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Expert Q&A

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Will I ever feel really secure in my life?

Asked by Ashley, Louisiana

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I have had a quite a few ups and downs in my life. I have had depression since I was 8 years old. (I am now 26 and was diagnosed as bipolar three years ago.) In my lifetime, I have suffered major emotional abuse and betrayals from a variety of people, not to mention rough circumstances (losing a job last year, and unstable conditions in my current job). I have now gotten to a point where I've become obsessive about money due to fears of once again becoming unemployed, and I find myself drifting away from friends because I don't feel safe being close to anyone any more. It's scary for me because I went through a major depressive episode from ages 14 to 18, and I had to fight just to keep myself alive (medication was not available for me at the time, either). I've fought so hard just to get to my current point in life, which was graduating from college and living independently. I'm just so terrified of losing everything that I've fought for and returning to those lows, but I feel like I have to strike it out on my own just to maintain myself. Is there any chance of me ever feeling any form of security in my life ever again?

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Mental Health Expert Dr. Charles Raison Psychiatrist,
Emory University Medical School

Expert answer

Dear Ashley,

I've spent a good deal of time in the last day thinking about your situation and your question. My immediate response was to reassure you that there is always a chance for you to find security, because that is the truth. But your story movingly identifies another -- deeper -- truth, which is that only people with bipolar disorder can truly understand the profound insecurity that arises from suffering with an illness that leaves them at the mercy of such ruthlessly unpredictable changes in emotion, energy and behavior. These changes often leave patients unable to trust themselves, at best, and completely unsure of who they even are, at worst.

You have a lot of factors in your favor, so let's start with these. First, you recognize that you have an illness, which for many people with bipolar disorder is no small accomplishment. Most of the really bad bipolar outcomes I've seen over the years happened to people who were not able to see that they had an illness, or saw, but did not want to do what it took to maximize their chances for mental health. The most heartbreaking cases are those in which the patient has clear insight into his condition when he is in a normal mood, but loses all touch with reality when he slips into a manic episode. I had a patient once who -- when normal -- would beg me to find a way to help her not lose her insight when she got sick, and then a week later, when in an episode, would accuse me of being the devil who poisoned her mind into submission when she wasn't manic.

So your clear insight into your condition is very encouraging. It is also promising that you have managed to get so far in life in the face of your illness. That also bodes very well for the future. It also suggests you have the drive and discipline to do the things most likely to bring you the security for which you long.

So, in a general sense, let me go over some of the things a person in your position can do to maximize your chances of developing stability in your internal emotional life and external dealings with the daily world. By far the most important thing one can do is make a commitment to do everything one can to avoid having either depressive or manic/hypomanic episodes. This is more difficult than it sounds, because people with bipolar disorder often enjoy the elevated mood, sharpened thought and increased productivity while hypomanic. But it is clear from many studies that the price tag for these periods of pleasure is too high. For example, being a little manic is a bigger risk factor for subsequently getting depressed than is being a little depressed.

The data are very clear that medications are an essential component of any strategy in the treatment of bipolar disorder. In particular, medications that stabilize mood are critical tools for helping abolish, or at least attenuate, the yo-yoing emotional ups and downs that ravage bipolar lives. Many people with bipolar disorder also need antidepressants, although there is a lot of ongoing debate within psychiatry regarding the relative benefit of these agents.

If you are really serious about finding stability you will also have to make a deep commitment to living a lifestyle most likely to promote this. If you are drinking more than a little, or using drugs, you should stop. You should keep a diary for a while to identify what types of things make you feel good and healthy and what types of things make you feel anxious and depressed, or giddily hypomanic. Abandon the things that increase your symptoms if you can. If you can't abandon them (for example, if your job gives you stress but you need the money), try to be creative in finding ways to minimize the negative impact.

Establish very regular sleep and wake times. While useful for "regular old depression," this is essential for individuals with bipolar disorder, because sleep disruption is probably the No. 1 immediate driver of both depressions and manias/hypomanias.

Finally, it is a dangerous thing for a person to pull back from other human beings. We know from multiple studies that loneliness and social isolation increase activity in stress and inflammatory systems that almost certainly contribute to the symptoms you are trying to avoid. On the other hand, people with really severe bipolar disorder often find it very stressful to get too close to people, because as we all know, relationships are often difficult at best and heartbreaking at worst, and this stress can make the illness worse. I don't know enough about the details of your situation to make a specific recommendation in this regard, but this is something you need to think about seriously. Your chances of stabilizing your life will be better if you can undertake this work -- not alone -- but in company with others who care about you and can help.

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