bipolar disorder, they happen in the context of a mood episode, they tend to last longer, and patients may be unable to reflect on their behavior.
Accurate diagnosis of BPD and bipolar disorder can be difficult, but it’s essential for proper treatment and optimal outcome. Remission rates in BPD can be as high as 85% in 10 years (Gunderson et al, Arch Gen Psychiatry 2011;68(8):827–837), particularly with effective psychotherapeutic treatments (Zanarini MC, Acta Psychiatr Scand 2009;120(5):373– 377). Unfortunately, such treatment is not always available. Some medications can be used in BPD, such as an SSRI for impulsivity, severe and persistent depression and/or suicidality, or an atypical antipsychotic for recurrent dissociative symptoms or disinhibition. However the only consensus seems to be that medications should be used as adjuncts to psychotherapy (Silk KR, J Psychiatric Practice 2011;17(5):311–319). The long-term use of a mood stabilizer or atypical should be reserved for known cases of bipolar disorder.
TCPR’s VERDICT: Clinicians sometimes think of a BPD diagnosis as pejorative (chronic and untreatable) and may be reluctant to disclose it, but patients and their families often find it helpful to be informed of the diagnosis. Similarly with bipolar disorder, accurate diagnosis often determines prognosis and effective treatment. For the clinician, however, it’s imperative that you make the proper diagnosis in these two often overlapping, but fundamentally quite distinct, conditions in order to optimize your patients’ outcomes.
Target Zero to Thrive This April
DBSA targets raising expectations for mental health treatment.
A month-long social media campaign, Target Zero to Thrive, challenges mental health care professionals, researchers, and individuals living with or affected by mood disorders to raise treatment goals to complete remission—to zero symptoms.
Of course the first priority for treatment is ensuring a person living with depression or bipolar disorder is out of crisis. However, too often the end goal established for successful long‐term care is for the person to maintain a stable mood. Better, or even stable, is not always well. Every person deserves the opportunity to not just survive but thrive, and to do that we need to ensure true wellness is the end‐goal for mental health treatment.
Consider this, successful treatment for cancer proceeds with the goal of removing every cancerous cell—to achieve complete remission. Why then, do we consider treatment for depression or bipolar disorder to be successful when symptoms persist, even if the person is considered to be stable?
The cost of settling for reduced symptoms is simply too great. It is, in fact, a matter of life and death—for when symptoms persist, individuals who have mood disorders are:
DBSA President Allen Doederlein shares, “Living with a mood disorder can damage hope and lower expectations; so a person may not expect or think they deserve a full life. We, as peers, clinicians, researchers, and family, need to help them expect and achieve more—by raising the bar for treatment. Targeting zero symptoms may seem like a formidable goal, but there are over 21 million reasons and Americans living with depression or bipolar disorder to make it a goal worth pursuing!”
(1) Am J Psychiatry. 2000 Sep;157(9):1501-4.
(2) J Clin Psychiatry. 2007 Aug;68(8):1237-45.
(3) Bipolar Disord. 2004 Oct;6(5):368-73.
(4) Psychiatr Serv. 2013 Dec 1;64(12):1195-202. doi: 10.1176/appi.ps.201200587.
That's how many Tennesseans were kept out of poverty by Social Security Income each year, on average, from 2010 to 2012. Of those, over 372,000 were 65 or older. Nationally, Social Security kept more than 22 million people out of poverty; over 15 million were 65-plus, according to an AARP Public Policy Institute report. Go to aarp.org/bulletin for more information.
The power of two
Your partner can become a pillar of strength when you work together as a couple
By Barbara Boughton, BP Spring 2013
There’s no doubt that the nature of your relationship with a “significant other” has a major effect on managing bipolar. Research now shows that having a supportive partner may be just as important as medication and psychotherapy in preventing relapse, according to Sagar Parikh, MD, a professor of psychiatry at the University of Toronto.
Likewise, the stress of high-conflict relationships or the emotions that accompany breakup and divorce can sometimes exacerbate symptoms of the disorder, Parikh says.
So what can you do to make your partner an ally in recovery?
The first step, says Parikh, is education—for both of you.
The more that both partners know about symptoms, treatments, and coping strategies, the more they can work together to address common challenges. Reading and online research, workshops presented by mental health organizations, discussions with mental health practitioners, and peer support groups are all good ways to get informed.
A partner or spouse who is up to speed on what it takes to live with bipolar will find it easier to understand when you ask for support.
The next step is learning to discuss matters relating to your illness openly and honestly.
For one thing, being able to share what’s going on in your life and your head provides your partner with a context for any irritability, sadness or high spirits you exhibit. For another, it gives you both a touchstone for recognizing early signs of a mood shift.
Elizabeth and her husband, Rory, who have been married since August 2012, have a conversation at least once a week about any symptoms Elizabeth might be experiencing.
“Regular communication is really important,” says Elizabeth, 32, of British Columbia. “We talk about what I’m feeling and things that he notices about me. Sometimes, it’s hard for me to see the forest for the trees, especially if I’m not feeling well.”
Rory’s feedback provides her with a reality check, Elizabeth says.
“Last year I had a manic episode and Rory realized something was wrong when I told him: ‘I want to go on a 5K run.’ I’m a pretty sedentary person, so for me that’s out of character. It gave Rory a clue that I might be experiencing mania,” she recalls.
In most intimate relationships, it’s important to make significant others aware of red flags, according to David Miklowitz, PhD, a professor of psychiatry and director of the Child and Adolescent Mood Disorders Program at the Semel Institute for Neuroscience and Human Behavior at the University of California–Los Angeles.
“People with bipolar disorder can make a list of symptoms and behaviors that they know indicate early signs of a manic or depressive episode. The partners can then refer back to these lists in order to spot early symptoms,” Miklowitz says.
comfort levelWith education and experience, partners often become adept at spotting subtle signs, Miklowitz notes—sometimes before the person with bipolar does.
“Then the question becomes: If your partner spots early signs of mania or depression, what do you want them to do with that information?” Miklowitz says.
“Do you want them to call your doctor? Do you want them to go in with you for a therapy session, or encourage you to take your medicines? Some people like that kind of active support from their partners, and some do not.”
In some cases, Miklowitz says, intervention from a spouse can be seen as “too parental or too controlling.”
The bottom line is this: In order to tell your partner how to be helpful, you first need to know what kind of help you want. That’s highly individual, so every couple will find a different fit. After a disturbing interaction with a friend or boss, one person may simply want to vent while another seeks advice on how to resolve the situation.
Bill, 67, has never looked for a lot of hands-on involvement from his wife, Telle. The couple lives in California, and has been married for 20 years.
“The main way that Telle has supported me is through her acceptance of me—and that’s been very important to me and our relationship. She knows that I can stand on my own two feet, and she doesn’t judge me,” says Bill, a retired refrigeration pipe fitter.
What Bill appreciates are Telle’s understanding and compassion for his symptoms, her trust that he is working to get the best treatment he can, and her emotional support when he’s had to be hospitalized.
Still, Telle has occasionally taken an active role in Bill’s care. In May 2012, Bill became delusional while being assessed at a hospital for a blood clot in his lung. Telle spoke to his psychiatrist, who arranged for Bill to be admitted for psychiatric intervention.
If your partner does take an active role, Miklowitz says, it’s important to understand that the person will probably make mistakes.
“It’s crucial to give your partner some leeway, especially in the beginning of a relationship, when they’re just getting to know you and the effects of your illness. They’re not trying to control you. They’re just trying to help, and they don’t always know how to best do that,” he says.
talking pointsOnce you are clear in your own mind about what role you’d like your partner to take, Miklowitz notes, it’s crucial to be direct in expressing your wishes—and also to listen to what your partner has to say.
Miklowitz recommends asking “clarifying questions” to make sure you understand your partner’s point of view. To doublecheck that you’re interpreting correctly, practice repeating back what the other person said—a technique known as reflective listening or mirroring.
Nancy Poirier, MPs, a clinical psychologist at the Douglas University Institute for Mental Health in Montreal, stresses the need to express your wants and feelings with compassion.
With mirroring, for example, first reflect your partner’s viewpoint, then express understanding and empathy to validate how the other person feels.
In addition, she says, “both partners should be careful to use ‘I statements’ rather than blaming the other person in talking about the bipolar disorder. The important thing is for both partners to feel understood.”
As far as practical approaches, Poirier recommends developing a relapse prevention plan that details early warning signs of a mood shift and how to respond. The Elizabeth and Rory’s plan includes a list of people whom Rory should call to get Elizabeth treatment and/or medication, as well as the name and contact information for the hospital where she’d like to be treated.
As a further step, Poirier notes, you and your partner can write a contract about what each of you will do when warning signs appear. A document you signed when well may be more effective against denial when you’re ill than a partner’s reminders.
There are other small but helpful ways partners can counter symptoms, she says. During a manic phase, reduce stimulation by decreasing light and loud music in the household, and keep credit and cash cards inaccessible. During a depressive phase, let more light into the house, encourage exercise, and gently urge completion of at least one pleasant activity each day.
On a day-to-day basis, agree on a system that keeps encouragement from feeling like nagging. Again, this will vary from couple to couple. Some might be comfortable with a daily check-in about medication compliance, for example, while others will prefer a more emotionally neutral chart system that both partners can refer to.
Couple’s therapy can be an effective way to develop strategies for coping with the disorder together, Miklowitz says.
“The counseling should help the couple solve problems that arise around the symptoms of bipolar disorder, and learn to communicate effectively about them,” he says.
In addressing specific issues, Miklowitz adds, it helps to realize that you may not get everything you want.
“You have to be willing to compromise,” he says. “You have to start with the assumption that everyone—you and your partner—are doing their best.”
“Doing your best” might involve taking as much responsibility as you can for your recovery and well-being, Poirier points out. For your partner, that might mean cutting you a little slack for symptomatic behavior.
Elizabeth says that when she succumbs to what she calls her “ooh, shiny!” syndrome, Rory usually accepts the impulsive action as part of her illness.
When she bought several hundred dollars’ worth of tea towels, she recalls, Rory commented that they were now stocked up for a few years. When she took their cat to the vet and came home with an extra kitten, Rory “accepted the kitten with open arms,” she reports—and they now have a rule that they only go to the vet’s together.
“He isn’t a pushover,” she says, “he just knows that in the spring, I pull a few whoppers and that is OK.”
In fact, she says, Rory took the news of her diagnosis better than she did. They were dating at the time, Elizabeth says, and Rory made it a point to find books that would be helpful.
“He never judged me for having bipolar,” she adds. “I’m very lucky to have found Rory.”
Barbara Boughton, a freelance health and medical writer, writes for Reader’s Digest, Medscape.com and other outlets. She lives in the San Francisco Bay area.
Learning when a hug can helpWhen Heather and Ken first met in fall 2002, Heather certainly wasn’t in the mood for romance. She was experiencing serious depression and “very resistant to dating,” but Ken waited patiently.
“When we did start dating, I was very forthright about having bipolar disorder, and he was very understanding,” recalls Heather, 44.
Now Heather’s relationship with her husband is a rock that steadies her when symptoms crop up. In Heather’s case, that’s often behaviors that signal depression—not getting out of bed, failing to eat healthy foods, and crying a lot.
After nine years of marriage, Ken has come to understand what his wife needs when she is ill. And Heather made it a priority to communicate to her husband about what kind of support she finds the most helpful.
“Sometimes it’s just the simple things that are important,” Heather says. “A hug from Ken can be very grounding when I’m having a difficult time. He also knows when to give me space, such as when I get irritable, angry, and when I lash out.”
Perhaps more importantly, Ken and Heather have an agreement that they’ll promptly address any worrisome symptoms.
Heather admits she’s not always receptive when Ken spots signs of depression or hypomania, such as being quick to anger or spending too much on online shopping, yet she will usually agree to call her doctor.
“Couples therapy has also helped us,” she says. “We’ve learned not to blame each other when we discuss sensitive issues such as my bipolar disorder, and to respectively express our feelings. Sometimes that may mean taking a break or even going to different rooms when a discussion becomes too heated.”
She adds, “What has been most important is for both of us to realize that I’m more than the identified patient in our relationship. I’m Heather, a wife who is more than her illness, and who needs and wants hope and love from her partner.”
In sickness and in healthDan and Dolores have weathered 43 years of marriage—and Dan’s bipolar swings.
Dan, now 73, was accurately diagnosed in his late 20s. He and Dolores were contemplating marriage, and she accepted the news along with the man.
“He was a real charmer and had a wonderful sense of humor,” Dolores remembers.
Dan was in a stable period when they met, but shortly after the wedding he slipped into depression. For the next decade, he cycled from months of mania marked by reckless spending and anger, to months of immobilizing depression, to stretches of stability that might last half a year. He went through a series of jobs, never keeping one for long.
“I was ill and non-productive and she was the provider and caretaker,” Dan says.
Dolores held down several part-time jobs, taking their two children to work with her because they couldn’t afford child care. The couple went through two bankruptcies.
“It was painful and it was devastating, but I didn’t leave because I don’t believe in divorce,” says Dolores, 75. “But even in the most difficult moments, Dan’s sense of humor would come shining through.”
They held on until Dan found the treatment he needed at Washington University. An equally important turning point was their decision to start a peer support group in 1980, which became one of the founding chapters of what is now the national Depression and Bipolar Support Alliance (DBSA).
The work not only helped his wife become more educated about the disorder, Dan says, but through running meetings “she gained many skills in talking with me in a very helpful and therapeutic way.”
“We learned how to communicate even around tough topics—and not blame the other person,” Dolores adds.
Dolores admits to “mixed feelings” about their marriage over the years, but says that their life improved as their ability to address Dan’s health got better.
“He has changed in a really positive way over the years,” she says. “And our communication strategies just got better and better. We feel so blessed now.”
Another definition of partnerPeople who are single may find a family member who becomes a partner in recovery. For Jackie that’s her dad, Larry.
“We’ve become an amazing team at managing my bipolar I,” explains the 25-year-old. “We even have a special binder that we keep on the coffee table that has copies of the most important papers about my illness and how we should handle things.”
The binder includes a list of her medications and what they’re for, contact information for her doctors, steps to take in various crisis situations, even copies of some of her homework from psychotherapy.
Jackie has found the skills she’s learning in dialectical behavior therapy especially helpful in managing her symptoms. When she comes home from group, she shares new information with her father. Also really helpful, she says, is “both of us reading everything we can get our hands on about bipolar. We test out new techniques for managing things to see what works best for us.”
For example, Jackie now keeps track of when (or whether) she’s taken her medications on a dry-erase board that hangs on the fridge. The chart not only reminds her to take the meds, but also keeps her father in the loop without having to bug her.
Jackie, who was diagnosed at 14, has seen a huge change since her father started educating himself. When she’s in a mood shift, they’re able to talk through what may have triggered it and how to get her back in balance. When her dad learned that people with mental illnesses sometimes use cigarettes to cope with stress, he stopped insisting she quit smoking. Instead, he encourages her to cut back.
“Before he started reading he didn’t understand nearly as well as he does now, which really goes without saying,” she reflects. “We fought a lot more and he really didn’t ‘get’ me. Now we fight less and he’s much more compassionate to what I’m enduring.”
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More on our speaker series
We recently announced the beginning of our speaker series in Blount County sponsored by Maryville Nami. Our first speaker on March 20 will be Sita Diehl National Director of State Advocacy for Nami national. I am very excited today to announce our second speaker today. On April 24 Doug Varney Commissioner for Dept of Mental Health and Substance Abuse will be coming to speak in Maryville. Tentatively his topic will be the scourge of drug abuse, particularly prescription drugs and meth, their relationship to mental health issues and efforts by the state to address these issues. It should be a great and informative evening. Please do all you can to spread the word about both of these presentations.
I'm sharing the news of my being among national Award Winners for accomplishments over the past year. It has been a pleasure to serve as State Director and local chapter President. And I consider it an honor to be recognized by DBSA national.
I appreciate all the wonderful support I was given by my fellow officers, Board members, and the chapter membership throughout the year. You may view the announcement on the national web site athttp://www.dbsalliance.org/site/PageServer?pagename=peer_chapter_spotlights
Congratulations to our 2013 Chapter Service Award Winners!
The DBSA Chapter Service Awards recognize exemplary service by DBSA
chapters, state organizations, and their leaders. Winners will be honored at the 2014 Chapter Leadership Forum in addition to receiving a cash award.
Steve Brannon of DBSA Jackson (TN) and DBSA Tennessee - Outstanding
Steve is an excellent role model for pursuing a wellness-focused life while living with a mood disorder. He fights stigma by openly sharing his journey in the local newspaper, on DBSA’s website, and on his weekly online newsletter. He has worked with the local police department to help educate and train police officers for crisis response teams. Steve was selected for DBSA Peer Advocacy Training and was a representative of DBSA for Hill Day in Washington, D.C.
At his local chapter, DBSA Jackson (TN), Steve gently encourages, trusts, and believes in support group participants. He instituted a monthly “share your inspiration” night in which group members report on what keeps them going, creating an environment of hope and personal growth. Steve is dedicated to further advancing DBSA’s mission into surrounding communities and across the state. The number of support groups has doubled in the past year under his direction, encompassing all major cities and some smaller cities across the state. He has traveled hundreds of miles at his own expense to conduct local chapter visitations as state director. Steve’s passion for the advancement of DBSA’s mission in Jackson and the state of Tennessee is so strong that he has diligently dedicated his time and resources for over a decade.
DBSA Tennessee - State Organization Service
DBSA Tennessee's amazing accomplishments made 2013 a rewarding year!
They supported chapters in their state by hosting educational presentations and training programs, giving them the tools necessary for successful chapters. With help from DBSA Tennessee, five local chapters were interviewed on television or radio to promote DBSA to the community. Leaders encouraged one chapter’s community outreach, resulting in a city-wide Mental Health Day declared by their mayor. DBSA Tennessee’s robust plan to help new chapters in the startup process helped find free meeting locations, assistance in affiliation fees and paperwork, and provided a sponsor from an already established chapter to assist the new chapter.
Five members of DBSA Tennessee attended DBSA’s Peer Advocate Training in Washington, D.C. and then created an advocacy plan for their state including a campaign against proposed budget cuts to close all 45 of Tennessee’s Peer Support Service Centers. DBSA Tennessee is a growing, thriving organization. With its advocacy for peer support and local chapter start-up, community outreach and commitment to peer education, DBSA Tennessee is one of the most energetic affiliates of DBSA.
DBSA Murfreesboro (TN) - Rookie Chapter Service
DBSA Murfreesboro began in July of 2013 with support from DBSA Tennessee.
The chapter started out with one support group, which saw its attendance
double in fewer than six months, becoming one of the fastest growing local
chapters in the state. The growth of the chapter can be attributed to the forces behind it that work tirelessly to get the word out about the group. Flyers and pamphlets are distributed to agencies and health care providers, the Salvation Army, local hospitals and businesses, and more. DBSA Murfreesboro provides post-hospitalization support for those who would otherwise have none. Educational materials, resources, and wellness tools are provided to each chapter participant. They have also started a family and friends support group.
Members of DBSA Murfreesboro participated in the state chapter meetings and backing of their U.S. Representative. For a chapter that achieved all of this in six months, DBSA Murfreesboro has a fine resume of accomplishments, but they consider their greatest success to be the level of support offered to each person who walks through their doors.
http://www.urban.org/health_policy/health_care_reform/localmedicaidexpansion.cfmS.L. Brannon on DBSA Life Unlimited web site
Ways to Gently Advocate for Mental Health
Posted on February 8, 2014 by Paulissa Kipp
Greetings, everyone. This April training course in Milwaukee is open to Veterans not currently employed in VA peer support positions who are interested in qualifying for such employment. To access the application, either click on the link below, or see the attached document. Please note the March 25, 2014 application deadline, and thank you in advance for circulating this to interested Veterans as appropriate.
Application link: http://www.dbsalliance.org/site/Survey?ACTION_REQUIRED=URI_ACTION_USER_REQUESTS&SURVEY_ID=8300
Best, Lisa Goodale
Lisa C. Goodale, MSW, LSW
Vice President, Peer Support Services
Depression and Bipolar Support Alliance / DBSA
(312) 642-0049, x155 or (312) 988-1155
Fax: (312) 642-7243
Veteran peer specialist training:
S.L. Brannon D.Div..