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Michael Freeman, M.D. - Guest
Dr. Freeman is a psychiatrist, psychologist, consultant and former CEO who serves on the faculty of the Department of Psychiatry at the University of California, San Francisco School of Medicine. His clinical practice is focused on the treatment of people with mood, anxiety and attention disorders, and his consulting practice is focused on entrepreneurship and performance enhancement coaching. Michael’s research addresses the strengths, vulnerabilities, and mental health issues faced by entrepreneurs. He has held CEO and C-level leadership positions in several public and private sector health care organizations. Michael brings medical, psychological, prevention/self-care and executive competencies to his clinical and consulting practice. |
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W. Keith Sutton, Psy.D. - Host
Dr. Sutton has always had an interest in learning from multiple theoretical perspectives, and keeping up to date on innovations and integrations. He is interested in the development of ideas, and using research to show effectiveness in treatment and refine treatments. In 2009 he started the Institute for the Advancement of Psychotherapy, providing a one-way mirror training in family therapy with James Keim, LCSW. Next, he added a trainer and one-way mirror training in Cognitive Behavioral Therapy, and an additional trainer and mirror in Emotionally Focused Couples Therapy. The participants enjoyed analyzing cases, keeping each other up to date on research, and discussing what they were learning. This focus on integrating and evolving their approaches to helping children, adolescents, families, couples, and individuals lead to the Institute for the Advancement of Psychotherapy's training program for therapists, and its group practice of like-minded clinicians who were dedicated to learning, innovating, and advancing the field of psychotherapy. Our podcast, Therapy on the Cutting Edge, is an extension of this wish to learn, integrate, stay up to date, and share this passion for the advancement of the field with other practitioners. |
Dr. Keith Sutton, Psy.D: (00:21)
Welcome to Therapy on the Cutting Edge, a podcast for therapists who want to be up to date on the latest advancements in the field of psychotherapy. I'm your host, Dr. Keith Sutton, a psychologist in the San Francisco Bay Area, and the Director of the Institute for the Advancement of Psychotherapy. Today, I'll be speaking with Michael Freeman, M.D, who is a psychiatrist, psychologist, consultant, and former CEO, who serves on the faculty of the Department of Psychiatry at the University of California at San Francisco School of Medicine. His clinical practice is focused on the treatment of people with mood, anxiety and intention disorders, and his consulting practice is focused on entrepreneurship and performance enhancement coaching. Michael's research addresses the strengths, vulnerabilities, and mental health issues faced by entrepreneurs. He has held CEO and C-level leadership positions in several public and private sector healthcare organizations. Michael brings medical, psychological prevention, self-care, and executive competencies to his clinical and consulting practice. Let's listen to the interview. Okay. Well, hi Michael. Thanks for joining me today.
Dr. Michael Freeman, M.D: (01:29)
My pleasure. Thanks so much for inviting me out to the podcast.
Dr. Keith Sutton, Psy.D: (01:32)
Yeah. So, I know you and of your work, so we're both in Marin County and you're a psychiatrist here, and we've shared some cases together. You also have wonderfully great holiday cards that you sent out with cartoon jokes and so on that you make, which are wonderful. And, we've talked over the years about your work, and particularly there's an area that you do a lot of work in, which is in working with bipolar disorder and also ADHD and particularly the realm of entrepreneurs and so on. And so I want to hear about your work and what you've been doing lately. But before we even get to that, I'd like to hear a little bit about how you got doing what you're doing, what the evolution of your kind of ideas and, and how you get to be doing this work.
Dr. Michael Freeman, M.D: (02:20)
Well, it's a long journey and it started before I even went to medical school. I was involved in creating large scale healthcare systems for the federal government in the Medicaid program, for example. I got subsequently trained as a psychologist, then as a psychiatrist. And after I finished all of my clinical training, I worked with venture capital firms, starting health insurance companies. So I was the founding Chief Medical Officer of United Behavioral Health, which is now the largest of the single specialty mental health companies out there. After doing that for a while, I got the idea of starting a company myself and I, over the years, have been a founder or a co-founder of maybe five or six businesses. But the one that I ran the longest where I was the CEO for 12 years had hundreds of corporate clients, including small, medium, large, and very large businesses. And I noticed with my mental health training that among the founders of the small businesses, there were just a lot of mental health issues that popped out at the time. It seemed to me that primarily hypomania and bipolar spectrum kinds of traits were pretty easy to recognize among the entrepreneurs. And that observation is what kind of led me in this direction. After we sold that company, I went back to UC San Francisco. I've been on the faculty over there for a long, long time, but I kind of did a deeper dive, rounded up some research colleagues and was involved in studying the mental health of entrepreneurs. I've been doing that continuously for the last six years, and my team has collected some great data sets. We have a lot of publications, and it turned out that the original hypothesis was accurate in part, in other words, there is elevated bipolar spectrum hypomania among entrepreneurs, but that's not the whole story. And as you know, people with bipolar disorder have a significant likelihood of also having ADHD. And people with ADHD also have a likelihood of having a bipolar spectrum condition. We've found a lot of ADHD among the entrepreneurs as well. And we found a lot of people who had both, as well as a broader mix of mental health differences. So that was a reader's digest version of the journey that got me into this. Now as a psychiatrist, I'm doing a lot of things, including starting another company, but I do have an ongoing practice a couple days a week, and all of my clients are entrepreneurs, and I'd say the majority of them have either ADHD or bipolar spectrum issues, or both, though not exclusively, so I've still got my sleeves rolled up and I'm working with people who are dealing with these issues while studying them and trying to create other solutions for them as well.
Dr. Keith Sutton, Psy.D: (05:58)
Yeah. So you're kind of boots on the ground, you know, working with people directly as well as, kind of, the larger view of kind of looking at, you know, the research and understanding better. So, I'm wondering if maybe we could start off with talking about bipolar disorder hypomania. I mean, I think that this is something that I've worked with a couple clients and oftentimes clients have come to me, you know, on medication or so on, that have truly had bipolar. I've also worked with a number of clients with complex PTSD that were diagnosed bipolar, but didn't seem to quite fit the diagnosis. Can you talk a little bit about, kind of, understanding and diagnosing and for a clinician in practice when they're working with a client, kind of the hallmarks of bipolar disorder that, I mean, of course in a clear cut case, significant mania, grandiosity and so on, but how about some of those more nuanced kind of situations? What, what are you looking for when you're diagnosing bipolar?
Dr. Michael Freeman, M.D: (07:09)
So, that's a good question, and just from a pragmatic perspective, let's start with your issue, which is has your patient been improperly diagnosed to begin with? The reality is that most people with bipolar spectrum conditions are not properly diagnosed for quite a while, and they more likely than not get misdiagnosed. In one study of that problem, the average patient had been misdiagnosed as many as eight different times before being properly diagnosed with a bipolar spectrum condition. So, I would say, you wanna have a kind of elevated index of suspicion if your client tells you, or if a referring provider tells you that this person has borderline personality disorder, or that this person has depression, or that this person has ADHD. You mentioned complex PTSD; there are symptoms of PTSD that are also found among people in the bipolar spectrum. So I would say, have a very high index of suspicion. For example, bipolar people are most commonly misdiagnosed as having depression, unipolar depression. That's because, particularly with bipolar two disorder, depression is the most prominent symptom. A person with bipolar two disorder would qualify for that diagnosis if they've only had one manic or hypomanic episode. And then what you mainly see is, you know, it looks like recurring unipolar depression with some differences. So I think the reality is that if a patient is depressed, about one in five of them will actually have bipolar depression. So, it's really important to sort that out because the psychotherapy and medication management is very different for bipolar depression compared with garden variety unipolar depression and its subtypes.
Dr. Keith Sutton, Psy.D: (09:50)
What kind of questions are you asking in the clinical interview as you’re assessing, you know, is this, major depression or is this a bipolar one?
Dr. Michael Freeman, M.D: (10:04)
Or bipolar two, most likely bipolar two.
Dr. Keith Sutton, Psy.D: (10:06)
Sorry, bipolar two. Yes. What kind of questions are you asking to kind of suss that out to separate?
Dr. Michael Freeman, M.D: (10:14)
So one thing is to ask about age of onset, because age of onset of bipolar disorder is typically 17 plus or minus three or four, whereas, age of onset for depression, you know, dysthymia, persistent depressive disorder, or uni recurring unipolar depression, is typically later in life. So early onset, think bipolar. Another thing to ask about is the characteristics of symptom onset. Was it like somebody flipped a switch and there was an abrupt onset? Or was it sort of a gradual worsening of a bad mood that turned into feeling blue that turned into feeling really depressed and evolved and emerged over time? If you find people who have abrupt onset and as including it switches off abruptly, again, think bipolar spectrum. People that have these more gradual onset and gradual remissions, I would think in the context of a major depressive disorder. Another way of sorting it out is to ask about seasonality. Bipolar mood fluctuations are much more seasonal than unipolar mood fluctuations. And they're not only seasonal, but there are danger zones. The danger zones are the two times of year when you have the accelerating rate of change of length of day. So in deep winter and in the middle of summer, daylight is getting longer or shorter by like a minute a day, two minutes a day. But if you go into fall and spring, the length of day is changing by five or six minutes every day, and so you really feel the impact of length of day change in those seasons. So if people start having what they call roughening, if their moods begin to get a little unstable or they develop irritability or insomnia or agitation or depression, or the opposite then to think bipolar. Typically depressive symptoms happen in fall, winter, and hypomania typically happens in spring and summer, you know, spring fever everybody gets, versus the bears that hibernate in the winter. Depression actually has some adaptive advantages from an evolutionary perspective, which is that you don't burn as many calories when you're depressed because you don't wanna get out of bed, and that's good in the winter because they're just in the world of hunter gatherers, there's just not that much food around. So, you know, Eskimos for example, can spend very long periods of time in their igloos during the winter without even coming out in like a meditative trance, which is akin to hibernation, which is where you get when you're, you know, deeply depressed. So seasonality would be another thing to look for to differentiate. The nature of the depression is a little bit different. The people in the bipolar spectrum are more likely to have an agitated kind of depression or they can have mixed state characteristics with some irritability less likely to see that with major depressive disorder. With major depressive disorder it's more likely to affect women than men, that is not necessarily the case with bipolar depression. However, it is also true that bipolar two disorder is associated more with women than with men, but not bipolar one, not cyclothymia, and not bipolar NOS (not otherwise specified). Those are the DSM five categories. So that, that gives you a flavor.
Dr. Keith Sutton, Psy.D: (15:03)
Okay. Yeah. Cause I always look through the periods of time where the person's not getting sleep or not needing sleep. Is that, kind of, a good differential or is that more, you know, bipolar one or more like a hallmark of the mania, not necessarily of the hypomania?
Dr. Michael Freeman, M.D: (15:25)
So, decreased need for sleep associates with hypomania and mania, but not particularly with bipolar depression, which is kind of what you're asking about. Hypersomnia is more common with all kinds of depression.
Dr. Keith Sutton, Psy.D: (15:40)
Yeah. That's often something that I'm looking at a little bit. If, like now, I'm sleeping okay or I'm getting more sleep than usual, then I'm kind of thinking, okay, maybe that's more depression than more of a bipolar.
Dr. Michael Freeman, M.D: (15:53)
No. People with bipolar depression will stay in bed for a couple days at a time, deep depressions.
Dr. Keith Sutton, Psy.D: (16:02)
Yeah. But they'll have times where they're maybe not getting so much sleep in the hypomanic or the manic state?
Dr. Michael Freeman, M.D: (16:08)
If they fluctuate. Yes. But what you typically see, is in bipolar one there is more mood fluctuation. With cyclothymia, there's more mood fluctuation. With bipolar two disorders, you can often see people who kind of alternate between depression and normal. And then we'll rarely get some breakthrough hypomania.
Dr. Keith Sutton, Psy.D: (16:32)
So it’s more that depression, like you're saying, those qualities of depression are really because you might only be seeing depressed or they might not really have those hypomanic states
Dr. Michael Freeman, M.D: (16:41)
Infrequently. Yes. And that's why they're misdiagnosed.
Dr. Keith Sutton, Psy.D: (16:45)
Got it. Got it.
Dr. Michael Freeman, M.D: (16:46)
Yeah. Again, going back on your differential diagnosis, it's important to do a family history. This is one thing I believe that a lot of mental health professionals could spend more time on family mental health history. Bipolar disorder is highly genetically transmitted. So if you know what to look for, you should be able to find other first degree family members, parents, siblings, children, possibly grandparents, second degree cousins, etc, who have bipolar disorder. However, since it's not really all that well understood by a lot of people, you have to ask questions a little bit differently. So if you find people that are highly accomplished, people who have achievements in the arts or in sciences, people who were big business builders, people who traveled a lot, were multilingual, people who made a million and lost a million, and people who committed suicide. Suicidality is elevated among bipolar in bipolar one disorder in particular. So those are clues that your patient also might be in the bipolar spectrum.
Dr. Keith Sutton, Psy.D: (18:26)
And as you're talking about these different kinds of potential things in the history, because if you ask “Is there somebody with bipolar?” they might say no. But then, you're asking are there people that made a bunch or lost a bunch or these kinds of aspects. Is there any knowledge about what percentage of people with bipolar disorder are these kinds of, not higher functioning, but entrepreneurs doing a lot of all this learning or these functional pieces, versus somebody that might be really struggling?
Dr. Michael Freeman, M.D: (19:01)
Yes. That question has been asked from a couple of different perspectives. It's not an easy question to ask because you can be a high achiever and highly impaired at the same time. And so which category do you fall in? On average though, people in the bipolar spectrum tend to be highly challenged, and bipolar disorder is typically associated with a great deal of disability. Also, keep in mind that most people with bipolar disorder have co-occurring mental health conditions. So if you are someone in the bipolar spectrum, you have an elevated likelihood of having anxiety, or having ADHD, or having substance use issues. I think those would be the most common, but not exclusively that. And then there's disabilities that are associated with those other conditions as well. But the research has shown two things. One, that there is a subset of like flat out bipolar one and bipolar two people who are really high achievers, and that the first degree relatives of people with bipolar disorder, in other words, the parents, siblings, and children, often have the positive traits of energy, creativity, sociability, that go with bipolar disorder that make you more successful as an entrepreneur, as an artist, as an academic without having some of the disabilities. And so that's sometimes referred to as soft bipolar disorder.
Dr. Keith Sutton, Psy.D: (21:14)
Okay. So they learn this from their parents? Or there's some kind of genetic residuals or so on?
Dr. Michael Freeman, M.D: (21:21)
Genetically transmitted.
Dr. Keith Sutton, Psy.D: (21:23)
Oh, got it. Okay.
Dr. Michael Freeman, M.D: (21:25)
Yes. So we found in one of our studies that close to 40% of entrepreneurs have one or more diagnosable mental health conditions, but of the 60% that don't, more than half of them had first degree family members with significant mental health issues. So, some people, from an evolutionary perspective, argue that the reason evolution created bipolar disorder is to get the first degree relatives. That the severely impaired individuals with bipolar one and bipolar two disorders who don't function very well, are kind of like evolutionary roadkill, similar to sickle cell anemia. So with sickle cell anemia, if you are a sub-Saharan African person and you inherit sickle trait from both parents, you will have sickle cell disease and you're gonna die young and it's not pretty. But if you only inherit the sickle trait from one parent, then you have a lot of protection against malaria so it's actually good for the tribe. So, what evolution figured out how to do is to protect populations, not individuals with bipolar disorder. These first degree relatives that are the high achievers with all of the energy and creativity and motivation, they're good for the population. And again, they're the leaders, they're the innovators, they're the hunters, they're the problem solvers. They're the ones that figure out how to adapt to changing conditions. And so evolution, once again, is protecting the population at the expense of some individuals. Having said that, the treatment of bipolar disorder has come a long way, and these days people with bipolar one, bipolar two disorder, cyclothymia, and bipolar NOS (not otherwise specified), can have great clinical outcomes and can lead really amazing lives. So we kind of outsmarted evolution with science. The treatments are just fabulous and the outcomes can be really, really good.
Dr. Keith Sutton, Psy.D: (24:23)
So I know there's some medication treatments, but what kind of work are you doing in therapy to work with clients with bipolar?
Dr. Michael Freeman, M.D: (24:35)
So first of all, I wanna emphasize to anybody listening who is not a psychiatrist, you must work with a psychiatrist. Whatever you do therapeutically will not work without medication. Having said that, that's not entirely true actually. There are some significant gains that can be made with therapy alone. And bipolar people can go off medication for periods of time without consequences. So it's not completely black and white. But I would say more than almost any other condition besides schizophrenia, the medication management is really, really important. And you're doing a disservice to your patient by not taking a collaborative care approach around this condition.
Dr. Keith Sutton, Psy.D: (25:34)
Yeah. Set the biological aspect,
Dr. Michael Freeman, M.D: (25:37)
It's highly biological. It's physiologically comparable to epilepsy. And many of the medications that treat bipolar disorder also treat epilepsy because the neurophysiology is so similar. So that's what you're dealing with. So having said that, the therapy that you talked about, the good news for therapists is that there is a very strong evidence base for psychotherapy with people who have bipolar. IPT CBT SRT and FFT and PE. So let's go through that. IPT: interpersonal therapy, CBT: cognitive Behavioral Therapy, FFT: family Focused Therapy, and PE: psychoeducation.
Dr. Keith Sutton, Psy.D: (26:55)
And I think you said SRT.
Dr. Michael Freeman, M.D: (26:58)
Social Rhythm Therapy.
Dr. Keith Sutton, Psy.D: (27:02)
Okay.
Dr. Michael Freeman, M.D: (27:04)
I would advise starting with psychoeducation. Just start with education, because knowledge is power and the more you educate people, and the more you help them become interested in their own condition, the more they can learn self-care skills. So I explain that bipolar disorder is something like a mental health version of diabetes, chronic illness genetically transmitted. There are a lot of things you can do to prevent, mitigate or reverse the symptoms. Just like with diabetes, it's a lot of its behavioral and lifestyle, but not exclusively so. Educate, educate, educate, read books. One recommendation is the Bipolar Disorder Survival Guide by a psychologist named David Miklowitz. There are others, but that's a very good one to start with. Then comes skill building. And each of those different therapies that I mentioned are evidence-based and they help people develop different skills. So, interpersonal therapy, which was developed for depression, is also effective for bipolar disorder. And what that focuses on is helping your patient identify the key relationships that they're in (parent, spouse, work relationships), and identify the ways in which bipolar symptoms are interfering with their ability to execute effectively in those role relationships. And then develop relationship skills that are founded upon managing the intrusion of the bipolar symptoms, practicing relationship skills, and focusing on one relationship at a time because the skills tend to generalize to other relationships. SRT, social rhythms therapy. I mentioned that bipolar disorder is seasonal. There's a seasonal, but there's also a diurnal component, meaning day night. It's common that people in the bipolar spectrum experience day night reversal where they’re night owls and then they sleep in and they also are disoriented to time. They lack punctuality. They can become absorbed in what they're doing or get tangential and distracted. And so they get disconnected from time, and their sleep wake cycles get or become disturbed. And so what social rhythm therapy does primarily is to help people establish time anchors in their days so that they can begin to create routine and structure, including sleep hygiene and sleep management, as well as linking time anchors that link you with the flow of the day. You always walk the dog in the morning, in the afternoon, you always have lunch at noon. You clear emails at the end of the day. You do your heavy lifting work products at the beginning of the day. So you have a few time anchors. Not too many, but you stick with them religiously. And what that does is it actually forces your circadian rhythm back into a pattern that is where you're more likely to be euthymic. In other words, where you're more likely to not get depressed and not get manic. If you haven't heard of that one before, look it up. Social rhythm therapy. It's very, very interesting.
Dr. Keith Sutton, Psy.D: (31:40)
Well, that's a lot of what we do too with the adults with ADHD, right. Creating structure and these anchors or these markers throughout because of the time blindness, and the distractibility, and the hyperfocus.
Dr. Michael Freeman, M.D: (31:56)
It's very similar to that with a little bit more emphasis on sleep regularity.
Dr. Keith Sutton, Psy.D: (32:01)
Good.
Dr. Michael Freeman, M.D: (32:01)
And with respect to sleep regularity, you can incorporate phototherapy mood lights, as length of day fluctuates, because mood is indirectly regulated by the pineal gland. The pineal gland has projections to the limbic system, and there are motion processing centers in the limbic system, which get dysregulated in bipolar disorder. And so by managing length of day, you can indirectly stabilize those emotional processing centers in the limbic system. And the way to do that is with these phototherapy lamps that have like 10,000 luxe broad spectrum wavelengths that you can deploy during the time of year when days become shorter. And if you build that into your social rhythm therapy, it's also beneficial. It's helpful. Even just as a single treatment. Measurable results, particularly for people that have a seasonal pattern.
Dr. Michael Freeman, M.D: (33:29)
So then cognitive behavioral therapy is similar to what you already know, only it's tilted a little bit for depression. So the way I explain it to patients, is that every mental health condition is associated with a storyline, a soundtrack, if you will, in depression it's helpless, hopeless, worthless, guilt. You just monitor your thoughts and that's gonna be helpless, hopeless, worthless, guilt, over and over again. In anxiety, it's what if, catastrophic thinking, risk, risk, risk, danger, danger, danger, and rumination on problems that never get solved. That's gonna be the narrative for anxiety. And then with bipolar disorder, the depression narrative is about the same. The hypomania narrative begins to be about, yes, I can and wouldn't it be great? And, if I take a risk, nothing bad's gonna happen to me. And, my ideas are definitely worth executing on and they're better than anybody else's, and I have plenty of time to sleep when I'm dead. And, what's the good of money if you can't spend it? And so, as with any other CBT intervention, it's a matter of identifying trigger thoughts, and then reevaluating them and replacing them with more accurate, realistic kinds of thoughts. And then also beginning to recognize what are early warning signs of an impending episode. Because in bipolar disorder, people tend to have prodromes. In other words, prodrome is an early warning sign that indicates you're about to have an episode and if you intervene at the prodrome stage, you can head it off, you can prevent the episode from actually happening. So that's CBT, FFT is family focused therapy.
Dr. Keith Sutton, Psy.D: (36:00)
Sorry. Can you mention some of the pro prodrome symptoms that you're seeing that are markers that an episode's coming?
Dr. Michael Freeman, M.D: (36:08)
Elevated energy, higher levels of motivation, greater ambition, less need for sleep, all of a sudden you think about having more sex with more people, increased use of drugs and alcohol, verbosity. Different people have different prodromes. And if you're working with somebody who's bipolar in the long run, a good thing to do, this is another one of those cognitive behavioral techniques on the behavioral side, is to create an advanced directive. What that consists of is like a three by five card only. Now there's digital versions, but on one side is “I know I'm getting manic when I spend more money, I stay up later at night, I start doing new projects, even though I didn't finish my old projects, I am more outgoing, and I'm the life of the party,” whatever it is for the individual. You know, your five early warning signs. And then on the back of the card, “when I am entering a bipolar prodrome, here's what I'm gonna do…1, 2, 3, 4, 5, check in with my therapist, talk to my psychiatrist about medication management get to bed on time, reduce the amount of stimulation in my life”. So those are the behavioral strategies, and there are many behavioral strategies for managing and proactively preventing the onset of mood swings up or down.
Dr. Keith Sutton, Psy.D: (38:12)
Okay. Great. Tell me about this family focused therapy.
Dr. Michael Freeman, M.D: (38:17)
So family focused therapy is a way of helping the individual with bipolar disorder by helping the family because bipolar moods and communication is very impactful on loved ones. And so, what is typical protocol is where you have 10 or 12 meetings with the individual and their family at the same time. And it's primarily psychoeducational and problem solving oriented. But what you want is for the family to fully understand that your family member is not obnoxious, and is not selfish, and is not a jerk, but that what you're actually seeing are symptoms of untreated bipolar disorder, and then learn skills like how to communicate without emotional escalations. And how to appropriately talk with each other about behavior that might be symptomatic, and about how to function as a family with someone who's bipolar, and how to modulate the way you interact with the bipolar person. There's a good book that clinicians can recommend to their patients and their family members called “Loving Someone with Bipolar Disorder” and it explains how to be a family member of somebody who is bipolar.
Dr. Keith Sutton, Psy.D: (40:10)
Yeah. I imagine too, you know, sometimes I'll utilize the system, roommate, partner, family member, to also be kind of a measure of the prodrome and noticing as things are coming up and being able to reflect that back to the person. Especially like you're saying with some of the manic symptoms that the person might not think are necessarily bad, they've got more energy, they're super motivated, or so on. So they might not necessarily be seeing it as a negative thing, but sometimes everybody around them can start to notice it and know where that's going, and maybe reflect that back to bring up the consciousness.
Dr. Michael Freeman, M.D: (40:44)
In a non-judgment way,
Dr. Keith Sutton, Psy.D: (40:47)
Yeah, definitely. A supportive way.
Dr. Michael Freeman, M.D: (40:49)
In a supportive way, and in a way which is also respectful of the many advantages and strengths that are associated, as well. And then one more thing I'd say to therapists is, do not make the mistake of getting sucked into insight oriented and regressive psychotherapies. That makes it worse. It's not one of those kinds of conditions. You're not dealing with people that have self-defeating behavior patterns that are a result of their family of origin that you can kind of work out through more traditional therapy. This is something else. Again, it's like diabetes or sickle cell anemia or hypertension where it's more about disease management than anything else. So you can make it worse, and therapists often do make it worse. The last thing I would say is, again, your bipolar spectrum patient is likely to have one or more co-occurring conditions, and they all have to be treated concurrently or else they won't get better. And they can create a negative feedback loop where someone with ADHD has a time management problem and misses an important meeting, then they get agitated because of the consequences of missing the meeting, and then the agitation triggers mood swings, and then you self-medicate the mood swings with drugs and alcohol, and the whole thing implodes at the same time. So you have to treat everything at once.
Dr. Keith Sutton, Psy.D: (42:35)
Actually with ADHD in bipolar, oftentimes for ADHD, the treatment of choice is a stimulant that, from my understanding, for somebody with bipolar can kind of push them into a hypomanic or a manic state. Is that correct? How do you work with that?
Dr. Michael Freeman, M.D: (42:51)
There are shades of gray around that, but Adderall and medications related to Adderall, dexedrine, Vyvanse, and so on, in the absence of a mood stabilizer have the potential to trigger mania. The same is true for methylphenidate, but to a much lesser extent. And so if somebody has ADHD and bipolar disorder, I typically first prescribe the mood stabilizers and get the mood completely stabilized, and then start with methylphenidate, or guanfacine…
Dr. Keith Sutton, Psy.D: (43:36)
Ritalin, concert of the Methylphenidates.
Dr. Michael Freeman, M.D: (43:38)
Yeah. Though, if someone takes Adderall, or one of the related drugs while mood stabilizers are in place, they probably won't get manic. It's when they're not in the context of the mood stabilizer.
Dr. Keith Sutton, Psy.D: (43:59)
Interesting.
Dr. Michael Freeman, M.D: (44:00)
And low dose Adderall actually has antidepressant effects and it's sometimes used to augment depression treatment as well. So the use of the stimulants sort of requires some nuance to do it properly.
Dr. Keith Sutton, Psy.D: (44:22)
…and expertise around that. Now, tell me about the work with the entrepreneurs and your research and what really stands out?
Dr. Michael Freeman, M.D: (44:32)
What stands out? So there is a subset of people in the bipolar spectrum and their first degree relatives who are very high achievers. They're gifted, they have elevated intellect, they are charismatic, they have high levels of motivation, they're ambitious, they're visionary, they’re creative, and many of them are high achievers in the creative and performing arts. Many of them are high achievers in academia and the scientific professions, and many of them we have discovered are high achievers in entrepreneurship as well. I don't like the pathologizing of mental health conditions and mental health differences. Pathologizing these things is very good for pharmaceutical companies, doctors, and hospitals, because it creates more customers, but it's not so good for the individual because they begin to think in a disease model, which is not inaccurate, but it's only part of the story.The bigger picture is that with bipolar disorder, it's an endowment that is associated with a lot of risks and vulnerabilities. And if you learn how to manage the risk and the vulnerabilities, you can take advantage of the strengths and the superpowers and the endowment. And that's what I do with entrepreneurs.
Dr. Keith Sutton, Psy.D: (46:11)
So rather than a defective model, more of a difference model. There's a difference that we need to address. And that by addressing and compensating for some of the downsides of it, we can also benefit from the upsides of it.
Dr. Michael Freeman, M.D: (46:28)
And strengthen that, and learn how to play your strong cards, and learn how to avoid situations which are likely to not work out for you because of the vulnerabilities.
Dr. Keith Sutton, Psy.D: (46:39)
Any particular things that you do to strengthen those or to increase those strengths beyond what you've already mentioned?
Dr. Michael Freeman, M.D: (46:49)
Do what you do best? What the entrepreneurs in the bipolar spectrum tend to do best often is product development and business development. Then leadership plus minus. They can be really effective, charismatic leaders, or they can drive people away with mixed episodes that lead to a lot of irritability and agitation. So basically I just assess people, and I first of all get all of the mental health conditions properly treated, then find out what are their strengths and superpowers and identify ways in which they can deploy those more frequently in their life as well as in their business. And then in what ways do they become their own worst enemies and then create some guardrails around that. It's a variation on the theme of strategies that I already talked about, only translated into the world of entrepreneurship and business.
Dr. Keith Sutton, Psy.D: (48:19)
You know, I'm wondering because we were talking a bit on the phone when we were chatting before about this, I was seeing an article on hypothymic temperament and I don't know how much you knew him, a colleague in your building and a colleague of mine recently unfortunately took his life and there was some potential bipolar kind of aspects going on in there. And the situations of Anthony Bourdain or Kate Spade, these kind of situations where they maybe were a little hypomanic throughout their life or more almost like soft bipolar, but then later kind of midlife all of a sudden having a big switch kind of flipping. Is that kind of an understanding? And I've known of some other kinds of situations too where somebody in their forties or fifties or sometimes sixties all of a sudden get the diagnosis of bipolar, which I know it's more likely that this onset is at 17, 18, 19 years old. Do you know much about that piece?
Dr. Michael Freeman, M.D: (49:22)
That is true. One of the assessment instruments that we use in our research is called the Hypomanic Personality Scale, and it measures the hyperthymic temperament that you just talked about, and people who score high on that assessment instrument are very likely to have a full-blown manic episode within the next five years. And so it's possible that this hyperthymic temperament that you described, what you're seeing there are the first degree relatives of the bipolar proband. But it's also possible that the hypothalamic temperament is really just a very long, very slow moving prodrome that eventually becomes bipolar disorder. Sometimes as a result of a trigger, like a major life event, sometimes as a result of drug use, like cannabis, for example, can trigger onset of bipolar disorder, and Adderall we just described. And sometimes as a result of taking medications, like antidepressants. If you give somebody who's bipolar an antidepressant, they can have a full-blown manic episode. And prednisone is another one of those, so yes it's a real thing. It's definitely a real thing.
Dr. Keith Sutton, Psy.D: (51:13)
And can you speak to just a little bit on suicide and bipolar, because I know that at least in this case, the family said that they felt like it just became a whole different person. There was the documentary, “The Bridge”, about the Golden Gate Bridge and people taking their life and one person that lived was bipolar and he talked about just, again, in this different state of mind ending up jumping off the bridge and living.
Dr. Michael Freeman, M.D: (51:44)
Well, suicide is elevated among people in the bipolar spectrum. Without treatment, people with bipolar one disorder can have up to 10% incidents of completed suicide. So, it's a real risk, it's a real concern and it typically happens during a period of impulsivity. And it can be triggered. Like for example, you mentioned the Golden Gate Bridge. What if you look at those suicides, people always jump off the side of the bridge facing the city, and they typically jump at twilight or at night. And apparently at least one theory is that the twinkling lights trigger a sort of an epilepsy. Remember I said bipolar is related to epilepsy. It has an epileptiform disinhibition of impulsivity that's associated with self-destructive behavior.
Dr. Keith Sutton, Psy.D: (52:57)
Interesting. Wow. I think it's all the more important like you're saying about getting that correct diagnosis so that the person can receive the proper treatment, particularly the medication treatment to stabilize that. And then be able to do the therapy to shore up the resources to give tools to help when going into the episodes, and kind of shore up the larger system to support them. Well this is great. And I love how you're also, again, highlighting that there's a lot of folks that can channel this into great success in entrepreneurship or, achievement in the arts or science or so on. I think it's just such a really interesting complex mental health difference that is not well understood, but I think a lot of these interventions can help people be very successful. So I thank you so much for your time today. This is really great. I really appreciate it.
Dr. Michael Freeman, M.D: (53:57)
My pleasure. Thanks for highlighting this issue. It's a really important one. And bipolar disorder is an equal opportunity condition. It occurs about the same incidents in every culture around the world. So it's very important and it's agnostic to socioeconomic status. That's not entirely true. Bipolar disorder is actually considered to be a disease of the rich. Because in these families, there are the high achievers that make a lot of money, but on the other hand, the people who are truly bipolar can be quite adversely affected socioeconomically as well. So I think that spending a little time on this condition is a great thing and I appreciate that you're doing it.
Dr. Keith Sutton, Psy.D: (54:51)
Great. Well, thank you so much for your time. I really appreciate it. Take care.
Dr. Michael Freeman, M.D: (54:55)
My pleasure, Keith. You too. Good luck with the podcast series. Thanks.
Dr. Keith Sutton, Psy.D: (54:58)
Bye-bye.
Dr. Michael Freeman, M.D: (54:59)
Bye now.
Dr. Sutton: (55:06)
If you're wanting to use this podcast to earn continuing education credits, please go to our website therapyonthecuttingedge.com. Our podcast is brought to you by the Institute for the Advancement of Psychotherapy, providing in-person and remote therapy in the San Francisco Bay Area. IAP provides screening for licensed clinicians through our in-person and online programs, as well as our treatment for children, adolescents, families, couples, and individual adults. For more information, go to sfiap.com or call (415) 617-5932. Also, we really appreciate feedback. And if you have something you're interested in something that's on the cutting edge of the field of therapy, and think clinicians should know about it, send us an email or call us. We're always looking for the advancements in the field of psychotherapy to help in creating lasting changes for our clients.
Welcome to Therapy on the Cutting Edge, a podcast for therapists who want to be up to date on the latest advancements in the field of psychotherapy. I'm your host, Dr. Keith Sutton, a psychologist in the San Francisco Bay Area, and the Director of the Institute for the Advancement of Psychotherapy. Today, I'll be speaking with Michael Freeman, M.D, who is a psychiatrist, psychologist, consultant, and former CEO, who serves on the faculty of the Department of Psychiatry at the University of California at San Francisco School of Medicine. His clinical practice is focused on the treatment of people with mood, anxiety and intention disorders, and his consulting practice is focused on entrepreneurship and performance enhancement coaching. Michael's research addresses the strengths, vulnerabilities, and mental health issues faced by entrepreneurs. He has held CEO and C-level leadership positions in several public and private sector healthcare organizations. Michael brings medical, psychological prevention, self-care, and executive competencies to his clinical and consulting practice. Let's listen to the interview. Okay. Well, hi Michael. Thanks for joining me today.
Dr. Michael Freeman, M.D: (01:29)
My pleasure. Thanks so much for inviting me out to the podcast.
Dr. Keith Sutton, Psy.D: (01:32)
Yeah. So, I know you and of your work, so we're both in Marin County and you're a psychiatrist here, and we've shared some cases together. You also have wonderfully great holiday cards that you sent out with cartoon jokes and so on that you make, which are wonderful. And, we've talked over the years about your work, and particularly there's an area that you do a lot of work in, which is in working with bipolar disorder and also ADHD and particularly the realm of entrepreneurs and so on. And so I want to hear about your work and what you've been doing lately. But before we even get to that, I'd like to hear a little bit about how you got doing what you're doing, what the evolution of your kind of ideas and, and how you get to be doing this work.
Dr. Michael Freeman, M.D: (02:20)
Well, it's a long journey and it started before I even went to medical school. I was involved in creating large scale healthcare systems for the federal government in the Medicaid program, for example. I got subsequently trained as a psychologist, then as a psychiatrist. And after I finished all of my clinical training, I worked with venture capital firms, starting health insurance companies. So I was the founding Chief Medical Officer of United Behavioral Health, which is now the largest of the single specialty mental health companies out there. After doing that for a while, I got the idea of starting a company myself and I, over the years, have been a founder or a co-founder of maybe five or six businesses. But the one that I ran the longest where I was the CEO for 12 years had hundreds of corporate clients, including small, medium, large, and very large businesses. And I noticed with my mental health training that among the founders of the small businesses, there were just a lot of mental health issues that popped out at the time. It seemed to me that primarily hypomania and bipolar spectrum kinds of traits were pretty easy to recognize among the entrepreneurs. And that observation is what kind of led me in this direction. After we sold that company, I went back to UC San Francisco. I've been on the faculty over there for a long, long time, but I kind of did a deeper dive, rounded up some research colleagues and was involved in studying the mental health of entrepreneurs. I've been doing that continuously for the last six years, and my team has collected some great data sets. We have a lot of publications, and it turned out that the original hypothesis was accurate in part, in other words, there is elevated bipolar spectrum hypomania among entrepreneurs, but that's not the whole story. And as you know, people with bipolar disorder have a significant likelihood of also having ADHD. And people with ADHD also have a likelihood of having a bipolar spectrum condition. We've found a lot of ADHD among the entrepreneurs as well. And we found a lot of people who had both, as well as a broader mix of mental health differences. So that was a reader's digest version of the journey that got me into this. Now as a psychiatrist, I'm doing a lot of things, including starting another company, but I do have an ongoing practice a couple days a week, and all of my clients are entrepreneurs, and I'd say the majority of them have either ADHD or bipolar spectrum issues, or both, though not exclusively, so I've still got my sleeves rolled up and I'm working with people who are dealing with these issues while studying them and trying to create other solutions for them as well.
Dr. Keith Sutton, Psy.D: (05:58)
Yeah. So you're kind of boots on the ground, you know, working with people directly as well as, kind of, the larger view of kind of looking at, you know, the research and understanding better. So, I'm wondering if maybe we could start off with talking about bipolar disorder hypomania. I mean, I think that this is something that I've worked with a couple clients and oftentimes clients have come to me, you know, on medication or so on, that have truly had bipolar. I've also worked with a number of clients with complex PTSD that were diagnosed bipolar, but didn't seem to quite fit the diagnosis. Can you talk a little bit about, kind of, understanding and diagnosing and for a clinician in practice when they're working with a client, kind of the hallmarks of bipolar disorder that, I mean, of course in a clear cut case, significant mania, grandiosity and so on, but how about some of those more nuanced kind of situations? What, what are you looking for when you're diagnosing bipolar?
Dr. Michael Freeman, M.D: (07:09)
So, that's a good question, and just from a pragmatic perspective, let's start with your issue, which is has your patient been improperly diagnosed to begin with? The reality is that most people with bipolar spectrum conditions are not properly diagnosed for quite a while, and they more likely than not get misdiagnosed. In one study of that problem, the average patient had been misdiagnosed as many as eight different times before being properly diagnosed with a bipolar spectrum condition. So, I would say, you wanna have a kind of elevated index of suspicion if your client tells you, or if a referring provider tells you that this person has borderline personality disorder, or that this person has depression, or that this person has ADHD. You mentioned complex PTSD; there are symptoms of PTSD that are also found among people in the bipolar spectrum. So I would say, have a very high index of suspicion. For example, bipolar people are most commonly misdiagnosed as having depression, unipolar depression. That's because, particularly with bipolar two disorder, depression is the most prominent symptom. A person with bipolar two disorder would qualify for that diagnosis if they've only had one manic or hypomanic episode. And then what you mainly see is, you know, it looks like recurring unipolar depression with some differences. So I think the reality is that if a patient is depressed, about one in five of them will actually have bipolar depression. So, it's really important to sort that out because the psychotherapy and medication management is very different for bipolar depression compared with garden variety unipolar depression and its subtypes.
Dr. Keith Sutton, Psy.D: (09:50)
What kind of questions are you asking in the clinical interview as you’re assessing, you know, is this, major depression or is this a bipolar one?
Dr. Michael Freeman, M.D: (10:04)
Or bipolar two, most likely bipolar two.
Dr. Keith Sutton, Psy.D: (10:06)
Sorry, bipolar two. Yes. What kind of questions are you asking to kind of suss that out to separate?
Dr. Michael Freeman, M.D: (10:14)
So one thing is to ask about age of onset, because age of onset of bipolar disorder is typically 17 plus or minus three or four, whereas, age of onset for depression, you know, dysthymia, persistent depressive disorder, or uni recurring unipolar depression, is typically later in life. So early onset, think bipolar. Another thing to ask about is the characteristics of symptom onset. Was it like somebody flipped a switch and there was an abrupt onset? Or was it sort of a gradual worsening of a bad mood that turned into feeling blue that turned into feeling really depressed and evolved and emerged over time? If you find people who have abrupt onset and as including it switches off abruptly, again, think bipolar spectrum. People that have these more gradual onset and gradual remissions, I would think in the context of a major depressive disorder. Another way of sorting it out is to ask about seasonality. Bipolar mood fluctuations are much more seasonal than unipolar mood fluctuations. And they're not only seasonal, but there are danger zones. The danger zones are the two times of year when you have the accelerating rate of change of length of day. So in deep winter and in the middle of summer, daylight is getting longer or shorter by like a minute a day, two minutes a day. But if you go into fall and spring, the length of day is changing by five or six minutes every day, and so you really feel the impact of length of day change in those seasons. So if people start having what they call roughening, if their moods begin to get a little unstable or they develop irritability or insomnia or agitation or depression, or the opposite then to think bipolar. Typically depressive symptoms happen in fall, winter, and hypomania typically happens in spring and summer, you know, spring fever everybody gets, versus the bears that hibernate in the winter. Depression actually has some adaptive advantages from an evolutionary perspective, which is that you don't burn as many calories when you're depressed because you don't wanna get out of bed, and that's good in the winter because they're just in the world of hunter gatherers, there's just not that much food around. So, you know, Eskimos for example, can spend very long periods of time in their igloos during the winter without even coming out in like a meditative trance, which is akin to hibernation, which is where you get when you're, you know, deeply depressed. So seasonality would be another thing to look for to differentiate. The nature of the depression is a little bit different. The people in the bipolar spectrum are more likely to have an agitated kind of depression or they can have mixed state characteristics with some irritability less likely to see that with major depressive disorder. With major depressive disorder it's more likely to affect women than men, that is not necessarily the case with bipolar depression. However, it is also true that bipolar two disorder is associated more with women than with men, but not bipolar one, not cyclothymia, and not bipolar NOS (not otherwise specified). Those are the DSM five categories. So that, that gives you a flavor.
Dr. Keith Sutton, Psy.D: (15:03)
Okay. Yeah. Cause I always look through the periods of time where the person's not getting sleep or not needing sleep. Is that, kind of, a good differential or is that more, you know, bipolar one or more like a hallmark of the mania, not necessarily of the hypomania?
Dr. Michael Freeman, M.D: (15:25)
So, decreased need for sleep associates with hypomania and mania, but not particularly with bipolar depression, which is kind of what you're asking about. Hypersomnia is more common with all kinds of depression.
Dr. Keith Sutton, Psy.D: (15:40)
Yeah. That's often something that I'm looking at a little bit. If, like now, I'm sleeping okay or I'm getting more sleep than usual, then I'm kind of thinking, okay, maybe that's more depression than more of a bipolar.
Dr. Michael Freeman, M.D: (15:53)
No. People with bipolar depression will stay in bed for a couple days at a time, deep depressions.
Dr. Keith Sutton, Psy.D: (16:02)
Yeah. But they'll have times where they're maybe not getting so much sleep in the hypomanic or the manic state?
Dr. Michael Freeman, M.D: (16:08)
If they fluctuate. Yes. But what you typically see, is in bipolar one there is more mood fluctuation. With cyclothymia, there's more mood fluctuation. With bipolar two disorders, you can often see people who kind of alternate between depression and normal. And then we'll rarely get some breakthrough hypomania.
Dr. Keith Sutton, Psy.D: (16:32)
So it’s more that depression, like you're saying, those qualities of depression are really because you might only be seeing depressed or they might not really have those hypomanic states
Dr. Michael Freeman, M.D: (16:41)
Infrequently. Yes. And that's why they're misdiagnosed.
Dr. Keith Sutton, Psy.D: (16:45)
Got it. Got it.
Dr. Michael Freeman, M.D: (16:46)
Yeah. Again, going back on your differential diagnosis, it's important to do a family history. This is one thing I believe that a lot of mental health professionals could spend more time on family mental health history. Bipolar disorder is highly genetically transmitted. So if you know what to look for, you should be able to find other first degree family members, parents, siblings, children, possibly grandparents, second degree cousins, etc, who have bipolar disorder. However, since it's not really all that well understood by a lot of people, you have to ask questions a little bit differently. So if you find people that are highly accomplished, people who have achievements in the arts or in sciences, people who were big business builders, people who traveled a lot, were multilingual, people who made a million and lost a million, and people who committed suicide. Suicidality is elevated among bipolar in bipolar one disorder in particular. So those are clues that your patient also might be in the bipolar spectrum.
Dr. Keith Sutton, Psy.D: (18:26)
And as you're talking about these different kinds of potential things in the history, because if you ask “Is there somebody with bipolar?” they might say no. But then, you're asking are there people that made a bunch or lost a bunch or these kinds of aspects. Is there any knowledge about what percentage of people with bipolar disorder are these kinds of, not higher functioning, but entrepreneurs doing a lot of all this learning or these functional pieces, versus somebody that might be really struggling?
Dr. Michael Freeman, M.D: (19:01)
Yes. That question has been asked from a couple of different perspectives. It's not an easy question to ask because you can be a high achiever and highly impaired at the same time. And so which category do you fall in? On average though, people in the bipolar spectrum tend to be highly challenged, and bipolar disorder is typically associated with a great deal of disability. Also, keep in mind that most people with bipolar disorder have co-occurring mental health conditions. So if you are someone in the bipolar spectrum, you have an elevated likelihood of having anxiety, or having ADHD, or having substance use issues. I think those would be the most common, but not exclusively that. And then there's disabilities that are associated with those other conditions as well. But the research has shown two things. One, that there is a subset of like flat out bipolar one and bipolar two people who are really high achievers, and that the first degree relatives of people with bipolar disorder, in other words, the parents, siblings, and children, often have the positive traits of energy, creativity, sociability, that go with bipolar disorder that make you more successful as an entrepreneur, as an artist, as an academic without having some of the disabilities. And so that's sometimes referred to as soft bipolar disorder.
Dr. Keith Sutton, Psy.D: (21:14)
Okay. So they learn this from their parents? Or there's some kind of genetic residuals or so on?
Dr. Michael Freeman, M.D: (21:21)
Genetically transmitted.
Dr. Keith Sutton, Psy.D: (21:23)
Oh, got it. Okay.
Dr. Michael Freeman, M.D: (21:25)
Yes. So we found in one of our studies that close to 40% of entrepreneurs have one or more diagnosable mental health conditions, but of the 60% that don't, more than half of them had first degree family members with significant mental health issues. So, some people, from an evolutionary perspective, argue that the reason evolution created bipolar disorder is to get the first degree relatives. That the severely impaired individuals with bipolar one and bipolar two disorders who don't function very well, are kind of like evolutionary roadkill, similar to sickle cell anemia. So with sickle cell anemia, if you are a sub-Saharan African person and you inherit sickle trait from both parents, you will have sickle cell disease and you're gonna die young and it's not pretty. But if you only inherit the sickle trait from one parent, then you have a lot of protection against malaria so it's actually good for the tribe. So, what evolution figured out how to do is to protect populations, not individuals with bipolar disorder. These first degree relatives that are the high achievers with all of the energy and creativity and motivation, they're good for the population. And again, they're the leaders, they're the innovators, they're the hunters, they're the problem solvers. They're the ones that figure out how to adapt to changing conditions. And so evolution, once again, is protecting the population at the expense of some individuals. Having said that, the treatment of bipolar disorder has come a long way, and these days people with bipolar one, bipolar two disorder, cyclothymia, and bipolar NOS (not otherwise specified), can have great clinical outcomes and can lead really amazing lives. So we kind of outsmarted evolution with science. The treatments are just fabulous and the outcomes can be really, really good.
Dr. Keith Sutton, Psy.D: (24:23)
So I know there's some medication treatments, but what kind of work are you doing in therapy to work with clients with bipolar?
Dr. Michael Freeman, M.D: (24:35)
So first of all, I wanna emphasize to anybody listening who is not a psychiatrist, you must work with a psychiatrist. Whatever you do therapeutically will not work without medication. Having said that, that's not entirely true actually. There are some significant gains that can be made with therapy alone. And bipolar people can go off medication for periods of time without consequences. So it's not completely black and white. But I would say more than almost any other condition besides schizophrenia, the medication management is really, really important. And you're doing a disservice to your patient by not taking a collaborative care approach around this condition.
Dr. Keith Sutton, Psy.D: (25:34)
Yeah. Set the biological aspect,
Dr. Michael Freeman, M.D: (25:37)
It's highly biological. It's physiologically comparable to epilepsy. And many of the medications that treat bipolar disorder also treat epilepsy because the neurophysiology is so similar. So that's what you're dealing with. So having said that, the therapy that you talked about, the good news for therapists is that there is a very strong evidence base for psychotherapy with people who have bipolar. IPT CBT SRT and FFT and PE. So let's go through that. IPT: interpersonal therapy, CBT: cognitive Behavioral Therapy, FFT: family Focused Therapy, and PE: psychoeducation.
Dr. Keith Sutton, Psy.D: (26:55)
And I think you said SRT.
Dr. Michael Freeman, M.D: (26:58)
Social Rhythm Therapy.
Dr. Keith Sutton, Psy.D: (27:02)
Okay.
Dr. Michael Freeman, M.D: (27:04)
I would advise starting with psychoeducation. Just start with education, because knowledge is power and the more you educate people, and the more you help them become interested in their own condition, the more they can learn self-care skills. So I explain that bipolar disorder is something like a mental health version of diabetes, chronic illness genetically transmitted. There are a lot of things you can do to prevent, mitigate or reverse the symptoms. Just like with diabetes, it's a lot of its behavioral and lifestyle, but not exclusively so. Educate, educate, educate, read books. One recommendation is the Bipolar Disorder Survival Guide by a psychologist named David Miklowitz. There are others, but that's a very good one to start with. Then comes skill building. And each of those different therapies that I mentioned are evidence-based and they help people develop different skills. So, interpersonal therapy, which was developed for depression, is also effective for bipolar disorder. And what that focuses on is helping your patient identify the key relationships that they're in (parent, spouse, work relationships), and identify the ways in which bipolar symptoms are interfering with their ability to execute effectively in those role relationships. And then develop relationship skills that are founded upon managing the intrusion of the bipolar symptoms, practicing relationship skills, and focusing on one relationship at a time because the skills tend to generalize to other relationships. SRT, social rhythms therapy. I mentioned that bipolar disorder is seasonal. There's a seasonal, but there's also a diurnal component, meaning day night. It's common that people in the bipolar spectrum experience day night reversal where they’re night owls and then they sleep in and they also are disoriented to time. They lack punctuality. They can become absorbed in what they're doing or get tangential and distracted. And so they get disconnected from time, and their sleep wake cycles get or become disturbed. And so what social rhythm therapy does primarily is to help people establish time anchors in their days so that they can begin to create routine and structure, including sleep hygiene and sleep management, as well as linking time anchors that link you with the flow of the day. You always walk the dog in the morning, in the afternoon, you always have lunch at noon. You clear emails at the end of the day. You do your heavy lifting work products at the beginning of the day. So you have a few time anchors. Not too many, but you stick with them religiously. And what that does is it actually forces your circadian rhythm back into a pattern that is where you're more likely to be euthymic. In other words, where you're more likely to not get depressed and not get manic. If you haven't heard of that one before, look it up. Social rhythm therapy. It's very, very interesting.
Dr. Keith Sutton, Psy.D: (31:40)
Well, that's a lot of what we do too with the adults with ADHD, right. Creating structure and these anchors or these markers throughout because of the time blindness, and the distractibility, and the hyperfocus.
Dr. Michael Freeman, M.D: (31:56)
It's very similar to that with a little bit more emphasis on sleep regularity.
Dr. Keith Sutton, Psy.D: (32:01)
Good.
Dr. Michael Freeman, M.D: (32:01)
And with respect to sleep regularity, you can incorporate phototherapy mood lights, as length of day fluctuates, because mood is indirectly regulated by the pineal gland. The pineal gland has projections to the limbic system, and there are motion processing centers in the limbic system, which get dysregulated in bipolar disorder. And so by managing length of day, you can indirectly stabilize those emotional processing centers in the limbic system. And the way to do that is with these phototherapy lamps that have like 10,000 luxe broad spectrum wavelengths that you can deploy during the time of year when days become shorter. And if you build that into your social rhythm therapy, it's also beneficial. It's helpful. Even just as a single treatment. Measurable results, particularly for people that have a seasonal pattern.
Dr. Michael Freeman, M.D: (33:29)
So then cognitive behavioral therapy is similar to what you already know, only it's tilted a little bit for depression. So the way I explain it to patients, is that every mental health condition is associated with a storyline, a soundtrack, if you will, in depression it's helpless, hopeless, worthless, guilt. You just monitor your thoughts and that's gonna be helpless, hopeless, worthless, guilt, over and over again. In anxiety, it's what if, catastrophic thinking, risk, risk, risk, danger, danger, danger, and rumination on problems that never get solved. That's gonna be the narrative for anxiety. And then with bipolar disorder, the depression narrative is about the same. The hypomania narrative begins to be about, yes, I can and wouldn't it be great? And, if I take a risk, nothing bad's gonna happen to me. And, my ideas are definitely worth executing on and they're better than anybody else's, and I have plenty of time to sleep when I'm dead. And, what's the good of money if you can't spend it? And so, as with any other CBT intervention, it's a matter of identifying trigger thoughts, and then reevaluating them and replacing them with more accurate, realistic kinds of thoughts. And then also beginning to recognize what are early warning signs of an impending episode. Because in bipolar disorder, people tend to have prodromes. In other words, prodrome is an early warning sign that indicates you're about to have an episode and if you intervene at the prodrome stage, you can head it off, you can prevent the episode from actually happening. So that's CBT, FFT is family focused therapy.
Dr. Keith Sutton, Psy.D: (36:00)
Sorry. Can you mention some of the pro prodrome symptoms that you're seeing that are markers that an episode's coming?
Dr. Michael Freeman, M.D: (36:08)
Elevated energy, higher levels of motivation, greater ambition, less need for sleep, all of a sudden you think about having more sex with more people, increased use of drugs and alcohol, verbosity. Different people have different prodromes. And if you're working with somebody who's bipolar in the long run, a good thing to do, this is another one of those cognitive behavioral techniques on the behavioral side, is to create an advanced directive. What that consists of is like a three by five card only. Now there's digital versions, but on one side is “I know I'm getting manic when I spend more money, I stay up later at night, I start doing new projects, even though I didn't finish my old projects, I am more outgoing, and I'm the life of the party,” whatever it is for the individual. You know, your five early warning signs. And then on the back of the card, “when I am entering a bipolar prodrome, here's what I'm gonna do…1, 2, 3, 4, 5, check in with my therapist, talk to my psychiatrist about medication management get to bed on time, reduce the amount of stimulation in my life”. So those are the behavioral strategies, and there are many behavioral strategies for managing and proactively preventing the onset of mood swings up or down.
Dr. Keith Sutton, Psy.D: (38:12)
Okay. Great. Tell me about this family focused therapy.
Dr. Michael Freeman, M.D: (38:17)
So family focused therapy is a way of helping the individual with bipolar disorder by helping the family because bipolar moods and communication is very impactful on loved ones. And so, what is typical protocol is where you have 10 or 12 meetings with the individual and their family at the same time. And it's primarily psychoeducational and problem solving oriented. But what you want is for the family to fully understand that your family member is not obnoxious, and is not selfish, and is not a jerk, but that what you're actually seeing are symptoms of untreated bipolar disorder, and then learn skills like how to communicate without emotional escalations. And how to appropriately talk with each other about behavior that might be symptomatic, and about how to function as a family with someone who's bipolar, and how to modulate the way you interact with the bipolar person. There's a good book that clinicians can recommend to their patients and their family members called “Loving Someone with Bipolar Disorder” and it explains how to be a family member of somebody who is bipolar.
Dr. Keith Sutton, Psy.D: (40:10)
Yeah. I imagine too, you know, sometimes I'll utilize the system, roommate, partner, family member, to also be kind of a measure of the prodrome and noticing as things are coming up and being able to reflect that back to the person. Especially like you're saying with some of the manic symptoms that the person might not think are necessarily bad, they've got more energy, they're super motivated, or so on. So they might not necessarily be seeing it as a negative thing, but sometimes everybody around them can start to notice it and know where that's going, and maybe reflect that back to bring up the consciousness.
Dr. Michael Freeman, M.D: (40:44)
In a non-judgment way,
Dr. Keith Sutton, Psy.D: (40:47)
Yeah, definitely. A supportive way.
Dr. Michael Freeman, M.D: (40:49)
In a supportive way, and in a way which is also respectful of the many advantages and strengths that are associated, as well. And then one more thing I'd say to therapists is, do not make the mistake of getting sucked into insight oriented and regressive psychotherapies. That makes it worse. It's not one of those kinds of conditions. You're not dealing with people that have self-defeating behavior patterns that are a result of their family of origin that you can kind of work out through more traditional therapy. This is something else. Again, it's like diabetes or sickle cell anemia or hypertension where it's more about disease management than anything else. So you can make it worse, and therapists often do make it worse. The last thing I would say is, again, your bipolar spectrum patient is likely to have one or more co-occurring conditions, and they all have to be treated concurrently or else they won't get better. And they can create a negative feedback loop where someone with ADHD has a time management problem and misses an important meeting, then they get agitated because of the consequences of missing the meeting, and then the agitation triggers mood swings, and then you self-medicate the mood swings with drugs and alcohol, and the whole thing implodes at the same time. So you have to treat everything at once.
Dr. Keith Sutton, Psy.D: (42:35)
Actually with ADHD in bipolar, oftentimes for ADHD, the treatment of choice is a stimulant that, from my understanding, for somebody with bipolar can kind of push them into a hypomanic or a manic state. Is that correct? How do you work with that?
Dr. Michael Freeman, M.D: (42:51)
There are shades of gray around that, but Adderall and medications related to Adderall, dexedrine, Vyvanse, and so on, in the absence of a mood stabilizer have the potential to trigger mania. The same is true for methylphenidate, but to a much lesser extent. And so if somebody has ADHD and bipolar disorder, I typically first prescribe the mood stabilizers and get the mood completely stabilized, and then start with methylphenidate, or guanfacine…
Dr. Keith Sutton, Psy.D: (43:36)
Ritalin, concert of the Methylphenidates.
Dr. Michael Freeman, M.D: (43:38)
Yeah. Though, if someone takes Adderall, or one of the related drugs while mood stabilizers are in place, they probably won't get manic. It's when they're not in the context of the mood stabilizer.
Dr. Keith Sutton, Psy.D: (43:59)
Interesting.
Dr. Michael Freeman, M.D: (44:00)
And low dose Adderall actually has antidepressant effects and it's sometimes used to augment depression treatment as well. So the use of the stimulants sort of requires some nuance to do it properly.
Dr. Keith Sutton, Psy.D: (44:22)
…and expertise around that. Now, tell me about the work with the entrepreneurs and your research and what really stands out?
Dr. Michael Freeman, M.D: (44:32)
What stands out? So there is a subset of people in the bipolar spectrum and their first degree relatives who are very high achievers. They're gifted, they have elevated intellect, they are charismatic, they have high levels of motivation, they're ambitious, they're visionary, they’re creative, and many of them are high achievers in the creative and performing arts. Many of them are high achievers in academia and the scientific professions, and many of them we have discovered are high achievers in entrepreneurship as well. I don't like the pathologizing of mental health conditions and mental health differences. Pathologizing these things is very good for pharmaceutical companies, doctors, and hospitals, because it creates more customers, but it's not so good for the individual because they begin to think in a disease model, which is not inaccurate, but it's only part of the story.The bigger picture is that with bipolar disorder, it's an endowment that is associated with a lot of risks and vulnerabilities. And if you learn how to manage the risk and the vulnerabilities, you can take advantage of the strengths and the superpowers and the endowment. And that's what I do with entrepreneurs.
Dr. Keith Sutton, Psy.D: (46:11)
So rather than a defective model, more of a difference model. There's a difference that we need to address. And that by addressing and compensating for some of the downsides of it, we can also benefit from the upsides of it.
Dr. Michael Freeman, M.D: (46:28)
And strengthen that, and learn how to play your strong cards, and learn how to avoid situations which are likely to not work out for you because of the vulnerabilities.
Dr. Keith Sutton, Psy.D: (46:39)
Any particular things that you do to strengthen those or to increase those strengths beyond what you've already mentioned?
Dr. Michael Freeman, M.D: (46:49)
Do what you do best? What the entrepreneurs in the bipolar spectrum tend to do best often is product development and business development. Then leadership plus minus. They can be really effective, charismatic leaders, or they can drive people away with mixed episodes that lead to a lot of irritability and agitation. So basically I just assess people, and I first of all get all of the mental health conditions properly treated, then find out what are their strengths and superpowers and identify ways in which they can deploy those more frequently in their life as well as in their business. And then in what ways do they become their own worst enemies and then create some guardrails around that. It's a variation on the theme of strategies that I already talked about, only translated into the world of entrepreneurship and business.
Dr. Keith Sutton, Psy.D: (48:19)
You know, I'm wondering because we were talking a bit on the phone when we were chatting before about this, I was seeing an article on hypothymic temperament and I don't know how much you knew him, a colleague in your building and a colleague of mine recently unfortunately took his life and there was some potential bipolar kind of aspects going on in there. And the situations of Anthony Bourdain or Kate Spade, these kind of situations where they maybe were a little hypomanic throughout their life or more almost like soft bipolar, but then later kind of midlife all of a sudden having a big switch kind of flipping. Is that kind of an understanding? And I've known of some other kinds of situations too where somebody in their forties or fifties or sometimes sixties all of a sudden get the diagnosis of bipolar, which I know it's more likely that this onset is at 17, 18, 19 years old. Do you know much about that piece?
Dr. Michael Freeman, M.D: (49:22)
That is true. One of the assessment instruments that we use in our research is called the Hypomanic Personality Scale, and it measures the hyperthymic temperament that you just talked about, and people who score high on that assessment instrument are very likely to have a full-blown manic episode within the next five years. And so it's possible that this hyperthymic temperament that you described, what you're seeing there are the first degree relatives of the bipolar proband. But it's also possible that the hypothalamic temperament is really just a very long, very slow moving prodrome that eventually becomes bipolar disorder. Sometimes as a result of a trigger, like a major life event, sometimes as a result of drug use, like cannabis, for example, can trigger onset of bipolar disorder, and Adderall we just described. And sometimes as a result of taking medications, like antidepressants. If you give somebody who's bipolar an antidepressant, they can have a full-blown manic episode. And prednisone is another one of those, so yes it's a real thing. It's definitely a real thing.
Dr. Keith Sutton, Psy.D: (51:13)
And can you speak to just a little bit on suicide and bipolar, because I know that at least in this case, the family said that they felt like it just became a whole different person. There was the documentary, “The Bridge”, about the Golden Gate Bridge and people taking their life and one person that lived was bipolar and he talked about just, again, in this different state of mind ending up jumping off the bridge and living.
Dr. Michael Freeman, M.D: (51:44)
Well, suicide is elevated among people in the bipolar spectrum. Without treatment, people with bipolar one disorder can have up to 10% incidents of completed suicide. So, it's a real risk, it's a real concern and it typically happens during a period of impulsivity. And it can be triggered. Like for example, you mentioned the Golden Gate Bridge. What if you look at those suicides, people always jump off the side of the bridge facing the city, and they typically jump at twilight or at night. And apparently at least one theory is that the twinkling lights trigger a sort of an epilepsy. Remember I said bipolar is related to epilepsy. It has an epileptiform disinhibition of impulsivity that's associated with self-destructive behavior.
Dr. Keith Sutton, Psy.D: (52:57)
Interesting. Wow. I think it's all the more important like you're saying about getting that correct diagnosis so that the person can receive the proper treatment, particularly the medication treatment to stabilize that. And then be able to do the therapy to shore up the resources to give tools to help when going into the episodes, and kind of shore up the larger system to support them. Well this is great. And I love how you're also, again, highlighting that there's a lot of folks that can channel this into great success in entrepreneurship or, achievement in the arts or science or so on. I think it's just such a really interesting complex mental health difference that is not well understood, but I think a lot of these interventions can help people be very successful. So I thank you so much for your time today. This is really great. I really appreciate it.
Dr. Michael Freeman, M.D: (53:57)
My pleasure. Thanks for highlighting this issue. It's a really important one. And bipolar disorder is an equal opportunity condition. It occurs about the same incidents in every culture around the world. So it's very important and it's agnostic to socioeconomic status. That's not entirely true. Bipolar disorder is actually considered to be a disease of the rich. Because in these families, there are the high achievers that make a lot of money, but on the other hand, the people who are truly bipolar can be quite adversely affected socioeconomically as well. So I think that spending a little time on this condition is a great thing and I appreciate that you're doing it.
Dr. Keith Sutton, Psy.D: (54:51)
Great. Well, thank you so much for your time. I really appreciate it. Take care.
Dr. Michael Freeman, M.D: (54:55)
My pleasure, Keith. You too. Good luck with the podcast series. Thanks.
Dr. Keith Sutton, Psy.D: (54:58)
Bye-bye.
Dr. Michael Freeman, M.D: (54:59)
Bye now.
Dr. Sutton: (55:06)
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