Beware of Relapse!

ibreakstock_AdobeStock

Managing and recovering from bipolar disorder is a lifelong endeavor—a “forever war.” I know because I have bipolar disorder, and it nearly destroyed me and all that I value. Following are some suggestions for clinicians in helping patients with bipolar disorder prevent relapse, along with 2 episodes that triggered me and could have caused a bipolar relapse.

Background

After a near lifetime of hyperthymia¹ (a continual case of mild mania), bipolar disorder struck me as a 47-year-old colonel in 2003 while I was leading thousands of soldiers in the Iraq War. The intense stress and thrill of combat triggered my genetic predisposition for bipolar, sending me into a high-performing mania that enhanced my abilities. Upon redeployment, I sank into depression, and for the next decade, my bipolar surged higher and sank lower, although it was unknown, undiagnosed, and untreated at the time. Meanwhile, I was promoted twice and advanced to more prestigious and stressful commands.

In 2014, I rocketed into full-blown mania and was removed from my 2-star command of the National Defense University. My boss, Martin Dempsey, a 4-star general and chairman of the Joint Chiefs of Staff, ordered me to undergo a psychiatric evaluation—a wise decision that likely saved my marriage and my life. I then crashed into severe, hopeless depression and terrifying psychosis for the next 2 years.

After agonizing in bipolar hell and struggling with suicidal ideation, I was saved by inpatient treatment with the US Department of Veterans Affairs (VA), family, friends, grace, and ultimately lithium. After years of pain, lithium lifted my depression and stabilized me. In just a week, I felt like my old, pre-bipolar self. I have been on my journey of recovery since September 2016.

But recovery is not a smooth or easy path. Individuals with bipolar must be vigilant and disciplined in defending themselves against the reemergence of active, destructive bipolar. Relapse is common—75%—and it can be more destructive and painful than the original onset.² Understanding triggers—subjects, activities, people, places, and behaviors—and avoiding them is crucial.³

Drawing and photo by Conor RK Martin

I am fortunate that 6 years into recovery, I have not had a recurrence of bipolar—but I have had 2 dangerous episodes that could easily have triggered a return. In this article, I will describe and analyze these experiences, and raise some key considerations for you.

What role should psychiatrists play in understanding and preventing bipolar triggers? As a clinician, how would you assess my condition based on these episodes? What are the policy and financial issues of establishing a more seamless collaboration between psychiatrists and therapists? What might be the role of case studies like my own in improving treatment?

2 Dangerous Episodes and What I Did Wrong

Episode 1: PTSD Flashback at Home Alone

For weeks I had been communicating with a colleague who, like me, became increasingly agitated over our chaotic and deadly withdrawal from Afghanistan. The chaos and American deaths angered both of us⁴ and retriggered his bipolar mania—the angry, mean, aggressive type. Our dialog grew increasingly toxic and moved into “no-go/guardrail” topics for me.

Suddenly, he became aggressive and insulting, insisting that I publicly call for the resignation or removal of the secretary of defense and chairman of the Joint Chiefs of Staff, who he felt were responsible for the fiasco. I know and respect both men and knew that the situation was far more complex than this simplistic explanation for the debacle. My colleague pushed harder, plunging us into toxic subjects (for me) that I had learned the hard way not to enter. “Bad politics” helped kill and maim our soldiers in the Iraq War, where I fought, and this topic fueled the intensification of my own bipolar disorder.⁵

Without warning, this topic hurled me back to spring 2003 and into Iraq, where bad political decisions⁶ torpedoed our mission⁷ and fueled the nascent insurgency. I felt like I was there, in Iraq—the sights, the sounds, the smells, and the hellish environment. I was there, on the ground again with the constant threat of improvised explosive devices (IEDs), rockets, ambushes, snipers, and violent mobs. Once again, I was weighted down in full body armor in searing 120-degree heat, moving through vast heaps of rotting garbage and dead animals and raw sewage running in the streets, and breathing in the nauseating stench.

In reality, I was sprawled on the living room floor, shaking and pounding my fists, with my breath heaving and heart racing, in an acute panic attack. This brief but intense episode was interrupted by a good friend who texted me at the right moment. My friend (my guardian angel?) pulled me back to reality. I was shaken but coherent, and by the next day, I felt fine.

What Went Wrong?

I engaged with a colleague who became toxic and aggressively pushed a toxic subject. I had guard-railed against this topic because it triggers intense agitation, anger, and stress. But it snuck up on me, and I did not learn from my own pain, so I made the same mistake again.

After the flashback, I cut off communications and blocked this colleague, which was painful but necessary, and I rebuilt the guardrail around the toxic subject of “bad politics.” I have not had any issues with this person, the topic, or posttraumatic stress disorder (PTSD) since. But I am fortunate this episode did not trigger a full-scale bipolar recurrence.

Psychiatrists and psychotherapists should get to know their patients, particularly those with bipolar disorder who are also struggling with PTSD, so that they can comfortably have these difficult discussions as issues arise. They can then help these patients build understanding and develop tactics to protect themselves from relapse.

Episode 2: Panic Attack With Psychosis Overseas

This incident felt exactly like the intense, angry mania I experienced in summer 2014, following my removal from 2-star command,⁸ when I was in a full-blown mania. (Note: I categorized the episode as “mania,” but clinicians at the VA called it a “panic attack with psychosis,” explaining that for it to be mania, it must last at least a week.⁹ But it absolutely felt like mania to me, even if only for a few hours.)

After years without a bad day—with “bad” defined as a manic or depressed mood—and only the single intense anxiety/PTSD attack I just described, the dam burst. I launched into a surprising and intense panic/psychotic episode that was alarming in its fury, but thankfully subsided quickly, with a soft landing. I returned to a normal state within 3 hours, although I was emotionally exhausted and ill for another 24 to 48 hours.

While vacationing overseas, I went into madness for a few hours, convinced my family had intentionally abandoned me. Alone, I found my way back to our house, but was locked out. I launched into a rage, complete with psychotic paranoid delusions—the first I had had since the hellish days of my life-threatening bipolar crisis of 2014 to 2016.⁸

In a spiraling fury, I went on a rant of increasingly angry, accusatory, mean, and insulting text messages that shocked family members, and myself in retrospect. While in my texting frenzy, my condition elevated, as violent thoughts and impulses flashed through my mind. Luckily, those thoughts passed harmlessly.

As usual with paranoid delusions, there were tidbits of perceived truth in each of them: small comments, looks, and behaviors that my mind twisted into something nefarious. But together they made no sense, at least in retrospect. However, the delusions were totally real as I experienced them. This episode could have easily become a much worse situation, with disastrous results (physical injuries, a car crash, violence, destruction of property, arrest, possible death, etc), but fortunately it did not escalate.

One potentially vital thing that I did not do at the time was call family members to ascertain what was going on and solve the problem. That was because, for a variety of reasons, I did not have overseas telephone coverage—a huge mistake! I did reach out to my family the next morning. I attempted to explain what had happened, and I apologized to each family member individually for my meltdown. Here is what I said to them:

“It’s about 24 hours since my manic-like/psychotic episode. Yesterday was my first ‘bad day’ in years… I’m sure each of you feel terrible. I feel dead inside—emotionally spent. Amazingly, the events that I ‘experienced’ in my alternate reality still ‘feel’ real, even though I know they were fabricated in my manic-like, delusional, paranoid mind. I now know that what I experienced in my mind was not reality. I apologize to each of you, even though the episode was the product of my bipolar disorder and not with intent to harm anyone.”

After I sent my explanations and apologies, everyone said, “no need to apologize—we understand.” My openness and clear explanations helped.

What Were the Triggers?

The first is place. I departed from my well-structured routine and purposeful life in Cocoa Beach. That safe, happy, energizing place keeps my mind, heart, and spirit healthy. But overseas, that place was an ocean away. I was out of my zone of safety and security. There was nothing to ground me, and I could not control my environment. In the Army, I knew how to manage chaos, and I thrived in it. But the combination of being overseas, not in control, out of my safe space, and engulfed by chaos triggered me. I needed a way to escape the chaos and ground myself. I needed to go inward to find my safe space and peace.

Second, my wife Maggie is an excellent partner who provides an extra set of eyes and ears for my moods, activities, and fluctuations. That role was disrupted by other priorities, activities, and family members gathered in 1 house, eager to explore a foreign land.

Dr Martin and his wife, Maggie, at the Cocoa Beach gym. Photo courtesy of Dr Martin.

Third was the stress of international travel. The combination of not being able to speak the language, lots of people coming and going, and the emotional strain of an impending divorce in the family created a toxic mix. That, when combined with some small but seemingly real comments, led my bipolar-infused brain to burst into rage, creating delusional “realities.”

Fourth, in preceding months, I was working harder on my life mission of mental health advocacy. I was “wound up”: writing more articles, giving more talks, taking more calls, and responding to more emails. This elevated my stress level, and stress is the enemy of bipolar recovery.

Fifth, I was hamstrung by my inability to communicate because I did not have overseas phone coverage. If I had had it, I could have telephoned family members, resolved the question of where they were, and perhaps preempted the false idea that I had been “abandoned.” If I had had this information, I might not have had an episode.

Clinically speaking, patients should tell their clinicians when they will be going on a trip or doing things that are outside of their normal routine. Clinicians may then be able to discuss contingency planning or otherwise help patients prevent or lessen their likelihood of having an episode when they are outside of their routine and/or home environment.

Clinicians should also advise patients to take practical, protective steps, like ensuring phone coverage, which would have helped immensely in my case. When patients do have an episode, however, clinicians can help them manage and recover from the situation and advise them on how to have potentially difficult conversations with anyone who might have been affected by the episode. Explaining and apologizing for an episode may not always be easy, but it helped me and my family move forward from this episode.

Concluding Thoughts

I will always have bipolar disorder; it will not go away. Even with years of strong recovery, my mental health burst suddenly in my brain, with potentially catastrophic effects. The ultimate lesson for me is to understand my mental condition; to know myself and my environment; and then to mitigate risk factors, have a partner to help monitor, and stay vigilant in my “forever war.”

One thing I have learned is that staying healthy is the most important defense against relapse. There are clear tactics that patients can implement to stay emotionally, mentally, and physically healthy in order to keep their bipolar at bay and prevent relapse.¹⁰ Here are some strategies you can share with your patients:

• Encourage your patients to reach and maintain a healthy biochemical balance in the brain by faithfully taking prescribed medications. The right medication is crucial—be sure to evaluate and adjust any prescription medications as needed.
• Teach your patients coping skills and ways to counteract harmful thinking, behaviors, and activities.
• Help patients identify their triggers and then avoid them by “constructing guardrails,” or fencing them off like the military fences off minefields. Discuss these with your patients so they can be aware and develop protective strategies.
• Encourage patients to live healthfully with exercise, a proper diet, adequate sleep, sufficient water, minimal stress, elimination of harmful substances, and the like.
• Share the “5 Ps strategy” with your patients and discuss it with them to ensure understanding and effective implementation. The 5 Ps are as follows:
  1. People: developing a network of happy, fun, positive friends
  2. Place: living in a safe, energizing location
  3. Purpose: a personal mission that inspires and serves a cause greater than self
  4. Perseverance: the will to succeed and to never give up
  5. Presence: situational awareness, or the ability to adapt to what is happening around you when your purpose is disrupted
• Encourage your patients to monitor their moods and their health, and to have a partner who helps them. This partner could be a spouse, a friend, a “battle buddy,” or part of a peer support system.¹¹ Monitor this aspect and ask patients, “Who is your mental wellness ‘battle buddy?’ How often do you talk?”

Gregg F. Martin, PhD, Major General, US Army (Retired). Photo courtesy of Dr Martin.

Recovery from bipolar disorder is a lifelong process, and despite years of solid recovery, patients may still relapse or experience episodes, like I did. Sharing valuable strategies with patients and having important conversations with them can enhance understanding and empower patients to fend off relapse and potential disaster.

Dr Martin is a 36-year Army combat veteran, a retired 2-star general, and a bipolar survivor, thriver, and warrior. A former president of the National Defense University, he is a qualified airborne-ranger-engineer and strategist who has commanded soldiers in combat. He has led organizations ranging from a platoon of 30 troops to a base of 30,000 soldiers and civilians. A graduate of West Point and MIT, he is an ardent mental health advocate. His forthcoming book is entitled Bipolar General: My ‘Forever War’ With Mental Illness.

These views in this article are solely those of the author and not of the US Department of Defense or the US government.

References

1. Martin G. Two-star general with bipolar disorder believes hypothermia factored into struggles. Florida Today. November 2, 2021. Accessed October 1, 2022. https://www.floridatoday.com/story/life/wellness/2021/11/02/hyperthymia-mental-illness-has-person-dealing-constant-mania/6199229001/

2. What you need to know about relapse in bipolar disorder. SANE. October 12, 2018. Accessed October 1, 2022. https://www.sane.org/information-and-resources/the-sane-blog/wellbeing/what-you-need-to-know-about-relapse-in-bipolar-disorder

3. Pistoia JC. All about bipolar disorder relapse. PsychCentral. Updated August 1, 2022. Accessed October 1, 2022. https://psychcentral.com/bipolar/what-you-need-to-know-about-relapse-in-bipolar-disorder

4. Martin G. Afghanistan war vets are enraged and hurting—reach out and listen to them. The Boston Globe. September 15, 2021. Accessed October 1, 2022. https://www.bostonglobe.com/2021/09/15/opinion/afghanistan-war-vets-are-enraged-hurting-reach-out-listen-them/

5. Martin G. Bipolar general: what can we learn? Proceedings. 2022;148(8):1434.

6. Pfiffner JP. US blunders in Iraq: de-Baathification and disbanding the Army. Intell Natl Secur. 2010;25(1):76-85.

7. Margolick D. The night of the generals. Vanity Fair. September 16, 2013. Accessed October 1, 2022. https://www.vanityfair.com/news/2007/04/donald-rumsfeld-iraq-war

8. Martin G, Martin P. Removed from command: a two-star general’s mental health disaster and fight to recover. Task & Purpose. March 12, 2021. Accessed October 1, 2022. https://taskandpurpose.com/news/bipolar-disorder-gregg-martin-military-veterans/

9. Mania. Cleveland Clinic. Accessed October 1, 2022. https://my.clevelandclinic.org/health/diseases/21603-mania

10. Martin G. The “4 Ps” of mental recovery: medical care and healthfulness. Psychiatric Times. July 7, 2022. Accessed October 1, 2022. https://www.psychiatrictimes.com/view/the-4-ps-of-mental-recovery-medical-care-and-healthfulness

11. Benefits of peer support services. Texas Health & Human Services Commission. Accessed October 1, 2022. https://www.hhs.texas.gov/providers/behavioral-health-services-providers/peer-support-services/benefits-peer-support-services#:~:text=Increases%20engagement%20in%20outpatient%20treatment,Reduces%20substance%20use