Contract For Preventing Mania

Law Of Attraction For Kids

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Your physician's name: _ Phone number, office: _

Phone number, emergency: _

Your therapist's name: _ Phone number, office: _

Phone number, emergency: _

Name of local hospital: _ Emergency room number: _

Your insurance carrier: _ Policy number: _

Group number (if applicable): _

1. List your typical early warning (prodromal) signs of a manic episode (from the exercise on page 192 above).

2. List the circumstances in which these prodromal symptoms are most likely to occur.

3. Ask one or more members of your core circle to add any other early warning signs they've observed, and, if relevant, the circumstances in which these signs first appeared.

4. List what behaviors you can perform when these symptoms start to appear

(examples: calling your doctor, getting your blood level tested, sticking closely to your medication regimen, trying to get regular sleep, getting back on a structured daily and nightly routine, avoiding alcohol, drugs, or caffeine, giving up your credit cards and car keys, avoiding major financial or other life decisions, avoiding risky sexual situations).


5. List what behaviors your relatives, significant others, or friends can perform

{examples; call your physician, talk to you in a supportive way, tell you what you are doing that worries them, tell you how much they care about you, keep you from overscheduling yourself, call the hospital emergency room, remind you to take your medication, accompany you to doctor's appointments, take care of your children, accompany you when you go out at night, help manage your money, help you stay on a regular sleep-wake cycle, help you stay away from alcohol or drugs).

6. List what you would like your psychiatrist to do (examples: meet with you on an emergency basis, take your blood level, revise your medication regimen as appropriate, cali the hospital and arrange for admittance, if necessary).

Signatures Date contract. Together they developed a list of his prodromal symptoms, which included mild irritability, mistrustfulness, standing too close to people and talking too loud, a sudden disinterest in his job, an increase in his sex drive, and a subjective feeling of mental clarity. They made a distinction between these early warning signs and signs of his full-blown manias, such as feeling elated or expansive, socially inappropriate outbursts of anger, spending excessively and impulsively, grandiose beliefs about his musical talents, severe loss of sleep, and a firm denial that anything was wrong. They also agreed on the environmental circumstances associated with his escalations: an excessive workload, family arguments, and financial problems.

Robert and Jessie negotiated a series of prevention steps. One of these involved giving Jessie the freedom to call his psychiatrist if Robert appeared to be escalating. They also agreed that when his symptoms were still mild, Jessie would help get him away from his immediate stressors (for example, encourage him to take a few days off work with her). They agreed, as a couple, to try to maintain regular sleep-wake routines, especially when one or more of his prodromal signs were observable. Finally, Robert consented to have Jessie accompany him to the hospital emergency room, if it became necessary.

Robert did not stay episode-free, however. His next manic episode began about two months later, but this time he and Jessie caught it earlier. Once again, he refused to make an appointment with his doctor: He admitted that he was probably escalating but didn't want to take any more medication. He and Jessie began to argue. As Robert later described it, Jessie became "rigid . . . finger-pointing, serious, not loving." Jessie got increasingly more desperate when she found that Dr. Barnard was out of town. She called Dr. Barnard's backup, who prescribed an increase in the dosage of Robert's antipsychotic medicine. Robert agreed to the medication adjustment, which kept him from going back into the hospital. Nonetheless, more damage was done to their relationship, and Jessie considered leaving. Robert also had more conflicts with his coworkers and other family members during this interval.

A meeting with his psychologist, arranged about a week after Robert changed his medication, focused on troubleshooting the relapse prevention plan. Robert, who was still slightly hypomanic, complained that the plan hadn't worked because of Jessie's emotional stance. He said that he needed her to be "kinder and gentler" in her approach. The psychologist asked him to be more specific, and he said, "I want her to tell me she loves me, and in a more tender way tell me that she thinks I need help and why, even if I'm not receptive." He added that he wished she wouldn't take his irritability so personally and instead see it as part of his disorder. Jessie, in turn, expressed frustration that he hadn't gone to his medication appointments when Dr. Barnard had been in town. "I want him to go for me or for our relationship, if he won't do it for himself, knowing that I'm speaking out of caring for him." She wasn't sure if she could take a gentler emotional stance when dealing with his escalating mood.

The psychologist encouraged Robert and Jessie to practice communicating in the way the other wished: Jessie, to be more tender in her approach and Robert, to cede a degree of control to her. They also discussed the potential involvement of other family members, such as Robert's son, at times of emergencies. Robert decided, however, that he wanted to shield Brian as much as possible from his illness and didn't want his son interacting with his doctors. Jessie agreed.

When she returned from her trip, Dr. Barnard met with Robert and Jessie and told them of a medication plan to undertake if Robert had one or more prodromal signs and could not immediately get in to see her: increase his dosage of Zyprexa and add a benzodiazepine (Klonopin) for sleep. She wrote a prescription with a plan for increasing the dosage, with the understanding that Robert would come in to see her as soon as possible after initiating the new dosing schedule. These modifications were all written into their modified contract (for example, "Robert to increase Zyprexa dosage; Robert to call his doctor and be willing to let Jessie make the call if he will not; Jessie to try to recognize Robert's irritability as part of the manic syndrome"). Robert and Jessie agreed to reexamine the contract every three months and revise it as necessary.

Robert has continued to have mood cycles, but his episodes increasingly resemble hypomanias rather than manias. He feels he has a good relationship with Dr. Barnard and his psychologist, and he and Jessie are still together and working on their problems. He has explained his bipolar disorder to his son, who, with time, is becoming more understanding.

Think of your mania prevention contract as a work-in-progress. The prevention steps can be defined, agreed-upon, and practiced when you're healthy, but no one can be certain how well they will work until you put them into action. Knowing your prodromal signs, being responsive to the feedback of others, and knowing when to ask for help are all central to making the contract effective in real life.

If you do have a manic episode despite your prevention contract, sit down with your doctor, family, or therapist after the dust has settled and try to decide what did and did not work. Were you unable to reach your physician or a backup physician? If so, ask your doctor to recommend medication adjustments that you can make on your own the next time you start to escalate. Ask him or her to write down your emergency medicine plan in prescription form, with the understanding that you will fill the prescription when your early warning signs appear and arrange an in-person meeting as soon as possible thereafter.

Were there other problems that prevented the contract from working? For example, were you hostile to significant others, who then threw up their hands and refused to help any further? Were your relatives unnecessarily controlling? Alternatively, did you ask for help but no one was available? If so, perhaps you can think of other relatives or friends to whom you are less likely to react negatively in emergencies, or who might be available with little notice.

Was the contract ineffective because you found the recommendations made by significant others unacceptable? If so, how could the contract be modified to make these recommendations more palatable? For example, Gabriel refused to see a certain doctor whom his parents insisted he see. He was, however, willing to see a doctor he had found by himself. Being able to see his preferred doctor was entered as a modification to their mania prevention contract. You will find that the contract has a much greater chance of succeeding if you have had input into each step, have listed choices of strategies rather than only one singular strategy, and can troubleshoot and revise the contract as you go along.

Because of the influences of your individual neurophysiology, you should not expect to be able to fully prevent manic episodes. But you have a window of opportunity in the early stages of manic escalation in which you may be able to decrease the severity of your oncoming episode. Being able to identify your episodes early and receive emergency treatment will give you a greater feeling of autonomy in the long run, even if it means having to give up control to others in the short run. A written contract, especially if it is developed and filled out when you are feeling well, will enhance the likelihood that your and others' prevention efforts will be successful.

Depressive episodes have a different quality. For most people, they do not come on suddenly and often last longer than manic episodes. But as is true for mania, identifying and combating the early warning signs of depression will help you feel more in control of your disorder. In Chapter 10, you'll see how you can use the support of your core circle, along with certain personal strategies such as behavioral activation and cognitive restructuring, to try to keep your depressions from becoming more serious or debilitating.

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