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As calls to the Suicide Prevention Lifeline surge, under-resourced centers struggle to keep up
On the day of Anthony Bourdain's death by suicide, calls to Community Crisis Services, Inc. (CCSI), a crisis center that answers calls to the National Suicide Prevention Lifeline, went up 500 percent. Across the country, counselors scrambled to field the spike in calls. Tim Jansen, the center's executive director, brought in extra staff and answered calls himself. It wasn't enough.
In the half hour it took Jansen to drive home, he heard the Lifeline number announced seven times on the radio. He checked his phone, watching as calls at the center queued up, knowing that after a long day, he "wasn't in the mental place to be able to dial in and help them."
On July 23, the House passed the National Suicide Hotline Improvement Act, which seeks to evaluate the effectiveness of the Lifeline and the feasibility of implementing a 3-digit dialing code like 911, a number that could be easier to remember than the current 10-digit number. But some local crisis center directors that field Lifeline calls and advocates say this could place more pressure on an overwhelmed and underfunded network.
Now, the bill sits on President Donald Trump's desk, awaiting action.
Already, calls to the Lifeline are on the rise. Over the next four years, the Lifeline expects 12 million calls, the same number of calls it previously received for the 12-year period between 2005 and 2017.
Community Crisis Services, Inc. in Hyattsville, Maryland, is a backup center for the National Suicide Prevention Lifeline. Photo by Corinne Segal
Local crisis centers on the front lines
CCSI is housed in an unassuming, one-story orange brick and glass building. Tucked behind slightly overgrown, dark green shrubbery at the end of a peaceful residential block in Hyattsville, Maryland, CCSI acts as one of more than 150 local crisis centers across the country that answers calls from the Lifeline.
The building's quiet exterior belies the activity inside. In the main "bullpen," as Jansen calls it, overlapping conversations from counselors fill the room as they type rapidly, and with a quiet urgency, into call reports on their dual-monitor desktop computers. Occasionally, a single voice rises above the others, punctuating the regulated hum and rhythm of the room.
"You know, somebody who's never been in that position, somebody who's never struggled with their mental health might not be able to understand when you say 'I'm frustrated and I know I'm taking it out on you, but it's not your fault,'" a counselor says.
Counselors answer calls at Community Crisis Services, Inc. in Hyattsville, Maryland. Photo by Vivekae Kim
Colorful cork boards refer to homeless shelters and bear prominently displayed phone numbers for social services. A plastic Mickey Mouse phone and an early 20th century rotary wall phone decorate a window that looks out onto the side of the tidy, gray stone house next to the center.
A counselor sits at her desk, recommending to a caller ways to cope in moments of crisis: snapping a rubber band, drawing on your legs, listening to music. She shares her own struggles with anxiety. "If I'm out in a public space, and I just get overwhelmed, I just kind of find somewhere I can sit down and write."
Sometimes ripping up that writing and throwing it away can serve as "another release of 'this is me throwing away my anxieties' or those inspirational things you hear all the time," she tells the caller with a chuckle.
Another counselor starting her shift places her Frappuccino on her desk, puts on a bright pink headset, and begins talking to a caller. "It's okay to struggle, you're human," she says.
Counselors at CCSI normally answer around 40-50 calls per shift. Most shifts are eight hours.
The camaraderie of the room is palpable. Jansen, who has trained people in crisis intervention for 20 years, circles his staff at work, chatting with one counselor about her upcoming trip to Las Vegas and listening to calls. "It's so awesome to hear my training words come out of people's mouths," he says.
Counselors at Community Crisis Services, Inc. take calls. Photo by Corinne Segal
Current funding isn't intended to support Lifeline calls
Some centers, like CCSI, are "national backup centers," which are meant to handle their local volume of calls along with overflow calls from other centers across the country.
The Lifeline receives around $5.3 million a year in an infrastructure grant from the Substance Abuse and Mental Health Services Association (SAMHSA). From that, crisis centers receive an annual stipend of $1,500, and an extra $1,000 if they collect data on veteran calls to their center. Backup centers receive $17,500 quarterly plus $10 for every call over 3,000 they answer through the backup routing system.
According to James Wright, the Lifeline project officer for SAMHSA, this amount is mainly meant to offset the costs of accreditation, a process required for operation within the Lifeline network. It assesses if the center is achieving base level practices and standards in their services.
The stipend is "more of a gesture," said Wright. It's not intended to serve as direct support for centers' work. "I've never heard a single crisis center report back to me and say that $1,500 a month supported the calls being answered," said Wright.
Suicide prevention information appears on the fridge at Community Crisis Services, Inc. Photo by Vivekae Kim
To accommodate the rising call volume, Dr. Draper, the director of the Lifeline, says local crisis centers need more resources–and that a lack of resources contributes to centers leaving the network or shutting down. From 2008-2012, nine centers dropped out of the network and from 2013-2017, 23 centers dropped out. Just this year, three centers shut down.
Remaining centers do what they can to stay functioning. This often means taking on extra contracts, like running local crisis lines, to support their suicide prevention work.
Crisis Call Center, a Lifeline backup center in Nevada, operates a sexual assault support service program and a substance abuse hotline. They also provide child protective service reports and take elder protective service reports after hours. Rachelle Pellissier, its executive director, says they have to "cobble together" these different funding streams to offset the costs of the suicide prevention calls they take.
"We really need about $1.1 million to run this organization," said Pellissier.
Centers like Provident in Missouri rely on their local United Way. The money they receive from the Lifeline, even as a backup center with more support, "pays for maybe two salaries of my 15 person team," said Jane Smith, the director of life crisis services for Provident. "We're a money-losing entity at Provident."
If backup centers are unable to take a call, that call is routed from one backup center to the next, until a counselor can talk. "All the calls can be answered. The only question is, how long do people wait?" Draper said.
For January to March of 2018, the average wait time for a caller after the Lifeline's automated greeting was 36 seconds at a local center and 88 seconds at a backup center. "It's simply a supply and demand challenge," Draper said.
Office supplies sit in an empty room, which will soon become additional space for counselors, at Community Crisis Services, Inc. in Hyattsville, Maryland. Photo by Vivekae Kim
Distance, low pay, and pressure on counselors
Answering calls from all across the nation at backup centers can create barriers to getting help. With no local centers serving Minnesota, for example, all callers in the state are routed to an out-of-state backup center. It's a solution that both increases the call volume pressure on backup centers and makes it difficult for centers to connect callers to resources in their area.
At CCSI, a counselor asks, "Do you have any community centers in your area or anything like that?"
In an emergency, it's often more difficult to initiate an "active rescue" for someone who may be at imminent risk of attempted suicide because of the lack of an established relationship between the center and the out-of-state law enforcement.
Sometimes, counselors get this response from police: "'Well, if they're going to do it they're going to need to do it. We'll hear about it on the news,'" said Jansen. He says those responses typically occur a couple of times a week.
The stress of the job and the pay can drive high turnover rates for counselors in some centers. Even taking a day off can make answering calls more difficult for other staff. Counselors often "feel concerned for their fellow staff members" when they're out of the office because "they know the impact that them not being there is going to cause," said Victoria Graham, chief program officer at Action in Community Through Service in Dumfries, Virginia.
Gene Dobrzynski, the assistant call center director at CCC, sees a direct link between lack of funding and staff turnover. He says with more funding, the center could hire more staff and counselors' mentality of "I gotta be at my desk because there's going to be another call coming in" could be eased. "They could get a little bit of relief and be able to walk away," he said.
Low pay for counselors is also a function of funding woes. "Let's be serious, we're paying frontline staff $11-12 an hour to do this crisis intervention, this life-and-death work," said Pellissier.
In Arizona, adjusting to increased calls
Not all Lifeline centers feel the same strain: Crisis Response Network in Arizona, for example, receives Medicaid funding and other social service funding from the state.
Like other centers, they've also seen an increase in calls. In June of 2017, Crisis Response Network and La Frontera Empact, another Arizona-based crisis center, fielded around 2,800 Lifeline calls. This past June, it was more than 4,400 calls. Unlike many other centers, they were able to increase their staffing to adjust to the increase in calls. At the busiest part of its day, Crisis Response Network might have 30 people on the phones.
Crisis Response Network also has "compassion rooms" where staff can go "to decompress after a tough call," said Alex Zavala, its chief experience officer. Ocean noises play in the background and staff are encouraged to take a break or meditate.
The difference between Crisis Response Network and Crisis Call Center is stark. At Crisis Call Center, they can't afford to replace the constantly-used chairs in their office when they wear down or clean their bathrooms as much as they'd like.
The numbers reveal Crisis Response Network's success. Based on numbers collected from June 2017 to June 2018, less than 1 percent of callers hang up or lose their call before a counselor answers them. The center attributes this to its "consistent and stable" funding that allows for effective staffing with changing call volume, said Sarah Schol, the senior director of contact center operations.
An award sits on a display case at Community Crisis Services, Inc. in Hyattsville, Maryland. Photo by Vivekae Kim
Seeking to solve unknowns in suicide prevention
The circumstances of each call center are wide-ranging, and so are reactions to the National Suicide Hotline Improvement Act.
The leadership of several centers told the NewsHour Weekend that a 3-digit number for the Lifeline would probably allow people to more easily access the help that they need. But the accessibility is a double-edged sword for centers like Crisis Call Center–they want more callers to have access to the Lifeline, but "do not have enough capacity to take the increase in calls," said Pellissier.
Draper says "it's a fair presumption that [a 3-digit number] would increase calls, we just don't know by how much." But not everyone agrees that a 3-digit number would mean a greater volume of calls. Graham says that she couldn't predict that, while Crisis Response Network believes an increase in call volume is possible, it doesn't see a change to a 3-digit number impacting their day-to-day operations.
The bill's lead House sponsor, Rep. Chris Stewart (R-UT), told the NewsHour Weekend that the legislation seeks to "increase awareness of resources and save lives," and co-sponsor Rep. Eddie Bernice Johnson (D-TX) added that "ease" in access is critical. Sen. Joe Donnelly (D-IN), who co-sponsored the bill in the Senate, believes the legislation will examine if there's a "simpler way" to "help in moments of crisis," according to his office. Sen. Orrin Hatch (R-UT) did not respond to request for comment via email.
John Madigan, the Senior Vice President of Public Policy for the American Foundation for Suicide Prevention, said he hopes the bill's study will answer "the million dollar question" of the current suicide prevention network's reach and "holes" in the system.
Tim Jansen sits at his desk at Community Crisis Services, Inc. in Hyattsville, Maryland. Photo by Vivekae Kim
Meanwhile, local crisis centers will continue to draw people who feel called to act and those who need to call.
Jansen entered the world of suicide prevention when he was 25 years old, after coming out as gay. He felt "fortunate" not to "lose people in [his] life."
"I started thinking, 'Gosh what happens when folks don't have somebody?'" he said. Then, he saw an ad for crisis counselors. A few weeks later, he was a volunteer. Now, he's spent 13 years as executive director at CCSI, which also takes backup calls for the Trevor Project, an organization that helps LGBTQ people in crisis.
Sometimes, on those calls, Jansen tells callers what it was like for him to come out–the fear he felt and the unexpected acceptance he found.
"I think when somebody needs to hear that you can actually come to the other side of it, hearing that somebody has done that can be powerful," he said.
Trauma is the experience of severe psychological distress following any terrible or life-threatening event. Sufferers may develop emotional disturbances such as extreme anxiety, anger, sadness, survivor's guilt, or PTSD. They may experience ongoing problems with sleep or physical pain, encounter turbulence in their personal and professional relationships, and feel a diminished sense of self-worth due to the overwhelming amount of stress.
Although the instigating event may overpower coping resources available at the time, it is nevertheless possible to develop healthy ways of coping with the experience and diminishing its effects. Research on trauma identifies several healthy ways of coping, such as avoiding alcohol and drugs, seeing loved ones regularly, exercising, sleeping, and paying attention to self-care.
How can we make sense of relentless senselessness?
Posted Aug 16, 2019
You are interested, I know, in the prevention of war, not in our theories, and I keep this fact in mind. Yet I would like to dwell a little longer on this destructive instinct which is seldom given the attention that its importance warrants. With the least of speculative efforts we are led to conclude that this instinct functions in every living being, striving to work its ruin and reduce life to its primal state of inert matter. Indeed, it might well be called the "death instinct"; whereas the erotic instincts vouch for the struggle to live on. —Sigmund Freud, in response to Albert Einstein's question "Is there any way of delivering mankind from the menace of war?"
Trauma is a complex issue. We know it all too well in its basic simplicity, an evolutionary fixture of organic life amplified by consciousness and culture. In other ways, we know nothing about trauma. It is eternally surprising even as it is utterly predictable. Trauma is heartbreaking.
Given how the world is today, the persistence of trauma in humanity's operating system is a more pressing issue than ever. If we don't deal with trauma, what's happening will keep happening, until it comes to its own conclusion.
1. Trauma is hard to pin down. Working with difficult experiences sometimes means going over them again and again in different ways, until something new emerges, as much as it also means taking breaks from that, perhaps for long periods of time. Sometimes things suddenly change for the better, either unexpectedly or as the result of choices. The word "trauma" doesn't suffice on its own, because it means so many different things to different people under various circumstances, but it does mean something we can all recognize.
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People don't agree on trauma. It has a subjective component. One person's trauma may be no biggie to another person, leading to rupture. We tend to compare our traumatic experiences with one another's. We may even compete.
We can find commonality and community in trauma, and we can find division and discord. Trauma often disrupts our sense of body and reality.
[You know] that fear and the drop in your stomach? My diaphragm seizes up. Then I have a hard time breathing, and my whole body goes into a spasm. And I begin to cry. That's what it feels like for trauma victims every day, and it's... miserable... I always say that trauma has a brain. And it works its way into everything that you do. —Lady Gaga
2. Trauma changes storytelling. We live entirely within a world of timeless frenzy, flashes of imagery going by without a coherent framework. Trauma keeps us from telling our stories clearly to ourselves—no envied, coherent narrative. Different contexts get mixed up. Present seems like past, people seem like other people. It feels like it is happening over and over. Freud saw this as a compulsion to repeat, yet what possibly unconsciousmotivation could make one wish to be re-traumatized? Is it more like a broken circuit? Or is that too reductive?
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3. Trauma distorts emotional reality, making feelings and memories very daunting. Trauma makes it hard to deal with ordinary emotions. We don't have the brain circuitry built up to handle the intense affect and unprocessed meaning of trauma. Learning from experience means we have to endure whatever feelings go along with the significance. We want wisdom, but there is no justification for suffering.
4. Trauma is common. Trauma happens to most everyone. With unresolved trauma, new experiences can seem dangerous, more than they are, and we can shy away from them or dive in blindly from time to time. This means we are flying on autopilot, rather than keeping our wits about us, while feeling attuned to our bodies and emotions.
Trauma is a potent contagion. We fear what we cannot understand, and we cannot understand what we can't imagine happening to us or people close to us. Digital reality spreads trauma. Where is the vaccination?
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5. We are beginning to better understand how the brain responds to adversity. Trauma shifts brain network activity. Resting-state or default mode networks re-tune so that the brain at rest drifts toward unpleasantries. The negative cognitive bias we inherit, making threat detection a primary task, is amplified by unresolved trauma. The salience networks of the brain which alter what we look for inside and outside are prejudiced and compromised. Trauma draws processing power away from working memory, making it harder for us to think clearly, to juggle information, and contributes to difficulty soothing.
Trauma is like not knowing how to balance while riding a bicycle. The brain keeps falling over to one side or the other, activation or deactivation. Dynamic balance among parts is lost, leading to parts not being in communication. Self-states are separated by dissociation, by an absence of connection, while others are over-connected, stuck together. Executive control networks are off-kilter. Stress biology makes big hubs in the executive control network less effective.
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6. Trauma can masquerade as personality. Borderline personality disorder, which shares some key features with complex trauma, is more frequent with complex trauma and more severe with more severe trauma. Identification with trauma can be protective, but also make it hard to let go and move forward. Trauma can mimic narcissism, dependency, schizoid states, and so on, wearing many guises. Identification with trauma can also yield great purpose, in the presence of the right factors.
When people fear losing identity, change is harder. Not because we actually would lose ourselves, but because that is what we may fear... itself a symptom of trauma.
7. Trauma doesn't necessarily last forever, but it can feel that way. Doing the work is important, being active. Self-compassion, soothing and rest are equally necessary, even though they are often avoided, may seem wasteful or vulnerable. Learning to breathe, to sooth, to de-escalate, to go from red alert to orange, and so on. Being able to surrender in some ways, while not giving up. Trauma can have a sense of being infinite, immortal even, by virtue of being timeless. Illusory and so real. People tend to be resilient, for better for worse.
8. Wait for it. Keats's concept of "Negative Capability" is a powerful if ineluctable tool. As Keats wrote, arguing against reductive rationality:
"It struck me what quality went to form a Man of Achievement, especially in Literature, and which Shakespeare possessed so enormously—I mean Negative Capability, that is, when a man is capable of being in uncertainties, mysteries, doubts, without any irritable reaching after fact and reason."
Except when trauma interferes with development, the brain's plasticity, ability to heal itself, tendency to return to homeostasis, and the depth of the mind with experience and new relationships often allow us to contain the trauma with ourselves, to occupy our bodies well, and locate a world we can live in with satisfaction and a good sense of self. Sometimes looking for the answers gets in the way of finding out the truth.
In a basic sense, some things just take a while to figure out. Some problems take a while to solve, like a 20-page math proof. Trying to get closure too fast can seriously delay properly wrapping things up. Telling apart what just takes time from what could get done sooner—it's important not to mix them up.
Getting the diagnosis right when symptoms are confusing
Posted Feb 13, 2014
Across the web you'll find increasing attention being given to the identification of bipolar mood symptoms and patterns. Solid educational information is important for those who are concerned that they may have bipolar disorder.
Even the best diagnosticians find that arriving at the diagnosis is a difficult endeavor. We're not yet at a point where we have easily obtainable biologically based tests that result in a definitive diagnosis. Similarly, we're far from being able to predict the disorder based upon genetic testing.
We're still faced with the reality of a mental health clinician sitting with a patient and relying upon clinical interview to come up with a clear picture to identify or rule out the presence of bipolar disorder. Sometimes even with extensive inquiry and careful consideration of the data obtained, clinicians still miss the bipolar diagnosis. It happens even with the most seasoned mental health professionals. I'd be dishonest if I said it's never happened to me. Longitudinal studies have shown us that the average time from initial onset of symptoms to an accurate bipolar diagnosis is ten to twelve years!
The reality is bipolar disorder is usually difficult to diagnose based on just an initial diagnostic interview with an individual. The diagnosis has to do with very broad patterns that exist over time. When meeting with a patient for the first time, all I'm really able to see is his or her behavior and mood state in the present, which excludes about 90% of the additional information that's required to ascertain the diagnosis. The acquisition of that 90% relies upon the clinician's ability to ask the right questions and the patient's ability to provide comprehensive and accurate answers. Even then, careful attention is needed before the bipolar picture can coalesce with validity.
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Bipolar symptoms present in many different forms and patterns. Each individual brings his or her own unique stamp to the clinical picture. We see variance in symptom acuity, symptom duration and symptom manifestations. While symptoms such as elevated energy, decreased need for sleep and accelerated thinking are common to most bipolar elevated mood states, one individual's hypomania/mania may be evident through euphoria and grandiosity while the mood elevation of another may entail irritability and outbursts of anger. Still a third may manifest his or her symptoms primarily through hyper-sexuality and impulsive spending. Further compounding the diagnostic challenge is the fact that the disorder often coexists with other psychiatric diagnoses such that we get a layering or commingling of symptoms from different diagnoses. The mental health professional is then faced with sorting out what symptoms belong to what diagnoses and how the different sets of symptoms may possibly potentiate each other.
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I find that the three diagnoses which are most often confused with bipolar disorder or potentially coexist and therefore interfere with the diagnosis are: 1) unipolar depression, 2) attention deficit-hyperactivity disorder and 3) the group of personality disorders. In this latter realm, the individuals we most often see coming in for treatment are those diagnosed with borderline and/or narcissistic personality characteristics. There are certainly other personality disorders that can come into this mix but we find that individuals with borderline/narcissistic features tend more often to seek psychotherapy. Additionally, some of the symptoms within these two personality types can easily be mistaken as belonging to the bipolar continuum (see previous Bipolar You blog: The Relationship between Narcissism and Bipolar Disorder).
So the question for the remaining discussion is: What are some of the guidelines that help us distinguish between straight depression, attention deficit-hyperactivity disorder, personality disorders and bipolar disorders?
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Let's start with the most common: unipolar depression. More often than not, bipolar disorder begins with episodes of depression. In fact, we may see adolescents go through a few years of intermittent depressive episodes during high school before they manifest the kind of mood elevation which tips the scale towards a bipolar diagnosis.
There may also be some symptoms within the overall depressive profile that can tip us off to the underlying bipolar disorder. I'm referring to things such as periods of feeling energized while also being irritable, angry and very pessimistic about life. With these people, their depressive symptoms have not flattened them out. It's more like the intense negative feelings are accompanied by a degree of agitation. These individuals may also find that their agitation interferes with their ability to get a good night's sleep. But, these small clues, in and of themselves do not rise to the level of a bipolar diagnosis. They are just features that should garner our attention and possibly alert us that there is more present than easily meets the eye.
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The next essential element is to obtain information about the broader family history of psychiatric diagnoses, and particularly bipolar disorder. If someone comes in presenting primarily with depressive symptoms but he/she has a parent, a sibling, a grandparent or even an aunt or uncle with bipolar disorder, then one has to approach the initial unipolar presentation of depression as if it may part of a broader bipolar disorder. I think of this as "bipolar brewing" where someone has the genetic predisposition but they've not yet manifested the full range of bipolar symptoms. In these instances the individual wouldn't be diagnosed with the disorder simply because of his/her genetics, but the treatment approach would likely be different than if there was no mood disorder evidence in the family background.
The other diagnostic piece that needs to be asked of almost any patient who comes into treatment is: "What is your mood and behavior like when you're feeling really good?" To take that even further, the individual should be asked, "Does your mood ever become more intense or more elevated than what you normally experience when you're in a generally good mood." You'd be surprised how often that simple line of questioning is omitted. After all, when someone comes in seeking help and everything he or she is talking about looks like, sounds like and feels like depression, it's easy to conclude that the individual should be treated for depression and possibly even be prescribed an antidepressant.
Here's the rub: Antidepressants, when prescribed to someone who is genetically predisposed towards bipolarity, may indeed precipitate hypomanic or manic symptoms, thus bringing about the bipolar diagnosis. We can't ever know with certainty whether that individual would have manifested bipolar symptoms if antidepressants were not prescribed. Had the right questions been asked up-front, the same individual may have been prescribed a mood stabilizer prior to the utilization of an antidepressant and his or her progression into hypomania or mania may have been averted.
The second complicated diagnostic issue involves attention deficit-hyperactivity disorder. This is a neurologic disorder which manifests through symptoms of attention and hyperactivity. With regard to attention we see behavior such as: poor attention to detail, frequent inattention or losing focus, difficulty following through with instructions relating to tasks, chores or homework, difficulty with organizing tasks and activities, frequently losing or misplacing things and consistent forgetfulness. In relation to hyperactivity we see: difficulties sitting still, tendencies to move around or be excessively active in situations where this is inappropriate, difficulty engaging in quiet leisure activities, excessive degree of physical activity - often acting "as if driven by a motor," and excessive talking. There is a further variation on hyperactivity including impulsivity. This can entail: tendencies to blurt out answers to questions before they have been completely asked, difficulties awaiting one's turn and tendencies to interrupt or intrude on others. Impulsivity can also entail rapidly making choices that do not reflect good judgment. Most of the preceding symptom descriptions reflect ADHD criteria from DSM-IV TR (American Psychiatric Association).
What's complicated about the above symptom list is that many of the same ones can be present during a hypomanic or manic episode. An individual's physical energy can be so elevated that he or she can easily appear to be hyperactive. There is also such cognitive acceleration and mood intensity that an individual's memory, attention to detail, capacity to remain focused and ability to appropriately inhibit action are all impaired. So how do we distinguish these sets of symptoms that can look so similar to each other?
The first part of the answer involves an important caveat: the distinction does not readily apply to those who are diagnosed with childhood bipolar disorder as such can exert its influence just as early as does ADHD. The salient differences are that feelings of grandiosity, intense elation and/or intense anger, racing cognition and lessened need for sleep are more salient in childhood bipolar than they are in attention deficit-hyperactivity disorder. This doesn't mean there won't be any of these themes in the attention deficit-hyperactivity realm but the preceding symptom cluster will likely have a stronger presence in childhood bipolar disorder as opposed to attention deficit disorder.
Now let's return to distinctions between attention deficit-hyperactivity disorder and bipolar disorder in adults. It's actually rather simple. The adult with bipolar disorder who did not have childhood bipolar disorder will have experienced a point of symptom onset sometime after mid to late adolescence. The implication here is that if I'm inquiring about symptom onset and the individual being assessed reports that none of his or her symptoms were present prior to some point in adolescence or early adulthood, then it's not likely that symptoms being discussed are reflective of ADHD.
A second key distinction is that many of the attention deficit-like symptoms that are typically present during elevated mood phases are absent during midrange mood and to a lesser extent, depressed mood, though sometimes depression does interfere with attention, concentration and memory so we can see what may appear as an overlap of ADHD and bipolar symptoms during depressed mood. The one obvious period of time when the attention-deficit-like symptoms are absent for the bipolar individual is during mid-range mood. This isn't the case for someone with attention deficit-hyperactivity disorder because their symptoms are part of their baseline functioning. They don't experience periods of time when their ADHD symptoms are absent. That's not to say there isn't some variability of symptom intensity, but the attention deficit individual won't have periods where attentional, focusing, organizational and impulse inhibitory functioning are perfectly normal. Keeping the above distinctions in mind, the tuned in diagnostician can usually tease out the differences between ADHD and bipolar disorder.
The differentiation of personality disorder symptoms from bipolar disorder entails two key variables, one of which is similar to the ADHD distinction. That is, if an individual struggles with personality disorder symptoms, their struggles will typically be ongoing. Similar to ADHD, there may be some variability in symptom acuity, but the individual typically won't have times where he or she is not under the influence of the psychological processes underlying the personality disorder. Individuals with personality disorders don't get to have a vacation from their personality dynamics. Conversely, the bipolar individual whose symptoms (impulsivity, hypersexuality, anger/irritability, tendencies towards idealization or devaluation, feelings of grandiosity, etc.) may look like they belong to a personality disorder diagnosis will present with enough of a difference within mid-range mood that most of the same symptoms will be absent.
The second critical distinction between the personality disorders and bipolar disorder is that all personality disorder issues manifest in relation to interpersonal relationships. The struggles which may activate strong personality disordered symptoms are almost always within the interpersonal realm. While there is some overlap here with bipolar disorder in the sense that interpersonal stresses may activate a shift in mood phase, bipolar individuals will also tell you that there are times when the onset of their symptoms, whether elevated or depressed, will seem to come out of nowhere. There is no obvious trigger or precipitant for their mood destabilization. The only reliable explanation is that there's been an endogenous shift in their brain activity and their neurochemistry.
The above discussion is by no means exhaustive regarding differential diagnostic distinctions between bipolar disorder and other psychiatric disorders that share similar symptoms. But it should give you a good sense of the kinds of issues the clinician will be looking at when trying to sort through whether one has bipolar disorder, another diagnosis or coexisting diagnoses.
I recommend that you be cautious if a mental health professional arrives at the bipolar diagnosis after only a short period of time with you or with a family member. The narrow exception here would entail someone with a strong genetic bipolar background who presents with hallmark bipolar symptoms in the absence of any other issues that may stimulate questions about comorbidity. But even here, in the name of thoroughness, diagnosticians should nonetheless be cautious about reaching conclusions prematurely.
Once a mental health professional has arrived at a valid bipolar diagnosis I feel most comfortable when the diagnosis is presented as a strong possibility along with a clear explanation of the basis upon which the conclusion has been reached. The patient should also be cautioned that the diagnosis will only be conclusively ascertained over a more extended period of time and that both patient and clinician will be looking at this together as treatment proceeds.
One last thing to keep in mind: If the diagnostic conclusion of your mental health professional doesn't ring true for you, if you do not get a thorough and detailed explanation as to why the bipolar diagnosis is likely, it is absolutely appropriate to pursue a second opinion.
Russ Federman, Ph.D., ABPP is in private practice in Charlottesville, VA (www.RussFederman.com). He is co-author of Facing Bipolar: The Young Adult's Guide to Dealing with Bipolar Disorder (New Harbinger Publications). www.BipolarYoungAdult.com
The frontal lobes are the regions of the brain that are thought to control many of the things that make us human. In fact, this region is proportionately much larger in humans than in other animals. It also takes the longest to mature, with development extending into young adulthood.
Functions of the frontal lobes include holding onto an idea and letting this notion guide our future behavior. The frontal lobes help us set goals and tasks for ourselves, choose appropriate actions among many options, suppress unacceptable reactions and responses, and determine the relationships between objects and concepts.
There are two main divisions of the frontal lobes: the cortex and the paralimbic regions. The cortex consists of the bodies of nerve cells lying right on the brain's surface. These cells communicate with one other via long wire-like processes called axons. Some axons plunge deep into the brain, where they communicate with structures closer to the brain's core.
Among the structures closer to the center of the brain are the paralimbic regions, which are thought to be related to basic emotions, functions, and drives. This is in contrast to the cortical regions, which are thought to be more complex, and which may allow us to think. Together, the cortex and paralimbic divisions of the frontal lobes allow us to perform tasks that are central to how we think of ourselves.
Setting Tasks
Unlike animals who just respond instinctively to what is in front of them, human beings have the ability to plan in advance. To do this, we need to be able to hold information in our mind. Otherwise, we would constantly forget what we were thinking about. This holding of information, even in the face of distraction, takes place in the ventrolateral region of the prefrontal cortex. The dorsolateral region of the prefrontal cortex is then able to manipulate the gathered information to formulate a plan.
Initiating and Sustaining Activity
The structures in the middle and frontal part of the brain (medial frontal structures) are thought to drive behavior. If these areas become damaged, a person may lose all motivation to do even the simplest task. This is known as abulia or akinetic mutism in extreme cases.
Monitoring Activity
The orbitofrontal cortex decodes and anticipates the reward values of signals, objects, and choices. For example, this region may help us determine whether something is likely to hurt or harm us in the future. The medial orbitofrontal cortex is thought to respond to rewards and the lateral orbitofrontal cortex, to punishment. The region closer to the back of the brain (posterior) is more concrete—this is the part that may immediately recognize the emotional significance of a slice of chocolate cake as being tasty and desirable.
The parts of the orbitofrontal cortex that are closer to the front of the brain (anterior) deal with more abstract and symbolic rewards, like the money that can go towards buying a chocolate cake.
Emotional Regulation
The orbitofrontal cortex also shows increased activity when someone is regulating their emotions. This is inversely related to the activities in the amygdala. Damage to the orbitofrontal cortex leads to disinhibition and thoughtless behavior, as seen in the famous case of Phineas Gage.
Anticipating and Monitoring Stimuli
The anterior cingulate cortex helps keep track of signals coming both from the outside world and our own mind and body. Anything unexpected can trigger additional processing before a response is given. For example, in the famous Stroop test, a list of brightly colored words is shown. The trick is that the word "red" may be printed in the color green. Someone taking a Stroop test is told to ignore the written word and just say the color. This careful selection and focus on just one aspect of the outside world require the use of the anterior cingulate.
Responding to Change in Salience
Salience is the measure of how important and relevant a particular signal is to you at a particular time. For example, if you're hungry, a piece of chocolate cake is quite salient. After eating half the cake, your desirability of that cake changes. To determine the significance of a piece of information, the brain must rapidly integrate sensory, visceral, and autonomic signals. The salience network involves the insula and part of the frontal cortex, which helps us give things meaning.
Switching Attention
Human beings have the ability to choose what deserves our attention. That said, depending on circumstances, our attention can quickly switch between different things in our environment.
The ventral attention network includes parts of the middle and inferior frontal gyrus and the temporoparietal cortex. This helps us orient to something rapidly, even if it interrupts a goal, and lets us decide whether we should continue to focus on the new stimulus or go back to the task at hand.
Executive Control
The abilities of the frontal lobes could all be seen as contributing to what neurologists call "executive control." This signifies our capability to control our responses to our environment, rather than just react to whatever is in front of us at the moment.
The executive control allows us to filter out distractions around us. It also allows us to control what we are thinking, and shift our focus in a way so that we are not distracted by our own thoughts. Executive control over emotions allows us to regulate how we appear to others and motivate ourselves even when we are not motivated. Finally, executive control over the motor network allows us to move our eyes or reach for something.
In 1878 Paul Broca, the French neurologist famous for so-called Broca's aphasia, coined the term "le grand lobe lymbique." The term "limbus" refers to a margin or rim. Dr. Broca was referring to the structures that surround the innermost part of the brain, at the margin of the brain's center.
Meaning of the Limbic System
The meaning of the term "limbic system" has changed since Broca's time. It is still meant to include structures between the cortex and the hypothalamus and brainstem, but different specialists have included different structures as part of the limbic system. The amygdala and hippocampus are widely included, as is the olfactory cortex. From there, however, opinions diverge as to what is considered part of the limbic system, and what is paralimbic, meaning a structure that interacts closely with the limbic system but is not truly part of it.
What Does the Limbic System Do?
The limbic system serves a variety of fundamental cognitive and emotional functions. The hippocampi, which lay on the inside edge of the temporal lobes, is essential to memory formation. The amygdalae sit on top of the front portion of each hippocampus. Each amygdala is thought to be important in processing emotion. The amygdala communicates closely with the hippocampus, which helps explain why we remember things that are more emotionally important. The amygdala also communicates closely with the hypothalamus, the area of the brain that is responsible for regulating temperature, appetite, and several other basic processes required for life.
The hypothalamus itself is sometimes, but not always, included as part of the limbic system. Through the hypothalamus, as well as some key areas in the brainstem, the limbic system communicates with our autonomic nervous system (which regulates things like heartbeat and blood pressure), endocrine system, and the viscera (or "gut").
Nerve cells in the brain are organized in different fashions depending on location. The cerebral cortex is predominantly neocortical, meaning that cells exist in 6 layers. This is different from the limbic system, where cells are either arranged in fewer layers (e.g. paleocorticoid), or more jumbled (corticoid). This less complex organization of the limbic system, as well as the limbic system's control of fundamental processes of life, has led doctors to believe that the limbic structure is evolutionarily older than the cerebral cortex.
Paralimbic Structures
The paralimbic structures form a complex network with the limbic system. Examples of paralimbic structures include the cingulate gyrus, orbitofrontal cortex, temporal pole, and part of the insula. The basal forebrain, nucleus accumbens, mammillary bodies and parts of the thalamus (the anterior and mediodorsal nuclei) are also often considered paralimbic structures due to their close interaction with the limbic system.
Each of these paralimbic structures has been connected with emotion or basic cognitive processes. The anterior cingulate gyrus, for example, has been tied to motivation and drive. The insula is connected with our ability to sense our own internal sensations (or "gut feelings"). The orbitofrontal cortex, nucleus accumbens, and basal forebrain are involved with sensations of pleasure or reward. The mammillary bodies and some thalamic nuclei are important to the formation of new memories.
All of these pathways are intricately connected. The amygdala, for example, communicates to the orbitofrontal pathway through a white matter bundle called the uncinate fasciculus, as does the insula. The amygdala communicates to parts of the hypothalamus and cingulate through the stria terminalis, and to the brainstem and several other structures through the ventral amygdalofugal pathway. The hippocampus largely communicates through a large white matter pathway called the fornix, which curves around the ventricles of the brain towards the mammillary bodies, sending out branches to the mammillary bodies, thalamus, and cingulate along the way.
The limbic system is a heterogeneous group of structures and serves many different functions. Those functions are fundamental to how we think, feel, and respond to the world around us.
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