Expert: Libby Bonner - 5/1/2006

Question
Dear Libby

I have a number of questions about 3 members of my family who have bipolar.Please bear with me as I give you a history in order for you to assist me with the answer to my questions.

My youngest son, who is now 33yrs of age, was diagnosed with bipolar manic disorder some 11 years ago. Since then he has had 5 relapses. He has been taking zyprexa and lithium for the past 7 years and has been relatively stable for the past 4 years.

The question I have for you is how to deal with his chronic inability to show initiative, motivation and planning for the future. I am well aware that executive functioning in the brain is affected by the constant relapses, however I have an added concern recently: I have been diagnosed with fourth stage terminal cancer and I am very concerned for his welfare. I am a single parent and his income at present is not sufficient to sustain his needs. He earns a token income from the church as he does missionary work on a part-time basis. The balance of his needs are met by myself.

He is generally reasonably high functioning, has excellent cognitive ability and those who do not know his background never guess that he has bipolar. He is extremely sociable, well-liked and affable, however his problems with short term memory retention,the ability to plan his life and become motivated to participate in every day activities impacts negatively on his ability to take care of all his needs.

Is there anything that can be done to improve this situation?

My second question concerns my eldest son who is 35yrs of age. He is married with three children and for many years has shown evidence of bipolar disorder. He does not want to acknowledge this, despite myself and his wife showing him the DSM-IV criteria to which, according to his wife, he answers every single one. Just recently he went through one million rand (the equivalent of about 370000 dollars) in a few months. He is extremely intelligent, is an amazing entrepeneur with the ability to make huge amounts of money. He does however spend it just as quickly and his family are constantly in financial trouble. His mood disorder, insomnia and strange behaviour is well known to those who are close to him.

My question is: Is there anything that can be done to encourage him to acknowledge that he has bipolar?

My third question is connection with my brother who I suspect also has bipolar. He has just recently been displaying 6 out of the 7 DSM-IV criteria for bipolar. He has gone through a lot of stress recently when his wife had a stroke, his eldest son a thyroid operation and his seriously retarded son, (whom he soley takes 90% responsibility for) has been ill. This seems to have precipitated all the signs that I noticed when my son first began to evidence the illness. My brother is 51yrs of age. I showed him the DSM-IV criteria and he acknowledged all but one of them. He also acknowldedged all of the criteria for Obsessive Compulsive Disorder (which my son has as well). He, unlike my oldes son, is very keen to receive help, however he does not have any medical aid. In this country this is a huge problem as our State aided medical Departments are not very competent (My son is under their care and they do not even check his lithium levels every 6 months - spending 2 -3 minutes asking him if he sleeps or hears voices and if both answers are in the negative they write out a script)

The question I have for you is this: Lithium is very inexpensive in this country, however neuroleptics are extremely costly. If we can find someone to diagnose him (I am working on this) then they will obviously prescribe medication. In your experience will just Lithium address his problem if he is indeed suffering from both bipolar and compulsive obsessive disorder?

Bipolar is a very prevalent condition in my family. My father had the condition and was hospitalized in a mental hospital for 9 months when I was only 18 months old. He was hospitalized on 2 or 3 more occassions that I was aware of during my youth. There are 3 other members on my father's side that have either bipolar or scizophrenia.

I do apologize for the long-winded questions, however I wasn't sure you would be able to assist if I didn't give you some information. I am finding that bipolar has coloured my life ever since the day I was born and appears to be escalating in its manifestation. I am not sure how much longer I have to make a difference due to my cancer diagnoses and would dearly love to assist those that I love as much as possible. I do not appear to have any symptoms that I am aware of as I do not seem to have any of the DSM-IV criteria.

Thank you in anticipation of your reply. I look forward to hearing from you.


Yours in Christ



Mischa  

Answer
I usually get to questions the day received, so I apologize for my delay.  In part, I was waiting for ample time in which to reply.

I am enormously sorry to hear of your grave illness and sorry that you have loved ones with difficult illnesses and difficult situations.

It seems to me that the solutions to your first two problems are legal...or, perhaps there is a legal solution to the problems of the 33-yr-old and some legal strategies available to the wife of the eldest son [since it is only she, and not you, who can seek them on her behalf.]

But of course there is our problem, yours and mine, of different countries, cultures, and legal-medical systems.  So perhaps my thoughts will be useful, but perhaps not.

However, were this the US, a parent probably would create a Trust for the youngest son and have monies distributed by the Trustee.....and/or you would name a trusted person as his guardian and trust the person to manage and distribute assets.  A formal Trust can even own the home in which he lives and/or see to its maintenance.

I am wondering, from a US context, whether there is any State system for disability payments and whether your son has applied for them and/or is eligible.  This might be a means of augmenting whatever assets you yourself can make available to a Trust/Trustee/guardian.  Again, in the US, a special Trust would then have to be crafted so that Trust assets would not cause ineligibility for State payments.

There is absolutely nothing you or anyone can do or say that will get your eldest son to acknowledge his illness.  Certainly FACTS will not, and rational discourse is a huge waste of your and everyone's energies.  Discard this as a goal, and instead encourage your daughter-in-law to minimize the damage that his illness is causing her, and can cause her, legally and financially.  If you have the means to help her secure legal help, do so.  

Again, from a US context:  here, she would be well-advised to have, if possible, some accounts and/or real property in her name only.  [--so that she is not left w/ nothing if and when he bankrupts himself.]  Equally, she would be well-advised to undertake all legal maneuvers NOW to keep from ever being personally responsible for his debts.  She should not co-own accts and property w/ him - I think - nor, certainly, co-sign loans.  SHE NEEDS AN ATTORNEY/BARRISTER/WHOMEVER TO DO EVERYTHING POSSIBLE TO REMOVE HER FROM FUTURE FINANCIAL PERIL.  --- If your son's 'strange behavior' perhaps includes spousal abuse, there could be other issues to be considered.

I don't know enough to help w/ your brother's problem.  I think lithium will not help w/ the obsessive/compulsive. I believe there is one SSRI that is felt to be useful, w/ probably cognitive-behavioral therapy or behavior modification techniques being more effective.  OCD, per se, is only [my opinion] a problem if it interferes greatly w/ work or w/ interpersonal relationships.  -- And it may also matter whether obsessions or compulsions dominate?  It is somewhat rare [?] for both to co-exist strongly?

As to lithium as sole therapy for bipolar disorder.  There is nothing to be lost in trying it.  You can probably make some prediction of its effectiveness, tho, if you know how much time your brother is manic or hypo-manic and how much of his time is spent depressed, as well as how often he cycles between these.  He will have the best luck w/ lithium alone, I think, if depression is NOT his primary problem and IF he does not cycle often.

My only other thoughts about help for your brother.  Are you near enough to a medical school that someone might take an interest in his family history and in him....and/or is any med school running clinical drug trials for which he would qualify?  These solutions would offer both physician services and meds. ---- In the US, pharmaceutical manufacturers in some cases will supply drugs directly to indigent patients, upon a doctor's request and w/ proof of indigency....but I gather your brother would be ineligible re income.

I hope someone is listening to you and to your own concerns about yourself right now.  Pls be kind to yourself and look to your needs as well as those of others....and use your energy and resources wisely.  Your youngest son seems to me to be the most urgent problem and likely the most easily solved.  Perhaps you can set about those responsibilities and have their completion as your main goal, only turning to the problems of other loved ones later....but always allowing time and attention to yourself.

I think there is not a NAMI affiliate in South Africa, but check anyway:  www.nami.org   The experience of others who have dealt w/ these problems would be such a help.  I wonder if, via your son's psychiatrist, you could identify any family support group/s near you?  Enlisting others to help start a NAMI affiliate there would be a most wonderful legacy to leave others.  --- There is a Canadian group w/ an international presence who might either already be there or, again, be a group that friends of yours could start.  See www.world-schizophrenia.org  They DEFINITELY deal w/ all the major mental illnesses.

This will not be a comfort, but:  State-aided medical departments are poor nearly everywhere, US included.

Thank you for writing.  I hope some of this will have helped.  Please know that you, and those you love and about whom you have written, are in my thoughts.