Guest blogger Sheila O’Donnell writes insightfully about living with two co-morbid conditions, Complex PTSD and Bipolar Disorder.
Post-traumatic stress disorder (PTSD) is a film reel constantly projecting your worst experiences in the back of your mind — you know, near the occipital lobe. Sometimes, the picture is faint and the sound is muted; other times, it’s 3-D and Dolby Digital Surround Sound on full blast. Bipolar affective disorder (BPAD, otherwise known as bipolar disorder) is a whiplash and nausea-inducing, twisted, horror movie amusement park, twirling you around like a 10-cent stuffed animal from a prize stand gripped tight in the sticky fingers of a little kid spinning you mercilessly. I live with both conditions. Here are 5 things you might not know about the struggles of managing co-occurring mental health diagnoses.
1) Your psychiatrist has to do a cost/benefit analysis of medications that may help manage one diagnosis but negatively impact the other.
You’re probably at least vaguely familiar with the symptoms of PTSD and BPAD. PTSD comes with a big old unwanted gift basket brimming with things like flashbacks, nightmares, panic attacks, fear of going out in public, avoidance of anything that may trigger you and a general lack of trust the world is “safe.” Then, there’s BPAD — swings between manic and depressive. My manic episodes are usually in the hypomanic or mixed manic range. Regardless of the title, when I’m anything-manic, I’m never able to calm down, sit still, think straight, sleep or eat. Medications for PTSD are often at odds with medications for BPAD — for example, one of the most effective medical treatments for PTSD is SSRI antidepressants, like Zoloft. Zoloft and bipolar do not mix, though. SSRIs can actually trigger manic or depressive states in the bipolar brain.
Likewise, a common treatment for bipolar management is having “as needed” benzodiazepines, like Klonopin, to take to aid in sleep when mania may be coming. But benzos are known to increase PTSD symptoms and run a high risk of dependency and addiction. Doctors don’t only warn against Benzos in the treatment of PTSD, they also warn against antipsychotics, such as Seroquel, which is a staple in bipolar treatment. You can see how tricky it is to navigate medication management in the case of co-occurring conditions as substantial as PTSD and BPAD. But with such seemingly at-odds treatment options, the symptoms can be surprisingly similar, making them quite the little tricksters. Which brings me to…
2) Differentiating symptoms is difficult and can lead to misdiagnoses.
Symptoms of the hyper-arousal side of PTSD include things like: difficulty sleeping, difficulty concentrating and a constant “on edge” feeling. Symptoms of mania include: not sleeping, distractibility/ racing thoughts, feeling wired and irritated. PTSD and Mania both carry with them the inclination to engage in risky behaviors, such as driving recklessly, abusing drugs/alcohol, unprotected sex with strangers, etc. Symptoms of depression are present in both PTSD and BPAD, and those are pretty much the same across the board. To further complicate things, someone who is hypomanic or manic will not seek help — when I’m hypomanic, I feel fine. I feel better than fine. Somewhere in me is the knowledge I’m running too hot and there’s trouble ahead, but that part of me is not in the driver’s seat during mania. It’s locked in the trunk. Even when I had a full blown manic episode with mixed features, I chalked it up to the PTSD and so did my providers.
Traditionally, I’ve only ever sought help during depressive episodes — and those episodes had to be pretty bad for me to break down and talk to someone — but I’ve never stayed on antidepressants for very long due to the side effects. For example, some SSRIs even caused side effects like depersonalization and hallucinations and, until recently, I’ve had a hard time getting myself to stay in regular therapy. After a little while, I feel good — like really good — and I don’t need those stupid drugs or a therapist. Because of this particular pattern of mine, everyone missed the bipolar symptoms. It is now evident I’ve been experiencing periods of hypomania since I was 19 years old. These periods increased in severity over time, as is common when bipolar goes untreated. In January of this year, after a psychiatric hospitalization, I was finally able to receive a full evaluation, resulting in a bipolar diagnosis. I’ll be 29 in two months.
3) Despite the difficulties in diagnosing, co-occurring diagnoses of BPAD and PTSD are more common than you may think.
Psychiatrists have established that anxiety disorders occur at higher rates within the bipolar population. According to one article, people living with bipolar affective disorder are up to six times more likely to have PTSD than the general population. The link is not entirely understood, but it could be the simple fact that mania is more likely to land someone in a truly dangerous situation which could result in trauma. It could also have to do with the fact that bipolar affective disorder tends to run in families and that genetic predisposition to the illness can be triggered by stressful life events.
Growing up in a chaotic household, one with little stability and that is frequently unpredictable or dangerous can cause PTSD. My own trauma largely occurred as a childhood witness to domestic violence and victim of child abuse. My biological father is also diagnosed bipolar I with psychotic symptoms. So, it seems, I got the one-two punch of genetics and environmental triggers. But only reaching out for help when depressed (characteristic of bipolar disorder) and avoiding talking in detail about my trauma to therapists (characteristic of PTSD) resulted in me moving through the majority of my adolescent and adult life (thus far) with a diagnosis of major depression. The PTSD symptoms came out in full force recently, when I left an abusive marriage, and the bipolar disorder was discovered even more recently.
4) Both diagnoses can change your view of self and of life.
Here’s a little glimpse into some of the thoughts I had when first diagnosed: “PTSD? You mean all that crap I survived is still with me? I didn’t ‘walk away’ like I thought I did? I’m going to have to live in its shadow for the rest of my life? There’s no actual escape from the abuse and the fear because it’s latched onto my brain chemistry and permanently altered my mental state? I have bipolar, too? What parts of me are “me?” The creative bursts I considered strengths? Is that ‘the bipolar’ or is it me? The days of being up, having millions of ideas, feeling inspired, insightful, blessed with an understanding of the universe and myself? Bipolar? Not just deep spiritual soul searching?”
For me, anyway, both of these diagnoses came as a shock and ripped my sense of “self” right out from under me at first. Before all of this, I viewed myself as strong and resilient, as creative, as a multilayered, complex, well-rounded person who had handled some really tough situations and comes out the other side unscathed and largely unaffected. When I first received these diagnoses, I started to doubt all of that. Realizing I need to “manage” my moods through medications and a routine ripped away my sense of freedom and autonomy. Realizing the abuse I’ve endured has marked me, permanently, with a condition that will be present for the rest of my life, at least to some extent, was nearly debilitating. I felt like I had lost. I felt defeated. But, only at first…
5) While neither condition can be “cured,” you can learn to manage them both and get your life back.
My diagnoses being so recent, this is something I am still working on. But I will say this: since I was hospitalized, I have come a long way. I am now taking the medications my treatment team deemed best for my situation, and they are helping immensely. I am in regular talk therapy to address some of the trauma, and I’m also learning about cognitive behavioral therapy (CBT) and dialectical behavioral therapy (DBT) to help with both PTSD and BPAD management. When I’m diligent with my medications and I stick to a routine during the days, I don’t experience the swings to the same extent I did, and I don’t have nearly as many nightmares, flashbacks or dissociative symptoms either. While the severity of my mental health crisis required leaving my job (ironically, I was a direct service mental health worker in a group home), I am now preparing to return to the job market. Admittedly, I’ll probably stay out of mental health work, at least for the time being.
While I initially almost let these diagnoses overtake my sense of self, I’m now realizing it can be “both/and,” and I’m not stuck with “either/or.” Yes, PTSD is a lasting struggle caused by the abuse I endured, but that doesn’t mean I’m not a survivor. It doesn’t mean I didn’t make it through hard situations. It doesn’t make me weak or a victim. I’m not condemned to a life of fear and suffering. I can recover. And yes, I do have bipolar affective disorder, and sometimes that manifests in me feeling creative, but my creativity isn’t bound to the BPAD. I can still write, even when I’m not manic. (In fact, my non-manic writing is much more coherent and easy to read). I can feel inspired without it being a terrible omen that “manic madness” is lurking in a closet in my brain, just waiting to jump out and snatch me. I can lead an interesting, fun life while still following a routine to help manage my moods and prevent going too high or too low. I’m still “me” — I’m just on a journey to becoming a healthier, stronger, happier version. So, if you’re one of my #bipolarbuddies and you’re also living with post-traumatic stress disorder, please know you are not alone, and there is hope for recovery. As messy as this journey can seem, I believe it’s worth it, and wonderful things are waiting on the other side of this mountain I’m climbing.