Xavier Amador

Q. My Mum was diagnosed as bi polar in 1988. She had severe highs and lows involving suicide attempts and when high over spending and running away with strange men. For the past 11 years she was fine until a GP advised her to come off her medication. This she did and within days started to become manic, this coupled with the stress of looking after an elderly relative tipped her over into a psychotic state. After a month she was sectioned and then transferred to another hospital nearer her home where the section was lifted because she began to take her medication freely.

However, she is still high, and doctors have advised her they want her to consider lithium, Mum has to take thyroxine as well and has had this dose reduced recently. Mum has been on lithium in the past and absolutely refuses to take it again. In addition to this and most frustratingly she also denies that she is ill and will not listen to anyone when she is told she is in hospital for her manic depression and treatment of such. My question is, is there an alternative to lithium that she will be offered or will the doctors be forced to section her again if she refuses to take lithium? Also, in her most extreme state she has said some horrible things to people and embarrassingly exposed herself to many people, what will her memory be of this? In the past she has remembered some things and not others, I don’t know if this is a choice not to remember though?

Finally, I am being quite direct with her when I speak to her, telling her why she is in hospital and what she needs to do to get better, because of this she sometimes will not talk to me or says horrible things to me, completely out of character, I am a ‘baddie’. Am I right to be so direct with her, I do get frustrated with relatives who just nod their head when she tells them she is only there because of her blood pressure and is coming out next week?

I apologise for all the questions, but I find it difficult to get sufficient answers from the nurses and doctors treating my mum, they all say different things.

I am curious about why her doctor advised her to stop taking her medication after having 11 years of success and stability. It might have been that she was complaining about the medicine and her doctor told her to stop, maybe out of frustration. She may have also misunderstood the doctor’s instructions, or decided to stop the medication on her own. Whatever the case, it’s clear that stopping the medication has caused immediate problems.

As for your specific questions, I will answer them below, one at a time.

You asked if there is an alternative to lithium for the treatment of bipolar disorder. I am not sure what medications are available in the UK but in the United States there are several alternatives to lithium. Some doctors, for instance, use a combination of antidepressant drugs such as Effexor or Cymbalta with antipsychotic medications like Zxprexa or Risperdal to control bipolar symptoms. How a doctor decides what medication to use in the treatment of psychiatric disorders can depend on number of factors such as symptoms, the availability of alternative drugs, cost, what is safe and what the client is willing to try.

You asked if when your mother is psychotic and behaving inappropriately, will she remember her actions and also, can she control whether or not she remember these events. These are interesting questions. The lack of memory reported during these episodes is a common characteristic of psychosis. The inability to remember does not seem deliberate. People do not seem to have selective memories. Many people legitimately cannot remember being psychotic, and even deny it ever occurred.

There are at least two possible explanations for why an individual may not be able to remember having a psychotic break. One reason is that psychologically, the psychosis is so horrific that a person mentally blocks out the event. This would be an unconscious defense mechanism. In this situation, the activation of the defense mechanism is involuntary. People who have had psychotic breaks rarely speak about these events and the few that do say that it was a “living hell.”

The second possibility for why individuals cannot recall how or if they experienced psychosis is that something is happening neurologically during the episode that blocks the memory.

The reason for the lack of memory during these episodes is complicated but to state it simplistically, it’s probably either a psychological or a neurological reason that inhibits a person’s ability to recall these events. There may be other explanations as well.

Xavier Amador in his book about serious mental illness entitled “I’m not sick I don’t need help” writes about the issue of lack of insight (i.e. you mentioned your mother has trouble admitting she is ill). Also included in the book is an interesting study that was conducted at Stanford University related to insight, memory and psychosis.

In the Stanford study, the researchers videotaped individuals during a psychotic episode and had the participants watch the tapes after they had been treated and stabilized. Prior to watching the video, the participants did not believe they had a psychotic episode and denied that they had any illness. It was only after watching the videotape that the participants realized that they had in fact had a psychotic episode. Many were shocked to see how they acted while having a breakdown.

Researchers do not know definitively if and how memory is affected during a psychotic break but there is some evidence that many individuals who experience psychosis truly seem unable to recall these incidents.

Your last question has to do with whether or not you should be “direct” with your mother. It is difficult to deal with a person who is unable to think logically. It can be very frustrating. If by direct you meant firm, concrete but still compassionate, I think interacting with her in this “direct” way is the best way to deal with her.

I hope this answers your questions. If you needed clarification or wanted to ask a follow-up question, please write in again. Thanks for your questions and I wish you and your mother well.