by David J. Miklowitz
Guilford Press, 2002
Review by Jack R. Anderson, M.D. on Oct 3rd 2003
This book is
crammed full of useful information for bipolar patients, their family members,
therapists, friends, lovers, employers and anyone else interested in bipolar
disorders. Philosophers with a deterministic bent might take exception to the
accounts of bipolar patients who discover that, despite the limitations of
their illness, they are still able to use their decision-making capacity--their
free will--to minimize the effects of their mood swings on their lives.
The author has
an impressive educational and research background and has earned numerous
awards for the outstanding quality of his work. The insights he shares with us
were not acquired simply by reading the voluminous literature on bipolar
disorder, although his doctoral and post-doctoral studies required enough of
that; during more than fifteen years of clinical practice and research, Miklowitz
has been personally involved in the care and treatment of hundreds of bipolar
patients and their families.
Part I, "The
Diagnosis and Course of Bipolar Disorder," describes the symptoms of
bipolar disorder, how it is diagnosed and explains how difficult it is for some
individuals to accept the diagnosis, which they consider tantamount to "a
this section of the book, the author, rather than defining concepts, gives
examples of actual episodes of depressive and manic behavior, unusual thoughts,
suicidal ideation, sleep disturbance, and impulsive, self-destructive and
addictive behaviors. This reviewer counted more than twenty-five separate
examples of individuals with bipolar disorder, who were quoted and described,
adding substance and verisimilitude to the four chapters of this section.
introductory part of his book, the author begins his emphasis on the active
part the patient should play in his own diagnosis and treatment. Rather than
unequivocally accepting whatever diagnosis is offered by his doctor, the
patient is given a self-administered checklist to be used in arriving at his
own diagnostic impression and is advised to question his doctor about possible
diagnostic errors. He is given a list and descriptions of other psychiatric
disorders often confused with bipolar disorder to assist him in the diagnostic
dialogue with his doctor. Differential diagnoses to be considered include:
Schizophrenia; ADHD: Borderline Personality Disorder; Cyclothymia; Recurrent
Major Depressive Disorder; and Substance Induced Mood Disorder.
In Chapter 4, "Is
It an Illness or Is It Me?" Miklowitz advises patients to accept the
diagnosis once it is firmly established rather than trying to manage their
feelings by rejecting or underidentifying with it. However he also warns
against overidentifying and provides the patient with another self-administered
checklist to help him differentiate between personality traits and normal mood
swings on the one hand, and symptoms of mania or depression on the other.
chapters of Part II, "Causes and Treatments," discuss the genetic and
experiential factors that combine to bring about bipolar disorders; how
medication and psychotherapy can be best used by the patient to control his
symptoms; and how to win the many arguments he has with himself about the need
to continue taking medications despite their inevitable side effects.
As he did in
Part I, the author continues to emphasize the importance of the patient's
assuming control of his life, rather than turning it over to medication prescribers,
psychotherapists, family members, or other caretakers.
To help understand
the genetic component of his disorder, the patient is shown the family pedigree
of a known bipolar patient and is given forms to use in drawing his own
pedigree. There is also a form to use in determining what role stress has
played in the causation and course of his disorder.
discouraged from blaming their parents for their genetic contribution to the
disorders, or other family members for their contributions in the form of
stress and conflict. Rather than wasting time and energy in finger-pointing, or
bemoaning the fact that they have a disorder, patients are encouraged to learn
how to best use available treatment modalities to minimize the symptoms and to
find success and satisfaction in their lives despite their disorder.
Chapters 6, "What
Can Medication and Psychotherapy Do for Me?" and 7, "Coming to Terms
With Your Medication," provide a wealth of detail about different kinds of
psychotherapy and medications, giving equal emphasis to the positive treatment
effects and negative side effects. To re-emphasize the importance of
patient-participation in all treatment modalities, Miklowitz lists the
objectives of psychotherapy for persons with bipolar disorder. He also provides
a form to be used by patients to keep a daily record of side effects they may
experience with all medications prescribed, and another form entitled "THE
PROS AND CONS OF TAKING MEDICATION." where the patients can list the
reasons to take the medications, their disadvantages, and things the patients
can do to improve their situations, like taking more responsibility for their
Part III, "Self-Management,"
is divided into five chapters: "How Can I Manage My Disorder?--Practical
Ways to Maintain Wellness;" "What Can I Do If I Think I'm Getting
Manic?" What Can I Do If I Think I'm Getting Depressed?" "Dealing
With Suicidal Thoughts and Feelings;" and "Coping Effectively in the
Family and Work Settings."
section of the book is nearly as long as the previous two sections together.
given very detailed instructions as to how to manage their lives successfully,
despite the negative consequences of their disorders. They are given a list of
risk factors that increase their chances of becoming ill, such things as family
distress, drinking alcohol or using drugs, sleep deprivation or missing
medication; and another list of protective factors that help protect them from
becoming ill, such as keeping charts of their moods, going to bed and getting
up at the same time every day and staying on their programs of medication and
Pages 209 and 210
contain a form entitled "CONTRACT FOR PREVENTING MANIA." The patient
is encouraged to put everything he has learned so far into this written
contract for relapse prevention. He then lists the early warning signs of a
manic episode he has previously identified; the circumstances under which these
symptoms are most likely to occur; and what he should do when these
circumstances arise, to avoid a full-blown manic episode. Then he signs this
contract and arranges for his physician, therapist, family members, friends,
lovers and any other interested parties to provide their signatures.
The chapter on
depression contains similar recommendations for recording prodromal symptoms, initiating
preventive measures before a clinically identifiable depressive episode
develops, and enlisting all social and professional members of the patient's
core circle in the prevention plans.
In the chapter
on suicide, the author quotes from various professional publications: ""By
some estimates, people with bipolar disorder are at 15 times the risk for
committing suicide of people in the general population. Up to 15% of people
with bipolar disorder die by suicide; as many as 50% attempt suicide at least
once in their lives." Miklowitz emphasizes: "Suicide Prevention
involves decreasing your access to the means to commit suicide and increasing
your access to support systems (doctors, therapists, family members and
friends)." As with the chapters on mania and depression, this chapter
includes the outline for a written plan with specific instructions as to what
can be done by whom, when and where to prevent suicide.
chapter on how to adjust to family and work settings gives patients realistic
advice as to how they can maintain employment and preserve satisfying
relationships with significant others. Details include advice as to how to
maintain satisfactory sexual relations despite the impact of manic or hypomanic
overactivity or the loss of libidinal drive during depression.
this book is so well written and so full of useful advice as to how to plan and
organize a life, that it could be profitably studied by anyone, whether or not
he or she has bipolar disorder or knows someone who does. I believe that if any
one of us would take the time and energy to put into practice Miklowitz's
advice about keeping detailed records of our feelings and relationships and
taking responsibility for maintaining and improving them, we would have more
successful lives. As for the meaning of "successful," I prefer
Thoreau's evocative lines:
day and the night are such that you greet them with joy, and life emits a fragrance
like flowers and sweet-scented herbs, is more elastic, more starry, more
immortal,--that is your success."
© 2003 Jack R. Anderson
Jack R. Anderson, M.D. is a
retired psychiatrist living in Lincoln, Nebraska.