Addiction Masking MI

Hi guys!

This was brought up in passing in another thread, and I relate to it so much I wanted to bring it up generally.

Some 25 years ago, I had been diagnosed with depression and anxiety for several years and yet with clear signs of hypomania and mania. It was not until a bout of hypersexuality that my pdoc of the time diagnosed BP (when I had brought it up about a year prior, he had said that people were finding BP under ever rock, in other words, thought it was way over-diagnosed, and therefore didn't apply to me (!!)).

Anyhow, I was first prescribed Lamictal (which helped enormously with depression, but not with hypo/mania). I had been an alcoholic for some 8 years before that. And poof! After the Lamictal kicked in, I just didn't crave alcohol anymore! Since then, I've had the occasional social drink, but that's it.

So has anyone had a similar experience? How prevalent do you think it is to self-treat MI with substances? And how difficult has it been to get your pdocs to understand this?

Hi Gabyunbound! I read your post earlier this morning, but didn't want to answer until I had a bit more time to.

Just to quickly address some of what you wrote earlier in your post, I think there are some psychiatrists that over diagnose bipolar disorder, and some that under diagnose. Certainly with many young people knowing more about bipolar disorder, there is the chance of them exaggerating their experiences to closely match the bipolar symptom lists. However, at least your psychiatrist now seems sure of your bipolar disorder dx. That's good. Many people never get the right one.

Lamictal is very activating for me, too. It likely has never helped curb my hypomania, and definitely not mania, but it is good for my bipolar depression. I don't think any doctor would call it a strong antimanic, but for many it helps sufficiently enough. At least now you know what's good for your depression. What do you have for your hypomania/mania control?

What came first? The chicken or the egg? Yes, a lot of people have doctors that put alcohol/substance abuse before the mental illness or emphasize the alcohol/substance abuse over the mental illness. It's really a catch-22. Can you become stable while using? Can you become sober or manage alcohol use when symptomatic with bipolar disorder? Ouch! It's tough. Yes, I relate.

Like you wrote, after my bipolar disorder was stabilized enough (and my drinking issues stopped), I no longer had major alcohol cravings and could drink moderately. That doesn't take my history of alcohol abuse away, but I do believe it should remove the word "alcoholic" as a descriptor for me. Honestly, I wonder if the same could be said for my father, but it's just too soon after his detox to safely test those waters. Plus, my father hasn't sought proper support/treatment for his alcohol abuse. Also, he likely has cognitive issues (dementia) that should discourage he ever drink again.

Though I do often have a daily half drink to two, I know that drinking too much can be destabilizing and is not good with my medications. Though I don't believe I am "an alcoholic" I know my drinking could get out of hand, if something triggered it (tragedy in my life, gradual increase in consumption, severe mood instability).

I know that some people just really are prone to addiction. In those cases, they should never drink/take drugs ever again.

In my case, my bipolar disorder was acknowledged as separate from my drinking, and diagnosed at the same time. No one thought drinking caused it. The bipolar disorder was present likely as early as 14 years old in me. I didn't drink way back then. I do think that drinking (or even more so, drug use) can sometimes bring on symptoms that may lead to incorrect psychiatric diagnoses. I've read of many cases where when the abuse stopped, the so-called psychiatric symptoms stopped.

Gabyunbound, what an absolutely incredibly important thread and a topic we do not discuss nearly enough, in my opinion.

In 2007, folks at Columbia published a paper showing that bp diagnoses in kids had increased more than 40-fold since the early 2000s. Then, in 2013, Mark Zimmerman published a "landmark" piece claiming that in adults, around 50% of bipolar diagnoses were in error. People absolutely freaked. Understandably. Virtually all of the "overdiagnosed" not apparently bipolar people were so overdiagnosed, Zimmerman claimed, due to coexisitng substance issues and their related symptoms.

The bottom line of Zimmerman's work and some others like it that followed is that their method for diagnosing bipolar disorder relied completely on following the DSM-V to the letter. Many, many US psychiatrists, and psychologists, for that matter, do not, in fact and in practice, make the diagnosis in this fashion, still today. One of the stated requriements of DSM-V-based bipolar diagnosis is that substances must be completely eliminated from the picture in order for a bipolar diagnosis to be coreectly made. That is a firm DSM-V requirement.

In the real world and on planet earth, where actual patients with actual lives live, this is often quite hard to accomplish. Patients sometimes do not come clean about meth use, say, as they are ashamed or firghtened of the police. Some people simply have a very hard time stopping drinking, as BD stated, while they are still bipolar-symptomatic. I was one of these. So, if we waited for every patient with a possible bp diagnosis to be totally sober and clean for 6 months, many, many patients would never be able to do that. That is just reality.

So, in the real world, strict reliance on the DSM-V is just not even possible for many folks. They can't do it. So, what are we to do? Jut not treat them, even though we are almost sure they have it, just because they do not meet full and official DSM criteria? That is moronic, unthoughtful, and inhumane, in my view. And totally impractical, as I say.

So, having reviewed the entire world literature on this as a former medical researcher with bp 1 and addcition, what I can tell you is that I and many experts believe as smart as Mark Zimmerman clearly is, that that paper simply is not accurate. It never was. The DSM-V simply does not account for what it is actually like for tons of folks who live with bipolar disorder to try to live in the actual world. That is just a fact. Not bashing, just being real.

I was initally dignossed with MDD and addiciton in 99. Finally had a huge manic and psychotic episode in 2005 and was able to get accurately diagnosed. In retrospect, all my addiction issues have been closely confined to periods when I was bipolar-symptomatic. Once those symptoms were treated, addiction vanished. Poof! A total and complete non-issue for me. My primary issue was never addiciton. It was untreated and poorly managed bipolar 1. I believe, like BirdDancer, there are tons and tons of patients in this situation. It does not mean they do not have bipolar diosrder. That is, in my opinion, a thinking and judgment error.

All of this obviously just my own personal opinion and nothing more.

If you are someone you love has been in this situation, I do strongly advise doing a very thorough and cautious life chart. It can shed light on this. You can google it and see some pictures of what one looks like.

Love and hugs!!!!!!!!!!!11

Thanks for your reply!

To clarify, I was referring to a pdoc I had over 20 years ago. I've since been re-diagnosed 3 times with BP 1. Like you, Lamictal (though I don't find it activating) has not helped with hypo/mania, but a great deal with depression. I also take Abilify.

My feeling is that, in my case, the alcohol was the result of BP (me treating my symptoms), only because, as I say, after taking Lamictal the cravings for alcohol just faded away, and this was after many years of alcoholism. It was amazing. I was very fortunate. No doubt the alcohol also affected my mood and I do think it can be difficult to make MH diagnoses when someone is on substances, but my symptoms were so classic that that moron of a pdoc should have bitten the bullet (he was so afraid of over-diagnosis, he underdiagnosed, at least in my case) and given me the diagnosis, only so that I would finally get the proper treatment.

It took some 16 years of experimenting with meds to finally find the cocktail that works for me, and I've been largely stable ever since (going on 4 years, with one major manic episode in there and another far shorter one, where it was caught right away by my current pdoc and she increased my AP, which worked). Unfortunately, my symptoms started in my early 20's, so this means a lot more time during which I suffered from both depression and hypo/mania. Granted, it wasn't all bad... There were certainly periods of stability and hypomania's that led me to experience things, wondrous things, that I wouldn't have otherwise... Anyway, I'm babbling at this point...