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Key points
- The progression of manic psychosis can often have destructive consequences to the established structure of one's life.
- Repairing the damage wrought through a psychotic episode is an essential aspect of living with bipolar I disorder.
Part I of this series discussed managing manic psychotic decompensation, particularly for family or loved ones involved with the manic individual. Part II gives a glimpse into the process of an evolving psychosis, the decision point for hospitalization, and the immense challenges in facing the damage and need for repair following a manic psychotic episode. The ensuing case description illustrates one patient’s experience with bipolar I manic psychosis. Some identifying information has been modified to protect patient confidentiality.
Mateo is a 34-year-old unmarried architect, originally from South America, who moved to the U.S. with his parents and two siblings during early childhood. Mateo describes his father, a physician, as temperamental and moody. And his mother is a software programmer. At age 28, Mateo obtained his graduate degree in architecture from a prestigious school in the Northeast.
Mateo’s life was progressing well until five years ago when he experienced his first manic episode. In the months preceding the episode, he had struggled through a series of highly stressful events. He, therefore, perceived the episode as an idiosyncratic reaction to unusual life stress, even though treating psychiatrists were rendering the opinion that he might be at the front end of bipolar illness.
Since the initial symptom onset, Mateo has had two additional manic psychoses, each of which was followed by prolonged bouts of depression and then the tasks of rebuilding his life by addressing the damage brought about by his relapse. Mateo is now fully cognizant of his bipolarity. He remains in psychotherapy and concurrent psychiatric treatment and is consistent in taking his medication. The one problem that had not been successfully addressed was his recurrent alcohol and cannabis intake, both of which contributed to continued elevated relapse risk.
Since Mateo’s recovery from his third manic psychosis, he had been doing well in numerous areas of his life. He was successful in his architectural career. He was actively dating. He was strongly engaged in the local mountain biking community. Relationships with his parents and siblings were on the mend following tensions brought about by previous relapses. Essentially, Mateo was beginning to feel hopeful that he could remain successful in quelling the bipolar intensity that marked the transition from his late 20s into his early 30s.
It should also be noted that by the time of his second relapse two years earlier, he had informed his employers of his diagnosis and was fortunate in receiving their support and willingness to continue his employment even though there had been some previous disruptions to his work productivity.
In early spring of this year, there were a few psychotherapy sessions where he was focused more “on the surface.” The depth of the work subtly shifted upward towards reporting day-to-day events, and I mistakenly attributed this to his simply doing well. Except for the mild superficiality of his interactions with me, there was nothing odd or unusual about his behavior or his thinking, at least not as conveyed in the sessions.
Then came the bad news. In his next session, he conveyed that he was asked to take a paid leave from work to “address his mental health issues.” He was informed that coworkers experienced some of his behavior as inappropriate for the workplace and that his access to the office was being suspended until he was able to provide a letter of medical clearance from his mental health providers.
In that session, it also became clear that Mateo was not aware that he was in the early phase of another psychotic relapse. He was not expressing concern over the imposed leave. In fact, he did not have a good explanation as to why he was asked to take a leave. He was mostly grateful that his employers were looking out for his well-being. He said he planned to do some work around his home and to travel and visit with friends. When I repeatedly inquired as to why he thought he had been placed on leave, he returned to simplistic explanations that his employers were supporting and encouraging his well-being.
Over the next month, there was a gradual decline toward delusional thinking, disorganized behavior, and increased substance use. Two family members came to town to put a safety net in place, though it was reported to me that interactions with family were increasingly bizarre. Similar unusual interactions were occurring with friends.
In session, it was as if he and I were existing in two different realities without my ability to connect the two through empathy, interpretation, or confrontation. As Mateo’s delusions became more paranoid in nature, he also became more evasive. When I’d attempt gentle confrontation and express my concerns about his status, my comments were met with bland responses: “I appreciate that.” Mateo’s psychiatrist and I were regularly talking, and it was apparent through our communication that Mateo was not being truthful with both of us. (Signed release forms were already in place in relation to the psychiatrist and key family members.)
Eventually, Mateo became more agitated and aggressive toward others. The overall picture of decompensation as well as the potential for dangerous behavior became apparent enough that family members were able to have an emergency custody order issued through a local magistrate. Mateo was psychiatrically hospitalized for four days. He was given both lithium and Abilify (an antipsychotic medication), and his psychotic symptoms rapidly began to diminish.
After a few months of recovery, Mateo was given the green light to return to work. But the longer-term work of recovery was just beginning. He needed to address the work of repairing the tensions and apprehensions that had become activated in friends and coworkers. This meant coming to terms with important choices such as what to disclose to others about his recent experience. Who could he trust with this personal-psychiatric information versus who might begin to look at him as a crazy, unstable person?
Mateo also needed to turn his attention to his financial affairs, as he had made impulsive purchases that went far beyond what he could afford.
To his credit, he was gradually acknowledging that his benign view of his substance use was invalid and that his intermittent drinking and more regular cannabis use represented important risk factors underlying his relapse. In response to this recognition, he has become involved in ongoing online recovery meetings through Smart Recovery.
Perhaps the most challenging aspect of Mateo’s recovery, still very much in process, entails coming to terms with the unpredictability of living with bipolar disorder. Except for his substance use, many of his lifestyle and self-care choices in the months leading up to his relapse were good. Through his active engagement in treatment, he thought he had developed sufficient self-observing awareness to be able to track the onset of symptoms if such were to occur. Essentially, he thought he was being successful with his bipolar journey until he wasn’t.
Mateo is continuing his forward progress, though not without strong shame and embarrassment about his last episode as well as his reality-based concerns about a potential future relapse. In regard to strengthening his relapse safety net: He has decided to engage the help of a mental health attorney to put together a set of advanced care directives in the event of another manic psychotic relapse. He has also assigned a limited financial power of attorney to one of his trusted family members for the purpose of managing his finances in the event of future relapse. Both choices are worthy of exploration for those who live with relapsing bipolar I disorder.
But what does one do with future bipolar uncertainty? It’s far too simplistic to say that one must accept the reality of this illness. Mateo certainly accepts it, but that doesn’t mean he can easily find hope and optimism about the future. Nor does it mean he should live with a sense of doom and gloom. Given his experience over the last half-decade, it would be unrealistic to assume that his condition will remain stable without any future relapse. What remains unknown is the severity with which his symptoms will manifest as he continues learning to live with his disorder and to better manage his lifestyle choices.
Continued psychotherapy and psychiatric treatments are important components of his continued prophylaxis against relapse. But the longer-term ingredients of success aren’t easily quantified or delivered through specific treatment approaches. They represent the gradual accrual of increasing self-acceptance and resilience in the face of adversity, which in many respects parallels the optimal maturational process that most individuals would hope to experience over the course of their lifespan.
