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Recognizing and treating reported depression in bipolar patients

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Length: 30 minutes

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Michael S. Perlman, MD

This talk will describe the differential diagnosis of the bipolar patient’s report of “depression,” will encourage the clinician to be open to the possibility that a feeling-state other than depression is present,  will describe some methods for determining whether such a feeling-state is present, and will discuss how to treat it.

When the bipolar patient reports “depression,” the clinician must consider whether what’s present is 1) major depression, and/or 2) dysthymia, and/or 3)  a mixed state, and/or 4) a problematic feeling or ego-state such as those related to grieving, whether acute or chronic,  or such as related to anniversary phenomena. Clinical examples of each will be given.

I often ask the patient where in her or his body the “depression” is felt, and then I ask the person to focus on that part of the body, give up control, wait and see what happens, and then put into words the feeling and/or picture that is experienced. This is a method I call affective association, a variant of free association in which the association begins from a bodily feeling. This method was inspired by the example of Elvin Semrad, MD,  the most influential clinician in Boston from the mid-1950s to his death in 1976,  who asked schizophrenic patients where in their body they were feeling emotional pain. By using this method the patient often becomes aware of previously warded-off feelings and memories, and, by bearing them with the encouragement and support of the clinician, has the opportunity to deal with them.


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